Investing in Global Health “Best Buys” and Priorities for Action in Developing Countries Fogarty...

Investing in Global Health“Best Buys” and Priorities for Action in

Developing Countries

Fogarty International Center of the U.S. National Institutes of Health, the World Bank, the World Health Organization, and the Population Reference

BureauGlobal Health Mini-University, 27 October 2006

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Presentation Overview

• Rationale for Disease Control Priorities• Objectives of the Project• Burden of Disease• Need for Cost-Effective Interventions• Cost-Effectiveness Analysis Results• Recommendations and Pearls

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Changes in Life Expectancy by World Bank Region

0

10

20

30

40

50

60

70

80

90

1960 1990 2002 2020

Lif

e E

xpec

tan

cy,

Yea

rs

Low - andMiddleIncomeHigh-Income

World

Region

4

In spite of improvement in the 20th century, progress has been uneven

44

69

50

4044

63

76

65

50

58

65

78

67

46

63

0

20

40

60

80

100

LMICs HICs World Sub-SaharanAfrica

South Asia

(Lif

e E

xpec

tan

cy)

Yea

rs

1960 1990 2002

5

76

87

5436

10

non-communicable diseasescommunicable diseasesinjuries

76

87

Developing countries carry a double

disease burden

5436

10

non-communicable diseasescommunicable diseasesinjuries

Low- and Middle-income countries High-income countries

Percentage of deaths by cause

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The 20th century witnessed the largest global increase in life expectancy in history.

Will the 21st century build on the successes of the last century, plateau, or will we see a retreat from the gains of the past?

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Will this be the century of disease?

• HIV/AIDS• Cardiovascular disease• The persistence of high, but

preventable levels of malaria, TB, diarrhea, and pneumonia

• Avian flu/emerging infections/pandemics

Four challenges:

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The Disease Control Priorities Project offers priorities for action that will lead to healthier and longer lives in developing countries.

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What is the DCPP?

DCPP is an alliance of organizations/partners designed to review, generate and disseminate information on how to improve population health in developing countries.

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• Fogarty International Center, US National Institutes of Health

• World Bank

• World Health Organization

• Population Reference Bureau

• Supported by the Bill & Melinda Gates Foundation

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Objectives of DCPP (1)

Inform health sector decision-making in developing countries to decrease illness, disability, death, and economic burden by:

Developing an evidence base to inform decision-making by:

• Providing estimates of the cost-effectiveness and impact of single interventions and packages

• Collaborating in defining disease burdens globally and regionally

• Summarizing implementation experience in different regions and globally

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Objectives of DCPP (2)

Communicating major findings

• Suggesting the “best buys” and the “worst buys” in any given setting

• Disseminating the results widely to multiple audiences

• Stimulating national priority setting and program implementation

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The best health care solutions:

• Target major causes of death, disability and illness in developing countries;

• Are cost-effective; and• Are available.

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How can DCPP improve health globally?

• Helps countries choose the best health care investments.

• Recommends 10 best health buys that are highly cost-effective in many settings.

• Identifies health policy priorities for developing countries.

• Suggests changes to infrastructure (health systems, financing, policies, R&D) to maximize results.

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Burden of Disease (BOD)

BOD analysis provides a standardized framework for integrating all available information on mortality, causes of death, individual health status, and condition-specific epidemiology to provide an overview of the levels of population health and the causes of loss of health

Consistent, comprehensive descriptive epidemiology Common metric or summary measure (e.g. DALY), that allows for comparisons across diseases and interventions

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The DALY:

• Combines years of life lost to premature mortality and years spent with a disability or illness

• Provides a metric of disease impact (“burden of disease”) reflecting both mortality and morbidity

• For example, diabetes in high income countries comprises 2.1% of deaths and 2.8% of DALYs

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The cause distribution of burden of disease, by region, 2001

Source: Mathers, Lopez & Murray, Burden of Disease Volume, 2006.

