The U.S. Commitment to Global Health Recommendations for the New Administration (2009) / Chapter Skim
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In today's market crisis, the financial policies and practices of the most developed nations, including the United States, are seen as the cause of painful economic spillovers in low- and middle-income countries. During economic downturns, population health declines, especially among the poor in low-income countries, who pay a large portion of their health care costs out-of-pocket, without the benefit of social safety nets.
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government commit to $13 billion for the health-related Millennium Development Goals (MDGs) and an additional $2 billion to address the challenges of noncommunicable diseases and injuries.
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America's traditional strength in the global health field is its capacity to generate knowledge. The committee recommends that Congress continue to fund research in important areas -- such as new interventions for the prevention and treatment of infectious diseases -- but also allocate a portion of the funding levels recommended in this report to increase funds for three purposes: to study the basic mechanisms of diseases that disproportionately affect poor countries; to identify means to control noncommunicable diseases that are applicable in low-resource settings; and to conduct health systems research to improve the delivery of existing interventions.
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The United States can, however, lead by setting an example of meaningful financial commitments, technical excellence, and respectful partnership; this will go a long way toward achieving the globally recognized Millennium Development Goals (MDGs) , adopted by the United Nations (UN)
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Working with partners in other countries and building on previous commitments, the United States has the opportunity to demonstrate global leadership by fulfilling its responsibility to save lives and improve the quality of life for millions around the world. Unprecedented commitments to global health The promise of potential solutions to global health problems has captured the interest of a new generation of philanthropists, students, scientists, private sector leaders, and citizens -- eager to make a difference in this interconnected world.
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During economic downturns, the health of a country's population worsens due to lowered household income and reduced access to health care.12 The poor in low-income countries are most affected because they pay a large portion of their health care costs out-of-pocket, without the benefit of social safety nets.13 It is therefore crucial for the reputation of the United States that the nation live up to its humanitarian responsibilities, despite current pressures on the U.S. economy, and assist low-income countries in safeguarding the health of their poorest members.
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commitment to avert conflict and promote a more peaceful world.20 Most of the people living in the societies of the world's poorest billion people are either currently engaged in a civil war or have recently been through one.21 Implementing disease control and public health activities -- which help break the cycle of poverty, conflict, and poor health -- is particularly challenging in fragile states and countries that have experienced conflict.22 For example, countries with the highest infant and child mortality rates are those most likely to be engaged in war;23 in both 1990 and 2005, Afghanistan, Angola, and Sierra Leone -- three war-torn countries -- had the highest mortality rates in the world for children under 5, even during times of relative peace.24 By improving health and restoring human dignity, the United States can help avoid or reverse the social fragmentation, economic decay, and political instability that often cause, prolong, or result from devastating conflict. The expansion of U.S.
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Technological innovation and diffusion main drivers of health improvements Health achievements in the last 50 years have been remarkable; global life expectancy has increased more in this period of time than in the preceding 5,000 years.29 Average life expectancy -- the age to which a newborn baby is expected to survive -- was approximately 40 years in low- and middle-income countries in 1950; 50 years later, life expectancy in these same countries has risen more than 60 percent to about 65 years.30 Most of the improvements in life expectancy are derived from reduced health risks for young children. Since record keeping on child mortality began in 1960 (when 20 million children died annually, or 180 deaths per 1,000 live births)
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The distribution of this simple pill as part of a supplementation program in low-resource settings was found to save the lives of millions, reducing child mortality by 23 to 34 percent.36 Today, as a vital component of child survival strategy, more than 60 nations have vitamin A supplementation programs (many supported by United States Agency for International Development [USAID]
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.49 This reality is made sharper by the knowledge that existing health interventions could reduce child mortality by as much as 63 percent if they could reach those in need.50 While progress has been made in important areas -- for example, deaths from measles fell by two-thirds between 2000 and 2006 due to dramatically improved vaccination programs covering 80 percent of children in developing countries51 -- the lack of well-functioning health care systems severely constrains the delivery of many essential health interventions.52 MDG 5: Improving maternal health. Ninety-nine percent of maternal deaths occur in low-resource settings, with sub-Saharan Africa and South Asia accounting for 86 percent of all such deaths (see Figure 2)
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S C o m m itm e n t to G l o b a l He a lth ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Box 1 United Nations Millennium Develpment Goals Goal 1 Eradicate Extreme Hunger and Poverty Goal 2 Achieve Universal Primary Education Goal 3 Promote Gender Equality and Empower Women Goal 4 Reduce Child Mortality • Target 1: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Goal 5 Improve Maternal Health • Target 1: Reduce by three quarters the maternal mortality ratio • Target 2: Achieve universal access to reproductive health Goal 6 Combat HIV/AIDS, Malaria, and Other Diseases • Target 1: Have halted by 2015 and begun to reverse the spread of HIV/AIDS • Target 2: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • Target 3: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Goal 7 Ensure Environmental Sustainability Goal 8 Develop a Global Partnership for Development Source: Millennium Development Goals (MDGs)
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.67 Figure 1 MDG 4: Under five deaths per 1,000 live births (1990, 2006, and 2015 target) CIS, Europe 27 17 45 Eastern Asia 24 Latin America and 55 the Caribbean 27 Northern Africa 82 1990 2006 Target 35 77 South-Eastern Asia 35 69 Western Asia 40 79 CIS, Asia 47 85 Oceania 66 Southern Asia 120 81 184 Sub-Saharan Africa 157 0 20 40 60 80 100 120 140 160 180 200 Rate per 1,000 Source: The Millennium Development Goals report, 2008.
