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Fundraising ~ Corporate Social Engagement ~ Interactive Services

Susan Raymond, Ph.D.Executive Vice President

February 20, 2014

Health Transitions in the “Developing” World

FUNDRAISING ~ CORPORATE SOCIAL ENGAGEMENT ~ INTERACTIVE SERVICES

The expertise to do it right.The passion to see it through.

ChangingOurWorld.com

Rule Number One in a World of Change

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I always skate to where the puck is going to be.Wayne Gretsky




Objectives

• Review what has changed– In the global health environment– in demographics and epidemiology

• Therefore the disconnect between past ways and current means• Discuss the financial implications of the change• Examine why global health is nearly the last development sector

to have recognized this reality

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What has Changed: The Demographic and Epidemiological Context




Global Health in the 1960s• Only the industrialized countries had reduced infant mortality

below 50 per 1000 live births• Fertility rates in developing countries were high, with an average

of 6 children per woman• Life expectancies were between 40 and 50• Communicable diseases took the majority of lives and took them

at young ages.• Caloric intake in developing nations averaged less than 2000

calories per day




Changed Demographic Future – By 2015

• Infant mortality by 75% since 1950• Child mortality by 80% since 1950• Life expectancy to within 10 years of industrialized

world• Fertility Population growth rates headed toward

replacement levels • Numbers of under-fives decline in absolute terms




Aging of the Developing World

05

101520

1950 1970 1990 2000 2010 2015 2020

% o

f pop

ulat

ion

under 5 over 60

• By 2020, the absolute number of children under five will decline

• A key issue is pace. The U.S. had 70 years for the 65 and over population to grow from 5% to12% of the population. Latin America will have 35 years and the clock started ticking over a decade ago.

Source: World Population Prospects




For Less Developed Nations, Marked Progress

-1

1

3

5

7

1950-55 1960-65 1970-75 1980-85 1990-95 2000-05 2010-15 2020-25

Declining Fertility Rate

Developed Less w/o Least Least

050

100150200250

1950-551960-651970-751980-851990-952000-052010-152020-25

Declining Infant Mortality Rate

Developed Less w/o Least Least

• Fertility is converging• Indeed, the UN reduced

its global population estimate by one billion people

• Infant mortality is plunging; in all but the least developed countries, IMR is now at or below 30

• Child mortality has dropped by 43%





• Life expectancy is rising; in 1950 there was a 30 year difference with industrialized countries; by 2030 it will be 9 years

• HIV/AIDS has taken its toll, but its net demographic impact is critical only in a few nations in Africa, although the financial impact (the "therapeutic mortgage") is a long term economic weight (more later)

303540455055606570758085

1950

-55

1960

-65

1970

-75

1980

-85

1990

-95

2000

-05

2010

-15

2020

-25

More Dev Less w/o Least

Least

Marked Progress (cont’d)





The Wages of Progress: Chronic Disease

• Even in high child and high adult subpopulations in developing regions, non-communicable diseases dominate

• CVD represents three quarters of non-communicable disease deaths

• 80% of CVD deaths occur in developing countries

0

10

20

30

40

50

60

Africa LAC E Med SE Asia

% T

otal

Dea

ths

Death Distribution in High Child/High Adult Mortality Populations

infectious/parasitic noncommunicable injury respiratory

Source: WHO State of the World’s Health




• In all but Sub-Saharan Africa, chronic diseases dominate death rates

• And the level of those death rates in the working ages have not been see in the industrialized world since the 1950s.

0

100

200

300

400

500

600

de

ath

s/1

00

,00

0 a

ge

gro

up

Brazil

India

S Afri

ca

China U.S

.

Russi

a

CVD Death Rates ages 30-59

Male

Female

…Focused on the Workforce

Source: A Race Against Time




• As the working age population expands, and if high death rates continue, the burdon will be on the shoulders of workers.

• In Brazil, between 2000 and 2030, 28% of CVD deaths will be among the workforce, compared to 12% in the U.S.

0102030405060708090

100

% C

VD

de

ath

s

Brazil U.S.

Death Distribution by Age Group 2000-2030

35-44 45-54 55-64 65-74 75 & over

With Higher Portions Dying Earlier

Source: A Race Against Time




….And women are not exempt

0

10

20

30

40

50

60

Argen

tina

Chile

Colom

bia

Ecuad

or

Mex

ico

Peru

S Afri

ca

China

India

% 15-34 Female Mortality due to

mat+HIV chronic

0

10

20

30

40

50

60

Argen

tina

Chile

Colom

bia

Ecuad

or

Mex

ico

Peru

S Afri

ca

China

India

% 35-44 Female Mortality due to

mat+HIV chronic

Source: WHO Mortality Database




This is not about rich men

• Studies in Brazil and South Africa show that the risks associated with chronic disease are higher among the poor in cities than among the rich.

• Just as in the West, chronic disease is coming to be a function of poverty.

• Disability and early death compromise fragile households and result in tens of millions of years of productive life lost. The fastest path to poverty is widowhood, no matter how it happens.

