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Introduction to Global HealthIntroduction to Global Health
September 30, 2011September 30, 2011
Amira Roess, PhD, MPHGW SPHHS, Dept Global Health
Slides adapted from Introduction to Global Health and Development i h d Sk l ik i C l iLectures, Richard Skolnik, Dr, Uriyoan Colon‐Ramos, Dr. Amira Roess,
Tova Reichel, Dr. Victor Barbeiro and from UN, USAID, UNAIDS written material
Learning objectivesLearning objectives
At the end of this lecture you should understand:• The key actors in global health and the manner in which they can cooperate to address critical global health issues.health issues.
• Key public health concepts, including: – the demographic and epidemiological transitions, the burden of diseaseburden of disease
– the determinants of health and risk factors for conditions of importance to global health. th b d f di i i i f th ld h– the burden of disease in various regions of the world, how it varies both within and across countries, and how the disease burden can be addressed in cost‐effective ways.
Life ExpectancyProgress Or Problems?
85
95
2015
2050Polio Eradicated/Certified (2010??)
45
75
85
1900
1980
2015
Penicillin Mass-Produced 1944Smallpox Eradicated 1979
35
45
PreHist
1789
1900 Penicillin Mass Produced 1944
Malaria (Ross/Manson/Grassi - Late 1800s)
18
0 20 40 60 80 100
PreHist
Y f Lif E tYears of Life Expectancy
Regonal trends in life expectancy
80
90
2000
70
s
N. America
Europe
50
60
Yea
rs p
L. America Impact of HIV??Impact of HIV??
40
50
Asia
Africa
301925 1950 1975 2000 2025 2050
Source: United Nations 2008 Population Council
Population/Family Planningh lThe Development Imperative
7
8T O T A L L D C D C
4
5
6
ns o
f Peo
ple
2
3
Bill
ion
0
1
1 9 5 0 1 9 6 0 1 9 7 0 1 9 8 0 1 9 9 0 2 0 0 0 2 0 1 0 2 0 2 0
The Demographic TransitionThe Demographic Transition
The Epidemiologic TransitionThe Epidemiologic Transition
~2005
Approximately 10.6 Million Children Die Annually (~70% From 5 Major Causes)From 5 Major Causes)
Malaria10% Pneumonia
UNICEF 2007 estimates 9.7 millionUNICEF 2007 estimates 9.7 million
18%Congenital
4%Measles
5%Other17%
DiarrheaInjuries
Malnutrition 56%
15%
HIV/AIDS3%
j3%
Birth TraumaBirth TraumaNeonatal DeathsNeonatal Deaths
Perinatal25%
3% TetanusTetanusFeverFeverLow Birth WeightLow Birth WeightSource: Lopez, et. al., 2006
How does the global community respond?
How does the global community respond?
Millennium Development Goals
See UN reports for more detailshttp://www.un.org/millenniumgoals/bkgd.shtmlhttp://www.mdgmonitor.org/
Why the MDGs ?y
The 1990s: a decade of faltering progressprogress continued
… but too slowly to reach agreed targets
… and slowing down d li Under‐5 mortality rate
Maternal mortality rate
Child malnutrition
Water and sanitation
Income poverty
Primary education
MDGsMDGs are are meantmeant to to accelerateaccelerate progressprogress
MDGs were set by all Government leaders at theUN Millennium Summit, September 2000)
All UN organisations decided to be guided byMDGs in their future action: unity of purpose,coherent action synergies and strategic approachescoherent action, synergies and strategic approachesby the UN system as a whole (guided by CEB)
Leaders pledged to strive individually andLeaders pledged to strive, individually andcollectively, towards these goals throughinternational, regional and national action,
d b hconcerted by the UN.