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0 50 100 150 200 250 300 350 400 450 500 550

High income

Europe and CentralAsia

Latin America andCaribbean

Middle East andNorth Africa

East Asia and Pacific

South Asia

Sub-Saharan Africa

DALYs per 1,000

HIV/AIDS

Other infectious and parasitic*

Maternal, perinatal andnutritionalCardiovascular diseases

Cancers

Neuropsychiatric

Other noncommunicable

Unintentional injuries

Intentional injuries

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BOD and Comparative Risk Assessment (CRA)

• BOD reflects impact of illness and disability

• Risk factors tell us the causes behind disease and disability

• Comparative risk assessment shows potential gains in population health from reducing the risk exposures

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Global Burden of Disease Study 1990:DALYs attributable to 10 selected risk factors

Risk factor Percent global total

Malnutrition 16%Poor water/sanitation 7%Unsafe sex 4%Alcohol 4%Occupation 3%Tobacco 3%Hypertension 1%Physical inactivity 1%Illicit drugs 0.6%Air pollution 0.5%

Intervention Cost-Effectiveness Summary of key

messages

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Objective: Improve Quality of Health Spending

• Provide information on the “price” of buying health through different interventions

• Policymakers can combine this information with other considerations to determine how best to improve health

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Neglected opportunities

Cost-effective interventions used widely

Interventions for which

scaling up is inefficient

Interventions to reconsider

Current Coverage

Cos

t E

ffec

tiven

ess High

Low

Low High

Identifying the Efficiency of Current and Potential Interventions

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Interventions Covered

• Cost effectiveness of 257 interventions in $/DALY averted (DCP1 had 68)

• Cost effectiveness of an additional 62 interventions using other metrics (26 in DCP1)

• Also provide information on• Cost-effectiveness by region• Target population• Personal versus population• Avertable burden• Quality of evidence

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Reduce Fatal and Disabling Injuries

Injuries and violence caused more than 5 million deaths in 2001, with an especially

heavy toll on young men.

• Install speed bumps at dangerous intersections.

• Increase penalties for speeding; awareness through media; and law enforcement.

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Traffic Accidents: Interventions to Reduce Injuries

0

20

40

60

80

100

120

140

160

180

EAP ECA LAC MENA SAR SSA

US

$/D

AL

Y

Increased penalties forspeeding and othereffective road safetymeasures, combinedwith media coverageand betterenforcement

Speed bumps

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Traffic Accidents: Interventions to Reduce Injuries

0

1000

2000

3000

4000

5000

6000

EAP ECA LAC MENA SAR SSA

US

$/D

ALY

Enforcement ofseatbelt lawsChild restraints

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Stop the Spread of Tuberculosis

Tuberculosis (TB) is spreading into new populations and resisting treatment

• Treat active TB cases with short-course chemotherapy.

• Increase case detection.• Manage multidrug resistant TB with

new drugs and drug combinations.

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Cost effectiveness (US$/DALY)

Tuberculosis

short-course chemotherapy (DOTS) of infectious TB (allowing for transmission, non-HIV+) for endemic TBshort-course chemotherapy (DOTS) of infectious TB (no allowing for transmission, non-HIV+) for endemic TB

short-course chemotherapy (DOTS) of non-infectious TB (non-HIV+) for endemic TB

short-course chemotherapy (DOTS) of infectious TB (allowing for transmission, non-HIV+) for epidemic TB

Tuberculosis: Short-course Chemotherapy

0

50

100

150

200

250

300

350

EAP ECA LAC MENA SAR SSA

US

$/D

AL

Y

Infectious TB (non-HIV+) forendemic TB (allowing fortransmission)

Infectious TB (non-HIV+) forendemic TB (not allowing fortransmission)

Infectious TB (allowing fortransmission, non-HIV+) forepidemic TB

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Tuberculosis: Management of Drug Resistance

0

200

400

600

800

1,000

1,200

US

$/D

AL

Y Endemic TB (standardregimen)

Endemic TB (individualizedregimen)

Epidemic TB (standardregimen)

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Control Malaria

Malaria claims the lives of 1 million children yearly, and it threatens nearly one-half of the world’s population.

