The Unfinished Agenda in Global Health. Richard Skolnik

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1 The Unfinished Agenda in Global Health Richard Skolnik

2 Objectives

3 Objectives: What do poor people in poor countries get sick and die from? What are the risk factors for this burden of disease? What can be done in low cost and highly effective ways to improve the health of the poor in low - income countries?

4 Secondary Objectives: If you only had $100 to spend, Mr. Minister, how would you spend it and why? How would you move Mr. Minister, from burying young people to burying old people, as fast as possible, and at the lowest possible cost?

5 Caveats: Mostly World Bank, but some WHO data Mostly 2001 GBD data, but some later WHO data Data-based but stylized presentation

6 Conclusions of the Unfinished Agenda Important progress, but uneven NCDs now predominate in all but SSA and SA However, the poor still have and will have plenty of CDs, etc Poor still die too often and too young Key risk factors are few nutrition, unsafe sex, water and sanitation, smoking Address the key risk factors, especially with the poor, and make the world a much better place

7 The Burden of Disease

8 Changes in Life Expectancy, , by World Bank Region Source: The World Bank, Key Development Data and Statistics, 2008,

9 Neonatal Mortality Rate, by WHO Region, 2000 Deaths per 1,000 live births Source: Data from World Health Organization. Neonatal and prenatal mortality, country, regional, and global estimates. Geneva: WHO: 2006: Annex 2.

10 Infant Mortality Rate, by World Bank Region, 2007 Deaths per 1,000 live births East Asia and Pacific Europe / Central Asia Latin America / Caribbean Middle East / North Africa South Asia Sub-Saharan Africa Source: World Bank, Socio-Economic Differences in HNP, September 2007.

11 Under-five Child Mortality, by World Bank Region, 2006 Deaths per 1,000 live births Source: Data from the World Bank. World Development Indicators, Data Query. Available at:

12 Maternal Mortality Ratio, by World Bank Region, 2005 Deaths per 100,000 live births East Asia/Pacific Europe/ Central Asia Latin America/ Caribbean Middle East/ North Africa South Asia sub-saharan Africa Source: Data from the World Bank, World Development Indicators, Data Query, Available at

13 Patterns in Disease Burden by Select World Bank Region, 2001 Percent E. Asia / Pacific Latin America / Caribbean Middle East / N. Africa South Asia Sub-Saharan Africa Communicable, maternal, perinatal, and nutritional conditions Noncommunicable diseases Injuries Source: Disease Control Priorities in Developing Countries, second edition, Table 4.1.

14 The Five Leading Causes of Death, by Broad Income Group, 2001 Low income Countries Middle Income Countries High Income Countries Cause Deaths (mill) % of Total Cause Deaths (mill) % of Total Cause Deaths (mill) % of Total 1. Lower respiratory infections Cerebrovascular disease Ischemic heart disease Ischemic heart disease Ischemic heart disease Cerebrovascular disease Diarrheal disease Chronic obstructive pulmonary disease Trachea, bronchus, and lung cancers HIV/AIDS Lower respiratory infections Lower respiratory infections Cerebreovascul r disease Trachea, bronchus lung cancer Chronic obstructive pulmonary disease Source: WHO, Global Burden of Disease and Risk Factors, 2004, Page 12, Table 3.10

15 The Ten Leading Causes of Death in Children Ages 0-14 in Low- and Middle Income Countries, 2001 Cause Deaths (millions) % of Total 1. Perinatal Conditions Lower respiratory infections Diarrheal diseases Malaria Measles HIV/AIDS Congenital anomalies Whooping cough Tetanus Road traffic accidents Source: Global Burden of Disease and Risk Factors, 2006, Table 3.8.

16 The Ten Leading Causes of Death in Adults Ages in Low- and Middle Income Countries, 2001 Cause Deaths (millions) % of Total 1. HIV/AIDS Ischemic heart disease Tuberculosis Road traffic accidents Cerebrovascular disease Self-inflicted injuries Violence Lower respiratory infections Cirrhosis of the liver Chronic obstructive pulmonary disease Source: Global Burden of Disease and Risk Factors, 2006, Table 3.9.

17 The Five Leading Causes of Death, by Sex, in Low- and Middle Income Countries, 2001 Males Females Cause Deaths (millions) % of Total Cause Deaths (millions) % of Total 1. Ischemic heart disease 2. Cerebrovascular disease Ischemic heart disease Cerebrovascular disease Lower respiratory infections 4. Perinatal conditions Lower respiratory infections HIV/AIDS HIV/AIDS Chronic obstructive pulmonary disease Source: Global Burden of Disease and Risk Factors, 2006, Table

18 Selected Causes of Death Among Children Under Five, 2001, for Selected Regions, as a Share of Total Deaths of Under Five Children Acute Respiratory Infections Congenital Anomalies Latin America / Caribbean South Asia Sub-Saharan Africa Diarrheal Disease HIV/AIDS Malaria Measles Perinatal Conditions Source: Data from Lopez, Alan D, Begg, Stephen, and Bos, Ed. Demographic and epidemiological characteristics of major regions, in Jamison, DT, Breman, JG, and Measham, AR, et al, eds. Disease Control Priorities in Developing Countries, 2 nd edition. New York: Oxford University Press, 2006.

