While public health is generally expected to be dealing with the regular challenges of a health system trying to address the problems of health across the usual life course in stable societies, we also must recognize that disasters of various kinds can post a serious public health emergency. And public health needs to be ready not only to meet them, in terms of coping with them and providing appropriate relief through well geared up health services, but also to try and mitigate their impact through proper planning and preparedness. What we know about the changing environment is that temperature extremes are more likely with climate change and they will be an increased frequency and intensity of extreme climatic events. And these extreme weather events are likely to result in a variety of natural disasters. And these are likely to cause a huge amount of death and disability apart from economic loss. In the last four decades, natural disasters have caused more than three million deaths and more than two trillion dollars in economic losses. The Indonesian earthquake and tsunami of 2004 as well as the earthquake in Haiti in 2010 had the highest death toll from all natural disasters in recent times. In terms of human actions, which increase vulnerability to disasters, deforestation leading to landslides is a very good example of improper resource management by humans leading to avertable disasters. All of this is quite often seen in number of developing countries which are rapidly denuding their forests and leading to soil erosion and landslides which kill people and cause a lot of challenges to their health and wellbeing. In terms of urbanization, while it is inevitable that we will see more of urbanization, unplanned, rapid urbanization results in informal settlements being built poorly with poor access to services and unhygienic conditions. And should a disaster strike, these would be extremely vulnerable population groups. About nearly 200,000 new citizens are added to urban populations every day, globally. And urban slums are also growing proportionately with this increasing urbanization. When we look at how a disaster develops, it’s not as though it strikes suddenly and leaves devastation in its wake. There is also a huge amount of vulnerability which is built up ahead, which makes the disaster even deadlier than it should have been. There are individual factors like vulnerable age, gender and disability which enhance the vulnerability of individual persons. But at the level of the society itself, we also recognize that there are unsafe conditions, like the way buildings are constructed and way urbanization takes place in an unplanned manner with fragile slums. Also, with poor access to health services where needed in the wake of a disaster. Reduced capacity to cope which is created by inability of different planning systems. Also, lack of access to information as to what might happen in the case of a disaster, or even advance warning of a disaster. All of these enhance vulnerability of persons and people. But the trigger event is an environmental hazard which comes in the form of a natural disaster but the vulnerability that exists aggravates the damage done. When we’re really looking at a disaster, in terms of the income status of the countries, not unexpectedly, low income countries have much higher mortality in relation to the middle income countries and high income countries from disasters, because they’re low in resources and also low in preparedness. How do disasters affect human health? Quite often the images that spring in our mind are of people being washed away by flood waters, or being swallowed by the earth when earthquakes strike. But disasters can harm human health in very many other ways. For example, there can be severe damage to buildings and supply chains which can affect health. If there is damage to civil engineering structures and water sources, then you can have heavy contamination of water. You can also have personal shortages. The movement of emergency relief can be impeded if either people are unable to reach the spot or if they themselves are incapacitated and the transport systems are disrupted. The availability and access to drugs also becomes a problem as well as emergency relief equipment if the supply chains break down. Further, there is also the threat of vector control being thrown out of gear. We can have proliferation of breeding sites for example of mosquitoes and other vectors. There is increased human vector contact, created by the disaster zone. And there is a disruption of the routine disease control programs which provide the protection in usual times. Food handling also becomes a major issue and food safety is a matter of serious concern. Power outages can result in spoilage of refrigerated foods. There can be damage to food preparation facilities. And even the relief supplies that are being rushed can be contaminated or degraded by a disaster. At the same time, one of the critical challenges is the provision of clean water supply and adequate sanitation, both of which are compromised in a disaster situation. Emergency water supplies can be greatly impeded in terms of both quantity and quality. And the management of waste matter is a big problem and if that starts contaminating water supplies, then you can have a huge proliferation of water borne diseases, various infections that come with water contamination. When we come to management of disasters we really ought to be looking at vulnerability and risk assessment. And that starts with planning and also with organization of systems in order to provide a good response in a timely and efficient manner. And whenever there is a disaster, we have to quickly assess what the extent of the disaster was and what its impact has been, provide the right response and then go in for rehabilitation and reconstruction immediately after the disaster. But we also have to look at disaster mitigation, reducing the probability of a disaster or reducing the likely damage from a disaster. In terms of disaster management, we ought to be really looking at a cycle where we have the immediate response and relief followed by rehabilitation, reconstruction and then we go in for mitigation and prevention of a potential recurrence of the next disaster. But at the same time, should it happen, we should be even better prepared. So while trying to mitigate, we must also prepare for an eventuality where disasters might strike again. In terms of further steps in disaster management, we ought to be really looking at vulnerability assessment. By determining the spatial proximity of the population subgroups to potential hazards, according to personal and socioeconomic characteristics which increase the vulnerability. We also ought to take actions from mitigation by reducing the impacts of future hazard events and reduction in the susceptibility of high risk groups by proper planning. But further on, we must insure that there is adequate emergency preparedness through strengthened capacity building, to manage all types of emergency and transition quickly and efficiently from relief through recovery to sustainable development. We need to have adequate planning at all levels from individual to community to national and international levels. And this planning has to be reflected both in terms of policy as well as in capacity building again, at all levels. In terms of the response itself, this is adequately conditioned by preparedness if the planning has been well done. And we’d require experienced, trained personnel who are absolutely vital for providing the right kind of relief and the relief phase much merge with recovery and development over time in a seamless manner. In terms of rehabilitation, reconstruction and recovery, we ought to pay attention to the physical, social, as well as psychological elements in terms of restoration of community life, appropriate environmental health infrastructure, ensuring that sanitation, water supply, shelter, all of these are provided without delay. At the same time as the rehabilitation takes place, there are important mental health effects of a community that has been shocked and shaken as a result of the damage due to disaster. So we ought to provide the necessary support also for mental health.
When we talk of global health in the 21st Century, one of the most important things that comes up is climate change and what its impact on global health is going to be and how can we actually respond to this major challenge, which is not merely environmental or ecological, but also threatens global health in very many ways. When we look at the temperature changes that have happened over a long period of human existence, over the last 20,000 years there have been some fluctuations in temperature, mostly because of changes in the way the earth has a planet has changed its ecology. However over the last 10,000 years we have had fairly stable temperature patterns which have helped humanity to thrive and progress. But towards the end of the 20th Century we have seen human interventions change the nature of the environment to the detriment of the climate, by raising temperatures high and at a very rapid pace so that the planet really is not prepared for this level of change. And this inevitably has an impact on health and nutrition. There is unequivocal evidence on climate change. We recognize that there are rising sea levels and global temperatures, retreating glaciers, extreme weather events. And despite some climate change deniers, there is absolute global consensus that climate change needs to be recognized as an important threat to humanity and that we need to collectively do something about it. Since the Industrial Revolution, atmospheric carbon dioxide has increased by a third. And the International Panel on Climate Change projects an increase in global temperatures by at least 1.8 degrees centigrade by 2100, by the end of this century, as the best case scenario. But there are other scenarios, if we do really nothing, of a doomsday scenario where the temperature can actually rise to up by about 5.8 degrees centigrade. And an increase in sea levels between 9 and 88 centimeters is very much possible in the next century, depending upon how much the temperature rises. Most of this change is related to human activity. That means it is anthropogenic. It is not mediated by natural changes in the earth’s environment or its geology, but it’s contributed entirely by humans. We recognize that there are very many scenarios possible with a wide range of temperature changes that are likely to occur based upon the International Panel on Climate Change modeling. But we do recognize that even in the best guess scenario we are likely to have a two-degree temperature rise or more if we do not do anything. Apart from the natural variability that occurs in the earth’s own environment, anthropogenic climate change will contribute substantially. And the kind of hazards that occur because of a variety of environmental distortions can actually accentuate global health challenges depending upon the amount of exposure that different population groups have, how vulnerable they are to these effects, and the impacts will automatically vary according to that. But there are also appropriate responses in terms of socioeconomic actions that we can undertake for mitigation as well as adaptation and how we can actually insure that there is a concerted global response to reduce some of the mediators of climate change. And they all will impact upon global health ultimately. In terms of human exposures there can be fairly acute events like heat waves or extreme weather events, also more steady rises in temperature as well as alterations in precipitation which can play out their effects over the longer period of time. Quite often the skeptics say, where is climate change because of global warming when we see sometimes extreme cold weather? That’s because global warming itself can disrupt weather patterns substantially resulting in what we can call freaky weather. Beyond global warming we are actually seeing global harming in very many ways. Based upon what the contamination pathways are, what the transmission dynamics are, and what’s the nature of changes in agro-economic systems and ecological systems and hydrology as well as the degree of socioeconomic and demographic disruption that takes place as a result of some of these exposures, you can have a variety of health effects. These will be temperature related illness and death, extreme weather related health effects, air pollution related health effects, water and food borne diseases, vector borne and rodent borne diseases. Effects of food and water shortages, particularly when agriculture and water supply are substantially affected. Mental, nutritional, infectious, and other health effects. Cumulatively, climate change can play havoc with human health over a period of time. There are direct effects of climate change, mainly from extreme weather events. Like for example, temperature extremes. In 2003, we had the major European heat wave. And most deaths were in the vulnerable populations, especially elderly with preexisting diseases. France particularly experienced this. And over 70,000 people were estimated to have died in the hottest summer that the world experienced since 1540. But there are also indirect effects of climate change which act via changing patterns of disease. Vector borne diseases, for example those due to mosquitoes or rodents. As the weather warms up, mosquitoes will start breeding at higher latitudes and at higher altitudes. And therefore you’ll see the spread of malaria to places which did not experience it before. Water, sanitation and hygiene related diseases are also going to be a major public health challenge. Reduced crop yields at lower latitudes will result in food shortages, accentuating food insecurity. At the same time, there will be migration compelled by climate change and related extreme weather events. So you’ll have climate refugees and population change will occur also as a result of that. We also recognize from the IPCC’s report that there will be negative impacts on crop yields. But while the whole world is going to be threatened, there will be some vulnerable populations within countries who are likely to suffer particularly more severe effects of climate change. The very old and the very young and the very poor and those who are socially and culturally marginalized are likely to suffer most, particularly you can imagine the plight of the homeless who have to live in very hot climates in the outdoor, exposed to extreme heat. Vulnerable cities. There are about 16 of the 23 global mega cities which are located in coastal areas. And they will have greater exposure to extreme weather events and storm surges. We’ll also see that climate change will accentuate conflict. It has been recorded that deviations from temperature and precipitation patterns correspond to significantly marked rise in conflict. And these are statistically significant rises. One degree increase in temperature, a rise in temperature increase the frequency of interpersonal conflict by 2.4% and inter-group conflict by 11.3%. So when we talk of hot weather, we must also recognize that people become hot tempered as a result. And the effect of rainfall on inter-group conflict is also interesting. As climate change reduces the amount of rainfall and accentuates water shortages, it has been noted that there is likely to be a greater possibility of inter-group conflict where they’re vying for scarce water resources. There is also a big challenge of how to adapt and how to mitigate. Mitigation is reducing the possibility of global warming through effective action. Adaptation is trying to adjust to some of the effects of climate change as it occurs and trying to improve our opportunities for survival despite some of the changes that we could not prevent. So the IPCC again suggests that the adaptive capacity is intimately linked to economic and social development. But this is unevenly distributed across countries and within countries, across population groups. Adaptation plans must be place and context specific. Like for example, heat action plans for different cities or looking at disaster response for different coastal cities. Action is needed at all levels, from individuals to governments. And the first step towards adaptation is reducing vulnerability and exposure. In terms of climate change, the mitigation strategies of course are very important to reduce the projected rise of temperature, even to limit the temperature rise to 2% or less is going to be a major challenge. And for this, we need to act in the main domains that are contributing to climate change. Food and agriculture. Our food and agriculture systems are now causing environmental disruption. And they themselves will again in turn suffer because of the effects of climate change. So this mutual degradation is something that we must stop because our food and agricultural systems are becoming water intensive, they’re also resulting in a lot of deforestation and all of this is something that we must take into account when we plan mitigation strategies. The use of household fuels, the increasing use of vehicular transport, and the way we generate power through coal plants, all of these are going to be important elements that we must look at as we design strategies to reduce the kind of forces that accelerate climate change and thereby we plan effective mitigation. When we look at some of the health co-benefits of climate change mitigation, we must recognize that the determinants are fairly common and the benefits are likely to be also complimentary. For example, when we talk about public transport and we promote cycling in cities, or more safe pedestrian pathways and reduce the dependence on vehicular transport, obviously in addition to reduced carbon emissions there is improved physical activity. There is also reduced air pollution with benefits for prevention of respiratory illnesses. And the improved physical activity itself will reduce the risk of diabetes, heart disease and other non-communicable diseases, including some cancers. Similarly, reduced meat consumption is something that we must look at, because livestock breeding is now responsible for 50% of global methane emissions, so it’s important that we address that even from the point of view of the environment. The WHO has come up with a work plan. It suggests that we must act, actively engag in advocacy to try and mitigate climate change but also promote appropriate plans for adaptation across the world, especially country level plans. It also suggests that we must promote partnerships to insure that health is well-represented in the climate change agenda. Climate change is not merely a matter for meteorologists or environmental experts or energy experts. After all, the consequences are going to be felt in terms of human health and nutrition. So the health community has to be there at the table when climate change agenda is being discussed. The WHO also says that we must coordinate reviews of links between climate change and health to develop a very strong research agenda which can inform and influence these debates on climate change from the health perspective. It also calls for strengthening of the health systems in countries and would like to assist countries in addressing their health system deficiencies and build capacity to reduce health vulnerability to climate change, the whole plan for adaptation. There are also main research areas in the climate change and health area. Firstly we need to establish baseline relationships between climate change and health. We must gather evidence for early effects of climate change. We must develop predictive modeling techniques and try and anticipate what are the likely consequences of positive or negative changes in the weather and the environment. And in terms of looking at the adaptive options and evaluating their comparative cost effectiveness in different country contexts, we must also estimate the benefits and costs of mitigation and adaptation overall. It is not far-fetched to think that if we do not control the forces that are accelerating climate change, human health would not only be degraded over the century that we live in, but in future centuries it may actually result in elimination of humanity itself. So it is from the public health perspective, from a global health platform that we must now engage in the debates on climate change and demand that climate change must not occur to the extent that humanity’s life would be threatened and also plan for mitigation and adaptation in the most effective manner possible in every country on earth.
When we talk of global health with all its complexity and challenges, the issue of governance becomes very important. The concept of governance of course arose from the feudal times when you had a ruler or a ruling class and those who are ruled or are governed. But even with the advent of democracy we had elected governments which were entrusted with the responsibility of providing a method of organizing the society and insuring the rule of law in an orderly fashion so that the society could function very well.
The notion of governance goes however beyond the formal mechanisms of government and refers to the totality of ways in which a society organizes and collectively manages its affairs. Because now we are living in a state of democracy when we recognize that it is not merely for the government to decide on how the society should be run. There are multiple actors in a society and all of them need to act concertedly after adequate consultation among themselves. So it’s a collective decision in which the responsibilities are shared, but ultimately the process of governance is contributed to by every one of the stakeholder groups.
In terms of global health governance, the concept of governance now extends across countries. It has been defined as the use of formal and informal institutions, rules and processes by states, intergovernmental institutions and non-state actors to deal with challenges to health that require cross-border collective action to address effectively. Where many of the determinants of health actually act transnationally, you’ll require international cooperation- better now known as global cooperation and global concord for collective action. And when we say state, we are talking about the collective, governmental, as well as societal image that captures a country’s interest and provides governance for that particular country.
But there are non-state actors who are acting independent of the elected state and those also need to be recognized as important contributors. In terms of the governance for global health, global governance for health refers to all governance areas that can affect health, implicitly because global health is fundamentally geared towards promoting health equity and reducing inequities. Global health can make the normative claim that health equity should be an objective for all participating sectors which goes beyond the health sector as well.
So, When we are talking about governance of global health, we are talking about governance with the health systems, when we talk about governance for Global Health we are talking about all sectors of development in human activity being aligned to the objectives of global health and being geared to promote global health equity. There are multiple global challenges that we are now seeing. For example, the threats from the past, infections, maternal and child health challenge as well as a host of emerging challenges like non-communicable diseases, zoonosis, antibiotic resistance. We’re also seeing challenges arising from globalization, increasing inequity in multiple areas whether it is access to drugs or even some of the problems of health systems compounded by migration of trained health workers from countries which need them to countries which can afford to purchase their services. We’re also seeing climate change and trade policies having an increasing influence on global health. So we recognize that no single nation or organization is currently capable of single-handedly addressing all its health challenges by itself. So we do need a global health platform in which countries can work together and multiple groups which represent different societal interests can work in concert.
At the global level we have apart from the World Health Organization and the individual national governments, we also have a number of other actors who are now coming into play. We have multilateral organizations which provide technical or even economic assistance for health. We have bilateral organizations which establish country to country collaborations. We have philanthropies which are now playing a much larger role across the world. We have academia. We have the civil society organizations. We have the private sector. We have the media. And we have hybrid partnerships which often link some of these actors. But at the level of the global health we find security becoming an important issue and health security is an important challenge for most countries now.
At the same time, we are finding other issues like migration, education, agriculture, environment, and a large number of other issues like trade and investment, all of them becoming important contributors to our debate on global health governance. So we are now reaching beyond the health sector, but we’re also bringing in a multiplicity of actors into play. But there are several challenges in this complexity. First is the sovereignty challenge. There is no government at the global level obviously. Even if the United Nations exists, it is more of a platform for consultation rather than a single authority which can dictate what should happen across the world. There is inherent tension between national sovereignty and international action. Most countries would like to collaborate with each other as long as their national interests are not affected. And therefore when we ask for shared sovereignty in the area of global health, there is always a concern that nations experience whether they’re actually surrendering their sovereignty. So we do need to find a healthy way media in which nations are comfortable with working with each other rather than feeling that they’re being compelled to act in the interests of another country.
