CCIH 2012 Conference, Plenary 3, Dr. Ariel Pablos-Mendez, Voices from the U.S. Government
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Dr. Ariel Pablos-Mendez of USAID shares the history of the agency, its successes and challenges, and the strength of faith-based organizations in global health.
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CCIH 2012 Conference, Plenary 3, Dr. Ariel Pablos-Mendez, Voices from the U.S. Government
- 1. Working Draft Last Modified 9/4/2007 9:23:32 PM Eastern Standard Time Printed 12/22/2005 3:28:39 PM GMT Standard Time CONFIDENTIAL Christian Connections for International Health June 9, 2012 Document Date Ariel Pablos-Méndez, MD, MPH Assistant Administrator for Global Health This report is solely for the use of client personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the client organization without prior written approval from McKinsey & Company. This material was used by McKinsey & Company during an oral presentation; it is not a complete record of the discussion.
- 2. • Marshall Plan enacted in 1947 for the purpose of rebuilding Europe after WWII • International Cooperation Administration, a forerunner of USAID • President Kennedy extended the hand of the American people through technical, financial, and political support in the developing world • USAID has pioneered many important developments in the fields of health, agriculture, and education • USAID is an important element of foreign policy (Diplomacy, Defense, Development) 2
- 3. A new chapter in Global health history End of Euro- End of the The Great colonialism Cold War Recession Tropical International Global A New World Medicine Health Health Health ? 1960's 1990's 2010's 3
- 4. Unprecedented economic growth across the globe 4
- 5. “The First Law of Health Economics” 9 Log Total Health Expenditures/Capita 8 o e lth x e d r s a ita L gH a E p n itue /c p 7 6 5 N = 178 4 R2 = 94% 3 2 1 4 5 6 7 8 9 10 11 12 Log GDP/capita Source: Jacques van der Gaag; WHO/IMF 2004 5
- 6. The Economic Transition of Health India - Projected THE/K and Affordability 6
- 7. USAID-assisted countries can now/soon buy essential package of health services 7
- 8. What are the implications for global health? • Engage developing countries in new ways • Evolve the US development enterprise • Celebrate success and embrace bold challenges 8
- 10. South & SE Asia: new HIV infections and Annual AIDS Deaths
- 11. Ending Preventable Child Death "Funeral of First Born" (Rural Russia, 1983). Oil on Canvas by Nicolai Yaroshenko (Russian, 1846-1898) 11
- 12. Ending Preventable Child Death in a Generation 12
- 14. Partners are the Key to Success • Far-reaching networks • Credibility • Service • A vision of a healthier world 14
- 15. Thank You! 15
- 16. USAID’s Core Global Health Priorities Unit of measure 1 Saving Mothers 4 Infectious diseases •Focus efforts on the 28 countries that contribute •Malaria – working through PMI, housed at USAID over 77 percent of the maternal deaths worldwide. •TB •NTDs Working Draft - Last Modified 9/4/2007 9:23:32 PM Child Survival •Avian influenza, emerging pandemic threats 2 •USAID focuses its work on 24 countries that account for over 70 percent of child deaths Family planning •We are working to galvanize the global 5 •Already transitioned 21 countries from USAID community around a child survival call to action, family planning support since the 1980’s, over the see below next five years USAID’s global health response will prioritize 24 countries that represent over 50 AIDS-free generation percent of the unmet need for family planning and 3 •prioritizes activities in three key areas that science graduate four more (Nicaragua, Honduras, Peru, Printed 12/22/2005 3:28:39 PM has identified as pivotal: preventing mother-to- and Egypt). child transmission (PMTCT), voluntary medical male circumcision, and treatment as prevention Health systems •Strength country efforts to care for the millions of 6 •During the next five years, USAID’s global health children orphaned and left vulnerable by the AIDS team will take deliberate steps to ensure that pandemic health system strengthening is built into all the work that USAID does * Footnote 16 Source: Source 16
