08 Aug 2020 20:09 IST

Be flexible in scaling up health programmes: Harvard’s Richard Cash

Speaking at IIMB, global health professor refers to role of incentives in policy implementation

Richard Cash, Professor on Global Health, Harvard TH Chan School of Public Health, addressing students of IIM Bangalore, in a public policy talk series, said, “Small is beautiful but big is necessary — that is the motto with scaling up health programmes.”


BRAC is the world’s largest NGO, that began operations in 1972 in post-war Bangladesh, to work with the poor to bring about a change in the quality of life. Cash’s 45-minute talk, drawing lessons from BRAC, was titled, ‘From One to Many: Scaling Up Health Programmes and Using Incentives Appropriately — The BRAC Experience.’Recalling his visit in January 2020 to St John’s Hospital, Cash said he was glad to be back in Bangalore, albeit online.

Strategy and implementation

To the students of postgraduate programme in Public Policy and Management (PGPPM) participating in the lecture, Cash said: “There will always be tension between strategy and implementation so you’ve got to be flexible,” adding that government is critical in scaling up environment. “It’s important to have pilot programmes based on research and train workers before a pilot project,” he added, listing challenges and solutions drawn from BRAC’s Directly Observed Therapy (DOTS) for TB treatment.

“Innovation, in BRAC’s DOTS programme,was in the form of introducing financial bonds given by patients, returned on completion of treatment but forfeited due to non-compliance,” he explained, pointing out that involvement of community health workers who got incentives for finding cases and completing treatment, a reliable backup healthcare system. The frequent supervision and excellent management and availability of external technical assistance had led to the success of the model, which was then extended to other fields like micro-finance, agriculture, and so on.

Innovation is simple

Speaking about the BRAC’s diarrhoea programme, also in post-war Bangladesh, he explained how mothers were taught in their homes to make Oral Rehydration Therapy (ORT) by female health workers using easily available ingredients at home — a pinch of salt and a scoop of ‘gud’ or jaggery in a seer of water. The simplicity innovations like a cholera cot with a sleeve that goes into a bucket to enable evacuation, measurement and replacement of lost fluid helped to keep mortality down and had a dramatic impact.

“Trust was built by the workers tasting the ORT themselves first,” he said, observing how this small act helped dispel myths that the community workers were propagating family planning. “The workers were evaluated on lessons learnt by the caregivers/ mothers. They were then paid on a prorated basis. This helped us assess what the mothers had learnt and what the workers should be paid. This message was so effective that ten years later, the message was remembered and shared.”

Commitment to improving health

Cash is the senior editor of ‘Casebook on Ethical Issues in International Health Research,’ a WHO publication. Scaling up health programmes is a major interest of his, and he is also the senior editor of ‘From One to Many: Scaling Up Health Programmes in Low-Income Countries.’ He has also documented the scaling up of the BRAC ORT program in ‘A Simple Solution.’ And as a member of the BRAC Health Group, he and his colleagues have documented the BRAC TB DOTS program in ‘Making Tuberculosis History: Community-Based Solutions for Millions.’ In 2006, he was the recipient of the Prince Mahidol Award and in 2011 he received the Fries Prize for Improving Health.

Cash’s lecture was followed by an interactive session that covered a spectrum of issues, including ways of motivating medical practitioners at the front line, the effect of the fear caused by Covid-19 on mortality in diseases like TB in India, and more.