All posts by Sam Byfield

Sam Byfield is the Non Communicable Diseases Coordinator at the Nossal Institute for Global Health in Melbourne, Australia. He previously worked at Vision 2020 Australia, where he contributed to cementing blindness prevention as a priority in Australia’s Aid Program; at the Yunnan Health and Development Research Organisation, where he worked on advocacy and programs to address environmental health problems in Southwest China; and at the Australian Parliament, where he undertook research and analysis across a range of foreign policy issues. His other interests include disability inclusive development (for three years he was a member of the Executive Committee of the Australian Disability and Development Consortium) and China’s emergence as an aid donor.

Global disease burden and funding – explaining the disparities

In May, the Institute for Health Metrics and Evaluation (IHME, who also published the influential Global Burden of Disease Study) published estimates of funding for global health for 1990-2013. The article contains noteworthy findings, including:

  • In 2013, health aid surpassed $31 billion, the highest level of funding to date and 5.5 times larger than the level in 1990;
  • In the past three years, ongoing increases in health aid have been fuelled largely by the Global Fund, GAVI Alliance and UK bilateral agencies, with reductions in funding elsewhere;
  • Funding remains highly focused, with a small number of donors accounting for a high percentage of the total; and
  • There are major disparities between burden of disease and funding allocated, with non-communicable diseases (NCDs) receiving a tiny percentage of funding, compared with their burden.

Funding disparities

NCDs are now the leading global cause of death and disability, including in developing countries, as I explored in a recent report by ACFID. This new IHME study shows these diseases receive only a tiny amount of funding when compared with their burden. In 2011, $7.7 billion was allocated to HIV/AIDS projects, while malaria, TB, and maternal, newborn and child health received $1.8 billion, $1.3 billion, and $6.1 billion respectively. NCDs received only 1.5% of all health aid.

Mixing an indicator solution with the patient’s urine, and then heating the solution, provides low-cost screening for diabetes. (Anirudh Kumar, Jamkhed: Comprehensive Rural Health Project.)
Mixing an indicator solution with the patient’s urine, and then heating the solution, provides low-cost screening for diabetes. (Anirudh Kumar, Jamkhed: Comprehensive Rural Health Project.)

Why the disparity?

Why does this disparity exist? IHME suggests that data on cost-effectiveness of NCD interventions are less clear than those for HIV/AIDS and other diseases. Additionally, the most cost-effective interventions may include prevention through taxation and regulation that do not require ongoing financial investment. Further, management of diabetes requires long-term monitoring and medication – whereas a vaccine, for instance, can be administered in one or a few doses, and return on investment can be more easily calculated.

While there is merit to these suggestions, I think there are also other forces at work.

Even if we start with the assumption that the lack of data has hindered investment, the logical counterargument is that this situation provides the perfect rationale for investing in more research to help determine what works and what doesn’t, and to help define the overall agenda.

Yet NCDs research (defined broadly, including medical research, epidemiology, and health systems) has also remained largely under-funded. Australian Aid’s Medical Research Strategy, for instance, explicitly states that it won’t fund NCD-related research. There are signs of improvement, however, including through the Global Alliance for Chronic Disease initiative.

Digging deeper – questions of methodology

What other factors might be behind the manifestly inadequate funding levels for NCDs?

One possibility is there may be a methodological limitation in determining what gets defined as an NCDs investment. What constitutes ‘health aid’ is not clear in the IHME article, though it appears to be defined along lines of strengthening health systems and basic health care.

If we look at interventions taking place in the NCDs space, many are outside of what might be strictly referred to as ‘health aid’. A good example is the Australian Aid-funded Development through Sports program, which has the goal of reducing the impacts of NCDs by increasing physical activity. This highlights the need for a nuanced understanding of the variety of sectors and programs that contribute to preventing NCDs.

Physical activity plays a vital role in preventing NCDs. (Anirudh Kumar, Jamkhed: Comprehensive Rural Health Project.)
Physical activity plays a vital role in preventing NCDs. (Anirudh Kumar, Jamkhed: Comprehensive Rural Health Project.)

Another methodological point is that funding for tobacco control is categorised separately, for unknown reasons. As a leading risk factor for NCDs, tobacco prevention and control is an integral part of the NCDs agenda. While it also plays an important role in the progression of other diseases (for instance, smokers are more than 2 times as likely to die from TB than non-smokers), separating tobacco from NCDs seems artificial in this context and is not conducive to getting the most accurate picture.

That said, the funding amount for tobacco is so minimal that its inclusion in the NCDs category would not have made a big difference – funding for HIV/AIDS, was 113 times as large as funding for tobacco control. Perhaps the whole point of this division between NCDs and tobacco was to highlight the minimal amounts of funding for tobacco?

Digging deeper – bridging evidence and policy

The exclusion of NCDs from the Millennium Development Goals has been a major barrier to getting NCDs on the agenda. While they will likely be included in the next iteration of the MDGs, which will help to increase funding, this raises another question: why weren’t NCDs included in the MDGs (and why are they likely to be included in the next iteration)?

One answer is that research and policy have not been effectively bridged. The existence of good evidence does not itself lead to change. What’s needed is advocacy and good policy work to bridge this gap – not only synthesising the available evidence, but understanding how policy works, what the entry points are, and what drives decision makers.

In some contexts, the people doing the research can also act as advocates, and networks between researchers and policy makers are important in enhancing the use of evidence in policy-making processes. However, the skills involved in policy and advocacy can be quite different from those in research, and the advocacy and policy work is often a distant second in terms of priorities, if it’s considered at all.

