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Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.
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BACKGROUND: Covid-19 has reinforced health and economic cases for investing in pandemic preparedness and response (PPR). The World Bank and World Health Organization (WHO) propose that low- and middle-income governments and donor countries should invest $31.1 billion each year for PPR. We analyse, based on the projected economic growth of countries between 2022 and 2027, how likely it is that low- and middle-income country governments and donors can mobilize the estimated funding. METHODS: We modelled trends in economic growth to project domestic health spending by low- and middle-income governments and official development assistance (ODA) by donors for years 2022 to 2027. We modelled two scenarios for countries and donors - a constant and an optimistic scenario. Under the constant scenario we assume that countries and donors continue to dedicate the same proportion of their health spending and ODA as a share of gross domestic product (GDP) and gross national income (GNI), respectively, as they did during baseline (the latest year for which data are available). In the optimistic scenario, we assume a yearly increase of 2.5% in health spending as a share of GDP for countries and ODA as a share of GNI for donors. FINDINGS: Our analysis shows that low-income countries would need to invest on average 37%, lower-middle income countries 9%, and upper-middle income countries 1%, of their total health spending on PPR each year under the constant scenario to meet the World Bank WHO targets. Donors would need to allocate on average 8% of their total ODA across all sectors to PPR each year to meet their target. CONCLUSIONS: The World Bank WHO targets for PPR will not be met unless low- and middle-income governments and donors spend a much higher share of their funding on PPR. Even under optimistic growth scenarios, low-income and lower-middle income countries will require increased support from global health donors. The donor target cannot be met using the yearly increase in ODA under any scenario. If the country and donor targets are not met, the highest-impact health security measures need to be prioritized for funding. Alternative sources of PPR financing could include global taxation (e.g., on financial transactions, carbon, or airline flights), cancelling debt, and addressing illicit financial flows. There is also a need for continued work on estimating current PPR costs and funding requirements in order to arrive at more enduring and reliable estimates.
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COVID-19 , Países em Desenvolvimento , Desenvolvimento Econômico , Modelos Econômicos , Pandemias , Humanos , COVID-19/economia , COVID-19/epidemiologia , COVID-19/prevenção & controle , Pandemias/economia , Saúde Global , Produto Interno Bruto , Gastos em Saúde/tendências , Gastos em Saúde/estatística & dados numéricos , Preparação para PandemiaRESUMO
Background: Cardiovascular diseases (CVD) remains a leading cause of mortality in Myanmar. Despite the burden, CVD preventive services receive low government and donor budgets, which has led to poor CVD outcomes. Methods: We conducted a cost-effective analysis and a budget impact analysis on CVD prevention strategies recommended by the WHO. A Markov model was used to analyse the cost and quality-adjusted life year (QALY) from healthcare provider and societal perspectives. We calculated transition probabilities from WHO CVD risk data and obtained treatment effects and costs from secondary sources. Subgroup analysis was performed on different sex and age groups. We framed the budget impact analysis from a healthcare provider perspective to assess the affordability of providing CVD preventive care. Findings: The most cost-effective strategy from the healthcare provider perspective varied. The combination of screening, primary prevention, and secondary prevention (Sc-PP-SP) (incremental cost-effectiveness ratio [ICER]: US$1574/QALY) is most cost-effective at the three times gross domestic product (GDP) per capita threshold, while at one time the GDP per capita threshold, secondary prevention is the most cost-effective strategy (ICER: US$160/QALY). Sc-PP-SP is the most cost-effective strategy from the societal perspective (ICER: US$647/QALY). Among age groups, intervention at age 45 years appeared to be the most cost-effective option for both men and women. The budget impact revealed the Sc-PP-SP would avert 55,000 acute CVD events and 28,000 CVD-related deaths with a cost of US$157 million for the first year of CVD preventive care. Interpretation: A combination of screening, primary prevention, and secondary prevention is cost-effective to reduce CVD-related deaths in Myanmar. This study provides evidence for the government and development partners to increase investment in and support for CVD prevention. These findings not only provide a basis for efficient resource allocation but also underscore the importance of adopting a total cardiovascular risk approach to CVD prevention, in alignment with global health goals. Funding: Pilot grant from Duke Global Health Institute, USA.
