Aid Stagnation, Shifting Disease Burdens, and the SDGs:

Aid Stagnation, Shifting Disease Burdens, and the SDGs: How Will Global Health Meet the Challenges? Gavin Yamey MD MPH Professor of the Practice of Global Health & Public Policy Director, Center for Policy Impact in Global Health Associate Director for Policy, Duke Global Health Institute July 4, 2016

Editorial: wjm, PLOS Medicine, PLOS NTDs Journalism: KFF Global Health Reporting Fellow Policy research: Evidence to Policy initiative (E2Pi), UCSF Teaching: Global health policy

This is my 7 th Geneva trip

Agenda Aims of the course 3 key lenses: - transitions - SDGs - GH2035 What will it take to reach GH2035 goals? How the course addresses post-2015 challenges

Aims of the Course: the 4Cs CRASH COURSE CONTEXT CONNECTIONS CURIOSITY Global health landscape: actors, architecture, governance, financing Evolution of our global health challenges: what lies ahead Policy options for the next era and beyond Where do the Geneva-based global health organizations fit into this picture? What role do they play in meeting the health needs of the world s most vulnerable people? Build personal networks of friends, colleagues, and mentors Ask questions of the world s leading voices in global health

Agenda Aims of the course 3 key lenses: - transitions - SDGs - GH2035 What will it take to reach GH2035 goals? How the course addresses post-2015 challenges

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 1993-2013: Extraordinary Health Progress Female life expectancy at birth for select countries compared to the frontier The frontier line indicates female life expectancy in the best-performing country in that year, which has been Japan for the past 20 years.

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 MDGs Were Catalytic Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action Murray CJ et al, Lancet 2014, Jul 21

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 Unprecedented Mobilization of Aid for Health Figure from Financing Global Health 2013, IHME

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 Scientific Innovations Played a Role

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 1993-2013: Extraordinary Economic Progress Movement of populations from low income to higher income between 1990 and 2011

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 1 Epidemiological & demographic 3 2 Financing Governance 4 MDGs to SDGs

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 The MDGs: Simplicity and Clarity

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 The 17 SDGs: An Expansive Agenda

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 SDG 3: The Global Health Goal Ensure healthy lives and promote wellbeing for all at all ages

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 SDG 3: Targets and Approaches 9 TARGETS 4 MEANS OF IMPLEMENTATION

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 Numeric targets Zero targets SDG 3: The Nine Targets (2030 End Date) 3.1 Reduce global maternal mortality ratio to under 70 per 100,000 live births 3.2 End preventable deaths of newborns and under-five children 3.3 End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases 3.4 Reduce by one-third pre-mature mortality from NCDs 3.5 Strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.6 Halve global deaths and injuries from road traffic accidents 3.7 Ensure universal access to sexual and reproductive health care services 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all 3.9 Substantially reduce number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 SDG 3: The 4 Means of Implementation 3.a Strengthen implementation of Framework Convention on Tobacco Control 3.b Support R&D of vaccines and medicines for the communicable diseases/ncds that primarily affect developing countries, provide access to affordable essential medicines and vaccines, provide access to medicines for all 3.c Increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS 3.d Strengthen capacity of all countries, particularly developing countries, for early warning, risk reduction, and management of national and global health risks

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 Global Health 2035: WDR 1993 @20 Years The World Bank s World Development Report 1993 Evidence-based health expenditures are an investment not only in health but in economic prosperity Additional resources should be spent on cost-effective interventions to address high-burden diseases The Lancet Commission on Investing in Health (chaired by Lawrence Summers and Dean Jamison) Re-examines the case for investing in health Proposes a health investment framework for low- and middle-income countries Provides a roadmap to achieving dramatic gains in global health by 2035

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 2015-2035: Three Domains of Health Challenges High rates of avertable infectious, child, and maternal deaths Global shift towards noncommunicable diseases (NCDs) and injuries Impoverishing medical expenses, unproductive cost increases Unfinished agenda Emerging agenda Cost agenda

Lens 1: Transitions Lens 2: SDGs Lens 3: Global Health 2035 Global Health 2035: 4 Key Findings A grand convergence in health is achievable within our lifetime The returns from investing in health are extremely impressive Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases and injuries Pro-poor pathways to universal health coverage are an efficient way to achieve health and financial protection

Agenda Aims of the course 3 key lenses: - transitions - SDGs - GH2035 What will it take to reach GH2035 goals? How the course addresses post-2015 challenges

The Global Health 2035 Goals A grand convergence in health is achievable within our lifetime The returns from investing in health are extremely impressive Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases and injuries Pro-poor pathways to universal health coverage are an efficient way to achieve health and financial protection

Two Centuries of Divergence; 4C Countries Then Converged Under-five mortality, China and Sweden, 1751-2008 5q0 per 1,000 live births 0 100 200 300 400 Sweden China Gap between China and Sweden 1750 1800 1850 1900 1950 2000 Year

Now on Cusp of a Historical Achievement: Nearly All Countries Could Converge by 2035

