Editorial J Epidemiol Community Health: first published as 10.1136/jech-2018-210605 on 21 May 2018. Downloaded from Understanding donor choices: Donors, non-communicable diseases challenges best solved by countries? and universal health coverage to high- A confluence of factors helps to explain donor paralysis in responding to NCDs, quality healthcare: an opportunity for health system strengthening and UHC. First, the additional cost to achieve action on global functions for health Sustainable Development Goal 3 in LMICs is projected at US$274–$371 billion annu- Arian Hatefi,1 Luke Allen2 ally through 2030; the CIH estimated that about US$70 billion of that would be In years past, the face of the global burden for infectious diseases. Left unreconciled needed for the unfinished agenda alone.1 9 of disease was a rural child suffering is the pressing need to address the global With only US$38 billion per year in total undernutrition and infections in a low-in- NCD crisis with strong health systems that development assistance for health, it is come country. The case for donor inter- equitably cover everyone. overwhelming for donors to provide vention—both bilateral and That burden is enormous. NCDs country-specific functions to these ends.6 philanthropic—was morally, technically accounted for 73% of global deaths Second, the emerging and cost agendas and economically clear. Today, however, it (40 million people) in 2016, of which are complicated by the difficulty of is more commonly an urban adult suffering 75% (30 million) were in low-income measuring the usual donor metrics of lives multiple chronic diseases in a middle-in- and middle-income countries (LMICs). saved or DALYs averted. Health systems, come country. How could donors provide A staggering 38% of global NCD deaths UHC and NCDs are the products of many universal health coverage (UHC) or meet (15 million) occurred in working-age variables, many of which exist outside of such an expansive need for healthcare adults in LMICs who are vital to their healthcare system control; interventions 4 5 services? Would they invest in adults who countries’ economic growth. Yet, NCDs in these domains generally do not produce have already had a shot at life and whose attract only 1.7% of development assis- measurable results in short time frames. 6 lifestyle choices are supposedly to blame? tance for health. Meanwhile, sector-wide Finally, NCDs have not enjoyed the What role could they have in a country approaches and health system strength- moral backing that other diseases have. with resources? These questions need ening (which ostensibly provide NCD Long held to be the products of choice answers. care) attract just 9.6% despite the burden and chance, NCDs are still incorrectly

In 2013, the Lancet Commission on of unsafe medical care: for example, thought of as privately held diseases of copyright. Investing in Health (CIH) grouped the in-hospital adverse events alone accounted the elderly in rich countries that are inca- agenda into three categories: for 23 million disability-adjusted life-years pable of spreading through and destabi- the unfinished agenda to reduce dispari- (DALYs) lost worldwide (15 million in lising societies.10 Pitted against infectious 6 7 ties in key infectious diseases and repro- LMICs). Furthermore, about half of diseases, which are often seen as acute, ductive, maternal and child health; the the world’s 7.3 billion people do not even public and global threats, NCDs have been emerging agenda to curb non-communi- have sufficient access to essential care, overshadowed. cable diseases (NCDs) and injuries; and the and health-related costs expose almost Other factors certainly contribute, cost agenda to provide universal coverage 1 billion people to financial hardship and 1 8 like complex, multifactorial aetiologies, to high-quality healthcare (figure 1). impoverishment each year. The world’s a weak civil society demand for action Since that time, pandemic preparedness poor suffer more from NCDs, are less

and vested commercial interests in main- http://jech.bmj.com/ has yet again emerged as an additional able to access minimum quality care and taining the status quo. Taken together, all priority. The donor response to these are more vulnerable to catastrophic health of these factors—too big, too complex, challenges primarily exists on two levels: expenditure. global functions, which transcend national sovereignty to provide globally dispers- ible benefits, and country-specific func- tions, which are targeted interventions that improve the health of any individual on September 29, 2021 by guest. Protected country (figure 1).2 3 Overwhelmingly, donors have focused their efforts on coun- try-specific functions for the unfinished agenda, or as of late, on global functions

1Division of Hospital Medicine, Department of Medicine, Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA 2British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK Correspondence to Dr Arian Hatefi, Division of Hospital Medicine, Department of Medicine; Institute for Global Health Sciences, University of California San Figure 1 Global functions will remain important in global health, while country-specific Francisco, San Francisco, CA 94143, USA; ​Arian.Hatefi@​ ​ functions will decrease as countries transition. Both will continue to support the major global ucsf.edu​ health priorities. Adapted from Jamison et al.3

