Richard Feachem

Global health 2035: a world converging within a generation

Prompted by the 20th anniversary of the 1993 World Development Report a Lancet Commission revisited the case for investment in health and developed a new investment frame work to achieve dramatic health gains by 2035. The report has four key messages each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. Conclusion 1: there is a very large payoff from investing in health. Conclusion 2: a grand convergence is achievable within our lifetime. Conclusion 3: scale-up of low-cost packages of interventions can enable major progress in NCDs and injuries within a generation. Conclusion 4: progressive universalism is an effi cient way to achieve health and fi nancial protection.

Expansion of cancer care and control in countries of low and middle income: a call to action

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health communitys assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.

The changing epidemiology of malaria elimination: new strategies for new challenges

Malaria-eliminating countries achieved remarkable success in reducing their malaria burdens between 2000 and 2010. As a result, the epidemiology of malaria in these settings has become more complex. Malaria is increasingly imported, caused by Plasmodium vivax in settings outside sub-Saharan Africa, and clustered in small geographical areas or clustered demographically into subpopulations, which are often predominantly adult men, with shared social, behavioural, and geographical risk characteristics. The shift in the populations most at risk of malaria raises important questions for malaria-eliminating countries, since traditional control interventions are likely to be less effective. Approaches to elimination need to be aligned with these changes through the development and adoption of novel strategies and methods. Knowledge of the changing epidemiological trends of malaria in the eliminating countries will ensure improved targeting of interventions to continue to shrink the malaria map.

Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente.

Abstract Objective: To compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California. Methods: The adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators. Results: The per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS. Conclusions: The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology. What is already known on this topic Comparisons of healthcare systems in different countries have to be undertaken with great care but can be instructive The overall healthcare system in the United States is more expensive than the NHS and population health outcomes are no better The US healthcare system comprises many discrete and unique subsystems, including the health maintenance organisations What this paper adds An integrated, non-profit health maintenance organisation in California (Kaiser Permanente), with over six million members, costs about the same as the NHS but performs considerably better Kaisers superior performance is mainly in prompt and appropriate diagnosis and treatment These findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment

Shrinking the malaria map: progress and prospects

Summary In the past 150 years, roughly half of the countries in the world eliminated malaria. Nowadays, there are 99 endemic countries—67 are controlling malaria and 32 are pursuing an elimination strategy. This four-part Series presents evidence about the technical, operational, and financial dimensions of malaria elimination. The first paper in this Series reviews definitions of elimination and the state that precedes it: controlled low-endemic malaria. Feasibility assessments are described as a crucial step for a country transitioning from controlled low-endemic malaria to elimination. Characteristics of the 32 malaria-eliminating countries are presented, and contrasted with countries that pursued elimination in the past. Challenges and risks of elimination are presented, including Plasmodium vivax, resistance in the parasite and mosquito populations, and potential resurgence if investment and vigilance decrease. The benefits of elimination are outlined, specifically elimination as a regional and global public good. Priorities for the next decade are described.

Adult mortality in developing countries

For the past decade, the international health community has focused on the burden of childhood mortality and morbidity in developing countries. As a consequence, there has been little comprehensive, as contrasted with disease-specific, interest in the health problems of adults. Underlying this lack of attention is the widespread belief that once a person reaches adulthood, there is little difference in mortality experience between developing and industrialized countries. Some would probably go so far as to suggest that adult mortality should be lower in some developing countries because of the rarity of certain ‘western’ risk factors for chronic diseases. The reality is different: adult mortality, as well as child mortality, is much higher in developing than in industrialized countries and represents an important target for development policy and intervention. Adults may be defined with reference to the roles that they play in society. They are the parents, the workers, and the leaders in all communities. Adults are also the providers and care-givers for children and the elderly. A functional definition of adulthood, while appealing, is not well suited to quantitative analysis. We have, therefore, defined adulthood as the population aged 15 to 59 years. This definition is consistent with the United Nations defmition of the ‘aged’, which includes the population over age 60. The age-span 15 to 59 includes those age-groups in which, in industrialized countries, we expect mortality to remain quite low. For most of us, deaths before age 60 are premature and should be prevented. With this definition of adulthood, 56% of the developing world’s population are adults; they number a httle over 2x 10 ; and 32% of them live in China. According to World Bank estimates, in the developing world as a whole, 38% of deaths occur in children aged ti years, while 27% occur in adults (15-59). To adjust for the expected age-distribution of deaths in a low mortality country, we can calculate avoidable deaths. These are deaths that would not occur if the mortality rates of a specified low mortality reference population applied to developing countries. Japanese death rates in 1987 have been used as a reference-Japan has the highest life expectancy in the world. According to these computations, there are 8 million avoidable adult deaths each year in the

The Health of adults in the developing world

1. Introducing adult health 2. Adult mortality: Levels, patterns and causes 3. Adult morbidity: Limited data and methodological uncertainty 4. The consequences of adult ill-health 5. Current and future determinants of adult ill-health 6. The emerging agenda for adult health Appendix Tables

