A multi-sectoral approach to dengue control

Dengue fever is rearing its ugly head again in India with new cases of infections and even deaths being reported from different States. The world’s fastest growing vector-borne disease, dengue sees an estimated 50-100 million cases being reported annually in over 100 endemic countries. Ever since its detection in the early 1950s, there has been a 30-fold increase in dengue incidence. Almost half of the world’s population is currently considered at risk of contracting dengue. The Southeast Asia region contributes to more than half of the global burden of the disease. About 52 per cent of the world’s population at risk resides in this region. Dengue is endemic in 10 of the 11 member states, and India, Indonesia, Myanmar, Sri Lanka and Thailand are among the 30 most endemic countries in the world. More than 4, 00, 000 cases of dengue were reported in this region in 2013.

The good news is that deaths due to dengue have been brought down substantially. This is because of greater awareness among treating physicians on the proper use of World Health Organization protocols in providing care to dengue patients. This is also attributed to increased knowledge among communities to seek early treatment for symptoms that resemble those of dengue.

Increase in number of cases

However, an area of concern is that the number of cases has been increasing year after year. To understand it, we need to comprehend and keep pace with the changing epidemiology of dengue, especially the multiple ecological factors that influence its spread. Being a vector-borne disease, ever-increasing numbers and varieties of mosquito-breeding habitats are being created with rapid and poorly planned urbanisation, globalisation, consumerism, poor solid waste and water management, and increasing population movement without adequate measures to prevent vector breeding. Climate change is also influencing ecology that encourages vector breeding.

The outbreak of dengue, like other vector-borne diseases, is determined by socio-economic factors that include reduced access to health services, housing, sanitation, water supplies and poverty. Efficient, effective and sustainable prevention and control of vector-borne diseases requires not only the application of biomedical tools, but interventions to address these factors as well.

The accumulation of modern non-biodegradable products such as automobile tyres, plastic containers and tin products provides a conducive environment for prolific breeding of Aedes aegypti and Aedes albopictus vectors of dengue. Hence, effective and sustainable prevention and control of dengue requires interventions that address these factors in an integrated and multi-sectoral manner.

The health ministers of the Southeast Asia region, in their recent meeting in September 2014, adopted the Dhaka Declaration on Vector-borne Diseases. The Declaration encourages a “whole of government” approach against diseases such as dengue. This was in recognition of the importance of a multi-sectoral approach to addressing dengue outbreaks and in order to advocate utmost need for Health in All Policies — an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. The theme of World Health Day 2014 focused on vector-borne diseases to acknowledge their public health importance, raise global awareness and increase commitment on controlling them.

Community empowerment

Global evidence conclusively shows that dengue control can never be achieved or sustained without community empowerment and ownership. Unfortunately, there is lack of awareness on the role of vectors in the community and the vital contributions that they can make to prevent dengue by mitigating vector breeding in their respective surroundings. Even the best public health systems in the world will not accomplish the desired task of containing dengue without the active participation of communities in this endeavour. Communities must work with public health authorities in preventing accumulation of material where water gets stored, allowing mosquitoes to breed. A simple preventive step is to protect oneself from mosquito bites by wearing clothes that cover the body completely. This can help in cutting short the transmission of this infection.

For many infectious diseases, good vaccines are available. Extensive research is on to develop a safe, efficacious and affordable vaccine against dengue too. WHO has been supporting these research and development efforts. A few candidate vaccines are now in advanced stages of clinical trials. We look forward to their early availability to public health systems in developing countries.

Till vaccines become available, dengue-control activities have to be a synergy of sound public health actions. This must include integrated vector management and active participation of individuals, families and communities in reducing the sources where mosquitoes breed. The battle against the disease can be won only through concerted actions by all.

Four Nobel-winning insights that matter for the Indian economy Jean Tirole's insights are very relevant to India

Jean Tirole, theorist of industrial organisation, incomplete contracts, and a lot else besides, has just won the Nobel Prizefor economics. Usually, his insights show how real-world incentives are complicated, and contracts can be difficult to write and enforce. Much of his work is very relevant to India; here are just four such insights gleaned from his 35-year career.
 
