Shaping the Future of Global Health

University of California San Francisco

April 2002

Sylvia Caras, PhD

Health and the economy are deeply linked.

Causal links are complex and run in both directions.

The CMH Report can be a tool that empowers health decision makers.

Health has become a central component in the development agenda.

Big hall full, 350, and an overflow room, 10 minute late start, welcome from medical school dean, Haile, fourth international health bay area conference, Richard Feacham, Director, Institute of Global Health and WHO bulletin editor, team effort, sponsors, tribute to last year’s host, deceased, Paul Basch.

Findings of the Commission on Macroeconomics and Health (CMH) report and policy making which was released in September 2001.

Julio Frenk, Minister of Health, Mexico (formerly with WHO)

Leading health care reforms in Mexico; many fundamental decisions that affect health are driven by economic policies, "health is not everything but without health there is nothing," Brundtland (WHO): places health more centrally in the development agenda. Poverty is a determinant of mortality; per capita income affects system investment in health system. Very low income countries have a huge burden of preventable disease and a package of interventions of perhaps $30/person would eliminate this burden and is out of the reach of poor countries. ( US $4000/person Somalia $11/person.) Health is a determinant of economic growth

Weak health condition countries cannot sustain economic growth. So focusing on economics turns argument on its head and focuses on development. US employer-based health insurance system limits employee mobility hence affects labor market. Health regulations of food stuffs are a non-tariff trade barrier. Increasing tobacco taxes reduces rate of new smokes. Need to increase international development assistance for health. If rich countries devoted one penny of every ten dollars of income, 8 million preventable deaths a year could be prevented. Increase level of investment in knowledge which is a global public good (and which the Bush budget has eliminated from the CMHS budget. S.) Health conditions of a country affect private investment decisions (in tourism, for instance). Health and the economy are deeply linked. Causal links are complex and run in both directions. Core set of economic health investments would provide six-fold return. The CMH Report can be a tool that empowers health decision makers. Health has become a central component in the development agenda. Development is all about people; the motor of development is people.

Geeta Rao Gupta, President of International Center for Research on Women, women’s health and economic status have significant implications for the health and well-being of countries; increased investments of global health need to recognize gender differences and the health needs of women and girls. (So much shocking data so fast I couldn’t record - for instance 40% of married Indian women have been beaten by their husbands; son-preference: in Pakistan, lower-income households seek care more often for boys than girls and higher quality care; in South Asia a girl is 30-40% more likely to die than a boy (before 5 years old)). Health interventions should not reinforce damaging gender stereotypes. Recognize and respond to gender-differentiated needs. Interventions must be gender sensitive. Don’t provide women and men the same treatment when their needs are different. Don’t provide different treatments to women and men when their needs are the same. Health interventions can transform gender norms. Couple counseling. Integrating education about the costs of violence against women in curative men’s programs. Empower women: provide women with access to key resources: information and education, marketable skills, economic assets and resources, services and technologies, social support networks, political agency.

Afterwards I asked Geeta to post her slides to the Internet.  Instead she gave me a paper copy.  Excerpts:

Gender plays an integral role in determining individuals' health.
Maternal Mortality and Child Health
    Newborns whose mothers die are less likely to survive
    Families that lose mothers are likely to suffer declining nutritional status
    In a study in Bangladesh, children under age 10 were up to 10 times more likely to die following the death of their mothers.
Women's Lifetime Risk of Death from Pregnancy, 1995
    Sub-Sharan Africa: 1 in 13
Estimates indicate that overall 75% of workers in the informal sector are women
Women and HIV/AIDS
    In a study in Western Kenya, over 1 in 12 girls was infected with HIV by her 15th birthday
    In Kenya and Zimbabwe, teenage women are six times more likely to be infected than teenage men.
Domestic Violence in India
    In a household survey of nearly 9,938 women in 7 sites across India, 40% of women reported experiencing physical violence by their husband during their married lifetime and 26% reported experiencing it in the last year.

Adel Mahmoud, Merck (vaccines), infectious disease is the epitome of globalization. Horizontal - health for all sounds good, but vertical - smallpox eradication - is what we see works.

James Orbinski, Medecins Sans Frontieres, access to essential medicines, neglected disease initiative - drugs as public goods, public responsibility requiring public funding. Www.msg.org, www.accessmed-msg.org, www.neglecteddiseases.org World pharmaceutical market - 2002 - $ 406 billion; 5%of the world population, North America, is 42% of the world drug market. Markets do not reflect health needs. There is a market failure - inadequate research and development for neglected diseases; instead skewed towards highest financial returns which is intensive care. This skew is social policy, a choice.