Hatefi A, Allen L. J Epidemiol Community Health Month 2018 Vol 0 No 0 1 Editorial J Epidemiol Community Health: first published as 10.1136/jech-2018-210605 on 21 May 2018. Downloaded from wrong turf—may seem to justify low and advocacy can lead to a virtuous cycle, Striking balance with the donor engagement, but donor investment whereby small investments can lead to provision of global functions in global functions may be a rational and strong issue attention, financial backing Finite resources mandate allocative effi- realistic way to meaningfully enhance and actor power. ciency between global and country-spe- donor assistance. Global functions must remain in service cific functions, and among competing to country-owned health development priorities. Zero-sum shifts in donor allo- priorities, and not the other way around. cations can be politicised and crippling, Global functions: a rational But sometimes sovereignty is counter- so synergistic, win-win strategies are para- choice for donors productive to health. When challenges mount. For example, donors can continue Global functions for health are a small exist at the interface of donors and coun- to exploit natural synergies between HIV but critical part of the response to today’s tries—for example, when states prioritise and NCD interventions from local to global health challenges. Global functions non-evidence-based approaches, cosy global scale so that both disease groups globalise health ‘goods’ and contain health up to problematic commercial interests, win and global functions enhance needed ‘bads’; flagship examples include creation suffer from despotic rule or inadequately country functions. of a safer world from the ‘Big 3’ infectious prioritise vulnerable populations—global Countries will not consume global diseases (via PEPFAR and the Global Fund functions may help by creating global public goods if they do not demand them to Fight AIDS, Tuberculosis, and ) public goods, exerting pressure on both or deem them useful, jeopardising returns or vaccine-preventable diseases (via Gavi, governors and the governed, and by on investment. Donors, then, must be the Vaccine Alliance) or through inter- leveraging negative externalities to incen- intensely focused on providing global national cooperative mitigation of the tivise participation in the international functions that are responsive to country tobacco pandemic (via the Framework order. needs, useful in nearly any country context Convention on Tobacco Control). Second, global NCD and health system and support their most vulnerable groups. Compared with country-specific func- research funding often better targets rich Global functions for the emerging and tions, global functions can efficiently country needs, like incremental drug cost agendas should not replace other support countries to fulfil their health development, than LMIC needs, like pressing global health challenges. The systems’ obligations by globalising the new cost-effective therapies or improved unfinished agenda remains unfinished, 12 13 benefits of relatively small investments. implementation strategies. The pandemics will continue to present them- 2 Yet they are grossly underprovided, donor community can enhance pro-poor selves and individual nation-states will probably because of some combination of research and development investments remain the most important actors in free-riding, zero-sum policies and vastly targeted at middle-income countries (eg, improving the health of their populations. copyright. diverse country needs. There is an increas- through research supporting the imple- The staggering burden of NCDs, iatro- ingly important opportunity for donors to mentation and scale-up of the WHO genic morbidity and mortality, and impov- provide global public goods for health in atherosclerotic heart disease programme, erishment from out-of-pocket payments general, and specifically on the emerging Global Hearts, into existing primary care are urgent global health challenges. Amid 14 and cost agendas. infrastructures). limited donor resources, transition to UHC, healthcare service delivery and Third, efforts to reduce individual-level middle-income status and accompanying action on NCDs are interdependent high-risk behaviours (eg, substance use, demographic and health shifts, the land- challenges that are ripe for global collec- poor diet and physical inactivity) have scape of donor engagement in health is tive action and co-investment. Resilient, not substantially reduced the NCD changing. Global functions may emerge 15 equitable and efficient health systems by burden. Donors can refocus NCD as the new part for donors to play in the http://jech.bmj.com/ definition will provide high-quality care prevention efforts on more cost-effective future of global health. for all patients, irrespective of acuity or population-level interventions aimed at disease category. Furthermore, health mitigating the globalisation of harmful Contributors AH conceived of and wrote the policymakers are increasingly focused on substances (eg, tobacco, alcohol and manuscript. LA provided valuable feedback and both global collective action for health sugar-sweetened foods) and promoting revision. Both authors agreed to the final version of the (though mostly for infectious diseases) healthy physical environments, studied manuscript. and the tremendous costs of their local across LMIC settings. For example, the Funding The authors have not declared a specific NCD burdens. This, in conjunction with insufficient evidence supporting the use grant for this research from any funding agency in the on September 29, 2021 by guest. Protected public, commercial or not-for-profit sectors. the upcoming United Nations General of WHO Best Buy interventions in LMICs Assembly Third High-level Meeting on is a potential funding opportunity for Competing interests None declared. NCDs, provides the appropriate timing donors.16 Patient consent Not required. for meaningful global-scale action on both Finally, although health promotion will Provenance and peer review Commissioned; the emerging and cost agendas. be important for generations to come, externally peer reviewed. It is unclear what the most cost-effec- high-quality, high-value healthcare for © Article author(s) (or their employer(s) unless tive or practical global functions are in all is needed now. Today there exists a otherwise stated in the text of the article) 2018. All this domain. Current and anticipated vibrant though often problematic private rights reserved. No commercial use is permitted unless otherwise expressly granted. challenges should determine which goods sector that will continue to exist irre- donors provide. Among the many possibil- spective of policymakers’ ideologies and ities, we identify four. values. Coordinated investments to help First, despite the Paris Declaration countries steward mixed, public–private 11 on Effectiveness, donor financing health systems (eg, in the Joint Learning To cite Hatefi A, Allen L. J Epidemiol Community Health remains uncoordinated and impractically Network) will be critical to attaining Epub ahead of print: [please include Day Month Year]. country-specific. Coordinated donor threshold quality and value of health doi:10.1136/jech-2018-210605 investments in global issue championship systems worldwide.17 Received 5 March 2018

2 Hatefi A, Allen L. J Epidemiol Community Health Month 2018 Vol 0 No 0 Editorial J Epidemiol Community Health: first published as 10.1136/jech-2018-210605 on 21 May 2018. Downloaded from

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