Michael MersonDirector, Duke Global Health InstituteWolfgang Joklik Professor of Global Health
Partners in Global Health
WHY DO WE NEED GLOBAL COOPERATION IN HEALTH?
For Security: Threats of Disease Globalization
• Communicable diseases: a disease in one country is a threat to others
• Since the 1970s, newly emerging infectious diseases have been identified at the unprecedented rate of one or more per year
• There are now nearly 40 diseases that were unknown a generation ago
Emerging andRe-emerging Infections
Source: Morens et al. 2004
Probable SARS Transmission on Flight CA112 in March 2003
Source: Osen SJ et al.
2014 Ebola Outbreak in West Africa - Outbreak Distribution Map
Direct Economic Impact of Selected Infectious Disease Outbreaks: 1990-2003
Source: Marsh TL, Shroeder TC, Mintert J. Impacts of meat product recalls on consumer demand in the USA. Applied Economics, 2004, 36:897–909.
• GSK
Antimicrobial Resistance
For Diplomacy
• Can perform when politics fail• Can serve as valuable ambassadors of goodwill • Can build bridges and trust by engaging with citizens
from other countries
CITIZENS (scientists, health providers, students)
CIVIL SOCIETY ORGANIZATIONS (universities, NGOs, and professional
societies)
PRIVATE COMPANIES
• Today over 35% of articles published in international journals are internationally collaborative, up from 25% 15 years ago
• The number of internationally co-authored papers has more than doubled since 1990
For Scientific Research
For Sustainable Development
Investing in health makes economic sense:• Countries with poor health
have more difficulty achieving sustained economic growth
• 10% improvement in life expectancy is associated with economic growth of about 0.3%
Source: Report of the WHO Commission on Macroeconomics and Health: World Health Organization; 2002.
For Health Commodity • Global healthcare industry is
worth over US$3.5 trillion annually
• Health services, research, pharmaceuticals and medical devices are international commodities and are an important part of global economies
• Health commodities, as objects of trade, are open to regulation by international trade agreements
• WTO: Trade-Related Aspects of Intellectual Property Rights
For Global Public Good
• Benefit society as a whole• Address issues in which the
international community has a common interest
• Share the protection of health worldwide
• Examples:• Smallpox eradication• Polio eradication• Global HIV Vaccine Enterprise• WHO Framework Convention
on Tobacco Control• Revision of the International
Health Regulations
For Human Rights• The right to health has been
enshrined in numerous international and regional human rights treaties as well as national constitutions all over the world
• The WHO Constitution states: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without the distinction of race, religion, political belief, economic or social condition.”
For Addressing Global Health Policy Issues
• Tobacco• Obesity• Universal health coverage• Access to ARVs • Eliminating preventable childhood deaths• Climate change• Meeting the MDGs and the Post-MDG Agenda
Cumulative tobacco-related deaths, 2005–2030
Source: WHO Mpower report: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf (2008)
Percentage of Men who Smoke
Source: TobaccoAtlas.org by American Cancer Society and World Lung Foundation
• A treaty adopted by the 56th World Health Assembly in May 2003 seeking "to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”
• The treaty's provisions include rules that govern the production, sale, distribution, advertisement, and taxation of tobacco; marks one of the first multilateral, binding agreements regarding a chronic NCD
• Status:• Signatories to the WHO FCTC: 168• Parties to the WHO FCTC: 179 (Last Party: El Salvador, October 2014)
• The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention
• Sixth session of the COP took place in Moscow in October 2014
WHO Framework Convention on Tobacco Control (WHO FCTC)
Source: http://apps.who.int/iris/bitstream/10665/85381/1/WHO_NMH_PND_13.2_eng.pdf
Projected Prevalence of Overweight* Women Aged 30 and Above, 2015
Source: WHO
*(BMI ≥ 25 kg/m2)
Source: 2013 UNAIDS Global Report, http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf
Treatment with Antiretroviral Drugs
Women and Children in the Post-2015 Agenda
MDG 4: Reduce by two-thirds the under-five mortality rate
• Under-five mortality rate has fallen from 12.7 million in 1990 to 6.3 million in 2013, not enough to meet MDG 4, but still remarkable progress
MDG 5: Reduce by three quarters the maternal mortality ratio
• Maternal mortality ratio has fallen by only 22% between 1990 and 2013, which is far off the target of a 75% reduction
Source: The Lancet, "Women, children, and adolescents: the post-2015 agenda." The Lancet 384.9949 (2014): 1159.
