Global Health Governance | Inside the Issues 5.19



today on inside the issues i speak with jeff stir chew on the subject of global health governance hello and welcome to this week's edition of inside the issues a cg online podcast my name is dr. Andrew Thompson I'm an adjunct assistant professor of political science at the University of Waterloo and senior fellow here at the Center for international governance innovation every week on the show we're joined by an expert in global governance international public policy or some other aspect of International Affairs here to the studio in Waterloo today my guest is Jeffster Cho he is the president and CEO of rape and Martin a health consultancy firm based in New York he's also the president our former president and CEO of the Global Health Council based in Washington welcome to the show my pleasure Jeff I wonder if we could start could you just say a little bit about Rabin Martin sure what is its mandates who are your clients etc yeah we're a global health consulting firm focusing on strategy and we look at a range of issues from everything from specific issues like maternal mortality and hiv/aids – you know how companies and foundations can do a better job of using the resources they have to improve health outcomes particularly for underserved populations and how long has Raven Martin been around about 12 years okay and what are some of the burning issues in the u.s. that that you're consulting on right mhm well I think you know our our practice is really more focused on on work outside the US but we do do some work in the US and I think that you know certainly our focus has been on the great disparities in care among different populations now which is something that most people who follow what happens in the US healthcare system would agree is is a major issue right now New York Times has reported on several occasions that despite a fairly rocky start Obamacare has actually performed quite well and perhaps even better than most people expected is that a fair assessment well I'm no expert but I you know I certainly have an opinion on that as most people do you know I think it's it's clear actually just recently the Congressional Budget Office had some new new figures on the estimate of how much the Affordable Care Act is going to cost over the next five years and so one one indicator of how well it's working is that that estimate is now about one-third less than it was when the Affordable Care Act was passed in March of 2010 so the estimate now is that it will cost about five hundred and six billion dollars over the next five years another important indicator of of how well it's working is that nearly twelve million people have signed up for health insurance right and that's made a big dent in the you know in the uncovered population in the US which has been a major challenge for the US healthcare system for years and you know so those show that you know as was originally predicted that that the Affordable Care Act would bend the cost curve over my the other coming years and so that seems to be happening from the indicators that we have and yet from day one it has been under attack where's all of this opposition coming from what is it rude in it well you know there there are a number of ways that you can look at this you know one is some of it is simply well it's hard to understand let's put it that way you know you one often hears the criticism that people want you know particularly elderly people who are happy with Medicare want the Obama administration to keep their hands off my Medicare but you know that doesn't make a lot of sense because Medicare is a government program right you know and by all accounts most people are happy with the way it's working you know I think partly the opposition aside from the political issues and I you know I'm really as I said I know expert in all of that but it seems that some of the Opposition is simply political it came from a Democratic administration the Republicans would like to have a different approach but part of it is just because the US healthcare system is so enormous and so intertwined with all parts of the economy and because the US population is generally conservative with a small see that is change is difficult to accept sure just the notion of completely reengineering the healthcare system that affects just about everyone is something that you know people are understandably nervous about but as I said you know the evidence so far seems to be that it's working well and there are a lot of things that people actually like about about Obamacare if you look at the surveys that have been done of the you know the general population if you ask questions about things that you know if you ask people in your you know in in your health care insurance would you like to have your children on the plan until they're the age 26 people overwhelmingly say yes if you ask them you know would you like to have insurance in which there's no lifetime cap on your benefits they overwhelmingly say yes if you ask them would you like to have insurance in which there's no within which there's a prohibition against exclusion for pre-existing conditions they overwhelmingly say yes if you ask them are you in favor of Obamacare you know the the opinion is mixed but all of those examples I've given our elements of Obamacare so you know it's just in part it's you know I think that people just lack information and as I said they're anxious about something that's so important for their families right but I I think what's happening and yes other observers have made this point as well is that as people see that millions of people are getting insurance who didn't have insurance before they see that the subsidies are working to make it more affordable they see that they are getting you know coverage for pre-existing conditions and their kids can stay on their plan for longer that the you know dire predictions about how insurance premiums were going to explode none of that's come true but they are getting better access to health care coverage you know I think over time the the opposition will decline and people who are happy with with the results will increase right I'm moving beyond the North American context globally what are the big health issues that we as a global community are facing right now well there are you know it's interesting to to pose the question in that way because you know the challenges we face in global health are so varied and and so daunting in some ways right