• Provide universal access to insecticide-treated nets in areas where malaria is endemic.

• Expand intermittent preventive treatment for pregnant women.

• Subsidize artemisinin combination therapy to ensure effective treatment.

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Malaria: Residual Household Spraying

0

5

10

15

20

25

30

SSA

US

$/D

AL

Y

Melathion, 1 round

DDT, 1 round

Deltamethrin, 1 round

Lambda-cyhalothrin targetdose, 1 round

Melathion, 2 round

DDT, 2 round

Deltamethrin, 2 round

Lambda-cyhalothrin targetdose, 2 round

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Ensure Healthier Children

More than 13 million children (including stillbirths) die each year in developing countries.

• Keep newborns dry, warm and clean.• Vaccinate children against major childhood

killers.• Monitor children’s health to prevent and treat

childhood pneumonia, diarrhea, and malaria.

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Diarrheal Disease

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

EAP LAC MENA SAR SSA

US

$/D

AL

Y

Rotavirus immunization

Cholera immunization

Water and sanitation (urban,5 years)Water and sanitation (rural, 5years)Breastfeeding promotion

Oral rehydration therapy

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Diarrheal Disease: CEA forBreastfeeding and Oral Rehydration

Therapy Interventions

0

500

1,000

1,500

2,000

2,500

3,000

EAP LAC MENA SAR SSA

US

$/D

AL

Y Breastfeeding promotion

Oral rehydration therapy

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Childhood Illness: Interventions for Acute Respiratory Infections

0

500

1,000

1,500

2,000

2,500

EAP LAC MENA SA SSA

US

$/D

AL

Y Community-level casemanagement (non-severe)

Facility-level casemanagement (non-severe)

Entire case managementpackage

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Combat Tobacco Use

Tobacco-related diseases are the fastest-growing cause of disease and disability in developing countries.

• Tax tobacco products to increase consumers’ costs by at least 33% to curb smoking.

• Restrict smoking in public places and workplaces.

• Provide nicotine replacement therapy and other cessation tools.

• Ban tobacco advertising.

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Most smokers now live in low- and middle-income countries.

18%

82%

Where Smokers Live

Low- and Middle-income Countries

High-income Countries

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Tobacco Use and Addiction

0

100

200

300

400

500

600

700

800

EAP ECA LAC MENA SA SSA

US$/D

AL

Y

Taxation - 33% priceincrease

Non-price interventions ateffectiveness of 2-10%

Nicotine ReplacementTherapy (NRT)

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How Much Health Will a Million Dollars Buy?

Preventing and Treating Non-Communicable DiseaseService or Intervention DALYs Averted ($ per DALY)• Taxation of tobacco products 24,000-330,000 ($3-50)• Treatment of MI or heart 40,000-100,000 ($10-25)

attacks with an inexpensive setof drugs

• Treatment of MI with 1,300-1,600 ($600-750)inexpensive drugs plus

streptokinase• Lifelong treatment of heart 1,000-1,400 ($700-1,000)

attack and stroke survivors withdaily ‘polypill’

• Coronary artery bypass grafting <40 (>$25,000)in specific identifiable high riskcases

• Bypass surgery for less severe Very small (Very high) coronary artery disease

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To get the best results:

• Choose interventions with low cost and high impact

• Strengthen health systems• Engage global partners and donors• Accelerate research and

development

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“Pearls” for Your Consideration

• You don’t have to be rich to be healthy

• Policymakers can vastly improve quality of health spending by targeting interventions that are proven to be cost-effective

• Other?

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Published April 2006, Oxford University Press.

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Published April 2006, Oxford University Press.

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Published April 2006, Oxford University Press.

Available in 7 languages

For more information, visit us at www.dcp2.org

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“Pearls” for Your Consideration

• You don’t have to be rich to be healthy

• Policymakers can vastly improve quality of health spending by targeting interventions that are proven to be cost-effective

• Other?