There is also a sectoral challenge. There are multisectoral influences on health and all of these are not embedded in the health sector, therefore we require cross-disciplinary policymaking which is largely absent in global health. Many of the agencies which deal within countries or across countries with agriculture and trade for example are totally insensitive to health concerns. There is also the accountability challenge. There is a democratic deficit related to the legitimacy of international government organizations, or inter-governmental organizations. Also there is a lack of clear mechanism for accountability of non-state actors. So the question is if inter-governmental organizations as well as non-state actors have a considerable influence on the health policies of a country or a group of countries, then are they really accountable in some manner just as national governments are? If they are not, then how can they actually be held to account?
The big question is which is the organization that really represents global health? The World Health Organization was established in 1948 in the aftermath of the Second World War. It is the first multilateral global health organization and the most respected. Its imprimatur is particularly valuable in the low and middle income countries which see it as an honest broker in global health. It functions through its headquarters in Geneva and six regional offices, which are located in the Americas, in the European region, and in what’s called the Eastern Mediterranean region, the Southeast Asia region, as well as the Western Pacific region and the African region. Now each of these encompasses many countries in that region. The Pan American Health Organization for example covers north, central, southern American countries as well as the Caribbean.
Many of these regions, despite the heterogeneity that exists within themselves do try to act in concert at the regional level and are accountable to the regional committees which represent the governments of those regions. And overall, they work in concert with the headquarters in Geneva. But there are often disconnects in that relationship.
The WHO remains the only actor in the current global health system that has universal membership of all sovereignty nations. There are of course several importante international treaties and initiatives that the World Health Organization has taken in the interest of global health. One of the landmark treaties, the very first public health treaty negotiated by the WHO is the framework convention on tobacco control which was adopted in 2003 by the World Health Assembly. And now 180 countries have signed up to the framework convention on tobacco control. There are also the international health regulations to address acute public health risks. There has also been a great deal of work done by the WHO for advancement of the millennium development goals. The WHO also takes the global leadership role or it is the coordination role in mobilizing emergency response, relief work, management of outbreaks, for example recently in Ebola.
While the WHO is a globally respected organization, whose leadership still remains widely acknowledged, the role of WHO has become somewhat diminished or even contested by the emergence of multiple other actors, particularly those who fund major health programs, whether it is individual high income countries, or inter-governmental organizations, or philanthropies. And we now see that there has been a call for a reform of WHO, partly because the WHO’s original role of being a predominantly normative and technical agency which provides guidelines to countries has been supplanted to some extent by having to provide response to multiple health system challenges which it may not be able to do entirely on its own.
There is also the major problem that the WHO is grossly underfunded and as a result has become increasingly donor dependent to run its own programs. To what extent are these donors influencing individual countries, or even now, using the WHO platform to advance their own prioritized agendas for health? So this concern has again started to increase within the global health community. At the same time, there is recognition that many of the regional offices are not performing very well, or perform in a manner that is quite disconnected with the headquarters and there is no real global coordination. While ‘One WHO’ was given as a slogan by the former director general, Dr. Gro Harlem Brundtland, there is little evidence to suggest that WHO functions in smooth unison across the world, because each regional office has a regional director elected by the countries of that region and therefore there is no real accountability to the global health community beyond that region. So we have multiple challenges which the WHO faces currently.
While there has been progress in health brought about by WHO initiatives, the question that has come up is, is the WHO capable of meeting the complex challenges of an altering global health scenario? The Chatham House which is an independent organization based in the United Kingdom, put together an expert group which recently reviewed the WHO’s performance and its changing role and came up with some recommendations for WHO reform. It suggested that the core functions of WHO should be much more explicit. It also suggested reviewing and restructuring regional offices and, and indicated that they should function with far greater accountability to their regions and spend lesser money for more results. It has suggested new avenues for collaboration which must be explored by WHO. It has also called for a reviewing of the skill mix that requires to go into WHO under separation of the technical and governance departments of WHO.
Now these recommendations of course will have to be considered by the countries who are member states of WHO and to see what extent the WHO can actually re-position itself as an important lead public health agency of the world. But that the global health has become a very crowded stage with multiple actors, there are about a 175 global health initiatives, funds, agencies and donors currently existing. Can WHO act as a convening platform for all of them without being unduly influenced by any of them? That’s the big question. At the same time, can WHO engage with other agencies which are dealing with issues like environment, trade, migration which have a substantial influence on health and effectively align them to the interests of global health? That again is a role that the WHO has to define for itself.
At the same time we recognize that the United Nations itself can also play a role as a convening platform for multisectoral action. It has indeed catalyzed broad development platforms initiating action on global health, for example the millennium development goals or the MDGs which were adopted by countries in the year 2000. And now the sustainable development goals which would be adopted by the countries in 2015 are also now likely to have a strong platform for global health action. At the same time, the United Nations held two high level summits, one on HIVAIDS in 2001 which led to the formation of the global fund for AIDS, tuberculosis and malaria and brought in considerable amount of funding into that field, with concerted donor coordination. It also had another high level political meeting on non-communicable diseases in September 2011, which is again, paving the way for global action on NCDs.
It has recently constituted a task force for concerted international action on Ebola. The Ecosoc, or the Economic and Social Council of the United Nations is again another platform where the United Nations can actually coordinate action across its multiple agencies. Whether it is the World Health Organization or the food and agriculture organization, or whether it is the World Trade Organization and the World Bank, this multi-agency platform has been effective in initiating work on tobacco control after the FTCT was adopted. And now that has been transformed into the U.N. task force on non-communicable diseases. When we are looking at multiple agencies now contributing to global health, we also have to look at not only conflicts between them, but also potential synergies. For example, the report for cancer research in U.K. in 2011 suggested that partnership between public authorities as well as charities for medical research could actually bring about great benefits in the form of shared costs, pooled risks, and more stability in family. However the issue of donor engagement brings in the whole question of accountability and responsible behavior by donors. Donors cannot set agendas which are not in the interests of the recipient countries. They also have to be accountable for the manner in which they conduct themselves.
So the Paris declaration of 2005 defined the roles and responsibilities of donor organizations to promote aid effectiveness and enunciated five principles: ownership, alignment, harmonization, managing for results, and mutual accountability. Now all of these are very important, providing ownership to the countries, a greater alignment with national priorities, harmonization among donors and effective managing for results and mutual accountability. It’s not just the countries which are accountable for the aid received, but the donors too are accountable for the way they conduct their business in the countries.
However, one of the major problems has been the multiplicity of donor organizations. With all the good intentions, there have been several donor organizations stepping into countries, for example in the area of HIVAIDS, you have had Ethiopia with 27 donor organizations in that area of health alone. Kenya with 26, or Tanzania with 25, Zimbabwe with 25, Rwanda with 23. It’s a whole crowded field. This imposes a huge burden on countries because they have to coordinate and liaise with all of these donors. They have to have separate reporting system for these donors. And the under-resourced health ministries of these countries crumble under the pressure of having to deal with multiple donors. So there is a great need for harmonization among the donors.
There is also the increasing role of civil society. Civil society groups can range from those which advocate for patient rights, or those which can advocate for better accountability of different health programs and voice the concerns of the communities. They can also participate in delivery of services. So the participation of civil society from policy to actual service delivery is becoming an important component of global health and these include both national NGOs as well as international NGOs. However, with the increasing number of NGOs we also have to differentiate between the nature of NGOs in terms of their intent and their origins. It has been humorously described that there are three categories of NGOs: the PINGOS or the public interest NGOs, the BINGOS are the business interest NGOs, or the GONGOS which are the government sponsored NGOs. So we’ll really have to deal with all of these, recognizing what their main interests are.
But there is yet another challenge in terms of global health governance, even when we recognize that the WHO could be an effective convening platform for multiple agencies, including civil society and the private sector, apart from the governments. The WHO itself is a soft governance organization. It provides guidelines and recommendations that members states can adopt or adapt based on their own discretion. They’re not mandatory. The member states can take them or leave them. Whereas organizations like the World Trade Organization are hard governance organizations. Their policies canbe much more definitive and binding for the member states. And they’re not always conducive to good health.
So we have to again, try and see how this balance of power nor asymmetry of power between different global organizations representing different interests can be reset and corrected so that the WHO get greater traction when it has to deal with agencies such as WTO or even others like FAO, or the World Bank.
So the implications are that WHO remains the lead public health agency of the world, but its influence and its role are now coming in for greater debate and to some extent, are being contested. We need to move towards a better defined global health governance system in which the WHO continues to play a very important role as a convening platform, the honest broker as I said, giving an effective role to each of these major players whether they’re individual governments or philanthropies or the private sector or the civil society, but insuring that the interests of global health predominate over any sectoral interest and also insuring that the roles played by all of these groups are complimentary rather than in conflict. And that is where the WHO has to now become a very new kind of organization, setting the agenda, coordinating and at the same time, becoming the conscience keeper of global public health.
In this chapter we’ll be dealing with universal health coverage as one of the key requirements of providing health for all citizens across the world.
Quite often we have looked at health as a very important investment for accelerated economic development. And indeed, the need to protect and promote productivity among individuals who contribute to economic growth in a society has been emphasized often enough to make sure that governments continue to provide increasing investments to health year round. However, while increased productivity is an important ingredient for making the argument for improved investments in health and for universal health coverage, we must recognize that merely a utilitarian argument of improved economic growth would not be appropriate because we need to bring in the equity argument as well and position health as a right. Otherwise a large number of people who are not contributing to increased economic growth, either because of age or because of illness and disability may be left out of that whole equation.
The reason why universal health coverage has become a major global priority in the last 15 years is because of the huge amount of impoverishment that healthcare expenditure is causing across the world. The World Health report of 2010, published by the World Health Organization estimated that every year about 150 million people face severe financial hardship and a 100 million are pushed below the poverty line because they fall ill, use health services and pay out-of-pocket. Many have to sell assets or go into debt to meet the payments.
And it is because of this healthcare related impoverishment, especially exacerbated by catastrophic health expenditure, but also because of a continued chronic drain on personal finances that ill health imposes, that we have to look at a more caring healthcare system in which we provide financial protection along with quality health services. And that adds up to universal health coverage. In terms of private, out-of-pocket expenditure, many countries, especially in the low and middle income countries, impose a huge burden on their citizens in terms of personal, private, out-of-pocket expenditure on health. Which means that beyond what the government provides, they’re spending quite often upwards of 50% from their own personal finances.
This is not acceptable because it is indeed a huge burden which results in healthcare related impoverishment. And we see this happening in different countries of Asia. If we look at 11 countries of Asia and look at what the out-of-pocket payment is and the proportion of people who are being pushed in to poverty each year, then we recognize that those countries which have low levels of out-of-pocket expenditure have low levels of impoverishment, especially due to healthcare expenditure. On the other hand, countries like India which have had high levels of out-of-pocket expenditure, have much higher levels of impoverishment annually, of people being pushed below the poverty line.
So we do really need to move towards a system which is much better and that is universal health coverage. Universal health coverage offers a way of sustaining gains
from and protecting investments in the countries that have already invested a fair amount on attaining the millennium development goals, which are related principally to maternal mortality, child mortality, poverty reduction, relief for under-nutrition and so on. Now clearly some of these goals have been attained partially and we need accelerated progress on attaining those goals. But a health system which is relatively inefficient or inequitable cannot bring about the required momentum. Universal health coverage on the other hand can galvanize the health system to perform better and achieve the goals which are only partially met. It also accommodates the changing agenda of global health which as we know, because of health transition is bringing a host of non-communicable diseases to the fore.
So universal health coverage by definition is the practical expression of the concern for health equity and the right to health. Moreover, access to services when needed also provide financial protection and also provide the comfort and assurance that people will get the services they need.
The Rio+20 United Nations Conference on Sustainable Development recognized the importance of universal health coverage for enhancing health, social cohesion and sustainable human and economic development. The U.N. in that meeting pledged to strengthen health systems towards the provision of equitable universal coverage. The countries participating in that meeting called for the involvement of all relevant actors for coordinated, multi-sectoral action to address urgently the health needs of the world’s population.
So universal health coverage as a goal, a strong health system as the vehicle, but also supported externally by concerted multi-sectoral action which will align actions in other sectors to the health needs and to the objectives of universal health coverage. And universal health coverage does provide financial protection which is the critical aim of universal health coverage. But beyond that, it insures greater health equity within countries and across countries. It also provides the population with improved health outcomes. Longer life, better quality of life, greater healthy life expectancy, far less disability. It also enables the creation of efficient, accountable and transparent health systems.
At the same time, it reduces poverty It leads to greater productivity, a healthy population is definitely going to be better for the economy through greater productivity. Most importantly, by creating a strong health system it can actually increase employment opportunities for a large number of young people and women because if universal health coverage is going to be focusing strongly on primary health services, in a world where there are the health workforce crisis, a great shortage of doctors, nurses, allied health professionals, you need to create more jobs on the front line. Many of them won’t be doctors, but a number of technology enabled front line health workers will have to be pressed into service for energizing primary health services. So in an era where the economic situation is not promising a lot of employment for young people seeking to enter the labor market, the health sector by embracing universal health coverage can actually provide a much larger pool of employment for a lot of young people who are aspiring for gainful livelihoods.
When we come to the implementation of UHC, there are two very important interconnected components. Firstly, coverage with the needed health services, prevention, promotion, and treatment and rehabilitation as well as coverage with financial risk protection for everyone. Since we said we will not be able to do everything overnight when we are introducing UHC, unless the country is very rich, many countries the low and middle income grouping will have to prioritize primary healthcare. Many countries look at primary healthcare, most of secondary healthcare, especially comprehensive maternal and child health services, essential surgical services and the emergency services as the initial package which they must introduce for universal health coverage and then expand by addition of other elements.
But again, primary healthcare becomes the absolute mandatory, initial component of any universal health coverage initiative. But at the same time, when we come to financial risk protection, we have to look at multiple sources. Virtually no country has achieved universal health coverage without a substantial infusion of tax revenues. That means a good part of universal health coverage has to be tax funded. Depending purely on health insurance, particularly employer provided or personally purchased health insurance doesn’t usually help because we need a large risk pool for insuring that there is sufficient sustainability for the program.
When we talk about a risk pool, we are talking about a number of people contributing to an insurance program where the sick minority is being subsidized by the healthy majority at any given point in time. Of course those who are sick can be healthy tomorrow. Those who are healthy today can become sick tomorrow. But it assumes that at any given time, the majority are healthy, they continue to pay insurance, but they’re subsidizing the sick. What we recognize is that in many of the countries, people are not always in the majority in the organized employed sector. Like for example in India, 93% of the workforce is in the unorganized sector. So you can’t have payroll deductions which automatically go into an insurance program. Many of the people are poor, they can’t afford to purchase private insurance. Even if the government provides substantially subsidized social insurance, many of the poor may not be able to get enrolled.
So as the risk pool shrinks, then the principle of that kind of an insurance where the healthy subsidize the sick or the rich subsidize the poor does not operate. On the other hand, in a tax funded health insurance system for universal health coverage you have the largest risk pool possible. And there the rich do subsidize the poor by paying higher taxes as a part of their social obligation. And the healthy majority does subsidize the sick. Therefore tax funding becomes an inescapable component of any financing for universal health coverage virtually in most parts of the world. And even in those countries, which have been really talking about insurance based systems, there is a substantial amount of government funding, even in the United States. So we need to look at a mixture of different funding sources with tax funding as the base and possibly other forms of insurance like employer provided insurance or government subsidized social insurance as additional components. One of the best known health economists, Bill Hsiao, or William Hsiao from Harvard writes that empirical evidence indicates that a free market for insurance cannot achieve social equity and that serious market failures allow insurers to practice risk selection.
That means they leave out the most vulnerable and make them uninsured. So if you are cherry picking and taking only relatively healthy people, for whom you do not have to pay much in terms of healthcare reimbursements, the people who really need healthcare are left uninsured. Dr. Hsiao also says that adverse selection among insurance buyers impairs the functions of the insurance market and deters pooling of health risks widely. Moreover the insurance markets high transaction costs yield highly inefficient results. However, there are some advantages. Dr. Hsiao indicates that evidence suggests that reliance on market competition for the provision of healthcare may hold potential for more efficient and higher quality care. What we are really looking at is the weaknesses of multiple competing insurance systems which adopt an adverse selection process. On the other hand, we still would like to bring in quality and efficiency into the healthcare system and even if we are going for a tax funded system, that is a requirement, to look for efficiency and higher quality of care.
Many countries have grappled with this problem and have adopted different models of universal health coverage, basically looking at their own country context and resource scenario. Indonesia has a social security providers law which replaced the previous community health insurance. And under this, 95% is paid by the government with the holder contributing 2% and the employer paying the remaining 3%. This has been particularly effective in Jakarta and is likely to be expanded across the country later.
Now in Canada, Medicare includes coverage based on health on need rather than the ability to pay. Provincial and territorial governments are responsible for the management, organization and delivery of health services for their residents. In Mexico, there have been a combination of different health insurance programs, substantially tax funded or government subsidized. Even though they are called insurance in the broad sense, they’re bringing a lot of government funded and government provided health services. And here particularly the introduction of Seguro Popular in 2003 brought financial risk protection to a further 50 million persons in the population. So that was a huge leap in terms of the number of people provided some assurance of healthcare with financial protection.
