Michael MersonDirector, Duke Global Health InstituteWolfgang Joklik Professor of Global Health

Partners in Global Health

WHY DO WE NEED GLOBAL COOPERATION IN HEALTH?

For Security: Threats of Disease Globalization

• Communicable diseases: a disease in one country is a threat to others

• Since the 1970s, newly emerging infectious diseases have been identified at the unprecedented rate of one or more per year

• There are now nearly 40 diseases that were unknown a generation ago

Emerging andRe-emerging Infections

Source: Morens et al. 2004

Probable SARS Transmission on Flight CA112 in March 2003

Source: Osen SJ et al.

2014 Ebola Outbreak in West Africa - Outbreak Distribution Map

Direct Economic Impact of Selected Infectious Disease Outbreaks: 1990-2003

Source: Marsh TL, Shroeder TC, Mintert J. Impacts of meat product recalls on consumer demand in the USA. Applied Economics, 2004, 36:897–909.

• GSK

Antimicrobial Resistance

For Diplomacy

• Can perform when politics fail• Can serve as valuable ambassadors of goodwill • Can build bridges and trust by engaging with citizens

from other countries

CITIZENS (scientists, health providers, students)

CIVIL SOCIETY ORGANIZATIONS (universities, NGOs, and professional

societies)

PRIVATE COMPANIES

• Today over 35% of articles published in international journals are internationally collaborative, up from 25% 15 years ago

• The number of internationally co-authored papers has more than doubled since 1990

For Scientific Research

For Sustainable Development

Investing in health makes economic sense:• Countries with poor health

have more difficulty achieving sustained economic growth

• 10% improvement in life expectancy is associated with economic growth of about 0.3%

Source: Report of the WHO Commission on Macroeconomics and Health: World Health Organization; 2002.

For Health Commodity • Global healthcare industry is

worth over US$3.5 trillion annually

• Health services, research, pharmaceuticals and medical devices are international commodities and are an important part of global economies

• Health commodities, as objects of trade, are open to regulation by international trade agreements

• WTO: Trade-Related Aspects of Intellectual Property Rights

For Global Public Good

• Benefit society as a whole• Address issues in which the

international community has a common interest

• Share the protection of health worldwide

• Examples:• Smallpox eradication• Polio eradication• Global HIV Vaccine Enterprise• WHO Framework Convention

on Tobacco Control• Revision of the International

Health Regulations

For Human Rights• The right to health has been

enshrined in numerous international and regional human rights treaties as well as national constitutions all over the world

• The WHO Constitution states: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without the distinction of race, religion, political belief, economic or social condition.”

For Addressing Global Health Policy Issues

• Tobacco• Obesity• Universal health coverage• Access to ARVs • Eliminating preventable childhood deaths• Climate change• Meeting the MDGs and the Post-MDG Agenda

Cumulative tobacco-related deaths, 2005–2030

Source: WHO Mpower report: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf (2008)

Percentage of Men who Smoke

Source: TobaccoAtlas.org by American Cancer Society and World Lung Foundation

• A treaty adopted by the 56th World Health Assembly in May 2003 seeking "to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”

• The treaty's provisions include rules that govern the production, sale, distribution, advertisement, and taxation of tobacco; marks one of the first multilateral, binding agreements regarding a chronic NCD

• Status:• Signatories to the WHO FCTC: 168• Parties to the WHO FCTC: 179 (Last Party: El Salvador, October 2014)

• The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention

• Sixth session of the COP took place in Moscow in October 2014

WHO Framework Convention on Tobacco Control (WHO FCTC)

Source: http://apps.who.int/iris/bitstream/10665/85381/1/WHO_NMH_PND_13.2_eng.pdf

Projected Prevalence of Overweight* Women Aged 30 and Above, 2015

Source: WHO

*(BMI ≥ 25 kg/m2)

Source: 2013 UNAIDS Global Report, http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf

Treatment with Antiretroviral Drugs

Women and Children in the Post-2015 Agenda

MDG 4: Reduce by two-thirds the under-five mortality rate

• Under-five mortality rate has fallen from 12.7 million in 1990 to 6.3 million in 2013, not enough to meet MDG 4, but still remarkable progress

MDG 5: Reduce by three quarters the maternal mortality ratio

• Maternal mortality ratio has fallen by only 22% between 1990 and 2013, which is far off the target of a 75% reduction

Source: The Lancet, "Women, children, and adolescents: the post-2015 agenda." The Lancet 384.9949 (2014): 1159.

