Dollars and disease Marrying social, economic and disease dynamic perspectives for public health Nim Arinaminpathy Imperial College London

Roles of transmission models in public health Supporting healthcare delivery Informing decision-making Basic science: contributing to evidence base for policy

Careseeking (unmeasured confounders) Health systems Macroeconomic shocks National politics with borderless infections (Klepac et al, PNAS 2011) Why economics/sociological processes Individual behaviour (Funk et al, PNAS 2009) Decision-making under economic constraints (Edmunds, 200x) Implementation and logistics Market dynamics

Careseeking (unmeasured confounders) Health systems Macroeconomic shocks National politics with borderless infections (Klepac et al, PNAS 2011) Why economics/sociological processes Individual behaviour (Funk et al, PNAS 2009) Decision-making under economic constraints (Edmunds, 200x) Implementation and logistics Market dynamics

Careseeking (unmeasured confounders) Health systems Macroeconomic shocks National politics with borderless infections (Klepac et al, PNAS 2011) Why economics/sociological processes Individual behaviour (Funk et al, PNAS 2009) Decision-making under economic constraints (Edmunds, 200x) Implementation and logistics Market dynamics

Implementation: logistical/resource factors Decision trees for clinical algorithms Operations research – E.g. diagnostic tests for TB control Eg: Rao, Schellenberg & Ghani, 2013 Dowdy, Cattamanchi et al, 2011 Central laboratory Peripheral sites

Careseeking (unmeasured confounders) Health systems Macroeconomic shocks National politics with borderless infections (Klepac et al, PNAS 2011) Why economics/sociological processes Individual behaviour (Funk et al, PNAS 2009) Decision-making under economic constraints (Edmunds, 200x) Implementation and logistics Market dynamics

Diseases of poverty The ‘big three’: HIV, TB, Malaria Poverty: – Increases risk of acquiring infection – Reduces access to essential healthcare Economic factors loom large for dynamics of infection

Russia Hungary Health in financial crises: Soviet Union in the 1990s Arinaminpathy, Dye (2010) J.R.Soc.Interface Strong associations between economic changes and TB epidemiology Process vs pattern? Most recent financial crisis?

Tuberculosis today 8.7M new TB cases,1.4M deaths in M TB/HIV+ cases, 430k deaths Global Tuberculosis Report, 2012 As yet no effective TB vaccine But most TB cases are curable with 6-9 months of drug treatment.

Ecology of TB drug markets Few manufacturers of TB drugs Global demand for drugs fragmented amongst many high-burden, low- income countries Irregular supply, with drugs of uncertain quality

Ecology of TB drug markets Global Drug Facility (GDF): What impact has the GDF had, on the TB drug market? – Private-sector prices as well as in national TB programmes What might be the effects of GDF expansion? Arinaminpathy, Cordier-Lassalle, Vijay, Dye (2013) Lancet

Health systems in infectious disease dynamics Lin, Langley, Mwenda et al (2011) Int.J.Tuberc Lung Dis.

Photo credit: Peter Small

Patient trajectories and infectious periods Kapoor, Raman, Sachdeva, Satyanarayana (2012) PLoS ONE

Driving questions What are the most effective levers, at the public/private interface? How might provider incentives be structured, to minimise diagnosis and treatment delays? What effects might such interventions have on TB transmission?

Conclusions Economic factors can be an important part of the interface between infectious disease modeling and public health Health-economic implications of given interventions have played an important role in decision-making Future directions: recognising economic/sociological processes as part of the disease-dynamical system, for public health