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

2

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

3

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

5

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

6

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

7

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

8

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

9

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

11

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

12

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

13

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

14

Contact

• Amanda Glassman

– aglassman@cgdev.org

– @glassmanamanda

– www.cgdev.org

15

APPENDIX

16

Source: World Health Organization Statistical Information System (WHOSIS), 2011

Total MIC fare worse than LIC on ARV coverage of HIV positive people

17

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)