Source: Building a Future for Women and Children: The 2012 Report.

Global Causes of Death among Children, ages 0–59 months, 2010

Neonatal Mortality Rates for 193 Countries, 2009

Source: PLoS Medicine. (2011) Trends in Neonatal Mortality Levels. Vol. 8 Issue 8.

-50 -20 0 +20 +50 +100

64

36

20

80

Percentage change in yields to 2050

UN DP, 2009

Plus climate-related:• Flood/storm/fire

damage• Droughts – range,

severity• Pests (climate-sensitive)• Infectious diseases

CLIMATE CHANGE: Poor Countries Projected to Fare Worst CHANGES IN CEREAL GRAIN YIELDS, 2050

Millennium Development Goals

• Eradicate Extreme Poverty and hunger• Achieve Universal Primary Education• Promote Gender Equality and Empower Women• Reduce Child Mortality• Improve Maternal Health• Combat HIV/AIDS, Malaria and Other Diseases• Ensure Environmental Sustainability • Develop a Global Partnership for Development

Based on Millennium Declaration, adopted September 2000

Sustainable Development Goals (SDGs)

SDGs are goals that embrace the “triple bottom line” approach to human wellbeing,

which is a combination of economic development, environmental sustainability,

and social inclusion

Source: Sachs J. From Millennium Development Goals to Sustainable Development Goals. Lancet. 2012

Goal 1 End poverty in all its forms everywhere

Goal 2 End hunger, achieve food security and improved nutrition and promote sustainable agriculture

Goal 3 Ensure healthy lives and promote well-being for all at all ages

Goal 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all

Goal 5 Achieve gender equality and empower all women and girls

Goal 6 Ensure availability and sustainable management of water and sanitation for all

Goal 7 Ensure access to affordable, reliable, sustainable and modern energy for all

Goal 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all

Goal 9 Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation

DRAFT SDGs

GOAL 3: ENSURE HEALTHY LIVES AND PROMOTE WELL-BEING FOR ALL AT ALL AGES

TARGETS:

3.1 By 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births

3.2 By 2030 end preventable deaths of newborns and under-five children

3.3 By 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases

3.4 by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing

3.5 strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.6 By 2020 halve global deaths and injuries from road traffic accidents

3.7 By 2030 ensure universal access to sexual and reproductive health care services

3.8 Achieve universal health coverage (UHC)

3.9 By 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination

WHO ARE THE STAKEHOLDERS IN GLOBAL HEALTH?

Governments

Multilateral & International Organizations

Foundations

Civil Society

Private Sector

Individuals

Key Stakeholders in Global Health

Development Assistance For Health, by Channel of Assistance (1990–2013)

Development assistance for health (DAH) has hit its highest levels to date, reaching an estimated $31.3 billion in 2013. (IHME, 2014)

United States31.7%

World Bank21.2%

United Kingdom

9.5%

UNFPA5.9%Netherlands

3.5%France3.0%

UNICEF2.8%

Japan2.7%

Germany2.2%

Norway1.9%

All Other DAC

12.8%

All Other Multilat-

erals2.8%

NOTES: Amounts in gross US$ disbursements. Health ODA combines data from three OECD CRS sub-sectors: (1) Health; (2) Population Policies/Programs and Reproductive Health (includes HIV/AIDS & STDs); and (3) Other Social Infrastructure and Services - Social Mitigation of HIV/AIDS. SOURCE: Analysis of data obtained via online query of the OECD Development Assistance Committee (DAC) Database and Creditor Reporting System (CRS); November 7, 2012.

Top 10 Donors for Health ODA, 2002 &2010

2002

Total = $4.4 billion

United States34.6%

Global Fund16.5%

United Kingdom

6.6%

World Bank5.1%GAVI

3.8%

EU Institutions2.6%Germany

2.6%

Canada2.5%

France2.3%

Japan2.1%

All Other DAC12.1%

All Other Mul-tilaterals

8.8%

Non-DAC0.4%

2010

Total = $18.4 billion

Global WHO Governance

WHO Corporate Strategy

Global Public Health Goods and WHO management systems Delivering the Corporate Strategy

Regional accountability

Regional WHO Policy and Country Support

Technical support to deliver national health and development goals

Common Criticisms of WHO

• Over-politicized to the detriment of its technical functions• Too bureaucratic• Timid• Overstretched/underfunded• Conflicted• Failing to adapt to change

