amanda glassman
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Global Health and the New Bottom Billion Input into thinking about policy implications for adult vaccination in middle-income countries
Amanda Glassman
Director of Global Health Policy Center for Global Development
September 2013
Source: Sumner, 2011
Most of the world’s poorest people live in middle-income countries
• In 1990, over 90% of the world’s poor lived in low-income countries (LIC)
• Now, more than 70% of the world’s poorest people live in middle-income countries (MIC)
• Most of the “new bottom billion” live in stable, non-fragile MIC
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Global Distribution of World Poverty
% of World’s Poor, $1.25/Day
Source: PoVCal
Number of LIC & MIC, 2000-2025E
Sources: Moss and Leo, 2011; World Bank, 2011 *If China is excluded
Even more of the world’s poor will live in MIC over time
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LIC (Countries) MIC (Countries)
2000 63 92
2003 61 93
2008 43 101
2009 40 104
2010 35 110
2025 (estimate) 20 130
• Moss and Leo (2011) project that there will be only 20 LIC in 2025
• Although the number of LIC continues to fall, global poverty, defined as total number of people living under US$1.25 or $2 per day remains around 1 bn to 2 bn, respectively*
Total burden of disease has also shifted to MIC
4
Total Burden of Disease (DALY), All Causes (MMs), 2010
Source: Institute for Health Metrics and Evaluation – GBD 2010 Data
462
266
1,112
346
1,724
284
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High income
DA
LYs
(MM
s)
MIC as a group has the greatest disease burden associated with tuberculosis
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Number of Cases of Tuberculosis (MMs), 1990-2009
Source: World Health Organization Statistical Information System (WHOSIS), 2011; IHME – GBD 2010 Data
2.06 1.58
7.75
1.47
10.80
0.41
3.50 1.74
7.00
1.20
9.93
0.19 0
5
10
15
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High income
Nu
mb
er o
f C
ase
s (M
Ms)
1990 2009
Burden of Disease Associated with Tuberculosis (DALY) (‘000), 2010
12,746
5,016
27,913
3,550
36,479
500 0
10,000
20,000
30,000
40,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High incomeDA
LYs
(‘0
00
)
Source: IHME – GBD 2010 Data
Disease burden related to measles is concentrated among the PINCI, while that of HIV / AIDS is equally concentrated among PINCI and upper MIC
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Burden of Disease Associated with Measles (DALY) (‘000), 2010
2,495 793
6,976
141
7,910
10 0
2,000
4,000
6,000
8,000
10,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High incomeDA
LYs
(‘0
00
)
Burden of Disease Associated with HIV / AIDS (DALY) (‘000), 2010
29,271
10,906 20,881 19,238
51,025
1,127 0
10,00020,00030,00040,00050,00060,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High incomeDA
LYs
(‘0
00
)
Source: IHME – GBD 2010 Data; World Health Organization Global Disease Burden Database, 2008 Note: Vaccine preventable diseases includes pertussis, poliomyelitis, diphtheria, measles, and tetanus; *poliomyelitis data is from the WHO and is 2004 data
In the case of vaccine-preventable diseases, MIC, particularly PINCI, have a much higher burden than LIC
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Total Burden of Disease Associated with Vaccine-Preventable Diseases (DALY) (‘000), 2010*
6,695
1,631
13,652
312
15,595
50 0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High income
DA
LYs
(‘0
00
)
Source: World Health Organization Statistical Information System (WHOSIS), 2011 Note: DTP-3 vaccination rate pertains to 1 year olds, calculated by multiplying the crude birth rate, life table survivors at the age of one, and the total population, divided by 100. The period is 2005-2010
The shift of disease burden to MIC is driven by population size, but also by lagging effort on public health prevention programs
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5,477
2,434
14,440
1,262
18,135
652
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High income
Nu
mb
er
of
Pe
op
le (
‘00
0)
PINCI have the largest number
of DTP3 unvaccinated
children
Number of DTP3 Unvaccinated Children (‘000), 2010
Armenia
Azerbaijan
Bangladesh
Bolivia (Plurinational State of)
Colombia
Congo
Dominican Republic
Egypt
Ethiopia
Ghana
Guinea Haiti
Honduras
India
Indonesia
Jordan
Kenya
Liberia
Maldives
Morocco
Namibia
Nepal Niger
Nigeria Pakistan
Philippines Republic of Moldova
Rwanda
Senegal
Sierra Leone
Swaziland
Timor-Leste Uganda
Zambia
Zimbabwe
0
1000
2000
3000
4000
5000
6000
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
GD
P p
er
Cap
ita
% DTP3 Vaccination Coverage
DTP3 Vaccination Coverage and GDP per Capita in LIC and Lower-MIC
Source: World Health Organization Statistical Information System (WHOSIS), 2011 Note: Line represents the income per capita threshold between LIC and MIC, which is $1,006 according to the most recent World Bank definition
Many MIC have relatively poor vaccination performance
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Graphic: Glassman, et al. / Vaccine 31S (2013)
Over the past 20 years, PINCI have done relatively poorly on different dimensions of quality and coverage of DTP3 vaccination
10
nd < 38 38 - 49 49 - 5959 - 69 69 - 79 79 - 90 > 90
Range
Source: Own calculations on OECD, WHO and WDI data.