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BACKGROUND: When countries reach the middle-income threshold, many multilateral donors, including Gavi, the Vaccine Alliance (Gavi), begin to withdraw their official development assistance (ODA), known as graduation. We hypothesised that bilateral donors might follow Gavi's lead, except in countries where they have strategic interests. We aim to understand how bilateral donors behave after a recipient country graduates from Gavi support and how bilateral donors might treat Gavi support countries differently, based on 'strategic interest'. We also aim to identify countries that were more vulnerable to 'simultaneous' transitions and financial cliffs after Gavi transition. METHODS: This is an observational dyadic analysis using longitudinal data. We collected country-level data on 77 Gavi-eligible countries between 2009 and 2018 and paired donor and recipient country in a specific year to conduct dyadic analysis. We included Gavi graduation status and Gavi disbursement as explanatory variables. We controlled for (1) donor-recipient relationship variables that represent potential strategic relationships (eg, distance between donor and recipient country) and (2) recipient-level characteristics (eg, population, income). We used Odinary Least Squares regression, Tobit and two-part model in Stata SE 15.0. FINDINGS: We found a country would receive $3.1 million less all sector ODA from a bilateral donor, and $0.6 million less health ODA, after they graduate from Gavi. For every additional 1% ODA a country would receive from Gavi, it would receive 0.14% more ODA and 0.16% more health ODA from individual bilateral donors. Gavi's graduation status or disbursement brought more change in percentage term to health ODA than to total ODA. Additionally, Gavi's graduation was observed to have a larger negative impact on bilateral ODA in the longer term. Countries that sent more migrants, had been colonised, and received more US military assistance tended to receive more ODA. There are similarities and differences across different donors and bilateral donors tend to provide more ODA to nearby countries and countries receiving fewer exports from the donor. We found that former colonies did not see a decline in aid after Gavi graduation. CONCLUSION: Bilateral donors behave in a similar manner to Gavi when it comes to funding health systems in low and middle-income countries. Therefore, some countries may be at risk of losing donor resources for health from a multitude of sources around the same time. However, countries that have a strategic interest in bilateral donors may be spared from such funding cliffs. This research has important implications for global health donors' funding policies and approaches in addition to recipient countries' transition planning.
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Cooperação Internacional , Vacinas , Humanos , Países em Desenvolvimento , Saúde Global , Política de SaúdeRESUMO
Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association.
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Saúde Global , Atenção Primária à Saúde , Humanos , Custos e Análise de Custo , Catálise , Países em DesenvolvimentoRESUMO
INTRODUCTION: Poverty-related and neglected diseases (PRNDs) cause over three million deaths annually. Despite this burden, there is a large gap between actual funding for PRND research and development (R&D) and the funding needed to launch PRND products from the R&D pipeline. This study provides an economic evaluation of a theoretical global pooled-funding mechanism to finance late-stage clinical trials of PRND products. METHODS: We modelled three pooled-funding design options, each based on a different level of coverage of candidate products for WHO's list of PRNDs: (1) vaccines covering 4 PRNDs, (2) vaccines and therapeutics covering 9 PRNDs and (3) vaccines, therapeutics and diagnostics covering 30 PRNDs. For each option, we constructed a discrete event simulation of the 2019 PRND R&D pipeline to estimate required funding for phase III trials and expected product launches through 2035. For each launch, we estimated global PRND treatment costs averted, deaths averted and disability-adjusted life-years (DALYs) averted. For each design option, we calculated the cost per death averted, cost per DALY averted, the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER). RESULTS: Option 1 averts 18.4 million deaths and 516 million DALYs, has a cost per DALY averted of US$84 and yields a BCR of 5.53. Option 2 averts 22.9 million deaths and 674 million DALYs, has a cost per DALY averted of US$75, an ICER over option 1 of US$49 and yields a BCR of 3.88. Option 3 averts 26.9 million deaths and 1 billion DALYs, has a cost per DALY averted of US$114, an ICER over option 2 of US$186 and yields a BCR of 2.52. CONCLUSIONS: All 3 options for a pooled-funding mechanism-vaccines for 4 PRNDs, vaccines and therapeutics for 9 PRNDs, and vaccines, therapeutics and diagnostics for 30 PRNDs-would generate a large return on investment, avert a substantial proportion of the global burden of morbidity and mortality for diseases of poverty and be cost-effective.