Report Recommendations on Future of WHO

• Recommendation 1: Core functions should promote and maintain global health security

• Recommendation 2: Provide strategic technical assistance to countries in support of its mission as a provider of global public goods

• Recommendation 3: Staff should align with core functions and leadership priorities

• Recommendation 4: Separate its technical departments from its governance and management by creating two posts of deputy director-general

• Recommendation 5: Appoint the director-general to a single, seven-year term without re-election

• Recommendation 6: Explore concrete and specific collaborations with non-governmental actors

• Recommendation 7: Restructure its regional offices

• Recommendation 8: Match staffing of country offices with needs of host countries

• Recommendation 9: Review how the value added by its regional and country offices could be increased, and its administrative and management costs reduced

Recommendations on WHO (con’t)

UN Health-Related Organizations

• World Health Organization (WHO)• World Bank (WB)• UN Children’s Fund (UNICEF)• UN Population Fund (UNFPA)• UN Program on HIV/AIDS (UNAIDS)• UN Development Program (UNDP)• UN Educations, Scientific and Cultural Organization (UNESCO)• Food and Agriculture Organization (FAO)• World Food Program (WFP)• UN High Commissioner for Refugees (UNHCR)• International Labor Organization (ILO)• UN Environment Program (UNEP)• UN Nations Office on Drugs and Crime (UNODC)• World Trade Organization (WTO)

Source: K. Lee et al 1996, British Medical Journal, 312, pp 302-312

UNAIDS

“An advocate for global action…it leads, strengthens, and supports an expanded response”

Consists of 10 UN agencies:

UNICEF UNFPA UNESCO WFP UNODCWHO UNDP ILO World Bank UNHCR

Functions:• leadership and advocacy • strategic information• tracking, monitoring and evaluation• civil society engagement and partnership • development• mobilization of resources

The Global Fund to Fight AIDS, Tuberculosis and Malaria • A multilateral financing mechanism designed to rapidly provide money to country owned

initiatives addressing three priority diseases

• Board of Directors• Voting: 20 members (including 2 NGOs, various ministries, USAID) • Non-voting: Gates Foundation, WHO, UNAIDS, World Bank

• The 4th Replenishment Conference was held in Washington, D.C. in December 2013 to secure 2014-2016 funding

• Transition to new funding model is underway, providing implementers with flexible timing, better alignment with national strategies and predictability on the level of funding available. 

TRP: Technical Review Panel GAC: Grant Approvals Committee

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Private Philanthropy: Top 10 U.S. Foundations by International Giving, 2013

Source: http://foundationcenter.org/gainknowledge/research/keyfacts2013/pdfs/Key_Facts_on_US_Foundations.pdf

Global Development Program• Agricultural Development• Emergency Response• Family Planning• Financial Services for the Poor• Global Libraries• Maternal, Neonatal & Child

Health• Nutrition• Polio• Vaccine Delivery• Water, Sanitation & Hygiene

Global Health Program• Discovery & Translational

Sciences• Enteric and Diarrheal Diseases• HIV• Malaria• Neglected Infectious Diseases• Pneumonia• Tuberculosis

Gates Foundation Global Programming

Gates Foundation 2011/2012 Funding Areas Comparison

Source: Gates Foundation 2012 Report.

• CHAI has reduced prices up to 87 percent for key drugs for HIV, malaria, and TB, and up to 80 percent for HIV diagnostics, saving more than $1 billion in total

• Currently, patients in more than 70 countries pay the reduced prices achieved through CHAI negotiations

Increasing Access to Medicines and Diagnostics Fact Sheet: http://www.clintonhealthaccess.org/news-and-information/access-fact-sheet-feb-2012

Clinton Health Access Initiative (CHAI)

Type of NGO Description Examples

Community-based organizations

Organizations that arise out of people’s own initiatives, i.e., sports clubs, women’s organizations, neighborhood organizations, religious or educational organizations

Coalition of Women Living with HIV/AIDS – Malawi, Concerned Parents and Youth Association-Uganda, Beacon of Hope-Kenya

City-wide organizations

Organizations that either exist for other purposes and become involved in helping the poor as one of their many activities or are created specifically for helping the poor.

Rotary or Lion’s Clubs, chambers of commerce and industry, coalitions for business, ethnic or educational groups and associations of community organizations

National NGOsNational level organizations formed with a purpose for advocating on behalf of a specific part of the population.

