Introduction to Global HealthIntroduction to Global Health

September 30, 2011September 30, 2011

Amira Roess, PhD, MPHGW SPHHS, Dept Global Health

Slides adapted from Introduction to Global Health and Development i h d Sk l ik i C l iLectures, Richard Skolnik, Dr, Uriyoan Colon‐Ramos, Dr. Amira Roess, 

Tova Reichel, Dr. Victor Barbeiro and from UN, USAID, UNAIDS written material

Learning objectivesLearning objectives

At the end of this lecture you should understand:• The key actors in global health and the manner in which they can cooperate to address critical global health issues.health issues.

• Key public health concepts, including: – the demographic and epidemiological transitions, the burden of diseaseburden of disease 

– the determinants of health and risk factors for conditions of importance to global health. th b d f di i i i f th ld h– the burden of disease in various regions of the world, how it varies both within and across countries, and how the disease burden can be addressed in cost‐effective ways.

Life ExpectancyProgress Or Problems?

85

95

2015

2050Polio Eradicated/Certified (2010??)

45

75

85

1900

1980

2015

Penicillin Mass-Produced 1944Smallpox Eradicated 1979

35

45

PreHist

1789

1900 Penicillin Mass Produced 1944

Malaria (Ross/Manson/Grassi - Late 1800s)

18

0 20 40 60 80 100

PreHist

Y f Lif E tYears of Life Expectancy

Regonal trends in life expectancy

80

90

2000

70

s

N. America

Europe

50

60

Yea

rs p

L. America Impact of HIV??Impact of HIV??

40

50

Asia

Africa

301925 1950 1975 2000 2025 2050

Source: United Nations 2008 Population Council

Population/Family Planningh lThe Development Imperative

7

8T O T A L L D C D C

4

5

6

ns o

f Peo

ple

2

3

Bill

ion

0

1

1 9 5 0 1 9 6 0 1 9 7 0 1 9 8 0 1 9 9 0 2 0 0 0 2 0 1 0 2 0 2 0

The Demographic TransitionThe Demographic Transition

The Epidemiologic TransitionThe Epidemiologic Transition

~2005

Approximately 10.6 Million Children Die Annually (~70% From 5 Major Causes)From 5 Major Causes)

Malaria10% Pneumonia

UNICEF 2007 estimates 9.7 millionUNICEF 2007 estimates 9.7 million

18%Congenital

4%Measles

5%Other17%

DiarrheaInjuries

Malnutrition 56%

15%

HIV/AIDS3%

j3%

Birth TraumaBirth TraumaNeonatal DeathsNeonatal Deaths

Perinatal25%

3% TetanusTetanusFeverFeverLow Birth WeightLow Birth WeightSource: Lopez, et. al., 2006

How does the global community respond?

How does the global community respond?

Millennium Development Goals

See UN reports for more detailshttp://www.un.org/millenniumgoals/bkgd.shtmlhttp://www.mdgmonitor.org/

Why the MDGs ?y

The 1990s: a decade of faltering progressprogress continued

… but too slowly to reach agreed targets

… and slowing down d li Under‐5 mortality rate

Maternal mortality rate

Child malnutrition

Water and sanitation

Income poverty

Primary education

MDGsMDGs are are meantmeant to to accelerateaccelerate progressprogress

MDGs were set by all Government leaders at theUN Millennium Summit, September 2000)

All UN organisations decided to be guided byMDGs in their future action: unity of purpose,coherent action synergies and strategic approachescoherent action, synergies and strategic approachesby the UN system as a whole (guided by CEB)

Leaders pledged to strive individually andLeaders pledged to strive, individually andcollectively, towards these goals throughinternational, regional and national action,

d b hconcerted by the UN.

