The making of public policy for a country as large, populous, and diverse as India is intrinsically a very complex task. Listen to Mr. CK Mishra, an administrator, policymaker, and public health strategist who has worked meticulously in the fields of health, education, industry, and power for more than 37 years, sharing his insights about the various public health programs in India, especially sharing his experience working on Mission IndraDhanush, India’s immunization program, one of the largest health programs of its kind in the world catering to a birth cohort of 25 million children annually.

VOICE OVER

You’ve tuned in to Badlaav for better. A podcast by B Medical Systems saving lives through reliable and innovative technology hosted by Jesal Doshi

Jesal Doshi

Hello and welcome to yet another episode of Badlaav for Better as you know, Badlaav for Better is our attempt through small conversation to bring about big changes in India’s healthcare system through a ripple effect. Today it gives me great pride and honour to introduce Mr. CK Mishra.

Mr. CK Mishra needs no introduction. With nearly 4 decades of public service, Mr. Mishra has served as an administrator, a policymaker, a public health strategist, holding a wide range of assignments in the fields of health, education, industry, and power, and reporting to the highest authority of our country. Mr. Mishra holds many, many hats. He was the additional secretary and Mission director of National Health Mission before this. He’s led multiple committees focused on eradicating COVID-19 and the fight against COVID-19. And he’s, I would say one of his biggest achievements, his mission Indra-Dhanush. Much before COVID, he realized the importance of vaccination and the child immunization program in India that he spearheaded, Mr. Mishra. It gives me great pleasure to welcome you here. Thank you so much, Sir, for joining us.

Mr. CK Mishra

Thank you. Thank you for having me over.

Jesal Doshi

We spoke about your career in the Indian Administrative Services, which has been incredibly illustrious. You’ve held position of secretary in 3 ministries. Tell us a little bit about this journey. Maybe starting off from the beginning. What motivated you to join the services?

Mr. CK Mishra

You know, that’s a question people often ask all those who got into the service. And very often a straight answer is that I wanted to serve the people I wanted to do several things for the country. All that is absolutely right. Let’s get practical for a while. When you are 20-21 years of age. And you’re looking at a career ahead. You weigh your options. In the early 80s, when I was weighing the option. By far this was the best choice. So to be very honest. I went for the best choice. And with that choice came the responsibility of being with the people. Serving them. But one very, very important thing that always kept me occupied in this journey was that you can be the change maker

And it’s not necessary that you succeed always. But if you succeed. The sweetness of that success really propels you to go ahead and do another good work. I have always admired being with people. And that is one of the reason why I got into the service apart from the social prestige and other things that it carries, it is an important thing for India, where you lead and by example try and bring about change. Try and about bring about change in lives of people the way looks at life. There’s been an incredible journey in the sense that there’s been many ups and downs. There have been several successes which I am very proud of. And there have been failures, which I acknowledge.

Successes have been very critical in life. But I think, looking back at 38 years in civil services. Those failures were great things that happened. They taught me how to move ahead. They taught me how to learn afresh and really get going. You know this service gives you a great opportunity to do a variety of things which you don’t get anywhere else. That is the biggest attraction.

Jesal Doshi

Thank you so much for such a candid response and you know, coming from someone who is, I would say, reporting to the no…. no less than the Prime Minister himself on multiple occasions. To have that sort of candid acknowledgment is truly remarkable. Thank you so much, Sir. And I think for all our listeners, there is a lesson here that about humility, that no matter how high you get, you still make mistakes. And it’s important to acknowledge and learn from them. But uh, so just, you know, you spoke about the early 80s when I was still crying and wearing diapers. And it’s…..it’s fascinating. And you spoke about being a change-maker. What is very unique about your career is that you have been a change-maker all throughout your career. And a lot of people believe that you can be a change-maker only after you reach a certain position or a certain level. So what would your advice be to such people?

