The Future of Global Health

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The Future of Global Health

• Jim Yong Kim M.D., Ph.D.
• François Xavier Bagnoud Center for Health and
  Human Rights
• Brigham and Womens Hospital
• Harvard Medical School
• Harvard School of Public Health
• Partners In Health

Global Classroom Columbia University
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The MDR-TB Death Sentence as Public Health Policy

• 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
  countriesit detracts attention and resources
  from treatingdrug-susceptible disease. - WHO
  1997

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August 1996MDR-TB treatment project initiated in
Peru by Socios en Salud and Harvard/Partners in
Health.
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Reduced prices of second-line TB drugs
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Scaling up of DOTS-Plus
Feb 2006 35 projects
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Changes in life expectancy in selected African
countries with high HIV prevalence, 1950 to 2000
65
60
Botswana
Uganda
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South-Africa
Life expectancy at birth, in years
Zambia
50
Zimbabwe
45
40
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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
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Act Up and Initial AIDS Protest Efforts
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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

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Global Protests Surrounding Access to ARVs
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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
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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."
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Number of people receiving ARV therapy in low-
and middle-income countries, 20022006
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Universal Access
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• ls

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HIV Prevention and Treatment Integration into
Primary Health Care
Boucan Carre June 03 VCT with Staff Essential
Meds Community outreach
Boucan Carre March 03
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The four pillars of primary health care
HIV prevention and careintegration into
primary health care services
Womens Health, reproductive health, family
planning, PMTCT
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What does the Rwinkwavu model cost?
New Sites/Capital investment (14)
Administration
Building/ Infrastructure
Labour, excl. accompagnateurs (32)
Referrals
Transport/ Communication
Labour, accompagnateurs only (5)
Social (education, housing, mutuelles,
micro-finance, etc.)
Outpatient Nutritional Support (5)
Supplies (28)
6000 US/Capita
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Lesotho
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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)
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Implementation bottleneck

• Vaccines
• Primary Health Care
• Drug Therapies
• Maternal and ChildHealth Care
• Basic Surgery

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Bill and Melinda Gates Foundation 6.5 BThe
Global Fund 8.6 BPresidents Emergency Plan
for AIDS 15 BInternational Finance Facility 4
BMulti-Country HIV/AIDS Program 1.1 BGlobal
Alliance 3 BPublic-private partnerships 1.2
BAnti-Malaria Initiative in Africa (proposed)
1.2 BUnited 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
2006311(5758)162-167.
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Gates grants
GATES GRANTS 448M - new health
technologies413M - HIV/AIDS vaccine 258M -
malaria vaccine165M - new malaria drugs 124M
- anti-HIV microbicides115M -
diarrhea/nutrition 106M - TB
vaccines/diagnostics
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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
• gt10 new vaccines

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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

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Harvard Business School Faculty experts on
delivery and operations research
Michael E. Porter, Bishop William Lawrence
University Professor, Harvard University
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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
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Mismatch in Skills Taught and Skills Needed
Bachelors
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
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Is there a place for a new discipline in health
education?
EvaluationSciences
Basic Science
Clinical Science
What is the pathophysiology?
What is the appropriate intervention?
Does the intervention work?
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Is there a place for a new discipline in health
education?
Basic Science
Clinical Science
EvaluationScience
Healthcare Delivery Science
How do we best deliverthe intervention to
everyone?
What is the pathophysiology?
What is the diagnosis and appropriate
intervention?
Does the intervention and delivery model work?
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Global Health in 2007 Increasing Access

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Our Response Building the Field of Global Health
Delivery
Better Health Care Outcomes
Advance Evidence Based Strategies
Build the Field and Disseminate Lessons Learned
Developing Leaders
Improving Service Delivery
Field Test Best Practices with Global Health
Practitioners
Training Programs
Community of Practice EMR Systems
Case Production
Create Innovation Network
Phase II
Phase I
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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

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The Fruits of Advocacy
Bridge to Nowhere- 398 Million
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Before
After
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The Fruits of Advocacy
Bridge to Nowhere- 398 Million
National Security FY2008 war supplemental-
196.4 Billion
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Before
After
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The Fruits of Advocacy
National Security FY2008 war supplemental-
196.4 Billion
Bridge to Nowhere- 398 Million
Corn- 5.1 Billion/yr
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Before
After
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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
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G7 Military Spending and Foreign Aid, 2006
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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

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people committed to leadership in alleviating
human suffering caused by disease. HARVARD
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