We must tackle the growing burden of obesity

Francesca Colombo, Head, Health Division, OECD Directorate for Employment, Labour and Social Affairs

In 2010, the OECD’s influential report, Fit not Fat:Obesity and the Economics of Prevention, warned about the rapidly rising challenge of obesity and its consequences for our health.

Nearly a decade later, the situation has unfortunately not improved enough. Our new data released today (http://www.oecd.org/health/obesity-update.htm) show that the obesity epidemic has spread further, even though this has happened at a slower pace than before. Today, over half of all adults and nearly one in six children are overweight or obese in the OECD area. In the United States and Mexico, one every three adults is obese (see our chart). Social disparities persist and have increased in some countries. Less-educated women are two to three times more likely to be overweight than those with a higher level of education.

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Obesity rates have grown rapidly in England, Mexico and the United States since the 1990s. The outlook for the future is worrying, as new projections show a continuing increase of obesity, if no significant change occurs. Obesity rates are projected to increase at a faster pace in Korea and Switzerland where rates have been historically low.

There are many reasons why we must tackle obesity. Obesity is a key risk factor for numerous chronic disease, such as diabetes and cardiovascular disease. The failure of health systems to tackle obesity leads to millions of deaths and disability. This also damages our economies. Obese people are less likely to be employed than normal-weight people. They are less productive at work due to more sick days and fewer worked hours, and they earn about 10% less than non-obese people (OECD/EU (2016), Health at a Glance: Europe 2016 – State of Health in the EU Cycle, OECD Publishing, Paris. http://dx.doi.org/10.1787/9789264265592-en.)

The good news is that much of this is preventable, as OECD work shows. Comprehensive policy packages, including school-based and worksite interventions, interventions in primary care settings, and broader regulatory and fiscal policies can address obesity effectively. A number of countries have recently implemented policies, ranging from tax measures (e.g. Belgium, Chile, Finland, France, Hungary, and Mexico) and subsidies to encourage active commuting instead of cars (e.g., Canada and France both at subnational level), to prescription of physical activity (e.g., France, Sweden), reformulation of food products (e.g., Canada, Chile, Korea, UK, Industry on its own) and change in portion sizes (e.g., France, Sweden, Turkey, UK, New York City ).

In the past few years, new policies to fight obesity have emerged, including communication. Improving nutrient information displayed on food labels through easy-to-understand symbol that is placed in front of pre-packaged food products can help consumers make healthier food choices. These symbols exist in Australia, Chile, Denmark, England, France, Iceland, Korea, Lithuania, New Zealand, Norway, and Sweden. Health promotion campaigns have also been spread through social media. Examples of health-promotion-dedicated website, mobile apps and online tools to help people change their behaviours can be seen in Chile, Estonia, England and the Netherlands. Some countries have reinforced the regulation of marketing of potentially unhealthy foods and sweetened beverages directed at children and young adults. Chile, Iceland, Ireland, and Mexico, for example, ban advertising of foods and beverages on television and radio during peak children audience hours. Other bans apply in schools (e.g., Chile, Spain, Turkey and Poland), in public transport (e.g., Australia) and in theatres (e.g. Norway). While the impact of these polices has not been fully evaluated yet, early evidence shows they empower people to make healthier choices, and can also affect food manufacturers’ behaviours.

These are just some examples. Most OECD countries are now using simultaneously complementary policy tools and creating synergies to promote healthier lifestyles. But there is no room for complacency. OECD countries on average still allocate only around 3% of their health budgets to public health and prevention. Addressing obesity requires investment, and comprehensive policies that target broad social and environmental determinants. Crucially, it requires strong leadership and political will.

Further reading

OECD Obesity Update 2017

Sassi, Franco (2010) “Fighting down obesity” OECD Observer No 281, October http://oecdobserver.org/news/fullstory.php/aid/3339/Fighting_down_obesity_.html

The Sustainable Development Goals: translating ambition into action

ACCESSOn 14 September, we published an article on health and the Sustainable Development Goals by Eduardo Pisani, Director General of IFPMA – the International Federation of Pharmaceutical Manufacturers and Associations. Today, Echo Collins-Egan, ACCESS Health International’s Country Manager in Morocco, gives her opinion.