MDGs are a combination ofMDGs are a combination of … 

Millennium Goals …– Emanate from UN Summits and Conferences of the 1990s…– … proposed in the UN Secretary‐General’sMillennium Report: 

« We, the peoples: the role of the United Nations in the 21st century »century

– … and endorsed in the United Nations Millennium Declaration (8 September 2000)

7 areas explicitly addressed in the Millennium Declaration:• Peace, security and disarmament• Development and poverty eradication• Protecting our common environment

Development goals& targetsProtecting our common environment

• Human rights, democracy and good governance• Protecting the vulnerable

M ti th i l d f Af i

g

• Meeting the special needs of Africa• Strengthening the United Nations

… and of International Development Goals… and of International Development Goals (IDGs)

F l f th k ifi i di t• For several of these key areas, specific indicators were included in the Millennium Declaration – constituting the international development goals (IDG)

• Subsequently, IDGs from other declarations were combinedSubsequently, IDGs from other declarations were combined and harmonised with the IDGs set in the Millennium Declaration goals

• The resulting set of goals, numerical targets and quantifiable indicators to assess progress constitute thequantifiable indicators to assess progress constitute the Millennium Development Goals… 

• … presented in the SG’s “Road map towards the implementation of the United Nations Millenniumimplementation of the United Nations Millennium Declaration” (September 2001)

Millennium Development GoalsMillennium Development Goals

1 Eradicate poverty and hunger1. Eradicate poverty and hunger

2. Universal education

3. Gender equality and equity

4. Reduce child mortality & infectious diseases

5. Reduce maternal mortality

6 Combat HIV/AIDS6. Combat HIV/AIDS

7. Ensure environmental stability

8. Global partnership for development

What makes up the “global p gcommunity”?

ActorsHealth governance model

State:Policymakers

Private ProvidersClients/Citizen

Adapted from: Brinkerhoff – RTI International Governance Presentation. USAID Mini University 2007

UNUNAIDS

BilateralAustralian AID

UNDPUNFPAUNICEF

Canadian IDADanish IDADept Intl. Dev UK

WHO Dutch AD CoopNorwegian AD CoopUSAID

MultilateralAfrican Development Bank (DB)

NGOCARECatholic Relief Services

FoundationsAga Khan Gates Foundation

Asian DBInter-American DBWorld Bank

Doctors without BordersSave the ChildrenPartners in Health

Clinton Foundation Rockefeller…

International Health ProgramsGlobal Alliance for Vaccines and Immunization (GAVI)Global Alliance for Vaccines and Immunization (GAVI)

Global Fund to Fight Against AIDS, TB, MalariaTropical Disease Research Program

UN Health‐Related Organizations

1 WHO 8 UN High Commission for1. WHO

2. World Bank

3 UN Children’s Fund

8. UN High Commission for Refugees (UNHCR)

9. International Labor 3. UN Children s Fund 

(UNICEF)

4 UN Population Fund

Organization (ILO)10. UN Environment Program

4. UN Population Fund (UNFPA)

5 UNESCO

11. UN Fund for Drug Abuse Control

12 Standing Committee5. UNESCO

6. FAO

7 World Food Program

12. Standing Committee Nutrition (UNSCN)

7. World Food Program

Source: Merson, et. al., pg 670

Host Governments (first and foremost)Host Governments (first and foremost)

• Ministry of Health and Social WelfareMinistry of Health and Social Welfare

• Ministry of Finance

i i f d i• Ministry of Education

• Ministry of Labor

• Office of the President/Prime Minister

• OthersOthers…

Six WHO Regions…

• Note that the WHO regions are not the same as those of the United Nations• Note that the WHO regions are not the same as those of the United Nations.

• EMRO – Eastern Mediterranean Regional Office (green)

• WPRO – Western Pacific Regional Office (dark red)

• SEARO South East Asian Regional Office (dark blue)• SEARO – South East Asian Regional Office (dark blue)

• AFRO – Africa Regional Office (cream)

• PAHO – Pan American Health Organization (red)

• EURO/WHO European Regional Office/World Health Organization (Geneva) (blue)• EURO/WHO – European Regional Office/World Health Organization (Geneva) (blue)

U.S. System for Global Cooperationy p

• United State Agency for International Development (USAID)p ( )– US foreign assistance agency.

– Economic growth, agriculture, trade.Economic growth, agriculture, trade.

– Global health (HIV/AIDS, Nutrition, International Development, etc). p , )

– Democracy, conflicted prevention, humanitarian assistance.

