Space Ethics and the
Post-2015 Development Agenda:
The Emerging Roles of
Implementation Science and
Health Diplomacy
James M. Sherry M.D. Ph.D.
Professor of Global Health and international Affairs
• Space Ethics
• Post 2015 Development Agenda
• Global Health Diplomacy
– Brief history of the MDG’s
– So what?
• Implementation Science
• Competing views of ‘our space’
• Looking forward
Space Ethics
The US Health Economy
• The U.S. health
economy measured
$2.6 trillion in 2010:
– 37% of global health
economy
– 17.9% of total U.S.
economy (in GDP)
– Larger than national
economies of the U.K,
France, Italy
2010 Total Health
Expenditure Globally: $7.05
trillion
U.S.
37%
Rest of
World
63%
Source: 2012 World Development Indicators
The U.S. Health Economy, cont’d
2010 Health Expenditure as % of GDP
20
18
16
14
12
10
8
6
4
2
0
U.S.
HIC
World
MIC
LIC
Source: 2012 World Development Indicators
The U.S. Health Economy, cont’d
• In the U.S., the health sector is the fastest
growing producer of new jobs in both
services and manufacturing
• U.S. health commodity exports were
valued at over $70 billion in 2010:
– 10% of all U.S. exports in 2010
– Comparable in scale to food and agricultural exports,
which totaled $120 billion
– Health export sector grew five times faster than
exports for all other manufactured goods
Source: AHC, 2011: America’s Health Ecosystem in the Emerging Global Health Market.
Global Health Expenditures
2010 World Economy:
$76.3 trillion
(GNI, PPP, Int'l $)
Health
9%
Other
91%
2010 Total Health
Expenditure: 7.05 trillion
(PPP adj., Int'l $)
Other
Private
20%
Out of
Pocket
18%
Public
63%
Source: 2012 World Development Indicators
The “20/80 Syndrome”
2010 World Population (6.9
billion), by Income Level
High
Income
16%
Low &
Mid
Income
84%
2010 Total Health
Expenditure (7.05 trillion), by
Income Level
Low &
Mid
Income
17%
High
Income
83%
Source: 2012 World Development Indicators
Out of Pocket Differences
Breakdown in THE,
High Income Countries
70%
(PPP adj., Int'l $)
Breakdown in THE,
Low Income Countries
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
(PPP adj., Int'l $)
0%
Public
Out of
Pocket
Other
Private
-10%
Public
Out of
Pocket
Other
Private
Source: 2012 World Development Indicators
People living with HIV/AIDS, 2009 (millions)
Concentration of Aid Versus Concentration
of Disease Burdens
PLWHA in High Burden
Countries by WB Income
Level (2009)
20
18
16
14
12
10
8
6
4
2
-
Low-Income
Middle-Income
Situational Paradox:
there is a narrowing
aid focus on lowincome countries at a
time when an
increasing percentage
of those in need are in
middle income
countries
High-Income
10
Concentration of Aid Versus Concentration of
Disease Burdens
Malaria Incidence by Country
Income Level - High-Burden
Countries
6.00
45
New malaria cases, 2010 (millions)
Probable and confirmed TB cases, 2010 (millions)
New TB Cases in High
Burden Countries by WB
Income Level (2010)
5.00
4.00
3.00
2.00
1.00
-
Low-Income
Middle-Income
High-Income
40
35
30
25
20
15
10
5
-
Low-Income
Middle-Income
High-Income
11
World of ODA Spending
Public financing of health in developing
countries: a cross-national systematic analysis
Chunking Lu PhD , Matthew T Schneider BA , Paul Gubbins
BA , Katherine Leach-Kemon MPH b, Dean Jamison PhD, Prof
Christopher JL Murray MD
The Lancet
Volume 375, Issue 9723, Pages 1375 - 1387, 17 April 2010
DAH by Country of Origin
DAH by Source
DAH by channel of Assistance
DAH by Disease
World of Global Health Spending
• What sort of leverage does the ‘global
public health sector’ actually have with
less than half a percent of the total?