In Thailand, the universal health coverage scheme started off with what was called the 30 Bhat Scheme where people paid less than one dollar and that plan added about 14 million previously uninsured people to the Thai system. And this scheme has now been transformed with even greater coverage and a greater degree of financial protection at even lesser contribution at the personal level. In China, where there was previously an urban employer provided insurance scheme and the rural and migrant populations were left uncovered, since 2003, two more schemes have been introduced. One for the rural population and one for the migrant population. And between these three schemes now the coverage by some form of health insurance for provision of healthcare with some financial protection has extended to 96%. That means 96% of the Chinese people have some form of coverage.
But since the depth of services is still a bit limited, they’re still seeing the effects of out-of-pocket expenditure and catastrophic expenditure. As public financing increases, this is likely to decrease, even in China. In Brazil, the unified health system which is the nationalized program, provides primary healthcare while a network of public and contracted hospitals deliver specialist care. Primary care provision has substantially increased since its inception. And this also includes a national immunization program. And Brazil has adopted universal health coverage as an objective because the constitution has a right to health incorporated and therefore UHC is an important value.
In the United Kingdom, where the National Health Service started off as a model for many other countries which are now aspiring for universal health coverage, the government is responsible for funding access to healthcare and for supplying health services. And this is now a very important area where we find tax funded services reaching all sections of the people with assurance.
The whole world is now moving towards universal health coverage it appears, because in 2005, the World Health Assembly adopted a resolution asking all countries to adopt universal health coverage as a goal. In 2010, the World Health report focused on health financing for universal health coverage and then introduced the concept of the cube and how the cube can be progressively filled. We recognize that in most countries you can’t fill cube all at once. But you have to start visualizing the cube, recognizing that universal health coverage will be incomplete unless we try and fill most of the cube, but start moving progressively by prioritizing on each dimension as to where you begin and how you move forward, moving from the essential to the optimal.
In 2012 the U.N. had the Rio+20 conference, which again adopted this as an important goal. And then surprise, in 2012, the United Nations had a session on health and foreign policy in which they brought universal health coverage as an important component, recognizing that universal health coverage is important for global development and therefore for global stability and therefore for global security and therefore must form an important component of foreign policy initiatives as well. So whether it is the World Bank or the WHO or the United Nations or even diplomats or public health experts or economists, now universal health coverage has become the common currency of development discourse.
One of the important things that we must remember is that as we move towards universal health coverage, we are also moving towards a higher civilizational state because universal health coverage cannot exist without social solidarity. Unless society feels that they’re responsible for each other’s health, that they’re willing to support healthcare for another citizen who is in need, by contributing to the risk pool of ensuring that the health of every individual in that society is adequately cared for, you will not have universal health coverage as a successful model. Therefore the moment we adopt universal health coverage, not merely as a political slogan, not merely as a public health system goal, but as a societal commitment, then we are moving towards social solidarity. Without that we will not have UHC. But we have to make it effective through a functioning health system and through adequate financial investments to provide financial protection.
So in the context of the sustainable development goals, we now are likely to see universal health coverage positioned as a part of the health goal in the post-2015 agenda. but it is important that all countries start understanding first what universal health coverage entails and then start preparing not only their health systems, but their financing mechanisms as well as multisectoral coordination processes in order to pave the way for successful introduction and implementation of universal health coverage to promote health equity within countries and across countries.
When it comes to reliability of supply systems we need a good distribution system that ensures the availability of all essential medicines at all levels of the health system- primary, secondary and tertiary. And we can have several strategies for this. Firstly we need to integrate medicines in the health sector development. We cannot look at this as a separate problem of a pharmaceutical department which is often not even in the health ministry. And if pharmaceutical production is seen more as a commercial or an industrial activity, divorced from the needs of the health sector there can’t be anything worse than that for universal health coverage. So we need to integrate the whole availability and production and supply of medicines into the health sector development program. We also need to ensure that there is a fairly efficient and well-functioning public-private NGO mix in terms of the approaches to supply delivery. So the supply chain, while it may be driven substantially by the public sector, ought to be able to accommodate the private as well as NGO sectors also because they’re also often very major contributors to supply. We need to assure the quality of medicines through regulatory control. This is absolutely important particularly where we are now seeing a huge need for medicines across the world which are being met by generics, but these generics will have to be quality assured. And this requires appropriate drug testing and regulatory control. We need to explore a variety of purchasing schemes and pool procurement often reduces the overall pricing of medicines. Because if you actually have procurement cooperatives, or pool procurement, you’ll be able to eliminate the middle man and then remove multiple intermediate stages where there is price markup and ultimately get almost directly from the manufacturer a bulk procurement which can be substantially low priced and very close to cost of production, rather than the traditional market price which has multiple layers of markup. So we have to look at pool procurement and procurement cooperatives. At the same time we need to look at also procurement of traditional medicines. We’re not only talking about allopathic medicines here, many countries, especially in low and middle income countries have traditional systems of medicine which form a part of the health system and which are frequently accessed by the people and are often affordable. So we ought to be able to look at the supply of traditional medicines as well in healthcare provision.
Coming to the whole area of stock-outs, you can see this happening not only across countries, but even in health systems within countries. For example, in India where there are multiple states with different health system capabilities. The health system in Tamil Nadu, which is very well-functioning, has a very little problem of stock-out. On the other hand, Bihar has much lower availability and a much higher level of stock-out at any given point in time, though recent improvements are beginning to change that situation. So we need to address this whole problem as an issue of health system capacity for effective functioning.
And that the global level, we actually meet other challenges. We see the whole area of trade coming sometimes as an opportunity but quite often as a barrier to access. Trade in pharmaceutical products has been heavily influenced by international trade agreements, intellectual property rights, and globalization. And pharmaceutical companies have been researching on development of new products which are mostly based on the market expectations of utilization in the rich countries and not by the needs in the developing world which constitutes the majority of the global population. They are looking at who is likely to buy and particularly at a high cost rather than who actually needs them in terms of life-saving medication. And therefore, we find that many of the neglected tropical diseases do not have medicines and some of the medicines available for even common diseases are not often available at affordable cost. Many of these companies are also exploiting patent laws for their own profit. For example, stretching of patents, even when the patents are supposed to be expiring and the drugs are supposed to be coming into common domain for production by other companies, some of the companies are actually resorting to what’s called evergreening, which is a method to retain the patent protection and royalties from products, either by extending patents or buying out competitors, particularly by minor changes in formulation. Or in the manner of delivery in terms of the time of release of the actual drug by minor changes in pharmacokinetics. They’re actually declaring a drug to be a new product and are trying to extend the patent and stretch the patent out. And these are some of the things that actually are becoming barriers in terms of pharmaceutical company practice and challenge to countries which want to really take drugs off patent and then put them in the health system in the form of generics. But trade agreements are not entirely dispensable. Sometimes they may actually provide support to the less developed countries in other domains, like for example, traditional knowledge and genetic resources. So some of these actually by patent protection may help some other low income countries and the middle income countries generate more resources for their own health system. So the challenge of global trade is to ensure- yes, there should be some degree of intellectual property rights being protected, but at the same time, we need to ensure that this does not become a major barrier for access to medicines. And we have to look at the availability of medicines as a social contract between the industry and the wider population in the world in which the need for live-saving essential medicines outweighs commercial considerations. And the whole area of affordable pricing has become a subject matter of TRIPS- the trade related aspects of intellectual property rights. This agreement was first signed in 1995 at the Uruguay Round Agreement of the World Trade Organization. This mandated minimum standards for patent protection for pharmaceuticals. Clearly the pharmaceutical industry, particularly concentrated in high income countries, had an interest in ensuring that their products were patent protected so that they could make profits out of them from their exclusivity of production. But between signing of the TRIPS and the WTO Doha Ministerial Accord, the world witnesses a major crisis in terms of access to the drugs for HIV/AIDS. And especially in Africa and this became a major global issue. When some of the generic antiretroviral drugs were being supplied to South Africa by an Indian generic manufacturer, there was a major challenge from the multinational company which was producing the drugs. Indeed, the Mandela government was sued by this pharmaceutical company, much to the consternation and shock of the rest of the world. But fortunately the public outcry and the revulsion as well as civil society action across the world, including communities in the high income countries compelled not only the pharmaceutical industry to withdraw and permit the utilization of generics, but it also led to the global community to look at how trade agreements ought to be modified in order to protect the interests of patients who most need life-saving drugs. And that is why the WTO Doha agreement then came about. In 2001, in Doha, there was a declaration on the TRIPS agreement and public health. While reiterating our commitment to the TRIPS agreement, that’s what the countries said, we affirm that the agreement can and should be interpreted and implemented in a manner supportive of the WTO members right to protect public health. And in particular, to promote access to medicines for all. So public health could now start trumping to some extent the right to intellectual property which became restrictive on occasions. Especially for public health emergencies. So this was a very important victory for looking at how public health could be still advanced despite some of the drugs being on patent. And in 2003, in Cancun, adjustments and provisions were made in the TRIPS agreement to allow improved access to essential medicines. So we have to really look at the whole area of trade and evolving developments in the trade agreements and trade related treaty discussions from the point of view of global public health. And when we come to chronic therapy, long-term therapies for cardiovascular diseases, cancers and diabetes, these countries are going to be bankrupted if the drugs are high-priced and people are going to be dying prematurely if they do not have access to life-saving medication.
So access to effective non-communicable disease related drugs remains a high priority for the rest of the world, especially those in the low and middle income countries who do have access at the moment to drugs produced by pharmaceutical industry in the high income countries, mostly for those markets. Even when we look at generic drugs, there is a disparity across the world in terms of international generic drug pricing. There is really no consensus on how generic drugs should be priced. There is a fair amount of opportunistic pricing which is being employed by different manufacturers. If we look at the potential for lowering of the pricing of generic drugs by domestic manufacture as opposed to internationally available generic drugs, we see a huge disparity. Like for example in South Africa or Kenya or other countries or Brazil, the domestically manufactured generic drugs are far lower than the internationally branded products or the internationally sold generic products.
We therefore need to ensure that in as many countries as possible, at least in the middle income countries, we ought to be able to increase the capacity for domestic production of quality assured, low priced generic drugs. When we look at improving access, we can look at seven major strategies. First is enhancing capacity for generic substitution and the specific solution there is to expand the scope of the WHO prequalification project and build capacity of local regulatory, drug regulatory authorities to fast-track registration of generics. Secondly is to expedite generic availability by overcoming legal barriers related to patents and licensing. This we can do by increasing the use of compulsory licensing under Article 31 of TRIPS. Compulsory licenses are where countries in extraordinary situations, where public health needs are to be prioritized, can actually issue license to other companies, even for a drug which is still under patent protection. Optimizing local procurement practices in the public sector is absolutely important and this is done by recruiting local support for better supply chain management and using mobile and information technology to map stock-outs. We have the capacity now to use information technology to forecast the needs, to track the availability, to spot where the stocks are diminishing and readily replenish them and we ought to use that technology much more effectively than is presently being done.
We also need to broaden global procurement where third party price negotiations. As we said, pool procurement at the national level can be very effective in reducing costs, especially for the public sector, or for networks of private sector hospitals. But even at the global level pool procurement is possible because agencies – whether they are WHO or other international agencies, or a community of countries can actually negotiate jointly to try and obtain drugs directly from the manufacturer at a much lower cost by assuring a very large market size, When it comes to engaging the private sector to differentially price medicines in low and middle income countries, there is a movement in that direction. Many of the large companies are now looking at the market size in the developing countries and saying, okay, we will differentially price medicines for high income countries and for low income countries. And we will ensure that people who need it in low and middle income countries can get it at a different tiered pricing arrangement.
We can regulate retail markups in the supply chain by use of government controls to restrict markups. Price control is an important mechanism that countries must utilize judiciously in order to reduce unnecessary markups. Finally, we must eliminate tariffs on medicines. We must adhere to international treaties to eliminate import tariffs and preferably eliminate national sales taxes. These are not luxury goods. These are goods required for saving people from death and disease. And therefore, to have import tariffs and sales taxes is absolutely improper because we are playing with people’s lives. So by adopting a variety of strategies to provide access to drugs of assured quality, preferably generic drugs, preferably obtained through pool procurement with affordable prices, and ensuring regular, predictable distribution through a supply chain that eliminates stock-outs, we can ensure access to drugs. But this cannot be done only for high income countries, or even for middle income countries, it has to become a globally assured supply of drugs which are needed. And this can only be done if universal health coverage becomes not only a national aspiration, but a shared global value.
In this chapter we’ll be looking at access to essential medicines. Very clearly the introduction of life-saving drugs has made a great deal of contribution to improving life expectancy as well as reducing disability. And when we are looking at global health, the access to medicines becomes a very important element of universal health coverage. Essential medicines are those that satisfy the priority healthcare needs of the population. Obviously there are several medicines, some of which are taken for relief of very temporary conditions, some are often taken as supplements to diet, some are taken for example to relieve cough or something like that. But essential medicines are those that are really required for protecting the health by reversing disease and reducing disability They’re selected with due regard to public health relevance, evidence on efficacy and safety and comparative cost effectiveness. Clearly there can be a wide range of medicines for treating the same condition but you need to be very sure that they’re effective, safe, at the same time, cost effective. Essential medicines are also intended to be available to the health system so that we are not uncertain about their regular availability for being provided in various healthcare facilities as needed. They should be available at all times in adequate amounts and in appropriate dosage forms with assured quality. Now quality is going to be an absolutely important criterion because without that, you cannot be sure either of effectiveness or of safety. And there should also be adequate information available about each of these drugs, not only for the physicians but also for the patients who are receiving it. And they should be available at a price that the individual and the community can afford and certainly the health system also should be able to afford it as a part of the public financing. Access to medicines has become a worldwide challenge and the World Health Organization estimates that about 1.3 to 2.1 billion, depending upon the criteria that are employed, do not have access to medicines. Unfortunately many of these are in the countries where there’s the greatest need in terms of unmet health challenges that is Africa and India. Access to essential medicines is closely related with the other aspects of the health system performance. That is, we find wherever there is a high level of disability- adjusted life years lost because of major health disorders, there, access to medicines which ought to be assured is unfortunately deficient. In terms of inequities in production and utilization, we ought to be able to really look at where the population lies and where the actual money is being spent in terms of purchase and prescription of medicines. Whereas the largest populations lie in the low and middle income countries and the low income countries and a much lower proportion of the population, about 16% is in the high income countries, the actual expenditure on medicines at the global level is the highest in the high income countries that is about 78.5%. Whereas in the low income countries, the expenditure is only 1%. This is a huge inequity in terms of availability and affordability of medicines across the world, reflected in the utilization patterns. When we are really looking at access, there are four critical elements which promote access. The World Health Organization says firstly there should be rational selection based on first quantification of the medicines that are there in the overall pharmacopoeia and then trying to select among them according to the criteria of essential medicines and forecasting the need according to the disease burdens and the various health system priorities within that country. And rational selection of course goes as I said, on the basis of effectiveness or efficacy, safety, and cost effectiveness. That brings us to affordable prices because we need to really look at how affordable these medicines are, both for public procurement by the health system and also for personal purchase by an individual patient. So that becomes the second element of how we actually ensure that the prices are within easy reach. And then we actually look at the procurement process which then brings the medicines into the health system. And we definitely require reliable supply systems. Unfortunately many public procurement systems and distributions systems do not pay attention to regularity of supply and there are frequent stock-outs that means non-availability of medicines within the facilities. And that means that many of the people who actually go to these facilities do not have the opportunity to get them on a regular basis as needed. And similarly if they’re also not available on a predictable manner in the open market for purchase at affordable prices, that again deprives people of access. So having reliable supply systems is absolutely critical. Rational selection refers to choosing safe and effective medicines which are appropriate to the country’s health situation. Accordingly, essential list of medicines will have to be prepared by each country. The World Health Organization, since 1977, has been providing a reference list of essential medicines, which actually serves as a guideline for individual countries which will adapt it for their own use based on their own national requirements. So each country has to have its own national list of essential medicines. And sometimes within large countries, provinces or states also modify the national list to suit some of their regional priorities. The number of countries which have essential list of medicines is of course is fairly large. But the number of medicines that enter the lists varies based on the national income. Low income countries for example have much lower number of essential medicines on their lists as compared to middle income. But the high income countries have a far higher number. The low income countries have had on an average, 355 drugs. The middle income countries have 441. Whereas the high income countries have a total of 1700 drugs as a part of their armamentarium in their essential list. Sustainable financing is the next step that we need to really look at, and here we need to increase the public funding for health system in general, but especially for essential medicines. Unless public financing of health through universal health coverage programs increases to a level where essential medicines can be procured and distributed at no cost or low cost we will find that there will be a continuing barrier to essential medicines for most of the people in that country. So we need to raise public financing and use a substantial fraction of that for procurement of medicines. We also will get an added benefit in that because much of the out-of-pocket spending in many of the countries is related to private expenditure on purchase of medicines. Of course by expanding various forms of health insurance, particularly social insurance or government subsidized insurance, we will be able to provide greater coverage and we need to bring in medicines also into the ambit of insurance programs which frequently do not cover outpatient care or provision of medicines. And of course there are other financing mechanisms that we ought to be looking at, including debt relief as well as international supply by various donor agencies. Sustainable financing of course requires a fair amount of public expenditure, which is predictable. As a paradoxical situation, high income countries seem to be having a greater degree of public financing as compared to private financing. And this situation has remained unchanged or even worsened over the years, when you compare 1996 to for example, 2006. In the other categories of countries, which are in the middle income or the low income bracket, we find that the private expenditure on medicines is increasing, which is again, quite indicative of the fact that public financing is at low levels as a response to the needs of the people and certainly fall short of the objectives of universal health coverage. When we look at the overall global situation in relation to sustainable financing, out of the high income countries, categorized by the WHO, the share of pharmaceutical expenditure in high income countries is about 18.2%. Whereas in low and middle income countries, it’s about 26.6%. And the low income countries, it’s 29.5%. Which means that these countries, despite the fact that they’re unable to invest adequate amounts of public financing into the universal health coverage program, or even into the health system as it exists today, are still having to spend a fair amount of their health budget on medicines. Unless the overall health financing goes up as public financing for the health sector, we will be unable to raise within the limitations of the currently available funding the expenditure on medicines to meet the huge gap in access to medicines.
 http://www.unmillenniumproject.org/documents/TheLancetTrade.pdf, http://whqlibdoc.who.int/hq/2004/who_edm_2004.4.pdf, http://globalhealth.thelancet.com/2014/06/06/stepping-out-silos-integrating-global-health-trade-negotiations, http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001485,
In this final lecture on health systems I want address a topic that’s often neglected in these discussions and that concerns the politics of health systems and universal health coverage. Universal health coverage and health systems reforms are fundamentally political. One could see this all over the world, not least in the United States, which is having great debates how it moves towards universal health coverage.
