Priority actions for the non-communicable disease crisis

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Global health philanthropy and institutional relationships: how should conflicts of interest be addressed?

David Stuckler and colleagues examine five large private global health foundations and report on the scope of relationships between these tax-exempt foundations and for-profit corporations including major food and pharmaceutical companies.

Does recession reduce global health aid? Evidence from 15 high-income countries, 1975-2007

OBJECTIVE

To test the hypothesis that economic recessions lead to reduced global development assistance for health (DAH).

METHODS

Data obtained from the Creditor Reporting System of the Organisation for Economic Co-operation and Development (OECD) for 15 OECD countries were used to model the percentage change (relative difference) in commitments and disbursements for DAH as a function of three measures of economic recession: recessionary year (as a dummy variable with 0 for no recession and 1 for recession), percentage change in per capita gross domestic product and percentage point change in unemployment rate for recessionary cycles from 1975 through 2007. We looked for an association both during the concurrent recessionary year and one and two years later.

FINDINGS

No statistically significant association was found in the short or long run between measures of economic recession and the amount of official DAH committed or disbursed.

CONCLUSION

Any important decrease in overall DAH following the current economic recession would have little historical precedent and claims of inevitability would be unjustifiable.

Addressing institutional amplifiers in the dynamics and control of tuberculosis epidemics

Tuberculosis outbreaks originating in prisons, mines, or hospital wards can spread to the larger community. Recent proposals have targeted these high-transmission institutional amplifiers by improving case detection, treatment, or reducing the size of the exposed population. However, what effects these alternative proposals may have is unclear. We mathematically modeled these control strategies and found case detection and treatment methods insufficient in addressing epidemics involving common types of institutional amplifiers. Movement of persons in and out of amplifiers fundamentally altered the transmission dynamics of tuberculosis in a manner not effectively mitigated by detection or treatment alone. Policies increasing the population size exposed to amplifiers or the per-person duration of exposure within amplifiers potentially worsened incidence, even in settings with high rates of detection and treatment success. However, reducing the total population size entering institutional amplifiers significantly lowered tuberculosis incidence and the risk of propagating new drug-resistant tuberculosis strains.

Health care capacity and allocations among South Africa's provinces: infrastructure-inequality traps after the end of apartheid

OBJECTIVES

We assessed the determinants of health care funding allocations among South Africa's provinces and their effects on health care from 1996 through 2007.

METHODS

We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province.

RESULTS

Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (b(private) = 0.12; 95% confidence interval [CI] = 0.08, 0.15), but public hospital density in the preceding year was not (b(public) = 0.05; 95% CI = -0.02, 0.11). Greater allocations were associated with a higher number of doctors (b = 0.54; 95% CI = 0.34, 0.75) but fewer nurses (b = -0.37; 95% CI = -0.72,-0.25) in the same year.

CONCLUSIONS

Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure-inequality trap, in which the distribution of funds to those with greater "absorptive capacity" exacerbates inequalities.

The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence

There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment. The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the "SIR" (susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses by governments. Like other emergencies and natural disasters, preparedness for financial crises should include consideration of consequences for communicable disease control.

International Monetary Fund and Aid Displacement

Several recent papers find evidence that global health aid is being diverted to reserves, education, military, or other sectors, and is displacing government spending. This is suggested to occur because ministers of finance have competing, possibly corrupt, priorities and deprive the health sector of resources. Studies have found that development assistance for health routed to governments has a negative impact on health spending and that similar assistance routed to private nongovernmental organizations has a positive impact. An alternative hypothesis is that World Bank and IMF macroeconomic policies, which specifically advise governments to divert aid to reserves to cope with aid volatility and keep government spending low, could be causing the displacement of health aid. This article evaluates whether aid displacement was greater when countries undertook a new borrowing program from the IMF between 1996 and 2006. As found in existing studies, for each $1 of development assistance for health, about $0.37 is added to the health system. However, evaluating IMF-borrowing versus non-IMF-borrowing countries reveals that non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. It is important to take account of the political economy of global health finance when interpreting data on financial flows.

Responding to the economic crisis: a primer for public health professionals

Does the current economic crisis require the deep cuts in public spending announced in the June 2010 emergency budget, with potential implications for public health? The arguments for and against such cuts in response to economic recession are complex, but if public health professionals are to engage in debates about future public spending, they should be informed by relevant evidence. In this perspective, we note that opinions among politicians and economists about how to respond to economic downturns are divided, while other EU countries, many with greater levels of debt than the UK, are protecting public expenditure unless required to do so by the International Monetary Fund. Current UK debt may in fact be viewed as sustainable given current information about interest rates, inflation and economic growth. Before accepting large cuts in public spending, it is important to contrast the lack of evidence for such short-term fixes with potentially dire repercussions for population health and welfare.

Raising the priority of preventing chronic diseases: a political process

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

Financing the Millennium Development Goals for health and beyond: sustaining the 'Big Push'

Many of the Millennium Development Goals are not being achieved in the world's poorest countries, yet only five years remain until the target date. The financing of these Goals is not merely insufficient; current evidence indicates that the temporary nature of the financing, as well as challenges to coordinating its delivery and directing it to the most needy recipients, hinder achievement of the Goals in countries that may benefit most. Traditional approaches to providing development assistance for health have not been able to address both prevalent and emergent public health challenges captured in the Goals; these challenges demand sustained forms of financial redistribution through a coordinated mechanism. A global social health protection fund is proposed to address recurring failures in the modern aid distribution mechanism. Such a Fund could use established and effective strategies for aid delivery to mitigate many financial problems currently undermining the Millennium Development Goals initiative.

Mining and risk of tuberculosis in sub-Saharan Africa

OBJECTIVES

We estimated the relationship between mining and tuberculosis (TB) among countries in sub-Saharan Africa.