- 17. Despite great progress over the decades, much to be done Unacceptably high levels of morbidity and mortality •7.5 million children died in 2010, 2/3 were preventable •One of every three children in developing world suffers stunting due to malnutrition •Women in developing countries are 125 times more likely to die from pregnancy-related complications •215 million women have an unmet need for family planning •8.8 million people were newly identified with Tb and 1.4 million died from TB •HIV/AIDS kill more people in Africa than any other disease. •Neglected Tropical Diseases affect over 1 billion people worldwide. •Rate of pathogen emergency is expected to increase five fold between 2000 and 2030 •Emerging importance of NCDs Barriers to addressing health issues •Poverty, ethnicity, socio-economic status, poor infrastructure, lack of health insurance, low status of women and girls •Lack of capacity and poorly functioning health systems •Limited access to information and knowledge 17
- 18. Default scenario: an explosion of unregulated private provision paid out-of-pocket, an inefficient and regressive form of financing 18
- 19. U.S. Official Development Assistance: Smaller share of total capital flows 19
- 20. Conclusion: 20
- 21. UNIVERSAL COVERAGE: the new frontier for global health Formal Health Coverage: 95-100% Positive 70-95% # countries THE as % Median formal 40-70% GDP coverage 10-40% High income 65 11.2% 100% Middle income Buy SmartDraw!- purchased82% 95 5.4% copies print this 0-10% Negativ document without a watermark . e Low income Visit www.smartdraw.com or call 1-800-768-3729. 49 4.3% 5% No data Source: Lancet 2009 (ILO data 2008; map by R4D.)
- 22. Strategy for Success in Global Health Ariel Pablos-Méndez, MD, MPH May, 2012
Editor's Notes
- GH Vision A world where people lead healthy, productive lives and women and children thrive GH Mission USAID supports partner countries in preventing and managing major health challenges of poor, underserved, and vulnerable people, leading to improved health outcomes by: Providing technical leadership in responding to new global health challenges Partnering strategically with a wide range of actors Accelerating the development and application of innovation , science, and technology Scaling up evidence-based , equitable, inclusive, and locally adapted health solutions Strengthening local health system capacity to support partner countries ’ leadership of health policies, strategies, and actions Promoting inclusion, gender equality , and female empowerment Working efficiently and being effective stewards of public trust and resources And our strategy is framed by the Global Health Initiative and USAID Forward , the wave of reforms in the agency introduced by Adminsitrator Shah
- USAID just celebrated it ’s 50 th Anniversary What began as a post-war reconstruction effort through the Marshall Plan Became International development with the launch of USAID by President Kennedy (together with the Peace Corps) Indeed, President Kennedy began a peaceful revolution of human progress which has been quite successful
- While coinciding with the grand recession, this inflexion point is driven by demographic and epidemiogic transitions
- Equally important but less appreciated is an unprecedented expansion of GDP in less developed nations Driven by better governance, trade, new technology, as well as the demographic dividend
- As developing countries grow, they will inevitably spend more on health Health spending WILL go up. Jacques Van Der Gaag studied 178 countries and found that health spending increased disproportionally with increases in GDP (income elasticity >1) USAID examined data for 65 countries which carried out own health accounts (rather than use modeled data). We also found that THE rises slightly faster than GDP.