But this is true in every country across the world. Now why is it that this issue of health coverage and universal health coverage is so political? It really is for a variety of reasons. Firstly, everybody wants good quality health services with financial protection. Universally it comes out in polls that this is the expectations of people across the world. So it matters a lot to people that they get this financial protection and they get the health services they need. Secondly, it’s actually a very easy concept to understand. And politicians find it therefore very easy to sell to electorates that this is something they’re going to bring to them. And in fact people demonstrate specifically for universal health coverage and an expectation that the states will deal with the healthcare financing. Now as I’ve mentioned in the previous lecture, universal health coverage requires public financing and a lot of it as well. It also must be done progressively with the healthy wealthy cross-subsidizing the sick and the poor. Now delivering this is inherently political. Finally, universal health coverage and health systems reforms can actually bring nationwide results very quickly. This is quite unusual for a government policy to have an impact right across the country, benefiting virtually all households so quickly. It doesn’t happen with infrastructure reforms and other economic reforms. Therefore it can bring very quick political benefits to people and that’s really why politicians are so interested in it. Now because it is so important to so many people, and it is so political, it’s absolutely essential that health reforms like this are led by the head of state. If it’s just done by the ministry of health, often this doesn’t work. There are so many political benefits to be gained, but also costs to be taken care of that this really is a head of state’s issue. Also, successful universal health coverage reforms really need the full cooperation across all of government. It’s way beyond just the remits of the ministry of health to deliver on this, but across cabinets and local governments as well. Often what you find though is ministries of health are actually often rather weak ministries within the cabinets. And ministries of finance often actually don’t want to suddenly increase public financing, maybe doubling the health budget. And really the only way they’ll be persuaded to do so is when they’re instructed to do so by the head of state. We’ve mentioned that big UHC reforms require significant increases in public financing. And the decision on, on doing that is therefore one that must be taken right across government. And in particular, the head of state, needing to take control of the situation, mobilizing supporters behind this political strategy, making sure that the public financing is, is raised properly, but also tackling the opponents which there will undoubtedly be for these reforms. What’s also interesting to note is that universal health coverage reforms are particularly popular in post-conflict states, or in new democracies.
And this is really for the reason around the quick wins that these policies can deliver. And new heads of state are often looking to demonstrate to the population that they brought around change that’s benefiting everyone. So universal health coverage could be quite a good way to legitimize the state and particularly a new state, because it provides tangible benefits to the population very quickly. And here’s some examples of countries that have done this, include the, the United Kingdom in the immediate aftermath of the Second World War, in introducing the National Health Service. Also right across Latin America, in the, in the last 20 or 30 years where there have been transitions, particularly from military dictatorships to democratic governments, often one of the first things the governments have done is introduce massive universal health coverage reforms. And other examples include Nepal in 2008. The new ANC governments in South Africa in 1994, one of their first policies was universal free healthcare for pregnant women and children. In Liberia, Sierra Leone, Burundi and Rwanda, these are all countries that have come out of periods of conflict and one of the first major policies they’ve introduced is universal health coverage reforms. Now looking at the transition that countries make from a system of privately financed system where there isn’t universal coverage to one where there is, what are the economic and political determinants of that process? Well firstly it’s undoubtedly the case that it’s economic growth and more resources that drives up health spending. Not surprisingly, as countries get richer, they spend more money on health. But what’s interesting to note is that as a proportion of GDP that rises as well. As countries get richer, people want more money to be spent on health. But another thing happens as well, which is very interesting is that as countries develop, the proportion of the financing of the health sector, that is public financing usually increases as well. You get this switch from a private voluntary financing system to one that is more governed by the state. Now that process is inherently political. And we’ve seen this process happening in countries all across the world, particularly in making the transition from being low income to middle income countries. But this process isn’t a slow and gradual linear process, what you tend to find happens is that suddenly there’s a step when countries make this transition to covering the entire informal sector, which as I mentioned before, invariably requires a big increase in public financing. Typically in the order of about 1% of GDP, which is a lot of money.
Now what prompts that is usually political windows of opportunity. A new government coming to power, a contested election. When a politician announces that they’re going to run on this platform and you see this sudden transformation. And therefore these processes are very associated with particular individuals and very strong charismatic leaders. And it’s very striking that across the world one can name almost the year and the politician that prompted these reforms. So for example, Nye Bevin in 1948 in the U.K. President Park in Korea in 1977. So if this is a good idea to move towards universal health coverage through a publicly financed system, why is it so difficult? Why do you find these processes are so contested? And really it’s because in making that move towards universal health coverage, there are undoubtedly winners in terms of people who are now covered, but also financially there are losers, people who now have to pay more into the public pool. The costs and the, the…associated with that transition tend to be concentrated in organized groups who possess a lot of political resources. Powerful groups like the medical profession like pharmaceutical industry and insurance companies and the urban elite who will have to, to pay more for their health services. Whereas the beneficiaries, the people who really like these transformations tend to be more in unorganized groups, lacking political resources, particularly the rural poor population. Now I’d like to describe one or two countries that are making this transition to illustrate these, these points. One country where there’s been a fascinating transformation or ongoing transformation of the health sector is Indonesia which recently elected a new president, President Joko. Now he previously was the governor of Jakarta and in becoming governor of Jakarta only in 2012, one of the first measures he introduced was universal health coverage in the city of Jakarta. And it was largely on the basis of the popularity of that scheme that he became so popular nationwide and in the election campaign announced that he was going to extend the benefits of this to the, the whole Indonesian population. And he was elected president only in July and has already started implementing this universal health coverage program. Now interestingly he’s financing this through increased tax revenues that he’s secured by reducing fuel subsidies. Indonesia had very high fuel subsidies. In fact they were spending three times as much on subsidizing fuel as they were on their health system. And now by removing these fuel subsidies he has the resources to be able to pay for universal health coverage. Now this is quite an interesting political tactic which seems to be followed by other countries as well and makes a lot of sense in terms of the broader sustainable development goals. Because many governments have found themselves historically now subsidizing fuel which they recognize isn’t a good idea economically and it’s also not a good idea for the environment as well. But unfortunately, these fuel subsidies are very popular and the population have got used to them. So therefore, in removing these subsidies, one needs to give something back to the population in return and give them benefits that they see relatively quickly. Governments therefore looking for quick win policies that can benefit all households and people being able to make the tradeoff between having subsidized fuel and other services. Now universal health coverage reforms fit this bill perfectly because all households require health services on a pretty regular basis. And governments are very cleverly looking now at linking increasing access to health services, in particular, access to medicines with removing fuel subsidies. So this is happening in Indonesia, but it’s also happening in Iran which has recently introduced universal health coverage reforms and likewise is linking these reforms to reducing fuel subsidies. So maybe this might be a trend for us to encourage thinking about the sustainable development goals. Other countries where this could be highly relevant are Nigeria, where there are to be elections in February, 2015, which now has a GDP of $3000 dollars per capita, relatively high and higher than Thailand had when it introduced universal health coverage 12 years ago. And Nigeria has a lot of oil resources that really one feels ought to be made available for providing universal health coverage. India is another country that spends a lot of money on fuel subsidies and surprisingly little on its health sector. Only about 1%, 1.2% of GDP. And it would be interesting to see as a, as a political strategy where the Indian population would be like other countries in recognizing that them getting better access to health services is a good deal as fuel subsidies are removed. Now one can’t really talk about health financing and universal health coverage without mentioning the United States as well, where President Barack Obama has invested enormous amounts of political capital in trying to improve the health financing situation in the U.S.’s notoriously inefficient and inequitable health financing system. And he’s taken big steps moving towards more of a mandatory health financing system which may indeed form a precursor towards more of a socialized health financing system in the future. So in concluding, universal health coverage is really as political as it is anything to do with technical issues, especially in moving towards a more equitable public financing system. Universal health coverage is also popular with people and politicians across the world. It really brings politics in to the health systems debate. And worldwide political actors and not really technocrats are the driving force behind universal health coverage. And really looking to the future that health developmental agencies should engage much more in the political economy of these health reforms and promote these health benefits and political benefits to political leaders.
In this third lecture on health systems I’m going to talk about a very important function of a health system and that is how the health system is financed. You’ll remember from previous lectures that one of the primary objectives of a health system is to achieve universal health coverage whereby all people receive the quality health services they need without suffering financial hardship.
Now health financing is extremely important. You’ll notice in that definition there’s a reference to not only people being covered by health services, but them not being financially compromised when they access these services. So there is this aspect of health financing built in to universal health coverage. And in recognizing this, the World Health report in 2010, produced by the World Health Organization, specifically addresses this issue of health systems financing. And if one looks at that definition of universal health coverage, you’ll see it’s fundamentally about equity. Firstly, that because it’s universal, everybody should be covered. Nobody should be left behind. Secondly, that the definition talks about health services being allocated according to need, with some people needing more health services than others. Thirdly, and this is the financial aspect, the financial contributions for paying for the health system are made according to one’s ability to pay. Now if one combines those two elements you can see that the health financing is really about healthy wealthy people cross-subsidizing the sick and the poor. So what are the major challenges facing countries as they try and finance their health systems to achieve universal coverage? First of all, they clearly need to raise sufficient funds to finance the health system. One needs a certain quantum of financing and recent estimates suggest that around $87 per capita is required as an absolute basic minimum to achieve universal health coverage. But secondly there’s this vital element of risk protection, financial risk protection so that people don’t face financial barriers which prevent them accessing the health services that they need. Also, that they don’t suffer financial ruin when accessing health services. And the third major challenge is ensuring that one maximizes efficiency in the use of these resources and also making sure that resources are allocated equitably, fairly. Now this whole issue of health financing has been extremely contentious over the years and continues to be so across the world. But the good news is that there really does appear to be a consensus emerging now on how countries should finance their health systems to achieve universal health coverage. The first point and very importantly is that market driven health systems which are privately financed never reach universal health coverage. And this is a realization from countries across the world now. Instead there’s a very high role for the state in organizing the way that the health financing system is organized, particularly enforcing healthy and wealthy people to cross-subsidize the sick and the poor. This doesn’t happen naturally in markets. Now achieving this of course is inherently political because not surprisingly, a lot of the healthy, wealthy people don’t necessarily want to cross-subsidize the sick and the poor. So this means that there is a very big role for the state in all the main functions of health financing, both in terms of raising the revenues to pay for the health system, in pooling of those revenues to create a big risk pool to buy services and in the allocation of those resources and the way that services are purchased. Now despite this big role for the states in, in health financing this doesn’t necessarily mean there’s no role for the private sector. Either in the administration arrangements of some of those financing arrangements, but also in the provision of services. What we’re talking about is public financing, but when it comes to the provision of services, this can be either done in the public or the private sector. Now other areas where a consensus is emerging, where there’s been tremendous controversy is in what are the best financing mechanisms to raise funds to finance the health sector? Now the most obvious way to finance a health sector is people just paying for services as and when they need them, through user fees. But really this is a terrible way to finance a health system because it involves no pooling of resources and is grossly inequitable in that poor people are excluded from getting the care that they need. And in fact, the president of the World Bank has recently said that user fees are unjust and unnecessary. Now other people have been suggesting that maybe a way to finance a health system would be through private voluntary insurance, including community based insurance, which is a mechanism that’s being piloted in a number of developing countries. But again, the evidence shows that this isn’t really a viable route to reach universal health coverage, because private insurance tends to be ineffective. It often doesn’t raise enough money. It’s inefficient, it has extremely high administration costs and it’s also inequitable because it excludes the poor. Now what does that leave? Quite simply the best way to finance the health system is through public financing. Now here there are two major mechanisms. Firstly, tax financing, out of general revenues, but then also through compulsory social health insurance contributions which in effect are a tax on wages. And you can see that the difference between the two is quite subtle. And in fact, what many countries are doing now is actually mixing those mechanisms of tax financing and social health insurance contributions. But the key point is that they’re compulsory and that they’re publicly governed. And another thing that countries are recognizing though is that where there are large informal sectors, it’s actually very difficult to get health insurance contributions from the informal sector. And really if you want to cover the entire informal sector you’ve got to predominantly use tax financing. Now as I mentioned, this has been quite a controversial area over the years and there have been great disagreements about the roles of these different mechanisms. But even people who 20 or 30 years ago were advocating a more privately financed health system are now recognizing that in fact public financing is better. And in a recent Lancet commission report called ‘Investing In Health’, the authors of the 1993 world development report that were advocating a more privately financed health system now acknowledge that public financing is best. And in fact they, a quote from one of the lead authors saying that, ‘the path to universal health coverage cannot work with reliance on voluntary private insurance.’ So there is this consensus now that public financing is best. Now given that, how can countries increase their public financing? And here there are a variety of methods that countries might look to do. Firstly, to improve existing tax collection, making sure people pay their taxes and clamp down on tax avoidance schemes. But also of course, introducing new taxes, particularly in developing countries, it’s often difficult to tax people’s income. In which case it’s a good idea to introduce new taxes on things like alcohol and tobacco, so-called ‘sin’ taxes, which actually these are products that adversely affect people’s health. So to tax them is a very good idea. But also potentially taxing remittances sent from abroad, or introducing a new value added tax like has been done in Ghana which is funding its national health insurance scheme largely out of this VAT levy. Another way of course is for governments to reallocate funds within the budget from less productive and less useful areas. For example, in reducing military spending or maybe trying to reduce subsidies that don’t make sense, either economically or for the environment, for example, in reducing fuel subsidies. And the third major area where countries can free up more resources for the health sector is in improving efficiency. WHO estimates that the countries can realize efficiency gains in the order of 20% to 40% and therefore get more health for the money that they have. And here, mechanisms can be reallocating money from specialist hospitals towards primary healthcare services and more cost effective community services. The area of medicines, where there are tremendous savings to be made in switching from branded medicines to generic medicines and improving procurement systems and reducing prices. And also in adjusting the skill mix and for example, investing more in community health workers who are very effective at reaching people in remote areas. These are good mechanisms for countries to follow, but how might a country start off on this route towards financing its health system? And a typical situation that countries find themselves in when they’re starting this process is that the richest quintile of the population are covered, maybe through social insurance schemes or they’re so rich that they don’t mind paying user fees. Also governments often make an attempt to cover the absolute poorest strata of society, maybe giving them a free health card. But unfortunately, these services often tend to be very poorly financed and really not adequate for, for people’s needs. But of course the major problem is that the majority of the population are still uncovered. And this is clearly not good for their health status, but also politically it’s not a good idea to leave these people in the cold. Now how do countries move away from this situation? One approach is to do it quite slowly and incrementally and from the top, down, maybe extends the health insurance schemes. Also from the bottom up, one can perhaps be a bit more generous with these basic safety nets as schemes. But unfortunately this process can take an awfully long time and leave a lot of people still uncovered. And what a number of countries are finding for example, in Indonesia or in Vietnam and the Philippines is that about a third of the population remain uncovered. Now another approach is to move much more rapidly to basically cover the entire informal sector at a stroke by injecting a large amount of tax financing into the system and not differentiating in the informal sector between the poor and non-poor. Now this is a strategy that’s been employed in many countries worldwide in the last 20 years, particularly right across Latin America and in Sri Lanka and in Turkey. And one very good example, which figures prominently in the World Health report is in Thailand. Thailand in 2002 had a situation where they hadn’t reached full coverage and a large proportion of the informal sector were uncovered. But on one particular day the government announced they were going to introduce a universal coverage scheme. And this at a stroke basically covered the rest of the informal sector and meant that everyone was now part of the health insurance program. This had the impact of increasing the utilization of services dramatically across the population and reducing unequal acecss. It also had the impact of reducing out-of-pocket expenditure and medical impoverishment which went down 82%. Also, satisfaction with this universal coverage scheme increased from 83% when it started to over 90% now. So you can see on all these measures of a health system that we’re tracking of utilization of services, financial protection, and satisfaction with this system, this is a very sensible thing to do. And it’s this type of approach that other countries seem to be looking to as they move towards universal health coverage.