ODA Component of LMIC Health
Expenditures
<1 percent
Low &
Mid
Income
17%
High
Income
83%
Post 2015 Development Agenda
Post 2015 Frameworks
UN Process
•Outcome of the 2010 High-level Plenary Meeting of the
General Assembly on the MDGs
– Member States requested the SG to begin making
recommendations on how to advance the UN development
agenda beyond 2015
•UN System Task Team on the Post-2015 UN Development
Agenda
– The Task Team is led jointly by the United Nations Department
of Economic and Social Affairs (UN DESA) and the United
Nations Development Programme (UNDP), andwill lead
system-wide preparations for the post-2015 UN development
agenda with support from all UN agencies and in consultation
with relevant stakeholders.
Post-2015 Frameworks, cont’d
UN Process Inputs
•Nov 2011- briefing of the General Assembly on
“Advancing the United Nations Development Agenda
Beyond 2015”
•April 4, 2012 – Update on the work of the Task Team for
ECOSOC Members and Observers
•July 2012 – Side Event at the 2012 ECOSOC Annual
Ministerial Review – Towards a Post-2015 UN
Development Agenda
Post-2015 Frameworks, cont’d
External Inputs
•National initiatives and thematic consultations (e.g.
health, nutrition and food security) are being undertaken to
feed into the post-2015 discussions
•Civil society, academia, and research institutions have
also been active in discussions
•Beyond 2015 – consortium of 500 organizations advocating for a
global development framework beyond the MDGs
•CIGI-led effort: Post-2015 Development Agenda
– 11 new future goals with indicators
– Wide participation by development and research organizations
•More
Post-2015 Frameworks, cont’d
Themes
– Preserve the catalytic power of the MDG framework
and build on it
– Maintain the focus on human development, while
addressing emerging challenges like
• Sustainable development (Rio+20)
• Inclusive Growth
• Inequalities
• Demographic Dynamics
• Human Rights
• Continuing Conflict
– Some call for more significant changes in paradigm
Post-2015 Frameworks, cont’d
The importance of focusing on the politics as much
as the policy
Source: World Vision International, 2011: Reaching the MDGs 2.0: Rethinking the politics.
Global Health Diplomacy:
Brief History of MDGs
• What is ‘health diplomacy’?
• When is it at odds with our public health
objectives?
History of the MDGs
Evolution of the role of summits and conferences
over the second half of the 20th century
•Period of UN Summitry in the 1960s and 70s:
– marked by target setting,
– but with inadequate or non-existent process monitoring targets,
plans of action, or actual commitments to action
•Pause in summits during the SAP period of the 1980s
•1990 as a pivotal year
– World Bank’s World Development Report 1990 – rehabilitation
of poverty as a concept
– UNDP’s first Human Development Report
– Return of UN Summits and Conferences by decision of the GA
History of the MDGs, cont’d
1990 UN Summits/Conferences
1. World Conference on Education for All
2. UN World Summit for Children
3. UNCTAD Conference on the Least Developed
Countries
4. Conference on Drug Problems
The UN World Summit for Children ‘Broke the
pattern’
History of the MDGs, cont’d
UN World Summit for Children
• Garnered Resources: Would serve as a model for future
summits and demonstrated the potential of summits to
successfully generate attention and financial resources
• Set Specific Goals: Related to infant, child and maternal
mortality, primary education, adult literacy,
malnutrition and access to water and sanitation, which
would become the antecedents of the MDGs
• Required Monitoring: Called for the development of
implementation plans and put into place processes for
implementation and monitoring
History of the MDGs, cont’d
Continuing the dialogue on development
•1992 – Rio Summit (UN Conference on Environment and
Development)
•1992 – International Conference on Food & Nutrition
– Resulting target of halving the number of hungry people in the
world would carry over to the MDGs
•1994 – International Conference on Population and
Development (Cairo)
•1995 – World Summit on Social Development (Copenhagen)
– attended by 117 heads of state, poverty reduction as the main focus
•1995 - UN Fourth World Conference on Women (Beijing)
History of the MDGs, cont’d
“From summit declarations to a list of targets”
•1995-1996 – OECD DAC ‘Groupe de Reflexion’ met to
strategize amidst concerns of dwindling aid budgets
– Objective to develop something that would gain the support of
both politicians and OECD publics, and establish a vision that
would motivate action
– Tasked with listing all UN Summit Declarations and consider
pulling them together
– These would become the DAC’s International Development
Goals
•UN and DAC dialogues continued, sometimes in
agreement and sometimes not