- Projected THE per capita assuming income elasticity = 1.0, compared to inflation adjusted CMH target ($38 in 2002 prices) and TFIF target ($54 in 2005 prices)
- We intend during these coming decades of development to achieve a decisive turn-around in the fate of the less-developed world, looking toward the ultimate day when all nations can be self-reliant and when foreign aid will no longer be needed. President John F. Kennedy, Special Message to the Congress on Foreign Aid March 22, 1961 Celebrate success and optimistic outlook (end games rather than problems as advocacy tactic) with bing bangs for grand next act in development: + AIDS free generation + ending preventable child death + HS foundations for UHC Engaging LMICs in new ways: * BRICS as development partners changing the “Aidscape” * Crowding back in * Stewardship of mixed systems and HFR towards UHC The USG development org * Move to capacity building, TA and HSS(and global pricing and R&D - domestic investment that generates global public good w/o crowding out LMICs) * Focus on poor and vulnerable (advocacy as leverage if <5% of THE) * Phasing out to concentrate in neediest countries * Consolidate ODA * HHS to do more peer TA, while USAID can lead on HSS/UHC And if the next phase (25 years) of international development is indeed a final one, let us build a grand finale with 3 big bangs : catalyzing an AIDS-free generation, ending (preventable) child deaths, and building the health system foundations for universal health coverage.
- “ An AIDS-free generation would be one of the greatest gifts the United States could give to our collective future.” -- Secretary of State Hillary Rodham Clinton, November 8, 2011 An AIDS-free generation means that: Virtually no children are born with the virus As these children become teenagers and adults, they are at a far lower risk of becoming infected than they would be today - They have access to treatment that helps prevent them from developing AIDS and passing the virus to others Treatment: By the end of 2013, PEPFAR will directly support more than 6 million people on antiretroviral treatment – two million more than our previous goal Over the next two years: Voluntary medical male circumcision (VMMC): PEPFAR will support more than 4.7 million VMMCs in Eastern and Southern Africa. Condoms: PEPFAR will distribute more than 1 billion condoms. PMTCT: PEPFAR will reach more than 1.5 million HIV-positive pregnant women with antiretroviral drugs to prevent them from passing the virus to their children.
- &quot;Funeral of First Born&quot; (Rural Russia, 1983). Oil on Canvas by Nicolai Yaroshenko (Russian, 1846-1898) http://www.nejm.org/doi/full/10.1056/NEJMra1111421?query=TOC * For centuries, the cumulative weight of experience fostered the conclusion that childhood deaths were inevitable. Many families, even those of plentiful means, lost half or more of their children. Seemingly nothing could be done — medically, politically, or economically — save to let nature take its course. Indeed, the mind of the public had changed little since the 2nd century, when the emperor Marcus Aurelius wrote, “One man prays, `How I may not lose my little child', but you must pray, `How I may not be afraid to lose him'” (Meditations 9.40). * One has but to view the tombstones in colonial cemeteries to understand that death in childhood represented a grievous but seemingly inexorable trajectory. The death toll from infection among the very young was often obscured in colonial epidemics, when smallpox, diphtheria, cholera, dysentery, and measles typically killed without respect to age. Apart from these individual tragedies, however, there was little recognition of the special susceptibility of children, particularly those under 5 years of age, until the diphtheria epidemic in New England (1735 through 1740), in which 80% of its 5000 victims — almost 2.5% of the population — were children. 13 * By the middle of the 19th century, a child's death, far from intolerable, was frequently viewed as blessed, a release from the torment of hectic infection or the lingering complications of diseases such as rheumatic fever
- USAID has partnered with Faith-Based Organizations for over 30 years. This picture is the mission statement of St. Luke’s hospital in Apam, Ghana, where I saw amazing services provided in partnership with USAID two weeks ago. Faith-based organizations are critical to our success, and partner with USAID on an equal playing field. We realize that organizations like the ones you work with have extensive networks that reach into the poorest regions. Faith-based organizations and community groups have an understanding of the places in which they live and work and serve as a credible voice to people. I know that the strides made in global health are due in important part to your work and values. I look forward to continuing to work with you on our shared vision of a healthier world.