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Análise de Custo-Efetividade , Doenças Negligenciadas , Humanos , Análise Custo-Benefício , Doenças Negligenciadas/prevenção & controleRESUMO
OBJECTIVES: This study aimed to assess Nigeria's preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria's attainment of UHC. DESIGN AND SETTING: We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis. PARTICIPANTS: Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia. RESULTS: Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions. CONCLUSION: Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria's demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration.
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Formulação de Políticas , Cobertura Universal do Seguro de Saúde , Humanos , Nigéria , Seguro Saúde , Políticas , Financiamento da Assistência à Saúde , Política de SaúdeRESUMO
BACKGROUND: Maternal and newborn mortality rates in Nigeria are among the highest globally, and large socioeconomic inequalities exist in access to maternal, newborn, and child health (MNCH) services in the country. Inequalities also exist in catastrophic health expenditure among households in Nigeria. We aimed to estimate the health and financial risk protection benefits across different wealth groups in Nigeria if a policy of public financing of MNCH interventions were to be introduced. METHODS: We did an extended cost-effectiveness analysis to estimate the health and financial risk protection benefits, across different household wealth quintiles, of a public-financing policy that assumes zero out-of-pocket costs to patients at the point of care for 18 essential MNCH services. We projected health outcomes (deaths in children aged <5 years [under-5 deaths] and maternal deaths) and private expenditure averted using the Lives Saved Tool with data extracted from national surveys. We modelled three scenarios: 1) coverage expansion at a rate equal to the trend observed between 2013 and 2018 (status quo); 2) annual coverage expansion by 5% compared with the status quo (uniform scale-up scenario); and 3) annual coverage expansion by 10%, 8%, 6%, 4%, and 2% compared with the status quo from the poorest to the wealthiest quintiles, respectively (pro-poor scale-up scenario). FINDINGS: Our analysis shows that, if an additional 5% increase in coverage was provided for all wealth quintiles between 2019 and 2030, this uniform scale-up policy would prevent more than 0·11 million maternal deaths and 1·05 million under-5 deaths, avert US$1·8 billion in private expenditure, and avert 3266 cases of catastrophic health expenditure. The incremental cost effectiveness ratio would be $44 per life-year gained, which is highly cost-effective when compared with the gross domestic product per capita of Nigeria for 2018 ($2028). The policy would prevent a higher number of under-5 deaths and catastrophic health expenditure cases in poorer quintiles, but would prevent more maternal deaths and private expenditure in wealthier quintiles. If poorer populations experienced a greater increase in service coverage (ie, the pro-poor scale-up scenario), more maternal and under-5 deaths would be prevented in the poorer quintiles and more private expenditure would be averted than would be under previous scenarios. INTERPRETATION: Public financing of essential MNCH interventions in Nigeria would provide substantial health and financial risk protection benefits to Nigerian households. These benefits would accrue preferentially to the poorest quintiles and would contribute towards reduction of health and socioeconomic inequalities in Nigeria. The distribution would be more pro-poor if public financing of MNCH interventions could target poor households. FUNDING: WHO Partnership for Maternal, Newborn, and Child Health.
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Saúde da Criança , Morte Materna , Criança , Recém-Nascido , Feminino , Humanos , Análise de Custo-Efetividade , Nigéria/epidemiologia , Gastos em Saúde , Política Pública , Financiamento GovernamentalRESUMO
This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.
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Serviços de Saúde , Setor Privado , Humanos , Programas Governamentais , Desenvolvimento Sustentável , PobrezaRESUMO
BACKGROUND: Amid the dwindling donor support for HIV in Nigeria, there is an urgent need for additional domestic HIV funding. This study estimates the required financial resources for people living with HIV (PLHIV) and the potential magnitude of domestic resources for HIV through the National Health Insurance Scheme (NHIS) and by prioritizing HIV within the health budget. METHODS: We estimated the resource needs for providing antiretroviral therapy (ART) to adults, children, and pregnant women living with HIV under 3 scenarios: current coverage rates, coverage rates based on historical trends, and a rapid scale-up situation. We conducted a fiscal space analysis to estimate the potential contribution from macroeconomic growth, the NHIS, and prioritizing HIV within the health budget from 2020 to 2025. RESULTS: At current coverage rates, the annual treatment costs for adults would range between US$ 505 million in 2020 to US$ 655 million in 2025; for children, it ranges from US$ 33.5 million in 2020 to US$ 32 million in 2025. The annual costs of providing PMTCT at current coverage rates range from US$ 65 million in 2020 to US$ 72 million in 2025. An additional US$ 319 million could potentially be generated between 2020 and 2025 through the NHIS for HIV. Prioritizing HIV within the health budget can generate an additional US$ 686 million. CONCLUSION: Substantial domestic funds can be mobilized by these means to sustain the HIV response. However, because this additional funding may not be sufficient to cover all PLHIV, a phased approach, initially prioritizing certain populations such as children or pregnant women, is recommended.
