PEPFAR Reauthorization by Congress Urgent for Global Health.

This Viewpoint discusses the importance of the US Congress reauthorizing funding for the President's Emergency Plan for AIDS Relief, a program developed in 2003 that has played a critical role in fighting HIV/AIDS worldwide as well as other emerging infections and noncommunicable diseases.

Assessing the impact of one million COVID-19 deaths in America: economic and life expectancy losses.

Between February 2020 and May 2022, one million Americans have died of COVID-19. To determine the contribution of those deaths to all-cause mortality in terms of life expectancy reductions and the resulting economic welfare losses, we calculated their combined impact on national income growth and the added value of lives lost. We estimated that US life expectancy at birth dropped by 3.08 years due to the million COVID-19 deaths. Economic welfare losses estimated in terms of national income growth supplemented by the value of lives lost, was in the order of US$3.57 trillion. US$2.20 trillion of these losses were in in the non-Hispanic White population (56.50%), US$698.24 billion (19.54%) in the Hispanic population, and US$579.93 billion (16.23%) in the non-Hispanic Black population. The scale of life expectancy and welfare losses underscores the pressing need to invest in health in the US to prevent further economic shocks from future pandemic threats.

COVID-19 and global equity for health: The good, the bad, and the wicked.

Elvin Geng and co-authors discuss monitoring and achieving equity in provision of vaccines for COVID-19.

Economic impact of tuberculosis mortality in 120 countries and the cost of not achieving the Sustainable Development Goals tuberculosis targets: a full-income analysis.

BACKGROUND: The tuberculosis targets for the UN Sustainable Development Goals (SDGs) call for a 90% reduction in tuberculosis deaths by 2030, compared with 2015, but meeting this target now seems highly improbable. To assess the economic impact of not meeting the target until 2045, we estimated full-income losses in 120 countries, including those due to excess deaths resulting from COVID-19-related disruptions to tuberculosis services, for the period 2020-50. METHODS: Annual mortality risk changes at each age in each year from 2020 to 2050 were estimated for 120 countries. This risk change was then converted to full-income risk by calculating a population-level mortality risk change and multiplying it by the value of a statistical life-year in each country and year. As a comparator, we assumed that current rates of tuberculosis continue to decline through the period of analysis. We calculated the full-income losses, and mean life expectancy losses per person, at birth and at age 35 years, under scenarios in which the SDG targets are met in 2030 and in 2045. We defined the cost of inaction as the difference in full-income losses and tuberculosis mortality between these two scenarios. FINDINGS: From 2020 to 2050, based on the current annual decrease in tuberculosis deaths of 2%, 31·8 million tuberculosis deaths (95% uncertainty interval 25·2 million-39·5 million) are estimated to occur, corresponding to an economic loss of US$17·5 trillion (14·9 trillion-20·4 trillion). If the SDG tuberculosis mortality target is met in 2030, 23·8 million tuberculosis deaths (18·9 million-29·5 million) and $13·1 trillion (11·2 trillion-15·3 trillion) in economic losses can be avoided. If the target is met in 2045, 18·1 million tuberculosis deaths (14·3 million-22·4 million) and $10·2 trillion (8·7 trillion-11·8 trillion) can be avoided. The cost of inaction of not meeting the SDG tuberculosis mortality target until 2045 (vs 2030) is, therefore, 5·7 million tuberculosis deaths (5·1 million-8·1 million) and $3·0 trillion (2·5 trillion-3·5 trillion) in economic losses. COVID-19-related disruptions add $290·3 billion (260·2 billion-570·1 billion) to this cost. INTERPRETATION: Failure to achieve the SDG tuberculosis mortality target by 2030 will lead to profound economic and health losses. The effects of delay will be greatest in sub-Saharan Africa. Affected countries, donor nations, and the private sector should redouble efforts to finance tuberculosis programmes and research because the economic dividend of such strategies is likely to be substantial. FUNDING: None.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission.

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

How will COVID-19 transform global health post-pandemic? Defining research and investment opportunities and priorities.

Michael Reid and co-authors introduce a Collection on the global health in the post-COVID-19 era.

Improving quality is necessary to building a TB-free world: Lancet Commission on Tuberculosis.