Mr. CK Mishra

See, it’s true that your change gets recognized if you are doing it at a particular level. But the fact that you can change doesn’t need a level. You do it at a very basic level. Not many people will talk about it if that satisfies you which it should feel happy, but if you move ahead to higher levels, you have to be that much more careful about the change that you’re bringing about, because that change must influence people’s life in a very positive way. So, I… I think it’s not about levels, it’s not about the status, it’s not about the stature where you can bring about change anytime provided. You believe in it.

Jesal Doshi

But you know, in a way, you’ve captured the essence of this podcast, which is really through small conversations, through conversations that may finally not lead anywhere, but really our attempt is to create that ripple effect that gets people to think to, to listen to the experts such as you and to really bring about change. Even at a small, at an individual level, because we truly, truly believe that this is where real change comes from.

Mr. CK Mishra

Absolutely. If you cannot bring about an individual change, I don’t think you’re suited for bringing about social change.

Jesal Doshi

Absolutely, that could not be better said than that. And in your 38 years of service. It’s a difficult question because I’m going to ask you to single out one or at the maximum 2 achievements that make you the proudest looking back at 38 years.

Mr. CK Mishra

Well, that’s a tough one. But let me try. You know if I am to single out 2 achievements.

One, I would say the health sector. Both as mission director and secretary at the Government of India level, as well as secretary at the state level. I think I was able to influence change in the existing systems. Brought about new thinking, brought about a fresh wave. And help bring down the MMR IMR and all those things. That is one thing that I would single out as my achievement.

The other thing which is, in hindsight, I am saying. Something that I didn’t really think while I was in service was, the policy making ability. You know, I was surprised myself when I was reading what I have done through my service. That I wrote at least 5 National and sub national policies. The health policy, the draft forest policy, the industry policy of Bihar. So, you feel good about it because you are actually contributing a lot. Individual instances are instant success, and they really make you feel elated. But it is these that live down the lane. Even today, everybody talks about the 2017 health policy for exam. So that’s critical.

Jesal Doshi

Absolutely. And I think that the health policy of 2017 was instrumental. Because we see many of the changes or proposals that were made back then are being implemented even today.

Mr. CK Mishra

And it gives you immense sense of satisfaction. I will give you another exam. I wrote the National Cooling action plan for example. It was only after we spoke to the industry and kind of implemented it, we were told that this was the first of its kind in the world.

Jesal Doshi

Wow

Mr. CK Mishra

So that gives you satisfaction and you know. This is not a short-term thing. It will last. So I always believe. That any government servant. I mean, it could apply to others as well, but particularly in government, if you are in a position to influence long-term policy, if you are in a position to create institutions for longer term. That’s better success and having a thumping result one year and not getting it 3 years later.

Jesal Doshi

One of the biggest successes, I believe that you were very closely you……you led yourself was Mission Indradhanush. So could you tell…tell our listeners a little bit about what exactly is Mission Indradhanush.

Mr. CK Mishra

See to rephrase what you were trying to say. You may be the pharmacy of the world. Producing several vaccines. But unless that vaccine reaches the arm, it has no meaning. And that is what, through routine immunization, try to do. The second basic principle is that if a child death or a death is preventable with a vaccine. Every death should be prevented. That’s the right of the person who lives.

So, it was with that kind of a thing that we started the vaccination program. You know, when we were going year after year, India was growing at about 1% full vaccination every year. And it was consistent. So, I got together with a colleague of mine, who was my joint secretary then. And he came up with the idea. Why don’t we think about something different?

So, we started talking. We started discussing with many people. And we realized that the growth was not happening because a huge amount of children, about 40% of them in many districts in about 200 odd districts of India were not getting their first shot or were not getting the all the shots to call it full immunization.

So, we decided that we have a legacy of Polio Micro Plan. Let us use the micro plan in a few districts and see if we can identify who that child is. We started with this…..it was a huge success. We were able to actually identify, and we came up with a number that X number of children today between zero to 5 are not fully vaccinated and where they live. So that is how mission Indradhanush happened

So, then I conceptualized the whole thing as to how we will reach them. Of course, it has very interesting aspects to it and I can share it with the listeners. You know, when I took it first to government, they thought this won’t work. So, I was told you discuss it with this. Discuss it with that. Then there were some changes in the ministry, and I made another attempt. And then I was told if you think you can do it, do it. So, when we experimented it and got down to mission Indra-Dhanush Phase 1, where we said these are the children, let’s start locating them and do the entire immunization. It didn’t do well, do too well in the Phase 1.