Convergence to Which Countries? Diverse group of middle-income countries showed the way Previously had high death rates Low- or lower middle-income in 1991 Achieved high level of health status by 2011 largely because of scale-up of health sector interventions 4C Countries Costa Rica, Cuba, Chile, China We show that nearly all countries could reach the same health status by 2035

Strategy 1: Aggressive Scale-Up of Today s Tools RMNCH, including family planning, pregnancy-related interventions, safe abortion and complications, and maternal nutrition HIV Malaria Tuberculosis Neglected tropical diseases Accelerated scale-up of coverage Global Investment Framework for Women's & Children's Health

Strategy 2: Strengthen Health Delivery Systems Photo: GAVI, the Vaccine Alliance

Strategy 3: Develop Tomorrow s Tools

Factors Accounting for Decline in Child Mortality, LICs and MICs, 1970-2000 Jamison, Murphy, Sandbu. Why Has Under-5 Mortality Decreased at Such Different Rates in Different Countries? Health Economics 2016;48:16-25

Impact and Cost of Convergence Low-income countries Lower middle-income countries Annual deaths averted from 2035 onwards 4.5 million 5.8 million Approximate incremental cost per year, 2016-2035 $25 billion $45 billion Proportion of costs devoted to structural investments in health system 60-70% 30-40% Proportion of health gap closed by existing tools (rest closed by new tools) 2/3 4/5

New Global Map of Disease: Pockets of Poverty Under-5 deaths in rural versus urban India

Global Health 2035: 4 Key Findings A grand convergence in health is achievable within our lifetime The returns from investing in health are extremely impressive Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases and injuries Pro-poor pathways to universal health coverage are an efficient way to achieve health and financial protection

Convergence Has Impressive Benefit: Cost Ratio Further proof that improvements in human survival have economic value well beyond their direct links to GDP Jim Kim World Bank President

Sources of Income to Fund Convergence Economic growth Mobilization of domestic resources Inter-sectoral reallocations and efficiency gains Development assistance for health IMF: low- and lower middleincome countries to add $9.6 trillion/y to GDP from 2015-2035 Cost of convergence ($70 billion/y) is about 1% of anticipated growth Taxation of tobacco, alcohol, sugar, extractive industries Removal of fossil fuel subsidies, health sector efficiency Subsidies account for 6.5% of global GDP Will still be crucial for achieving convergence Health aid will need to evolve to support global functions

Single Greatest Opportunity To Curb NCDs is Tobacco Taxation 50% rise in tobacco price from tax increases in China prevents 20 million deaths + generates extra $20 billion/y in next 50 y additional tax revenue would fall over time but would be higher than current levels even after 50 y largest share of life-years gained is in bottom income quintile

Essential Package of Clinical Interventions WHO best buys NCD Intervention Liver cancer Cervical cancer CVD and diabetes Heart attack Hepatitis B vaccine VIA and treatment of precancerous lesions Counselling and multi-drug therapy for high-risk patients Aspirin

We Recommend Scale-up in All Countries Cost-effective 80% coverage by 2020 would avert 37% of global burden of cardiovascular disease Low coverage Except for hepatitis B vaccine, very low coverage across LICs/MICs Feasible 1 st step for all countries; costs $9bn/y; we argue that HPV vaccine & morphine should be included

Phased Expansion Pathways Choice of packages and expansion pathway will vary with pattern of disease, delivery capacity, domestic health spending

Sudden Price Drops Affect Expansion Pathway For drugs, diagnostics, and vaccines, which can usually be delivered without complex infrastructure, price reductions can sometimes occur very rapidly Price drop might be large enough for intervention to be used earlier in expansion pathway Price

Our Recommendation on UHC: Pro-Poor Pathway (Blue Shading) + essential package for NCDIs

Benefits to Countries of Adopting Pro-Poor UHC 1 Poor gain the most in terms of health and financial risk protection 2 Approach yields high health gains per $ spent 3 Public money is used to address negative externalities of infectious disease transmission 4 Implementation success in many low- and middleincome countries has shown feasibility

Agenda Aims of the course 3 key lenses: - transitions - SDGs - GH2035 What will it take to reach GH2035 goals? How the course addresses post-2015 challenges

Lecture: Women s, Children s and Adolescents Health in the SDG era Site visits: Global Fund, GAVI, WHO SHOC room, FIND & MMV Policy competition: malaria vaccine COURSE ROADMAP 1 Lecture: Global health financing A grand convergence in health is achievable within our lifetime The returns from investing in health are extremely impressive Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases and injuries Pro-poor pathways to universal health coverage are an efficient way to achieve health and financial protection Lecture: Global mental health Panels: Tobacco control, violence and injuries Panel: UHC

Cross-cutting issues: governance, trade, humanitarian intervention COURSE ROADMAP 2 A grand convergence in health is achievable within our lifetime The returns from investing in health are extremely impressive Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases and injuries Pro-poor pathways to universal health coverage are an efficient way to achieve health and financial protection Panel: Governance for global health Site visits: MSF, WTO

Thank you gavin.yamey@duke.edu @gyamey GlobalHealth2035.org #GH2035 @globlhealth2035