The Lancet Commission on Tuberculosis (TB) set out to establish a roadmap for how high burden countries could get on track to meet the goals established by the UN High Level Meeting (UNHLM) in September 2018. The report sought to answer the question "How should TB high-burden countries and their development partners target their future investments to ensure that ending TB is achieved?" It provides a comprehensive analysis and specific recommendations to address this question and, ultimately, remove the barriers to building a TB-free World. Notably, the report highlights the importance of improving the quality of care as an essential component of ending the epidemic. Strategies for improving quality must be hard-wired into how National TB Programs are organized, to ensure greater equity in TB service provision and implementation of evidence-based practices and clinical guidelines. Investing in TB research and development, especially implementation, policy and programmatic research to determine how to deliver high quality care must also be high priority. In addition, improving the quality of TB programs is contingent on strategies that enhance accountability at all levels, from the level of Head of State to the local TB clinics. To this ends it is essential that TB survivors and their advocates have a voice to raise inconvenient truths and demand improvements in quality. The Commission concludes that the prospect of a TB-free world is a realistic objective that can be achieved with the right commitment of leadership and resources but will only be realized as and when quality of care is prioritized as a central tenet of all TB programs.

Achieving Universal Health Coverage (UHC): Dominance analysis across 183 countries highlights importance of strengthening health workforce.

BACKGROUND: Despite increasing political will to achieve Universal Health Coverage (UHC), there is a paucity of empiric data describing what health system indicators are useful surrogates of country-level progress towards UHC. We sought to determine what public health interventions were useful tracers of country-level UHC progress. METHODS: Across 183 countries we evaluated the extent to which 16 service delivery indicators explained variability in the UHC Service Coverage Index, (UHC SCI) a WHO-validated indicator of country-level health coverage. Dominance analyses, stratifying countries by World Bank income criteria, were used to determine which indicators were most important in in predicting UHC SCI scores. FINDINGS: Health workforce density ranked first overall, provision of basic sanitation and access to clean water ranked second, and provision of basic antenatal services ranked third. In analysis stratified by World Bank income criteria, health workforce density ranked first in Lower Middle Income-Countries (LMICs) (n = 45) and third in Upper Middle Income-Countries (UMICs) (n = 51). CONCLUSIONS: While each country will have a different approach to achieving UHC, strengthening the health workforce will need to be a key priority if they are to be successful in achieving UHC.

Monitoring Universal Health Coverage (UHC) in high Tuberculosis burden countries: Tuberculosis mortality an important tracer of UHC service coverage.

BACKGROUND: There is a paucity of empiric data evaluating whether Tuberculosis (TB) is a useful surrogate measure for Universal Health Coverage (UHC), despite recognition of the importance of TB control efforts as part of the broader UHC agenda. We hypothesized that indicators of TB burden and coverage are sensitive tracers of UHC, when compared to other disease-specific indicators of service provision. METHODS: Linear regression models were used to determine the extent to which variability in UHC Service Coverage Index (SCI) was accounted for by (1) TB incidence rates and (2) TB mortality rates across 183 countries. Dominance analyses, stratifying countries by World Bank income criteria and TB burden, were used to determine the importance of TB treatment coverage in predicting UHC SCI scores, relative to other disease-specific indicators of service provision. RESULTS: Across 183 countries, TB incidence rate and TB mortality rate were negatively correlated, with UHC SCI score, (r = -0.67 and r = -0.74, respectively). In linear regression models including all 183 countries, TB incidence rates explained 45% of the variability in SCI scores; TB mortality rate explained 55% of variability. Restricting models to the 30 highest TB burden countries, both incidence and mortality explained less of the variability in SCI score (16% and 36%, respectively). In dominance analysis, comparing 13 disease-specific indicators of service provision, TB effective treatment coverage, ranked ninth overall. In dominance analysis stratified by TB burden, the TB treatment coverage estimate was ranked ninth in the 30 high burden countries and sixth in the 153 non-high burden countries. In separate analyses stratified by world bank income status, TB coverage ranked as third most important variable in LICs and fifth in LMICs and UMICs, but was less important in analysis restricted HICs (ranked seventh). CONCLUSIONS: Compared to other disease-specific indicators of service provision, TB coverage was an important indicator of overall UHC service coverage, especially in low-income countries. These findings highlight that national-level inequities in TB-coverage may be an important tracer of universal health coverage.

Building on the HIV platform: tackling the challenge of noncommunicable diseases among persons living with HIV.

: The global HIV response has enabled access to prevention and treatment interventions for millions of people around the world. This investment has enabled the strengthening of health systems, which offers a remarkable opportunity to integrate care for noncommunicable diseases for persons living with HIV who are at risk for or have a noncommunicable disease.

Transforming Global Health by Improving the Science of Scale-Up.

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage.