aid stagnation, shifting disease burdens, and the sdgs · 3.1 reduce global maternal mortality...

Aid Stagnation, Shifting Disease Burdens, and the SDGs:

How Will Global Health Meet the Challenges?

Gavin Yamey MD MPH

Professor of the Practice of Global Health & Public PolicyDirector, Center for Policy Impact in Global Health

Associate Director for Policy, Duke Global Health Institute

July 4, 2016

Editorial: wjm, PLOS Medicine, PLOS NTDsJournalism: KFF Global Health Reporting Fellow

Policy research: Evidence to Policy initiative (E2Pi), UCSFTeaching: Global health policy

This is my 7th Geneva trip

Aims of the course

3 key lenses:

- transitions

- SDGs

- GH2035

What will it take to reach GH2035 goals?

How the course addresses post-2015 challenges

Agenda

Aims of the Course: the 4Cs

CRASH COURSE• Global health landscape: actors, architecture,

governance, financing• Evolution of our global health challenges:

what lies ahead• Policy options for the next era and beyond

CONTEXT• Where do the Geneva-based global health

organizations fit into this picture?• What role do they play in meeting the health

needs of the world’s most vulnerable people?

CONNECTIONS • Build personal networks of friends, colleagues, and mentors

CURIOSITY • Ask questions of the world’s leading voices in global health

Aims of the course

3 key lenses:

- transitions

- SDGs

- GH2035



Agenda

1993-2013: Extraordinary Health Progress

Female life expectancy at birth for select countries compared to the frontierThe frontier line indicates female life expectancy in the best-performing country in that year, which has been Japan for the past 20 years.

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035

MDGs Were Catalytic

“Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action”

Murray CJ et al, Lancet 2014, Jul 21


Unprecedented Mobilization of Aid for Health

Figure from Financing Global Health 2013, IHME


Scientific Innovations Played a RoleLens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035

1993-2013: Extraordinary Economic Progress

Movement of populations from low income to higher income between 1990 and 2011


Epidemiological & demographic

Financing

Governance

MDGs to SDGs

1

2

3

4


The MDGs: Simplicity and Clarity


The 17 SDGs: An Expansive Agenda


SDG 3: The Global Health Goal

“Ensure healthy lives and promote wellbeing for all at all ages”


9 TARGETS

4 MEANS OF IMPLEMENTATION

SDG 3: Targets and Approaches


3.1 Reduce global maternal mortality ratio to under 70 per 100,000 live births 3.2 End preventable deaths of newborns and under-five children 3.3 End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases 3.4 Reduce by one-third pre-mature mortality from NCDs3.5 Strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.6 Halve global deaths and injuries from road traffic accidents 3.7 Ensure universal access to sexual and reproductive health care services3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all 3.9 Substantially reduce number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination

SDG 3: The Nine Targets (2030 End Date)Numeric targets

Zero targets


SDG 3: The 4 Means of Implementation

3.a Strengthen implementation of Framework Convention on Tobacco Control 3.b Support R&D of vaccines and medicines for the communicable diseases/NCDs that primarily affect developing countries, provide access to affordable essential medicines and vaccines, provide access to medicines for all 3.c Increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS 3.d Strengthen capacity of all countries, particularly developing countries, for early warning, risk reduction, and management of national and global health risks


Global Health 2035: WDR 1993 @20 Years

The World Bank’s World Development Report 1993

• Evidence-based health expenditures are an investment not only in health but in economic prosperity

• Additional resources should be spent on cost-effective interventions to address high-burden diseases

The Lancet Commission on Investing in Health (chaired by Lawrence Summers and Dean Jamison)

• Re-examines the case for investing in health

• Proposes a health investment framework for low- and middle-income countries

• Provides a roadmap to achieving dramatic gains in global health by 2035


2015-2035: Three Domains of Health Challenges

High rates of avertable infectious, child, and

maternal deaths

Unfinished agenda

Global shift towards non-communicable diseases

(NCDs) and injuries

Emerging agenda

Impoverishing medical expenses, unproductive

cost increases

Cost agenda


Global Health 2035: 4 Key Findings

The returns from investing in health are extremely impressive

A grand convergence in health is achievable within our lifetime

Fiscal policies are a powerful, underused lever for curbing non-

communicable diseases and injuries

Pro-poor pathways to universal health

coverage are an efficient way to achieve health

and financial protection


Aims of the course

3 key lenses:

- transitions

- SDGs

- GH2035



Agenda








The Global Health 2035 Goals

Two Centuries of Divergence; ‘4C Countries’ Then Converged

1750 1800 1850 1900 1950 2000

01

00

200

30

04

00

Under-five mortality, China and Sweden, 1751-2008

Year

5q0

pe

r 1

,00

0 liv

e b

irth

s

Sweden

China

Gap between China and Sweden

Now on Cusp of a Historical Achievement:Nearly All Countries Could Converge by 2035

Convergence to Which Countries?