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95 Eastern Asia 50 58 CIS 51 Latin America and the 180 Caribbean 130 1990 2005 Target 250 Northern Africa 160 190 Western Asia 160 450 South-Eastern Asia 300 550 Oceania 430 620 Southern Asia 490 920 Sub-Saharan Africa 900 0 100 200 300 400 500 600 700 800 900 1000 Deaths per 100,000 live births Source: The Millennium Development Goals report, 2008. Figure 2 Neglected health systems undermine health progress Functional health systems are sorely lacking in most poor countries, undermining the achievement of the health-related MDGs.68 A functioning health system, as defined by the WHO, should include access to a well-performing health workforce; reliable and timely health information; essential medical products, vaccines, and technologies; adequate financing; and strategic policy frameworks to provide effective analysis, oversight, and governance.69 More than half of the meager spending on health in low-income countries is in the form of out-of pocket payments made by patients -- the most inequitable type of financing because it disproportionately hurts the poor, and provides no protection from the costs of catastrophic illness.
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These threats include infectious diseases as well as unhealthy imports, such as tobacco and processed foods, which heighten the risk of many noncommunicable and chronic diseases.82 As a result of rapid urbanization, more than half of the world's 6.6 billion people now live in cities, where they are exposed to a variety of risk factors for chronic disease.83 City dwellers live more sedentary lives than their agrarian counterparts and have easier access to cheap, high-energy, high-fat food.84 Emerging pandemic threats like bird flu, which can spread with alarming rapidity in today's globalized world, need urgent preparation. Infectious disease outbreaks have significantly increased during the last several decades85 and are dominated (60 percent)
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Unless large numbers of adults quit, smoking will account for 1 billion deaths this century.94 The prevention and treatment of chronic and noncommunicable diseases should become a priority in global health, along with interventions to reduce risk factors such as tobacco use, obesity, and sedentary lifestyles. As noncommunicable diseases are not included in the MDGs,95 the WHO has called for a global commitment to reduce chronic disease death rates by an additional 2 percent annually or by 36 million deaths by 2015.96 Increased mortality from chronic disease is not merely a result of fewer deaths from infectious disease.
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Appoint White House Senior Official and Interagency Committee on Global Health The 1997 IOM global health committee called for the establishment of an Interagency Task Force on Global Health within the U.S. government to anticipate and address global health needs and to maximize global health opportunities -- both for the United States and the world -- in a coordinated and strategic fashion.
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government has a coherent strategy for ongoing investments in global health, including the means to achieve measurable, significant, and sustained health gains. The Interagency Committee would also play the critical role of making sure health is taken into account when setting U.S.
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4000 3000 2000 1000 0 2001 2002 2003 2004 2005 2006 2007 2008 Year Maternal and Child Health Family Planning and Reproductive Health Other Infectious Diseases HIV/AIDS Source: Committee's calculations based on Salaam-Blyther, 2008. Figure 4 19
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During the same period, USAID programs for children and women's health received only $4.6 billion, representing little or no increase in real terms.120 While pursuing the goal of $13 billion per year for the health-related MDGs, the committee strongly recommends that the Deputy for Global Health and the Interagency Committee work with Congress to create balance in the traditional portfolio of global health aid.
