Hot topics in public health go global in Berlin at the World Health Summit

The burning issue at this year’s World Health Summit in Berlin was health security. At this 8th WHS it was clearer than ever that the walls between the traditional disciplines of ‘global health’ and (European) ‘public health’ are rapidly coming down, with health threats anywhere in the world becoming a domestic challenge as well as an international development issue. The topics driving the agenda in Berlin are increasingly preoccupying European Heads of State as well as their G7 and G20 counterparts. It is a welcome signal that the patrons of the WHS, Chancellor Merkel and European Commission President Juncker, are joined by France’s President Macron. Nevertheless, in a blistering keynote speech MSF International President Joanne Liu challenged the mostly-European audience to protect health wherever and whenever threats arise and not only when they reach our shores.

Antimicrobial resistance (AMR) emerged as one of the principal topics under discussion at the 2017 World Health Summit in Berlin, with a number of sessions looking at it from a global, “One Health” perspective and in the broader context of international policy action in support of achieving the Sustainable Development Goals.

Ahead of the WHS, the UK government, with the Wellcome Trust and the governments of Ghana and Thailand, organised another event in Berlin hosted by Professor Dame Sally Davies. EPHA Secretary General Nina Renshaw was invited to present and spoke about the importance of binding measures to tackle pollution in the antibiotic supply chain, as a major accelerator of resistant bacteria in the local environment of pharmaceutical factories which can then spread rapidly.

At the WHS session on AMR, Dr Rüdiger Krech (WHO), underlined the global scope of the AMR problem, recalling that gonorrhoea is becoming increasingly resistant to antibiotics, while also mentioning multi-drug resistant TB, E.Coli and hospital infections including MRSA.

EPHA’s points appear to be echoed by attendees at both events. Notably, Thomas Cueni (Director General, International Federation of Pharmaceutical Manufacturers & Associations) recognised the problem of environmental spill-over in e.g. India in the supply chain of cheaply produced generic drugs, with public procurement (e.g. certified suppliers) and consumer choice as powerful tools that could be exploited. He also stated that if voluntary initiatives don’t work, regulatory approaches could be considered, with some companies willing to share data with WHO.

Jeremy Knox of the Wellcome Trust emphasised that the evidence base regarding behaviour change is not as developed as it should be. He pointed out that Wellcome is developing a new policy and advocacy stream on AMR working in collaboration with civil society, while at the same time making a major investment in the CARB-X Global Partnership.

Discussion turned to the question of developing and managing antimicrobials effectively as a “global public good” and the flawed business model for antibiotics, with companies not following rhetoric with action, according to Dr Krech, keen on investing in more profitable medicines and on avoiding any regulation. In turn, Cueni explained some key industry obstacles, noting high risk of failure in the development process. He argued for a globally funded model but was sceptical that this would happen anytime soon. Mr Knox stated that it was high time that governments and companies began to experiment with available innovation models, the best of which combine push and pull incentives.

Another problem highlighted by participants was that antibiotics are cheaper than diagnostics, which means it is easier to omit testing before prescribing them.

Representing the German Federal Ministry of Health, Karin Knufmann-Happe also mentioned the environmental dimension of AMR – specifically, antibiotic waste and residues in water – as a key element of Germany’s inter-sectoral national strategy (2015), designed to be closely aligned with the WHO Global Action Plan. She revealed that Germany’s efforts to influence the G7 and G20 agendas is motivated by the recognition that some issues cannot be tackled at the national level alone, and that tackling AMR also involves health systems strengthening. A new global AMR R&D hub is planned to be established in Germany to pursue a long-term vision.

Vaccination also featured strongly at the WHS, including as a measure to reduce antibiotic use, especially reflecting growing concerns over vaccine hesitancy and recent vaccine-preventable disease outbreaks, including measles in Europe. 


Obesity a bigger threat to world health than malnutrition: Global Nutrition Report 2017

Overweight and obesity are on the rise in almost every country, with 2 billion of the world’s 7 billion people being overweight or obese, says The Global Nutrition Report 2017.

In India, 16% of adult men and 22% of adult women are overweight.

The study, conducted across 140 countries, says there is a less than 1% chance of meeting the global target of halting the rise in obesity and diabetes by 2025.