• The threat is compromised economies just as the promise of growth is within our grasp.

A Riff on the Middle East

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The Obese: BMI ≥ 30kg/m2

0

5

10

15

20

25

30

35

40

45

50

% a

dults

Male

Female

16

Source: WHO Global Database on Body Mass Index




02468

101214161820

Percent Adult Population with Diabetes

By 2025, 20% of UAE adult population will be diabetic, 12% in Egypt and even 10% in Jordan and Morocco

How is this NOT “Global Health”?




The rural-urban divide may not apply

0

20

40

60

80

100

Riyadh Jeddah North'n Najran Tabouk Hafr alBatri

Saudi Arabia CVD Hospital Visits Per 1000 Population (2006)

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• In Morocco, hypertension rates are higher in rural than in urban areas. (Bulletin Epidemiologique 2003)

• In Saudi Arabia, CVD-associated diagnoses can represent a higher portion of hospitalizations in rural areas than in Riyadh. (Review of Health Situation, Saudi Arabia 2006)

• In Jordan, 6 provinces have higher CVD death rates than Amman, four of which are largely rural. (Mortality in Jordan, 2004)

0

20

40

60

80

100

120

Amman Irbid Zarqa Balqa Karak Madaba Ajloun

Jordan CVD Death Rate/100,000 2004




Children• There are no trend or cross-region data on childhood obesity.

• A study of King Saud University students showed that 31% were overweight, and another 23% were obese (Al Turki 2006).

• A 2005 study showed that 10-15% of elementary students and 20-40% of secondary students in the Gulf were overweight (Rabbu 2005).

• Unfortunately, these numbers approximate those of the U.S. where 30% of young people are overweight.




CVD as Percent Female Deaths Ages 35-64

0

5

10

15

20

25

30

35

40

45Jo

rdan

Eg

ypt

Bah

rain

UA

E

Qat

ar

Ku

wai

t

Po

rtu

gal

Fra

nce

Sources: WHO Mortality Statistics, Ministries of Health

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How is this NOT

“women’s health”?




CVD Female Death Rates by Age

0

100

200

300

400

500

600

700

35-44 45-54 55-64

Egypt

Kuwait

Bahrain

Qatar

France

Source: WHO Mortality Statistics

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What Changed: The Economic Context

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Yesterday’s Economic Context• Nearly 60% of the world’s population lived on less than $1 per

day• South Korea, Taiwan, Singapore were poor and considered

economic basket cases; the literature considered South Korea to be a likely recipient of global aid for the foreseeable future

• Even by the 1980s, Malaysia, Thailand and Indonesia were poor• India was a recipient of constant relief and a global famine

concern




IMF Projections % Change in Economic Output

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The advanced economies went into the recession deeper, came out slower, and will stabilize at lower rates of growth.




Rising Global Middle Class• By 2030, only 20 years from now, 2 billion people will join the

global middle class.• This will represent 30% of the world’s population, dwarfing the

19th century middle class explosion.• This stretches far beyond the growth of India and China. Nations

with projected Middle Class bulge include– Egypt– Philippines– Indonesia– Mexico– Brazil

India and China per Capita Income Growth

1820-1950 0%1950-1973 68%1973-2002 254%




• By 2030, middle income countries will account for 43% of global GDP (in dollar terms) compared to 15% today.

• The global distribution of income is narrowing. By 2050, middle income individuals will account for 40% of global incomes, compared with 30% today.

• By 2030, Asia Pacific will account for 59% of middle class consumption, compared to 10% in North America and 20% in Europe.

26

Kharas and Gertz, Brookings




And Africa is not the exception.

• By 2040, Africa will have the largest workforce in the world.• 50% of the population will live in cities.• Impact investing in agriculture (Africa accounts for 60% of

uncultivated land in the world) will increase rural incomes.

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• By 2020, half of African households will have discretionary spending power.

• In transition economies (e.g., Tanzania) 72% of GDP will be from manufacturing and services; in diversified economies (e.g., Egypt), 83%.

• Service sectors will create jobs driven by urbanization. In 2020, Johannesburg will be larger than New Delhi. 0

10

20

30

40

50

60

70

80

90

100

2000 2008 2020

% of Households Per Income Bracket

Global

Consuming Middle Class

Emerging Consumers

Basic Consumer Needs

Destitute

Again, Africa is not the exception. African economies are diversifying

28McKinsey & Company




Why does this matter now? The disappearing window of opportunity

% Population Dependent

20

25

30

35

40

45

50

55

60

65

2000 2010 2020 2030 2040

BrazilRussiaIndiaS AfricaChina





So, what is our operating environment?• Marked demographic change• Changing disease patterns, with changing relationships to

behavior• Changing groups of people at risk• Changing implications for economiesWhen• Economies are growing• Internal capacities are growing• Knowledge and education are growing

• Poverty persists, but within an entirely different context.

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This does not mean abandoning the poor….

