Christopher J.L. Murray Richard Saltonstall Professor of Public Policy

Harvard University Initiative for Global Health

Christopher J.L. Murray

Richard Saltonstall Professor of Public Policy

Director, Harvard University Initiative for Global Health

Lecture 26: Challenges and Opportunities


OUTLINE

Review of Global Health Challenges

Nine Policy Opportunities


050

100150

200250

300350

400450

500550

600650

700750

800850

0 25 50 75 100 125 150 175 200 225 250 275 300 325Child Mortality (5q0 per 1000 live births)

Ad

ult

Mo

rtal

ity

(45q

15 p

er 1

000)

Adult vs. child mortality, males, 191 Member States, 2000

050

100150

200250

300350

400450

500550

600650

700750

800850

0 25 50 75 100 125 150 175 200 225 250 275 300 325Child Mortality (5q0 per 1000 live births)

Ad

ult

Mo

rtal

ity

(45q

15 p

er 1

000)

Adult vs. child mortality, males, 191 Member States, 2000


Neoplasms

Diabetes mellitus

Nutritional/ endocrine disorders

Infectious and parasitic diseases

Respiratory infections

Maternal conditions

Perinatal conditions

Cardiovascular diseases

Sense organ disorders

Neuropsychiatric disorders

Congenital abnormalities

Unintentional injuries Intentional

injuries

Respiratory diseases

Digestive diseases

Diseases of the genitourinary

system

Skin diseases

Oral diseases

Musculoskeletal diseases

Nutritional deficiencies

Global Burden of Disease, 2002Global Burden of Disease, 2002


Leading Causes of the Global Burden of Disease 2002

1. Perinatal conditions 6.5

2. Lower respiratory infections 6.1

3. HIV/AIDS 5.7

4. Depression 4.5

5. Diarrhoeal diseases 4.2

6. Ischaemic heart disease 3.9

7. Cerebrovascular disease 3.3

8. Malaria 3.1

9. Road traffic accidents 2.6

10. Tuberculosis 2.3

DALYs%

Source: World Health Report, 2004Source: World Health Report, 2004


Attributable Disease Burden of 20 Risk Factors

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0%

Underw eight

Unsafe sex

High blood pressure

Tobacco

Alcohol

Unsafe w ater, sanitation, and hygiene

High cholesterol

Indoor smoke from solid fuels

Iron deficiency

High BMI

Zinc deficiency

Low fruit and vegetable intake

Vitamin A deficiency

Physical inactivity

Occupational risk factors for injury

Lead exposure

Illicit drugs

Unsafe health care injections

Lack of contraception

Childhood sexual abuse

Attributable DALY (% of global DALY - Total 1.46 billion)

High-mortality developing

Lower-mortality developing

Developed


0

5

10

15

20

25

30

35

1975 1980 1985 1990 1995 2000 2005

Year

% o

be

se

USA

Australia

Korea

New Zealand

England

Trends in Measured ObesityTrends in Measured Obesity


SWEDEN

Val

ue

Year1750 1775180018251850187519001925195019752000

0

0.1

0.2

0.3

0.4

0.5

Male 5q0Female 5q0

Val

ue

Year1750 177518001825185018751900192519501975 2000

0

0.2

0.4

0.6

0.8

1

Male 45q15Female 45q15

Two and A Half Centuries of Mortality DeclineTwo and A Half Centuries of Mortality Decline


Distributions of median deaths forecasted by a replay of the 1918-20 pandemic in the year 2004 by region and age-group

62.1 Million Global Deaths


Total Developing 402; 13%

Global Expenditure on Health, 2002 (US$ Billions)Total: 3,224


Health Adjusted Life Expectancy X Per Capita Total Health Expenditure (I$)

20.0

30.0

40.0

50.0

60.0

70.0

80.0

10 100 1000 10000

Per Capita Total Health Expenditure - 2001 Estimation (I$)

Healt

h A

dju

ste

d L

ife E

xp

ecta

ncy -

2002 E

sti

mati

on

(Y

ears

)

Sao Tome & Prince

GeorgiaCuba

JapanMalta USA


OUTLINE

Review of Global Health Challenges

Nine Policy Opportunities


Two key components of the global control policy: Two key components of the global control policy:

Artemesin combination therapy (ACT) substitution for Artemesin combination therapy (ACT) substitution for choloquine in national control programscholoquine in national control programs

Insecticide treated bednets that reduce child mortality Insecticide treated bednets that reduce child mortality 20% in endemic areas. 20% in endemic areas.

