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Susan Raymond, Ph.D.Executive Vice President
February 20, 2014
Health Transitions in the “Developing” World
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Rule Number One in a World of Change
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I always skate to where the puck is going to be.Wayne Gretsky
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Objectives
• Review what has changed– In the global health environment– in demographics and epidemiology
• Therefore the disconnect between past ways and current means• Discuss the financial implications of the change• Examine why global health is nearly the last development sector
to have recognized this reality
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What has Changed: The Demographic and Epidemiological Context
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Global Health in the 1960s• Only the industrialized countries had reduced infant mortality
below 50 per 1000 live births• Fertility rates in developing countries were high, with an average
of 6 children per woman• Life expectancies were between 40 and 50• Communicable diseases took the majority of lives and took them
at young ages.• Caloric intake in developing nations averaged less than 2000
calories per day
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Changed Demographic Future – By 2015
• Infant mortality by 75% since 1950• Child mortality by 80% since 1950• Life expectancy to within 10 years of industrialized
world• Fertility Population growth rates headed toward
replacement levels • Numbers of under-fives decline in absolute terms
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Aging of the Developing World
05
101520
1950 1970 1990 2000 2010 2015 2020
% o
f pop
ulat
ion
under 5 over 60
• By 2020, the absolute number of children under five will decline
• A key issue is pace. The U.S. had 70 years for the 65 and over population to grow from 5% to12% of the population. Latin America will have 35 years and the clock started ticking over a decade ago.
Source: World Population Prospects
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For Less Developed Nations, Marked Progress
-1
1
3
5
7
1950-55 1960-65 1970-75 1980-85 1990-95 2000-05 2010-15 2020-25
Declining Fertility Rate
Developed Less w/o Least Least
050
100150200250
1950-551960-651970-751980-851990-952000-052010-152020-25
Declining Infant Mortality Rate
Developed Less w/o Least Least
• Fertility is converging• Indeed, the UN reduced
its global population estimate by one billion people
• Infant mortality is plunging; in all but the least developed countries, IMR is now at or below 30
• Child mortality has dropped by 43%
Source: World Population Prospects
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• Life expectancy is rising; in 1950 there was a 30 year difference with industrialized countries; by 2030 it will be 9 years
• HIV/AIDS has taken its toll, but its net demographic impact is critical only in a few nations in Africa, although the financial impact (the "therapeutic mortgage") is a long term economic weight (more later)
303540455055606570758085
1950
-55
1960
-65
1970
-75
1980
-85
1990
-95
2000
-05
2010
-15
2020
-25
More Dev Less w/o Least
Least
Marked Progress (cont’d)
Source: World Population Prospects
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The Wages of Progress: Chronic Disease
• Even in high child and high adult subpopulations in developing regions, non-communicable diseases dominate
• CVD represents three quarters of non-communicable disease deaths
• 80% of CVD deaths occur in developing countries
0
10
20
30
40
50
60
Africa LAC E Med SE Asia
% T
otal
Dea
ths
Death Distribution in High Child/High Adult Mortality Populations
infectious/parasitic noncommunicable injury respiratory
Source: WHO State of the World’s Health
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• In all but Sub-Saharan Africa, chronic diseases dominate death rates
• And the level of those death rates in the working ages have not been see in the industrialized world since the 1950s.
0
100
200
300
400
500
600
de
ath
s/1
00
,00
0 a
ge
gro
up
Brazil
India
S Afri
ca
China U.S
.
Russi
a
CVD Death Rates ages 30-59
Male
Female
…Focused on the Workforce
Source: A Race Against Time
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• As the working age population expands, and if high death rates continue, the burdon will be on the shoulders of workers.
• In Brazil, between 2000 and 2030, 28% of CVD deaths will be among the workforce, compared to 12% in the U.S.
0102030405060708090
100
% C
VD
de
ath
s
Brazil U.S.
Death Distribution by Age Group 2000-2030
35-44 45-54 55-64 65-74 75 & over
With Higher Portions Dying Earlier
Source: A Race Against Time
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….And women are not exempt
0
10
20
30
40
50
60
Argen
tina
Chile
Colom
bia
Ecuad
or
Mex
ico
Peru
S Afri
ca
China
India
% 15-34 Female Mortality due to
mat+HIV chronic
0
10
20
30
40
50
60
Argen
tina
Chile
Colom
bia
Ecuad
or
Mex
ico
Peru
S Afri
ca
China
India
% 35-44 Female Mortality due to
mat+HIV chronic
Source: WHO Mortality Database
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This is not about rich men
• Studies in Brazil and South Africa show that the risks associated with chronic disease are higher among the poor in cities than among the rich.
• Just as in the West, chronic disease is coming to be a function of poverty.
• Disability and early death compromise fragile households and result in tens of millions of years of productive life lost. The fastest path to poverty is widowhood, no matter how it happens.