Source: Building a Future for Women and Children: The 2012 Report.
Global Causes of Death among Children, ages 0–59 months, 2010
Neonatal Mortality Rates for 193 Countries, 2009
Source: PLoS Medicine. (2011) Trends in Neonatal Mortality Levels. Vol. 8 Issue 8.
-50 -20 0 +20 +50 +100
64
36
20
80
Percentage change in yields to 2050
UN DP, 2009
Plus climate-related:• Flood/storm/fire
damage• Droughts – range,
severity• Pests (climate-sensitive)• Infectious diseases
CLIMATE CHANGE: Poor Countries Projected to Fare Worst CHANGES IN CEREAL GRAIN YIELDS, 2050
Millennium Development Goals
• Eradicate Extreme Poverty and hunger• Achieve Universal Primary Education• Promote Gender Equality and Empower Women• Reduce Child Mortality• Improve Maternal Health• Combat HIV/AIDS, Malaria and Other Diseases• Ensure Environmental Sustainability • Develop a Global Partnership for Development
Based on Millennium Declaration, adopted September 2000
Sustainable Development Goals (SDGs)
SDGs are goals that embrace the “triple bottom line” approach to human wellbeing,
which is a combination of economic development, environmental sustainability,
and social inclusion
Source: Sachs J. From Millennium Development Goals to Sustainable Development Goals. Lancet. 2012
Goal 1 End poverty in all its forms everywhere
Goal 2 End hunger, achieve food security and improved nutrition and promote sustainable agriculture
Goal 3 Ensure healthy lives and promote well-being for all at all ages
Goal 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
Goal 5 Achieve gender equality and empower all women and girls
Goal 6 Ensure availability and sustainable management of water and sanitation for all
Goal 7 Ensure access to affordable, reliable, sustainable and modern energy for all
Goal 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all
Goal 9 Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation
DRAFT SDGs
GOAL 3: ENSURE HEALTHY LIVES AND PROMOTE WELL-BEING FOR ALL AT ALL AGES
TARGETS:
3.1 By 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 By 2030 end preventable deaths of newborns and under-five children
3.3 By 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing
3.5 strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6 By 2020 halve global deaths and injuries from road traffic accidents
3.7 By 2030 ensure universal access to sexual and reproductive health care services
3.8 Achieve universal health coverage (UHC)
3.9 By 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination
WHO ARE THE STAKEHOLDERS IN GLOBAL HEALTH?
Governments
Multilateral & International Organizations
Foundations
Civil Society
Private Sector
Individuals
Key Stakeholders in Global Health
Development Assistance For Health, by Channel of Assistance (1990–2013)
Development assistance for health (DAH) has hit its highest levels to date, reaching an estimated $31.3 billion in 2013. (IHME, 2014)
United States31.7%
World Bank21.2%
United Kingdom
9.5%
UNFPA5.9%Netherlands
3.5%France3.0%
UNICEF2.8%
Japan2.7%
Germany2.2%
Norway1.9%
All Other DAC
12.8%
All Other Multilat-
erals2.8%
NOTES: Amounts in gross US$ disbursements. Health ODA combines data from three OECD CRS sub-sectors: (1) Health; (2) Population Policies/Programs and Reproductive Health (includes HIV/AIDS & STDs); and (3) Other Social Infrastructure and Services - Social Mitigation of HIV/AIDS. SOURCE: Analysis of data obtained via online query of the OECD Development Assistance Committee (DAC) Database and Creditor Reporting System (CRS); November 7, 2012.