Undernutrition in children is decreasing globally, but progress is not fast enough to meet internationally-agreed nutrition goals, including the Sustainable Development Goals (SDG) target to end all forms of malnutrition by 2030.

According to the report, 155 million under-fives are stunted; and 52 million children worldwide are defined as wasted, meaning they do not weigh enough for their height.

The report brings to light the crucial need to tackle the double burden of undernutrition and obesity, in order to address India’s national nutrition strategy.

Thirty-eight percent children in India under the age of 5 are affected by stunting, and 21% of under 5s are defined as ‘wasted’ or ‘severely wasted’, meaning they do not weigh enough for their height.

Rising rates of anaemia in women of reproductive age is also a big concern, with the report showing more than half of India’s women and almost one in three women affected worldwide and no country on track to meet global targets.

A staggering 88% of countries studied face a serious burden of two or three forms of malnutrition.

“The world can’t afford not to act on nutrition or we risk putting the brakes on human development as a whole,” said Corinna Hawkes, co-chair, Global Nutrition Report’s Independent Expert Group, and director, of the Centre for Food Policy at City, University of London.

“We will not achieve any of the Global Goals for SDGs by the 2030 deadline unless there is a critical step change in our response to malnutrition in all its forms. Equally, we need action throughout the goals to tackle the many causes of malnutrition.”

Where India stands

  • 38%: Stunted under-5 children
  • 21%: Wasted’ or ‘severely wasted’ under-5 children who weigh less for their height
  • 16%: Overweight adult men
  • 22%: Overweight adult women
  • 51%: Anaemia in women of reproductive age

Source: The Global Nutrition Report 2017


World Health Organisation warns of airborne Madagascar plague spreading to Africa

The organisation has said more than 1,300 people have become infected with the disease, which is primarily affecting Madasgascar off the coast.

It has spent millions of dollars in efforts to fight the disease and has sent specialists to the affected areas in cities like Antananarivo.

Figures from the WHO state at least 93 people have died, and there was a high risk it could spread to countries on the eastern coast of the continent of Africa, like Tanzania, South Africa and Mozambique.

Some of the cases of plague are reported to be pneumonic, which means it can be transmitted by coughing or sneezing, and is airborne.

It is almost always fatal if left untreated, but if caught early enough, can be eliminated with antibiotics.

The disease is caused by the same type of bacteria which wiped out nearly 50 million people in Europe during the years of the Black Death.


Robert Mugabe Was Just Appointed a World Health Organization 'Goodwill Ambassador'

Zimbabwean President Robert Mugabe has been called a lot of things by supporters and critics over his 94 years on this planet: revolutionary; freedom fighter; dictator; alleged perpetrator of human rights violations. He’s about to add another controversial moniker to the list—”Goodwill Ambassador” to the World Health Organization (WHO).

New WHO director-general Tedros Adhanom Ghebreyesus announced that Mugabe would be a goodwill ambassador to the public health agency at a conference in Uruguay. Mugabe, according to Ghebreyesus, who is from Ethiopia, could then leverage the high profile (if largely symbolic) role “to influence his peers in his region,” ostensibly referring to African countries. Mugabe would be an ambassador on broad health issues like noncommunicable diseases such as heart disease and cancer.

The decision was immediately met with outrage by major public health and medical groups like Cancer Research UK, the World Heart Federation, Action Against Smoking, and about two dozen others who slammed Mugabe’s “long track record of human rights violations.” Zimbabwe has faced long-standing international sanctions over such allegations—including of violent crackdowns on political dissidents, claims of electioneering, and starkly anti-LGBT policies. Economic crises have also rocked the nation, making health recovery efforts that much more difficult.

So why would the WHO make such a controversial appointment? Part of the answer may lie in Zimbabwe’s significant life expectancy reversal in recent years. When Mugabe first came to power in 1980, average life expectancy was just over 59 years, according to the World Bank. It fell precipitously through 1990s and mid-2000s in the wake of the HIV epidemic, ongoing economic turmoil, collapsing health and food resources. “The government of Robert Mugabe presided over the dramatic reversal of its population’s access to food, clean water, basic sanitation, and health care,” wrote the charity group Physicians for Human Rights in 2008, two years after life expectancy in Zimbabwe had fallen catastrophically to just over 42 years.