MDGs are a combination ofMDGs are a combination of …
Millennium Goals …– Emanate from UN Summits and Conferences of the 1990s…– … proposed in the UN Secretary‐General’sMillennium Report:
« We, the peoples: the role of the United Nations in the 21st century »century
– … and endorsed in the United Nations Millennium Declaration (8 September 2000)
7 areas explicitly addressed in the Millennium Declaration:• Peace, security and disarmament• Development and poverty eradication• Protecting our common environment
Development goals& targetsProtecting our common environment
• Human rights, democracy and good governance• Protecting the vulnerable
M ti th i l d f Af i
g
• Meeting the special needs of Africa• Strengthening the United Nations
… and of International Development Goals… and of International Development Goals (IDGs)
F l f th k ifi i di t• For several of these key areas, specific indicators were included in the Millennium Declaration – constituting the international development goals (IDG)
• Subsequently, IDGs from other declarations were combinedSubsequently, IDGs from other declarations were combined and harmonised with the IDGs set in the Millennium Declaration goals
• The resulting set of goals, numerical targets and quantifiable indicators to assess progress constitute thequantifiable indicators to assess progress constitute the Millennium Development Goals…
• … presented in the SG’s “Road map towards the implementation of the United Nations Millenniumimplementation of the United Nations Millennium Declaration” (September 2001)
Millennium Development GoalsMillennium Development Goals
1 Eradicate poverty and hunger1. Eradicate poverty and hunger
2. Universal education
3. Gender equality and equity
4. Reduce child mortality & infectious diseases
5. Reduce maternal mortality
6 Combat HIV/AIDS6. Combat HIV/AIDS
7. Ensure environmental stability
8. Global partnership for development
What makes up the “global p gcommunity”?
ActorsHealth governance model
State:Policymakers
Private ProvidersClients/Citizen
Adapted from: Brinkerhoff – RTI International Governance Presentation. USAID Mini University 2007
UNUNAIDS
BilateralAustralian AID
UNDPUNFPAUNICEF
Canadian IDADanish IDADept Intl. Dev UK
WHO Dutch AD CoopNorwegian AD CoopUSAID
MultilateralAfrican Development Bank (DB)
NGOCARECatholic Relief Services
FoundationsAga Khan Gates Foundation
Asian DBInter-American DBWorld Bank
Doctors without BordersSave the ChildrenPartners in Health
Clinton Foundation Rockefeller…
International Health ProgramsGlobal Alliance for Vaccines and Immunization (GAVI)Global Alliance for Vaccines and Immunization (GAVI)
Global Fund to Fight Against AIDS, TB, MalariaTropical Disease Research Program
UN Health‐Related Organizations
1 WHO 8 UN High Commission for1. WHO
2. World Bank
3 UN Children’s Fund
8. UN High Commission for Refugees (UNHCR)
9. International Labor 3. UN Children s Fund
(UNICEF)
4 UN Population Fund
Organization (ILO)10. UN Environment Program
4. UN Population Fund (UNFPA)
5 UNESCO
11. UN Fund for Drug Abuse Control
12 Standing Committee5. UNESCO
6. FAO
7 World Food Program
12. Standing Committee Nutrition (UNSCN)
7. World Food Program
Source: Merson, et. al., pg 670
Host Governments (first and foremost)Host Governments (first and foremost)
• Ministry of Health and Social WelfareMinistry of Health and Social Welfare
• Ministry of Finance
i i f d i• Ministry of Education
• Ministry of Labor
• Office of the President/Prime Minister
• OthersOthers…
Six WHO Regions…
• Note that the WHO regions are not the same as those of the United Nations• Note that the WHO regions are not the same as those of the United Nations.
• EMRO – Eastern Mediterranean Regional Office (green)
• WPRO – Western Pacific Regional Office (dark red)
• SEARO South East Asian Regional Office (dark blue)• SEARO – South East Asian Regional Office (dark blue)
• AFRO – Africa Regional Office (cream)
• PAHO – Pan American Health Organization (red)
• EURO/WHO European Regional Office/World Health Organization (Geneva) (blue)• EURO/WHO – European Regional Office/World Health Organization (Geneva) (blue)
U.S. System for Global Cooperationy p
• United State Agency for International Development (USAID)p ( )– US foreign assistance agency.
– Economic growth, agriculture, trade.Economic growth, agriculture, trade.
– Global health (HIV/AIDS, Nutrition, International Development, etc). p , )
– Democracy, conflicted prevention, humanitarian assistance.