the that often people will just focus on one or their particular topic of interest to them or that there were most concerned about I think overall the big challenge is that if you look at a planet that has seven billion people and still a couple of billion people living in extreme poverty the biggest challenge is what are we going to do to ensure that all seven billion people have access to you know a basic package of care right and that's really the the impetus behind or the the issue behind the move to universal health coverage which the UN adopted as a an aspiration a couple of years ago and which countries are now in the process of of working toward you know in Canada of course you know you've had universal health coverage with a single-payer system for some time that's right so you know this is you know Canada the National Health Service and the UK these are some of the models that you know that policymakers have been looking at now of course the challenge and this gets back to the big issue is that you know most countries where the seven billion people live don't have the level of resources right that a Canada or the UK have and and also let's face it you know you're just talking about Obamacare in the u.s. so one of the wealthiest countries in the world hasn't been able to achieve universal health coverage so you have to ask yourself well how well other countries do it and I think that you know partly it will be through defining a package of care that is you know what kinds of conditions will be covered how much will they be covered you know will there be access to different kinds of surgery as well as treatment for chronic disease and you know they're a whole range of conditions but it really requires a complete sea change in the way in which politicians and policymakers think about the obligations and responsibilities they have to the populations who put them in office and how they're going to do the best job they can with the resources available of getting maximum health for the money that that they can invest and to what extent are the current global institutions that deal with health and I would include foundations that category as well to what extent are they able to help state governments provide or deliver this basic level of care anew well it's you know this is a really complex and sort of messy problem it really is because you know we're just think of the challenge you've got you know billions of people around the world many of them most of them in fact living in countries with relatively relatively straightened economic resources and then you know others in countries like China and India where you know 2/7 of the world population live you know have extreme disparities in what the wealthy versus the poor are able to do my own as as you know it's often been observed there are more poor people in in emerging markets and wealthy countries now than there are in in poor countries or developing countries so that remains a challenge for the global system and so what's happening now is that people are trying to get a handle on you know what do the challenges look like in individual countries what resources do they have available and where can they get help both in terms of technical assistance and and you know foreign assistance to help meet the gap between what they're able to provide now and what their population actually needs and at the same time there's been a change a concomitant change in the way in which global institutions look at governing the system of provision of health care so you know let's just go back to when the the World Health Organization was was instituted in the late 1940s right that was a world in which you had the World Health Organization as the central institution for providing you know both normative standards and technical assistance in global health and its budget was commensurate with the challenges that faced and they tended to deal with other with governments it was largely an intergovernmental organization and you know that's the sort of world we had back in the late 1940s now if you fast-forward to now the World Health Organization it's gone undergoing its own reform process but what's become clear is and we saw this in the Ebola outbreak in West Africa recently what's become clear is that the World Health Organization has such has expanded its mandate or I should say the member states have expanded its mandates so much over the last few decades that they don't have anywhere near the resources they need to achieve all the things they've been asked to do and at the same time the landscape has changed dramatically because if you look at you know the the resources available the money available for global health you know countries themselves don't or in the developing world in emerging markets don't actually provide all of the money that they need by themselves from domestic resources so you have tremendous flows of billions of dollars every year from donor countries but now what's interesting is that the financial flows are not just from donor countries so this you know the notion that you know had a world in which you had donor countries and recipient countries and that together with the domestic resources of recipient countries you could cover all the issues that he needed to you know now you've got for instance a world in which remittances from populations who have left developing countries to go live in the north are greater than the flow of official development assistance and in which for instance you now have an institution like the Gates Foundation which has a budget for its grants every year which is greater than the assessed contributions of the of the World Health Organization and and at the same time you've also got a proliferation of other institutions that are doing parts of the work that we're left decades ago to the World Health Organization and governments right so you have public-private partnerships you have you know like the Global Alliance for vaccines and immunization the Global Fund Against AIDS TB and malaria the Stop TB partnership the roll back malaria partnership they're just literally dozens of these organizations that are taking over aspects of the work that used to be done just by governments and the World Health Organization you know and I'm just speaking about global health right now so what hasn't happened you know at the same time that we have this gap between the aspiration the governments have to provide universal health coverage for the seven billion people on