In the previous lectures we were discussing the various influences on health and the role of the health system in achieving universal health coverage. There are many influences on people’s health, not only within the, the health sector, but also other sectors concerning agriculture, education, water and sanitation, housing, income levels. So the broad health system includes all those social determinants of health, which those of us interested in improving public health must get involved in. However, it clearly is the case that the health sector, delivering health services has an impact on people’s health. And the whole movement towards universal health coverage recognizes this. In stressing that people should be covered by a broad spectrum of health services from preventive health services to curative services, rehabilitative services, and palliative care for people’s ends of lives. And it’s also important that we look not only at people consuming services, but that this is a mechanism to them reducing impoverishment. Now looking at the way that health services impact on health outcomes, one would have thought intuitively, it’s the case that the more that people consume health services, the better impact there is on health outcomes. But surprisingly, the, the evidence on, on that score has been relatively limited. But recently some pioneering research done by Peter Smith and Rodrigo Moreno-Serra, written up in, in The Lancet showed that in a 153 countries, countries that have higher coverage of services actually do indeed have better health indicators, lower mortality rates. Also, more recent research has showed that rapid reductions in child mortality in Africa in the last decade were largely due to scaled up health service coverage. And in particular, coverage of one preventive health measure of mass distributions of bed nets to, to counteract malaria. So literally children being covered by these important preventive health measures has reduced mortality. Now WHO have done more work looking at the way that the health system functions and how health services impact on health outcomes. And building on their previous work, they now identify six basic building blocks or functions that lead to improved performance. Firstly, the leadership and governance issue that I’ll describe in a subsequent lecture. Then around the information that is required to run the health sector efficiently. Also, health workforce and human resources for health, vital inputs to running health systems properly. Medicines and medical products and technologies are also vital elements in the armory in improving health system performance. Combining those inputs efficiently through improved service delivery is another key function of the health system. And finally and I’ll deal with this topic in another lecture, financing the health system, another key function that needs to be taken into account. WHO and many in the public health world also emphasize the vital importance of primary healthcare in improving health systems. And here we’re talking about essential healthcare based on values of universal access, equity, participation and intersectoral action, working with other sectors that impact on health. With this particular emphasis on the primary or first contact level where people first interact with the overall health system. So looking at service delivery, we’re really talking about how these inputs are organized and managed to ensure improved access to services, that services are of good quality, that they’re safe for people to consume. And also that there’s a continuity of care across services as people interact with the health system. So for example, making a primary healthcare contact, being referred to more specialist care, and then maybe continuing rehabilitative care back in the community. But it’s not just really about the supply side. We should also be concerned about raising appropriate demand for services so people access services when they need them. But also that people don’t inappropriately use services. For example, consuming antibiotics when they don’t need them. It’s vital too that the services are integrated. And as you can see, there’s a broad spectrum of services and it’s important that all the elements work well together and efficiently together. Government should also be concerned about the overall management of the provider network and making sure that it’s supervised properly and people doing the jobs that they’re meant to do and not providing inappropriate services or for example, charging for services that they shouldn’t be doing. And finally the other important element is making sure that the whole infrastructure is organized properly and distributed so that everyone can benefit from the health services that they need. And that the logistical systems work so that medicines are, are available in the health centers and health workers are paid on time. And mentioning health workers, one of the key inputs and functions of the, of the system that I was mentioning with human resources for health, which WHO identified recently as what they regard as the most important input for the health system. One of the main reasons for this is it’s the most costly and typically governments are spending over 50% of their health expenditure on human resources. And it’s vital for an effectively running health system. But unfortunately in many countries the, the availability of health workers is inadequate. And in fact 83 countries have been identified as not having the basic minimum of around 23 skilled health workers per 10,000 population. So it’s very important that we scale up the availability of qualified health workers and improved their distribution across the country so that health workers aren’t just working in say urban centers, catering for the elite but are reaching populations right across the country. It’s also important that there’s an appropriate skill mix between you know the different professions of doctors and nurses and midwives and ancillary staff as well. And maybe the countries you know trying to improve the efficiency of the system should look to shift tasks that can be done by lower paid workers and free up time for specialists to do the services that they’re trained to do. Now in ensuring that the health workers are you know working efficiently and safely, it’s very important that they’re trained adequately, both before they start their work, but also that there’s regular in service training so people are kept up to date with the developments in their field. And the whole health workforce requires extensive management of the health labor market and governments to be involved in the recruitment of health workers, retaining them and making sure that they’re working in places where they benefit the population, providing incentives for them to do the correct work and you know making sure that they don’t do things that are going to adversely affect people’s health. And this also requires keen supervision of the work that health workers do and making sure that when health workers don’t behave appropriately, that there are sanctions as well. Now one area that, that a number of countries are looking to expand is, is that of community health workers to insure that health services really do reach remote rural populations. Community health workers are usually recruited from local communities and provide particularly primary healthcare services, both of preventive and curative nature as well. And it’s been estimated there are around 1.3 million community health workers at the moment and there’s a growing campaign for there being lots of more of the community health workers. Some very good examples of those have been in China where there are the famous barefoot doctors program which started in the 1960s and ’70s, was very effective and efficient way of getting primary healthcare services to rural populations. More recently in Ethiopia, they’ve recruited over 30,000 community health workers and they’ve been extremely effective in improving child health outcomes and indeed Ethiopia is on track to achieve its child health MDGs. Another very important area is insuring that there are efficient health information systems, because the generation in strategic use of information is an integral part of the stewardship function. It’s practically impossible to run an efficient health system if you don’t know what’s going on and you therefore need good information. So countries need to generate both population data about the health status and health needs of the population, but also information on the way that the health system is responding and facility based data, tracking where people are being treated and whether these services are having an impact. And there are a number of ways of generating this information through censuses, surveys, civil registration systems, public health surveillance systems, medical records and also, systems that measure the performance of health units. Now one area where it’s obviously vital to be detecting and using information is, is that looking at public health security. And the recent Ebola outbreak in West Africa is a very good example of needing rapid information about the spread of communicable disease. But it’s also vitally important that in generating all this information, that it’s synthesized and used strategically. And therefore that the management really uses this information to change systems performance. And finally, when one looks at service delivery and improving services, it’s vital to address the issue of the quality of services, because just measuring whether people come to an outpatient clinic or they deliver their babies in a health unit, isn’t good enough, because these services will only have an impact on people’s health if they are effective, they work. And therefore they must be of good quality. And in measuring the quality of services, it’s also not just good enough to look at the technical quality, whether the medicines work, but also there’s vital elements about the consumer’s perception of quality. Are they treated with dignity? Are they seen on time? Those more sort of customer friendly aspects. Because unless health systems look at those, those customer perceptions, people simply won’t go to the health facilities and use the services and therefore they’ll be useless in impacting people’s health.
Today I want to talk about health systems and in particular, the role of health systems in delivering universal health coverage which you’ve heard about in another lecture. So what is a health system? According to the World Health Organization, a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.
This includes efforts to influence determinants of health as well as more direct health improving activities. So you can see this is really quite a broad definition. And the health system is certainly much bigger than really just talking about public health units and hospitals. And in fact, if one thinks about the entire health system, it also includes the private health sector providers, both in terms of commercial, for-profit providers, but also non-government organization providers of services. But it also includes people caring for sick relatives at home. Another big area of course is in preventive healthcare and things like vector control programs to control mosquitoes for example. Behavior change programs would also be in the health system, encouraging people to lead healthier lifestyle by reducing the amount of fat intake and tobacco and taking more physical exercise. The health system also includes occupational health and safety legislation. Those are all activities that one would typically associate with the health sector, but also in really thinking about the much broader health system, it also includes intersectoral action to promote interventions that improve health. For example, the education of girls is very important for improving health status. Encouraging legislation to reduce tobacco, alcohol and sugar consumption and road safety measures. These are all what we’d call part of the broader health system. So that’s what a health system is. Now what should a health system be trying to do? Now here the World Health Organization have been extremely helpful and back in 2000, produced a memorable World Health report all about health systems and improving the performance of health systems.
In this document, they stated that there are three major goals for, for a health system. Firstly, to improve health indicators. Measures such as life expectancy, mortality rates, but also associated with people leading healthier lives. Here we’re not only interested in the overall levels of these indicators, but their distribution as well, to avoid the situation of there being big health inequalities between different population groups. Another goal for the health system is that it should be responsive to people’s non-medical expectations. That when people interact with the health system they’re treated courteously and in a timely manner and with respect as well. And the third major area is that the health system should be fair, particularly in terms of the financial contributions that people make towards financing the health system. So we’ve described what a health system is trying to achieve, now how does it go about trying to do that? And again the World Health report provided good structure in terms of describing four key functions of a health system. Firstly, in creating the resources that are required to run the health system, the inputs that go into the health system. Here one can think of things like medicines and health workers and computers, the basic inputs that go into the system. The next major area of course is in combining those inputs in delivering services. And this whole issue of how does one deliver efficient and equitable services? This will be the topic of the next lecture. The third major function concerns the financing of the health system. Again, we’ll discuss this in another lecture, but here one should consider the functions of how one raises the finances for the health system, how one pools resources, and then also the very important issue of purchasing services efficiently. And the final major function concerns stewardship. The overall management and oversight of the health system, where it’s an extremely important role for the state. Now when these functions combine effectively together and work well in an efficient and equitable way, this is how one improves the health system and delivers those outcomes that one’s looking for of improved health indicator figures, better fair financial contributions and also a system that is responsive to people’s needs. I’d like to just dwell briefly on this very important issue of stewardship and why it’s so important that the state gets involved in the running of the health sector. Now why should this be the case? Well firstly because health should be a national priority, all countries everywhere, people, it’s very important for them and the welfare of their families that they lead long, healthy lives and don’t suffer financial hardship in accessing services. So health really should be a national priority that good governments are concerned about. Secondly, it’s clear that free markets in health services don’t deliver equitable health systems. And really this is to do a lot with what they call market failures in the way that health systems worked. And the, the providers and suppliers of health services have a lot more information than the users of services. And in this type of situation, it’s very easy for people to be exploited by unscrupulous healthcare providers. And really this is one of the major reasons that it’s very important for the state to be heavily involved in the stewardship of the, of the health system. So the state really should be involved in setting the rules of the game of running the health system. And also in monitoring the performance of providers of services and improving accountability to the population who are paying for them. Now one area that has attracted quite a lot of controversy over the years is the role of the public and private sectors in, in a health system. And here, Professor Julio Frenk at the Harvard School of Public Health has provided a very useful description of the different roles of the public and private sectors, looking at those functions I was describing before. So thinking of that overall stewardship and accountability function, clearly that lies predominantly within the public sector, to set the rules and regulations to the system, with only perhaps a very small role for the private sector there. Likewise, it’s becoming increasingly clear that to achieve universal health coverage in an equitable health system, one needs to predominantly be looking at a publicly financed system. However, looking at the issue and function of service provision, it’s slightly less clear. And indeed, many countries the, the majority of health service providers are actually in the private sector, contracted, using public financing. So here there tends to be more of a mix of public and private providers. But when one looks at that final function or resource generation, manufacturing the inputs that go into the health sector, here the tendency is more for the private sector to produce the medicines and the computers and the basic inputs that go into the system. Now another area that’s attracted quite a lot of controversy over recent years is how one measures health service performance. And countries are very keen to match, to identify how their health sector is performing against others. Now how does one do this? How do you measure performance? Well clearly the indicators you should be trying to use are those around those objectives we were talking about of improved health status, better financial protection, and a more responsive system. And again, we don’t want just to be looking at absolute levels of those measures, but how they’re distributed across society. Now the World Health report in 2000 did this and ranked health systems across the world and created an index and therefore created a lead table. This was quite a controversial exercise and in that, at that time it was the French system that was deemed to be the best performing. Other organizations have been doing this as well. Most notably the Commonwealth Funds that assesses the performance, particularly of high income countries looking at measures of quality of care, access to health services, the efficiency of the system, equity and also those all-important health indicators. And in the most recent study that the Commonwealth Fund done, they showed that the British National Health Service scored the highest, was ranked the highest performing sector. Of course the system that is predominantly publicly financed and interestingly, the United States, of the eleven countries surveyed was actually bottom of the lead table, largely due to problems with inequitable access to services. Now what was striking is that the United States’ health system spend more than twice what a number of other OECD countries are doing, are spending. So it’s interesting therefore that necessarily spending more money on a health system doesn’t always improve performance. And therefore governments can learn about improving efficiency and doing more with the money that they have available. Thank you.
In this chapter, we will be looking at one of the major rising causes of death and disability in the world which are injuries, especially road traffic accidents and alcohol which is Frequently related to these accidents and injuries. The global burden of disability study which looked at the contribution of different diseases to death and disability in 1990 as well as in 2010 categorized diseases and causes of death and disability into three major groups. First is the grouping of communicable diseases or infectious diseases with deaths related to pregnancy, early childhood, later childhood, and nutritional conditions which often result in death or disease because of severe under-nutrition in many forms. These are generally considered diseases associated with under-developed economies and are generally expected to decrease in terms of their contribution to the global burden of disease as countries advance economically and socially. The second category is one of non-communicable diseases, which are actually diseases of mal-adapted modernity and which have been rising quite a lot as a result of countries advancing economically, urbanizing and industrializing without appropriate balancing measures to prevent unhealthy lifestyles from becoming established as a pattern in society. These two are now a major cause of concern in the 21st Century. The third category is one of injuries. These can be intentional or unintentional. Of course injuries have been found as causes of death right from times immemorial. People could have died by being mauled by a wild animal, or being thrown off a horse, or being struck by an arrow fired by an enemy. But in modern times, you find many more people dying by being mauled by a speeding truck or a car or being shot by a bullet. And as we now see injuries rising in contribution, the major categories of injuries which are rising are those related to road traffic accidents, suicides as well as homicide. And these are contributing to a rising burden which now exceeds the burden contributed by HIVAIDS, tuberculosis, and malaria put together. About 5.8 million people die each year as a result of injuries. This accounts for about 10% of the world’s deaths and is considerably more than the number of deaths resulting from some of these major infectious diseases like HIV, TB and malaria. Men are the major victims of intentional as well as unintentional injuries in a variety of forms, whether it is homicide or suicide or drowning or falls or poisoning. And of course markedly in terms of being road traffic accident victims. But women seem to be outnumbering men in terms of being victims of fire related injuries. That’s mostly because they are the ones mostly in the, cooking. In terms of the global burden, male sustained about 68% of all injury related deaths in 2010. But what is really disconcerting is the fact that many of these injuries strike young. About 40% of all deaths in the age group of 15 to 24 years were accounted for by injuries. Fifty-two percent of deaths in males, age 15 to 29 years were due to injuries. Again, like in case of many of the non-communicable diseases, a large fraction of these injury related deaths occurs in low and middle income countries. Eighty-nine percent of all injury related mortality is in these countries. South Africa has injuries as the second leading cause of death in that country. And about 95% of deaths and disability adjusted life year loss from interpersonal violence that is often due to fights or homicide. All of these occurring between people, these are found in low and middle income countries. And we know that war and conflict causes a huge number of deaths, almost exclusively in the low and middle income countries, even if the conflicts, geopolitical causes of those conflicts arise from other parts of the world. We also recognize that transportation related injuries and intentional injuries are among the leading causes of death worldwide, among the entire injury spectrum. And of these, road traffic accidents really are at the very top. And they’re rising in different parts of the world which are particularly now on the faster development trajectory. And we find that in Africa and the Middle East, the rates of road traffic accident related deaths per 100,000 population are among the highest in the world. In terms of unintentional injuries, we can actually take a large number of public health measures which have been shown to be very effective, like compulsory helmets, use of seatbelts, imposition of speed limits, improved built environments and road conditions. All of these actually help mitigate some of the disease burdens. In terms of intentional injuries we do require a fair amount of counseling from the healthcare system to people who are likely to be having suicidal intent. So treatment of depression, preventing suicidal attempts and providing psychological support systems and counseling to prevent self-harm, all of these are going to be important. Also, conflict resolution and means to prevent interpersonal violence are also part now of the public health agenda. And gun control becomes a very important area. And we now recognize that in countries with poor levels of gun control, homicidal and other interpersonal violence related injuries are very high indeed. In terms of preventing injuries, we also have to look at the response systems, particularly in terms of the emergency healthcare response. We need to look at the pre-hospital stage where for example a traffic accident victim needs to be immediately attended to by first responders, we need improved communications and provision of appropriate emergency transport. At the same time, in the hospital, we need again, a multidisciplinary trauma team to look after the person who is injured, who may have multiple injuries which might require different specialized care. But we also require to train nonprofessional caregivers to provide care when trained staff are not available. We also need rehabilitation of people who have had injuries and have survived them and a large number of people living with disabilities, post-injury need sufficient rehabilitation support now. We recognize that road traffic accidents are indeed the major preventable cause of injuries. And about 1.3 million people die on the roads every year. That is about 3,500 every day. Something like ten jumbo jets crashing every day. Now 50 million people are left with injuries, many with severe disabilities. And particularly in the young population of 10 to 24 years age, we find road traffic accidents are the single biggest cause of fatality in that young age group. We recognize that in high income countries some progress is being made by a decline in the rate of road traffic accident related death rates. But in low and middle income countries the death rates are rising. And when we look at the middle income countries in comparison with the high income countries, while the vehicular numbers are almost comparable across these two income groups, the deaths are far, far higher in the middle income group. So these are countries which are modernizing with a higher vehicular density, but are still unable to implement adequate safety measures which can bring down the road traffic accidents and the fatalities associated with it. Now half of the deaths related to road traffic accidents are unfortunately among the very vulnerable road users like pedestrians, cyclists, motorcyclists. That means it’s not just the car drivers and the truck drivers who die because of careless driving, but also the innocents who fall victim are the people who use the roads in other ways. Now we need to take very effective measures in, in order to control the road traffic accident related damage to health and prevent the death and disability in different settings. The five factors that can be controlled for by effective legislation. Speed of the vehicles can be controlled by speed laws. Drinking and driving has to be strictly curbed. And testing alcohol content in the breath and blood of drivers who are suspected to be driving under the influence of alcohol is a very important measure. Applying child restraints in cars prevents them from tossing around and getting injured in a speeding vehicle. And motorcycle helmets must be made mandatory everywhere to prevent head injuries. Again, seatbelts have made a great difference to the degree and number of injuries obtained during road traffic accidents. But very few countries implement all of these laws. If you take any single one of them, you find that the use of these is still limited only to some countries among the huge number of countries across the world. For example, when you look at drunk driving laws, then these are in fact applied very, in very few places. Urban speed laws are also applied in very few places. So also child restraint laws. While seatbelt laws and motorcycle helmet laws are more frequently applied, how well they’re enforced is also a big question. When we look at what are the contributory causes to some of this, drink driving comes out as one of the top causes of road traffic accidents. Now in South Africa, about 50% of those involved in road traffic accidents had elevated blood alcohol concentrations in 2001. And this is true of many rapidly urbanizing cities in low and middle income countries now. About 3.3 million people die every year due to harmful use of alcohol. In the age group of 20 to 39 years, about 25% of all deaths are attributable to alcohol. This is of course not only because of road traffic accidents, but because of the other harmful effects of alcohol as well. And we know that alcohol is the cause of cirrhosis that is a liver problem which because of alcohol gets fibrosis in the liver. Cancers which are again, attributable to alcohol particularly gastrointestinal cancers. All of these are growing problems now. But alcohol consumption, especially immoderate alcohol consumption is also associated with mental illness. And that can lead to intentional injuries, particularly alcohol provoked interpersonal conflict. Alcohol consumption, especially heavy drinking has been linked to both suicide as well as violence. And all of these can aggravate the number of injury related deaths and disability. We also know that there are huge economic costs apart from the social costs of alcohol. We have direct costs like costs for healthcare services, costs related to law enforcement, costs related to increased crime and accidents, costs related to domestic violence. Now there are indirect costs from loss of productivity, reduced output and earnings as a result of alcohol use. Absenteeism. Or even people being away from productive occupations because they’re under the influence of alcohol. Then intangible costs which are assigned to pain and suffering and poor quality of life. So given all of this, alcohol has become a major public health challenge again, not only in the context of non-communicable diseases, but in the overall context of development. Many countries have started looking at ways by which they can control the problem of excessive alcohol consumption which is deleterious to health. And taxation has been shown to be one of the very important elements by which public health can address the problem of alcohol, by raising prices and reducing the demand. And the, the taxation in different countries has been linked to the quality of alcohol, quantity of alcohol, the concentration of alcohol and so on. But taxing adequately is important as a measure. Now restricting availability of alcoholic beverages is also an important element. Not only age related restrictions but some countries have also imposed restrictions on the total amount of alcohol that can be sold to individuals over a period of time. Implementing bans on alcohol advertisements is absolutely critical. Both direct and indirect forms of alcohol advertisement and sponsorship and promotion must be banned. The other effective measures are measures against drunk driving. The word ‘drink driving’ itself is very suggestive. It suggests that it’s not the human being who is driving, it is the drink that is actually driving the vehicle when the alcohol concentration has exceeded a particular limit. So we do need to enforce that kind of legislation where we have random breath-testing and people who are driving under the influence alcohol are taken off the street and are also stripped of their licenses to drive. And strict penalties are imposed in order to inhibit such practices. We also need of course support systems by way of de-addiction counseling and other support systems, the health system as well as social support systems can provide. And all of these measures can reduce the problem of alcohol in our society and remove one of the important contributory causes to road traffic accidents.
