The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.

The relationship between joining a US free trade agreement and processed food sales, 2002-2016: a comparative interrupted time-series analysis.

OBJECTIVE: To examine changes in sales of highly processed foods, including infant formulas, in countries joining free trade agreements (FTAs) with the US. DESIGN: Annual country-level data for food and beverage sales come from Euromonitor International. Analyses are conducted in a comparative interrupted time-series (CITS) framework using multivariate random-effects linear models, adjusted for key confounders: gross domestic product (GDP) per capita, percent of the population living in urban areas and female labor force participation rate. Memberships in other FTAs and investment treaties are also explored as possible confounders. SETTING: Changes are assessed between 2002 and 2016. PARTICIPANTS: Ten countries joining US FTAs are compared with eleven countries without US FTAs in force; countries are matched on national income level, world region and World Trade Organization membership. RESULTS: After countries join a US FTA, sales are estimated to increase by: 0·89 (95 % CI 0·16, 1·6; P = 0·016) kg per capita per annum for ultra-processed products, 0·81 (95 % CI 0·47, 1·1; P < 0·001) kg per capita per annum for processed culinary ingredients and 0·17 (95 % CI 0·052, 0·29; P = 0·005) kg per capita under age 5 per annum for baby food. No significant change is estimated for minimally processed foods. In statistical models, large unexplained variations in country-specific trends suggest additional unmeasured country-level factors also impact sales trends following entry into US FTAs. CONCLUSIONS: These findings strongly support the conclusion that joining US FTAs can contribute to detrimental changes in national dietary consumption that increase population risk of non-communicable diseases.

Measuring human capital: a systematic analysis of 195 countries and territories, 1990-2016.

BACKGROUND: Human capital is recognised as the level of education and health in a population and is considered an important determinant of economic growth. The World Bank has called for measurement and annual reporting of human capital to track and motivate investments in health and education and enhance productivity. We aim to provide a new comprehensive measure of human capital across countries globally. METHODS: We generated a period measure of expected human capital, defined for each birth cohort as the expected years lived from age 20 to 64 years and adjusted for educational attainment, learning or education quality, and functional health status using rates specific to each time period, age, and sex for 195 countries from 1990 to 2016. We estimated educational attainment using 2522 censuses and household surveys; we based learning estimates on 1894 tests among school-aged children; and we based functional health status on the prevalence of seven health conditions, which were taken from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016). Mortality rates specific to location, age, and sex were also taken from GBD 2016. FINDINGS: In 2016, Finland had the highest level of expected human capital of 28·4 health, education, and learning-adjusted expected years lived between age 20 and 64 years (95% uncertainty interval 27·5-29·2); Niger had the lowest expected human capital of less than 1·6 years (0·98-2·6). In 2016, 44 countries had already achieved more than 20 years of expected human capital; 68 countries had expected human capital of less than 10 years. Of 195 countries, the ten most populous countries in 2016 for expected human capital were ranked: China at 44, India at 158, USA at 27, Indonesia at 131, Brazil at 71, Pakistan at 164, Nigeria at 171, Bangladesh at 161, Russia at 49, and Mexico at 104. Assessment of change in expected human capital from 1990 to 2016 shows marked variation from less than 2 years of progress in 18 countries to more than 5 years of progress in 35 countries. Larger improvements in expected human capital appear to be associated with faster economic growth. The top quartile of countries in terms of absolute change in human capital from 1990 to 2016 had a median annualised growth in gross domestic product of 2·60% (IQR 1·85-3·69) compared with 1·45% (0·18-2·19) for countries in the bottom quartile. INTERPRETATION: Countries vary widely in the rate of human capital formation. Monitoring the production of human capital can facilitate a mechanism to hold governments and donors accountable for investments in health and education. FUNDING: Institute for Health Metrics and Evaluation.

World Trade Organization membership and changes in noncommunicable disease risk factors: a comparative interrupted time-series analysis, 1980-2013.

OBJECTIVE: To investigate the relationship between joining the World Trade Organization (WTO) and the availability of several commodities with both harmful and protective effects for the development of noncommunicable diseases. METHODS: We used a natural experiment design to compare trends in the domestic supply of tobacco, alcohol and seven food groups, between 1980 and 2013, in 21 countries or territories joining WTO after 1995 and 26 non-member countries, using propensity score weights. We applied a comparative interrupted time-series framework, by using multivariate random-effects linear models, adjusted for gross domestic product per capita, the percentages of urban population and female labour force participation. In the tobacco model, we controlled for Member States that had ratified the Framework Convention on Tobacco Control and in the alcohol model, the percentage of the population identifying themselves as Muslim. FINDINGS: Following accession to WTO, member states experienced immediate increases in the domestic supply of fruits and vegetables of 55 g per person per day on average, compared to non-member countries. The analysis showed gradual increases in the geometric mean of the supply of tobacco and alcohol of 6.2% and 3.6% per year, respectively. We did not detect any significant changes in the availability of red meats and animal fats; seafood; nuts, seeds and legumes; starches; or edible oils; and results for sugars were inconsistent across model variations. CONCLUSION: The results suggest that WTO membership may lead to increases in both harmful and protective factors for noncommunicable disease, but further exploration of country-specific variation is warranted.