Diverse group of middle-income

countries showed the way

Previously had high death rates

Low- or lower middle-income in

1991

Achieved high level of health status by

2011 largely because of scale-up of health sector interventions

“4C Countries”

Costa Rica, Cuba, Chile, China

We show that nearly all countries could

reach the same health status by

2035

Strategy 1: Aggressive Scale-Up of Today’s Tools

Accelerated scale-up of coverage

Global Investment Framework for Women's & Children's Health

• RMNCH, including family planning, pregnancy-related interventions, safe abortion and complications, and maternal nutrition

• HIV• Malaria• Tuberculosis• Neglected tropical diseases

Strategy 2: Strengthen Health Delivery Systems

Photo: GAVI, the Vaccine Alliance

Strategy 3: Develop Tomorrow’s Tools

Factors Accounting for Decline in Child Mortality, LICs and MICs, 1970-2000

Jamison, Murphy, Sandbu. Why Has Under-5 Mortality Decreased at Such Different Rates inDifferent Countries? Health Economics 2016;48:16-25

Impact and Cost of Convergence

Low-income countries Lower middle-income countries

Annual deaths averted from 2035 onwards

4.5 million 5.8 million

Approximate incremental cost per year, 2016-2035

$25 billion $45 billion

Proportion of costs devoted to structural investments in health system

60-70% 30-40%

Proportion of health gap closed by existing tools (rest closed by new tools)

2/3 4/5

New Global Map of Disease: “Pockets of Poverty”

Under-5 deaths in rural versus urban India

Convergence Has Impressive Benefit: Cost Ratio

“Further proof that improvements in human

survival have economic value well beyond their direct links

to GDP”

Jim KimWorld Bank President

Sources of Income to Fund Convergence

Economic growth

• IMF: low- and lower middle-income countries to add $9.6 trillion/y to GDP from 2015-2035

• Cost of convergence ($70 billion/y) is about 1% of anticipated growth

Mobilization of domestic resources

• Taxation of tobacco, alcohol, sugar, extractive industries

Inter-sectoral reallocations and efficiency gains

• Removal of fossil fuel subsidies, health sector efficiency

• Subsidies account for 6.5% of global GDP

Development assistance for

health

• Will still be crucial for achieving convergence

• Health aid will need to evolve to support global functions








The Global Health 2035 Goals

Single Greatest Opportunity To Curb NCDs is Tobacco Taxation

50% rise in tobacco price from tax increases in China

prevents 20 million deaths + generates extra $20 billion/y in next 50 y

additional tax revenue would fall over time but would be higher than current levels even after 50 y

largest share of life-years gained is in bottom income quintile

Essential Package of Clinical Interventions

WHO “best buys”

NCD Intervention

Liver cancer Hepatitis B vaccine

Cervical cancer VIA and treatment of pre-cancerous lesions

CVD and diabetes Counselling and multi-drug therapy for high-risk patients

Heart attack Aspirin

We Recommend Scale-up in All Countries

Cost-effective

80% coverage by 2020 would avert 37% of global burden of cardiovascular disease

Low coverage

Except for hepatitis B vaccine, very low coverage across LICs/MICs

Feasible

1st step for all countries; costs $9bn/y; we argue that HPV

vaccine & morphine should be included

Phased Expansion Pathways

Choice of packages and expansion pathway will vary with pattern of disease, delivery capacity, domestic health spending

Sudden Price Drops Affect Expansion Pathway

For drugs, diagnostics, and vaccines, which can usually be delivered without complex infrastructure, price reductions can sometimes occur very rapidly

Price drop might be large enough for intervention to be used earlier in expansion pathway

Price

Our Recommendation on UHC:Pro-Poor Pathway (Blue Shading)

+ essential package for NCDIs

Benefits to Countries of Adopting Pro-Poor UHC

1 • Poor gain the most in terms of health and financial risk protection

2 • Approach yields high health gains per $ spent

3 • Public money is used to address negative externalities of infectious disease transmission

4 • Implementation success in many low- and middle-income countries has shown feasibility

Aims of the course

3 key lenses:

- transitions

- SDGs

- GH2035



Agenda








Lecture: Women’s, Children’s and Adolescents’ Health in the SDG eraSite visits: Global Fund, GAVI, WHO SHOC room, FIND & MMVPolicy competition: malaria vaccine

Lecture: Global health financing

Lecture: Global mental healthPanels: Tobacco control, violence and injuries

Panel: UHC

COURSE ROADMAP1








COURSE ROADMAP2

Cross-cutting issues: governance, trade, humanitarian intervention

Panel: Governance for global healthSite visits: MSF, WTO

Thank [email protected]

@gyamey

GlobalHealth2035.org

#GH2035@globlhealth2035

aid stagnation, shifting disease burdens, and the sdgs · 3.1 reduce global maternal mortality...

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