It is 2015 and we have reached the deadline. The Millennium Development Goals (MDGs), which we aimed to achieve by this year, have a new incarnation.

The Sustainable Development Goals (SDGs) represent a renewed and revitalized global effort to come together and face our common human challenges. There is so much to applaud about both the how and the what of these new goals. The United Nations has sought to address many of the criticisms aimed at the MDGs in terms of both creation and content. The SDGs have been arrived at through a thorough consultation process involving non-governmental organizations, academia, the private sector and, of course, governments. They place a new emphasis on topics such as gender equality, the importance of partnerships and the part that business and industry have to play. Although the Millennium Development Goals were, in theory, universal they were tacitly considered to be objectives for low and middle income countries to aim for with the financial aid of richer nations. The Sustainable Development Goals help undermine the age old paradigm that there are developed and developing countries. Instead these new Goals will apply to all of us.

The advantage of such a joint declaration of global intention is that it acknowledges all the pillars that must be simultaneously erected to make development work for the people it is built for. Education is no good without health, a healthy justice system no use without gender equality. And none of these will be relevant if climate change catches up with us. I call them pillars because they must be strengthened together to be able to support sustainable development. Ignore one of these pillars and the others will struggle to stabilize. As the SDGs state we must find integrated solutions to our collective problems; that means across sectors and across countries. The down side of all this of course is scale. Each of the Goals represents a thousand challenges and a thousand complexities. In other words the problems in poverty eradication, gender equality, economy and health are sometimes overwhelming in their size and scope. We could accuse the SDGs of being too aspirational or too vague. To arrive at global objectives which we can all agree upon is difficult, that they be actionable and accountable seems almost impossible. Yet there is no way around the fact that we have to try. The Goals are an expression of that unavoidable reality, we must come together to solve our common problems. They serve the very real purpose of focusing the development sectors’ minds. They help drive funding and streamline our efforts.

Ultimately however the question has to be how we translate our ambitions into action. How we make those actions accountable. How we measure their impact. ‘We will also build upon the achievements of the Millennium Development Goals and seek to address their unfinished business.’ We need to think about why we did not achieve all our previous goals by 2015 and how we can improve upon them this time around.

Sometimes it can feel as though these Global Challenges, Partnerships, Projects, Alliances and Goals are something vague and somehow separate from those of us working in the development sector, in the field or even in local government. I work for a global healthcare organization in Morocco and often find myself asking how we can link these global objectives to the practical realities faced by the four hundred million people in the world who still lack access to good quality healthcare. This globalized world has become a smaller place but one whose complexities are more obvious than ever. We have more information and the means of communicating it; we are living in a moment where we have more tools than ever before to help us close the gap between ambitious global vision and local on the ground realities.

I, like Eduardo Pisani, want to focus on two of the Sustainable Development Goals:

Goal 3. Ensure healthy lives and promote well-being for all at all ages and specifically its sub point 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

And Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

As someone who spends a lot of her time thinking about Universal Health Coverage I welcome the inclusion of this goal. The concept of Universal Health Coverage has gained astounding momentum over the last few years and helped pushed the agenda for more accessible healthcare service for all. But what does it mean? Like the SDGs themselves, we could accuse Universal Health Coverage of being a vague pipe dream which although worthy, is almost impossible to achieve (or define!). But like the goals it also provides a platform for us as an industry to reflect on the multifaceted challenges we face if we are to one day offer access to quality essential healthcare services for all.

Which leads me to Goal 17. There is something deeply insightful that one of the Goals revolves around the concept of partnerships. It is one of the first lessons I learned about development: nothing can be achieved without strong complementary partnerships. We cannot have Goal 3 without it. Goal 17’s sub points cover precisely the areas I see are needed all around me every day and they demonstrate that these Goals are about implementation. Finance; Technology; Capacity Building; Systemic Issues; Multi-stakeholder partnerships; Data, monitoring and accountability. Music to my colleagues’ and my ears.

