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

1. Lecture 26: Challenges and Opportunities Christopher J.L. Murray Richard Saltonstall Professor of Public Policy Director, Harvard University Initiative for Global Health Harvard University Initiative for Global Health

2. OUTLINE Review of Global Health Challenges Nine Policy Opportunities Harvard University Initiative for Global Health

3. Harvard University Initiative for Global Health

4. Global Burden of Disease, 2002 Harvard University Initiative for Global Health

5. Leading Causes of the Global Burden of Disease 2002 DALYs % • Perinatal conditions 6.5 • Lower respiratory infections 6.1 • HIV/AIDS 5.7 • Depression 4.5 • Diarrhoeal diseases 4.2 • Ischaemic heart disease 3.9 • Cerebrovascular disease 3.3 • Malaria 3.1 • Road traffic accidents 2.6 • Tuberculosis 2.3 Source: World Health Report, 2004 Harvard University Initiative for Global Health

6. Attributable Disease Burden of 20 Risk Factors Harvard University Initiative for Global Health

7. Trends in Measured Obesity Harvard University Initiative for Global Health

8. Two and A Half Centuries of Mortality Decline Harvard University Initiative for Global Health

9. 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 Harvard University Initiative for Global Health

10. Global Expenditure on Health, 2002 (US$ Billions) Total: 3,224 Total Developing 402; 13% Harvard University Initiative for Global Health

11. Japan Malta USA Cuba Georgia Sao Tome & Prince Harvard University Initiative for Global Health

12. OUTLINE Review of Global Health Challenges Nine Policy Opportunities Harvard University Initiative for Global Health

13. 1. Promote Insecticide Treated Bednets to Reduce Child Mortality from Malaria Two key components of the global control policy: Artemesin combination therapy (ACT) substitution for choloquine in national control programs Insecticide treated bednets that reduce child mortality 20% in endemic areas. Long-acting 3-5 year bednets cost $5. Coverage for both is very low. Harvard University Initiative for Global Health

14. Harvard University Initiative for Global Health

15. More Aggressive ITN Programs When DOTS and ARV programs are founded on principles of free care for the patient, ITNs distribution should also be free. Experience with voucher programs in Tanzania and other social marketing strategies should be evaluated. Effective strategies for increasing distribution and uptake should be developed and scaled. Harvard University Initiative for Global Health

16. 2. Increase the Case Detection Rate for Tuberculosis Since 1991 global tuberculosis control (called DOTS) is focused on detecting symptomatic cases that present to public facilities using sputum microscopy for diagnosis and institution of directly observed short-course treatment. The DOTS strategy has been successful and improving treatment outcomes in the smear-positive cases that are detected. There has been little progress at increasing the case-detection rate over the last fifteen years. Harvard University Initiative for Global Health

17. WHO Global Tuberculosis Report 2006 Harvard University Initiative for Global Health

18. Active Case-Finding Half of tuberculosis cases do not get detected and 50% of these individuals go on to die from the disease. Innovative strategies to actively identify tuberculosis cases in the community need to be tested in different cultural and epidemiological settings. Resources to support active case-finding need to be included in applications to the Global Fund for AIDS, Tuberculosis and Malaria and other funders. Harvard University Initiative for Global Health

19. 3. Develop and Test New Service Delivery Models for Child Survival Interventions Many new technologies to reduce child mortality -- vitamin A supplementation, zinc supplementation, rotavirus vaccine, pneumococcal vaccines, others. WHO strategy to deliver child survival technologies for the last decade based on Integrated Management of Childhood Illness protocols emphasize services delivered to sick children coming to public clinics. IMCI Evaluations in Brazil, Peru, Uganda, and Bangladesh show that less than 20% of sick children are taken to public clinics. Harvard University Initiative for Global Health

20. Top Ten Interventions to Reduce Global Child Mortality Source: Jones G, et al. The Lancet, vol 362 Harvard University Initiative for Global Health