Analyzing the impacts of global trade and investment on non-communicable diseases and risk factors: a critical review of methodological approaches used in quantitative analyses.

BACKGROUND: A key mechanism through which globalization has impacted health is the liberalization of trade and investment, yet relatively few studies to date have used quantitative methods to investigate the impacts of global trade and investment policies on non-communicable diseases and risk factors. Recent reviews of this literature have found heterogeneity in results and a range of quality across studies, which may be in part attributable to a lack of conceptual clarity and methodological inconsistencies. METHODS: This study is a critical review of methodological approaches used in the quantitative literature on global trade and investment and diet, tobacco, alcohol, and related health outcomes, with the objective of developing recommendations and providing resources to guide future robust, policy relevant research. A review of reviews, expert review, and reference tracing were employed to identify relevant studies, which were evaluated using a novel quality assessment tool designed for this research. RESULTS: Eight review articles and 34 quantitative studies were identified for inclusion. Important ways to improve this literature were identified and discussed: clearly defining exposures of interest and not conflating trade and investment; exploring mechanisms of broader relationships; increasing the use of individual-level data; ensuring consensus and consistency in key confounding variables; utilizing more sector-specific versus economy-wide trade and investment indicators; testing and adequately adjusting for autocorrelation and endogeneity when using longitudinal data; and presenting results from alternative statistical models and sensitivity analyses. To guide the development of future analyses, recommendations for international data sources for selected trade and investment indicators, as well as key gaps in the literature, are presented. CONCLUSION: More methodologically rigorous and consistent approaches in future quantitative studies on the impacts of global trade and investment policies on non-communicable diseases and risk factors can help to resolve inconsistencies of existing research and generate useful information to guide policy decisions.

Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection.

Policy Points: Strengthening accountability through better measurement and reporting is vital to ensure progress in improving quality primary health care (PHC) systems and achieving universal health coverage (UHC). The Primary Health Care Performance Initiative (PHCPI) provides national decision makers and global stakeholders with opportunities to benchmark and accelerate performance improvement through better performance measurement. Results from the initial PHC performance assessments in low- and middle-income countries (LMICs) are helping guide PHC reforms and investments and improve the PHCPI's instruments and indicators. Findings from future assessment activities will further amplify cross-country comparisons and peer learning to improve PHC. New indicators and sources of data are needed to better understand PHC system performance in LMICs. CONTEXT: The Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low- and middle-income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released. METHODS: The PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross-referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in-person facilitated discussions with experts. FINDINGS: The PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC. CONCLUSIONS: The availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.

Mapping of health research funding in India.

BACKGROUND.: We aimed to estimate the total annual funding available for health research in India. We also examined the trends of funding for health research since 2001 by major national and international agencies. METHODS.: We did a retrospective survey of 1150 health research institutions in India to estimate the quantum of funding over 5 years. We explored the Prowess database for industry spending on health research and development and gathered data from key funding agencies. All amounts were converted to 2015 constant US$. RESULTS.: The total health research funding available in India in 2011-12 was US$ 1.42 billion, 0.09% of the gross domestic product (GDP) including only 0.02% from public sources. The average annual increase of funding over the previous 5 years (2007-08 to 2011-12) was 8.8%. 95% of this funding was from Indian sources, including 79% by the Indian pharmaceutical industry. Of the total funding, only 3.2% was available for public health research. From 2006-10 to 2011-15 the funding for health research in India by the three major international agencies cumulatively decreased by 40.8%. The non-industry funding for non-communicable diseases doubled from 2007-08 to 2011-12, but the funding for some of the leading causes of disease burden, including neonatal disorders, cardiovascular disease, chronic respiratory disease, mental health, musculoskeletal disorders and injuries was substantially lower than their contribution to the disease burden. CONCLUSION.: The total funding available for health research in India is lower than previous estimates, and only a miniscule proportion is available for public health research. The non industry funding for health research in India, which is predominantly from public resources, is extremely small, and had considerable mismatches with the major causes of disease burden. The magnitude of public funding for health research and its appropriate allocation should be addressed at the highest policy level.

Improving the estimation of the tuberculosis burden in India.