Long-acting 3-5 year bednets cost $5. Long-acting 3-5 year bednets cost $5.

Coverage for both is very low.Coverage for both is very low.

1. Promote Insecticide Treated Bednets to Reduce Child Mortality from Malaria


Percent of Children under 5 who slept under an ITN the night before the survey, 1999-2005

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Benin

Burkina F

aso

Cam

eroon

Eritrea

Guinea

Ghana

Kenya

Malaw

i

Mali

Mauritania

Niger

Nigeria

Senegal

Sw

aziland

Togo

Uganda

Tanzania

Zam

bia

country

%

1999-2001

2003-2005


When DOTS and ARV programs are founded on When DOTS and ARV programs are founded on principles of free care for the patient, ITNs distribution principles of free care for the patient, ITNs distribution should also be free. should also be free.

Experience with voucher programs in Tanzania and other Experience with voucher programs in Tanzania and other social marketing strategies should be evaluated. social marketing strategies should be evaluated.

Effective strategies for increasing distribution and uptake Effective strategies for increasing distribution and uptake should be developed and scaled. should be developed and scaled.

More Aggressive ITN Programs


Since 1991 global tuberculosis control (called DOTS) is Since 1991 global tuberculosis control (called DOTS) is focused on detecting symptomatic cases that present focused on detecting symptomatic cases that present to public facilities using sputum microscopy for to public facilities using sputum microscopy for diagnosis and institution of directly observed short-diagnosis and institution of directly observed short-course treatment. course treatment.

The DOTS strategy has been successful and improving The DOTS strategy has been successful and improving treatment outcomes in the smear-positive cases that treatment outcomes in the smear-positive cases that are detected. are detected.

There has been little progress at increasing the case-There has been little progress at increasing the case-detection rate over the last fifteen years. detection rate over the last fifteen years.

2. Increase the Case Detection Rate for Tuberculosis


WHO Global Tuberculosis Report 2006WHO Global Tuberculosis Report 2006


Half of tuberculosis cases do not get detected and 50% of Half of tuberculosis cases do not get detected and 50% of these individuals go on to die from the disease. these individuals go on to die from the disease.

Innovative strategies to actively identify tuberculosis Innovative strategies to actively identify tuberculosis cases in the community need to be tested in different cases in the community need to be tested in different cultural and epidemiological settings. cultural and epidemiological settings.

Resources to support active case-finding need to be Resources to support active case-finding need to be included in applications to the Global Fund for AIDS, included in applications to the Global Fund for AIDS, Tuberculosis and Malaria and other funders. Tuberculosis and Malaria and other funders.

Active Case-Finding


Many new technologies to reduce child mortality -- Many new technologies to reduce child mortality -- vitamin A supplementation, zinc supplementation, vitamin A supplementation, zinc supplementation, rotavirus vaccine, pneumococcal vaccines, others. rotavirus vaccine, pneumococcal vaccines, others.

WHO strategy to deliver child survival technologies for the WHO strategy to deliver child survival technologies for the last decade based on Integrated Management of last decade based on Integrated Management of Childhood Illness protocols emphasize services Childhood Illness protocols emphasize services delivered to sick children coming to public clinics.delivered to sick children coming to public clinics.

IMCI Evaluations in Brazil, Peru, Uganda, and IMCI Evaluations in Brazil, Peru, Uganda, and Bangladesh show that less than 20% of sick children Bangladesh show that less than 20% of sick children are taken to public clinics. are taken to public clinics.