METHODS

We used multivariate regression to estimate the contribution of mining activity to TB incidence, prevalence, and mortality, as well as rates of TB among people living with HIV, with control for economic, health system, and population confounders.

RESULTS

Mining production was associated with higher population TB incidence rates (adjusted b = 0.093; 95% confidence interval [CI] = 0.067, 0.120; with an increase of mining production of 1 SD corresponding to about 33% higher TB incidence or 760,000 more incident cases), after adjustment for economic and population controls. Similar results were observed for TB prevalence and mortality, as well as with alternative measures of mining activity. Independent of HIV, there were significant associations between mining production and TB incidence in countries with high HIV prevalence (≥ 4% antenatal HIV prevalence; HIV-adjusted B = 0.066; 95% CI = 0.050, 0.082) and between log gold mining production and TB incidence in all studied countries (HIV-adjusted B = 0.053; 95% CI = 0.032, 0.073).

CONCLUSIONS

Mining is a significant determinant of countrywide variation in TB among sub-Saharan African nations. Comprehensive TB control strategies should explicitly address the role of mining activity and environments in the epidemic.

An evaluation of the International Monetary Fund's claims about public health

The International Monetary Fund's recent claims concerning its impact on public health are evaluated against available data. First, the IMF claims that health spending either does not change or increases with IMF-supported programs, but there is substantial evidence to the contrary. Second, the IMF claims to have relaxed strict spending requirements in response to the 2008-9 financial crisis, but there is no evidence supporting this claim, and some limited evidence from the Center for Economic Policy Research contradicting it. Third, the IMF states that wage ceilings on public health are no longer part of its explicit conditionalities to poor countries, as governments can choose how to achieve public spending targets; but in practice, ministers are left with few viable alternatives than to reduce health budgets to achieve specific IMF-mandated targets, so the result effectively preserves former policy. Fourth, the IMF's claim that it has increased aid to poor countries also seems to be contradicted by its policies of diverting aid to reserves, as well as evidence that a very small fraction of the Fund's new lending in response to the financial crisis has reached poor countries. Finally, the IMF's claim that it follows public health standards in tobacco control contrasts with its existing policies, which fail to follow the guidelines recommended by the World Bank and World Health Organization. The authors recommend that the IMF (1) become more transparent in its policies, practices, and data to allow improved independent evaluations of its impact on public health (including Health Impact Assessment) and (2) review considerable public health evidence indicating a negative association between its current policies and public health outcomes.

Is wealthier always healthier? The impact of national income level, inequality, and poverty on public health in Latin America

Despite findings indicating that both national income level and income inequality are each determinants of public health, few have studied how national income level, poverty and inequality interact with each other to influence public health outcomes. We analyzed the relationship between gross domestic product (GDP) per capita in purchasing power parity, extreme poverty rates, the gini coefficient for personal income and three common measures of public health: life expectancy, infant mortality rates, and tuberculosis (TB) mortality rates. Introducing poverty and inequality as modifying factors, we then assessed whether the relationship between GDP and health differed during times of increasing, decreasing, and decreasing or constant poverty and inequality. Data were taken from twenty-two Latin American countries from 1960 to 2007 from the December 2008 World Bank World Development Indicators, World Health Organization Global Tuberculosis Database 2008, and the Socio-Economic Database for Latin America and the Caribbean. Consistent with previous studies, we found increases in GDP have a sizable positive impact on population health. However, the strength of the relationship is powerfully influenced by changing levels of poverty and inequality. When poverty was increasing, greater GDP had no significant effect on life expectancy or TB mortality, and only led to a small reduction in infant mortality rates. When inequality was rising, greater GDP had only a modest effect on life expectancy and infant mortality rates, and no effect on TB mortality rates. In sharp contrast, during times of decreasing or constant poverty and inequality, there was a very strong relationship between increasing GDP and higher life expectancy and lower TB and infant mortality rates. Finally, inequality and poverty were found to exert independent, substantial effects on the relationship between national income level and health. Wealthier is indeed healthier, but how much healthier depends on how increases in wealth are distributed.

Drivers of inequality in Millennium Development Goal progress: a statistical analysis

BACKGROUND

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.

METHODS AND FINDINGS

We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15-49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.

CONCLUSIONS

Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

The International Monetary Fund's effects on global health: before and after the 2008 financial crisis

In April 2009, the G20 countries committed US $750 billion to the International Monetary Fund (IMF), which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries, but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs. These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books. In practice, they often translate into reductions in social spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies, there is a need to establish what we know and do not know about the IMF's effects on global health. This article introduces a series in which contributors review the evidence on the relationship between the IMF and public health and discuss potential ways to improve the Fund's effects on health. While more evidence is needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated with weakened health care systems, reduced effectiveness of health-focused development aid, and impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and limiting progress toward the health Millennium Development Goals.

Rapid large-scale privatization and death rates in ex-communist countries: an analysis of stress-related and health system mechanisms

During the transition to capitalism, the postcommunist countries have experienced devastating rises in mortality, although there has been considerable variation within and between countries and regions. Much of this population-level variation remains unexplained, but alcohol and psychological stress are found to be major proximal causes of rising mortality rates. The authors show that implementation of neoliberal-inspired rapid, large-scale privatization programs ("mass privatization") was associated with significant declines in life expectancy, as well as with greater alcohol-related deaths, heart disease, and suicide rates. The authors interpret these findings as evidence that rapid organizational reform created excess psychosocial stress, which, consistent with the public health literature, increases risk of death at the individual level. However, they also find that rapid privatization modestly contributed to a decline in health care resources, such as the number of physicians, dentists, and hospital beds per capita, although there is weak evidence that these reductions in health system capacity explain substantial differences in mortality at the country level.