the planet and the and the available resources you also have a challenge in that we haven't figured out how this new complex network of public/private organizations nongovernmental organizations foundations and public-private partnerships is actually going to coordinate its efforts to actually achieve the results we like to see which is to really you know let me just stop there for a minute because I lost the word sure you know what what we have is we haven't figured out how those complex new organizations are going to coordinate their work to erase the gap between what those who need health care coverage actually have and what they need right so it you know it's just as I said before it's you know it's what some economists and and others call a wicked problem all right because it's just so complicated it's hard to see what the solution is well and perhaps we could focus a little bit on this question of public-private partnerships now you've been involved with one very successful one in Botswana the a chap initiative could you say a little bit about this sure sure I you know I think that you know there have been literally hundreds of public/private partnerships in health developed over the last 20 years and the the one the project in Botswana that you you mentioned was one I was involved in when I used to work for Merck sharpened doma a large pharmaceutical company it's known as Merck frost here in Canada right and the the idea this was set up in 2000 the idea was at the time that we looked at at setting up this partnership countries in Africa were really facing you know a an extremely challenging future with respect to the AIDS epidemic which seemed at the time frankly to be out of control right you know there were tens of millions of people infected the number of infections was increasing every year deaths from AIDS were increasing every year and there were you know some efforts to deal with it led by you and AIDS but it just seemed that that African countries weren't getting much traction in actually addressing prevention of new infections as well as treatment of those who are already infected and and you know by that time pharmaceutical companies in around 2000 had begun to come up with triple combination therapy that actually provided the prospect of long term treatment that could turn aids into a chronic disease from what was essentially a death sentence but still you know the available resources were out of sync with where the problem was and there was a lack of coordination of all the different efforts that were being made to address parts of the problem so I was at MSD at the time and we thought what if you went to a country and Botswana was the country we chose in part because at the time it had the highest prevalence rate among adults of any country in the world we said what if you went to a country like Botswana and said instead of just dealing with you know focusing on prevention instead of just trying to ensure that more people get antiretroviral treatment what if you dealt with the entire spectrum of issues in prevention care treatment of HIV and AIDS and that would go from stigma and discrimination at the community level to ensuring that people change their behavior and engaged in less risky sexual practices that the government actually was testing people to find out who had HIV and then was making the appropriate treatment resources available and we also thought that it would be useful to work together with the government and also with another partner who could bring other resources and expertise to bear on this and so we went to the Gates Foundation and asked them if they would be interested in collaborating and so this program was set up in 2000 the Gates Foundation and and Merkin company each put in 50 million dollars and the idea was over the next ten years let's try this comprehensive approach to HIV prevention care and treatment in Botswana and the results were you know now this this idea of taking a comprehensive approach of partnerships in the fight against AIDS is something that's become commonplace right you know PEPFAR the u.s. president's emergency program for AIDS relief which is now treated something like seven million people for HIV and AIDS in the countries that it's focused in you know has something like 700 partnerships with private sector entities and others in different aspects of what they've been doing in Africa and elsewhere world so now it's become a common approach but then this was really the only example you could point to in which a government a foundation and the company were collaborating to try to really change the course of the epidemic in in Botswana and the results have been dramatic Botswana was the first country in Africa to reach universal coverage which was a a major goal of the 3×5 initiative the World Health Organization at the time that we started something like two out of five babies born to HIV positive mothers were HIV positive but now they have almost universal coverage for prevention of maternal fetal transmission and the percentage of babies born hiv-positive has gone from 40 percent to less than 4% Wow really a dramatic change and you know I there are a number of other indicators like that but you know this this approach of bringing together public and private partners you know with the government leading the way you know it was really the government's strategic plan for how to deal with HIV the Botswana government it's not a good job of coordinating its development partners in this and PEPFAR was a major focus yeah I mean there are plenty of of actors who were we're partners in this but you know that partnership really was the catalyst that led to those outcomes and I think it's it shows how powerful that kind of partnership can be because working together you know the government of Botswana wasn't able to solve this problem on its own right and working together with the Gates Foundation and Merck and many other partners they were able to bring together the complementary skills and resources that were needed to really make a difference right well I wonder if we could maybe talk about indicators for a few moments and could you say a little bit about the global burden of disease report the one that came out in in 2013 and what it tried to measure and and perhaps some of its findings yeah well it you know you're referring to the Lancet Commission report called Global Health 2035 and you know that was based on an analysis of a really remarkable database that the Institute for