Global health

For the bibliographic database, see Global Health database.

Global health is the health of populations in a global context and transcends the perspectives and concerns of individual nations. In global health, problems that transcend national borders or have a global political and economic impact, are often emphasized. It has been defined as 'the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide'. Thus, global health is about worldwide improvement of health, reduction of disparities, and protection against global threats that disregard national borders. The application of these principles to the domain of mental health is called Global Mental Health.

The major international agency for health is the World Health Organization (WHO). Other important agencies with impact on global health activities include UNICEF, World Food Programme (WFP), and the World Bank. A major initiative for improved global health is the United Nations Millennium Declaration and the globally endorsed Millennium Development Goals.

History

Many of the key events on the modern global health and development timeline occurred in the 1940s with the formation of the United Nations, World Health Organization and World Bank Group. In 1948, the member states of the newly formed United Nations gathered together to create the World Health Organization. A cholera epidemic that took 20,000 lives in Egypt in 1947 and 1948 helped spur the international community to action.

One of the greatest accomplishments of the international and global health communities since then was the eradication of smallpox. The last naturally occurring case of the infection was recorded in 1977. Resulting enthusiasm regarding the potential for eradication of other diseases, however, displaced efforts to build primary health care systems centered on community participation. Thus, even though community-centered PHC was advocated at the Alma Ata Conference sponsored by WHO and UNICEF in 1978, the global agenda abruptly changed in 1979 to an alternative strategy deemed “Selective Primary Health Care”. Buoyed by success with smallpox eradication, its main focus was to control other important infectious diseases, selected from a global list of 23. If higher priority had been given to promoting leadership skills, developing countries might have progressed in both public health and in developing primary health care (PHC), particularly for rural and disadvantaged communities. While both approaches were genuine attempts to improve health status in developing countries, the ensuing decades witnessed partial failure of both. Local communities failed to develop integrated PHC models, often having to compete for priority and resources with vertically driven disease control strategies heavily supported by external donors. While success is being achieved with some disease specific initiatives, more basic health provisions such as clean water, food security and attending to locally prevalent conditions languished, with little impact on overall health status. With benefit of hindsight, these deficiencies are now widely acknowledged, and efforts are underway in some countries to enable communities to participate in defining their needs and solutions, and with donors approaching health systems development more respectfully.

The Millennium Development Goals (MDGs) At a United Nations Summit in 2000, member nations pronounced eight Millennium Development Goals (MDGs) to be achieved by 2015, reflecting major challenges facing human development globally. Among these eight, goals 4, 5 and 6 focus explicitly on health, while others address broad social conditions. Across all eight goals, there are 18 targets, supported by 48 health indicators. Here are the eight goals in summarized form:

Goal 1: Eradicate Extreme Poverty and Hunger

Goal 2: Achieve Universal Primary Education

Goal 3: Promote Gender Equality and Empower Women

Goal 4: Reduce Child Mortality by 2/3

Goal 5: Reduce Maternal Mortality by 3/4

Goal 6: Combat HIV/AIDS, Malaria, and Other Diseases

Goal 7: Ensure Environmental Sustainability

Goal 8: Develop a Global Partnership of Development

The declaration has been matched by unprecedented global investment by donor and recipient countries. Each year, the United Nations issues a report on progress. The report released on July 2, 2012 reveals that several MDG targets have been met ahead of the 2015 timeline, there is progress on others, and some e.g., goal 5, are seriously lagging.

Aid Effectiveness: In 2005, over 100 donors and developing countries agreed to the Paris Declaration on Aid Effectiveness. Among the distinguishing features was a commitment to hold each other to account for implementing its principles at the country level, and to achieve joint progress by 2010 and beyond, through attention to the following elements:

Ownership - Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption.

Alignment - Donor countries align behind these objectives and use local systems.

Harmonization - Donor countries coordinate, simplify procedures and share information to avoid duplication.