Nafis Sadik , economics says there is no such thing as "unmet need," there is only the market. Must emphasize prevention, public health. Public leadership, political support, community and family leadership, changed behavior. Conservatism stands in the way of prevention of sexually transmitted disease, accidental pregnancies, adolescent education, ... Capacity building. Partnerships must be broader than just public:private. Consensus building is inclusive. Social services for all.

(Not one word so far about disability, or mental health. Only health. S.)

Breakout: Overview of Healthcare Information Technology in the Developing World - 20 people

John Peabody, DD, Institute for Global Health, IT is a managerial: operational, business resource, strategic tool: clinical: information systems, decision support, education; payment mechanisms; national health insurance, private insurance, out of pocket (dominant in developing countries); provision of services: public, private; incentives for IT systems are motivated by payers, when payment is out-of-pocket, little IT incentive. IT systems can inform policy changes. IT is crucial to raising quality and lowering costs. IT adoption, although unlikely to occur in the near future, is ideally done ‘rationally.’

Sandra Dratler, UC Berkeley Center for Public Health Practice, IT and Health, MIS, Health Sector Reform: change in management structures, change in management capabilities, transparency, accountability, data-driven. Levels of information needs: facility/program, ministry of health, central government, donors; management functions: planning - internal data, external data, analysis, strategies/goals; organizing - implement strategies, developing and improving processes; controlling: monitoring, analyzing, reporting, communicating; evaluation - internal, external; uses of MIS: operational tool: transaction processing systems; business resource: MIS, DSP; strategic tool: executive information systems, workflow redesign, networking, electronic data interchange; MIS needs: accessible, reliable, timely data; simple, understandable system; comparative data; ability to analyze; reasonable cost.

Wei Yu, How to adopt clinical information technology in developing countries? VA Decision Support System. Comparing very simple Chinese system and very complex US system. A clinical information technology system can be very expensive. Objectives of establishing a clinical information system in developing countries must be cost-effective. Government financing is needed.

Panel of three speakers: basic problem is Internet access, aggressive Chinese Internet access policy, Seva: agreed in advance protocol, local work-up, still image data transferred by computer, consult in developed world, result: local surgical training and skills increase; mixed data whether the electronic medical record improves care; chronic disease where a record that reflects continuity of care is a new concept.

Issues of privacy/confidentiality were not mentioned. Primary value to the patient was only mentioned in the discussion of systems in rural China. I didn’t make this comment from the audience: A piece of health information technology is the interest of the individual with a health concern, assessing the provider, comparing insurance plans, exploring a diagnosis, researching treatment options, sharing with others - this will drive systems from the outside as much as the internal forces.

Estimated global R&D funding 1998: 73.5 billion (34.5 % public funding, advanced and transition countries; 30.5 % private funding, pharmaceutical industry)

Richard Smith, Editor, BMJ (the best medical journal; everyone’s free to make a fool of himself in my journal), The Future, 25 people

Dangers and difficulties of looking to the future, why bother then? How best to think about the future? what is Foresight (UK futures project) , ... talk and slides will be at www.bmj.com under talk section

Attach probabilities to possibilities, extrapolating from current trends won’t work in this time of fast change, prepare for, and maybe shape the future, think of the drivers of change, imagine different scenarios

Audience generated drivers:

aging population

have:have-not gap increasing

increase in communication technology

leadership

wider ownership of concept of right to health

proliferation of international organizations

international trade agreements

diminished role of nation states

epidemiology/disease

global interdependence

environment, food, water

who has the power

new voices, new players

empowerment of the individual

deflation of professional privilege

less medicalisation

spirituality

exponential knowledge growth

exponential technology growth

rising education

rising expectations

alternative medicines

medical research

We in the audience were handed transparencies and markers and asked to each draw their visions of the health future. Porous nation state borders, growth and more importance of communities which are networked, all overlaid by global governance. Individualization. Community care.

Frustration (conflict is human nature, hence more frustration). Homogenization. Interconnected flow. Live forever carefree. Interconnection via computer. Equitable distribution. Fee for service for the rich; managed care K-mart supermarket for the middle class; safety net for the poor. From self-care to authority.

A comment was made about toppling The Big Guys; I thought that went with empowering the individual. She said no, her idea was political. As if self-empowerment wouldn’t have huge political impact. <shrug>

Plenary Q&A:

Why assume that free trade is A Good Thing? Yes: Openness is generally good, for health, for democracy, ... Poverty reduction strategies. Practical, not ideological. No: Free market has had a decimating effect on health in Russia. African structural adjustments have reduced the ability of government to tax.

Report follow-up: how can we increase the resources to implement the report. Bush: 2004 $10 billion, Millennium fund, international assistance.

Greater accountability of public:private partnerships.

Malaria: people who live in malaria-prone regions and do not get sick, who then leave to live elsewhere, and then return, develop unusually severe malaria.