Health metrics and evaluation at the University of Washington has constructed over over the past few years which they look at you know something close to 200 different conditions and in you know every country in the world basically and are trying to get a sense of you know what are the trends what are people dying from what are the greatest sources of morbidity and my you know really to get a sense of you know what's the evidence base for what needs to be done to improve global health around the world and in global health 2035 the argument that they made was that with with greater concentration on a relatively small number of interventions we could actually make it possible by 2035 for there to be a what they called a grand convergence between the state of health in developed countries in the state of health and developing countries okay and one of the reasons for this is that although there's been a lot of attention in the past couple of decades to infectious disease like HIV AIDS TB and malaria actually the global burden of disease is one in which the majority of the deaths actually come from chronic diseases or what are known as non communicable diseases and the four major non communicable diseases are diabetes respiratory disease cardiovascular disease and different forms of cancer right and so it used to be that people thought that if you lived in a developing country you died of AIDS TB or malaria or other infectious diseases and if you lived in a country like Canada or the United States you might die of a heart attack or breast cancer or lung cancer or you know some other chronic condition but the fact is that what's happened is there's been a demographic transition in the last several decades in which the you know infectious disease is still a problem but there's been so much effort to deal with infectious disease that no HIV infections are now declining rather than increasing millions fewer people are dying from malaria than used to die from malaria you know there so there's been progress in those areas but at the same time the countries that have had a heavy burden of disease infectious disease such as countries in sub-saharan Africa have an equally heavy burden of chronic disease now so that and and because the resources haven't been into chronic disease in the way that they have a new infectious disease what you have are increasingly large disparities and outcomes you know for instance if a child in Canada has leukemia they have a something like a ninety percent chance of living to the age of five the child in most of Africa has leukemia their chance of you know is something like five percent of my living to the you know they have a 90 percent chance of dying before the age of five so you know in those disparities are just becoming even starker as we understand more about the impact and the burden of these chronic conditions and in in developing countries and emerging markets now right now something like three fifths of deaths around the world or caused by chronic conditions and and of those sixty percent of deaths around the world four out of five are in developing countries so it just shows how that burden is distributed and and I think you know the challenge now is to figure out how we can reorient the resources that have been going to other areas you know the estimate there was an estimate a couple of years ago from the center and global development that only about three percent of all of the work excuse me all of the money that has goes to health for through overseas or official development assistance only about three percent of that was for chronic disease and all the rest was for other things you know that you know all of which are important but but when you look at the burden of disease there really needs to be a reorientation and of course these chronic diseases also have implications for economic development it's not just that they caused morbidity and mortality among populations but David bloom from Harvard and some colleagues did an estimate a few years ago that suggested that between now and 2030 the global economy would have something like 47 trillion dollars in economic losses if the burden of chronic disease wasn't dealt with more effectively you know and a large part of that comes from mental health which actually wasn't even included in the the core chronic diseases when the w-h-o you know took a look at this and began to establish programs to really address non communicable diseases in the aftermath of the 2011 high-level meeting on non communicable diseases of the UN when this was taken on as a as a global priority so there's you know there just is a lot that is still left to be done the good news you know so I don't want this to sound completely bleak right the good news is that many of these chronic diseases are preventable and so if we simply do a better job of encouraging people to change behaviors to exercise more not to smoke not to abuse alcohol and and also to eat well and you know just not eat junk food all the time but but have more healthy diets a large part of that burden of disease can be avoided right and so and and you know the other part the reason that that's good news is that it doesn't actually cost as much to persuade people to change their behaviors as it does to treat the outcomes of you know of those behaviors left unchecked so it you know of course there's still part of that burden that can't be avoided just because of these behaviors but a large chunk of it can and so you know and in fact to get back to the question you posed about global health 2035 the report in The Lancet their conclusion is that the single biggest thing that could be done to improve the outcomes and to actually encourage movement toward that grand convergence in which developing countries and developed countries will both have you know healthier populations is to really press the the need to regulate tobacco more effectively and to implement the recommendations of the Framework Convention on tobacco control and that alone would have a dramatic impact on health outcomes around the world right I wonder if we might end off by focusing on the health story that probably got the most attention in 2014 and continues to be an ongoing crisis and that's the Ebola crisis of that that hit West Africa is it too soon to draw some lessons from that experience and the global response to that particular in crisis well you know I think there are some lessons that beetron and you know again I you know I don't want to presume to