U.S. System for Global Cooperationy p

• Centers for Disease Control and Prevention (CDC)Clinical expertise: Disease and outbreak–Clinical expertise: Disease and outbreak control

M it d t t d t h–Monitor, detect, conduct research.

–Develop, advocate, implement

–Applied research

U.S. System for Global CooperationU.S. System for Global Cooperation

• National Institutes of Health – Fogarty• National Institutes of Health – Fogarty International Center (NIH)– Scientific Research and Training US and international

–AIDS/TB, behavioral research, communications, maternal and child health, Vaccine development and testing, etc.

Foundation Global Cooperationp

G t F d ti HIV/AIDS t l h lth• Gates Foundation – HIV/AIDS, neonatal health, immunizations, new vaccines

• Clinton Foundation– climate change HIV/AIDS &• Clinton Foundation climate change, HIV/AIDS & Malaria, Childhood obesity, sustainable development

• Rockefeller Foundation – surveillance networks, health systems, investment, social problems.A Kh i hi li• Aga Khan:  community partnerships, policy dialogue, sustainable health systems.

ActorsH l h d lHealth governance model

I t ti lUN

State:Policymakers

International Donors

Host Government UNi iti UNuniversities

Funding

Foundations

Private ProvidersClients/Citizen UN

universities

Adapted from: Brinkerhoff – RTI International Governance Presentation. USAID Mini University 2007

NGOUN

Issues facing the Global Health AidIssues facing the Global Health Aid

• Inadequate funding (country and partner)

• Multiplicity of donors and initiatives  fragmentation  overload of countries

• Multiple plans, assessments, monitoring approaches, reportingMultiple plans, assessments, monitoring approaches, reporting requirements 

• Donors set priorities – countries not in the lead

W k h l h d h• Weak health systems and human resources

• “Vertical” programs fail to build sustainable systems and country capacity

• Lack of transparency and accountability p y y

• “Health system strengthening investments” not always translated into better health outcomes

I i t t tt ti t RESULTS• Inconsistent attention to RESULTS

Source:  Wright et al.  Mini Univeristy 2007

Paris Declaration on AID Effectiveness 2005Paris Declaration on AID Effectiveness 2005

• Ownership:  Partner countries exercise effective leadership over their development policies and strategies and co ordinate development actionsdevelopment policies and strategies and co‐ordinate development actions

• Alignment: Donors base their overall support on partner countries’ national development strategies, institutions, and proceduresp g , , p

• Harmonization: Donors’ actions are more harmonized, transparent, and collectively effective

• Managing results: Managing resources and improving decision‐making for results

• Mutual accountability: Donors and partners are accountable for development results

MDG‐1: two targets and five indicatorsMDG‐1: two targets and five indicatorsMillennium Development Goal 1 Initiative 

target

1. Poverty Target:Halve, by 2015, the proportion

of people on income of less than

2. Hunger Target:Halve, by 2015, the

proportion of people who ff f h

TWO TARGETS

ONE GOAL

$US1 a day suffer from hunger

* 4. Prevalence of underweight children under 5 (UNICEF-WHO)

1. Proportion of population living

2. Poverty gap ratio [incidence x

TARGETS

FIVE Currently 146 million children under 51

5. Proportion of population below i i l l f di t

below $US1 (World Bank)

depth of poverty] (WB)

3. Share of poorest i til i ti l

INDICATORS

minimum level of dietary energy consumption (FAO)

Currently 852 million2 (of which approximately 350-400 million3 are children under 18 plus pregnant and lactating women)

quintile in national consumption (WB)

* Key Impact Indicator p p g g )

1. Progress for Children: A Report Card on Nutrition (UNICEF, 2006); 2. State of Food Insecurity in the World (FAO, 2004); 3. WFP working estimate

Indicator

TITLE: Goal, target and key impact indicator for the End Child Hunger Initiative.SOURCE: Millennium Summit, September 2000.