• The threat is compromised economies just as the promise of growth is within our grasp.
A Riff on the Middle East
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The Obese: BMI ≥ 30kg/m2
0
5
10
15
20
25
30
35
40
45
50
% a
dults
Male
Female
16
Source: WHO Global Database on Body Mass Index
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02468
101214161820
Percent Adult Population with Diabetes
By 2025, 20% of UAE adult population will be diabetic, 12% in Egypt and even 10% in Jordan and Morocco
How is this NOT “Global Health”?
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The rural-urban divide may not apply
0
20
40
60
80
100
Riyadh Jeddah North'n Najran Tabouk Hafr alBatri
Saudi Arabia CVD Hospital Visits Per 1000 Population (2006)
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• In Morocco, hypertension rates are higher in rural than in urban areas. (Bulletin Epidemiologique 2003)
• In Saudi Arabia, CVD-associated diagnoses can represent a higher portion of hospitalizations in rural areas than in Riyadh. (Review of Health Situation, Saudi Arabia 2006)
• In Jordan, 6 provinces have higher CVD death rates than Amman, four of which are largely rural. (Mortality in Jordan, 2004)
0
20
40
60
80
100
120
Amman Irbid Zarqa Balqa Karak Madaba Ajloun
Jordan CVD Death Rate/100,000 2004
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Children• There are no trend or cross-region data on childhood obesity.
• A study of King Saud University students showed that 31% were overweight, and another 23% were obese (Al Turki 2006).
• A 2005 study showed that 10-15% of elementary students and 20-40% of secondary students in the Gulf were overweight (Rabbu 2005).
• Unfortunately, these numbers approximate those of the U.S. where 30% of young people are overweight.
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CVD as Percent Female Deaths Ages 35-64
0
5
10
15
20
25
30
35
40
45Jo
rdan
Eg
ypt
Bah
rain
UA
E
Qat
ar
Ku
wai
t
Po
rtu
gal
Fra
nce
Sources: WHO Mortality Statistics, Ministries of Health
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How is this NOT
“women’s health”?
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CVD Female Death Rates by Age
0
100
200
300
400
500
600
700
35-44 45-54 55-64
Egypt
Kuwait
Bahrain
Qatar
France
Source: WHO Mortality Statistics
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What Changed: The Economic Context
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Yesterday’s Economic Context• Nearly 60% of the world’s population lived on less than $1 per
day• South Korea, Taiwan, Singapore were poor and considered
economic basket cases; the literature considered South Korea to be a likely recipient of global aid for the foreseeable future
• Even by the 1980s, Malaysia, Thailand and Indonesia were poor• India was a recipient of constant relief and a global famine
concern
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IMF Projections % Change in Economic Output
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The advanced economies went into the recession deeper, came out slower, and will stabilize at lower rates of growth.
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Rising Global Middle Class• By 2030, only 20 years from now, 2 billion people will join the
global middle class.• This will represent 30% of the world’s population, dwarfing the
19th century middle class explosion.• This stretches far beyond the growth of India and China. Nations
with projected Middle Class bulge include– Egypt– Philippines– Indonesia– Mexico– Brazil
India and China per Capita Income Growth
1820-1950 0%1950-1973 68%1973-2002 254%
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• By 2030, middle income countries will account for 43% of global GDP (in dollar terms) compared to 15% today.
• The global distribution of income is narrowing. By 2050, middle income individuals will account for 40% of global incomes, compared with 30% today.
• By 2030, Asia Pacific will account for 59% of middle class consumption, compared to 10% in North America and 20% in Europe.
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Kharas and Gertz, Brookings
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And Africa is not the exception.
• By 2040, Africa will have the largest workforce in the world.• 50% of the population will live in cities.• Impact investing in agriculture (Africa accounts for 60% of
uncultivated land in the world) will increase rural incomes.
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• By 2020, half of African households will have discretionary spending power.
• In transition economies (e.g., Tanzania) 72% of GDP will be from manufacturing and services; in diversified economies (e.g., Egypt), 83%.
• Service sectors will create jobs driven by urbanization. In 2020, Johannesburg will be larger than New Delhi. 0
10
20
30
40
50
60
70
80
90
100
2000 2008 2020
% of Households Per Income Bracket
Global
Consuming Middle Class
Emerging Consumers
Basic Consumer Needs
Destitute
Again, Africa is not the exception. African economies are diversifying
28McKinsey & Company
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Why does this matter now? The disappearing window of opportunity
% Population Dependent
20
25
30
35
40
45
50
55
60
65
2000 2010 2020 2030 2040
BrazilRussiaIndiaS AfricaChina
Source: World Population Prospects
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So, what is our operating environment?• Marked demographic change• Changing disease patterns, with changing relationships to
behavior• Changing groups of people at risk• Changing implications for economiesWhen• Economies are growing• Internal capacities are growing• Knowledge and education are growing
• Poverty persists, but within an entirely different context.
