1. Using Burden of Disease to Improve Implementers’ Decision Making and Program Relevance Kim Longfield Lek Ngamkitpaiboon Amy Ratcliffe GHME Conference Seattle, WA June 18, 2013

2. Background  66 developing countries  More than 60 products and services

3. PSI Strategic Plan 2012 - 2016 RELEVANCE SCALE VALUE ::

4. Methods Tanzania Interventions: HIV basic care package Condoms (male & female) Emergency contraception Contraceptive implants Injectable contraceptives IUDs Misoprostol for post abortion care Oral contraceptives LLINs Water treatment tablets Safe water solution Cambodia Interventions: Condoms Contraceptive implants Injectable contraceptives IUDs Medication Abortion MVA ACTs Malaria net retreatment Diarrhea treatment kits (ORS, zinc) Water treatment tablets Pneumonia treatment (antibiotics) 40% relevance in Tanzania 19% relevance in Cambodia Global Burden of Disease CategoryIntervention(s) TuberculosisTB DOTS HIV/AIDSCondoms, MC, HTC, Needle & Syringe, ART, PMTCT DiarrheaORS, Zinc, Water Treatment Lower Respiratory InfectionsPneumonia PPT MalariaLLINs, ACTs, RDTs Maternal DisordersAll FP products and services :: Maternal HemorrhageMisoprostol for PPH :: Maternal SepsisClean Delivery Kits :: AbortionAbortion services, Post-Abortion Care Neonatal Disorders :: Preterm Birth ComplicationsAll FP products and services :: Sepsis and Other Infectious Disorders of the Newborn BabyClean Delivery Kits Nutritional Deficiencies :: Vitamin A DeficiencySprinkles :: Iron-Deficiency AnemiaSprinkles Sexually Transmitted Diseases Excluding HIV/AIDSSTI Kits, Condoms Acute Hepatitis B & CNeedles & Syringes Liver Cancer Secondary to Hepatitis B & CNeedles & Syringes Cervical CancerVisual Inspection and Cryotherapy Opioid Use DisordersNaloxone Tobacco Smoking (risk factor)Smoking cessation program

5.  PSI targets 20.5% of DALY burden in countries where it works.  Programs in Africa are most relevant (18-50%) with a heavy focus on HIV and malaria.  Programs in Asia and Latin America are less relevant (1-31%) because of higher shares of non- communicable diseases and injuries, which PSI has not traditionally targeted. General Findings 335m DALYs 335,515,910 DALYs = 20.5% 1,638,175,656 DALYs 1.33b DALYs79.5% 20.5%

6. Case Study: PSI’s Response to HIV/AIDS in Southern Africa Image from: GBD Compare, © University of Washington HIV/AIDS, 2010 Percent of total DALYs Source: GBD 2010 PSI delivers HIV/AIDS-related interventions or services in countries that represent 89% of all DALYs due to HIV/AIDS 29.8% of the world’s HIV burden comes from just 9 countries in Southern Africa In these countries, HIV represents 18-40% of the national disease burden 48% of PSI’s HIV-related impact is generated in these countries HIV Burden – There are 81.5 million HIV/AIDS DALYs globally

7. Case Study: Respiratory Infections Lower respiratory infections, 2010 Percent of total DALYs Image from: GBD Compare, © University of Washington PSI currently has pneumonia interventions in 7 countries: Cambodia, DRC, Madagascar, Malawi, Myanmar, South Sudan, and Uganda

8. How can relevance inform decision-making? Image from: GBD Compare, © University of WashingtonSource: GBD 2010 Relevance and potential health impact inform where we could expand our programs LRI represents a high % of national burden and a large number of DALYs in Ethiopia, Kenya, Cote d’Ivoire, and Pakistan Top 15 in % burden: PNG, Tajikistan, Guinea, Guatemala, Ethiopia, Zimbabwe, Liberia, Benin, Laos, Kenya, Kyrgyzstan, Cote d’Ivoire, Malawi, Togo, Pakistan 8.2-12.7% of national disease burden Top 15 in absolute burden: India, Nigeria, Pakistan, China, Ethiopia, DRC, Tanzania, Kenya, South Sudan, Cote d’Ivoire, Myanmar, Mozambique, Russia, Malawi 58% of global DALYs from LRI In countries where PSI works

9. Next Steps: Increasing our relevance with NCDs Cervical Cancer, 2010 Percent of total DALYs Image from: GBD Compare, © University of WashingtonSource: GBD 2010 NCDs account for 47% of the burden of disease in countries where PSI works

10. Limitations At PSI, relevance includes scoping and pilots to reward innovation Relevance does not account for scale Relevance can only be as specific as available GBD data ::

11. Interpretation Adoption of a relevance goal has encouraged spread of existing PSI interventions and innovative work in new health areas PSI can increase relevance by: :: Expanding successful programs to new countries: For example, pneumonia treatment, nutrition, TB diagnosis and treatment :: Learning from pilots to target new health areas: For example, cervical cancer, smoking-related burden, injury prevention, other NCDs ::

12. Relevance is just one of several factors for decision making Burden Strategic advantage Potential health impact Logistical feasibility Policy environment Funding

13. Thank You Kim Longfield Director, Research & Metrics Amy Ratcliffe Sr. Technical Advisor, Metrics Lek Ngamkitpaiboon Data Analyst Graham Smith Associate Researcher Hongmei Yang Researcher Meghan Reidy Consultant metrics@psi.org