CASH: Hello, my name is Richard Cash. I am a visiting professor at the Public Health Foundation of India and on the faculty of the Harvard School of Public Health. I am here with Dr. Vikram Patel, who is also with the Public Health Foundation of India and the London School of Hygiene and Tropical Medicine. We’re here to discuss mental health issues from a global perspective. Vikram, let me ask you, why do you feel that mental health issues are such an important topic to address?
VIKRAM PATEL: Well Richard, the first thing to say is that when we talk about mental health, we’re typically actually talking about mental illness and mental disabilities. And I think for many people the word mental illness and mental disabilities tends to reflect a particular kind of, of syndrome, characterized by agitated behavior and disturbed thinking. But in fact when we talk about mental illness, we’re talking of an extremely wide range of health conditions affecting people across the life course.
Consider for example we would include conditions like autism and intellectual disability in early childhood, ADHD and anxiety disorders in middle childhood, depression and self-harm behaviors in adolescence, psychosis and substance use in adulthood and dementia in old age. And for a moment if you start thinking of this range of conditions and thinking that almost everyone in the world must know at least one person who is affected by one of these conditions, you realize that the single most important reason why these are of significance is because they’re incredibly common. They affect people everywhere, in our immediate social networks and in our populations in large numbers.
CASH: But given the commonality of these conditions, which I certainly agree with, why has mental health. Why have mental health issues not been so much a part of the major agenda of global health programs? You hear about it, you’ve heard about it more recently. But it has traditionally not been an area of broad interest and discussion.
PATEL: I think that’s a really important question. You know I think we’ve been struggling to find out why, in spite of the evidence of the large numbers of people who are affected, there is such little interest to respond to the needs of these people. And I think there are several possible explanations for this. The first is, I think we’ve had very little evidence on the impact that these conditions have on people’s daily lives. For example, we now know today that mental illnesses are amongst the leading causes of household impoverishment, that poverty and mental illness for example are natural bedfellows. People who live in conditions of poverty are more likely to develop mental illnesses. And if you have a mental illness, you’re more likely to slide into poverty. A typical vicious cycle. Another example of an impact is the impact on caregivers and family members. So we now know today that many mental illnesses are associated with the need for informal carers at home. Effectively meaning that family members have to give up work or other forms of productive employment in order to actually care for the person at home. So these are just two examples of impacts that are typically not measured by typical health metrics, in terms of for example, mortality. These are social outcomes. And today we’re beginning to recognize that the social consequences of mental illness are enormous and therefore need attention. The second kind of evidence gap, it has to be said, was that for far too long we only parroted numbers. But we couldn’t really describe solutions. And I think that has been a dramatic change in the last decade or so in which we can now talk about effective interventions, but perhaps more importantly, ways that we can deliver these interventions even in places where there are very few specialist resources.
CASH: Let me hone in on this last issue, the issue of what in fact can be done to reduce the impact of this huge number of conditions that you’ve outlined. What interventions are there that in fact can reduce the morbidity, the caretaking needs of these individuals? And I would probably add, even mortality since there’s probably a good bit of excess mortality, premature mortality associated with mental health conditions. What can we do?
PATEL: So before I go to the what-can-we-do, I’d actually like to just build on your last point about excess mortality. I completely agree with you. If one looks at the global burden of disease statistics, you will find that mental illnesses account for a relatively small fraction of years of life lost, due to premature mortality. But that’s because of a peculiar way in which years of life lost are computed. So for example, suicide is not attributed to mental illness. It counts as an independent cause of death in the injury categorization of the global burden of disease. So you’re absolutely correct. The true mortality, true estimates of mortality that could be attributed to mental illness have been underestimated historically. And if one includes suicide as well as the effects of mental illness on other chronic diseases, the risk of chronic disease like cardiovascular disease, in fact one could argue that the mortality associated with mental illness is very high. And of course you can add dementia to that list as well. So the true burden of mental illness in terms of mortality has been historically underestimated. In countries like India, we’ve shown that suicide today is the leading cause of death in young people. And in fact this is true of many countries around the world today. And if one argues that the young people of countries like India are the, are the demographic engine of these economies, then the fact that suicide is the leading cause of death in this, this demographic group must be cause of concern to the highest levels of policymakers. But let me come to your, your main question, which is really about how do we deliver these? First of all, what interventions do we have and how do we deliver, deliver them? Actually we’ve had knowledge about effective interventions, drug interventions. For example, anti-psychotic drugs for schizophrenia, psychological interventions such as for example, cognitive behavior therapy for depression and social interventions such as for example, support groups for people with alcohol abuse disorders. I just give three examples here. But the problem has been that for many people, the impression is that to deliver these interventions you need highly qualified mental health professionals, psychiatrists, psychologists and, and the like. And the reality of course in the global context is there are few of these mental health professionals in most parts of the world. So in effect there’s been a sense of nihilism, we can’t really do anything about delivering these interventions, because we don’t have the requisite human resources for them. Actually I draw a parallel with this nihilism to what we saw with HIV/AIDS and I’m ure you’ll remember. It wasn’t that long ago when people said, we couldn’t really deliver life-saving treatments in Africa because we didn’t have the human resource and medical infrastructure to deliver antiretroviral drugs. And we’ve come a long way since then. And I think in the mental health field we’ve drawn lessons from the global HIV/AIDS story and begun to apply the same sorts of health system intervention innovations and shown in fact, that as with HIV/AIDS, one can deliver effective interventions even in low resource settings by using alternative human resources and alternative ways of delivering services.
CASH: Let me return a bit to this mortality and morbidity issue that we touched on. How do you approach the situation where the individual’s mental, mental health may well affect many, many others in the community? Most diseases we look at is how it affects the individual, but in this instance as you pointed out, there are caretakers, there are others and I think it’s been shown in a number of studies that, of those individuals incarcerated in prison, very high percentage of them suffer from some form of mental illness. So that the impact of individuals with these conditions on family members and on society itself would seem to me to be rather significant and yet I don’t see how this is ever counted.
PATEL: You’re absolutely right, it isn’t counted. And even though it’s not counted, mental illnesses already are considered to be among the major causes, uh, health related causes of loss of economic growth potential in countries. If you actually counted the non-health impacts of mental illness and I think you brought up some great examples, one which we often under count is the impact of untreated mental illness on the criminal justice system. And a good example of would that be disruptive behavior disorders in adolescents and its relationship to you know offending behavior which then leads to a consequence to do with incarceration and so on. So there are many hidden costs or uncounted costs due with mental illness which I think further raise the further highlight why we need to prioritize mental health in the global health agenda. In addition to these uncounted costs is the untold society of the human rights abuses that continue to be played out every day against people with mental illness. I’d suggest to you that there is no human health condition that is associated with such systematic denial of basic human rights, basic as in for example the right to live a life in freedom, a right to live a life with dignity, without being incarcerated against your will, et cetera. I cannot think of any group of conditions that is associated with such a denial of human rights as mental illnesses. Today you will see instances of people being denied their basic rights in communities. People being chained to trees, in homes, being tied to their beds. But perhaps most tragically of all being sent to prison rather than hospital in for example, in some of the richest countries of the world as in the U.S. where prisons have become de facto mental hospitals. And finally in mental health care centers where people are often abused in a variety of ways. `So it seems to me that if one considers one of the driving forces of global health as being issues around human rights, then that potentially indicates the great importance of mental health as a global health priority.
CASH: Let me go back again and explore other possible reasons that you noted early on as to why this set of conditions may not be addressed. And that is that of stigmatization. The, the notion that mental illness, that people who are mentally ill are possessed, that they stigmatize families, that is that the very, the very notion of a person who is not following the norms of society is somehow tainted or possessed in other ways that we can’t explain. Might that also play a large role in why we are uncomfortable in touching this set of conditions? Or why we, we relegate it to other non-health elements in society that try to expunge these, these ideas and these feelings?
PATEL: Clearly stigma plays a very important role in explaining why people shun those who have mental illness, why people are uncomfortable discussing this topic and why people are reluctant to respond to the needs of people with mental illness. But equally, I should say that stigma isn’t unique to mental illness. We have seen in medical history stigma being attached to a number of health conditions. Consider for example leprosy, but also more recently HIV/AIDS, a very feared disease. And the point I, make about both of bringing physical health conditions into this discourse is that there are important lessons to be drawn from the ways that we’ve been able to address stigma against people living with HIV/AIDS or leprosy, we can learn from and apply to mental illness. And to me one of those important lessons is making effective treatments available. I think that if you make effective treatments available, close to people’s homes, in the community of primary care context as opposed to locking people away as they did with leprosy some time ago, do you remember, historically we used to lock people away with leprosy in sanatoria? We did the same thing with people with HIV/AIDS, we took them away from their homes and stuck them in prisons and other sorts of institutions. But instead today what we see with leprosy and HIV, a decentralization of care and availability of care in routine healthcare setting. And I believe that that has been a very powerful force in combating stigma. And I think the same lesson should be extended to mental illness.
CASH: So that the idea that we can actually provide care, let’s be more widely, more widely spread and people need to be better educated about this, because you’re suggesting that by having care available, people say well okay, we can do something about this. I suspect that if there was no treatment for HIV, we would not be nearly as far along as you suggest we are. That is if HIV was still the, the universal killer that it was in the late ’80s, we’d be in a different place right now.
PATEL: Yeah, absolutely. Of course. The fact that you can now live with HIV, that you can live a healthy, productive life with treatment has transformed people’s view of HIV. It’s not surprising though. So if I told you that I could with effective treatment enable recovery from say, depression or schizophrenia, it becomes a less feared condition, naturally it does.
CASH: We have tended to see, it seems to me, mental illness as an individual issue. That is, we have someone who has a condition and we treat that condition. What about looking at mental illness as a societal issue? That is, that, that the way society is structured, the way society puts values on certain things can have a major impact on both the mitigation of this and maybe even the development of medical health conditions. How do you see that particular issue, individual versus a larger population based approach?
PATEL: Yeah. So that’s a difficult question to answer because of the very heterogeneous nature of mental illnesses. And so a single answer will not apply to all conditions. So what I mean is that in the range of mental illnesses that I spoke about a little earlier, social determinants, societal influences will play a different role according to the kind of condition we’re talking about. There are some conditions that are very heavily influenced by individual vulnerabilities. And those tend to be often biological. Hallmark examples of that might be autism and schizophrenia and dementia.Then there are other conditions which are much commoner and where I believe societal factors play just as important a role as individual factors. And I think the hallmark conditions there would be things like depression, self-harm behavior, and substance use disorders. Amongst those conditions there’s no doubt in my mind that societal factors are important. I’ll give you one example. One example might be the way alcohol is perceived by a community in terms of its role as a recreational substance. There is no question that when you have a permissive attitude towards alcohol the proportion of people who will drink will be greater. It’s natural. And the more people who drink in a population just by simple epidemiological estimates you will have more people with alcohol use problems. Which is why you often find that the prevalence of alcohol use disorders tends to be higher amongst, in those communities where there is a more liberal attitude towards alcohol. That is not to say the liberal attitudes at fault, it’s simply to demonstrate how a societal influence can have an impact on the prevalence of a mental disorder. Similarly with depression, we see that the rates of depression in substance use tend to be higher in those populations in which there’s greater inequality. I think the best example of this comes from work done in OECD countries where there is a very clear relationship between the prevalence of drug use and depression and income inequality, such that the more unequal a society the higher the prevalence. Now exactly why that happens, it’s still unclear. But there is a clear observation of that association.
CASH: Given the extensive prevalence of mental health conditions, it would seem that almost every society then, even if it’s ignored by the medical establishment will have developed its own ways of dealing with this, through traditional practitioners or other approaches, religious-wise, non-religious, non-physicians, non-health people. Do you find that in fact this is the case, that there are, that there are structures, that there are elements within most of the societies in which you’ve worked and I know you’ve worked in, certainly in Europe and Africa and in South Asia and so on, that are supportive of or valuable in looking at those elements that might deal more effectively with this condition?
PATEL: So I think your question really points to a very important potential resource in every community in the world to address mental health problems and those are traditional and informal providers. I strongly endorse the role of these providers for multiple reasons. First of all, they’re just very much more numerous. Historically, people have felt comfortable going to these providers because these providers share with their local communities a common understanding of the sorts of phenomena that we associate with mental illness. So engaging traditional providers within a public health response for mental health conditions I think seems like a sensible way forward. Having said that, a couple of caveats. The first is that many traditional providers also commit fairly serious offenses of human rights. So one should not use a, a brush to sort of romanticize the whole of traditional medicine. And in fact, some of the worst abusers of human rights take place in traditional medicine. And also one shouldn’t forget that traditional medicine is expensive. It’s a private practice. And so I don’t see this as an alternative to a publicly provided primary mental healthcare system, I see it as a complimentary system with which we should establish a dialogue with, of mutual respect and insure that people with mental health problems are being well managed with adequate quality in both systems. The second thing I want to say is that, and link to the first point, is that traditional systems of medicine were also used for physical health problems. It’s not true to say that there were only for, for mental health problems. It’s not long ago when I remember when I worked in Zimbabwe that the most common treatment for HIV/AIDS used to be a whole set of traditional interventions like herbs that were used. And, and people completely rejected the biomedical approach. I’m talking of as recently as the 1990s. And I think in that sense, the same analogy could be applied to mental health, that is to say, why have people started using biomedical services in such large numbers for HIV? It is because the service is available. It’s affordable. It’s accessible. It’s of good quality. And I think the same basic principles of healthcare should also be extended to the public healthcare system. I say this only because very often I hear policymakers say, oh but in our country you know we’ve historically gone to traditional medical practitioners of mental illness, almost as a way of absolving themselves of a responsibility to develop a public mental healthcare system clear that that is not actually the right strategy.
CASH: Since most of the practitioners, be they of the allopathic system or the traditional system, are men, and yet many of the other half of the population has issues that oftentimes are unrelated to their own experience and after all, the, the care that we deliver is often related to our experience, to what we’ve gone through and, and yet there are very few women practitioners that I’m aware of, maybe more at the village level. Is this an issue and how do you address it?