21. Taking Advantage of a New Focus on Child Survival UNICEF, Gates Foundation, Government of Norway bringing renewed attention to the reducing child mortality in poor countries. Strategies to reach out and deliver effective technologies to children who would not otherwise go to public facilities need to be developed and tested. Reality of severe shortages of trained health workers must factor into the development of these strategies. Harvard University Initiative for Global Health

22. 4. Reduce Deaths from Road Traffic Accidents Through Proven Policies Many high-income countries have dramatically reduced road traffic fatalities through road design, seatbelt enforcement, airbags, traffic calming, speed limits, alcohol breath testing. Some Eastern European countries and nearly all developing countries have not adopted this package of interventions or have not invested in their enforcement. Many components of the policy package are not costly. Harvard University Initiative for Global Health

23. Harvard University Initiative for Global Health

24. 5. Introduce Community Treatment of Depression and Psychosis in Developing Countries Depression, bipolar disorder and schizophrenia cause a significant burden of disease. Up to 20% of the burden can be addressed using pharmacological interventions in primary care settings. Cost per year of life saved is affordable in all middle-income and some low-income countries. Harvard University Initiative for Global Health

25. Harvard University Initiative for Global Health

26. 6. Use the Polypill to Reduce Cardiovascular Mortality in Developing Regions by Half Large and growing burden of cardiovascular diseases in developing countries. Western management model for CVD too costly. No policy attention in most countries – still focused on maternal and child health agenda International organizations, NIH and Gates Foundation not investing in solutions for CVD. Harvard University Initiative for Global Health

27. Developing Country CVD Epidemic Getting Worse Global burden of cardiovascular disease* • 11.4 million deaths in 2000 – projected 60% increase by 2020 Harvard University Initiative for Global Health

28. The polypillaka “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 Harvard University Initiative for Global Health

29. How the polypill reduces cardiovascular risk by 65% ? 30% Overall 65% 30% 25% Chance of developing heart attack or stroke Treatments Harvard University Initiative for Global Health

30. 7. Prevent Catastrophic Health Spending Through Expanding Social Insurance Many households face catastrophic health spending which often pushes them below the poverty line. Catastrophic spending is due to the triad of low-income, high service availability and a failure of risk protection mechanisms (insurance or tax-based financing). Harvard University Initiative for Global Health

31. Proportion of households with catastrophic expenditures vs. share of out-of-pocket payment in total health expenditure 15 8 3 1 % of hhs with catastrophic exp. (logarithm) .1 .03 .01 5 10 20 40 60 80 100 % of OOP in total health exp.(logarithm) Harvard University Initiative for Global Health

32. Mexico Extends Insurance Coverage to the Entire Population Seguro Popular enacted May 2003 Extends insurance coverage to the 50% of population who were uninsured 7 year phase-in Basic package of services includes 91 interventions Harvard University Initiative for Global Health

33. 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 Harvard University Initiative for Global Health

34. 8. Measure Health System Efficiency and Performance Little comparable information on inputs, outputs, outcomes and efficiency of public health and medicine. Huge variation in the relationship between inputs and outputs. Credible, comprehensible and comparable information on health systems is an essential ingredient for creating accountability. Harvard University Initiative for Global Health

35. Effective Coverage of Health Interventions By State, 2005/6 Harvard University Initiative for Global Health

36. Harvard University Initiative for Global Health

37. 9. Reduce Persistent Health Inequalities Using Incentives to Manage Known Risks Worst-off groups in US, UK, Australia, and other Western countries have persistently bad health outcomes. New health knowledge and interventions are nearly always used by better off groups more than the disadvantaged. UK, Canada and other countries are trying to reduce health inequalities by tackling poverty and other broader social determinants. Harvard University Initiative for Global Health

38. Life Expectancy for the Eight Best and Worst US Counties, Males Harvard University Initiative for Global Health

39. Incentives and Targeted Risk Reduction Effective coverage of anti-hypertensives, statins, and other risk management interventions is significantly lower in disadvantaged groups. Financial and other incentives can work to influence behaviour of providers and individuals. We should explore the use of these incentives to increase effective coverage of effective interventions. Harvard University Initiative for Global Health

40. Four Themes For Tackling Global Health 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. Harvard University Initiative for Global Health