Results - Developing countries and donors shift focus to development results and results get measured . Mutual Accountability - Donors and partners are accountable for development results.

Sustainable Development Goals: Just as some of the MDGs have been met, and several others are beginning to show success, the focus for new global health policy initiatives is converging with one of the main outcomes of the Rio+20 Conference (June 20-22, 2012), namely agreement by member States to launch a process to develop a set of Sustainable Development Goals (SDGs), which will build upon the Millennium Development Goals and converge with the post 2015 development agenda. Implicit within this remain key challenges for health, as a central component of human development.

Sustainable development is most frequently defined as "development that meets the needs of the present without compromising the ability of future generations to meet their own needs.” Human health is thus embodied within an ecological context of sustainable development: all aspects of human ecology fundamentally dependent on the quality of the natural environment, such as clean water, clean air, wholesome nutrition and recreation. This duly recognized, the challenges encountered in sustainable development for health not only include environmental and social determinants, but are also substantively influenced as well by organizational and technological systems.

For example, major reductions in the burden of malaria have been achieved by improved prevention and treatment. Yet, such success cannot be taken for granted: tuberculosis control is now threatened by the emergence of multiple antibiotic-resistant strains. While this disease has social and environmental determinants, it is a health systems and technological challenge as well. Similarly, while health promotion and primary prevention are critical in combating the NCD pandemic, they are much less than 100% effective: hundreds of millions of people are developing NCDs, most of them poor; affordable technologies must be made accessible to assist in their management. The world must respond to this challenge as well, as is now being addressed by the World Health Organization, in a new Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020.

Disciplinary perspectives

Global health is a research field at the intersection of medical and social science disciplines — including demography, economics, epidemiology, political economy and sociology. From different disciplinary perspectives, it focuses on determinants and distribution of health in international contexts.

An epidemiological perspective identifies major global health problems. A medical perspective describes the pathology of major diseases, and promotes prevention, diagnosis, and treatment of these diseases.

An economic perspective emphasizes the cost-effectiveness and cost-benefit approaches for both individual and population health allocation. Aggregate analysis, e.g., from the perspective of governments and non-governmental organizations (NGOs), focuses on analysis for the health sector. Cost-effectiveness analysis compares the costs and health effects of an intervention to assess whether health investments are worthwhile from economic perspective. It is necessary to distinguish between independent interventions and mutually exclusive interventions. For independent interventions, average cost-effectiveness ratios suffice. However, when mutually exclusive interventions are compared, it is essential to use incremental cost-effectiveness ratios. The latter comparisons suggest how to achieve maximal health care effects from the available resources.

Individual health analysis from this perspective focuses on the demand and supply of health. The demand for health care is derived from the general demand for health. Health care is demanded as a means for consumers to achieve a larger stock of "health capital." The optimal level of investment in health occurs where the marginal cost of health capital is equal to the marginal benefit resulting from it (MC=MB). With the passing of time, health depreciates at some rate δ. The general interest rate in the economy is denoted by r. Supply of health focuses on provider incentives, market creation, market organization, issues related to information asymmetries, and the role of NGOs and governments in health provision.

Another ethical approach emphasizes distributional considerations. The Rule of Rescue, coined by A.R. Jonsen (1986), is one way to address distributional issues. This rule specifies that it is 'a perceived duty to save endangered life where possible'. John Rawls ideas on impartial justice is a contractual perspective on distribution. These ideas have been applied by Amartya Sen to address key aspects of health equity. Bioethics research also examines international obligations of justice, in three broadly clustered areas: When are international inequalities in health unjust? Where do international health inequalities come from? How do we meet health needs justly if we can't meet them all?

A political approach emphasizes political economy considerations applied to global health. Political economy originally was the term for studying production, buying and selling, and their relations with law, custom, and government. Originating in moral philosophy (e.g., Adam Smith was professor of Moral Philosophy at the University of Glasgow), political economy of health is the study of how economies of states — polities, hence political economy - influence aggregate population health outcomes.