To make both these Goals a reality we need practical tools that support the kinds of partnerships that will help us achieve this dream. Mario Pezzini, director of the OECD Development Center emphasised the need for knowledge-sharing platforms for policymakers to dialogue and develop common strategies to achieve the Sustainable Development Goals.

I would like to briefly talk about one such platform that I have had the honor to work with. The Joint Learning Network for Universal Health Coverage (JLN) is for me an example of what partnerships can help us achieve when it comes to health and development. The Joint Learning Network connects practitioners and policymakers across countries to help bridge the gap between theory and the practical ‘how to’ of implementing reforms to achieve universal health coverage. Practitioners and policymakers from member countries set the agenda and technical priorities. Technical Facilitators frame the issues based on international experience and harvest the tacit knowledge of members. Network members participate in a variety of joint learning activities to share their experiences, learn from one another, and co-produce new knowledge. Technical Facilitators work closely with members of the network to develop and adapt new knowledge products focused on the ‘how to’ of health reform implementation. Members so far include Ghana, Kenya, Indonesia, India, Philippines and many more.

It is an active community of people trying to convert a big goal into a day-to-day reality. Last month, we helped organize a workshop for costing of health services for provider payments in Bangalore, India. An essential but often challenging topic for countries on the path to Universal Health Coverage. Participants from ten countries learned about different costing methodologies, how to manage costing data and how to use that data to reform provider payments. But most crucially they were trained to become trainers themselves, to go back to their countries and share the lessons learned with others. A month later, costing workshops are being organized in almost all the countries that participated.

Platforms such as these allow for an understanding that each country has unique contexts and challenges but that working together makes us stronger.

I would advocate for many more such networks and the resources to support them.

Ultimately the Sustainable Development Goals are an expression of hope. They represent a grand vision rather than a work plan. It is our leaders who will sign this declaration but it is the millions of us on the ground who must really act, in partnership, to make these goals a reality. So let’s get to work.

Useful links

OECD and the Sustainable Development Goals

OECD work on health

OECD work on development

Smarter, greener, healthier and more productive: The new old

A more cheerful outlook
A more cheerful outlook

Today’s post is by Tobias Vogt and Fanny Kluge from the Laboratory of Survival and Longevity at the Max Planck Institute for Demographic Research, Rostock, Germany

Ageing populations are a threat to the sustainability of modern societies. This is a dominant line of thought in the political, public and scientific discussion that warns us about the consequences of demographic change. It refers to the concern that the needs of an increasing share of older people have to be met by a decreasing number of younger members of our societies. These warnings must be taken seriously if current conditions prevail. The changes in the age structure will bring major challenges to public finances and the demand for an adjustment of current social policies, in particular, in countries with large public welfare programs for the elderly. Yet, the demographic future may not look as bleak as we generally think. The greying of a population may even embrace certain advantages simply because of the natural transformation of the age structure. This thought was the starting point for a, so far rare, project that focused on the potentials and chances of demographic change. In this case study (downloadable from PLoS One) we focused on Germany as the second oldest country worldwide in terms of its population’s median age of 44.3 years and identified five different areas that may benefit if observed trends of the past continue into the future.

To understand the anticipated challenges as well as the opportunities of demographic change one has to keep in mind that they only result from a change in the age structure of a population. If we depict the current age composition in Germany or in most industrialized countries, it looks rather more like a tree than the usual population pyramid. Yet, this illustration will also only be a snapshot as the over-represented older age groups will become smaller and eventually disappear in the coming decades. Despite ongoing low fertility and a general population decline, this will result in a more stable age structure after 2040 than in the decades when the large baby boom cohorts reach retirement age. In the last decades the share of Germans above age 65 rose by 2 to 3 percentage points. Between 2020 and 2040 this share of Germans will increase by 10 percentage points from 23% to 33%. In the following two decades it will remain stable at this high level and go up slightly.