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Síndrome da Imunodeficiência Adquirida , Administração Financeira , Infecções por HIV , Gravidez , Adulto , Criança , Humanos , Feminino , Nigéria , Programas Nacionais de SaúdeRESUMO
Objective: Tracking global health funding is a crucial but time consuming and labor-intensive process. This study aimed to develop a framework to automate the tracking of global health spending using natural language processing (NLP) and machine learning (ML) algorithms. We used the global common goods for health (CGH) categories developed by Schäferhoff et al. to design and evaluate ML models. Methods: We used data curated by Schäferhoff et al., which tracked the official development assistance (ODA) disbursements to global CGH for 2013, 2015, and 2017, for training and validating the ML models. To process raw text, we implemented different NLP techniques, such as removing stop words, lemmatization, and creation of synthetic text, to balance the dataset. We used four supervised learning ML algorithms-random forest (RF), XGBOOST, support vector machine (SVM), and multinomial naïve Bayes (MNB) (see Glossary)-to train and test the pre-coded dataset, and applied the best model on dataset that hasn't been manually coded to predict the financing for CGH in 2019. Results: After we trained the machine on the training dataset (n = 10,534), the weighted average F1-scores (a measure of a ML model's performance) on the testing dataset (n = 2,634) ranked 0.79-0.83 among four models, and the RF model had the best performance (F1-score = 0.83). The predicted total donor support for CGH projects by the RF model was $2.24 billion across 3 years, which was very close to the finding of $2.25 billion derived from coding and classification by humans. By applying the trained RF model on the 2019 dataset, we predicted that the total funding for global CGH was about $2.7 billion for 730 CGH projects. Conclusion: We have demonstrated that NLP and ML can be a feasible and efficient way to classify health projects into different global CGH categories, and thus track health funding for CGH routinely using data from publicly available databases.
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Processamento de Linguagem Natural , Justiça Social , Humanos , Saúde Global , Teorema de Bayes , Aprendizado de MáquinaRESUMO
BACKGROUND: Although it is difficult to quantify, previous estimates suggested that China's global health aid has increased sharply since the early 2000s. Unlike many donors, China has no official aid reporting obligations, nor does it voluntarily disclose detailed aid information. Our study aimed to create a standardised estimate using commonly accepted definitions of aid and frameworks for categorising health projects. METHODS: We categorised AidData's Chinese Official Finance Dataset health-related projects according to health aid frameworks from the Organisation for Economic Co-operation and Development (OECD) and the Institute for Health Metrics and Evaluation (IHME). Only projects that complied with the definition of official development assistance were included. We analysed the project count and financial value to assess China's priority health aid areas. FINDINGS: Between 2000 and 2017, China funded 1339 health-related aid projects, or 13% of its total aid project portfolio. Most of these projects were located in sub-Saharan Africa. According to the OECD framework, the priority focus areas of these projects were: medical services, such as specialty equipment and tertiary services (n=489, 37%); basic health care, such as basic medical services and drugs (n=251, 19%); malaria control (n=234, 18%) and basic health infrastructure (n=178, 13%). Under the IHME framework, health systems strengthening accounted for 74% (n=991) of total projects, primarily due to China's contributions to human resources for health, infrastructure and equipment. The only other major allocation under the IHME framework was malaria (n=234, 18%). When we estimated missing financial values under the OECD framework, China was the fifth largest health aid donor to African countries from 2002 to 2017, after the USA, the UK, Canada and Germany. CONCLUSION: Our findings enable a better understanding of Chinese health aid in the absence of transparent aid reporting, which could contribute to better coordination, collaboration and resource allocation for both donor and recipient countries.