It means creating a complex business model that can adapt and innovate as operating conditions change.

It means differentiating between relief and development.It means building on change to create self-reliance.

It means working yourself out of a job.

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Why Is This So Hard for Global Health?

(Note Ascension Health innovation in Flint, Michigan points the way)

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1. Visibility of the Problem: Have You Seen Someone Who Looks Like This?

© Changing Our World, Inc. 2006 May not be reproduced without permission. For reprint permission or additional copies, contact Changing Our World, Inc.




Versus: Have You Seen Someone Who Looks Like This?





1. Implications of Visibility

• Yesterday’s Approach• Knew a problem when you saw one• Could be presented pictorially and

gain sympathy• Clearly humanitarian, even relief,

dimensions of the problem• Motivated public concern and

hence provided a rallying point for governments

• Today’s Problems• Risk factors may be visible (smoking,

obesity) but they are common.• Some risk factors may not be visible

at all.• Some risk factors may be considered

self-inflicted.• Presence of disease itself is invisible.• Hard to motivate public concern for

or rally governments to the invisible.• Hard to counter the visible of existing

agendas with the invisible of emerging agendas.





2. Prevention 3. Targets

• Yesterday’s Approach• Clear definition of prevention that can be

distinguished from therapy.• Binary problems = diseases can be

eliminated• Eliminating disease = elimination of the

disease as a cause of death• Today’s Problems• Prevention of risk factors means

prevention of early onset of disease.• Because chronic disease is progressive,

therapy is actually prevention. The question is management not eradication.

• Must invest in both therapy and prevention, but even that will not eradicate disease. Death is the inevitable result of life.

• Yesterday’s Approach• Women of childbearing age, but

usually only their reproductive organs• Children under the age of five• Only for certain diseases and still a

maternal-child health preference• Today’s Problem• Men and women of all ages• Multiple organs• Everyone who is undertaking risk

behaviors• Everyone who is not undertaking risk

behaviors but who might do so, including children over the age of five





4. Skills 5.Timeframe

• Yesterday’s Approach• Therefore, global health could exist in

a “stovepipe” of singular skills and concentration.

• Programs could turn on public health as a profession.

• Today’s Problems• Public health is not the only skill, or

even the most prominent one.• Few programs in public health of

chronic disease.• Medical diagnosis and management,

finance, actuarial sciences, etc.

• Yesterday’s Approach• Projects designed and contracted

over 2 years and implemented over 3-5 years.

• Objectives met in five years• Projects refunded with similar

timeframes if gains not sustained• Today’s Problems• Generational in length.• No clear end point.• Decades of commitment.• Fundamental progress on chronic

disease is a film not a snapshot.





6. Policy Rigidity 7. Governance

• Yesterday’s Approach• Narrow limits on where.• Difficulty in organizing a constituency

for any policy, so tendency to stick with policy as made or risk losing all.

• The wise option is the status quo, even when the status quo does not match the problem.

• Today’s Problem• Developing a way to have a flexible

policy about what and where global health invests, without a policy that invests in everything.

• Integrating health with a plethora of other kinds of policies.

• Yesterday’s Approach• Work with government ministries• Central government dictates to

subsidiary entities• Resource relationship at the level of

central government• Today’s Problem• Rise of local government and

authority• Rise of Civil Society and multiple

points of empowerment• Decreasing central control over local

decisions and resources• Multiple voices, views, and votes




And so……money does not move and does not cause organizational movement

39

Subject matter of grants authorized for Global Programs by foundations 2007-2012

Source: Calculated from the Foundation Center




Highlighted Expertise Areas

•Essential drugs•Reproductive health•HIV/AIDS•Infectious diseases•Malaria•Neglected tropical diseases•Maternal health•Child health•Neonatal health•Gender•Human rights in conflict zones•Relief

Affiliations•UNICEF•Management Sciences for Health•Interaction•amfAR•Save the Children•John Snow International•Population Council•Population Action•American Society for Tropical Medicine and Hygiene•Friends of Africa•AMREF•Center for Human Rights and Public Health•PATH•International HIV/AIDS Alliance

And the incentives to change leadership loci are nonexistent: The new Board of the re-established Global Health Council

40



But, there may be reason to hope…..• UN working groups and resolutions (but so far without money)• Multinational corporate disability cost concerns in emerging

markets• Relatively new interest in performance based financing, which

will force a more comprehensive view of disease• Innovation Fund investment in Pro Mujer• Media coverage

• But, the danger that over-reaching will create controversy and a backlash – TRIPS and the trade/intellectual property dimensions of a “public health crisis”

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And so we return to where we came in, the theme of change

But, perhaps, with a different perspective than that of Wayne Gretzky

The perspective of perhaps the greatest American oracle to ever have graced the stage of this great land.

It’s hard to make predictions, especially about the future.Yogi Berra

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Thank You

fundraising ~ corporate social engagement ~ interactive services new york | london | los angeles |...

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developing world slide

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global population

world of change

epidemiological context

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developing countries