Effective interventionsEffective interventions

• Increasing/improvingIncreasing/improving breastfeeding/complementary feeding

• Micronutrient intake• Micronutrient intake

• Diarrhea and parasite control

• Treatment of severe acute malnutrition

• Household food securityy

REACH 2009‐2011 Partnershipp

Boston Consulting Group

Boston Consulting Group

SummaryT di i llTraditionally…

• Public health approachPublic health approach– Forced testing

Compulsory treatment and Isolation– Compulsory treatment and Isolation 

• Vertical financing to horizontal financing

• Donors ownership

• International sustainability vs. in‐country sustainability

SSummaryGlobal Health Approach and Agenda 2009:

M i ‘ i h ’• More attention to ‘rights’– Human rights framework to policies, programs.

• More attention to voice of the vulnerableMore attention to voice of the vulnerable– Mothers, children, girls.– Neglected tropical diseases.C lt ll i t h i t ti t diti l– Culturally‐appropriate approaches, integration traditional medicine.

• More attention to partnerships public ‐private.– Innovation, business models– Improved information sharing– Cross‐sectoral, cross‐disciplinesCross sectoral, cross disciplines

Graphic or photo and text slideGraphic or photo and text slide

• Click to add textClick to add text

INSERT GRAPHIC TO ADD PHOTO

Bilateral Donor Funding Levels FY 2004Bilateral Donor Funding Levels FY 2004

10000

12000

6000

8000

2000

4000

0USG Britan Japan Fran Ger Den SIDA CIDA EC

USG Britan Japan Fran Ger Den SIDA CIDA ECUSG Britan Japan Fran Ger Den SIDA CIDA EC

Grants/loans in 2006Source:  Wright et al.  Mini Univeristy 2007

Grants/loans in 2006

All Donors – Top Ten Recipients (2004‐)2005)

1. Iraq                   6. India$ b ll$12.924 billion

1. Nigeria$3.160 billion

$1.785 billion7. Ghana

$1 394 billion2. China

$2.682 billion3. Afghanistan

$1.394 billion8. Egypt

$1.319 billion3. Afghanistan        $1.946 billion

4. Indonesia$1.867 billion

9. Vietnam$1.312 billion

10 S d$

10.Sudan$1.163 billion

United States – Top Ten Recipients ( )(2004‐2005)

6. Jordan1. Iraq

$6.926 billion2 Afghanistan

6. Jordan$368 million

7. Colombia2. Afghanistan

$1.060 billion3. Egypt

$366 million6. Palestinian Authority 

$227 milliongyp$750 million

4. Sudan$575 million

$227 million7. Uganda

$225 million$575 million

5. Ethiopia$552 million

8. Pakistan$224 million

Emerging Donor CountriesEmerging Donor Countries

• ChinaChina

• Russia

il• Brazil

• India

• South Africa

• MexicoMexico

Measuring the Burden of DiseaseMeasuring the Burden of Disease

• HALE (Health‐Adjusted Life Expectancy) ‐ Number of years to be lived in the equivalent of good health

• DALY (Disability Adjusted Life Year) ‐Measure of t d th d l d t ill dpremature deaths and losses due to illness and 

disabilities in a population‐more frequently used

Brief introduction to DALY

• DALY = sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years p y p pLost due to Disability (YLD) for incident cases of the health condition– DALY= YLL+YDL

• YLL = number of deaths multiplied by the standard life expectancy at the age at which death occurs– YLL = N x L 

N b f d th– N = number of deaths 

– L = standard life expectancy at age of death in years 

Brief introduction to DALY

• To estimate YDL for a particular cause in a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale fromreflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). – YDL = I x DW x LYDL   I x DW x L

– I = Number of incident cases

– DW = disability weight 

– L = average duration of the case until remission or 

death (years)

The Global Burden of Disease• Causes of death for low‐ and middle‐income countries:countries:‐ Non‐communicable diseases (** %)‐ Communicable diseases (** %)‐ Injuries (** %)

• Causes of death for high‐income countries:bl d (** )‐ Non‐communicable diseases (** %)

‐ Injuries (** %)Communicable diseases (** %)‐ Communicable diseases (  %)

The Global Burden of Disease• Causes of death for low‐ and middle‐income countries:countries:‐ Non‐communicable diseases (54 %)‐ Communicable diseases (36%)‐ Injuries (10 %)

