Summary Background In China, there are more than 300 million male smokers. Tobacco taxation reduces smoking-related premature deaths and increases government revenues, but has been criticised for ...disproportionately affecting poorer people. We assess the distributional consequences (across different wealth quintiles) of a specific excise tax on cigarettes in China in terms of both financial and health outcomes. Methods We use extended cost-effectiveness analysis methods to estimate, across income quintiles, the health benefits (years of life gained), the additional tax revenues raised, the net financial consequences for households, and the financial risk protection provided to households, that would be caused by a 50% increase in tobacco price through excise tax fully passed onto tobacco consumers. For our modelling analysis, we used plausible values for key parameters, including an average price elasticity of demand for tobacco of −0·38, which is assumed to vary from −0·64 in the poorest quintile to −0·12 in the richest, and we considered only the male population, which constitutes the overwhelming majority of smokers in China. Findings Our modelling analysis showed that a 50% increase in tobacco price through excise tax would lead to 231 million years of life gained (95% uncertainty range 194–268 million) over 50 years (a third of which would be gained in the lowest income quintile), a gain of US$703 billion ($616–781 billion) of additional tax revenues from the excise tax (14% of which would come from the lowest income quintile, compared with 24% from the highest income quintile). The excise tax would increase overall household expenditures on tobacco by $376 billion ($232–505 billion), but decrease these expenditures by $21 billion (−$83 to $5 billion) in the lowest income quintile, and would reduce expenditures on tobacco-related disease by $24·0 billion ($17·3–26·3 billion, 28% of which would benefit the lowest income quintile). Finally, it would provide financial risk protection worth $1·8 billion ($1·2–2·3 billion), mainly concentrated (74%) in the lowest income quintile. Interpretation Increased tobacco taxation can be a pro-poor policy instrument that brings substantial health and financial benefits to households in China. Funding Bill & Melinda Gates Foundation and Dalla Lana School of Public Health.
Summary Background The way in which a government chooses to finance a health intervention can affect the uptake of health interventions and consequently the extent of health gains. In addition to ...health gains, some policies such as public finance can insure against catastrophic health expenditures. We aimed to evaluate the health and financial risk protection benefits of selected interventions that could be publicly financed by the government of Ethiopia. Methods We used extended cost-effectiveness analysis to assess the health gains (deaths averted) and financial risk protection afforded (cases of poverty averted) by a bundle of nine (among many other) interventions that the Government of Ethiopia aims to make universally available. These nine interventions were measles vaccination, rotavirus vaccination, pneumococcal conjugate vaccination, diarrhoea treatment, malaria treatment, pneumonia treatment, caesarean section surgery, hypertension treatment, and tuberculosis treatment. Findings Our analysis shows that, per dollar spent by the Ethiopian Government, the interventions that avert the most deaths are measles vaccination (367 deaths averted per $100 000 spent), pneumococcal conjugate vaccination (170 deaths averted per $100 000 spent), and caesarean section surgery (141 deaths averted per $100 000 spent). The interventions that avert the most cases of poverty are caesarean section surgery (98 cases averted per $100 000 spent), tuberculosis treatment (96 cases averted per $100 000 spent), and hypertension treatment (84 cases averted per $100 000 spent). Interpretation Our approach incorporates financial risk protection into the economic evaluation of health interventions and therefore provides information about the efficiency of attainment of both major objectives of a health system: improved health and financial risk protection. One intervention might rank higher on one or both metrics than another, which shows how intervention choice—the selection of a pathway to universal health coverage—might involve weighing up of sometimes competing objectives. This understanding can help policy makers to select interventions to target specific policy goals (ie, improved health or financial risk protection). It is especially relevant for the design and sequencing of universal health coverage to meet the needs of poor populations. Funding Bill & Melinda Gates Foundation.
