The Future of Global Health Jim Yong Kim

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 Feb 2006 – 35 projects

Changes in life expectancy in selected African countries with high HIV prevalence, 1950 to 2000 Life expectancy at birth, in years 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

Universal Access 2005 G 8 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. ”

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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

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 SOUTHERN KAYONZA Rukira 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 Kwa. Zulu-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 $448 M - new health technologies $413 M - HIV/AIDS vaccine $258 M - malaria vaccine $165 M - new malaria drugs $124 M - anti-HIV microbicides $115 M - diarrhea/nutrition $106 M - 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 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 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 Developing Leaders Improving Service Delivery Community of Practice EMR Systems Phase I 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: FY 2008 war supplemental- $196. 4 Billion

Before After

The Fruits of Advocacy “Bridge to Nowhere”- $ 398 Million Corn- $5. 1 Billion/yr National Security: FY 2008 war supplemental- $196. 4 Billion

Before After

The Fruits of Advocacy “Bridge to Nowhere”- $ 398 Million Corn- $5. 1 Billion/yr National Security: FY 2008 war suppleme - $196. 4 Billion Sugar- up to $1. 9 Billion/yr

G 7 Military Spending and Foreign Aid, 2006

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