The Future of Global Health
Jim Yong Kim M.D., Ph.D.
François Xavier Bagnoud Center for Health and Human Rights
Brigham and Women’s Hospital
Harvard Medical School
Harvard School of Public Health
Partners In Health
Global Classroom
Columbia University
The MDR-TB Death Sentence as Public Health Policy
“In developing countries,
people with multidrugresistant 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 treating
drug-susceptible disease.”
- WHO 1997
August 1996
MDR-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
Amikacin
% Decline
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
40
Projects approved
35
Feb 2006 – 35 projects
30
25
20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
Changes in life expectancy in selected African countries
with high HIV prevalence, 1950 to 2000
65
60
Botswana
Uganda
55
South-Africa
Zambia
50
Zimbabwe
45
40
35
1950-55 1955-60 1960-65 1965-70 1970-75 1975-80 1980-85 1985-90 1990-95 1995-00
Source: United Nations Population Division, 1998
4
Act Up and Initial AIDS Protest Efforts
Objections to Treatment
July 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 TIMES
11/30/2003
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 $300 a year -which places a tremendous possibility
within our grasp. Ladies and gentlemen,
seldom has history offered a greater
opportunity to do so much for so many”
January 28, 2003
"The British government has
learned that Saddam Hussein
recently sought significant
quantities of uranium from
Africa."
Number of people receiving ARV therapy in low- and
middle-income countries, 2002—2006
1 800
North Africa and the Middle East
Europe and Central Asia
1 600
East, South and South-East Asia
Latin America and the Caribbean
1 400
Sub-Saharan Africa
1 200
1 000
800
600
400
200
6
en d
- 200
006
mid
-2
200
5
en d
005
mid
-2
200
4
en d
004
mid
-2
200
3
en d
003
mid
-2
200
2
0
en d
People receiving ARV therapy (in thousands)
2 000
Universal Access
2005 G8 Summit at Gleneagles, Final Communiqué:
“…working with WHO, UNAIDS and other international
bodies to develop and implement a package of HIV
prevention, treatment and care, with the aim of as
close as possible to universal access to treatment for
all those who need it by 2010.”
• ls
HIV Prevention and Treatment
Integration into Primary Health Care
Boucan Carre June
03:
VCT with
Staff
Essential Meds
Community outreach
Boucan Carre March 03
Women’s Health, reproductive health,
family planning, PMTCT
HIV prevention and care—integration
into primary health care services
The four
pillars of
primary health
care
What does the ‘Rwinkwavu’ model cost?
Summary of detailed unit costing, extrapolated
to a full district
Estimated ‘catchment’ area of unit
100% = US$ 4.7 million in ‘steady state’ (2011)
100% = 265,000
New Sites/Capital investment (14%)
Administration
Building/
Infrastructure
Labour, excl.
accompagnateurs
Referrals
(32%)
Transport/
Communication
Methodology:
Rwinkwavu
Rwinkwavu
SOUTHERN KAYONZA
SOUTHERN KAYONZA
Rukira
Rukira
Mulindi
Mulindi
Labour,
accompagnateurs
only (5%)
Social (education,
housing, mutuelles,
micro-finance, etc.)
Supplies
(28%)
Outpatient
Nutritional
Support (5%)
~25 US$/Capita
Theoretical
catchment area
+ Patients coming
from other areas
(based on survey)
- Overlaps
between centres
= Actual population
served
Murama
~6000 US$/Capita
Lesotho
KZN XDRTB Survey
Patient Characteristics*
Characteristics
• No prior TB Treatment
• Prior TB treatment
– Cure or Completed treatment
– Treatment Default or Failure
• HIV-infected (44 tested)
• Dead (Includes 34% on ARV)
• Identical M. tb spoligotype
No. (%)
26 (51)
14 (28)
7 (14)
44 (100)
52 (98)
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 bottleneck
• Vaccines
• Primary Health
Care
• Drug Therapies
• Maternal and Child
Health 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 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 +
•
•
•
•
•
Vaccines
Primary Health Care
Drug therapies
Maternal Child Health Care
Basic Surgery
Gates 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
• Markets not working;
incentive misalignment
• Slow diffusion of knowledge
• Lack of management skills
• Inadequate funding of
infrastructure development
Health care delivery is a complex,
multidimensional phenomenon
that is difficult to understand
and even more difficult to
manage
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
•No defined
degree
program in
global health
•Focus on
quantitative
methodology
and research
•Broad liberal
arts courses on
on social or
basic science
•Populationlevel
interventions
•Field-work on
an ad-hoc
basis
•Field-work on
an ad-hoc
basis
MBA/MPA
MD
•Private/public
management
emphasis
•Focus on
clinical and
basic science
•Little
discussion of
work in
resource-poor
settings
•Little
education on
health care
delivery or
public health
issues
•No education
of health
science
•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?
Basic
Science
Clinical
Science
Evaluation
Sciences
What is the
pathophysiology?
What is the
appropriate
intervention?
Does the
intervention
work?
Is there a place for a new discipline
in health education?
Basic
Science
Clinical
Science
Healthcare
Delivery
Science
What is the
pathophysiology?
What is the
diagnosis and
appropriate
intervention?
How do we
best deliver
the intervention
to everyone?
Evaluation
Science
Does the
intervention
and delivery
model work?
Global Health in 2007: Increasing Access
Our Response:
Building the Field of Global Health Delivery
Better Health
Care
Outcomes
Advance Evidence
Based Strategies
Improving
Service Delivery
Community of Practice
EMR Systems
Phase I
Developing
Leaders
Build the Field and
Disseminate
Lessons Learned
Training
Programs
Field Test Best Practices
with Global Health
Practitioners
Case Production
Create Innovation
Network
Phase II
Objections to HIV Treatment
April 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
“Bridge to Nowhere”- $ 398 Million
Before
After
The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million
National Security: FY2008 war
supplemental- $196.4 Billion
Before
After
The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million
Corn- $5.1 Billion/yr
National Security: FY2008 war
supplemental- $196.4 Billion
Before
After
The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million
Corn- $5.1 Billion/yr
National Security: FY2008 war
supplemental- $196.4 Billion
Sugar- up to $1.9 Billion/yr
G7 Military Spending and Foreign Aid, 2006
Military Spending
Foreign Aid
600
522
500
$ Billions
400
300
200
100
51.1
44.7
41.6
30.2
27.5
13.1
10.8
10.1
Japan
France
9.92
17.2
5.05
10.9 3.73
0
United
States
United
Kingdom
Germany
Italy
Canada
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
committed
to leadership in
alleviating human
suffering caused
by disease.”
HARVARD MEDICAL SCHOOL
MISSION STATEMENT