There are many perspectives and approaches to take when it comes to issues of global health, hence why the global health system is still struggling. Some perceive the immunization and prevention of disease to be a form of public democracy, others view it as a moral duty or an investment in self-protection. The journalist, Laurie Garrett explores the various perspectives shaping global health and suggests that it is due to perspective divergence that is hindering monetary funding and philanthropic efforts of organizations to properly control disease. There are dangers to having divergent perspectives especially if it is a biased one; such as exemplified by Andrew Natsios of USAID, when he proclaimed that antiretrovirals should not be distributed to HIV-stricken Africa due to the occupants lacking a concept of time and clocks to properly facilitate the proper sequence of drug consumption. In addition, divergent perspectives can lead to "stove-piping", which localizes funding to only specific causes while neglecting the larger and more important issues. The most important aspect in achieving global health is instead to take on a research approach and act accordingly to data and proven research because global health needs to be focused on as a whole, rather than in increments.

Measurement

Measurement of global health includes the collection of health indicators followed by analysis of the same to draw a conclusion. Several measures exist: disability-adjusted life year (DALY), quality-adjusted life years (QALYs), and mortality measurements. The choice of measures can be controversial and includes practical and ethical considerations.

Life expectancy

Life expectancy is a statistical measure of the average life span (average length of survival) of a specified population. It most often refers to the expected age to be reached before death for a given human population (by nation, by current age, or by other demographic variables). Life expectancy may also refer to the expected time remaining to live, and that too can be calculated for any age or for any group.

Disability adjusted life years

The DALY is a summary measure that combines the impact of illness, disability and mortality on population health. The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of 'healthy' life and the burden of disease as a measurement of the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability. For example, DALYs for a disease are the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition. One DALY represents the loss of one year of equivalent full health.

Quality adjusted life years

QALYs are a way of measuring disease burden, including both the quality and the quantity of life lived, as a means of quantifying in benefit of a medical intervention. The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behaviour. QALYs attempt to combine expected survival with expected quality of life into a single number: if an additional year of healthy life expectancy is worth a value of one (year), then a year of less healthy life expectancy is worth less than one (year). QALY calculations are based on measurements of the value that individuals place on expected years of survival. Measurements can be made in several ways: by techniques that simulate gambles about preferences for alternative states of health, with surveys or analyses that infer willingness to pay for alternative states of health, or through instruments that are based on trading off some or all likely survival time that a medical intervention might provide in order to gain less survival time of higher quality. QALYs are useful for utilitarian analysis, but does not in itself incorporate equity considerations.

Infant and child mortality

Life expectancy, DALYs and QALYs represent the average disease burden well. However, infant mortality and under-five child mortality are more specific in representing the health in the poorest sections of a population. Therefore, changes in these classic measures are especially useful when focusing on health equity. These measures are also important for advocates of children's rights. Approximately 56 million people died in 2001. Of these, 10.6 million were children under 5 years of age, 99% of these children were living in low-and middle-income countries. That translates to roughly 30,000 children dying every day.

Morbidity

Morbidity measures include incidence rate, prevalence and cumulative incidence. Incidence rate is the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.

Health conditions

The main diseases and health conditions prioritized by global health initiatives are sometimes grouped under the terms "diseases of poverty" versus "diseases of affluence", although the impacts of globalization are increasingly blurring any such distinction.