The AIDS Support Organisation (TASO)-Uganda, Coalition on Violence against Women-Kenya, Uganda Private Midwives Association

International NGOsOrganizations that provide technical assistance, advocacy support, or funding for local NGOs, institutions or projects.

Save the Children, CARE, FHI, PSI, AMREF, faith-based organizations such as World Vision, World Relief, etc.

Civil Society: Types of NGOs

Source: Top 10 NGO’s from the 100 Best List. The Global Journal. 2012 http://www.miratelinc.com/blog/top-10-ngos-from-the-100-best-list-2012-by-the-global-journal/

Top 10 from the 100 Best NGOs in 2012 (The Global Journal)

US-based NGOs with the highest cumulative overseas health expenditures, 2007-2010

Expenditures shown in millions of 2011 US dollars

Internationally-based NGOs with the highest cumulative overseas health expenditures, 2007-2010

Source: Financing Global Health 2013: Transition in an Age of Austerity. Seattle, WA: IHME, 2014.

Private Sector Involvement in HealthModel Company Description

Public-Private Partnership

Merck & Company ACHAP is a partnership between the Govt of Botswana, Merck and the Gates Foundation to implement a comprehensive approach to prevention, care, treatment and support

Corporate Social Responsibility

ExxonMobil Foundation ExxonMobil Malaria Initiative has committed more than $68 million in funding for programs to fight malaria in 20 different African countries

Training BD Under the leadership of the Government of Kenya, BD is training Kenyan health workers as master trainers in safe blood draw practices

Social Investment Acumen Fund Acumen provides debt/equity investment to strengthen and scale business models that effectively serve the poor

Service Delivery The HealthStore Foundation’s Child and Family Wellness (CFW) shops network

CFW Shops is a micro-franchise system of clinics and drug shops that provide access to essential medicines to marginalized populations in the developing world

Categories of Public-Private PartnershipsPurpose Partnership Examples

Product development Global Alliance for TB Drug Development, International AIDS Vaccine Initiative, Medicines for Malaria Venture and Malaria Vaccine Initiative

Access to health care products Mectizan Donation Programme

Global coordination mechanisms Global Alliance for Vaccines and Immunization (GAVI)

Strengthening health services Global Health Workforce Alliance (WHO)

Public advocacy and education Alliance for Microbicide Development

Regulation and quality assurance

The International Conference on Harmonization of Technical Requirements for Registrations of Pharmaceuticals for Human Use

Source: Nishtar S. 2004

The GAVI mission: “To save children’s lives and protect people’s health by increasing access to immunization in poor countries”

GAVI’s mission is supported by four strategic goals:

WHAT ROLE SHOULD THE US PLAY IN ADDRESSING GLOBAL HEALTH?

Why should the US spend money on global health?

Does the US public engage in global health?

Total

Democrats

Independents

Republicans

30%

24%

30%

39%

30%

29%

31%

32%

31%

40%

30%

20%

Too much About the right amount Too little

NOTE: Don’t know/Refused answers not shown.SOURCE: Kaiser Family Foundation 2013 Survey of Americans on the U.S. Role in Global Health (conducted August 6-20, 2013)

Views of Current Levels of U.S. Global Health Spending By Party IDDo you think the U.S. is now spending too much, too little, or about the right amount on efforts to improve health for people in developing countries?

U.S. Funding for Global Health, FY 2001 - FY 2014

Kaiser Family Foundation, “U.S. Funding for Global Health: The President’s FY 20145Budget Request,” April 2014, http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/

U.S. President’s Global Health Budget Request, FY 2014

Kaiser Family Foundation, “U.S. Funding for Global Health: The President’s FY 20145Budget Request,” April 2014, http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/

U.S. Government’s Global Health Architecture

Independent Agency

Labor

Peace Corps

CDC

HomelandSecurity

Commerce

EPA

The White House

Defense

USDA

NIH

FDA

HRSAPEPFAR

HHSOGHAOPHS

MCC

PMI

Water for Poor

NTD

Avian Influenza

Action Group

Department

Multi-Agency Initiative

Dept. Operating Unit

KEY

CONGRESS

GHI

StateOGACOES

AmbassadorsMissions

USAIDBureaus for: Global Health;

Economic Growth, Agriculture & Trade; Democracy, Conflict,

Humanitarian Assistance

Tanzania: A Coherent Response to AIDS?

WHAT ROLE SHOULD YOU PLAY IN GLOBAL HEALTH?