Funding for NCDs in Australia’s aid program is illustrative. It still seems to be the case that NCDs are swept aside by more vocal interest groups, or placed in the ‘too hard’ basket. The Australian Government has a series of NCD investments in the Pacific, but there is little to indicate an interest in NCDs beyond our immediate region.

There is no unified ‘voice’ to push the agenda and to work with Government in finding solutions, which has also historically limited funding from other bilateral donors, multilateral bodies and philanthropic foundations.

At the global level, such a voice has now emerged, with the NCD Alliance playing an important role in elevating NCDs on the agenda and providing a model for how similar alliances can be established at country-level. NCDFREE also plays an important voice in generating social awareness about these challenges.

Yet in Australia, a cohesive coalition focused on the integration of NCDs in aid programming has yet to emerge, and consequently there has been little impetus for the Australian Government to establish a comprehensive, global approach to addressing NCDs.

With the growth of evidence, momentum, and global actors and frameworks, the NCDs funding situation will change dramatically over the next five years. Hopefully, this will mean future studies of global health funding will demonstrate a clear and proportionate commitment to addressing NCDs (and perhaps even the establishment of a Global Fund-type organisation committed to addressing them). Once this occurs, we might also start to see a reversal of the rise in the global burden of NCDs.

Tobacco, Poverty and the Need for Global Action

The recent High Court judgement in Australia upholding legislation to enforce plain packaging for tobacco products provides a good opportunity to look at the impacts of tobacco in low and middle income countries, and what’s needed to stem the tide of poverty and mortality they cause.

Image credit: iStock photo

It’s increasingly recognised that non communicable diseases (NCDs) are among the greatest threats to global public health. According to the WHO, in 2008 NCDs (consisting of cardio-vascular diseases, chronic respiratory diseases , cancers, and diabetes) were responsible for 63% of all deaths worldwide. The key source for statistics on the burden of NCDs – the WHO’s Global Status Report on NCDs 2010 – presents clear evidence that NCDs primarily affect low and middle income countries. In 2008, 80% of all NCDs deaths occurred in low and middle income countries – an increase from 40% in 1990.

Tobacco use is a major driver of the NCD epidemic, and is one of the single biggest public health threats the world has ever seen. Tobacco causes around 6 million deaths each year, and ultimately kills around half of its users. 10% of people killed by tobacco aren’t even smokers – but instead are killed by exposure to second hand smoke. Importantly, 80% of all smokers are in low and middle income countries. Tobacco use isn’t only a health problem, but is actually a development issue. Tobacco users who die prematurely deprive their families of income, raise the cost of health care and hinder economic development. Money spent on tobacco would obviously be better spent on healthy food and education.

Over recent years there has been increased momentum in global tobacco control. In February 2005, the WHO Framework Convention on Tobacco Control came into force, and since then it has become one of the most widely embraced treaties in the United Nations’ history, with more than 170 Parties covering 87% of the world’s population. The WHO Framework Convention is an important contribution to global public health – it reaffirms the right of people to the highest standard of health, provides legal foundations for international health cooperation and sets high benchmarks for compliance.

Much more, however, is needed if we are to stall and reverse the growth in tobacco use and NCDs more broadly. One of the key elements of the tobacco threat, as countries like Australia recognise and address this problem, is that tobacco companies are adopting increasingly aggressive strategies to increase their infiltration of developing countries. In countries like China, India and Indonesia, overall rises in economic development have led to an increase in tobacco use. A good example of this is the Tobacco Asia Conference, which is scheduled to be held in Indonesia on 19 September 2012.  A coalition of civil society groups came out strongly against this conference, noting that ‘The conference committee deems Indonesia a tobacco-friendly market with no smoking bans or other restrictions or regulations compared to other ASEAN countries. That is an insult to our nation because it means we are supporting death, and we are urging the government to ban this conference.’ Such protest and awareness raising has a vital role to play in ensuring that the tobacco industry and governments are held accountable and that the damage to low and middle income countries is halted.

Image credit: hakaider

It’s also vital that the tobacco control lessons that have been learnt in the developed world are shared with low and middle income countries. In July 2012, the Australia India Institute Taskforce on Tobacco Control launched a report outlining steps that could be taken in India to reduce the use and impacts of tobacco products. Drawing upon achievements in Australia, the report outlines how legislative change, public education, enhanced Government accountability, plain packaging and pictorial warnings will help reduce the roughly 1 million Indians who die from tobacco use each year.

It’s also important that tobacco control is seen as a core element of efforts to improve global public and eliminate poverty. One way this can be achieved is through elements of tobacco control being funded through the aid programs of developed countries like Australia, the United States and the United Kingdom. AusAID has started funding tobacco control in the Pacific, including through activities like surveys on youth smoking, promotion of the Framework Convention on Tobacco Control, and interventions including enforcement training. AusAID is also providing funding to address the disease outcomes of tobacco use, including cancer. This funding is currently focused on the Pacific, and it’s important that Australia’s commitment broadens to include other countries with major tobacco and NCD problems in Southeast Asia and beyond.

Finally, it’s vitally important that international development agencies embrace the need to tackle tobacco use. At present, programs to reduce tobacco use and control NCDs are largely limited to agencies that have a specific focus on these issues. The World Health Assembly’s decision in May 2012 to adopt a new global target of a 25% reduction in premature mortality from NCDs by 2025 was a step in the right direction; as was the inclusion of NCDs in the Rio + 20 Earth Summit’s outcomes document The Future We Want. What’s needed now is for tobacco control and NCDs to be placed at the centre of the international development discourse. The Oxfams and World Visions of the world need recognise and respond to the problem, and the post 2015 MDGs need to have a clear commitment to this crucial public health and development issue.