PPPs, renegotiation and “incomplete contracts”
 
The Nobel work: From the early 1980s onward, Tirole – with a succession of co-authors – demonstrated the danger of writing contracts that could be easily renegotiated. Standard economics assumes that any contract can easily predict all future states of the world, and that possible payoffs are clear to both contracting sides. This assumption is easily violated in practice. Under such circumstances, cost overruns, for example, should very rarely occur in procurement contracts, or in public-private partnerships. Tirole’s work shows that “systematic unforeseeen cost overruns” are a possibility.
 
The India application: In India, private-public partnerships have been plagued by cost and time overruns. Tirole’s papers provide a basis for estimating exactly how this happens over and over again. In many cases, it demonstrates quite clearly the dangers of renegotiation of a settled contract. This is not just unjust to the other firms that have bid, if the contract is handed out in an auction setting. If in general renegotiation is a possible, Tirole’s work shows, then a climate in which renegotiation is inevitable will emerge – and so will cost overruns.

In later work, Tirole argues for an independent evaluation of all PPP contracts before they are signed, to prevent collusion between companies and bureaucrats. PPPs that are “unbundled” – in which development and operations are handled by separate contractors – are far less likely to lead to large-scale corruption. He also shows that firms use the threat of quitting a project to blackmail public parners into submission; if the government gives in, then a perverse incentive is created. Above all, Tirole shows that the simpler it is to write contracts and predict the future, and the more transparent the institutional structure, the fairer and more implementable contracts will be.
 
“Efficient access pricing”

The Nobel work: One of the central problems of a modern economy is how to open up networks – such as telecom or power networks – to competition and new companies. Tirole showed that new entrant companies who were given access to the expensive networks built up by incumbents would indulge in “cream-skimming” – work to wean away only the incumbents’ most lucrative customers. As the Nobel committee says:  “Giving the incumbent the responsibility for covering the fixed cost of the network all by itself, and letting entrants free-ride by paying very low marginal-cost access prices, would inefficiently distort consumer choices towards the entrant.”

The India application: In India, problematic power supply is often cited as a major constraint for industrialisation. “Open access” to electricity has been promised for over a decade. This means that factories, for example, should be able to make contracts to have power supplied to them by companies other than their local state-controlled electricity utilities – but over the networks set up by the state electricity boards. There have been many complaints that “wheeling” or transmission charges have been charged by local electricity boards. Tirole’s work explains why such fees are charged – but it also provides guides and models to determine whether such charges are excessive.
 
Accountability and “multiple objectives”
 
The Nobel work: To what degree can government bureaucrats – or company managers – be trusted? What sorts of tasks will allow for greater accountability? Tirole and his co-authors have written a series of papers that have made major insights into these and related questions. In particular, when agencies or bureaucrats or executives have multiple missions, then they show mathematically that they are likely to be given less autonomy. When they have “fuzzy” missions – in other words, their job is too complex to be easily understood – then they are even less trusted.
 
The India application: Agencies like, say, the Reserve Bank of India, will find their independence easier to preserve if they commit to a single, monitorable target such as the consumer price index. Managers, too, will find themselves more free if just judged on the profits they make. However, consider Tirole’s own insight: “Incentives that are related to an easily measured objective (for example, the cost per student for a university, which can be easily reduced by teaching large numbers of students in large lecture halls) can cause one to ignore equally important objectives that one has neglected to measure (such as the quality of teaching or research).” Approaches such as India’s to financing and regulating education have typically ignored this insight.
 
Corruption and regulation
 
The Nobel work: Much of Tirole’s work has focused on how regulators and bureaucrats can be led into corruption. In one early paper, he showed that interest groups were actually more politically powerful when they benefited from inefficient regulation. If two groups were equally willing to bribe officials, but one bribed them towards efficiency and the other towards inefficiency, the latter would wind up with more influence. In another paper, he examined how companies could suffer long-term effects from a single failure in quality – a logic he extended to the effects on bureaucracies of a short period in which corruption happened to increase. A bureaucracy only had to give into corruption once – after that, corruption would become entrenched, and lack of trust endemic.
 