Summary Background The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence ...governments. We propose, as a quantitative health target, “Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages”. Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50–69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide. Methods UN sources yielded overall 1970–2010 mortality trends. WHO sources yielded cause-specific 2000–10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third. Results Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970–2010, particularly in childhood. From 2000–10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000–10) were: 34% at ages 0–4 years; 17% at ages 5–49 years; 15% at ages 50–69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide). Interpretation Moderate acceleration of the 2000–10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0–49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0–69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic. Funding UK Medical Research Council , Norwegian Agency for Development Cooperation , Centre for Global Health Research , and Bill & Melinda Gates Foundation.
Summary Background Measuring a country's health performance has focused mostly on estimating levels of mortality. An alternative is to measure rates of decline in mortality, which are more sensitive ...to changes in health policy than are mortality levels. Historical rates of decline in mortality can also help test the feasibility of future health goals (eg, post-2015). We aimed to assess the annual rates of decline in under-5, maternal, tuberculosis, and HIV mortality over the past two decades for 109 low-income and middle-income countries. Methods For the period 1990–2013, we estimated annual rates of decline in under-5 mortality (deaths per 1000 livebirths), the maternal mortality ratio (deaths per 100 000 livebirths), and tuberculosis and HIV mortality (deaths per 100 000 population per year) using published data from UNICEF and WHO. For every 5-year interval (eg, 1990–95), we defined performance as the size of the annual rate of decline for every mortality indicator. Subsequently, we tested the feasibility of post-2015 goals by estimating the year by which countries would achieve 2030 targets proposed by The Lancet 's Commission on Investing in Health (ie, 20 deaths per 1000 for under-5 mortality, 94 deaths per 100 000 for maternal mortality, four deaths per 100 000 for tuberculosis mortality, and eight deaths per 100 000 for HIV mortality) at observed country and aspirational best-performer (90th percentile) rates. Findings From 2005 to 2013, the mean annual rate of decline in under-5 mortality was 4·3% (95% uncertainty interval UI 3·9–4·6), for maternal mortality it was 3·3% (2·5–4·1), for tuberculosis mortality 4·1% (2·8–5·4), and for HIV mortality 2·2% (0·1–4·3); aspirational best-performer rates per year were 7·1% (6·8–7·5), 6·3% (5·5–7·1), 12·8% (11·5–14·1), and 15·3% (13·2–17·4), respectively. The top two country performers were Macedonia and South Africa for under-5 mortality, Belarus and Bulgaria for maternal mortality, Uzbekistan and Macedonia for tuberculosis mortality, and Namibia and Rwanda for HIV mortality. At aspirational rates of decline, The Lancet 's Commission on Investing in Health target for under-5 mortality would be achieved by 50–64% of countries, 35–41% of countries would achieve the 2030 target for maternal mortality, 74–90% of countries would meet the goal for tuberculosis mortality, and 66–82% of countries would achieve the target for HIV mortality. Interpretation Historical rates of decline can help define realistic targets for Sustainable Development Goals. The gap between targets and projected achievement based on recent trends suggests that countries and the international community must seek further acceleration of progress in mortality. Funding Bill & Melinda Gates Foundation, NORAD.
Summary Background The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive ...assessment of development assistance for health (DAH) from 1990 to 2007. Methods We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country. Findings DAH grew from $5·6 billion in 1990 to $21·8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $14·5 billion DAH in 2007 for which project-level information was available, $5·1 billion was for HIV/AIDS, compared with $0·7 billion for tuberculosis, $0·8 billion for malaria, and $0·9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product. Interpretation This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds. Funding Bill & Melinda Gates Foundation.
Summary The slow global response to the Ebola crisis in west Africa suggests that important gaps exist in donor financing for key global functions, such as support for health research and development ...for diseases of poverty and strengthening of outbreak preparedness. In this Health Policy, we use the International Development Statistics databases to quantify donor support for such functions. We classify donor funding for health into aid for global functions (provision of global public goods, management of cross-border externalities, and fostering of leadership and stewardship) versus country-specific aid. We use a new measure of donor funding that combines official development assistance (ODA) for health with additional donor spending on research and development (R&D) for diseases of poverty. Much R&D spending falls outside ODA—ie, the assistance that is conventionally reported through ODA databases of the Organisation for Economic Co-operation and Development. This expanded definition, which we term health ODA plus, provides a more comprehensive picture of donor support for health that could reshape how policy makers will approach their support for global health.