So again, you know the government system, they start telling you… you unnecessarily get wasting everybody’s time and this etcetera. But by the time Phase 2 came. The mission took off so well … so well that all international bodies, including all the magazines British Medical Journal, Lancet. Everybody started writing that this is one of the most novel experiments that we are doing in reaching out to children. And then, of course, everybody else happy. Best achievements in terms of delivery, if we can vaccinate children well. We prevent a lot of morbidity and mortality. And therefore, a lot of expenditure on health in future.

Jesal Doshi

Absolutely. And as you rightly said, you know if….if as a country, if we can prevent every single death that we should….. absolutely that is preventable, we should absolutely make sure that we prevent those, and I think vaccination is ….is probably the single best investment out there to achieve that.

VOICE OVER

You’ve tuned in to the 6th episode of Badlaav for better. An Indian healthcare story.

Jesal Doshi

But talking a little bit about what I mentioned at the beginning about Bihar and eliminating polio from Bihar, that for a lot of us today, we may not even understand what is polio. Because it’s been eradicated from the country for so many years now. But why don’t you explain to us you know what it was? How big was the problem and how you went about solving it?

Mr. CK Mishra

You know that was the last phase of polio and polio cases were being reported in India only from UP and Bihar. So, the world, WHO and all other international organizations were after me when I was a health secretary there that… this is… this is something that you need to do. So, we tried to figure out where are we and we realized that it was only the Koshi region of Bihar where this problem existed. There was a problem of denial. There was a problem of nonacceptance and there was a problem of access and reach.

Jesal Doshi

So all of the problems put together.

Mr. CK Mishra

On the and so we, we converged on that area. And drew up a house-wise micro plan. It was so difficult because major part of the population who were missing out, you know, were mobile populations. They’re working here today. They go there tomorrow, so the vaccination gets discontinued. You will not believe it in 6 months. We were able to launch a campaign where our frontline health workers were riding buffaloes and other animals to cross streams to actually go and vaccinate, every bus stop had a vaccination program. Every train station had a vaccination program. And it was not the health department, Patna, which was doing. It was actually the frontline health workers of Koshi who took this course, they said. There’s a lot of confusion. We spoke to all religious leaders. And they made appeals continuously and finally, 6 months after that, we realized that we had actually done it. And when India did it, there was this sense of numbness that I felt. That I had some small part to play. Gives you so much happiness.

Jesal Doshi

I…. I cannot even fathom the happiness and the pride you would have, especially the way you described it. It seemed like it was a war, you know, to fall…..

Mr. CK Mishra

It was, you know, in a normal conventional war, you know the weapons here, you don’t know the weapons.

Jesal Doshi

Yeah, exactly.

And ….and when you describe it so vividly, you know to do micro family planning, to know exactly in which house how many people are there, how many children are there, they are there today. Tomorrow they are somewhere else and then to send people on buffaloes. As you said, I mean it’s nothing short of a heroic effort like a war.

Mr. CK Mishra

People responded like anything. And that was the core reason for success.

Jesal Doshi

Absolutely. And I think also unlike a war where, you know, your enemy is real it’s very tangible Something like polio is not so tangible, especially when there is a lack of awareness.

Mr. CK Mishra

Absolutely. I mean, only people who have suffered know it, others don’t. So you have to make sure that… that awareness is built in strongly into people’s mind so that you create that acceptance. And another thing I will tell you. In a rural setting. Even if one is not aware, but he sees a lot of activity on a particular thing, he gets excited and interested. And your job as an administrator is to capture that interest. And put it into the system.

Jesal Doshi

No, it’s… it’s fascinating, I’m sure. On behalf of the people of Koshi, I think we’re all very grateful to you and the team and the frontline workers who eventually made this happen.

Mr. CK Mishra

0! I am so grateful to them.