U.S. System for Global Cooperationy p
• Centers for Disease Control and Prevention (CDC)Clinical expertise: Disease and outbreak–Clinical expertise: Disease and outbreak control
M it d t t d t h–Monitor, detect, conduct research.
–Develop, advocate, implement
–Applied research
U.S. System for Global CooperationU.S. System for Global Cooperation
• National Institutes of Health – Fogarty• National Institutes of Health – Fogarty International Center (NIH)– Scientific Research and Training US and international
–AIDS/TB, behavioral research, communications, maternal and child health, Vaccine development and testing, etc.
Foundation Global Cooperationp
G t F d ti HIV/AIDS t l h lth• Gates Foundation – HIV/AIDS, neonatal health, immunizations, new vaccines
• Clinton Foundation– climate change HIV/AIDS &• Clinton Foundation climate change, HIV/AIDS & Malaria, Childhood obesity, sustainable development
• Rockefeller Foundation – surveillance networks, health systems, investment, social problems.A Kh i hi li• Aga Khan: community partnerships, policy dialogue, sustainable health systems.
ActorsH l h d lHealth governance model
I t ti lUN
State:Policymakers
International Donors
Host Government UNi iti UNuniversities
Funding
Foundations
Private ProvidersClients/Citizen UN
universities
Adapted from: Brinkerhoff – RTI International Governance Presentation. USAID Mini University 2007
NGOUN
Issues facing the Global Health AidIssues facing the Global Health Aid
• Inadequate funding (country and partner)
• Multiplicity of donors and initiatives fragmentation overload of countries
• Multiple plans, assessments, monitoring approaches, reportingMultiple plans, assessments, monitoring approaches, reporting requirements
• Donors set priorities – countries not in the lead
W k h l h d h• Weak health systems and human resources
• “Vertical” programs fail to build sustainable systems and country capacity
• Lack of transparency and accountability p y y
• “Health system strengthening investments” not always translated into better health outcomes
I i t t tt ti t RESULTS• Inconsistent attention to RESULTS
Source: Wright et al. Mini Univeristy 2007
Paris Declaration on AID Effectiveness 2005Paris Declaration on AID Effectiveness 2005
• Ownership: Partner countries exercise effective leadership over their development policies and strategies and co ordinate development actionsdevelopment policies and strategies and co‐ordinate development actions
• Alignment: Donors base their overall support on partner countries’ national development strategies, institutions, and proceduresp g , , p
• Harmonization: Donors’ actions are more harmonized, transparent, and collectively effective
• Managing results: Managing resources and improving decision‐making for results
• Mutual accountability: Donors and partners are accountable for development results
MDG‐1: two targets and five indicatorsMDG‐1: two targets and five indicatorsMillennium Development Goal 1 Initiative
target
1. Poverty Target:Halve, by 2015, the proportion
of people on income of less than
2. Hunger Target:Halve, by 2015, the
proportion of people who ff f h
TWO TARGETS
ONE GOAL
$US1 a day suffer from hunger
* 4. Prevalence of underweight children under 5 (UNICEF-WHO)
1. Proportion of population living
2. Poverty gap ratio [incidence x
TARGETS
FIVE Currently 146 million children under 51
5. Proportion of population below i i l l f di t
below $US1 (World Bank)
depth of poverty] (WB)
3. Share of poorest i til i ti l
INDICATORS
minimum level of dietary energy consumption (FAO)
Currently 852 million2 (of which approximately 350-400 million3 are children under 18 plus pregnant and lactating women)
quintile in national consumption (WB)
* Key Impact Indicator p p g g )
1. Progress for Children: A Report Card on Nutrition (UNICEF, 2006); 2. State of Food Insecurity in the World (FAO, 2004); 3. WFP working estimate
Indicator
TITLE: Goal, target and key impact indicator for the End Child Hunger Initiative.SOURCE: Millennium Summit, September 2000.