But Zimbabwe has also taken steps to buck the trend over the past decade and life expectancy is now back to about the level it was at when Mugabe took office. The country has dedicated far more resources toward HIV testing and treatment than many other African nations and enlisted young frontline community health care workers to combat HIV/AIDS and provide primary medical services to local communities. That’s likely what led Tedros to refer to Zimbabwe as “a country that places universal health coverage and health promotion at the center of its policies to provide health care to all” during his speech.

The rationale may not be good enough for many who point to Mugabe’s use of state violence and homophobic policies and rhetoric which may, for instance, lead fewer at-risk men to get tested for HIV/AIDS. But it appears the WHO doesn’t want the perfect to be the enemy of the good in public health initiatives, controversial though the Mugabe decision may be.



7 000 newborns die every day, despite steady decrease in under-five mortality, new report says

At current trends, 30 million newborns will die within first 28 days of life between 2017 and 2030

News release

19 OCTOBER 2017 | NEW YORK/GENEVA/WASHINGTON DC - Every day in 2016, 15 000 children died before their fifth birthday, 46% of them – or 7 000 babies – died in the first 28 days of life, according to a new UN report.

Levels and Trends in Child Mortality 2017, reveals that although the number of children dying before the age of five is at a new low– 5.6 million in 2016, compared with nearly 9.9 million in 2000 – the proportion of under-five deaths in the newborn period has increased from 41% to 46% during the same period.

“The lives of 50 million children under-five have been saved since 2000, a testament to the serious commitment by governments and development partners to tackle preventable child deaths,” said UNICEF Chief of Health, Stefan Swartling Peterson. “But unless we do more to stop babies from dying the day they are born, or days after their birth, this progress will remain incomplete. We have the knowledge and technologies that are required – we just need to take them where they are most needed.”

At current trends, 60 million children will die before their fifth birthday between 2017 and 2030, half of them newborns, according to the report released by UNICEF, the World Health Organization, the World Bank and the Population Division of UNDESA which make up the Inter-agency Group for Child Mortality Estimation (IGME).

Most newborn deaths occurred in two regions: Southern Asia (39%) and sub-Saharan Africa (38%). Five countries accounted for half of all new-born deaths: India (24%), Pakistan (10%), Nigeria (9%), the Democratic Republic of the Congo (4%) and Ethiopia (3%).

“To achieve universal health coverage and ensure more newborns survive and thrive, we must serve marginalized families," says Dr Flavia Bustreo, Assistant Director-General for Family, Women’s and Children’s Health at WHO. "To prevent illness, families require financial power, their voices to be heard and access to quality care. Improving quality of services and timely care during and after childbirth must be prioritized.”

The report notes that many lives can be saved if global inequities are reduced. If all countries achieved the average mortality of high-income countries, 87% of under-five deaths could have been averted and almost 5 million lives could have been saved in 2016.

“It is unconscionable that in 2017, pregnancy and child birth are still life-threatening conditions for women, and that 7 000 newborns die daily,” said Tim Evans, Senior Director of Health Nutrition and Population at the World Bank Group. “The best measure of success for Universal Health Coverage is that every mother should not only be able to access health care easily, but that it should be quality, affordable care that will ensure a healthy and productive life for her children and family. We are committed to scaling up our financing to support country demand in this area, including through innovative mechanisms like the Global Financing Facility (GFF). ”

Pneumonia and diarrhea top the list of infectious diseases which claim the lives of millions of children under-five globally, accounting for 16% and 8% of deaths, respectively. Preterm birth complications and complications during labour or child birth were the causes of 30% of newborn deaths in 2016. In addition to the 5.6 million under-5 deaths, 2.6 million babies are stillborn each year, the majority of which could be prevented.

Ending preventable child deaths can be achieved by improving access to skilled health-professionals during pregnancy and at the time of birth; lifesaving interventions, such as immunization, breastfeeding and inexpensive medicines; and increasing access to water and sanitation, that are currently beyond the reach of the world’s poorest communities.

For the first time, mortality data for older children age 5 to 14 was included in the report, capturing other causes of death such as accidents and injuries. Approximately 1 million children aged 5 to 14 died in 2016.

