The past decade has witnessed unprecedented levels of investment and engagement in global health spurred by the global HIV/AIDS crisis, the development of the Millennium Development Goals, momentum in polio eradication, and global outbreaks of infectious diseases such as SARS with its US$40 billion cost to society. Characterized by a sense of urgency, pragmatism, and opportunity, global health services and public health systems are being advanced to respond to rapidly expanding demands with dramatic results. However, much more remains to be done. After a decade in emergency mode, the next phase of global health work requires an even more precise approach and smarter investments. Many “donor” nations and organizations have tightened their belts in response to the recent economic downturn, while at the same time increasing the numbers of “recipient” countries, and are now better able to invest more of their own resources to benefit and protect their own citizens. In this climate, global health investments in programs and innovations must be better targeted and better informed by strategic information about disease burdens, at-risk populations, and program effectiveness.
Global Health Investment
Improved living standards and poverty alleviation alone are known to result in better health outcomes. Targeted investments through development assistance and partnerships for global health have resulted in impressive additional gains in numerous health indicators. According to the recent Lancet Commission on Investing in Health, worldwide development assistance for health increased more than four-fold from US $6.7 billion in 1993 to US $28.4 billion in 2011. Accompanying this investment was a striking decline in mortality in children under five years of age from 12.6 million deaths in 1990 to 6.6 deaths million in 2012. Improvements in health are not the only positive outcome of these investments. The same Commission concluded that global health is a smart investment – for every dollar invested in health, it can be expected that there will be a 10-20 fold return in economic benefit to society. Healthier people are more productive and contribute back to the economy. Healthier people also lower health care costs, naturally, by requiring less care.
The case for global health investments is even stronger for specific evidence-based interventions when targeted towards specific diseases, specific geographic locations with greatest disease burden, and specific populations and age groups most at-risk. The progress being made through historic targeted investments tells a compelling story. From 2004 to 2013, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) provided US $52 billion to global HIV/AIDS, The Global Fund and bilateral TB program efforts. An additional US $14 billion from 2002 to 2012 for HIV/AIDS, TB, and malaria was provided from other contributors to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM). In that same time period in sub-Saharan Africa alone, these investments along with others including those from the affected countries themselves resulted in a 25% decline in AIDS-related deaths from 1.6 million to 1.2 million people, and a 33% decline in new HIV infections from 2.4 million to 1.6 million people. Thanks to this targeted investment, the downward trend in life expectancy that began in the 1990s in several African countries due to AIDS (e.g., South Africa, Botswana, Zimbabwe, Swaziland, Uganda, Kenya) has also begun to reverse itself and has been increasing steadily again over the past decade. This is encouraging but clearly more remains to be done.
The remarkable success in global measles control provides another example of the impact of investment on child mortality when a highly efficacious vaccine is systematically targeted towards vulnerable children. The Measles Rubella Initiative (MRI) has been a global partnership since 2001 led by the American Red Cross, the United Nations Foundation, CDC, UNICEF, and WHO. Accompanying an investment of US $950 million in 80 countries, the MRI has delivered more than 1.1 billion doses of measles vaccine raising childhood vaccination coverage to 84%. Accompanying the expanded measles vaccination has been a decline in measles cases from 853,000 in 2000 to an historic low of 223,000 cases in 2012. An estimated 13.8 million deaths from measles alone have been prevented as a result of global investment in measles vaccinations. However, even at this impressive pace, measles elimination targets are not likely to be met by 2015 and will require enhanced efforts.
Polio eradication yields the ultimate return on investment in global health because its goal is to permanently eliminate a virus from Earth, as was done successfully with smallpox when WHO certified it as being globally eradicated in 1979. In the 1980s, approximately 350,000 children became paralyzed from polio each year. In 1988 a partnership between public and private donors began, and to date a total of US $9 billion has been invested to eradicate polio through the Global Polio Eradication Initiative (GPEI). These contributions have already generated net benefits of $27 billion. Polio cases have been reduced by 99%. Four hundred and six (406) children became paralyzed in 2013.
Global health investment clearly works, but needs to be maintained to meet global targets and give countries time to sustain their own health advances over the long term and to further scale up effective and high quality programs for those most-at-risk. Strategic information is necessary to design, guide, and evaluate interventions that have maximum impact and can be sustained.
Targeting investments is essential to improve health where it is threatened most. Effective targeting requires access to information that identifies where the greatest burden of disease lies, who is at-risk, and where interventions are needed. Additional levels of information are needed to develop, apply, monitor, and evaluate interventions. The advancement of global health is highly dependent on the integration of information on four levels: data on disease burden, identification of risk factors, program monitoring data, and impact measurement. Though getting better, smart information to guide smart decision-making has been inadequate.