Jesal Doshi

Absolutely. I mean, I cannot imagine somebody sitting on a Buffalo carrying vaccines and trying to track down each and every person in some of the most rural parts of the country. But you know, you spoke several times about maternal health, child health. You spoke about IMR and MMR. And so. Where do you think today as a country, we can do more for our mothers and children?

Mr. CK Mishra

See, we have come a long way. And from a completely dismal position where we were being criticized by the rest of the world, we’ve come to a reasonably respectable position. We are still losing a lot of mothers and lot of kids. If you lose them because there is no option. You can’t do anything. But you are losing them when you have an option when you have a tool to save them. It’s tragic.

Jesal Doshi

Absolutely.

Mr. CK Mishra

So what we were really able to do and one of the biggest reason. That I always mention and the drop in MMR, IMR is our consistent improvement on institutional delivery. Today we are getting 90% of people into institutions for delivery. So,

A – The best possible care is being given and B – We know how to track them till the end. Not just that we are able to track all the kids who were born for vaccination. So, the entire MCH kit, so to say. Is very, very critical to, you know, you can spend a lot of money on tertiary care. If you ask me, and many people don’t agree with me. If you ask me. If the government has money, it should go into preventive promotive health. We need to invest in primary healthcare and what is the bullmark of Primary Health care?

Good maternal child health care which ensures that the mother survives. The child not only survives, but thrives. So you don’t have a future generation of sick people, so I would say that the policy dilemma before the country is do you want to just treat sick people and cure them if they can. Or do you want to invest in a system where you ensure that people do not get sick.

Jesal Doshi

It’s a very interesting thought that you mentioned because the way you described it, to me, it seemed like a no-brainer. And yet you mentioned it’s a dilemma and many people don’t agree with your view. Can you…Can you tell us why? Why do people think it’s better to treat sick people instead of avoiding getting them sick.

Mr. CK Doshi

I’ll tell you. There is a thinking that you need to provide health care when people actually need it. Now take Indian example, the health seeking behaviour is low. So, you get people only when they are sick or very sick, and you, as a government said that I will treat them. That is visible. That is a direct impact. So politically and otherwise speaking that gets you those eyeballs. If you carry on a low grade maternal child health campaign where you ensure that there are 3 ANC, when you ensure that Asha is going and giving the right pills. You ensure that the vitamin A supplement goes, you ensure that the delivery takes place in a good, you know, labour room. You ensure that hygiene is there, the nutrition is taken care of. These are not direct eyeball-catching things. And that, I think, is a policy dilemma.

One of the biggest success, let me tell you, that the country has had in healthcare over the last 3 decades or 4 decades is the National Health mission. And the reason for the success of National Health Mission was two-fold.

1. Its focus on maternal child health.

And B. It’s focused delivery with backed by resources. And that is why. I dare say. That since 2005, when it was launched, there’s been no change in the program, it’s only added a few extra chapters to it.

Jesal Doshi

And that’s the proof that one is looking for. As you said, you know a policy which is focusing on maternal and child health, which is focused on preventing sickness in the first place. I think that’s a great story since 2005, something that has been now built on over almost 2 decades and is continuing to grow in success.

Mr. CK Mishra

Yeah, every year new chapters are being added. New ideas are being added….. just growing. So that is a concrete investment into human lives. You’re making lives better.

Jesal Doshi

Absolutely

VOICE OVER

Aap sunn rahe hai Badlaav for better. A podcast by B Medical Systems saving lives through reliable and innovative technology. Jesal Doshi dwara hosted.

Jesal Doshi

Coming back to your,…..the point you were making about the politics behind policy-making and the fact that while a sound policy may be very sound, it may not appeal directly to voters and therefore to politicians. In this specific context, do you think COVID has changed that in… that now people are saying, look, I need to get healthier?