“This new report highlights the remarkable progress since 2000 in reducing mortality among children under age 5,” said UN Under-Secretary-General for Economic and Social Affairs Mr. LIU Zhenmin. “Despite this progress, large disparities in child survival still exist across regions and countries, especially in sub-Saharan Africa. Yet many deaths at these ages are easily preventable through simple, cost-effective interventions administered before, during and immediately after birth. Reducing inequities and reaching the most vulnerable newborns, children and mothers are essential for achieving the SDG target on ending preventable childhood deaths and for ensuring that no one will be left behind.”

The report also notes that:

  • In sub-Saharan Africa, estimates show that 1 child in 36 dies in the first month, while in the world’s high income countries, the ratio is 1 in 333.
  • Unless the rate of progress improves, more than 60 countries will miss the UN Sustainable Development Goal (SDG) to end preventable deaths of newborns by 2030 and half would not meet the target of 12 neonatal deaths per 1,000 live births by 2050. These countries account for about 80% of neonatal deaths in 2016.

Notes to editors

Broadcast quality images and b-roll available here. Download the report here.


The United Nations Inter-agency Group for Child Mortality Estimation or UN IGME was formed in 2004 to share data on child mortality, harmonise estimates within the UN system, improve methods for child mortality estimation report on progress towards child survival goals and enhance country capacity to produce timely and properly assessed estimates of child mortality.

UN-IGME is led by UNICEF and includes WHO, the World Bank Group and the United Nations Population Division of the Department of Economic and Social Affairs. For more information visit: 



Microchip to check on patients' compliance with TB meds

Imagine a doctor or nurse could log in to an application on their phone to check if one of their patients has taken their tuberculosis (TB) medication that day, or any day for that matter?

Imagine all it requires is a microchip the size of a few grains of sand, a skin patch and a Bluetooth-enabled cell-phone?

Paperless access

According to preliminary research announced at the Union World Conference on Lung Health, held in Mexico this week, this could soon be a reality.

The easy-to-use United States Federal Drug Authority-approved technology works by inserting a microchip into the anti-TB drugs that is able to measure the levels of the drug in a person’s system in near real-time allowing health workers paperless access to their patient’s drug-taking behaviour. The chip is the size of a few grains of sand and is easily inserted into any medication.

A small skin path on the patient’s torso transmits the chip’s data to internet-based servers where both patients and clinicians can see when and how much medication a patient has taken – or has not.

It is a tool that is greatly needed because TB is notoriously difficult to monitor for treatment adherence. The current “gold standard”, and the method recommended by the World Health Organisation, is called directly observed therapy (DOT). This is when a health worker observes a patient taking their medication every day which often is a great inconvenience to patients who have to travel to health facilities daily for months.

“In the United States health workers drive to you, your home or your workplace for DOT and it still does not work well,” Dr Sara Browne, lead researcher for the study, told Health-e News.

They wanted to know if this technology had the potential to improve adherence rates – which are often dismally low. But they first had to establish that the technology actually detected the medication accurately and if it confirmed more doses than DOT.

Risk of drug resistance

The study found that the detection accuracy was close to 100% and that the method confirmed 54% more doses that DOT because all doses were electronically recorded while DOT confirmations often don’t happen over weekends or on public holidays and are documented manually.

Browne said that patients often find it difficult to adhere to long treatment regimes that often come with side effects.

Ordinary TB takes six months of treatment with multiple medicines, and drug-resistant TB can take over two years to treat with toxic drugs. But if patients don’t take their medication as prescribed they risk developing drug-resistance or further drug-resistance – limiting their treatment options significantly and increasing their chances of death.

The new technology named WOT (wirelessly observed therapy) “has the potential to revolutionise TB care” because a health worker can quickly, easily and conveniently access a spreadsheet that clearly indicates when a patient is not adhering to their medication.

“A nurse can then for example call the patient and ask why they haven’t taken their medication that day,” said Browne.

The results are preliminary and need to be confirmed in other settings. South Africa is being considered as one of the settings for the next phase of the trial.

At what cost?

“We need to know how this technology works in low and middle income countries and adapt it to different contexts,” said Browne.

Although the cost of the technology is currently not known, as the company who produces is has donated it for research purposes, Browne said it is not expected to be expensive. She said there is an economic analysis currently underway to find out at what cost the technology will be feasible to low and middle income countries.

According to Browne, and others, DOT is “resource-intensive, inconvenient, intrusive, difficult to administer” and is simply “unfeasible”.

According to Dr Yogan Pillay, from the South African Department of Health, although DOT is an official policy “it is not monitored carefully”. “Many people find DOT disempowering,” he said.