3. Develop and Test New Service Delivery Models for Child Survival Interventions


Top Ten Interventions to Reduce Global Child Mortality

Percent of Remaining Child Mortality That Can be Prevented

Oral rehydration therapy 15%

Breastfeeding 13%

Insecticide-treated materials 7%

Complementary feeding 6%

Antibiotics for sepsis 6%

Antibiotics for pneumonia 6%

Zinc 5%

Antimalarials 5%

Clean Delivery 4%

Hib Vaccine 4%

Source: Jones G, et al. The Lancet, vol 362


UNICEF, Gates Foundation, Government of Norway UNICEF, Gates Foundation, Government of Norway bringing renewed attention to the reducing child bringing renewed attention to the reducing child mortality in poor countries. mortality in poor countries.

Strategies to reach out and deliver effective technologies Strategies to reach out and deliver effective technologies to children who would not otherwise go to public to children who would not otherwise go to public facilities need to be developed and tested. facilities need to be developed and tested.

Reality of severe shortages of trained health workers Reality of severe shortages of trained health workers must factor into the development of these strategies. must factor into the development of these strategies.

Taking Advantage of a New Focus on Child Survival


Many high-income countries have dramatically reduced Many high-income countries have dramatically reduced road traffic fatalities through road design, seatbelt road traffic fatalities through road design, seatbelt enforcement, airbags, traffic calming, speed limits, enforcement, airbags, traffic calming, speed limits, alcohol breath testing.alcohol breath testing.

Some Eastern European countries and nearly all Some Eastern European countries and nearly all developing countries have not adopted this package developing countries have not adopted this package of interventions or have not invested in their of interventions or have not invested in their enforcement. enforcement.

Many components of the policy package are not costly. Many components of the policy package are not costly.

4. Reduce Deaths from Road Traffic Accidents Through Proven Policies


Road Traffic AccidentsAge-standardized death rate (per 100,000)

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000

Year

AS

DR

(p

er 1

00,0

00)

Australia

Greece

USA


Depression, bipolar disorder and schizophrenia cause a Depression, bipolar disorder and schizophrenia cause a significant burden of disease.significant burden of disease.

Up to 20% of the burden can be addressed using Up to 20% of the burden can be addressed using pharmacological interventions in primary care settings. pharmacological interventions in primary care settings.

Cost per year of life saved is affordable in all middle-Cost per year of life saved is affordable in all middle-income and some low-income countries. income and some low-income countries.

5. Introduce Community Treatment of Depression and Psychosis in Developing

Countries


Global Burden Due to Mental Health Disorders,2002

76%

2%

7%

4%

13%

6%2%

3% Other

HIV

TB

Malaria

Avertable Neuropsychiatric

Non-Avertable Neuropsychiatric

Neuropsychiatric Not studied


Large and growing burden of cardiovascular diseases in Large and growing burden of cardiovascular diseases in developing countries. developing countries.

Western management model for CVD too costly.Western management model for CVD too costly.

No policy attention in most countries – still focused on No policy attention in most countries – still focused on maternal and child health agendamaternal and child health agenda

International organizations, NIH and Gates Foundation International organizations, NIH and Gates Foundation not investing in solutions for CVD.not investing in solutions for CVD.

6. Use the Polypill to Reduce Cardiovascular Mortality in Developing Regions by Half


Developing Country CVD Epidemic Getting Worse

• 11.4 million deaths in 2000 – projected 60% increase by 2020

Developed30%

South Asia29%

East Asia20%Other

developing21%

Global burden of cardiovascular disease*


The polypill aka “The Little Red Heart Pill”

aka“The risk pill”

– Statin, low-dose aspirin & blood pressure drugs

– 65% reduction in heart attack & stroke risk

– Very safe and tolerable– ~$20 per person per year


17.5%

12.3%9.2%

25.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

No Rx BP BP+Chol BP+Chol+Asp

Treatments

How the polypill reduces cardiovascular risk by 65% ?