One major concern of this population structure is that fewer and older individuals are expected to be less productive. This assumption ignores the fact that certain productivity determinants among older individuals like education and health will not remain constant but change over time.

During the last decades participation rates in higher education have increased from cohort to cohort which is reflected in the share of individuals in the labor force with tertiary education. In 2008, every fifth individual in the age groups 25-29 and over age 50 attained tertiary education. These shares will rise considerably. After 2050, every third individual in the respective age groups will have a tertiary education. If current labor force participation rates among these groups remain as they are, this would mean that 46% of the German labor force will hold a higher education degree compared to 28% today.

These changes in educational levels are accompanied by an improvement in individual health. Over the last 30 years, the age at which Germans report worsening subjective health has become later and later. If we forecast this trend into the future we find that not only average life expectancy as such will increase but also the number of years we live in good health. Already today Germans can expect to spend up to 60% of their life in good health. By 2050, this share will increase to 80%, which suggests that most of the years of gained life expectancy may not necessarily be years of bad health. Of course, this scenario is based on past developments and neglects potential future health threats like the consequences of increasing obesity levels and rising cognitive impairments at older ages. Nevertheless, fears of productivity losses may be partially absorbed by the improvements in individual health and education.

A smaller and older population may not only be more productive than expected but even cause less environmental pollution. When we observe individual consumption patterns and their ecological consequences, we find that over the life course younger individuals travel and consume more and, thus, cause higher CO2 emissions than individuals at retirement age. This implies that if today’s consumption behavior prevails, older and smaller populations may generate substantial CO2 reductions. We found that the change in population size and consumption preferences led to a 30% increase in emissions between 1950 and 2020. In the following decades, emissions could decline even to pre-1950s levels.

Apart from the challenges and opportunities on the population level, demographic change will certainly influence our individual lives and our family relationships. On average, we will live longer in good health and need care later, but there will be fewer younger individuals in our family network to support their elderly parents or other relatives. Whether changes in time use can make up for these missing individuals is questionable. We find that if the current work and leisure patterns prevail, individuals will spend slightly more time on leisure and housework and the share of work time drops from 14.5% to 11.9%. Whether the young really spend the additional time they have with the elderly remains to be seen. One important question in this respect is also how valuable the elderly will be in terms of resources they can provide. The wealth they pass on to the next generation will have to be shared with a smaller number of siblings and thus younger family members might be better off.

Certainly this study does not solve the challenges we face in the future, but it sheds some light on potential opportunities that aging populations create. During the coming decades societal frameworks will change and individuals will adapt their behavior to new expectations. The magnitude of the future effects is thus unknown, but we should start to discuss this potential, and favorable adaptations in our society. The future is not too bright, but also not as dark as sometimes argued and we do have the potential to change it.

Useful links

Ageing (Un)equally? OECD Forum 2014

Working better with age OECD review of policies to improve labour market prospects for older workers

OECD health data

We’re all going to die

See you again soon?
See you again soon?

Imagine this scene between doctor and patient. The doctor: “I’ve got good news and bad news”. “Gimme the good news, doc”. “I’ve found you a bed in a hospital”. “Great! What’s the bad news?” “It’s in the Hospital for Incurables”. They were up-front if not exactly upbeat about these things in the old days, but could incurable diseases come back? The question is asked every time a new virus like the latest strain of coronavirus appears.

The last time a coronavirus caused world-wide panic was ten years ago when SARS killed around 9000 people in 37 countries. That’s half the number of victims of the 2009 H1N1 outbreak. Around 18,000 victims is a lot, but it’s nothing compared to the previous appearance of H1N1 in 1918, when the virus infected half a billion people (a fifth of the world’s population) and killed 40 to 100 million of them. At that time there was no treatment, but today antibiotics can cure even something as terrifying as the plague.