• Causes of death for high‐income countries:bl d ( )‐ Non‐communicable diseases (87%)

‐ Injuries (7.5 %)Communicable diseases (5 7%)‐ Communicable diseases (5.7%)

The Global Burden of DiseaseThe Global Burden of Disease

• Leading causes of DALYs for low‐ and middle‐income countries:‐ Perinatal conditionsLower respiratory infections‐ Lower respiratory infections

‐ Ischemic heart disease

• Leading causes of DALYs for high‐income countries:‐ Ischemic heart diseaseCerebro asc lar disease‐ Cerebrovascular disease

‐ Unipolar depressive disorders

Other Burden of Disease Breakdowns of Importance

• Causes of death/DALYs by region‐ the higher the income within the region, the more likely it is that the leading causes of burden of disease is non‐communicable‐Why?y

• Causes of death/DALYs by age‐ children in low and middle income countries die more from communicable diseasesincome countries die more from communicable diseases compared to high income countries 

• Causes of death/DALYs by sex – heart disease and stroke are leading cause of death among males and females– Diabetes has become one of the 10 leading cause of death among g g

female– Road traffic accidents are more prevalent among male

Check this website: http://www.who.int/healthinfo/global_burden_disease/en/index.html

Deaths and Disease within Countries Vary By

G d• Gender

• Urban vs rural location

• Ethnicity

• Education 

• Socioeconomic Status

Trends

• Life expectancy has improved in all regions of the world since 1990, except in Europe and Central Asia and in Sub‐Saharan Africa

• Communicable diseases will continue to be veryCommunicable diseases will continue to be very important to the burden of disease in South Asia and Sub‐Saharan Africa

• When will non‐communicable disease start becoming equally important for these countries?becoming equally important for these countries?

Risk Factors

• NCD is attributed to: – Personal behavior and life style– Environmental exposure– Inherited characteristics

C di i b i k f• Condition to become a risk factor: – Should have epidemiological evidence known to be associated with health related conditions

• How are risk factors related with determinants of health?

• Differences in risk factors between low‐middle income countries and high income countries‐ how does it look like?does it look like?

The transitions

• Demographic: A transition from high fertility and high mortality to low fertility and low mortalityy y y– Where‐

– How – hygiene and nutrition improved and also had an epidemiological transition (are these related?) 

• Epidemiological: from communicable to non‐i bl dicommunicable diseases

– Where?

How? Improvements of the determinants of health public– How?   Improvements of the determinants of health, public health interventions and also medicine

• How are these related to the ‘age’ of a country? WhatHow are these related to the  age  of a country? What other factors contribute? 

Types of Population pyramid reflecting demographic transition 

Implications of the transitions

• Low and middle income countries –– Decision about where the fund is to spent by a country

– More focus on young generation with high fertility for education and health

M i i bl di– More on preventing communicable diseases 

• High income countries ‐– more on elderly and retired people  

– More on non‐communicable diseases 

How can a rapid transition be achievedHow can a rapid transition be achieved 

• Lessons from the transitioned countries: – Focusing on investment in nutrition, health and education targeted for poor people (reduce the inequity)

– Improve people’s knowledge of good hygiene p p p g g yg– Making selected cost‐effective and high impact investments – e.g. vaccination for children and TB control A t i GDP h di t li l ti hi t th– A countries GDP has a direct linear relationship to the transitions but may not be causing it…e.g. Kerala 

• What are the other factors?

– Healthy Human resource is a precondition of development

Main MessagesMain Messages

A b f f t i fl h lth t t• A number of factors influence health status• Risk factors are central to health and to addressing health concernsaddressing health concerns

• Policy making needs to be data driven• Cardiovascular disease is now the leading cause ofCardiovascular disease is now the leading cause of death worldwide

• The poorest countries have a relatively larger burden from communicable diseases than from non‐communicable diseases

Department of Global HealthDepartment of Global Health

• ghfacultyadvising@gmail.com

• Epidemiology ID, EZIDD h Ethi i• Demography, Ethiopia

• Nutrition, Food Security• NCDNCD• mHealth technologies• Diaspora health• HIV/AIDS China, Middle East• Development, Conditional Cash Transfer