Mr. CK Mishra

I hope it has. If COVID hasn’t changed that, I don’t know what will. Because this was a direct attack on your life

Jesal Doshi

Absolutely

Mr. CK Mishra

And nothing threatens people or policymakers, more than losing lives. So, this should have happened. The learnings from COVID need to be carried on. But if you look at the entire scenario. I hope and pray that the investment levels continue to be the same. Health is given central….Health…

The biggest problem is that it is not a central issue of political discourse in India. And unless it becomes a matter of political discourse, it will not get the central tension that it deserves. We talk about population dividend. What dividend, if you have an unhealthy young generation. You will not get any dividend out of it. So, I think it’s time that health became central to all conversations.

Jesal Doshi

No, it’s very important that you know, health becomes the center of all conversations, the center of public discourse. And my hope personally is that through conversations with experts like you. We can at least start getting health into the mainstream conversation. And I’m sure that by listening to, you know your experience and your expertise, there will be a lot of people who will actually start thinking along these lines. I want to move into something totally different now. You, in addition to being secretary of the Ministry of Health, you were also Secretary of the Ministry of Environment, Climate Change and Forests. One of the very interesting topics at the intersection of both of these is One health. And for a lot of our listeners, it’s probably not something they hear often, can you.. Can you tell us a little bit about One health and what it means?

Mr. CK Mishra

Yeah. That I’m so happy that I had both the challenging positions I was part of it. You see. We were looking at health only, either from the human health angle or the animal health angle. Time has come. When we look at health as one entity. As everything that impacts health is a part of that one health policy. Health is not a stand-alone thing. You don’t get unhealthy because your body …….

There are various players around you, various things happening around you, which influence you. You need to take all that into account. And today, One health is one of the most critical issues before us. If we can address this, from the point of view of One health. Then we have a larger chance of success. And what Environment Ministry has taught me really is……is that the globe start needs to start talking about the intersection of climate and health

We are talking about health separately, climate separately. It’s time we put the 2 together. The intersection of climate and health resulting in one health policy is what we need for the group today.

Jesal Doshi

It’s fascinating. And tell us a little bit more about how climate change, in particular impacts health and One health.

Mr. CK Mishra

Let’s take climate change adverse impacts. You know climate, like any other disaster, impacts the vulnerable the most. The most vulnerable countries will get impacted. The most vulnerable populations will get impacted, so let me give you an example of a vulnerable women. If climate adverse impacts. Reduce availability of water. Can you imagine what impact will it have on women in the world ?

The way they’ll have to go further to carry water, the lesser water they will get, hygiene will reduce. I mean, you know, diarrheal deaths will increase. The other is heat. The more heat you will get. Worse off in healthy conditions, zoonotic diseases, everything is combined. It has… when climate impact is there on every part of your body. And they all react differently to climate change. If you have too much of rain and water logging you have different impact if you have no rain in a completely dry season, you will have a different impact. So, you have to really, really look at it that way.

Then you look at, let’s say the animal side. The way they are being impacted. It’s all interrelated. When you know, I used to tell everyone. But please be very careful. The viruses were contained in the animal Kingdom. You went too close. And you took that on yourself. Now you need to resolve this puzzle of who stays where and how. So, One health is a concept which whether one likes it or not, one will have to accept because that is the way to moving ahead in a healthy life.

Jesal Doshi

And you, you mentioned climate change like all other disasters, impacts are vulnerable the most. We all, today, acknowledge the impact of climate change. We see it happening on a daily basis. And yet I feel collectively as a world we are not doing enough to address climate change. Somewhere, do you believe because it impacts the vulnerable the most, that collectively we are unable to take decisive action?

Mr. CK Mishra

My own belief is that, the best action that the globe takes is when the voices that are heard are all around, here are voices that are subdued because they’re all vulnerable people. Small island nation, for example. The world is cognizant of the problem, so they talk about it. But since the voices do not create enough pressure, they don’t act on it. And these are completely different things. Look at the world today, the finances in the technology that has been promised by developing countries is nowhere to be seen.

Each country is left to fend for itself when it comes to climate change. So really the vulnerable today do not have a voice in the central marketplace, so to say. And somebody needs to work on that to give them a voice or the other side needs to you know…..clear its ears to listen to that voice. As long as that is happening, there will be a huge gap between what is professed. All those big meetings that we have today and what is implemented.