Effective interventionsEffective interventions
• Increasing/improvingIncreasing/improving breastfeeding/complementary feeding
• Micronutrient intake• Micronutrient intake
• Diarrhea and parasite control
• Treatment of severe acute malnutrition
• Household food securityy
REACH 2009‐2011 Partnershipp
Boston Consulting Group
Boston Consulting Group
SummaryT di i llTraditionally…
• Public health approachPublic health approach– Forced testing
Compulsory treatment and Isolation– Compulsory treatment and Isolation
• Vertical financing to horizontal financing
• Donors ownership
• International sustainability vs. in‐country sustainability
SSummaryGlobal Health Approach and Agenda 2009:
M i ‘ i h ’• More attention to ‘rights’– Human rights framework to policies, programs.
• More attention to voice of the vulnerableMore attention to voice of the vulnerable– Mothers, children, girls.– Neglected tropical diseases.C lt ll i t h i t ti t diti l– Culturally‐appropriate approaches, integration traditional medicine.
• More attention to partnerships public ‐private.– Innovation, business models– Improved information sharing– Cross‐sectoral, cross‐disciplinesCross sectoral, cross disciplines
Graphic or photo and text slideGraphic or photo and text slide
• Click to add textClick to add text
INSERT GRAPHIC TO ADD PHOTO
Bilateral Donor Funding Levels FY 2004Bilateral Donor Funding Levels FY 2004
10000
12000
6000
8000
2000
4000
0USG Britan Japan Fran Ger Den SIDA CIDA EC
USG Britan Japan Fran Ger Den SIDA CIDA ECUSG Britan Japan Fran Ger Den SIDA CIDA EC
Grants/loans in 2006Source: Wright et al. Mini Univeristy 2007
Grants/loans in 2006
All Donors – Top Ten Recipients (2004‐)2005)
1. Iraq 6. India$ b ll$12.924 billion
1. Nigeria$3.160 billion
$1.785 billion7. Ghana
$1 394 billion2. China
$2.682 billion3. Afghanistan
$1.394 billion8. Egypt
$1.319 billion3. Afghanistan $1.946 billion
4. Indonesia$1.867 billion
9. Vietnam$1.312 billion
10 S d$
10.Sudan$1.163 billion
United States – Top Ten Recipients ( )(2004‐2005)
6. Jordan1. Iraq
$6.926 billion2 Afghanistan
6. Jordan$368 million
7. Colombia2. Afghanistan
$1.060 billion3. Egypt
$366 million6. Palestinian Authority
$227 milliongyp$750 million
4. Sudan$575 million
$227 million7. Uganda
$225 million$575 million
5. Ethiopia$552 million
8. Pakistan$224 million
Emerging Donor CountriesEmerging Donor Countries
• ChinaChina
• Russia
il• Brazil
• India
• South Africa
• MexicoMexico
Measuring the Burden of DiseaseMeasuring the Burden of Disease
• HALE (Health‐Adjusted Life Expectancy) ‐ Number of years to be lived in the equivalent of good health
• DALY (Disability Adjusted Life Year) ‐Measure of t d th d l d t ill dpremature deaths and losses due to illness and
disabilities in a population‐more frequently used
Brief introduction to DALY
• DALY = sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years p y p pLost due to Disability (YLD) for incident cases of the health condition– DALY= YLL+YDL
• YLL = number of deaths multiplied by the standard life expectancy at the age at which death occurs– YLL = N x L
N b f d th– N = number of deaths
– L = standard life expectancy at age of death in years
Brief introduction to DALY
• To estimate YDL for a particular cause in a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale fromreflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). – YDL = I x DW x LYDL I x DW x L
– I = Number of incident cases
– DW = disability weight
– L = average duration of the case until remission or
death (years)
The Global Burden of Disease• Causes of death for low‐ and middle‐income countries:countries:‐ Non‐communicable diseases (** %)‐ Communicable diseases (** %)‐ Injuries (** %)
• Causes of death for high‐income countries:bl d (** )‐ Non‐communicable diseases (** %)
‐ Injuries (** %)Communicable diseases (** %)‐ Communicable diseases ( %)
The Global Burden of Disease• Causes of death for low‐ and middle‐income countries:countries:‐ Non‐communicable diseases (54 %)‐ Communicable diseases (36%)‐ Injuries (10 %)
• Causes of death for high‐income countries:bl d ( )‐ Non‐communicable diseases (87%)
‐ Injuries (7.5 %)Communicable diseases (5 7%)‐ Communicable diseases (5.7%)
The Global Burden of DiseaseThe Global Burden of Disease
• Leading causes of DALYs for low‐ and middle‐income countries:‐ Perinatal conditionsLower respiratory infections‐ Lower respiratory infections