- Saving Mothers Continuum-of-care approach with high-impact interventions Target the complications of pregnancy and birth that result in the highest mortality Focus efforts on the 28 countries that contribute over 77 percent of the maternal deaths worldwide. Child Survival About 7 million children under the age of five still die annually, ~40 percent of these are newborns USAID focuses its work on 24 countries that account for over 70 percent of child deaths Nearly half of all child deaths occur in just five of these countries: India, Nigeria, DRC, Pakistan, Ethiopia We are working to galvanize the global community around a child survival call to action, see below AIDS-free generation Prevention efforts, fortified by intensive capacity building of the enabling systems required to sustain success, form the core of USAID ’s strategy. prioritizes activities in three key areas that science has identified as pivotal: preventing mother-to-child transmission (PMTCT), voluntary medical male circumcision, and treatment as prevention improve health systems including supply chains, build governmental and non-governmental institutional capacity, explore innovative financing options to build and allocate country resources more effectively, address gender norms and inequities Strength country efforts to care for the millions of children orphaned and left vulnerable by the AIDS pandemic USAID programs 57 percent of the total PEPFAR funding for antiretroviral treatment, and it will continue to play a major role in delivering life-saving treatment to those with AIDS in 100 countries Technical assistance Interagency cooperation Infectious diseases Malaria – working through PMI, housed at USAID to provide prevention and treatment, build capacity, strengthen health systems, working with partners e.g. RBM, GFATM TB -- Lead international working group of the Federal TB Task Force; support research for the development of a new TB drug regimen that could shorten the treatment regimen, including the treatment of multi-drug resistant TB; working with partners including Stop TB, WHO, UNITAID NTDs – effective, efficient programs; strong collaboration with for profit private sector Avian influenza, emerging pandemic threats – working with CDC, DoD and others to build capacity in “hot spots” where threats more likely to emerge Family planning Already transitioned 21 countries from USAID family planning support since the 1980 ’s, over the next five years USAID’s global health response will prioritize 24 countries that represent over 50 percent of the unmet need for family planning and graduate four more (Nicaragua, Honduras, Peru, and Egypt). Health systems Increasingly recognized as a binding constraint to progress During the next five years, USAID ’s global health team will take deliberate steps to ensure that health system strengthening is built into all the work that USAID does Improving staff capacity, harmonizing tools and standards, generating state-of-the-art evidence on cost-effective approaches to health system strengthening; pursuing a thoughtful learning agenda to strengthen the evidence base; and developing consensus on standardized indicators and on better communicating concrete achievements
- Barriers to addressing health issues Poverty, ethnicity, socio-economic status, poor infrastructure, distance from health facilities, lack of health insurance, and the low status of women and girls, continue to limit equitable access to health care Lack of capacity and poorly functioning health systems challenge the delivery of quality affordable health care, especially to the poor Limited access to information and knowledge prevent the most vulnerable from taking appropriate measures to protect themselves from disease
- Default scenario is explosion of unregulated private services paid for out-of-pocket in poorly governed systems with mixed public-private provision with inefficiency, regressive financing, where health bills become number one cause of impoverishment. Xu et al studied 89 countries covering 89% of the world ’s population. They found that around 150 million people each year suffer financial catastrophe, and 100 million are pushed under the poverty level simply because they need to pay for health services they use. More than 90% of these people live in low-income countries. Krisjanson et Krishna looked at India and Kenya and found that the vicious cycle of ill health, health spending, loss of work from illness and high-interest debt to pay for these were closely associated with household impoverishment. Left alone these patterns will become entrenched as larger and larger shares of growing economies, less amenable to change. Witness Egypt, where health spending is high, out of pocket spending is a large share, and attempts to reform the Health Insurance Organization, develop national health insurance, and mobilize both public and private providers have met with major opposition.