There are worries though that the microbes are winning again. Microbes resistant to penicillin appeared within a few years of the drug’s introduction, and since then medical science has been fighting an increasingly serious battle against resistance to cheap and effective first-choice, or “first-line” drugs. Moreover, bacterial infections which contribute most to human disease are also the most resistant: diarrhoeal diseases, respiratory tract infections, meningitis, sexually transmitted infections, and hospital-acquired infections.

The human and other consequences are enormous. In South Asia, for example, one newborn baby dies every two minutes due to treatment failure caused by antibiotic resistance. About 3 million women are at risk of impaired fertility following failure in the treatment of gonorrhoea. Treating multidrug-resistant tuberculosis in South Africa costs around $4300, compared with $35 if first-line drugs are effective. It’s not just in developing countries either. In their gloriously entitled report Bad Bugs, No Drugs, the Infectious Diseases Society of America estimated that 70% of the 90,000 deaths from bacterial infections were attributable to antibiotic resistant strains, and that “for many patients, there are simply no drugs that work”.

Resistance is becoming more serious due to a number of social, economic and behavioural causes. Urbanisation facilitates the spread of typhoid, tuberculosis, respiratory infections, and pneumonia. Pollution, environmental degradation, and changing weather patterns affect incidence and distribution, especially of diseases spread by insects. A growing number of elderly people need hospital care and are at risk of exposure to highly resistant pathogens found in hospitals. AIDS has enlarged the population of patients at risk from many previously rare infections. Global mobility increases the speed and facility with which diseases and resistant micro-organisms can spread.

Irrational use of antibiotics is also promoting microbial resistance. This is due to their being prescribed when not needed or in self-medication, or because patients do not complete courses for financial or other reasons. Antibiotics use in agriculture is another factor. In North America and Europe, half of all antimicrobial production by weight is used in farm animals and poultry, notably as regular supplements for prophylaxis or growth promotion, exposing even healthy animals to frequently subtherapeutic concentrations of antimicrobials. This is accompanied by an increased resistance in bacteria (such as salmonella and campylobacter) that can spread from animals, often through food, to cause infections in humans.

But while new diseases such as the latest coronavirus are emerging and others appearing in new locations (dengue fever in Texas and West Nile encephalitis in New York) only two new classes of antibiotics have been brought to the market in the past 30 years. You may remember that the Human Genome Project was supposed to lead to radical innovation in health care, characterised by new, highly-effective, targeted treatments for a vast range of diseases. It hasn’t happened. Two-thirds of the new applications to the US Food and Drug Administration (FDA) are for modifications to existing drugs rather than new drugs.

There are fears that a pessimistic scenario could come about in which biotechnology never lives up to its promise, the flow of major new treatments dries up, and the profits of big pharmaceutical companies decline, creating a vicious circle where there is less money to invest in long-term R&D to find new products. The discovery deficit is then made worse by investor and government reluctance to continue funding basic research and long-term projects that do not produce payoffs.

As Harvey Rubin pointed out in his 2011 study of pandemics for the OECD Future Shocks project, antimicrobial agents make less money for drugs companies than other prescription drugs. A study of ten-day treatment costs of all new drugs approved by the FDA between January 1997 and July 2003 showed that new antimicrobial drugs cost $137 (all anti-microbial agents) or $85 if anti-HIV medications are excluded, compared with $848 for anti-cancer agents.

Health is one of the indicators in the OECD Better Life Index, that shows what matters to individuals (you can make and share your own index here). It would be interesting to see how the average of all the BLI indices compiled so far compares with what governments think is important, based on budget allocations. It would also be interesting to see within health if conditions that affect or could affect people most are the ones receiving the most funding.

Useful links

OECD work on health

Who pays if you’re sick?

Emerging economies have made good progress on health coverage recently, but the share of out-of-pocket payments in total health expenditure remains significantly higher than in most advanced countries. Direct payments by people receiving healthcare can represent quite a blow to the living standards of households’. This is especially the case for poor households, though can also be true for relatively better-off households when the costs of hospitalisation, medicines, or even forgone income are high.

