Quiz

Setting Priorities in Public Health: Local and Global Levels

Neff Walker, PhD Johns Hopkins University

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How Do We Decide?

Section A

 It is a zero-sum game  We have limited funds to spend to reach our goals  Spending on one intervention or approach means less money for other approaches

• “Universal Access” and “Health for All” are slogans, not solutions  Focusing on one disease or intervention takes people and energy away from others  Therefore, people have to make choices and set priorities

So How Do We Decide What to Do?

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 Burden of disease  Typically measured in morbidity, mortality, or disability-adjusted life years (DALYs)

 Effectiveness of interventions

 Costs of interventions

 Scalability  Difficulty of intervention  Current health delivery system  Methods of delivery

What Information Do We Need to Set Priorities?

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 Burden of disease  Typically measured in morbidity, mortality, or disability-adjusted life years (DALYs)

 Effectiveness of interventions

 Costs of interventions

 Scalability  Difficulty of intervention  Current health delivery system  Methods of delivery

 Funding sources (violating zero-sum assumptions)

 Alternative approaches and comparisons

What Information Do We Need to Set Priorities?

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 Cost-effectiveness analysis approaches try to bring together the aforementioned categories and estimate the cost per life saved, case averted, or DALY averted

 It is very difficult to do a complete job  Data for inputs are often scarce  Analysis and results are often country and delivery platform dependent

Cost-Effectiveness Analysis

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 Lancet neonatal series (2013)  Costs and effectiveness of “kangaroo mother care”

 WHO Choice and expansion path (22 childhood interventions)

 New vaccines for enterotoxigenic Escherichia coli (ETEC) and Shigella

Examples of Cost-Effectiveness Issues

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The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Setting Priorities

Section B

 In an ideal world, we would do these types of analyses for each country or region

 Then, on the basis of the results, we would prioritize health interventions

 Even then, we would have questions about the reliability of these analyses, as well as their generalizability

Setting Priorities

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 AIDS

 Influenza/epidemics

 Polio

Some Examples of Global Priority Setting in Health

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 Until approximately 2000, UNAIDS provided estimates of impact and costs of interventions every two years

 Around 2003, United States pledged money through President's Emergency Plan for AIDS Relief (PEPFAR)

 Brazil decided to provide antiretrovirals for all citizens of their country, in part by ignoring patent laws, thus putting pressure on drug companies

 Drug companies and United Nations were quietly discussing possibility of providing second-tier drugs to low- and middle-income countries at lower cost  Wall Street Journal released news of these discussions  UN agreed to drug companies’ plan

 Bono and Jessie Helms bonded over Jesus and helped make AIDS a global priority

HIV/AIDS

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 Misalignment of priorities and reality:  AIDS orphans in China  Prevention of mother-to-child transmission (PMTCT) in Bangladesh  Distribution of antiretrovirals versus antibiotics in Africa

What Has This Done to the System in Many Countries?

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 We track flus in Asia (generally the source) and then predict issues

 Look for specific types that have high transmissibility and case fatality rate

 When we find a flu like this and there is some spread, then we react

The Great Influenza, SARS, and the Probability of One

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Pandemic Year Influenza virus type

People infected (approximate)

Estimated deaths worldwide

Case fatality

rate

Spanish flu 1918–1919 A/H1N1 33% (500 million) 20–100 million >2.5%

Asian flu 1956–1958 A/H2N2 ? 2 million <0.1%

Hong Kong flu 1968–1969 A/H3N2 ? 1 million <0.1%

Seasonal flu Every year Mainly A/H3N2, A/H1N1, and B

5–15% (340 million –

1 billion)

250,000–500,000 per year

<0.1%

H1N1 2009–2010 Pandemic H1N1/09

> 622,482 (lab- confirmed)

14,286 (lab-confirmed, ECDC); 18,036 (lab- confirmed, WHO)

0.03%

20th-Century Flu Pandemics

Source: “2009 Flu Pandemic.” In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/w/index.php?title=2009_flu_pandemic&oldid=645718514. Accessed February 24, 2015. 7

 Scared everyone to death

 Billions of new funding for basic and applied research

 Stockpile of Tamiflu (oseltamivir phosphate) and other antivirals

So What Did We Do?

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The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Polio Eradication

Section C

 How did this become a global priority?

 Set target for eradication by the year 2000

 Cost was initially estimated at 4-6 billion dollars

 Since 2000, we have spent more than 10 billion dollars

 Level of polio is very similar to what it was before campaign, with some regional successes, but we are not really any closer to eradication

 So why do we do it?

Polio Eradication

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Estimated Savings

Sources: Duintjer Tebbens, R. J., Pallansch, M. A., Cochi, S. L., et al. (2010). Economic analysis of the global polio eradication initiative. Vaccine, 29(2), 334–343. Image: Polio Global Eradication Initiative. Economic Case for Eradicating Polio (Summary). Available at: http://www.polioeradication.org/Resourcelibrary/ Strategyandwork.aspx. Accessed February 23, 2015.

An economic analysis by infectious- disease experts (Duintjer Tebbens, et al., 2010) estimated that by preventing some 8 million cases of polio paralysis from 1985 to 2035, the GPEI will create net gains of $40 to $50 billion, mostly in the developing economies

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Polio: An American Story, by David Oshinsky

Source: Oshinsky, D. M. (2006). Polio: An American Story (1st edition). Oxford ; New York: Oxford University Press. 4

 Except in a few cases (e.g., perhaps United Kingdom and new treatments), few priorities are set by objective and repeatable methods

 Instead, priority setting depends on building a consensus for need, which is just as often a political or social function as one driven by science

 Also, usually the people who are promoting an issue or intervention have a vested interest, so the buyer must beware

 Consider who has money and who gets money

 Consider the role of confirmation bias

So, How Are Priorities Set?

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Lecture Evaluation

Your feedback is very important and will be used for future revisions. The Evaluation link is available on the lecture page.

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