Browne said often nurses dispense medication without watching a patient take it – an obstacle that wouldn’t exist with WOT. She said more results are likely to be presented early next year.

“If the second phase of our trial is successful and we can access the technology affordably this could truly be transformative for TB control.” – Health-e News.


Former CDC chief launches $225 million global health initiative

Tom Frieden, former director of the Centers for Disease Control and Prevention, is starting a new initiative to tackle some of global health's thorniest issues: cardiovascular disease and epidemics.

Frieden, a former New York City health commissioner who spent seven years leading the CDC during the Obama administration, said he chose those two issues based on his "unique vantage point of surveying the world and seeing where there were areas that really are at a tipping point." Strategic investment and action in each of these areas can make substantial differences, he said.

The $225 million initiative, called Resolve, announced Tuesday in New York, aims to reduce the global burden of heart disease and stroke, the world's leading causes of death. It also will focus on helping low- and middle-income countries fight infectious disease epidemics by strengthening laboratory networks so emerging threats are identified promptly, and training disease detectives to track and investigate disease outbreaks, including those that circulate in animals and jump to humans.

Frieden led the CDC longer than any director since the 1970s. Some of the major disease outbreaks that took place during his tenure include the 2009 global H1N1 swine flu pandemic, the deadly respiratory virus known as MERS, and the Ebola and Zika epidemics.

Resolve will be housed in a New York-based public health nonprofit organization called Vital Strategies, which operates in more than 60 countries.

The initiative's five-year funding is coming from some of the biggest names in global public health: Bloomberg Philanthropies ($100 million), the Chan Zuckerberg Initiative ($75 million) and the Bill and Melinda Gates Foundation ($50 million).

"I hope five years from now we'll look back and see this was the inflection point for rapid progress in preventing global cardiovascular disease deaths and improving epidemic preparedness," Frieden said. "In a few years, we hope that blood pressure control, sodium reduction, elimination of trans fats and strong public health systems will have become the new normal."

Cardiovascular disease causes about 18 million deaths per year, an estimated 31 percent of all deaths worldwide. In lower-income countries, nearly half of those deaths are in people younger than 70, Frieden said.

Progress has stalled because "there is virtually no money going into this space," he said. "Globally, very few countries are reducing sodium or trans fat or treating high blood pressure effectively."

But with proven strategies, the initiative aims to save more than 100 million lives over 30 years, he said.

In the United States, progress has also slowed in preventing stroke deaths, according to a CDC report last week. The report did not identify the reasons for the slowdown, but other studies have pointed to increased numbers of Americans with stroke risk factors such as high blood pressure, obesity and diabetes.

Global health security was a top priority for the Obama administration, which created a partnership in early 2014 to prevent deadly outbreaks from spreading, and sought to help countries bolster their capacity to detect and monitor infectious diseases in the wake of the Ebola epidemic.

Although the collaboration has resulted in more than 50 countries posting public "report cards" about their readiness to battle epidemics, "the fact is, most countries are still not prepared and there is limited progress in closing the gaps that have been identified," Frieden said. "The world now needs to step up and accelerate these countries to close those gaps."

Bill Gates, co-chairman of the Bill and Melinda Gates Foundation, said: "While our foundation typically focuses on infectious diseases because they disproportionately affect the world's poorest, we are increasingly concerned about the growing rate of cardiovascular disease in low- and middle-income countries."

Resolve will also support and work closely with the World Health Organization, the Bloomberg School of Public Health at the Johns Hopkins University, the CDC, the World Bank and the Campaign for Tobacco-Free Kids.

As CDC director, Frieden was often frustrated by the months-long delays in securing critical funding for pressing public health emergencies, such as Zika.

"One of the things that makes me particularly gratified to have this opportunity is the ability to move quickly" and the freedom to choose where to work and with what organizations, he said.

The initiative will have about 10 to 15 staff members in New York City, but also will be able to draw from Vital Strategies' staff of 100 people in Manhattan and 300 people globally.

A New York native, Frieden is once again working closely with his old boss, former mayor Michael Bloomberg, who supported many of the high-profile public health campaigns Frieden started as head of the city's Department of Health and Mental Hygiene. During Frieden's tenure, the number of smokers dropped significantly, and New York City became the first place in the United States to eliminate trans fats from restaurants and require certain restaurants to post calorie information.