Respiratory diseases and measles

Infections of the respiratory tract and middle ear are major causes of infant and child mortality. In adults, tuberculosis is highly prevalent and causes significant morbidity and mortality. Mortality in tuberculosis has increased due to the spread of HIV. The spread of respiratory infections is increased in crowded conditions. Current vaccination programmes against pertussis prevent 600 000 deaths each year. Measles is caused by the morbillivirus and spread via the airways. It is highly contagious and characterized by flulike symptoms including fever, cough, and rhinitis and after a few days deveopment of a generalized rash. It can effectively be prevented by vaccination. In spite of this, almost 200,000 people, mostly children under 5 years of age, died from measles in 2007.[2] Pneumococci and Haemophilus influensae cause approximately 50% of child deaths in pneumonia, and also cause bacterial menigitis and sepsis. Novel vaccines against pneumococci and Haemophilus influensa are clearly cost-effective in low-income countries. Universal use of these two vaccines are estimated to prevent at least 1 000 000 child deaths annually. For maximal long-term effect, vaccination of children should be integrated with primary health care measures.

The Global Initiative for Asthma (GINA) estimates that the number of disability-adjusted life years (DALYs) lost due to asthma is 15 million per year globally. This reflects about 1% of all DALYs lost. Asthma was number 25 in a list of causes of DALYs lost in 2001. The social and economic determinants that potentially increase the incidence of asthma are air pollution, tobacco smoking, lack of education, lack of health care resources and poverty. Many of the places that have burdens of disease associated with lack of sanitary water also experience a lack of clean air. In low to middle income countries air is often polluted as a result of crowded living conditions and lack of formal policies to control industrial pollution. In these areas women and children are also subjected to toxins produced when cooking on open flames within their homes.

One barrier that must be approached to significantly change asthma related DALYs in low to middle income countries, is the need for standardized diagnosis. Many regions have differing definitions of asthma and this interferes with the ability to perform valid research. GINA has noted that some surveys will seek information from only those that have been diagnosed with asthma while others may seek information from anyone that has experienced difficulty breathing or wheezing symptoms. Many people in developing countries have very little access to medical care; they may never be diagnosed with asthma, and may never receive treatment for asthma symptoms. Medical resources need to be more available in low and middle income countries so those suffering from asthma can receive treatment.

Additionally, poor education poverty and poor infrastructure have significant roles in the number of DALYs lost as a result of asthma. Lack of education on how to safely cook food, and prevent the release of asthma triggers into the air is an acknowledged disparity. Programs that seek to educate women on safe cooking and air pollution prevention should be designed to reduce the DALYs lost from asthma. Asthma is a chronic disease that has tremendous economic cost, mortality and is a key cause of morbidity. There are conditions that are known to exacerbate asthma conditions and methods to reduce those conditions should be sought i.e.; decrease exposure to triggers such as; air pollution, smoke, and dust. The treatment of asthma episodes is where the most significant amount of medical care resources is spent on asthma. It seems that the best way to avoid DALYs lost and the expense of medical costs and treatment would be to perform standard research in areas affected by asthma and then educate these areas on what they can do to deter asthma episodes. If these two goals can be reached it may be possible to have low to middle income countries lessen the burden of asthma in their communities.

Diarrhoeal diseases

Diarrhoeal infections are responsible for 17 per cent of deaths among children under the age of five worldwide, making them the second most common cause of child deaths globally. Poor sanitation can lead to increased transmission through water, food, utensils, hands and flies. Rotavirus is highly contagious and a major cause of severe diarrhoea and death (ca 20%) in children. According to the WHO, hygienic measures alone are insufficient for the prevention of rotavirus diarrhoea. Rotavirus vaccines are highly protective, safe and potentially cost-effective. Dehydration due to diarrhoea can be effectively treated through oral rehydration therapy (ORT), with dramatic reductions in mortality. By mixing water, sugar and salt or baking soda and administering it to the affected child, dehydration can be effectively treated. Important nutritional measures are promotion of breastfeeding and zinc supplementation.

Maternal health

Maternal health clinic in Afghanistan (source: Merlin)

Main article: Maternal health

In many developing countries, complications of pregnancy and childbirth are the leading causes of death among women of reproductive age. A woman dies from complications from childbirth approximately every minute. According to the World Health Organization, in its World Health Report 2005, poor maternal conditions account for the fourth leading cause of death for women worldwide, after HIV/AIDS, malaria, and tuberculosis. Most maternal deaths and injuries are caused by biological processes, not from disease, which can be prevented and have been largely eradicated in the developed world - such as postpartum hemorrhaging, which causes 34% of maternal deaths in the developing world but only 13% of maternal deaths in developed countries.