PATEL: So first of all, I want to just touch on the issue of gender and mental health more broadly, as a social determinant. And I think there’s a profound interaction just as there is with poverty and mental illness. There’s a profound interaction between gender and mental illness. So for example, women who suffer from severe mental illness often are far more likely to be stigmatized and discriminated against than men. In south India for example in, in fact in India more generally, a man with mental illness is, is much more likely to get married than a woman is, because the general idea is that the wife will look after him. But there’s no opposite opportunity for the woman. Gender and, and mental illness interact in many ways. Women are much more likely to suffer depression and that’s often to do with the far greater difficulties in terms of life events that they face in their daily lives. But equally men are more likely to suffer substance use disorders. And that’s because again, of the definition of masculinity and, and, and the idea that the, the definition of masculinity included within it the idea that, that young men will get intoxicated in many parts of the world. And that makes them more vulnerable to develop substance use conditions. Now the question you asked is a somewhat different one. Should there be gender matching you know in a sense? Should women with mental health problems more likely to be able to discuss their problems with other women or vice versa? I think it’s an interesting question, I’ve often thought about that. And certainly all the work that I do with community health workers, most of our community health agents are actually women. And so it’s usually the other way around, that we look at challenges, are men more likely to be able to discuss their personal problems in their substance use problems with women community based workers? And my experience so far has been yes, it does happen, but it’s very infrequent. And it’s so infrequent that it doesn’t really justify a male worker for a male patient and a female worker for a female patient. I think it’s logistically quite complex, but also practically, I haven’t found in my experience that most men feel uncomfortable talking about their problems with a female counselor, especially if that counselor, a therapist is well-trained to deal with gender issues, which clearly must be an important part of their, of their competencies.
CASH: Vikram, we’ve spent a lot of time on talking about treatment therapy, let me look at the issue of prevention. Are there things that we can do as societies, as families that could reduce the incidence of conditions either in childhood or later on in life? The preventive aspects of mental health. DR. PATEL: So once again, I want to just remind ourselves that we’re talking about a very heterogeneous group of conditions, each which has its own etiology and life course trajectory. So a single answer will not be able to address all of them. There are some conditions which unfortunately the knowledge that we have today about etiology is extremely weak. And so therefore preventive interventions which typically would target risk factors or, or strengthen protective factors therefore have much less evidence to support their design and implementation. But there are others for which we do have much better evidence. And if I had to answer the question, what are the best buys for prevention in the mental health sector, I would start with early child development. So interventions that promote early child development and parenting interventions across childhood into adolescence to me are the best buys for preventing mental health problems both in childhood as well as in adulthood. The second best buy for me would be strengthening life skills in adolescence. Of course this is done both at home, but importantly also in schools where adolescents and children spend extended periods of their lives, but also where some of the determinants of mental illness actually take place. For example, bullying and academic pressure. So that would be my second best buy. The third best buy would be regulatory and legislative interventions that promote the rights of people with mental illness, prevent discrimination. And in the case of alcohol and suicide, where there are regulatory interventions limiting access, so for example, in the case of suicide, limiting access to lethal means, in the case of alcohol, just as with tobacco, taxation is a very cost effective preventive intervention. These would be in my view, I might have missed a couple here or there, but these would be the best buys in the prevention field.
CASH: What is being done at global level to deal with this large burden of disease? We’ve talked about sort of individual communities and so on. But is there, are there any types of global movements, global initiatives that are trying to address this problem? DR. PATEL: Yes, there are many. And in fact that’s the positive story about global mental health is that finally the evidence that has been generated over the last few decades of the burden, the effective interventions and the effective delivery methods in lower resource settings are finally having an impact. So let me give you some examples of the impacts that we’re seeing that indicate the importance that mental health is being given in global health and development. In 2013, the World Health Organization passed a resolution unanimously from all the member states for a comprehensive mental health action plan that sought to make every country commit to a set of actions that would improve access to care, promote mental health, strengthen research and governance for mental health by the year 2020. Another example would be at the national level. Countries committing new resources and new ways of thinking about addressing mental health problems. You’re seeing this mostly in the middle income countries of the world where there are more resources for health. The best examples would be the sort of mental healthcare reforms you’re seeing in countries like China, where more than 4 million people, 4 million people with serious mental illness are now registered with China’s universal mental healthcare system, which is called the 686 program and provides a community based care model for people with serious mental illness. You see similar examples in many other countries. Let’s look at another example of change which is research. There is now renewed interest in implementation research in the mental health sector. And major funders such as the NIH are committing new resources. By my back of the envelope calculation, since 2011 when we published the grand challenges in global mental health, more than $70 million U.S. dollars have now been committed for new research, to support the grand challenges in global mental health. So these are two very important examples. But I want to really finish with a third very important example which is the mobilization of people with mental illness to speak for themselves, to speak for their rights, to advocate and demand for action by governments to address their needs. And one example of that is the movement for global mental health. It’s a virtual movement. It’s a virtual platform upon which people with mental illness, professionals and policymakers can stand shoulder to shoulder, together as it were, a combined front and demand actions from government and other stakeholders to address the unmet needs of people living with mental illness worldwide.
CASH: Vikram, we talked about interventions, various strategies that countries have used and are using. Maybe you could focus your attention on low-income countries because the argument always is well we just don’t have the resources to make any significant interventions. We can’t give these drugs out. That there’s a lot of issues that impact on our ability to do anything. How do you address that issue?
PATEL: If I had to choose a single innovation or solution, it would be to empower a cadre of community based workers, using exactly the same model that many low-income countries have used to improve maternal and child health, community based workers with the requisite competencies to detect mental health problems, provide first level psycho-social interventions and refer up the healthcare system to the more specialized providers. Alongside that, mobilize people, raise awareness, et cetera. This would be the single most important innovation I would recommend. Obviously twinned with that, ensuring adequate skills in primary health centers to diagnose and deliver pharmacological treatments and making sure that a, a basic basket of cost effective drugs are available in primary healthcare would be a second important recommendation.
CASH: Vikram, I’d like to thank you very much for a very stimulating discussion on global mental health issues. I’m sure there is much we haven’t covered, but I think we’ve made a good, you have made a very good intro into this very important and up until recently, ignored aspect of human health.
Thank you. DR. PATEL: Thank you, Richard.
We will be talking of respiratory illnesses in this chapter. Clearly the lungs can be affected by very many conditions. Infections which are acute, infections which are long-lasting, like tuberculosis or cancers, but what we will be talking about today is one of the major forms of non-communicable disease, the chronic obstructive pulmonary disease, or chronic obstructive airway disease as it is called. COPD is one of the major problems affecting the health of human beings across the world. And in 2010, it was estimated that 329 million people, that�s about 4.8% of the global population were affected by chronic obstructive pulmonary disease. In 2012, it was the third leading cause of death. But these numbers too appeared to be underestimates because COPD is not often registered as a cause of death because cause of death is attributed to other things like cardiovascular and so on which may coexist or which may actually result from COPD, because congestive heart failure is not an infrequent manifestation of lung disease which then stresses the heart. Most countries don’t have national registries or good population data for the disease and therefore this disease may be even more frequent than has been estimated. But even at the level of the burden that has been now measured, 90% of the deaths occur in low and middle income countries. In 2010, it was estimated that COPD resulted in an economic loss of $2.1 trillion dollars globally, half of which was occurring in the developing world. Now if 90% of the deaths are occurring in the developing world but only 50% of the economic burden is in the developing world, that’s not because the developing world suffers less, but because the wages are estimated to be lower in terms of lost productivity losses. So the low and middle income countries do suffer hugely, both in terms of health and economy. Of this $2.1 trillion, $1.9 trillion is because of direct costs of medical care, which again is sparse in some of the developing countries. About $.2 trillion are indirect costs of missed work. Tobacco smoke is the biggest single risk factor for chronic obstructive pulmonary disease, followed by exposure to air pollution, which can occur both indoor and outdoor. Of lifelong smokers, half develop chronic obstructive pulmonary disease, if they’re not claimed already by cancer or heart attacks. Secondhand smoke is responsible for about 20% of the disease, even in nonsmokers. So lung problems can occur in active as well as passive smokers. COPD is unfortunately not curable. The problem with COPD is that cigarette smoke or other forms of smoke destroy the small airways in the lungs. They shrink the functioning lung tissue which becomes less capable of filling air and extracting oxygen. They also denude the airways of fine hair-like structures which act like brooms to clear the mucous. And when that happens, mucous accumulates and can become the seat of infection. And treatment can slow down the progress but cannot totally reverse the damage that’s already been done on infections or respiratory failure can be the frequent problems in COPD. We also know that there are other risk factors like environmental exposures in the form of biomass fuel consumption. Now when solid fuels are burned in the kitchens for example of homes in low and middle income countries, we have smoke emanating from there and filling the lungs. About 3 billion people are exposed annually to such biomass related air pollution. Outdoor air pollution or ambient air pollution is another major cause of air pollution which can damage the lungs. In addition, there are occupational exposures to a variety of dusts. Like for example the coal dusts in so-called anthracosis or sand in so-called silicosis. All of this dust can also enter the lungs and damage the lungs. In terms of air pollution, we now recognize it as the one, the largest single environmental health risk. In 2012, seven million people died prematurely due to air pollution. And in the same year, 2.7 million of these 7 million deaths were attributable to ambient or outdoor air pollution; 4.3 million premature deaths were attributable to household air pollution. The ambient air pollution is of particular importance where there is a fair amount of pollution because of a large number of causes, particularly industrial pollution as well as transport related pollution. These pollutants contain ozone, nitrogen dioxide, sulfur dioxide and particulate matter, all of which can damage the lungs and cause chronic obstructive pulmonary disease, apart from some of them being also cancer causing. In terms of particulate matter, this is a complex mixture of solid and liquid particles of organic and inorganic substances. And you have sulfates, nitrates, ammonia, sodium chloride, black carbon, mineral dust and water in a fairly deadly mix of pollutants which can damage the lungs very severely. But the particulate size also matters. What we call PM10, or particulate matter under the size of 10 microns, these lodge themselves deep inside the lungs and can cause cardiovascular disease, respiratory diseases and lung cancer. Whereas smaller particles, less than 2.5, what we call PM2.5 can cross into the bloodstream and cause damage to the blood vessels, can also cause a variety of diseases, including cardiovascular disease. Therefore when we are looking at all of these materials, we are really concerned about the quantity as well as the size of the particulate matter. In terms of households air pollution, about 3 billion people cook with solid biomass fuels. And in low and middle income countries, this is the kitchen’s curse, where women cook with these fuels, often holding small babies in their arms or babies have, the children are playing around in the kitchen. And about 50% or more of the under-five deaths in children are due to pneumonia who are exposed to this risk factor, which is soot inhaled from the households air pollution. Women too suffer and you have diseases like pneumonia, stroke, ischemic or coronary heart disease, chronic obstructive pulmonary disease and lung cancer resulting from exposure to indoor smoke from solid fuels. The countries of South Asia, India, Nepal, and others shoulder the biggest burden of households air pollution. It has been said that having an open fire in your kitchen is like burning 400 cigarettes an hour. And that is a level of pollution to which women and children in these countries are exposed when they use solid fuels in the kitchen. In terms of ambient air pollution, which is outdoor air pollution, about 16,000 cities worldwide monitor and report air pollution. But only 12% of the people living in all of these cities have air quality which meets the standards set by the World Health Organization. The most polluted cities in the world, no surprise, are in the low and middle income countries. Karachi, New Delhi, Katmandu, and Beijing are among the most polluted ones in Asia. Whereas Lima and Arequipa are among the most polluted in Latin America and Cairo in African cities. But obviously many others in these regions also have very high levels of air pollution. If you are looking at use of solid fuels for cooking, worldwide it has gone up in the last 20 years and particularly in Africa and South Asia. When we look at the health effects of air pollution, we see a number of diseases which can result. Stroke, heart disease, lung cancer, chronic as well as acute respiratory disease, including infections and a lot of childhood asthma. Childhood asthma can be provoked by multiple smoke exposures, including tobacco smoke or dust. About 80% of outdoor air pollution related deaths were due to ischemic or coronary heart disease, 14% due to chronic obstructive pulmonary disease and 6% due to lung cancer. In 2013, the International Agency for Research on Cancer concluded that air pollution is definitely carcinogenic to humans. When it comes to particulate matter, as we have said there is absolutely no safe threshold and therefore we must try and minimize the exposure to particulate matter both in terms of quantity, size and duration of exposure. When it comes to households air pollution, we ought to make sure that we have alternative fuels because biomass cookstoves or safe cookstoves as they’ve been called, which have tried to protect people who are continuing to use solid fuels, have not had a substantial reduction in the amount of exposure to some of these potential disease causing agents. And obviously we now require better fuel which can be utilized in the form of liquid petroleum gas or a greater supply of electricity which makes it possible for women to use induction heaters. So energy security becomes a very important issue when we’re dealing with households air pollution. And it’s important for us to recognize that when we’re dealing with ambient air pollution too, if we control vehicular emissions by reducing vehicular density, that also contributes to energy security. So we are moving in public health to areas of energy security rather than just looking at air pollution as a health problem alone. When we are looking at ambient air pollution clearly we require a multisectoral approach. We do require to curb industrial emissions which are one of the major sources of ambient air pollution all over the world. We need to reduce transport related air pollution and emissions by reducing vehicular density across the crowded cities of the world. We need to reduce also construction related air pollution in countries which are rapidly expanding their cities. We need to provide more green spaces and by providing greater access to public transport which has an effect on reducing the number of vehicles on the road, we can actually curb a fair amount of air pollution. So by linking up many of these public health measures to urban design, urban transport, energy security and of course tobacco control, we can actually make a dent in what is otherwise an incurable disease.