First, information on the burden of disease is necessary in order to drum up support, to understand the extent to which the population is affected, and to communicate the anticipated damage to society that can occur if we fail to act. Knowing disease burden provides a rationale for action – globally, nationally, and locally. Without reliable data on burden of disease, it is challenging at any level to make a strong case for investment in a context of competing priorities and limited resources. These data are often not readily available in all countries and even less often at the sub-national level. High-income countries accumulate strong data on cause of death and disease burden from vital registration systems and regular population-based surveys. However, the vast majority of births, deaths and the cause of death go unrecorded around the world. Worldwide, most people are never actually counted upon birth or death!
As a result, health professionals must often resort to models to approximate disease burden when data about causes of death and disease burdens are unavailable. Models provide useful information, but the data that models provide are only as good as the assumptions used. In addition, models are not designed to provide information at the local level where decisions actually need to be made about the financing, design, implementation, and monitoring of programs. Moreover, disease burden is not uniformly distributed across populations, as models assume. Additional investment in appropriate vital registration systems can help to adequately inform society about what is killing its citizens.
In the meantime, investment in well-designed and well-conducted population-based surveys can help provide key information for HIV/AIDS, TB, malaria, tobacco, and noncommunicable diseases. For example, Kenya’s recent AIDS Indicator Survey reports that 5.6 percent of the persons aged 15-64 years, and 0.9 percent of persons aged 18 months-14 years, are infected. Of those it is estimated that 58.8 percent are eligible for ART under current Kenya guidelines, and 60.5 percent of those who are eligible are on ART. Seventy-five percent of those on treatment have succeeded in achieving viral load suppression, meaning their treatment is working. And Kenya has this information by region so they can focus on the under-performing areas.
Disease risk is distributed heterogeneously across populations, yet programs often lack this information and money is wasted through implementing programs for those who do not need it. So the second level of information needed to advance global health concerns is the identification of specific risk factors that make some segments of a population more vulnerable to a given disease than other groups. These data are needed so that appropriate programs and interventions can be designed and implemented to reduce incidence (prevent new cases) and prevalence (the proportion of the population with the disease), assuming that evidence-based interventions are available and accessible. Knowing which populations are most susceptible to a specific health threat saves money by targeting prevention interventions to those at risk, rather than spending resources on those who are not vulnerable. It also achieves greater impact in the end by allowing professionals and experts more deliberate targets in the preventative process.
Disease surveillance systems are the mainstay of detecting and tracking disease burden in populations, particularly for monitoring trends over time, place, and person. Investments in risk factor or epidemiologic research and surveillance to monitor risk factors can assist with identifying and targeting appropriate interventions. For example, knowing where in a country the levels of malaria parasitemia are the highest in young children and why (including parasite and mosquito resistance) will help national malaria programs to better target distribution of long-acting insecticide-treated bed nets, indoor residual spraying, test kits for malaria diagnosis, and antimalarial treatment. Polio eradication efforts likely make the best use of epidemiologic risk factor and laboratory data, using a combination of active disease surveillance (looking for cases instead of waiting for them to be reported) and genetic sequencing of virus strains from children with polio to show where and when the virus was actually transmitted. Supplemental vaccination campaigns in addition to routine immunization can then be delivered precisely where they are needed instead of across the population, thereby interrupting transmission at lower cost. Polio eradication actually demonstrates the more ambitious our public health goal (you cannot be more ambitious than “eradication”), the more precise our strategic information needs to be. Pinpointing transmission to person, place, and time, though potentially costly, provides disease control professionals with the ultimate information need to achieve impact and is well worth the investment.
The third level of information needed is program monitoring data to inform decision-makers when and where corrective action needs to be taken. The effectiveness of an intervention in a population is a function of its efficacy and the coverage achieved in the target population. Program monitoring data can come from health information systems, surveys (such as immunization coverage), and other sources. What is most important about program monitoring is for decision-makers to use the data to take corrective action when results are not as expected. For example, the rollout of ART services for HIV/AIDS was making good progress in Haiti, but not at the rate expected. When the program leaders identified this issue and took time to analyze performance, they realized the stringent criteria for patients’ enrollment needed to be simplified. Until then, the criteria required multiple visits and disclosures of HIV status to others before ART could be started. Once there was more flexibility, ART uptake among patients increased 50 percent in 2012 and 2013.
Finally, the fourth level of information needed is impact measurement to assess and communicate the ultimate return on global health investments. The ability to measure impact depends on availability and access to the first three levels of information described above.
To determine if impact has been achieved and at what level, we must have information on disease burden that has stimulated public health action, data on risk factors used to target vulnerable groups with effective programs, and the results of monitoring of program performance. What is measured to quantify impact is defined by the reason for public health action in the first place. For the big killers — HIV/AIDS, TB, malaria and others — reducing incidence and mortality are ultimate goals driving action and investments. But impact can be measured in different ways depending on your audience. For example, a study conducted in Kenya among tea plantation workers showed that ART not only saved lives, but also restored the functional level of a worker with HIV/AIDS to 90 percent of the level when they were healthy, demonstrating ART’s impact on productivity. Impact measurement is the ultimate parameter and is necessary to be able to answer the questions around what society has gained from investment.