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Peacebuilding and statebuilding come before the Millennium Development Goals

 Guest post by Donata Garrasi of the OECD’s Development Co-operation Directorate and Co-ordinator of the International Dialogue for Peacebuilding and Statebuilding

Imagine you can’t take your child to the doctor because the clinic is on the other side of a bridge it’s too dangerous to cross. Imagine you’re trying to get an education but you can’t read after sunset because there’s no light. Imagine the only people who’ll protect you from an armed gang are the members of another armed gang. Imagine you’re a government trying to deal with problems like these after a civil war or invasion that’s lasted for years and destroyed your country and you’ll easily understand why no fragile state has achieved a single Millennium Development Goal, or is likely to do so by the 2015 target date, even though these states receive over 30% of development assistance.

If the MDGs set the bar impossibly high, what should fragile states aim for? The International Dialogue on Peacebuilding and Statebuilding was created in 2008 after the Accra High Level Forum on Aid Effectiveness to devise a set of realistic peacebuilding and statebuilding objectives that address the root causes of conflict and fragility. The first Dialogue, held in Dili, Timor-Leste in April 2010, saw the formation of the g7+, “an independent and autonomous forum of fragile and conflict affected countries and regions”. At the second global meeting in Liberian capital Monrovia last week, delegates from over 40 countries, international agencies and civil society organisations had a “frank and open exchange of views” on what has worked, what hasn’t and what can be done starting now.

“The problem is, you guys don’t trust us,” Timor Leste’s finance minister Emilia Pires told the donor countries, urging them to lose their control freak attitude. But delegates from fragile states were just as harsh regarding their own responsibilities, with one Togolese speaker suggesting that citizens of donor countries would refuse to spend another penny on aid if they knew where most of the money went. There was disagreement on using the term “fragile”, with some arguing that it stigmatised countries, other that it was simply being realistic and could be useful in determining whether particular kinds of assistance should be granted. One participant claimed that fragile would be an improvement on the state his country was in at present. Olivier Kamitatu, DR Congo’s planning minister, summed up the majority feeling, and the ambitions of the Dialogue, when he said that “The g7+ is extremely useful in giving us a common voice in international discussions, but it’s a club we’d like to leave as quickly as possible”.

The “Monrovia Roadmap”, agreed on by the whole range of development partners, defines five practical objectives for peacebuilding and statebuilding. “Establish and strengthen citizen security” is one of the five. Without security and the assurance that people can go about their daily lives in safety, the rest is meaningless. But who should implement objectives, and monitor progress? If the state hasn’t functioned for years or is seen as defending special interests, then political processes have to start by building trust among groups who may be hostile to each other, including the government and civil society. Therefore the Roadmap calls on states to “Foster inclusive political settlements and conflict resolution”.

Reggae legend Peter Tosh understood another of the objectives when he sang that he didn’t want peace but “equal rights and justice”. It is vital to “Address injustices and support increasing citizen access to justice”. Unemployment is a source of tension and can fuel conflict when joining an armed group may be the most attractive job available, or the only one. The objective to “Generate employment and improve livelihoods” will require a mix of labour-intensive public and community works, increased agricultural productivity, and domestic private sector development. All this costs money, and although international partners will continue to finance some activities, the objective is to “Manage revenues and build capacity for accountable and equitable social service delivery”. It’s an ambitious set of objectives, but as Liberian President Ellen Johnson Sirleaf pointed out in her closing remarks, “The challenges are huge, but they’re not bigger than challenges we’ve faced in the past”.

Useful links

OECD work on conflict and fragility

GPs and healthcare costs

It may be common knowledge that doctors’ pay outstrips average wages, with the really high earnings going to medical specialists. But now, more and more doctors are becoming specialised, with implications for costs and healthcare policy more generally. There were some 3.2 million doctors in the OECD area in 2008, which is over 40% more than in 1990 in absolute terms. But looked at on a per head basis, the number of specialists expanded by about 50% over the same 18 year period,  compared with a mere 15% rise per capita for GPs.