present myself as an expert on all this I haven't been in West Africa recently and I wasn't directly involved in any of the response but you know just in in following closely what happened and in reflecting on this in the context of you know these issues that that we've been working on over the last couple of decades you know I think there there are a few key conclusions one is and and this is actually analogous to the point I was just making about prevention in global health you know had had the w-h-o and the rest of the global community mobilized sooner the the human consequences of that outbreak would not have been as great you know it was the first cases occurred at the very end of 2013 it wasn't until August of 2014 that the w-h-o declared it an international health emergency and then you know within a couple of months of that declaration all of a sudden you know you had the u.s. sending 3000 troops you had the UK and France and others carry counts you know yeah exactly you know it was taken so it really was taken up then as a priority and and you know I don't want to denigrate the progress that was made because you know at that time in August in September of last year people were were predicting that there might be as many as a million people effective or more than a million people affected in those in that region and that you know those predictions never came true that you know because the number of people affected was you know in the tens of thousands and and that was as a consequence of actually taking those actions and implementing you know some of the basic public health precautions that were required for an epidemic outbreak like that so that's one thing that you know had had action been mobilized sooner the the course of the outbreak might have been handled more efficiently and with with fewer people dying in the end but the the second thing is that you know the experts who have been looking at this and that involves you know people like David Nabarro who let the UN's response and Tom Frieden the head of CDC and in in the u.s. Peter Piot who was one of the co discoverers of the Ebola virus and who has been active in in thinking about how to improve the response to this outbreak and many others is that you know there were certain basic public health precautions that that the public health community has known about for years in which you know you isolate the people who are who are infected you trace their contacts and then make sure that you've monitor those contacts you know for the 21 days to see if they've actually developed Ebola and you know had that been done more systematically again it you know it probably would have even moderated the outbreak but the challenge was that and then this is the third the third point that the health infrastructures in the countries that were most directly affected Guinea Sierra Leone and Liberia were really there's no easy way to say this they were very weak because you know of all you know because of conflict situations and they were still you know the economies were recovering the government was recovering the society in general was recovering from years of conflict in some cases and let's face it these are still relatively poor countries so they simply didn't have the kind of health care infrastructure that that you know that would have been required to implement those public health measures and then also you know this this legacy of conflict and and having weak governments in in recent years also led people you know the population to be skeptical and sometimes hostile to the government and so you know and you know there's even been analysis of the outbreak being in in parts of the country in in these countries where opposition politicians you know came from and so the government you know some people have argued that the government's may not have moved as quickly as they might have otherwise you know I don't know if you know how how much credence to put in those kinds of rumors but but the point is that you know you had weak health care infrastructure you had governments that were just barely hanging on you know because of the impact of the outbreak and then you have this residual kind of skepticism and even hostility toward government action so so that kind of is a is just a recipe for disaster you know but but again the bright side is that you know now Liberia appears to be Ebola free you know the the number of infections has been declining over the past couple of months in in Guinea in Sierra Leone and it looks like the you know the help that the the global community has been able to give to those three countries has turned the tide on the epidemic but the the and also I should say that you know there's been a really dramatic effort on the part of a number of pharmaceutical companies including Merck Sharp and dome and GlaxoSmithKline and and Janssen to put new candidate Ebola vaccines into clinical trial right much more rapidly than has has usually been done you know and that's been a result of collaboration with the w-h-o and with regulatory authorities around the world I just read that the The Merck vaccine candidate is going to go into Phase three trials and Guinea fairly soon so right so that's moving along very quickly and you know hopefully that will lead to vaccines that will be helpful for the next the next outbreak sure but I think the other lesson to be learned from this is that you know there have been a Ebola outbreaks regularly in Africa over the last several years and this one was different in that it was the first time that it actually came in to urban populations but you know there's probably I strive masa Giwa who's the head of Econet Wireless and has been he's special envoy for the African Union on the business response to Ebola in Africa you know he he observed when I had a chance to talk to him recently that there's probably another Ebola outbreak in Africa right now you know it just hasn't come to light yet it probably is in some you know far you know some rural area which is more you know more a traditional route for the outbreaks to to happen but the lesson that we have to learn is next time we have to be prepared to apply the lessons of this Ebola outbreak right Jeff this has been absolutely fascinating thank you so much for joining us thank you and thank you to our audience you've been watching or listening to inside the issues the CGT online podcast look for us online at cg online org on facebook on youtube

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