Top 10 Donors for Health ODA, 2002 &2010
2002
Total = $4.4 billion
United States34.6%
Global Fund16.5%
United Kingdom
6.6%
World Bank5.1%GAVI
3.8%
EU Institutions2.6%Germany
2.6%
Canada2.5%
France2.3%
Japan2.1%
All Other DAC12.1%
All Other Mul-tilaterals
8.8%
Non-DAC0.4%
2010
Total = $18.4 billion
Global WHO Governance
WHO Corporate Strategy
Global Public Health Goods and WHO management systems Delivering the Corporate Strategy
Regional accountability
Regional WHO Policy and Country Support
Technical support to deliver national health and development goals
Common Criticisms of WHO
• Over-politicized to the detriment of its technical functions• Too bureaucratic• Timid• Overstretched/underfunded• Conflicted• Failing to adapt to change
Report Recommendations on Future of WHO
• Recommendation 1: Core functions should promote and maintain global health security
• Recommendation 2: Provide strategic technical assistance to countries in support of its mission as a provider of global public goods
• Recommendation 3: Staff should align with core functions and leadership priorities
• Recommendation 4: Separate its technical departments from its governance and management by creating two posts of deputy director-general
• Recommendation 5: Appoint the director-general to a single, seven-year term without re-election
• Recommendation 6: Explore concrete and specific collaborations with non-governmental actors
• Recommendation 7: Restructure its regional offices
• Recommendation 8: Match staffing of country offices with needs of host countries
• Recommendation 9: Review how the value added by its regional and country offices could be increased, and its administrative and management costs reduced
Recommendations on WHO (con’t)
UN Health-Related Organizations
• World Health Organization (WHO)• World Bank (WB)• UN Children’s Fund (UNICEF)• UN Population Fund (UNFPA)• UN Program on HIV/AIDS (UNAIDS)• UN Development Program (UNDP)• UN Educations, Scientific and Cultural Organization (UNESCO)• Food and Agriculture Organization (FAO)• World Food Program (WFP)• UN High Commissioner for Refugees (UNHCR)• International Labor Organization (ILO)• UN Environment Program (UNEP)• UN Nations Office on Drugs and Crime (UNODC)• World Trade Organization (WTO)
Source: K. Lee et al 1996, British Medical Journal, 312, pp 302-312
UNAIDS
“An advocate for global action…it leads, strengthens, and supports an expanded response”
Consists of 10 UN agencies:
UNICEF UNFPA UNESCO WFP UNODCWHO UNDP ILO World Bank UNHCR
Functions:• leadership and advocacy • strategic information• tracking, monitoring and evaluation• civil society engagement and partnership • development• mobilization of resources
The Global Fund to Fight AIDS, Tuberculosis and Malaria • A multilateral financing mechanism designed to rapidly provide money to country owned
initiatives addressing three priority diseases
• Board of Directors• Voting: 20 members (including 2 NGOs, various ministries, USAID) • Non-voting: Gates Foundation, WHO, UNAIDS, World Bank
• The 4th Replenishment Conference was held in Washington, D.C. in December 2013 to secure 2014-2016 funding
• Transition to new funding model is underway, providing implementers with flexible timing, better alignment with national strategies and predictability on the level of funding available.
TRP: Technical Review Panel GAC: Grant Approvals Committee
The Global Fund to Fight AIDS, Tuberculosis and Malaria
Private Philanthropy: Top 10 U.S. Foundations by International Giving, 2013
Source: http://foundationcenter.org/gainknowledge/research/keyfacts2013/pdfs/Key_Facts_on_US_Foundations.pdf
Global Development Program• Agricultural Development• Emergency Response• Family Planning• Financial Services for the Poor• Global Libraries• Maternal, Neonatal & Child
Health• Nutrition• Polio• Vaccine Delivery• Water, Sanitation & Hygiene
Global Health Program• Discovery & Translational
Sciences• Enteric and Diarrheal Diseases• HIV• Malaria• Neglected Infectious Diseases• Pneumonia• Tuberculosis
Gates Foundation Global Programming
Gates Foundation 2011/2012 Funding Areas Comparison
Source: Gates Foundation 2012 Report.
• CHAI has reduced prices up to 87 percent for key drugs for HIV, malaria, and TB, and up to 80 percent for HIV diagnostics, saving more than $1 billion in total
• Currently, patients in more than 70 countries pay the reduced prices achieved through CHAI negotiations
Increasing Access to Medicines and Diagnostics Fact Sheet: http://www.clintonhealthaccess.org/news-and-information/access-fact-sheet-feb-2012
Clinton Health Access Initiative (CHAI)
Type of NGO Description Examples
Community-based organizations
Organizations that arise out of people’s own initiatives, i.e., sports clubs, women’s organizations, neighborhood organizations, religious or educational organizations
Coalition of Women Living with HIV/AIDS – Malawi, Concerned Parents and Youth Association-Uganda, Beacon of Hope-Kenya
City-wide organizations
Organizations that either exist for other purposes and become involved in helping the poor as one of their many activities or are created specifically for helping the poor.
Rotary or Lion’s Clubs, chambers of commerce and industry, coalitions for business, ethnic or educational groups and associations of community organizations
National NGOsNational level organizations formed with a purpose for advocating on behalf of a specific part of the population.