Ch

ance

of

dev

elo

pin

g h

eart

at

tack

or

stro

ke

30%

30%

25%

Overall 65%


Many households face catastrophic health spending Many households face catastrophic health spending which often pushes them below the poverty line. which often pushes them below the poverty line.

Catastrophic spending is due to the triad of low-income, Catastrophic spending is due to the triad of low-income, high service availability and a failure of risk protection high service availability and a failure of risk protection mechanisms (insurance or tax-based financing).mechanisms (insurance or tax-based financing).

7. Prevent Catastrophic Health Spending Through Expanding Social Insurance


.01

.03

.11

38

15

%

of h

hs w

ith c

ata

stro

phi

c e

xp.

(loga

rith

m)

5 10 20 40 60 80 100

% of OOP in total health exp.(logarithm)

Proportion of households with catastrophic expenditures vs. share of out-of-pocket payment in total health expenditure


Seguro Popular enacted May 2003Seguro Popular enacted May 2003

Extends insurance coverage to the 50% of population Extends insurance coverage to the 50% of population who were uninsuredwho were uninsured

7 year phase-in7 year phase-in

Basic package of services includes 91 interventionsBasic package of services includes 91 interventions

Mexico Extends Insurance Coverage to the Entire Population


Probability of incurring catastrophic expenditures for households using health services with 95% CI, controlling for socio-demographic and economic characteristics, according to six different measures


Little comparable information on inputs, outputs, Little comparable information on inputs, outputs, outcomes and efficiency of public health and outcomes and efficiency of public health and medicine. medicine.

Huge variation in the relationship between inputs and Huge variation in the relationship between inputs and outputs. outputs.

Credible, comprehensible and comparable information on Credible, comprehensible and comparable information on health systems is an essential ingredient for creating health systems is an essential ingredient for creating accountability.accountability.

8. Measure Health System Efficiency and Performance


Effective Coverage of Health Interventions By State, 2005/6Effective Coverage of Health Interventions By State, 2005/6


Health System Coverage vs. Total Health Expenditure per Capita (2003)

Ukraine

Swaziland

Chad

Malawi

0%

10%

20%

30%

40%

50%

60%

70%

80%

10 100 1000 10000

Health Expenditure per Capita

Co

mp

os

ite

Co

ve

rag

e


Worst-off groups in US, UK, Australia, and other Western Worst-off groups in US, UK, Australia, and other Western countries have persistently bad health outcomes. countries have persistently bad health outcomes.

New health knowledge and interventions are nearly New health knowledge and interventions are nearly always used by better off groups more than the always used by better off groups more than the disadvantaged. disadvantaged.

UK, Canada and other countries are trying to reduce UK, Canada and other countries are trying to reduce health inequalities by tackling poverty and other health inequalities by tackling poverty and other broader social determinants.broader social determinants.

9. Reduce Persistent Health Inequalities Using Incentives to Manage Known Risks


Life Expectancy for the Eight Best and Worst US Counties, Males

55

60

65

70

75

80

85

1980 1985 1990 1995 2000

Year

Lif

e e

xp

ec

tan

cy

at

bir

th


Effective coverage of anti-hypertensives, statins, and Effective coverage of anti-hypertensives, statins, and other risk management interventions is significantly other risk management interventions is significantly lower in disadvantaged groups. lower in disadvantaged groups.

Financial and other incentives can work to influence Financial and other incentives can work to influence behaviour of providers and individuals. behaviour of providers and individuals.

We should explore the use of these incentives to increase We should explore the use of these incentives to increase effective coverage of effective interventions. effective coverage of effective interventions.

Incentives and Targeted Risk Reduction


Passion for finding ways for the 5 billion in the world with poor health to catch up and keep up with the 1 billion with good health.

Scepticism for all claims about the magnitude of health problems or the effectiveness of solutions.

Systematic analysis of the evidence on problems, potential solutions, system barriers and political/economic dimensions.

Optimism that in our lifetimes it will be possible to make extraordinary progress on global health.

Four Themes For Tackling Global Health

Documents

Christopher J.L. Murray Richard Saltonstall Professor of Public Policy