- At the same time, ODA patterns are changing. Private capital flows dwarfing ODA. Among traditional ODA providers (OECD countries) projected growth slower New ODA providers – BRICS, TIMBIs, Korea, Others Unique window – while we still have influence, when we can influence agendas of new actors, before patterns become entrenched and we lose our influence
- A new era: 1. A historical, dramatic increase in per capita GDP around the world in the last generation, 2. Followed by commensurate increases in domestic health spending, and 3. Progressive dilution of ODA dollars by private capital - in some countries framing a closing window of opportunity this decade. This has brought about unprecedented gains in health and development in the world (e.g. halving the number of people living in poverty, and 70% decrease in child mortality rates during USAID's existence), but also new challenges as most of the new health spending is out-of-pocket (inefficient, regressive, number one cause of impoverishment) absent a modern health financing arrangements (i.e. social or private health insurance), as NCDIs add a new dimension to the burden of disease. IMPLICATIONS: 1. Celebrate the success of the effort and investment of the American people and partners - the ultimate day President Kennedy spoke of in 1961 is indeed at hand for most countries (USAID indeed withdrawing from Brazil and China as we did before from South Korea and Turkey). 2. A new compact for development: emerging economies (BRIC, TIMBIS) should invest in international development, and with other LMICs invest more (and more equitably) in their poor and vulnerable people (including health financing reforms) while joining in new ambitious world health goals (as India and Ethiopia re doing in co-convening the call to action in June). The GHI already prescribes change for USG: consolidate ODA, move to country ownership and health systems strengthening, progressively replacing direct service provision with technical assistance and diplomacy. USAID will increasingly concentrate its efforts in the neediest countries. 3. Rather than worrying about the current budget strains in OECD countries, leverage this success for optimistic and bold end-games like the AIDS-free generation, the end of preventable child death in a generation and an equivalent for maternal mortality. There is also an opportunity, a need indeed, to lay the health systems foundations for universal health coverage (a universal aspiration, moving coverage from 40% to 80% of all humans and halving OOP spending from 60 to 30% by 2020).
- We’ve constructed this map , the first of its kind, based on a recent report by the International Labor Organization (which defined coverage as the population “ formally” covered by social health protection – explaining the US and South African rank) Universal health coverage, the hallmark of a well-functioning health system, Is the right aspiration on human rights and economic grounds It is feasible: t here are nearly 50 countries in the world with UHC today And it is a measurable indicator of progress in health systems strengthening But in Africa and Asia, where most poor people live, most countries don’t have UHC (or we can’t even tell) Yet, it is happening already, from Mexico to Thailand, budding in Ghana, Rwanda and Vietnam, and even China and India. We believe THS efforts, directly or indirectly, will help fill in blue several countries by next decade We also believe making health systems visible and more appealing will facilitate the promotion of this agenda 51 countries (or 46.3%) of 110 countries the ILO has data for have formal UHC (>95%). 1 Low-Income (LI) Country (equal to 0.9% of the total and 4% of the LI group). Countries in this group with UHC: Gambia. 7 Lower-Middle Income (LMI) Countries (equal to 6.36% of the total and 21.8% of the LMI group). Countries in this group with UHC: Armenia, Bosnia and Herzegovina, Mongolia, Thailand, The FYR of Macedonia, Tunisia, Ukraine. 13 Upper-Middle Income (UMI) Countries (equal to 11.8% of the total and 61.9% of the UMI group). Countries in this group with UHC: Argentina, Belarus, Bulgaria, Chile, Costa Rica, Croatia, Cuba, Lebanon, Serbia and Montenegro, Panama, Romania, South Africa, Venezuela. 30 High-Income (HI) Countries ( equal to 27.2% of the total and 93.75% of the HI group). Countries in this group with UHC: Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Netherlands, New Zealand, Norway, Oman, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom, United States . Formal Health Coverage: “ Measured in terms of the population formally covered by social health protection, e.g. under legislation, without reference being made to effective access to health services, quality of services or other dimensions of coverage” (ILO definition). Not always a reliable measure of access to services. Out-of-Pocket (OOP) Expenditure : OOP remains as a key financing mechanism for many low-income countries. Universal formal health coverage does not always mean low OOP (e.g. Tunisia has almost universal health coverage while its OOP is 45%).