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The Future of Global Health
Jim Yong Kim M.D., Ph.D.Jim Yong Kim M.D., Ph.D.FranFranççois Xavier Bagnoud Center for Health and Human Rightsois Xavier Bagnoud Center for Health and Human Rights
Brigham and Women’s HospitalBrigham and Women’s HospitalHarvard Medical School Harvard Medical School
Harvard School of Public HealthHarvard School of Public HealthPartners In HealthPartners In Health
Global Classroom Global Classroom Columbia UniversityColumbia University
“In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” - WHO 1996
“MDR TB is too expensive to treat in poor countries;it detracts attention and resources from treatingdrug-susceptible disease.” - WHO 1997
The MDR-TB Death Sentence as Public Health Policy
August 1996MDR-TB treatment project initiated in Peru by Socios
en Salud and Harvard/Partners in Health.
Reduced prices of second-line TB drugs
Drug Formulation 1997 price 1999 price % Decline
Amikacin 1 gm vial $9.00 $0.90 90%
Cycloserine 250 mg tab $3.99 $0.50 87%
Ethionamide 250 mg tab $0.90 $0.14 84%
Kanamycin 1 gm vial $2.50 $0.39 84%
Capreomycin 1 gm vial $29.90 $0.90 97%
Ofloxacin 200 mg tab $2.00 $0.05 98%
Scaling up of DOTS-Plus
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006
Projects approvedFeb 2006 – 35 projects
Changes in life expectancy in selected African countries
with high HIV prevalence, 1950 to 2000
South-Africa
35
40
45
50
55
60
65
1950-551955-601960-651965-701970-751975-801980-851985-901990-951995-00
Lif
e e
xp
ecta
ncy a
t b
irth
, in
years
Botswana
Uganda
Zambia
Zimbabwe
Source: United Nations Population Division, 1998
4
Act Up and Initial AIDS Protest Efforts
Objections to TreatmentJuly 2000
There are many ways to communicate the vital information about HIV/AIDS. What works best in one country may not be appropriate in another. But to tackle the disease, everyone must first understand that HIV is the enemy. Research, not myths, will lead to the development of more effective and cheaper treatments, and hopefully a vaccine. But for now, emphasis must be placed on preventing sexual transmission.
- Durban Declaration signed by over 5000 attendees of the XIII International AIDS Conference in Durban, South Africa
Global Protests Surrounding Access to ARV’s
No program to treat people in the poorest countries has more intrigued experts than the one started in Haiti by Partners In Health…” NEW YORK TIMES11/30/2003
“
Launching PEPFAR“AIDS can be prevented. Anti-retroviral drugs can extend life for many years. And the cost of those drugs has dropped from $12,000 a year to under $300 a year -- which places a tremendous possibility within our grasp. Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many”
January 28, 2003
"The British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa."
Number of people receiving ARV therapy in low- and middle-income countries, 2002—
2006
0
200
400
600
800
1 000
1 200
1 400
1 600
1 800
2 000P
eo
ple
re
ce
ivin
g A
RV
th
era
py
(in
th
ou
sa
nd
s)
North Africa and the Middle East
Europe and Central Asia
East, South and South-East Asia
Latin America and the Caribbean
Sub-Saharan Africa
Universal Access
2005 G8 Summit at Gleneagles, Final Communiqué:“…working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010.”
• ls
Boucan Carre June 03:
VCT with
Staff
Essential Meds
Community outreach
HIV Prevention and Treatment Integration into Primary Health Care
Boucan Carre March 03
The four pillars of
primary health care
HIV
pre
ven
tio
n a
nd
car
e—in
teg
rati
on
in
to p
rim
ary
hea
lth
car
e se
rvic
es
Wo
men
’s H
ealt
h, r
epro
du
ctiv
e h
ealt
h,
fam
ily p
lan
nin
g, P
MT
CT
Building/ Infrastructure Labour, excl.
accompagnateurs (32%)
What does the ‘Rwinkwavu’ model cost?
Labour, accompagnateurs only (5%)
Outpatient Nutritional Support (5%)
Supplies (28%)
Social (education, housing, mutuelles, micro-finance, etc.)
Transport/ Communication
Referrals
Administration
Summary of detailed unit costing, extrapolated to a full district
100% = US$ 4.7 million in ‘steady state’ (2011)
Estimated ‘catchment’ area of unit
100% = 265,000
Rwinkwavu
MulindiRukira
SOUTHERN KAYONZA
Rwinkwavu
MulindiRukira
Murama
SOUTHERN KAYONZA
Methodology:
Theoretical catchment area+ Patients coming from other areas (based on survey) - Overlaps between centres
= Actual population served
New Sites/Capital investment (14%)
~25 US$/Capita ~6000 US$/Capita
Lesotho
KZN XDRTB Survey Patient Characteristics*
Characteristics No. (%)• No prior TB Treatment 26 (51) • Prior TB treatment
– Cure or Completed treatment 14 (28)– Treatment Default or Failure 7 (14)
• HIV-infected (44 tested) 44 (100)
• Dead (Includes 34% on ARV) 52 (98)• Identical M. tb spoligotype 26/30* Moll A, Gandhi NR, Pawinski R, Lalloo U, Sturm AW, Zeller K, Andrews J, Friedland G.