Cancer is the most dreaded of all non-communicable diseases. Indeed, it’s been called the emperor of maladies. It caused about 8.2 million deaths worldwide in 2012 and is rapidly rising now to possibly cause 22 million deaths by 2030 as per projections. The low and middle income countries of Africa, Asia, Central and South America account for 60% of all annual new cancers and 70% of cancer deaths across the world. Indeed, the most common cancers are those of lung, liver, stomach, colorectal cancer, or the cancers of the large bowel and breast cancer. And these are found almost everywhere in the world. They do differ however across gender in terms of men having more of lung cancer deaths and women having more of breast cancer deaths. But even among women where smoking rates are high, now lung cancer is rapidly rising. Breast cancer among women accounts for about 23% of all new cancer cases and 14% of all cancer deaths. Whereas in men, the lung cancer accounts for about 17% of all new cancer cases and 23% of all cancer deaths. In terms of risk factors, while we do classify cancers among non-communicable diseases and cancers indeed are linked to other non-communicable diseases through common risk factors like low fruit and vegetable intake, high body mass index or overweight and obesity, that is a high percentage of body fat, lack of physical activity, tobacco use and alcohol use. There are other conditions which give rise to cancers as well, including infections. About 30% of all cancer deaths however are related to these major risk factors of non-communicable diseases and are therefore eminently modifiable and preventable. Among the very many risk factors for cancer, tobacco is the single most important one. Indeed, 20% of all cancer deaths and 70% of all lung cancer deaths are attributable to tobacco. The idea that tobacco is a deadly killer also came up from the study of lung cancer in the first place. But we now know that apart from smoke forms of tobacco, which cause cancer, even the chewed forms of tobacco can cause oral cancer. About 90% of all oral cancer deaths are due to chewed tobacco. We also know that alcohol is an important risk factor for cancers of the food pipe and also of some of the other organs in the body. So, given that alcohol and tobacco which are imminently preventable risk factors, we ought to focus a great deal of public health attention on those. But in addition we also know that cancer can be caused by viral infections. Hepatitis B virus, hepatitis C virus and the human papillomavirus which causes cancer of cervix, all of these viruses together contribute to about 20% of all cancers in low and middle income countries. Urban air pollution is an increasing cause of cancer risk and again, is becoming a problem in many developing countries. Indoor smoke from households use of solid fuels where women burn solid fuels for cooking also is a contributor to increase in cancer risk. Exposure to radiation is a major problem whenever there is a massive radiation exposure, for example, what we found after Hiroshima and Nagasaki. But even other levels of radiation, for example, those who are undergoing repeated x-rays or exposed to radiation and other forms also have an increased risk of cancer. Now we know that cancer is not only deadly but causes a huge economic loss both in terms of life years lost and in terms of the costs of treatment. It’s been estimated that about $895 billion dollars represent a loss due to cancer. And when we consider the fact that cost of reducing exposure to key risk factors like smoking, drinking, and poor diet costs only $1.8 billion dollars, there is absolutely no reason why we should not invest more in prevention rather than suffer the huge economic and health consequences of cancer that’s not been prevented. We know cost effective solutions exist. By reducing smoking, by reducing immoderate consumption of alcohol, and by promoting healthy diets we can prevent one in three cancer cases. In terms of cancer control, we ought to be looking at different types of strategies at different levels of prevention. Firstly we have what’s called primordial prevention that
is preventing the acquisition or augmentation of risk in the first place. Like for example, preventing people from taking up smoking, from becoming overweight, or consuming alcohol in huge amounts. Secondly, we also ought to be looking at primary prevention. That means people have already acquired the risk factor, like for example, smokers. They need to be encouraged to give up smoking before they run the risk of developing cancer. Similarly encouraging people to shift to healthier diets or abstain or moderate their intake of alcohol, all these come under primary prevention. Now in terms of secondary prevention, this is where screening and early detection of cancer in its early stages is very helpful, where we can prevent it from going into advanced stages, or where we can actually cure it. Now tertiary intervention is where the cancer has actually advanced and we have treated, but we are preventing recurrence and trying to insure that cancer does not become a problem again in the life course of that individual. But we also have to look at people who have reached a stage of cancer where treatment has failed. And their palliative care and end of life care become very important to make the last few months or years pain free and relatively comfortable even if cancer still is an unresolved problem. Now in terms of prevention, again, it is worth emphasizing that tobacco control remains one of the major public health interventions. Promotion of healthy diets is very important. We now know that fruit and vegetables and healthy fats are important for cancer prevention as well. And a balanced diet is probably one of the best things that we can do in order to prevent cancer. Physical activity does reduce the risk of cancer, especially that of large bowel or colorectal cancer. Exposure to sun, particularly in people who do not have much of melanin pigment in their skin can cause skin cancer and we therefore need to reduce the exposure to skin or protect ourselves against ultraviolet irradiation. At the same time prevention of exposure to viruses or treatment of those viral conditions very promptly is also helpful. Alcohol use should certainly be very moderate if at all and that again is an important measure of cancer prevention. Now in terms of detection, there are several tests that are often used in order to detect cancer early, like the pap test for cervical cancer, mammography for breast cancer, fecal occult blood test for cancer of the large bowel or the colon. And sigmoidoscopy for again, looking at colorectal cancer and prostate specific antigen for looking at prostate cancer in men. Now all of these tests are frequently employed, but we need to look at guidelines where they can be most optimally employed in the most cost effective manner. And periodically these guidelines are produced by expert groups to ensure that we pick up the…. We increase the pickup rate of cancer detection without unnecessarily undertaking extensive high cost screening in all people. Now in terms of cancer care, early detection helps us to initiate early treatment. And cancer screening is often used in order to pick up cancer in the pre-cancerous stage or in the very early stages of cancer where definitive treatments can be very useful in curing cancer and then subsequently we may have to follow with other therapy for prevention of recurrence. Therefore screening should be fairly optimally employed in order to prevent advanced cancer being the first clinical manifestation and where we can actually pick up very early on and prevent complications. It’s been clearly shown that organized screening substantially reduces the age standardized mortality of cancer death rates in populations and that is an important public health measure. In terms of treatment however, we see across the world, huge inequalities between developed and developing countries. For example, many of the developing countries have very few machines or no machines for cancer therapy in their health systems, particularly in their hospitals for treatment of cancer, when already detected. In the United States, there is one machine per 250,000 population, whereas over 20 countries, mostly African countries have no machines at all within their countries. And the existing machines are also poorly maintained or when they are available, do not have trained radiotherapists and physicists to operate them. And we do see that there is a huge variation of the number of people served by radiotherapy across different countries. Countries which have very high burden have very limited treatment coverage. We also know because of these reasons of late pickup and poor treatment, we have varied mortality rates of cancer across different countries. And these vary by national income levels. Those countries which belong to low income levels have much higher rate of mortality for any given level of incidence of cancer, whereas those in high income countries for the same level of incidence have much lower mortality. Therefore the case fatality rates are much lower in the high income countries and this is because of their health systems being much better endowed both for early detection and more effective treatment. And one of the clear-cut inequalities is demonstrated in the use of anti-cancer drugs which frequently are very expensive. And we see that whereas the burden of cancer is mostly in the low and middle income countries, for example in the African, in Asia and Latin America, the actual use of drugs is very limited in those countries. And we find that countries of the United States and Europe and Japan use a very large fraction of the anti-cancer drugs in the world just because they can afford it. At the same time, while we are trying to make anti-cancer drugs more widely available, accessible and affordable to all populations across the world, we must also recognize that those who have advanced to end stage of cancer are now suffering in many developing countries because of denial of appropriate pain relieving therapies. This is where palliative care becomes very important. It is an approach that improves the quality of life of patients and their families when they are faced with life-threatening illness through prevention and relief of suffering by early identification and management of pain and other problems which require physical, psychosocial and spiritual approaches for their management. Indeed cancer becomes one of the largest reasons for requiring palliative care. And because we recognize that 34% of all palliative care needs globally are due to cancer, of course other chronic conditions also require palliative care when they reach an end stage. We have to particularly focus on insuring adequate pain relief and supportive therapy for cancer patients. And unfortunately, our health services which ought to be better organized for providing palliative care to the terminally ill and also providing support to the patients and their families are found wanting in this respect across many health systems. Physical, social, psychological and spiritual support of patients with a life limiting illness has to be delivered by a multidisciplinary team. Not merely doctors but nurses, physiotherapists, psychological counselors, all of them are required and Nutritionists. But unfortunately we do not have in many countries such teams easily available. Indeed many trials of early palliative care have shown that the groups that have received palliative care have done much better both in terms of quantity of life being prolonged and quality of life being much improved. But one of the main areas of palliative care and pain relief is opioid treatment. And unfortunately opioids for pain relief are not widely available in many countries or even permitted by their legal systems to be used. And therefore we see a huge discrepancy in the amount of opioids consumed for pain relief in palliative care between the United States, which consumes a very large amount per case as opposed to people in China, India, Mexico, Uganda or in Haiti. And this again is a huge inequity, if people are condemned to live in pain, this is indeed an injustice. So we really have to gear up our health systems to be much more sensitive to the issue of palliative care and pain relief of the terminally ill, especially the cancer patients who do not have much hope of cure. And therefore we require a public health approach to cancer, in terms of prevention of cancer, because much of cancer is still very much preventable, whether it is the living habits like diet, tobacco, or alcohol and physical inactivity that need to be addressed or elimination of viral infections which cause cancer cervix, or cancer of the liver, which again are very amenable to public health interventions, or early screening for effective detection of early stages of cancer or precancerous conditions so that treatments can be applied in order to cure and prevent them from proceeding to advanced stages, or in advanced stages too, providing the appropriate therapies with adequately equipped health systems and health services. And finally by providing palliative care and pain relief to all those who need it without really denying drugs to people in low and middle income countries, merely because of price related factors. All these become public health priorities and in a global scenario where cancer is becoming an increasing global threat, all of these issues need to be addressed, not merely at the national level, but as a part of a global health response.
Heart diseases and blood vessel diseases are together known as cardiovascular disease. There are of various types. The leading cardiovascular diseases are coronary heart disease, also known as ischemic heart disease, which is because of blockages in the blood vessels of the heart, ultimately resulting in heart attacks and damage to the heart muscle and sudden cardiac deaths in some instances. Cerebral vascular disease is also called stroke or brain attack. Some of the earlier manifestations of coronary heart disease and stroke are called angina or transient ischemic attack. Also you have peripheral vascular disease which is disease of the blood vessels elsewhere in the body. Now these, the coronary heart disease, stroke and peripheral vascular disease are all united by common risk factors, which cause these blood vessel blockages and the subsequent damages in the brain or in the heart. And these risk factors are high blood pressure, high blood fats, also called dyslipidemia, diabetes and its precursor impaired glucose tolerance, smoking, both active and passive, physical inactivity and there are several other risk factors also implicated, but less important. For example, genes are also frequently talked about, but they do not contribute to much of the disease variants that we see within populations or across populations. All of these factors often combine to cause serious blood vessel damage. There are other forms of heart disease like congenital heart disease which are cardiac malformations present in birth and which can manifest at different periods of life. Then you also have heart muscle disease which are basically cardiomyopathies. Then there are some diseases of the heart which are related to infections, like rheumatic heart disease which affects the heart valves but is principally because of the body’s reaction against streptococcal sore throat. And you have other forms of blood vessel disease also called aorta arthritis. But the most frequent ones which are the major killers in the world are coronary heart disease and stroke. Cardiovascular diseases are now by themselves the number one killer in the world. Indeed, according to the global burden of disease study in 2010, ischemic heart disease or coronary heart disease accounted for about 13.3% of global deaths and stroke or brain attack accounted for about 11.1%. Now if you combine coronary and cerebrovascular disease, then together their contribution to global deaths has risen from 1 out of 5 deaths in 1990 to 1 out of 4 deaths in 2010. And you have other problems also now occurring arrhythmias, or electrical disturbances of the heart are increasing, particularly with aging populations and one of the common problems that we are seeing in the elderly now is atrial fibrillation which has risen over 200% between 1990 and 2010. When we look at what the trends in cardiovascular disease death rates are across the world, then we see that in high income countries for example, the United States we find cardiovascular disease death rates are declining over the last 20 or 30 years. In fact they’ve risen sharply in the early part and mid part of the 20th Century and they started declining towards the latter part of the 20th Century and seem to be relatively on a stable decline even now. On the other hand, in developing countries like China and India and elsewhere, in Latin America, and parts of Africa, you are seeing cardiovascular mortality rates rising, particularly age standardized cardiovascular mortality rates are sharply on the rise. In China, cerebrovascular disease or stroke is the prominent form of death. Unlike coronary heart disease is the dominant form of cardiovascular disease in Europe or in United States. This variation between coronary heart disease and stroke is happening across different parts of the world because of different stages of health transition. Now early on in health transition high blood pressure which in one of the most important risk factors for coronary heart disease and stroke results in a bleeding stroke where there is bleeding into the brain from the blood vessels, called hemorrhagic stroke, or hypertensive heart failure where the heart model fails because of longstanding uncontrolled high blood pressure. However as other risk factors are added in the population, like for example increased blood lipids because of abnormal blood fats going up due to unhealthy fat intake or smoking or diabetes, the clotting tendency in the blood increases and the same uncontrolled high blood pressure now results in a clotting stroke and coronary heart disease or blockages in the blood vessels of the heart. So the differences that we see across different regions are not because of marked ethnic differences but because of different pace of progression of the epidemic in different regions of the world. Ultimately it is likely that we will see that most parts of the world will have a very high burden of coronary heart disease and thrombotic stroke. Obviously, many of the risk factors are common, both to stroke and to coronary heart disease. Though blood pressure by and large is the most important risk factor for stroke, it also has other risk factors like smoking, diabetes and abnormal blood fats. But for coronary heart disease, all of these are almost equally important. And then of course you have physical inactivity, dietary issues like reduced fruit and vegetable consumption. All of these which contribute both to coronary heart disease and also to raised blood pressure. Now raised blood pressure also can result in kidney disease. So some people look at hypertension as a disease, others would like to look at it as a risk factor. And then look at what causes high blood pressure? High salt intake, low fruit and vegetable intake, physical inactivity and so on. However way we look at it, it is very clear that high blood pressure and smoking are among the most important risk factors along with physical inactivity and unhealthy diets. And we need to act upon all of them. Now the Framingham study which started in 1948 in the United States in a small village in Massachusetts called Framingham, actually came up with the concept of risk factors and identified smoking, high blood pressure, and high cholesterol as some of the most important risk factors for coronary heart disease. Now we know across the world from studies such as the INTERHEART which studied 52 different populations across the world that virtually all of the world has common risk factors for the heart attack. And by studying people with the first heart attack, they identified that smoking, abnormal fats, high blood pressure, diabetes, abdominal fat deposition, psychosocial risk factors, low intake of fruit and vegetables and lower levels of physical activity and variable intake of alcohol have all been responsible for 90% of the risk in populations across the world for the first heart attack. So much as we may differ in the manifestations of stroke and coronary heart disease at different stages of the epidemic, we recognize that the risk factors are fairly common across the world. And now we are also seeing new risk factors coming up in terms of their contribution being identified. For example we recognize that air pollution is an increasingly incriminated risk factor across the world. Previously this was not thought to be a problem for the heart, it was only thought to be a problem for the lungs. But now we know that air pollution can damage blood vessels everywhere in the body and can result in an increased risk of acute heart attack or even stroke. So we also have to look at other risk factors which are not conventional risk factors. For example, again, in the last 15 to 20 years we have come to recognize that low birth weight also is an important risk factor, particularly if there is a gain in weight between the ages of two and twelve in a low birth weight baby. So what we call rebound adiposity which means an increased amount of body fat at the expense of muscle can happen in such babies and this can set the stage for heart attacks and diabetes and strokes later on in life, especially in early adulthood. We now know that cardiovascular disease is the number one problem all across the world. But in terms of the economic impact, it has a very serious negative influence on developing countries because of the prematurity of deaths. As we know, most of the non-communicable diseases are killers at a younger age in the developing countries and this is true of cardiovascular disease as well. Indeed, about 80% of all cardiovascular deaths occur in the low and middle income countries and most of the premature deaths below the age of 65 years that occur because of cardiovascular disease globally are in these countries. So we have a huge loss of productivity. We have high healthcare costs. Indeed, as a cardiologist, I know that all affairs of the heart are expensive, not merely in the poetic sense. So, we now recognize that even as the epidemic advances most of the deaths in the developing countries are going to be occurring below the age of 70 years, especially below the age of 65 years. And in India for example, it has been estimated , we lost about 9.2 million potentially productive years of life because of premature cardiovascular deaths in the age group of 35 to 64 years and if the epidemic proceeds as projected, we will lose close to about 18 million potentially productive years of life in year 2030. This is 570% more than what the United States lost in the year 2000 and will be 900% more than what the U.S. will lose in that age band in terms of potential productive years by 2030. So developing countries cannot afford this hemorrhaging of human resources in midlife. When we look at what happens to individual families as well we see that many of them are pushed into poverty because they suffer catastrophic health expenditure. In China for example, about 37% of the patients who survive stroke were pushed into poverty and 62% of those without insurance went into poverty. This again brings into question not only the devastating economic effect on families, but also the whole health system issue of whether people have financial protection when they have a serious health problem, whether it’s a stroke or a heart attack. For example, in Kerala in India, we also observed that about 73% of those who survived a cardiovascular event had experienced catastrophic health expenditure. And 50% of them had distressed financing. That means they had to sell some part of their property. Forty percent of the patients who survived lost sources of income. And this again is essentially because of not only the high healthcare costs but because of lack of financial protection. So we not only need to prevent disease, but we also need to bring in universal health coverage in order to take care of people who do develop health problems. But prevention is absolutely the critical priority. And we look at both the population based strategy as well as the high risk strategy when addressing prevention through risk reduction. Now the population based strategy essentially says that the risk factor is distributed across the population. There is a rising gradient of risk at all levels of rising risk factors. So even if you have a blood pressure of 140, you are at a higher risk than a person with a blood pressure of 130 and that person is at a higher risk than a person with blood pressure of 120. So we try and bring about small shifts in the average risk factor levels of the population so that the cumulative benefits across the population are quite massive. But at the same time we try and identify individuals at a high risk, either because of a markedly elevated single risk factor or more commonly because of a combination of multiple risk factors which are modestly elevated. But together they add up to a huge amount of absolute risk. And therefore we try and focus our interventions in terms of therapy which could mean either change in living habits, of diet, giving up smoking, et cetera, or even addition of drugs in people with high risk. But bringing about changes for example in the salt consumption in a population or an increase in fruit and vegetable consumption in a population or increase in physical activity across a population can have huge benefits through population shifts and risk factors. Now even small reductions in the blood pressure, if they occur across a population can result in marked reductions in the number of strokes and heart attacks and the deaths because of those diseases across the population. It might not make much of a difference in terms of clinical management, but across the population, the benefits can be quite huge. And indeed, it has been shown by modeling studies across different countries where the risk factors as well as heart attack death rates have fallen, that more than 50% in most of the countries of the fallen death rates has been attributed to fallen risk factor levels. And less than 50% in most cases in attributable to treatments. We need both but certainly focusing on risk factor reduction through population wide strategies is absolutely a priority. And this is best illustrated by Finland, which in the early ’60s was the table leader in terms of coronary mortality across the world. And many of the people were dying young and therefore the government of Finland initiated a major study called the North Karelia Study in which a large number of behavioral shifts were brought about in the population, partly by changing the nature of the food consumption, including salt reduction in processed foods, increased production of berries instead of dairy products and so on. So a combination of policy and public education resulted over the next 20 years in a dramatic decline in the cardiovascular mortality rates in Finland, making it a sort of poster child for prevention in Europe and elsewhere in the world. And much of this could be attributed to shifts in the population levels of smoking, high blood pressure and cholesterol. Now the Finnish success story is remarkable indeed, between 1971 and 1995, cardiovascular mortality decreased in North Karelia by 73% and by example, the rest of Finland followed and across the nation, it declined by 65%. So we know great changes can be brought about by these kind of interventions at the population level. But at the same time we must recognize that poverty is a major barrier and that is where the problem is within populations of developed countries and also across populations in the low and middle income countries. We talked about the Barker hypothesis where children born malnourished are at a greater risk of cardiovascular disease in later life. And then as they grow up, poor people consume more of tobacco; they are forced to consume unhealthy diets. They have poor access to information and services. And in adult life, because they cannot access health services, onset of cardiovascular disease deprives them of appropriate healthcare, wage loss, job loss or even death, which affects their families. And in the elderly, if they’re uninsured, the high healthcare costs will have a huge out-of-pocket expenditure. We therefore need to act upon risk factors at various levels. And the important thing for us it to distinguish between how we look at risk. Most of the researchers will be looking at what’s called relative risk. That is, does a person who is exposed to a particular risk factor, what is the level of additional risk he or she has as compared to a person who is not exposed? Like a smoker versus a nonsmoker. But that does not tell you how widely prevalent that risk factor is in the population. Now if the risk factor has a high risk in terms of relative risk, but has low prevalence in the population, it does not require as energetic a policy response as a risk factor which has a modest relative risk, but is widely prevalent in the population. Smoking for example, therefore because smoking has a huge population attributable risk, because of its wide prevalence in the population, it requires a very strong policy response. Now there is also something called the absolute risk where multiple risk factors combine in an individual to raise the overall absolute risk of getting a heart attack. Therefore, you may have a person with modest elevation of blood pressure, a modest elevation of cholesterol, each of which may not carry much risk by itself at that level, but cumulatively they carry a huge risk. And particularly if you add smoking to the mix. So in terms of clinical decision-making, absolute risk becomes important. And public health also has to insure that health systems recognize the importance of absolute risk thresholds while managing patients in health system practice. So relative risk for research, absolute risk for clinical decision-making thresholds and population attributable risk for policy. All three are important instruments in public health. And if we actually look at risk factors as the major areas for intervention, we will be able to prevent cardiovascular disease across the population. Remember, today’s risk behaviors are tomorrow’s risk factors. Today’s risk factors are tomorrow’s heart attacks and strokes. So we need to promote healthy behaviors. We need to detect risk factors early and reduce them before they go on to fatal heart attacks or strokes anywhere in the world.