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This does not mean abandoning the poor….
It means creating a complex business model that can adapt and innovate as operating conditions change.
It means differentiating between relief and development.It means building on change to create self-reliance.
It means working yourself out of a job.
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Why Is This So Hard for Global Health?
(Note Ascension Health innovation in Flint, Michigan points the way)
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1. Visibility of the Problem: Have You Seen Someone Who Looks Like This?
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Versus: Have You Seen Someone Who Looks Like This?
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1. Implications of Visibility
• Yesterday’s Approach• Knew a problem when you saw one• Could be presented pictorially and
gain sympathy• Clearly humanitarian, even relief,
dimensions of the problem• Motivated public concern and
hence provided a rallying point for governments
• Today’s Problems• Risk factors may be visible (smoking,
obesity) but they are common.• Some risk factors may not be visible
at all.• Some risk factors may be considered
self-inflicted.• Presence of disease itself is invisible.• Hard to motivate public concern for
or rally governments to the invisible.• Hard to counter the visible of existing
agendas with the invisible of emerging agendas.
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2. Prevention 3. Targets
• Yesterday’s Approach• Clear definition of prevention that can be
distinguished from therapy.• Binary problems = diseases can be
eliminated• Eliminating disease = elimination of the
disease as a cause of death• Today’s Problems• Prevention of risk factors means
prevention of early onset of disease.• Because chronic disease is progressive,
therapy is actually prevention. The question is management not eradication.
• Must invest in both therapy and prevention, but even that will not eradicate disease. Death is the inevitable result of life.
• Yesterday’s Approach• Women of childbearing age, but
usually only their reproductive organs• Children under the age of five• Only for certain diseases and still a
maternal-child health preference• Today’s Problem• Men and women of all ages• Multiple organs• Everyone who is undertaking risk
behaviors• Everyone who is not undertaking risk
behaviors but who might do so, including children over the age of five
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4. Skills 5.Timeframe
• Yesterday’s Approach• Therefore, global health could exist in
a “stovepipe” of singular skills and concentration.
• Programs could turn on public health as a profession.
• Today’s Problems• Public health is not the only skill, or
even the most prominent one.• Few programs in public health of
chronic disease.• Medical diagnosis and management,
finance, actuarial sciences, etc.
• Yesterday’s Approach• Projects designed and contracted
over 2 years and implemented over 3-5 years.
• Objectives met in five years• Projects refunded with similar
timeframes if gains not sustained• Today’s Problems• Generational in length.• No clear end point.• Decades of commitment.• Fundamental progress on chronic
disease is a film not a snapshot.
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6. Policy Rigidity 7. Governance
• Yesterday’s Approach• Narrow limits on where.• Difficulty in organizing a constituency
for any policy, so tendency to stick with policy as made or risk losing all.
• The wise option is the status quo, even when the status quo does not match the problem.
• Today’s Problem• Developing a way to have a flexible
policy about what and where global health invests, without a policy that invests in everything.
• Integrating health with a plethora of other kinds of policies.
• Yesterday’s Approach• Work with government ministries• Central government dictates to
subsidiary entities• Resource relationship at the level of
central government• Today’s Problem• Rise of local government and
authority• Rise of Civil Society and multiple
points of empowerment• Decreasing central control over local
decisions and resources• Multiple voices, views, and votes
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And so……money does not move and does not cause organizational movement
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Subject matter of grants authorized for Global Programs by foundations 2007-2012
Source: Calculated from the Foundation Center
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Highlighted Expertise Areas
•Essential drugs•Reproductive health•HIV/AIDS•Infectious diseases•Malaria•Neglected tropical diseases•Maternal health•Child health•Neonatal health•Gender•Human rights in conflict zones•Relief
Affiliations•UNICEF•Management Sciences for Health•Interaction•amfAR•Save the Children•John Snow International•Population Council•Population Action•American Society for Tropical Medicine and Hygiene•Friends of Africa•AMREF•Center for Human Rights and Public Health•PATH•International HIV/AIDS Alliance
And the incentives to change leadership loci are nonexistent: The new Board of the re-established Global Health Council
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But, there may be reason to hope…..• UN working groups and resolutions (but so far without money)• Multinational corporate disability cost concerns in emerging
markets• Relatively new interest in performance based financing, which
will force a more comprehensive view of disease• Innovation Fund investment in Pro Mujer• Media coverage
• But, the danger that over-reaching will create controversy and a backlash – TRIPS and the trade/intellectual property dimensions of a “public health crisis”
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And so we return to where we came in, the theme of change
But, perhaps, with a different perspective than that of Wayne Gretzky
The perspective of perhaps the greatest American oracle to ever have graced the stage of this great land.
It’s hard to make predictions, especially about the future.Yogi Berra
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Thank You
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