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