The AIDS Support Organisation (TASO)-Uganda, Coalition on Violence against Women-Kenya, Uganda Private Midwives Association
International NGOsOrganizations that provide technical assistance, advocacy support, or funding for local NGOs, institutions or projects.
Save the Children, CARE, FHI, PSI, AMREF, faith-based organizations such as World Vision, World Relief, etc.
Civil Society: Types of NGOs
Source: Top 10 NGO’s from the 100 Best List. The Global Journal. 2012 http://www.miratelinc.com/blog/top-10-ngos-from-the-100-best-list-2012-by-the-global-journal/
Top 10 from the 100 Best NGOs in 2012 (The Global Journal)
US-based NGOs with the highest cumulative overseas health expenditures, 2007-2010
Expenditures shown in millions of 2011 US dollars
Internationally-based NGOs with the highest cumulative overseas health expenditures, 2007-2010
Source: Financing Global Health 2013: Transition in an Age of Austerity. Seattle, WA: IHME, 2014.
Private Sector Involvement in HealthModel Company Description
Public-Private Partnership
Merck & Company ACHAP is a partnership between the Govt of Botswana, Merck and the Gates Foundation to implement a comprehensive approach to prevention, care, treatment and support
Corporate Social Responsibility
ExxonMobil Foundation ExxonMobil Malaria Initiative has committed more than $68 million in funding for programs to fight malaria in 20 different African countries
Training BD Under the leadership of the Government of Kenya, BD is training Kenyan health workers as master trainers in safe blood draw practices
Social Investment Acumen Fund Acumen provides debt/equity investment to strengthen and scale business models that effectively serve the poor
Service Delivery The HealthStore Foundation’s Child and Family Wellness (CFW) shops network
CFW Shops is a micro-franchise system of clinics and drug shops that provide access to essential medicines to marginalized populations in the developing world
Categories of Public-Private PartnershipsPurpose Partnership Examples
Product development Global Alliance for TB Drug Development, International AIDS Vaccine Initiative, Medicines for Malaria Venture and Malaria Vaccine Initiative
Access to health care products Mectizan Donation Programme
Global coordination mechanisms Global Alliance for Vaccines and Immunization (GAVI)
Strengthening health services Global Health Workforce Alliance (WHO)
Public advocacy and education Alliance for Microbicide Development
Regulation and quality assurance
The International Conference on Harmonization of Technical Requirements for Registrations of Pharmaceuticals for Human Use
Source: Nishtar S. 2004
The GAVI mission: “To save children’s lives and protect people’s health by increasing access to immunization in poor countries”
GAVI’s mission is supported by four strategic goals:
WHAT ROLE SHOULD THE US PLAY IN ADDRESSING GLOBAL HEALTH?
Why should the US spend money on global health?
Does the US public engage in global health?
Total
Democrats
Independents
Republicans
30%
24%
30%
39%
30%
29%
31%
32%
31%
40%
30%
20%
Too much About the right amount Too little
NOTE: Don’t know/Refused answers not shown.SOURCE: Kaiser Family Foundation 2013 Survey of Americans on the U.S. Role in Global Health (conducted August 6-20, 2013)
Views of Current Levels of U.S. Global Health Spending By Party IDDo you think the U.S. is now spending too much, too little, or about the right amount on efforts to improve health for people in developing countries?
U.S. Funding for Global Health, FY 2001 - FY 2014
Kaiser Family Foundation, “U.S. Funding for Global Health: The President’s FY 20145Budget Request,” April 2014, http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/
U.S. President’s Global Health Budget Request, FY 2014
Kaiser Family Foundation, “U.S. Funding for Global Health: The President’s FY 20145Budget Request,” April 2014, http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/
U.S. Government’s Global Health Architecture
Independent Agency
Labor
Peace Corps
CDC
HomelandSecurity
Commerce
EPA
The White House
Defense
USDA
NIH
FDA
HRSAPEPFAR
HHSOGHAOPHS
MCC
PMI
Water for Poor
NTD
Avian Influenza
Action Group
Department
Multi-Agency Initiative
Dept. Operating Unit
KEY
CONGRESS
GHI
StateOGACOES
AmbassadorsMissions
USAIDBureaus for: Global Health;
Economic Growth, Agriculture & Trade; Democracy, Conflict,
Humanitarian Assistance
Tanzania: A Coherent Response to AIDS?
WHAT ROLE SHOULD YOU PLAY IN GLOBAL HEALTH?
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