‐ Ischemic heart disease
• Leading causes of DALYs for high‐income countries:‐ Ischemic heart diseaseCerebro asc lar disease‐ Cerebrovascular disease
‐ Unipolar depressive disorders
Other Burden of Disease Breakdowns of Importance
• Causes of death/DALYs by region‐ the higher the income within the region, the more likely it is that the leading causes of burden of disease is non‐communicable‐Why?y
• Causes of death/DALYs by age‐ children in low and middle income countries die more from communicable diseasesincome countries die more from communicable diseases compared to high income countries
• Causes of death/DALYs by sex – heart disease and stroke are leading cause of death among males and females– Diabetes has become one of the 10 leading cause of death among g g
female– Road traffic accidents are more prevalent among male
Check this website: http://www.who.int/healthinfo/global_burden_disease/en/index.html
Deaths and Disease within Countries Vary By
G d• Gender
• Urban vs rural location
• Ethnicity
• Education
• Socioeconomic Status
Trends
• Life expectancy has improved in all regions of the world since 1990, except in Europe and Central Asia and in Sub‐Saharan Africa
• Communicable diseases will continue to be veryCommunicable diseases will continue to be very important to the burden of disease in South Asia and Sub‐Saharan Africa
• When will non‐communicable disease start becoming equally important for these countries?becoming equally important for these countries?
Risk Factors
• NCD is attributed to: – Personal behavior and life style– Environmental exposure– Inherited characteristics
C di i b i k f• Condition to become a risk factor: – Should have epidemiological evidence known to be associated with health related conditions
• How are risk factors related with determinants of health?
• Differences in risk factors between low‐middle income countries and high income countries‐ how does it look like?does it look like?
The transitions
• Demographic: A transition from high fertility and high mortality to low fertility and low mortalityy y y– Where‐
– How – hygiene and nutrition improved and also had an epidemiological transition (are these related?)
• Epidemiological: from communicable to non‐i bl dicommunicable diseases
– Where?
How? Improvements of the determinants of health public– How? Improvements of the determinants of health, public health interventions and also medicine
• How are these related to the ‘age’ of a country? WhatHow are these related to the age of a country? What other factors contribute?
Types of Population pyramid reflecting demographic transition
Implications of the transitions
• Low and middle income countries –– Decision about where the fund is to spent by a country
– More focus on young generation with high fertility for education and health
M i i bl di– More on preventing communicable diseases
• High income countries ‐– more on elderly and retired people
– More on non‐communicable diseases
How can a rapid transition be achievedHow can a rapid transition be achieved
• Lessons from the transitioned countries: – Focusing on investment in nutrition, health and education targeted for poor people (reduce the inequity)
– Improve people’s knowledge of good hygiene p p p g g yg– Making selected cost‐effective and high impact investments – e.g. vaccination for children and TB control A t i GDP h di t li l ti hi t th– A countries GDP has a direct linear relationship to the transitions but may not be causing it…e.g. Kerala
• What are the other factors?
– Healthy Human resource is a precondition of development
Main MessagesMain Messages
A b f f t i fl h lth t t• A number of factors influence health status• Risk factors are central to health and to addressing health concernsaddressing health concerns
• Policy making needs to be data driven• Cardiovascular disease is now the leading cause ofCardiovascular disease is now the leading cause of death worldwide
• The poorest countries have a relatively larger burden from communicable diseases than from non‐communicable diseases
Department of Global HealthDepartment of Global Health
• Epidemiology ID, EZIDD h Ethi i• Demography, Ethiopia
• Nutrition, Food Security• NCDNCD• mHealth technologies• Diaspora health• HIV/AIDS China, Middle East• Development, Conditional Cash Transfer