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countries (2007) 1 0.95 0.93 0.9 0.9 0.81 0.81 0.8 0.7 0.6 As % of GNI 0.54 Millennium Development Goals Target (0.54)
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The United States should maintain funding for antiretroviral treatment for individuals already supported by PEPFAR, but also act diligently to ensure that the program prevents as many HIV infections as possible, especially among young women in Africa (who are three times more likely to be infected than men of the same age in many high-burden countries) .122 This committee supports the 2007 IOM committee findings on PEPFAR implementation, which state that in order to help countries make gains against the HIV/AIDS epidemic, PEPFAR will need to emphasize effective, evidence-based prevention with the same urgency and intensity it has focused on treatment.123 Without a stronger focus on prevention, PEPFAR costs could crowd out other equally important global health initiatives.124 Additional funding for noncommunicable diseases and injuries While the recommended $13 billion per year for global health would support the health-related MDGs, additional resources will be required to meet the global burden of disease for the 21st century.
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to achieve sustained, significant, and measurable health gains. By working in partnership with low- and middle-income countries and other donors to support country-led health plans, and by including a rigorous evaluation of health programming, the United States can improve health outcomes -- such as reducing child mortality or preventing HIV infections -- while delivering aid that encourages countries to take ownership for the long-term health of their populations.
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Improving comprehensive care delivery can also improve the life of the child's mother, who would visit a health clinic because of her sick child, but gain access to cervical cancer screening, antenatal care, family planning, treatment for sexually transmitted infections, and HIV testing and counseling. The committee commends the language in the reauthorization of PEPFAR, which calls for expanded efforts to strengthen health systems and human resources, and to collaborate with other programs, such as child and maternal health, clean water, food and nutrition, and education.137 Leveraging the implementation successes of PEPFAR to support broader national health priorities would go far in making even greater improvements to health outcomes.
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Beyond counting the number of vaccines administered or health workers trained, it is important to ask tough questions such as, "Are we preventing HIV infections in adolescent women? " and "Do our efforts lead to sustained reductions in child mortality?
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The committee recommends that Congress continue to fund research in important areas -- such as new interventions for the prevention and treatment of infectious diseases -- but also allocate a portion of the funding levels recommended in this report to increase funds for three purposes: to study the basic mechanisms of diseases that disproportionately affect poor countries; to identify means to control noncommunicable diseases that are applicable in low-resource settings; and to conduct health systems research to improve the delivery of existing interventions. Given the tight budgets for research, there is now, more than ever, a need for increased coordination, transparency, and accountability in the use and distribution of funds to the various U.S.
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More recently, Fogarty built on this model and designed the Millennium Promise Awards, a program that builds research capacity in low- and middle-income countries in fields related to cancer, cerebrovascular disease, lung disease, obesity, lifestyle factors, and genetics as related to chronic diseases.154 The United States can increasingly expect to find institutions in middle-income countries that are among the world's centers of excellence on public health and science, thereby enabling the establishment of meaningful partnerships. Public spending on health research by developing countries now exceeds $2 billion a year.155 In an example of an emerging economy taking the lead in global health research, the International Vaccine Institute in Seoul, Korea, is conducting vaccine research to help children in poor countries with funding from numerous public and private donors including the NIH, the National Science Foundation, and USAID.156 Another example is provided by Brazil's recent plan to invest $23 million in a pharmaceutical factory in Mozambique that will use raw materials from India to produce much-needed antiretrovirals for Africa.157 Federal Executive Branch agencies and departments should strengthen existing partnerships with the private sector and explore new collaborations with the public and the private sectors in low-income and emerging economies.
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This burgeoning community -- comprising more than 40 bilateral donors, 26 UN agencies, and 20 global and regional funds, all supporting more than 90 global health initiatives159 -- is vast and diverse, and greatly in need of strong leadership. The WHO is uniquely positioned to provide this leadership by virtue of its role in setting evidence-based norms on technical and policy matters, highlighting best practices that improve health globally, and monitoring and coordinating action to address current and emerging global health threats.
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For 50 years, the CDC's tremendous concentration of technical expertise in public health has been a key source of input and support to a range of bilateral and multilateral organizations, with CDC staff being placed at the WHO, the World Bank, and in individual nations. This important in-country presence during the design, implementation, and evaluation of health initiatives has contributed to numerous programmatic successes.
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government has a coherent strategy for ongoing investments in global health, including the means to achieve measurable, significant, and sustained health gains. For the term of the Presidency, the committee proposes two objectives.
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