Devi Sridhar

Barriers to improvement of mental health services in low-income and middle-income countries

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.

Global health funding: how much, where it comes from and where it goes.

Global health funding has increased in recent years. This has been accompanied by a proliferation in the number of global health actors and initiatives. This paper describes the state of global heath finance, taking into account government and private sources of finance, and raises and discusses a number of policy issues related to global health governance. A schematic describing the different actors and three global health finance functions is used to organize the data presented, most of which are secondary data from the published literature and annual reports of relevant actors. In two cases, we also refer to currently unpublished primary data that have been collected by authors of this paper. Among the findings are that the volume of official development assistance for health is frequently inflated; and that data on private sources of global health finance are inadequate but indicate a large and important role of private actors. The fragmented, complicated, messy and inadequately tracked state of global health finance requires immediate attention. In particular it is necessary to track and monitor global health finance that is channelled by and through private sources, and to critically examine who benefits from the rise in global health spending.

Misfinancing global health: a case for transparency in disbursements and decision making

To address the gap between health investments and financial flows worldwide, we identified the patterns in allocation of funds by the four largest donors--ie, the World Bank, Bill & Melinda Gates Foundation (BMGF), the US Government, and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria--in 2005. We created a disbursement database with information gathered from the annual reports and budgets. Funding per death varied widely according to type of disease--eg, US

Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

1029.10 for HIV/AIDS to

Global and regional estimates of COPD prevalence: Systematic review and meta-analysis

3.21 for non-communicable diseases. The World Bank, US Government, and Global Fund provided more than 98% of their funds to service delivery, whereas BMGF gave most of its funds to research. BMGF grants in 2005 were given largely to private research organisations, universities, and civil societies in rich countries, whereas the US Government and Global Fund primarily disbursed grants to sub-Saharan Africa. Publicly available data for global health disbursements is incomplete and not standardised. Continued attention is needed to develop country ownership, particularly in planning and priority setting.

Bridging the divide: global governance of trade and health

Harvard Global Health Institute (Prof A Jha MD, S Moon PhD, L R Woskie MSc, J A Leigh MPH), Harvard T.H. Chan School of Public Health (Prof A K Jha, S Moon, L R Woskie, J A Leigh), and Harvard Kennedy School (S Moon), Harvard University, Boston, MA, USA; University of Edinburgh Medical School, Edinburgh (Prof D Sridhar DPhil); Duke Global Health Institute, Durham, NC, USA (M A Pate MD); Bill, Hillary & Chelsea Clinton Foundation, New York, NY, USA (C Clinton DPhil); Medecins Sans Frontieres, New York , NY, USA (S Delaunay MA); Campaign for Good Governance, Freetown, Sierra Leone (V Edwin MA); Action Contre La Faim International , Monrovia, Liberia (M Fallah PhD); Indiana University Maurer School of Law, Bloomington, IN, USA (Prof D P Fidler JD); Council on Foreign Relations, New York, NY, USA (L Garrett PhD); University of California, San Francisco, CA, USA (Prof E Goosby MD); Georgetown University, Washington, DC, USA (Prof L Gostin JD); Chatham House, London, UK (Prof D L Heymann MD); Simon Fraser University, Burnaby, BC, Canada (Prof K Lee DPhil); Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (Prof G M Leung MD); Center for Strategic and International Studies, Washington DC, USA (J S Morrison PhD); AIDS Executive summary The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confi dence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine jointly launched the Independent Panel on the Global Response to Ebola. Panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the Ebola outbreak. After diffi cult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. The Panel’s conclusions off er a roadmap of ten interrelated recommendations across four thematic areas:

Achieving global targets for antimicrobial resistance

Background The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases. Methods We conducted a systematic search of Medline, EMBASE and Global Health for original, population–based studies providing spirometry–based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta–analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta–estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Banks income categories and settings (urban and rural). We developed a meta–regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more. Findings Our search returned 37 472 publications. A total of 123 studies based on a spirometry–defined prevalence were retained for the review. From the meta–regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%–14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%–15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in women. Conclusions Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.

Who sets the global health research agenda? The challenge of multi-bi financing.

Summary The main institutions responsible for governing international trade and health—the World Trade Organization (WTO), which replaced the General Agreement on Tariffs and Trade (GATT) in 1995, and WHO—were established after World War 2. For many decades the two institutions operated in isolation, with little cooperation between them. The growth and expansion of world trade over the past half century amid economic globalisation, and the increased importance of health issues to the functioning of a more interconnected world, brings the two domains closer together on a broad range of issues. Foremost is the capacity of each to govern their respective domains, and their ability to cooperate in tackling issues that lie at the intersection of trade and health. This paper discusses how the governance of these two areas relate to one another, and how well existing institutions work together.

The Joint Action and Learning Initiative: Towards a Global Agreement on National and Global Responsibilities for Health

The UN should promote targets, funding, and governance After decades of neglect, antimicrobial resistance (AMR) has captured the attention and concern of the public health community and global leaders. In September 2016, a high-level meeting of the United Nations General Assembly (UNGA) will discuss how countries can cooperate to preserve global access to effective antimicrobials. This will be only the fourth health issue (and the first One Health issue, integrating human, animal, and environmental health) to bring together heads of state at the UNGA for a rare opportunity to set a global agenda to combat the crisis. We believe that (i) setting targets for reducing drug-resistant infections, (ii) adequate financing for global action, and (iii) defining the global health architecture to address AMR should be elements of a UN plan.

Reforming the World Health Organization

As part of a cluster of articles critically reflecting on the theme of “no health without research,” Devi Sridhar discusses a major challenge in the governance of research funding: “multi-bi” financing that allows the priorities of funding bodies to dictate what health issues and diseases are studied.