Although India is considered to be the country with the greatest tuberculosis burden, estimates of the disease's incidence, prevalence and mortality in India rely on sparse data with substantial uncertainty. The relevant available data are less reliable than those from countries that have recently improved systems for case reporting or recently invested in national surveys of tuberculosis prevalence. We explored ways to improve the estimation of the tuberculosis burden in India. We focused on case notification data - among the most reliable data available - and ways to investigate the associated level of underreporting, as well as the need for a national tuberculosis prevalence survey. We discuss several recent developments - i.e. changes in national policies relating to tuberculosis, World Health Organization guidelines for the investigation of the disease, and a rapid diagnostic test - that should improve data collection for the estimation of the tuberculosis burden in India and elsewhere. We recommend the implementation of an inventory study in India to assess the underreporting of tuberculosis cases, as well as a national survey of tuberculosis prevalence. A national assessment of drug resistance in Indian strains of Mycobacterium tuberculosis should also be considered. The results of such studies will be vital for the accurate monitoring of tuberculosis control efforts in India and globally.

Bien que l'Inde soit considérée comme le pays le plus touché par la tuberculose, les estimations de l'incidence, la prévalence et la mortalité relative à cette maladie en Inde reposent sur des données insuffisantes marquées d'une forte incertitude. Les données disponibles pertinentes sont moins fiables que celles obtenues dans les pays qui ont récemment amélioré leur système de signalement de cas ou qui ont récemment investi dans des enquêtes nationales de prévalence de la tuberculose. Nous avons exploré les moyens d'améliorer l'estimation de la charge de morbidité de la tuberculose en Inde. Nous nous sommes concentrés sur les données de signalisation des cas (parmi les données les plus fiables disponibles) et sur les moyens d'étudier les niveaux associés de sous-déclaration, ainsi que le besoin d'une enquête nationale de prévalence de la tuberculose. Nous discutons de plusieurs développements récents (c.-à-d. les changements dans les politiques nationales relatives à la tuberculose, les recommandations de l'Organisation mondiale de la Santé pour la recherche sur la maladie et un test diagnostique rapide) qui devraient améliorer la collecte des données pour estimer la charge de morbidité de la tuberculose en Inde et ailleurs dans le monde. Il serait utile de mettre en œuvre une étude d'inventaire pour évaluer la sous-déclaration des cas de tuberculose, une étude de la prévalence de la tuberculose et une évaluation de la résistance aux médicaments des souches indiennes de Mycobacterium tuberculosis. Les résultats de ces études seront d'une importance vitale pour le suivi précis des efforts de contrôle de la tuberculose en Inde et dans le monde.

Aunque la India se considera el país con la mayor carga de tuberculosis, las estimaciones de la incidencia, la prevalencia y la mortalidad de la enfermedad en el país se basan en datos escasos con falta de fiabilidad considerable. Los datos disponibles pertinentes son menos fiables que los datos de los países que han mejorado recientemente los sistemas de notificación de casos o que han invertido últimamente en encuestas nacionales de prevalencia de la tuberculosis. Se estudiaron los modos de mejorar la estimación de la carga de tuberculosis en la India, con un enfoque en los datos de la notificación de casos, que se encuentran entre los datos más fiables disponibles, y las formas de analizar la correspondiente falta de notificación de casos, así como en la necesidad de una encuesta nacional de prevalencia de la tuberculosis. Se examinaron varios acontecimientos recientes, es decir, los cambios en las políticas nacionales en materia de tuberculosis y las directrices de la Organización Mundial de la Salud para la investigación de la enfermedad, así como una prueba de diagnóstico rápido, que se espera que mejoren la recogida de datos para la estimación de la carga de la tuberculosis en la India y otros lugares. Sería conveniente realizar un estudio de inventario para evaluar la falta de notificación de casos de tuberculosis, una encuesta sobre la prevalencia de la tuberculosis y una evaluación de la resistencia a fármacos en cepas de Mycobacterium tuberculosis de la India. Los resultados de estos estudios serán vitales para el seguimiento preciso de los esfuerzos de control de la tuberculosis, tanto en la India como en el resto del mundo.

Social determinants of health in India: progress and inequities across states.

INTRODUCTION: Despite the recognized importance of social determinants of health (SDH) in India, no compilation of the status of and inequities in SDH across India has been published. To address this gap, we assessed the levels and trends in major SDH in India from 1990 onwards and explored inequities by state, gender, caste, and urbanicity. METHODS: Household- and individual-level SDH indicators were extracted from national household surveys conducted between 1990 and 2011 and means were computed across population subgroups and over time. The multidimensional poverty index (MPI), a composite measure of health, education, and standard of living, was calculated for all three rounds of the National Family Health Survey, adjusting the methodology to generate comparable findings from the three datasets. Data from government agencies were analyzed to assess voting patterns, political participation, and air and water pollution. RESULTS: Changes in the MPI demonstrate progress in each domain over time, but high rates persist in important areas: the majority of households in India use indoor biomass fuel and have unimproved sanitation, and over one-third of households with a child under the age of 3 years have undernourished children. There are large, but narrowing, gender gaps in education indicators, but no measurable change in women's participation in governance or the labor force. Less than 25% of workers have job security and fewer than 15% have any social security benefit. Alarming rates of air pollution are observed, with particulate matter concentrations persistently above the critical level at over 50% of monitoring stations. CONCLUSIONS: This assessment indicates that air pollution (indoor and outdoor), child undernutrition, unimproved sanitation, employment conditions, and gender inequality are priority areas for public policy related to SDH in India.