Information on disease burden drives action. Risk factors target interventions to specific places and populations.
Program monitoring guides decision-making around taking corrective action to improve effectiveness, and impact measurement tells us whether the investment was worthwhile. Strategic gathering and use of data must drive the cycle of global health to make the most of limited resources and to sustain global health progress.
In addition to targeted interventions and strategic information, innovation is needed in many forms and at all levels for global health to progress. Innovation is needed for investments to work and for information to be collected, analyzed, and used for decision-making. It is needed at the community level, for example to overcome cultural obstacles (e.g., gender inequity, harmful practices and traditions) and logistical challenges (e.g., long distances to health facilities, poor water and sanitation). Innovation is also needed by government leadership, for example to stamp out corruption, retain health workers, and find ways to finance the health system.
The most apparent global health innovations are found in expanding research and development to create better tools – drugs, vaccines, diagnostics, medical devices, commodities, and information systems.
For example, the recent application of a desktop diagnostic machine, GeneXpert MTB/RIF, constitutes a major advance in addressing the very worrisome situation around drug-resistant tuberculosis (TB). Delays in TB diagnosis and detection of drug resistance result in more transmission to others, increased morbidity and mortality, and more drug-resistant TB. Shortening the time for the test to give a result from 6 weeks or longer with traditional TB methods to less than 2 hours offers great promise with GeneXpert testing, which can be performed in low-resourced settings without highly skilled personnel or specialized laboratories. The ability to place cutting edge technologies like GeneXpert in rural and hard-to-reach settings around the world means that TB cases and drug resistance could potentially be diagnosed more rapidly, effective treatment begun immediately, and infections reduced dramatically. But cost considerations and weak health systems will need to be overcome before technological advances like GeneXpert realize their full potential.
Follow-on innovations are needed to take new tools and technologies and rapidly make them affordable to low-resourced countries, communities, and clinics. The challenge of expanding anti-retroviral treatment for people living with HIV is a compelling example.
When PEPFAR was beginning in 2004, there were approximately 50,000 people on antiretroviral treatment (ART) worldwide and the cost of the drugs alone was in the range of $5,000-$10,000 per year in South Africa, well out of reach of the vast majority of people living with HIV/AIDS. A decade later there are more than nine million people on ART, and the cost of even safer and more efficacious ART drugs is now down to less than $100 per year, a decline of 98 percent. Making ART available to nearly 10 million people around the world is a wonderful success. But it took 24 years to get from the first report of unusual cases of pneumonia in gay men – later proved to be HIV related – to the point where ART became widely available in the most heavily impacted areas of sub-Saharan Africa. Far too many have died during the long wait.
In the past decade, many advances in technologies have come from donor countries. However, global health is now transitioning as increasing numbers of countries who have been recipients of global health investments in the past are able to contribute resources to their own programs. In that context, important innovations are coming from communities most impacted by disease.
For example, remote communities are now using cell phones to raise the alarm when there is a medical emergency, such as obstructed labor and the need for rapid transportation of pregnant women for caesarian sections. Others have identified unique transportation, such as modified three-wheeled motorcycle “ambulances” for pregnant women to reach hospitals for delivery of their infants. Innovative country-owned health care financing mechanisms such as fee retention by the health facility, health insurance plans that help create universal access to health care and innovative incentives to retain scarce health workers will continue to be critical for improving coverage and assuring sustainability.
As innovations solve long-standing global health problems, increase access to much-needed tools and services, and arise from local conditions and knowledge; advances in global health can be sustained and accelerated.
Lowered cost and farther reach of new technologies will enable countries to expand the impact of their in-country resources to accomplish more. In Ethiopia, for example, the government recently completed the ambitious rollout of an innovative plan including 15,000 community health posts and 35,000 health extension workers to deliver preventive and basic curative services at the primary care level. With this country-grown solution in place, they have turned their attention to other priorities, including improving emergency services, addressing the severe shortage of doctors and specialists, and devising a health insurance plan financed by a tax on wages. Other countries, including South Africa, Botswana, Namibia, Zimbabwe, Zambia, and Tanzania are also establishing their own solutions to sustain public health services that have been supported over the past decade through PEPFAR, the Global AIDS Fund, and other donors. The challenge remains for countries to scale up their investment in time to meet the growing demand for services as donor assistance remains relatively plateaued over the foreseeable future.
Over the past decade PEPFAR, the President’s Malaria Initiative (PMI), the Global Fund, GAVI, and a host of other donors and programs have produced new tools, services, surveillance systems, laboratory networks, and collaborations--dramatically reducing the number of lives lost and people sickened by disease and other health threats.
We must not lose ground at a moment when an AIDS-free generation and the eradication of polio are within reach. We must also be able to meet the new challenges facing global health such as multidrug-resistant TB and non-communicable diseases that are on the rise. Present and future global health challenges can be met by targeted global health investments made to support evidence-based programs and innovative tools that can be sustained and scaled up.
These are the foundation of global health progress today and tomorrow.