Spatial Distribution of Own Vaccination Performance
Graphic: Glassman, et al. / Vaccine 31S (2013)
Although most LIC and MIC governments spend less on their own vaccination programs, some mostly self-finance
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nd < 14 14 - 29 29 - 4343 - 57 57 - 71 71 - 86 > 86
Range
Source: Own calculations on OECD, WHO and WDI data.
Spatial Distribution of Own Vaccine Financing and Management
Source: LIC/LMIC/UMIC/HIC spending based on own calculations from WHOSIS; cost of a WHO-recommended load of vaccines based on Medecins Sans Frontieres (2012) report includes 1 BCG, 3 oral polio vaccine, 3 DRP, 2 measles, Hep B, Hib, PCV, rotavirus and rubella. The Saxenian and Hecht (SH) figure of $62 includes new vaccines in addition to the WHO-recommended load: HPV, Japanese encephalitis, pentavelent, pneumo, yellow fever and typohoid
However, judging from existing levels of spend and projected costs, many MIC will face challenges in self-financing their immunization programs
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Vaccine Spending per Child by Income Group
Estimated cost of a full package of WHO recommended routine immunization schedule
$1
$8
$25
$38
$62
$69
$0
$10
$20
$30
$40
$50
$60
$70
$80
Low income Lower middleincome
Upper middleincome
Medecins sansFrontieres
Saxenian andHecht
High income
Vac
cin
e S
pe
nd
ing
pe
r C
hild
Spending versus estimated cost of a full package of WHO recommended routine immunization schedule
A new, tailored MIC strategy needs to be developed
• Eliminating income thresholds as an across-the-board eligibility criteria – Working in poorer regions in populous MIC
• Setting up regional pooled procurement schemes as at PAHO, or creating a MIC window at GAVI
• Building evidence-based priority-setting institutions in MIC
• Establishing better measurement and accountability mechanisms
• Providing technical support to MIC
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Sources
• Glassman A., Duran, D., and Sumner, A., “Global Health and the New Bottom Billion: What Do Shifts in Global Poverty and the Global Disease Burden Mean for GAVI and the Global Fund?” CGD Working Paper 270 (Washington: Center for Global Development, 2011). http://www.cgdev.org/publication/global-health-and-new-bottom-billion-what-do-shifts-global-poverty-and-global-disease
• Sumner A. (2010) Global Poverty and the New Bottom Billion. IDS Working Paper.
• Edward P., and Sumner A., “The Future of Global Poverty in a Multi-Speed World: New Estimates of Scale and Location, 2010-2030” CGD Working Paper 327 (Washington: Center for Global Development, 2013). http://www.cgdev.org/sites/default/files/future-of-global-poverty_1.pdf
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Contact
• Amanda Glassman
– @glassmanamanda
– www.cgdev.org
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APPENDIX
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Source: World Health Organization Statistical Information System (WHOSIS), 2011
Total MIC fare worse than LIC on ARV coverage of HIV positive people
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Number of People Infected with HIV and not receiving ARV Treatment (‘000), 2008
8,138
3,343
6,315 7,171
16,829
1,315
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Low income Lower middleincome
(net of PINCI)
PINCI Upper middleincome
Total MIC High income
Nu
mb
er
of
Pe
op
le (
‘00
0)