HIV associated Extensively Drug-Resistant TB (XDR-TB) in Rural KwaZulu-Natal (South Africa MRC Expert Consultation Sept 8, 2006)
Implementation bottleneckImplementation bottleneck
• Vaccines
• Primary Health Care
• Drug Therapies
• Maternal and ChildHealth Care
• Basic Surgery
Bill and Melinda Gates Foundation $6.5 B
The Global Fund $8.6 B
President’s Emergency Plan for AIDS $15 B
International Finance Facility $4 B
Multi-Country HIV/AIDS Program $1.1 B
Global Alliance $3 B
Public-private partnerships $1.2 B
Anti-Malaria Initiative in Africa (proposed) $1.2 B
United Nations Fund $360 M
TOTAL $40.7 B
*Funds pledged, committed, or spent. Overlap exists between organizations (e.g., PEPFAR money supports the Global Fund).Adapted from Jon Cohen, The new world of global health. Science 2006;311(5758):162-167.
Gates grantsGates grants
GATES GRANTS$448M - new health technologies
$413M - HIV/AIDS vaccine
$258M - malaria vaccine
$165M - new malaria drugs
$124M - anti-HIV microbicides
$115M - diarrhea/nutrition
$106M - TB vaccines/diagnostics
Implementation bottleneck +Implementation bottleneck +
• Vaccines
• Primary Health Care
• Drug therapies
• Maternal Child Health Care
• Basic SurgeryGates Foundation develops:
• Microbicides and other preventive tools
• New malaria and TB drugs, diagnostics
• New combination therapies
• Drugs for neglected diseases
• >10 new vaccines
Conventional wisdom explaining delivery failures
Health care delivery is a complex, multidimensional phenomenon that is difficult to understand and even more difficult to
manage
• Markets not working; incentive misalignment
• Slow diffusion of knowledge
• Lack of management skills
• Inadequate funding of infrastructure development
Harvard Business School Faculty: experts
on delivery and operations research
Michael E. Porter, Bishop William Lawrence University Professor, Harvard University
HOW DO WE STUDY COMPLEX STRATEGY PROBLEMS? • Careful study of numerous case studies spanning multiple settings and
encompassing both success and failure
• Conduct in-depth field research focused on the role of organizational leaders and their choices, studied in context
• Employ a mix of quantitative and qualitative analysis
• Develop analytic frameworks that can be applied prospectively to guide practice
• Develop theoretical principles about the underlying phenomenon based on experience from other industries
• Encompass the complexity of the whole problem
• Intensive interaction with practitioners to disseminate concepts and refine implementation in specific country settings
Michael E. Porter, Harvard Business School
Mismatch in Skills Taught and Skills Needed
Bachelor’s MPH MBA/MPA MD
•No defined degree program in global health
•Broad liberal arts courses on on social or basic science
•Field-work on an ad-hoc basis
•Focus on quantitative methodology and research
•Population-level interventions
•Field-work on an ad-hoc basis
•Private/public management emphasis
•Little discussion of work in resource-poor settings
•No education of health science
•Focus on clinical and basic science
•Little education on health care delivery or public health issues
•Focus on single-patient interventions
No or extremely limited focus on health care delivery
Is there a place for a new discipline in health education?
BasicScience
ClinicalScience
EvaluationSciences
What is the pathophysiology?
What is the appropriate
intervention?
Does the intervention
work?
Is there a place for a new discipline in health education?
BasicScience
ClinicalScience
EvaluationScience
What is the pathophysiology?
What is the diagnosis and
appropriate intervention?
Does the intervention and delivery model work?
HealthcareDeliveryScience
How do we best deliver
the intervention to everyone?
Global Health in 2007: Increasing Access
Our Response:Building the Field of Global Health Delivery
Community of PracticeEMR Systems
Field Test Best Practiceswith Global Health
Practitioners
Case ProductionCreate Innovation
Network
Advance Evidence Based Strategies
Developing Leaders
TrainingPrograms
Build the Field and Disseminate
Lessons Learned
Better Health Care
Outcomes
Improving Service Delivery
Phase I Phase II
Objections to HIV TreatmentApril 2006
The standard policy prescription is that in order that to maximize health, with a limited budget, funds should first be allocated to more cost- effective interventions, and only then to interventions with lesser cost effectiveness. With limited resources, should the focus of efforts to combat HIV/AIDS be on prevention or treatment?...if the goal is to maximize the health benefits produced, developing country governments and international institutions should focus their health spending first on the prevention of HIV transmission, before moving on to treatment. The opportunity cost of emphasizing HIV/AIDS treatment over prevention in a resource-constrained environment is measured in millions of lives needlessly lost.
David Canning, Professor of Economics and International Health at the Harvard School of Public Health
The Fruits of Advocacy The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million
BeforeAfter
The Fruits of AdvocacyThe Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million National Security: FY2008 war supplemental- $196.4 Billion
Before After
The Fruits of AdvocacyThe Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million National Security: FY2008 war supplemental- $196.4 Billion
Corn- $5.1 Billion/yr
Before
After
The Fruits of Advocacy The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million National Security: FY2008 war supplemental- $196.4 Billion
Corn- $5.1 Billion/yr Sugar- up to $1.9 Billion/yr
G7 Military Spending and Foreign Aid, 2006
522
51.1 44.7 41.630.2
17.2 10.927.5
13.1 10.8 10.1 9.92 5.05 3.730
100
200
300
400
500
600
UnitedStates
UnitedKingdom
Japan France Germany Italy Canada
$ B
illi
on
sMilitary Spending Foreign Aid
American Perceptions on Foreign Aid and Defense Budget
• Recent 2005 survey showed Americans typically believed that economic and humanitarian aid = 10% of total federal budget– Only 18% guessed less than 3%– Actual = 1.6%
• When asked what % should be allocated to foreign aid, median response = 15%
“ To create and nurture a community of the best people committedto leadership in alleviating human suffering caused by disease.”
HARVARD MEDICAL SCHOOL MISSION STATEMENT