Summary Background Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents ...(age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. We report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models. Methods For this empirical analysis, we obtained birth-history data from surveys done over a 25-year period from 1986 by the Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. We used these data to calculate mortality risks for children aged 5–14 years, and compare these risks to corresponding estimates of mortality in children younger than 5 years in the same countries. We used regression analysis to model these associations, generate estimates of the risks, and derive estimates of the numbers of deaths for 1990 and 2010 by applying those risks to population estimates from the UN World Population Prospects (WPP) 2012 Revision. We then compared the numbers of deaths with those given by the UN WPP itself and by the Institute for Health Metrics and Evaluation's Global Burden of Disease (GBD) 2010 study. Findings The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to our estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million (95% CI 1·9–2·7) in 1990 to about 1·5 million (1·2–1·8) in 2010. From our estimates we concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, our estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Interpretation Our analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our findings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents. Funding The Lancet Commission on Investing in Health and the Bill & Melinda Gates Foundation.
Summary The marginal costs and benefits of converting malaria programmes from a control to an elimination goal are central to strategic decisions, but empirical evidence is scarce. We present a ...conceptual framework to assess the economics of elimination and analyse a central component of that framework—potential short-term to medium-term financial savings. After a review that showed a dearth of existing evidence, the net present value of elimination in five sites was calculated and compared with effective control. The probability that elimination would be cost-saving over 50 years ranged from 0% to 42%, with only one site achieving cost-savings in the base case. These findings show that financial savings should not be a primary rationale for elimination, but that elimination might still be a worthy investment if total benefits are sufficient to outweigh marginal costs. Robust research into these elimination benefits is urgently needed.
Abstract Background Subsidies are used to encourage or discourage the consumption of health-relevant goods by changing their market price to the consumer. While the income elasticity of the demand ...for many goods could be inferred from household surveys, the price elasticity of demand is often unknown. We show how price elasticity can be estimated from income elasticity of demand. As an example, we use this approach to predict the cost and the effectiveness of using subsidies to increase the proportion of households owning toilets in rural India. Methods An analytical relation between income elasticity of demand and uncompensated own-price elasticity of demand for a given class of goods is derived within the mathematical framework of the Florida Preference Independence model. Three inputs are required: the income elasticity of demand, the mean budget share allocated to the class of goods of interest, and the elasticity of the marginal utility of income. The first and the second are calculated from survey data using multilevel regressions, and the third is a measure of convexity of the utility function and can be extracted from published studies. Findings As an example, using household data from the District Level Household and Facility Survey (DLHS)-2 and DLHS-3 surveys, the model predicts that if subsidies covered 25% of the annual cost of installing toilets (in households with no sanitation facility), the expected increment in coverage would be between 5·6% and 7·5% at an annual (non-administrative) cost ranging between US$20 million and $30 million. Interpretation The model presented here allows the prediction of the price elasticity of demand using the income elasticity of demand. It can help estimate the impact of instruments of financial policy (eg, subsidies), and it can be used as a tool for early planning of health policies based on financial incentives, even in highly complex and heterogeneous socioeconomic settings. Funding Bill & Melinda Gates Foundation.
The international community can best support countries to implement progressive universal health coverage by financing population, policy, and implementation research, such as on the mechanics of ...designing and implementing evolution of the benefits package as the resource envelope for public finance grows. Antimicrobials based on a new mechanism of action Combined diarrhoea vaccine (rotavirus, enterotoxigenic Escherichia coli, typhoid, and shigella); protein-based universal pneumococcal vaccine; respiratory syncytial virus vaccine; hepatitis C vaccine ..
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