A new global malaria eradication strategy

On Oct 17, 2007, Bill and Melinda Gates called for complete eradication to be adopted as the new goal for the age-old fi ght against malaria, with the Director General of WHO, Margaret Chan, promptly echoing their conviction. Although debate over the wisdom of this target will continue, growing impatience with the low ambitions of current eff orts, fuelled by reductions in morbidity and mortality in some countries and progress in the development of new drugs and the fi rst-ever vaccine, will lead many decision makers to adopt eradication of malaria as the primary aim for their organisations. Two crucial questions stand out for those organisations that will now begin striving towards malaria eradication. When and how can it be achieved? Barring a magic bullet, which the most promising vaccine candidates are not, even the most optimistic malaria experts agree that eradication is decades away. The latter question, however, requires prompt attention. If a goal as ambitious as eradication is to be achieved, key groups—including donors, technical agencies, the scientifi c community, and countries where the disease is endemic—must align their energies and resources behind a common approach. That strategy should not be so prescriptive as to prevent appropriate variation among countries and donors, but should provide strong direction to ensure that global investment is well targeted and coordinated. Alternatively, if each donor and agency pursues their own agenda, the momentum gathered over the past 5 years will be lost and the fatalism and inaction that characterised the last decades of the 20th century will return. The malaria community should therefore take immediate steps, including broad debate and detailed technical consultation, to develop a common approach. In November, 2007, the Roll Back Malaria Partnership endorsed the creation of a global malaria business plan to guide collective eradication eff orts. With this Viewpoint, we hope to begin a debate on the strategy that can provide the best overarching framework for that plan and often collective malaria eff orts. The fi rst global strategy for the fi ght against malaria was adopted in 1955 at the start of the now notorious Global Malaria Eradication Program. This strategy called for massive and rapid application of di chlorodiphenyltrichloroethane (DDT) to interrupt transmission of the disease in countries around the world, regardless of geography and epidemiology (the notable exception was the exclusion of sub-Saharan Africa from this, so called, global strategy). This approach failed to interrupt transmission completely in many countries and malaria resurged to previous or even higher levels as eradication programmes crumbled and the strategy was abandoned. Although no-one will argue for the resurrection of this strategy in full, current impatience has revived interest in rapid indiscriminate attacks to eradicate malaria. Countries such as Kenya, Rwanda, and Zambia, which generated enthusiasm for an all-out attack with success in reducing malaria mortality by as much as 60%, also show why this strategy would not be advisable. Even if one of these countries did successfully eliminate transmission of malaria, they would fi nd it nearly impossible to sustain, because the parasite would inevitably be reintroduced by migrants and travellers from neighbouring countries with high transmission. Both experience and modelling show us that even a few infections can quickly lead to an epidemic in areas with effi cient vectors and limited protective measures. One of the principal lessons of the fi rst global eradication campaign was that the intensive eff ort needed to prevent resurgence in areas with continued exposure to parasite reservoirs cannot be maintained over time, because fi eld workers tire and lose precision and donors and governments shift resources to seemingly more urgent problems. Thus, even with the large arsenal and war chest available today, an indiscriminate push to eliminate malaria could lead to epidemics and erosion of years of work and investment. Today’s eff orts against malaria target a reduction in malaria mortality through progressive scaling up of a package of interventions. Progress in implementation was at fi rst poor. In the past 3 years, however, many countries have reported more promising results, with steep reductions in morbidity through increased use of insecticide-treated bed nets and other interventions. Seeking to expand this success, a new report launched at the 2008 World Economic Forum in Davos compellingly makes the case for a concerted short-term push to increase coverage of key interventions above 80% and slash morbidity and mortality in malaria-endemic countries. Aggressive scaling up should be the central component of any new strategy, with a dedicated group of well managed professionals helping countries to overcome bottlenecks and to achieve their goal. But the Davos report and other descriptions of this approach leave an essential question unanswered: what happens after aggressive short-term targets are achieved? Maintainence of intensive interventions will be diffi cult once malaria is no longer a major public-health threat and donors and populations lose interest. A breakthrough intervention, such as a highly protective and long-lasting vaccine, will not be available for at least 20 years, while widespread changes in living standards of the sort that contributed to elimination in Europe and the USA will undoubtedly take much longer. Hence, a short-term push must be complemented by a long-term strategy. Lancet 2008; 371: 1633–35

Call to action: priorities for malaria elimination

The Lancet’s four-part Series on malaria elimination summarises the remarkable progress achieved over the past 100 years and discusses the substantial technical, operational, and financial challenges that confront malaria-eliminating countries.1–4 The Series comes at a time when there are increased resources to combat malaria worldwide. A three-part strategy to achieve malaria eradication has been developed and is widely endorsed: aggressive control in high-burden regions; progressive elimination from endemic margins to shrink the malaria map; and research and development, to develop new tools and techniques.5 All three components are important and must proceed simultaneously. This Comment focuses on the priorities, requirements, and responsibilities that are associated with the second part of this strategy: shrinking the malaria map.

Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications.

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.