History of the MDGs, cont’d
Approach of the 2000 UN Millennium Summit
– UN Report: We the Peoples: The Role of the United
Nations in the 21st Century
• Aimed to provide a working document for the summit;
• Named different goals than the IDGs
– IMF, OECD, UN and World Bank Report: A Better
World for All: Progress towards the International
Development Goals
• Demonstrated ‘unprecedented solidarity’ from the four
leading multilateral donors
– Summer 2000 negotiations over the content of the
Millennium Declaration were based on these two
documents
History of the MDGs, cont’d
The Millennium Declaration was a success, but
was only the beginning
•UN was tasked with developing implementation plan for
global poverty eradication
•Indicators and data sources were discussed, identified,
and in some cases developed anew
•Carry over disagreements between the two documents
(IDGs and ‘We the People’) remained to be resolved, out of
which the Millennium Development Goals were born
Implementation Science
Moving Research to Practice
“it takes 17 years, on
average,
…for 14 % of research
…to translate into
practice”
Research
Research
Research
Practice
Balas EA. Appropriate care to evidence-based medicine. Pediatr Ann. 1998; 7:581–
4.; slide credit to Helen Meissner, NIH
Research to Practice Pipeline
Green, LW et al. 2009. Annual Rev. Public Health. 30: 151-174
Slide Credit: Helen Meissner, NIH
Implementation Science: bridging the gap
Implementation Science is “the application of
systematic learning, research and evaluation to
improve health practice, policy and programs in
developing countries.”
(USAID document “Discovery to Scale Up: Implementation Science in Global Health)
Public Health Knowledge
(what we know)
Implementation
Science
Public Health Practice
(what we do)
Implementation Research (IR)
Implementation research is the scientific study of methods to
promote the systematic uptake of research findings and other
evidence-based practices into routine practice, and, hence, to improve
the quality and effectiveness of health services. It includes the study
of influences on healthcare professional and organizational behavior.
Eccles M.P., and B.S. Mittman. (2006) “Welcome to Implementation Science.” Implementation Science 1(1): 1-3.
Implementation research is that subset of health services
research (HSR) that focuses on how to promote the uptake
and successful implementation of evidence-based
interventions and policies that have, over the past decade,
been identified through systematic reviews. Sanders, D. and A. Haines.
(2006). “Implementation Research Is Needed to Achieve International Health Goals.” PLoS Med 3(6): e186.
Characteristics of IR
IR asks: “What is happening in the design, implementation,
administration, operation, services and outcomes of social
programs? Is it expected or desired? And why is it happening
as it is?” IR asks the “how” and “why” questions…
(Werner 2006, A Guide to Implementation Research)
Systematic
Multidisciplinar
y
Contextual
Complex
Determining an IR Approach
Consider where does the intervention falls on the spectrum
Real-life
effectiveness
Equitabilit
y
Program
integration
Replication
Sustainability
Common
practice at
scale
The implementation research questions will determine the
appropriate methods to be used
IS/IR Challenges
• Discipline is not well-defined; type of
research/science is seen as inferior to other
approaches
• IR requires ‘communities of practice’ with
policy and advocacy partners to facilitate
dissemination of evidence
• Agenda should be driven by – or at least be
responsive to – program implementers and
policy makers, but often is not
Competing Views
• The growing need for practical public
health programming expertise…
• coupled with decreases in programming
resources are challenging the global health
community…
• to reconsider the shape of collaborations
between academic institutions, the USG,
private sector, and international NGOs…
• shifting landscape of global health…
Health professionals for a new century:
transforming education to strengthen health
systems in an interdependent world
Julio Frenk, MD, Lincoln Chen, MD, Zulfiqar A Bhutta, PhD, Jordan Cohen,
MD, Nigel Crisp, KCB, Timothy Evans, MD, Harvey Fineberg, MD, Patricia
Garcia, MD, Yang Ke, MD, Patrick Kelley, MD, Barry Kistnasamy, MD, Afaf
Meleis, PhD, David Naylor, MD, Ariel Pablos-Mendez, MD, Srinath Reddy,
MD, Susan Scrimshaw, PhD, Jaime Sepulveda, MD, David Serwadda, MD and
Huda Zurayk, PhD
The Lancet
Volume 376, Issue 9756, Pages 1923-1958 (December 2010)
Source: The Lancet 2010; 376:1923-1958 (DOI:10.1016/S0140-6736(10)61854-5)
Terms and Conditions
Lancet Commission View…
• “The total global expenditure for health professional
education is about US$100 billion per year, again with great
disparities between countries.