Jesal Doshi

So in a…. in a way it’s similar to, for example, COVID vaccination in Africa. Which clearly, you know, was one of the most vulnerable, but a voice which was not heard.

Mr. CK Mishra

Absolutely. I mean, if you look at anything. Look at routine immunization. Look at medicines. Look at generic drugs reaching equity has been the biggest problem. An equity is very often spoken about. But never really looked at for a solution. And unless you have equity in a program. You cannot do it, you know, it’s a strange thing that some countries say that we will be net zero by X period.

Does it help the world because the country next to it is not net zero? So even that country which claims to be net zero is going to be adversely impacted. So, it has to be a cross. I mean, there are cliches saying nobody should be left behind, etcetera, etcetera, and all global conversations are surrounded by it. I personally feel there is a lack of will to create that micro plan which will actually implement.

Jesal Doshi

It’s interesting you’re talking about a micro plan for climate change. That’s not something that would seem very intuitive at first. But I think you’re spot on, when you talk about equity, I think. One of the areas where India has done remarkably well on equity is COVID. In terms, especially in terms of vaccination, right to ensure that no one is left behind. If you were to sort of apply a similar lens to India’s fight against climate change, how would you rank India?

Mr. CK Mishra

Why just COVID even the routine immunization in India is a shining example of equity to the world.

Jesal Doshi

Absolutely.

Mr. CK Mishra

Let me narrate a story to you. It was, I think, 2010. If I am not mistaken, 10 or 11. Mr Bill Gates came to Bihar. And said that I want to see some far-flung areas, backward areas where immunization has or has not been done. And he while we were flying in the chopper, the 2 of us were together and he mentioned to me that, you know, I have heard that certain populations do not get these doses. So, we landed in a very far-flung area, crossed the river on a boat which used to ferry sand. We sat on the sand and went to the other side. And will you believe it?

Every house he went to, the children had been vaccinated.

Jesal Doshi

Wow

Mr. CK Mishra

That is equity. And India has been a shining example of that. And we again proved it during COVID. But coming back to climate, the current discourse on climate change is to a great extent limited to energy transition. An energy transition is a slightly remote subject as far as the underprivileged and the marginalized are concerned. We are yet to draw plans for them. And I would think that would really begin to happen when we have a district-level plan for adaptation.

Jesal Doshi

Right.

Mr. CK Mishra

Mere mitigation plans are not going to help. We need to focus on adaptation in our rural areas so that the underprivileged, who are not to be left behind, are actually brought into the sea.

Jesal Doshi

And do you think it’s only a matter of time before that happens?

Mr. CK Mishra

Should happen. I see no reason why it will not happen. And to be very honest in this entire flight in climate change space that is going on across the globe. India has been singularly ahead of others. This is one country which is doing really well, so there is no reason. Why it should not be looking at equity sooner than others do.

Jesal Doshi

No, I think it’s a matter of great pride for us and these are things that not all of us know, but it’s fantastic, hearing it from the person who’s made it happen, Mr Mishra, I would love to continue, but we are running short on time, so I would like to end with one question. You’re role model for millions of aspirants in our country who are applying, who would like to join the Indian Administrative services, what would your advice be to those millions of young people out there?

Mr. CK Mishra

Very difficult to pontificate, you know, but. I would say don’t get into the service with the overcrowded, clogged mind. Go with an open mind. Make the best of every opportunity you get. And don’t do things only because you’re supposed to do it and being paid for it. Enjoy whatever you do. As long as. You enjoy. You will do a good job.

Jesal Doshi

Fantastic words coming from the man who’s helped eradicate polio in India, whose helped fight COVID in India, whose helped India’s fight against climate change. Mr. Mishra, thank you so much, Sir, for your valuable time. This has indeed been a true honour for us.

Mr. CK Mishra

It was such a pleasure, such a pleasure. Thank you. So much thank you.

Jesal Doshi

Thank you.

You were listening to Badlaav for better. An Indian healthcare story, a podcast by B Medical Systems. Saving lives through reliable and innovative technology. Hosted by Jesal Doshi.