The design of the Resolve initiative will be similar to the program Bloomberg Philanthropies began a decade ago to reduce tobacco use.


How to Compromise on Health Care

Progressives are understandably breathing a sigh of relief following the Senate’s failure to repeal Obamacare and replace it with legislation that would have scaled back health-insurance coverage. But they shouldn’t be too comfortable in their victory — it’s temporary.

President Donald Trump has threatened not to support the Affordable Care Act. If the Trump administration decides not to make critical payments to insurers, or stops enforcing the tax penalty for people who don’t buy insurance, the law could be in serious trouble. And even if the administration continues to support Obamacare’s success, progressives should be clear that the law still needs improvements to ensure that premiums don’t continue to increase at an unsustainable rate, and that households in all parts of the country continue to have access to insurance through the individual market.

What’s needed to move forward? Republicans and Democrats working together.

A major problem with the Affordable Care Act is the way it was passed: on a party-line vote, without support from a single Republican. This made the law vulnerable and created uncertainty about its future among market participants. The unsuccessful GOP repeal-and-replace efforts have been just as divisive. For a policy change of this magnitude to be lasting and stable, it should have at least some bipartisan support.

President Barack Obama’s lasting health-care legacy is winning the fight over whether universal coverage is the right goal. Mr. Obama was correct that it is, and as I’ve argued recently, conservatives should agree. But what is needed to get us there in best way? Let me outline a few corollary goals.

Universal coverage should be pursued in a way that is affordable, both to households and to the government, and that helps lower the trajectory of health-care costs overall. It should lead to higher-quality medical care, to make being insured attractive to households, and should encourage innovation, productivity and technological progress in the health-care sector. It should encourage young and healthy people to be covered in order to balance the risk pool facing insurers, making it attractive for insurers to offer insurance. It should ensure that even the hard-to-cover are insured.

To achieve these goals, both conservatives and progressives are going to have to give ideological ground.

Conservatives in Congress have already given quite a bit. For example, even the most hard-line conservatives in the House voted in favor of the federal government providing subsidies to low-income households to help them purchase health insurance.

But congressional Republicans will have to go further. Subsidies for low-income households need to be generous enough to make insurance against catastrophic medical expenses affordable. Republicans shouldn’t try to cut taxes as part of health reform. And Republicans should accept that we need a robust health-insurance safety net that covers all citizens living in poverty or living with medical conditions that will make insurance prohibitively expensive.

This will involve accepting a larger role for Medicaid than existed before Obamacare, and adequately funding high-risk pools for individuals with pre-existing medical conditions who won’t have access to affordable coverage. It’ll also mean making room for regulation requiring that as long as individuals maintain insurance coverage, they can move from employer coverage to the individual market without being charged higher premiums due to medical conditions.

Progressives have to travel further than this. In order to achieve the goals I laid out, they need to accept that catastrophic health-insurance coverage still counts as coverage. The social problem we face occurs when uninsured individuals get seriously sick or injured, and can’t afford their treatment. Those costs get passed on to the rest of us. The policy solution, then, should focus on the problem of individuals not being insured against very high medical costs — not on insuring for preventative care, or against your annual sinus infection.

In order to encourage the appropriate levels of innovation and productivity, progressives must accept that health insurance — and the market for medical services generally — is too heavily regulated. Obamacare removes choice and options in the individual health-insurance market by specifying what has to be included in insurance plans. In addition, the law’s individual mandate penalizing people who don’t buy insurance is too weak to be effective — but a stronger mandate is both politically untenable and undesirable. So progressives should ditch the mandate and accept another way to encourage young and healthy individuals to be covered: auto-enrollment with an opt-out.

In order to put health-care costs on a sustainable trajectory, progressives must accept that Medicaid, the current health safety net for the poor, needs to change its financing system — in which the federal government matches a share of state spending. They also must accept that market discipline is needed. Catastrophic events are hard to foresee and hard for households to afford, but households should be more exposed to the actual costs of routine care.

Given the current political atmosphere in Washington, I wouldn’t bet on success anytime soon. But these are the right goals, and after the Obama-Trump years, we’ve learned that a bipartisan effort to define universal coverage sensibly and then put it into effect is needed to ensure long-term stability for health policy.