• This amount is less than 2% of health expenditures
worldwide, which is pitifully modest for a labour-intensive
and talent-driven industry.
• Stewardship, accreditation, and learning systems are weak
and unevenly practised around the world.
• (There is a)…scarcity of information and research about
health professional education.
• Although many educational institutions in all regions have
launched innovative initiatives, little robust evidence is
available about the effectiveness of such reforms. “
Lancet Commission View …
• Health systems worldwide are struggling to keep up, as
they become more complex and costly, placing
additional demands on health workers.
• Professional education has not kept pace with these
challenges, largely because of fragmented, outdated, and
static curricula that produce ill-equipped graduates.
• The problems are systemic: mismatch of competencies to
patient and population needs; poor teamwork; persistent
gender stratification of professional status; narrow
technical focus without broader contextual
understanding; episodic encounters rather than
continuous care; predominant hospital orientation at the
expense of primary care; quantitative and qualitative
imbalances in the professional labour market; and weak
leadership to improve health-system performance.
Lancet Commission View …
• Laudable efforts to address these deficiencies have
mostly floundered, partly because of the so-called
tribalism of the professions—ie, the tendency of the
various professions to act in isolation from or even in
competition with each other.
Alliance for Healthcare Competitiveness View
AMERICA’S HEALTH ECOSYSTEM
IN THE EMERGING GLOBAL HEALTH
MARKET
A Unique Opportunity for Growth, Employment and
Better Health
Ed Gresser
Alliance for Healthcare Competitiveness
Alliance for Healthcare Competitiveness…
• “The world’s demand for high-quality care is
surging as the global middle class grows, and as
new technologies open up the possibility of
regular basic care, safe pregnancies and
childhoods, and efficient treatments during
illness for a billion low-income and rural
people.”
Alliance for Healthcare Competitiveness…
• “America’s health eco-system – by virtue of its
sheer size, its innovativeness and technical
excellence, and its demonstrated record as a
provider of care to the ethnically and
economically diverse American population – is
likely the only health system able to meet this
demand at scale.”
Recommendations Going
Forward
Lancet Commission…
Source: The Lancet 2010; 376:1923-1958 (DOI:10.1016/S0140-6736(10)61854-5)
Alliance for Healthcare Competitiveness…
“…an ambitious and strategic trade policy
can develop the global health ecosystem,
enlarge the spectrum of patient and
provider choice, and bring top-quality
health care to wider populations even as it
supports American exports and growth.’
Alliance for Healthcare Competitiveness…
...the U.S. government in partnership with
foreign negotiating partners would need three
things:
1. An institutional structure which can design and sustain
a health-ecosystem trade strategy over time; and
2. Data and information which can help negotiators,
policy analysts and private-sector stake holders more
fully understand the current environment, set
negotiating priorities and evaluate progress over time;
3. A systematic approach to the health-care ecosystem,
with differing goals and objectives suited to the full
spectrum of America’s trade discussion fora and
negotiating venues;
For the Academic
Community?
Avoiding Pitfalls
Synergy or Centrifugal Forces?
Missing Skill-sets
• Finance
• Regulatory Sciences
• Human Resource Development
• Institutional Development
Rethinking a few Principles in
Operational Terms
• Global health as a separate discipline?
• Country ownership objectives in limited capacity setting?
• What does ‘going to scale’ mean in our new context?
• How ‘Research Based’ should Implementation Science be?
• What if we just produce practitioners like ourselves?
What is our current model?
• Masters degree
• Practicum/Internships/Peace Corps
• What is missing?
• Do we need a Global Health Residency
Program?
Global Health Residency Program?
• Who should run it?
• Who should host it?
• Who should pay for it?
• Who might benefit from it?
Looking Forward