Assessing the impact of community-based interventions on hypertension and diabetes management in three Minnesota communities: Findings from the prospective evaluation of US HealthRise programs.

BACKGROUND: Community-based health interventions are increasingly viewed as models of care that can bridge healthcare gaps experienced by underserved communities in the United States (US). With this study, we sought to assess the impact of such interventions, as implemented through the US HealthRise program, on hypertension and diabetes among underserved communities in Hennepin, Ramsey, and Rice Counties, Minnesota. METHODS AND FINDINGS: HealthRise patient data from June 2016 to October 2018 were assessed relative to comparison patients in a difference-in-difference analysis, quantifying program impact on reducing systolic blood pressure (SBP) and hemoglobin A1c, as well as meeting clinical targets (< 140 mmHg for hypertension, < 8% Al1c for diabetes), beyond routine care. For hypertension, HealthRise participation was associated with SBP reductions in Rice (6.9 mmHg [95% confidence interval: 0.9-12.9]) and higher clinical target achievement in Hennepin (27.3 percentage-points [9.8-44.9]) and Rice (17.1 percentage-points [0.9 to 33.3]). For diabetes, HealthRise was associated with A1c decreases in Ramsey (1.3 [0.4-2.2]). Qualitative data showed the value of home visits alongside clinic-based services; however, challenges remained, including community health worker retention and program sustainability. CONCLUSIONS: HealthRise participation had positive effects on improving hypertension and diabetes outcomes at some sites. While community-based health programs can help bridge healthcare gaps, they alone cannot fully address structural inequalities experienced by many underserved communities.

Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis.

BACKGROUND: In addition to the inherent importance of education and its essential role in economic growth, education and health are strongly related. We updated previous systematic assessments of educational attainment, and estimated the contribution of improvements in women's education to reductions in child mortality in the past 40 years. METHODS: We compiled 915 censuses and nationally representative surveys, and estimated mean number of years of education by age and sex. By use of a first-differences model, we investigated the association between child mortality and women's educational attainment, controlling for income per person and HIV seroprevalence. We then computed counterfactual estimates of child mortality for every country year between 1970 and 2009. FINDINGS: The global mean number of years of education increased from 4·7 years (95% uncertainty interval 4·4-5·1) to 8·3 years (8·0-8·6) for men (aged ≥25 years) and from 3·5 years (3·2-3·9) to 7·1 years (6·7 -7·5) for women (aged ≥25 years). For women of reproductive age (15-44 years) in developing countries, the years of schooling increased from 2·2 years (2·0-2·4) to 7·2 years (6·8-7·6). By 2009, in 87 countries, women (aged 25-34 years) had higher educational attainment than had men (aged 25-34 years). Of 8·2 million fewer deaths in children younger than 5 years between 1970 and 2009, we estimated that 4·2 million (51·2%) could be attributed to increased educational attainment in women of reproductive age. INTERPRETATION: The substantial increase in education, especially of women, and the reversal of the gender gap have important implications not only for health but also for the status and roles of women in society. The continued increase in educational attainment even in some of the poorest countries suggests that rapid progress in terms of Millennium Development Goal 4 might be possible. FUNDING: Bill & Melinda Gates Foundation.

Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA.

INTRODUCTION: As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation. METHODS: The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time. RESULTS: Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges. CONCLUSIONS: Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Addressing NCDs: Protecting Health From Trade and Investment Law Comment on "Addressing NCDs: Challenges From Industry Market Promotion and Interferences".

Building on Tangcharoensathien and colleagues' description of four tactics used by the tobacco, alcohol, processed food, and breast milk substitute industries to interfere with the development and implementation of health policies, we present a fifth tactic: trade and investment disputes. We describe recent examples of trade and investment claims filed by the tobacco industry to challenge plain packaging legislation, which may serve as a model for future claims by this and other industries. Next, we clarify specific areas of potential conflict between non-communicable disease (NCD) control policies and trade and investment agreement (TIA) commitments, identifying possible vulnerabilities that may be exploited by industry to challenge the legality of these policies. We conclude with ideas to strengthen the position of health policies vis-à-vis commitments in TIAs.