The India application: Tirole found that anti-corruption campaigns simply don’t work – they just encourage bureaucrats to postpone corruption till attention is elsewhere. Counter-intuitively, an amnesty for past corruption might actually help clean up bureaucracies. To reduce the threat of regulatory capture by business, the best thing for governments is to “reduce the stakes that interest groups have in regulation” – in other words, to ensure that the payoffs to even good firms from favourable regulatory decisions are small. More market, less regulation – counter to the popular conclusion that Tirole’s work argues for more regulation of big business.

Frenchman Tirole wins Nobel economics prize

French economist Jean Tirole won the Nobel prize foreconomics today for research on market power and regulation.

The Royal Swedish Academy of Sciences cited Tirole for clarifying "how to understand and regulate industries with a few powerful firms."

Tirole, 61, works at the Toulouse School of Economics in France.

"From the mid-1980s and onwards, Jean Tirole has breathed new life into research on such market failures," the academy said, adding his work has strong bearing on how governments deal with mergers or cartels and how they should regulate monopolies.

"In a series of articles and books, JeanTirole has presented a general framework for designing such policies and applied it to a number of industries, ranging from telecommunications to banking," the academy said.

The economics prize completed the 2014 Nobel Prize announcements.

Last week, different panels of Nobel judges announced the awards for medicine, physics, chemistry, literature and the Nobel Peace Prize.

The awards will be presented on December 10, the anniversary of prize founder Alfred Nobel's death in 1896.

Even though the economics award is not an original Nobel Prize - it was added in 1968 by Sweden's central bank - it is presented with the others and carries the same prize money.

Last year the economics prize went to three Americans who shed light on the forces that move stock, bond and home prices.

A Nobel for incentives The importance for India of Jean Tirole

It is a common complaint about modern economics, particularly theoretical economics, that it is too far removed from the real problems of economics. In the West, this takes the form of the accusation that most economists failed to predict or warn about the possibility of the 2008 financial crisis. In India, there is concern that economic theory developed in the West fails to provide the tools required to analyse the pressing public policy problems in India. In many ways these are unjust criticisms. By awarding the 2014 NobelMemorial Prize in Economics to Jean Tirole, an economic theorist based out of the University of Toulouse in France, the Royal Swedish Academy of Sciences has in fact demonstrated just how unjust they are.

Prof Tirole is one of the most quietly influential of economists. He may not be a public intellectual like Paul Krugman, with a wide-ranging audience for his newspaper columns; unlike Larry Summers, he may not have taken up a major public position; and he has not positioned himself, like Joseph Stiglitz, as a prominent critic of globalisation. Yet his work has been as influential as that of any of the others. As the Nobel committee points out, it spans several different sub-disciplines of economics; but in each case it focuses on rigour and the careful analysis of strategies and incentives. Modern "industrial organisation" - the theory of the firm, of pricing strategies, of regulation and of monopolies - has developed more thanks to Prof Tirole's work since the early 1980s than anything else. By organising a deeply disorderly field, and by ensuring that properly rigorous models are used, he has taken the study of the firm out of the fuzziness common to "management studies" and into the greater clarity of the economics profession. The consequences have been considerable. One the Nobel committee mentions is the demonstration, through mathematical modelling, that monopolies in one field can be extended into another through vertical integration. A question that Prof Tirole famously asked is: "What is worse than a monopoly?" And he answered it thus: "A chain of monopolies." This insight has changed the way that regulators behave - the various antitrust actions against Microsoft earlier this century were not unrelated to this development.

Rigour such as Prof Tirole brings to basic questions of incentives is clearly missing in the debate on Indian corporate bodies, as well as on public policy. One of the few theoretical papers of quality to focus on the incentives behind public-private partnerships or PPPs, for example, was authored by Prof Tirole together with a frequent collaborator, Eric Maskin. One of the things that they discover: "PPP contracts [between a bureaucrat and a company] need to be carefully reviewed by independent authorities that can expose hidden rent backloading... PPPs can be expected to entail higher transaction costs." It is worth noting that this paper has been available since June 2007. This insight is something that Indian policymakers are only now accepting after considerable pain - though a clear independent authority is still not even on the anvil. More than most Nobel prizes in economics in the recent past, Prof Tirole's work is relevant to Indian public policy. It is to be hoped it leads to a revolution in rigour and formal modelling in Indian economic circles.

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