I'm going to talk about three broad issues in global health policy and governance. I'll start with an overview of global health issues and then move on to key policy challenges in global health. I'll conclude my talk with the proposal for the G7 summit in May 2016 here in Japan which will try to tackle the major challenges in global health policy and governance. First, it is essential for us to understand how and where people suffer from Death and Burden Disease. The Global Burden Disease project, abbreviated as GBD, is trying to answer the very basic question. I have been involved in the GBD for the past two decades. And GBD is a systematic and scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factor by age, sex and, geography for specific points in time. The major objective of the GBD study are threefold- First, to decouple epidemiological assessment and advocacy, and second, to inject non-fatal health outcome into health policy debate And third, to use a common metric for burden of disease assessment using summary measure of population health. Therefore, GBD takes into account, not only death, but also non-fatal health outcomes such as disabilities. GBD also puts emphasis on three principles. First, comparability across population and over time. Second, on consistency across major parameters, such as mortality prevalence and incidences. And finally, comprehensiveness of disease and risk factors. Let us first look at the top 10 causes of death in the world. GBD classifies disease into two broader categories. Communicable, non-communicable disease, and injuries. So what is top- number 10? It- Tuberculosis. Number 9, Diabetes. Number 8, HIV/AIDS. Number 7, road injuries. Number 6, lung cancer. Fifth, Alzheimer disease. Number four, lower respiratory infections, pneumonia. Number three, COPD, Chronic Obstructive Pulmonary Disease. And number two is cerebrovascular disease, stroke. And top leading cause is ischemic heart disease. So those disease in that are communicable disease: maternal and child causes and nutritional causes. I’ve brought up traditional diseases category in these developed countries. Those in blue are so-called non-communicable diseases, NCDs. And green represent injuries. So GBD uses a common metric to combine both mortality and non-fatal health outcomes. Let me explain what it means using this figure. The green line is a hypothetical survival curve. The x-axis represents age, and the y-axis shows the proportion of those who have survived at the particular age. The area under that green line is A plus B. Here, represents the life expectancy at birth. Now, let me introduce another line, pink here. There, under the pink curve A, represent those who are alive without any disabilities. That is disability for your life expectancy. Area B, between pink and green lines, represent those who are alive with various disabilities. There are two types of population summary measures. One is health gains such as healthy life expectancy. In this figure, it is the summation of area A and some function of transformation of area B. A plus function transformation B, that represents healthy life expectancy. The other is health gap, gap between the ideal health status and observed one. Supposed that the ideal health status in this hypothetical population is that everybody lives up to age 100. Then the health gap is the sum of the area B that represents those who are alive with disability, and area C that represents those who are dead. Now, let me introduce one of the summary measures of population health employed in the GBD that is Disability-Adjusted Life Years, DALYs. DALYs is the measure of health gaps between the actual population health and some specified goal. And in the construction of DALYs, the time was used as the common metric for mortality and non-fatal health outcomes. There are two components for this, years of life lost due to premature mortality, and years lived with a disability. So combined, YLLs and YLDs will get DALYs. So using DALYs, let us look at the top 10 leading causes of global burden of disease. Number 10, malaria. Number 9, HIV/AIDS. Number 8, neo-natal and preterm births. Number 7, road injuries, same as in the case of death. Number 6, Diarrhea. Number 5, COPD. Number 4, now, it is non-fatal health outcome, lower back pain, or neck pain, musculoskeletal conditions. Number 3, lower respiratory infection, that is, pneumonia. Number 2, cerebrovascular disease, and the top leading cause is, again, ischemic heart disease. So as you can see from this table, in terms of global burden of disease, it is a mixture of both communicable and non-communicable disease. So communicable disease in red and non-communicable diseases in blue so that represents we are facing the double burden of disease across the globe. In 1990, the leading cause of global burden of disease were different. Number five was neonatal conditions. Number four, cerebrovascular disease. Number three was diarrhea. Number two was ischemic heart disease. On top and leading causes was lower respiratory infection. So we see the health transition here. When we talk about the double burden of disease, we need to discuss about issues of compression or expansion of morbidity. There has been a long-run debate over James Fries' hypothesis on compression of morbidity, which was proposed in the 1980s. If the pace of the extension of life expectancy is slower than the delay in the age of onset of a chronic condition, morbidity may be compressed into a period before the time of death. Fries suggested that if the hypothesis is confirmed, health care costs and the patient health overall will be improved. However, the latest GBD 2013 study suggest that as life expectancy has increased, the number of healthy years lost due to disability has also increased in most countries. Therefore, according to the GBD, there seems to be an expansion of morbidity and that has a huge implication for health systems. To summarize this session, there seems to be a huge global health transition. And I think it is extremely important to understand metrics to quantify the burden of disease. So whether you use Death or DALYs that will have huge difference. And second, in terms of health transition, we are facing the double burden of disease which is a combination of communicable and non-communicable disease. And there seems to be an expansion of morbidity across the globe, that is growing share of disabilities. And finally, all of this will have a huge health system challenges and health policy implications.