19 The Ten Leading Causes of Burden of Disease in DALYs, in Low- and Middle Income Countries, 2001 Cause DALYs (millions of years) 1. Perinatal Conditions Lower respiratory infections Ischemic heart disease HIV/AIDS Cerebrovascular disease Diarrheal diseases Unipolar depressive disorders Malaria Tuberculosis Chronic obstructive pulmonary disease Source: Global Burden of Disease and Risk Factors, 2006, Table % of Total DALYs

20 Estimated Number of People Ages 20 to 79 with Diabetes, By Region, 2003 and 2025 Number of People (millions) Prevalence (percent) Region Developing countries East Asia and the Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa Developed countries World Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 30.1.

21 Risk Factors

22 The Top Ten Risk Factors for Disease (DALYs), Low- and Middle Income Countries, 2001 Risk Factor DALYs (in thousands) 1. Childhood underweight 120, Unsafe sex 80, High blood pressure 78, Smoking 54, Unsafe water, sanitation, and hygiene 51, Alcohol use 49, High cholesterol 42, Indoor air pollution from solid fuels 41, Low fruit and vegetable intake 32, Overweight and obesity 31, % of Total DALYs Source: Data from Global Burden of Disease and Risk Factors, 2006, Table 1.2.

23 Cost Effective Interventions

24 Copenhagen Consensus, Micronutrient supplements for children (vita A and zinc) 2. The Doha development agenda 3. Micronutrient fortification (iron and salt iodization) 4. Expanded immunization coverage for children 5. Biofortication 6. Deworming and other nutrition programs at school 7. Lowering the price of schooling 8. Increase and improve girls schooling 9. Community-based nutrition promotion 10.Provide support for women s reproductive role 11.Heart attack acute management 12. Malaria prevention and treatment 13. Tuberculosis case finding and treatment Source:

25 Cost per DALY Averted in US$ for Selected Health Interventions in South Asia, 2006 Intervention Coronary Bypass Graft Drug and Psychosocial Treatment of Depression Oral Rehydration Therapy for Diarrhea Improved Emergency Obstetric Care TB Treatment Basic Childhood Vaccines $1 $10 $100 $1,000 $10,000 $100,000 Dollars Per DALY Averted Source: Disease Control Priorities in Developing Countries, Figure 2.2.

26 Cost-effectiveness of Interventions for Childhood Conditions in Low- and Middle-Income Countries Condition Intervention Cost-effectiveness Ratio ($ per DALY averted) Lower acute respiratory infection (0-4 years) Underweight child (0-4 years) Childhood illness Tuberculosis, diphtheriapertussis-tetanus, polio, measles Case management at community, facility, and hospital levels 398 Child survival program with nutrition component 42 Integrated management of childhood illness 39* Traditional Expanded Program on Immunization 7 Note: *Sub-Saharan Africa only. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2.

27 Cost-effectiveness of Interventions for Maternal and Perinatal Conditions Intervention Package (Beyond Routine Maternity Care) Incremental Cost per DALY Averted South Asia Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table Sub-Saharan Africa Increased primary-level coverage $148 $92 Improved quality of care with nutritional supplements $142 $83 Improved quality of care without nutritional supplements $240 $77 Improved quality of comprehensive emergency obstetric care $255 $151 Improved quality of care and coverage with nutritional supplements $144 $86 Improved quality of care and coverage without nutritional supplements $203 $84

28 Annual Cost per Person of Nutritional Programs Intervention Cost Conditional Cash Transfer $ $77.00 Iron Supplements $ $3.17 Vitamin A Supplements $ $2.55 Nutrition Education $2.50 Salt Iodization $ $0.50 Source: World Bank, Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action (2006): Table 1.2.

29 Cost-effectiveness of Selected Malaria Interventions Intervention Mean Cost per DALY Averted Insecticide-treated bednets (net + insecticide treatment) $11-$17 Insecticide-treated bednets (without provision of nets) $5-$11 Indoor residual spraying (1 round) $9-$12 Indoor residual spraying (2 rounds) $17-$24 Intermittent preventive therapy during pregnancy $13-$24 Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 21.6.

30 Cost-effectiveness of Interventions for Epidemic Tuberculosis in Low- and Middle-Income Countries Intervention Cost-effectiveness Ratio ($ per DALY averted) Management of drug resistant TB Treatment for latent TB DOTS for infectious TB Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2.

31 Cost-effectiveness of Interventions for HIV/AIDS Prevention in Low- and Middle-Income Countries Intervention Cost-effectiveness Ratio ($ per DALY averted) Prevention of mother-tochild transmission Blood and needle safety* Condom promotion and distribution* Diagnosis and treatment of STIs* Voluntary counseling and testing Peer education for high-risk groups 6-68 Note: *Sub-Saharan Africa only. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2

32 Cost-effectiveness of Interventions for HIV/AIDS Treatment in Low- and Middle-Income Countries Intervention Cost-effectiveness Ratio ($ per DALY averted) Treatment of Kaposi's sarcoma 34,968-69,930 Antiretroviral therapy 350-1,494* Home care 673* Treatment of opportunistic infections Prevention and treatment of tuberculosis co-infection 6-235* Note: *Sub-Saharan Africa only. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2.

33 Conclusions of the Unfinished Agenda Important progress, but uneven NCDs now predominate in all but SSA However, the poor still have and will have plenty of CDs, etc Poor still die too often and too young Key risk factors are few nutrition, unsafe sex, water and sanitation, smoking Address the key risk factors, especially with the poor, and make the world a much better place

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