HIV/AIDS

Main articles: HIV and AIDS

Human immunodeficiency virus (HIV) is a retrovirus that first appeared in humans in the early 1980s. HIV progresses to a point where the infected person has AIDS or Acquired Immunodeficiency Syndrome. HIV becomes AIDS because the virus had depleted CD4+ T-cells that are necessary for a healthy immune system. Antiretroviral drugs prolong life and delay the onset of AIDS by minimizing the amount of HIV in the body.

HIV is transmitted through bodily fluids. Unprotected sex, intravenous drug use, blood transfusions, and unclean needles spread HIV through blood and other fluids. Once thought to be a disease that only affected drug users and homosexuals, it can affect anyone. Globally, the primary method of spreading HIV is through heterosexual intercourse. It can also be passed from a pregnant woman to her unborn child during pregnancy, or after pregnancy through breast milk. While it is a global disease that can affect anyone, there are disproportionately high infection rates in certain regions of the world.

In June 2001, the United Nations held a Special General Assembly to intensify international action to fight the HIV/AIDS epidemic and to mobilize the resources needed towards this aim, labelling the situation a "global crisis".

A positive outlook on HIV issues on global health came into play when scientists found evidence of antiretrovirals (ARVS), a combination of anti-HIV drugs that could potentially reduce the rapid spread in the body and deaths. Many wealthy men and women, infected with HIV started using these drugs soon after they were introduced. The United States and Europe had a reduced number of people infected with AIDS by 1997 by a substantial margin due to the usage of ARVS.

Malaria

Malaria is an infectious disease caused by protozoan Plasmodium parasites. The infection is transmitted via mosquito bites. Early symptoms may include fever, headaches, chills and nausea. Each year approximately 500 million cases of malaria occur worldwide, most commonly among children and pregnant women in underdeveloped countries. Malaria can hinder economic development of a country. Economic effects of malaria include decreased work productivity, treatment cost, and time spent for getting treatment.

Deaths in malaria can be sharply and cost-effectively reduced by use of insecticide-treated bednets, prompt artemisin-based combination therapy, and supported by intermittent preventive therapy in pregnancy. However, only 23% of children and 27% of pregnant women in Africa were estimated to sleep under insecticide-treated bednets.[3]

Nutrition and micronutrient deficiency

Greater than two billion people in the world are at risk of micronutrient deficiencies (including lack of vitamin A, iron, iodine and zinc). Among children under the age of five in the developing world, malnutrition contributes to 53% of deaths associated with infectious diseases. Malnutrition impairs the immune system, thereby increasing the frequency, severity, and duration of childhood illnesses (including measles, pneumonia and diarrhoea). Micronutrient deficiencies also compromise intellectual potential, growth, development and adult productivity.

However, infection is also an important cause and contributor to malnutrition. For example, gastrointestinal infections causes diarrhoea, and HIV, tuberculosis, intestinal parasites and chronic infection increase wasting and anemia.

Fifty million children under the age of five are affected by vitamin A deficiency. Such deficiency has been linked with night blindness. Severe vitamin A deficiency is associated with xerophtalmia and ulceration of the cornea, a condition that can lead to total blindness. Vitamin A is also involved in the function of the immune system and in maintaining epithelial surfaces. For this reason, vitamin A deficiency leads to increased susceptibility to infection and disease. In fact, vitamin A supplementation was shown to reduce child mortality rates by 23% in areas with significant levels of vitamin A deficiency.

Iron deficiency affects approximately one-third of the world's women and children. Iron deficiency contributes to anemia along with other nutritional deficiencies and infections and is associated with maternal mortality, prenatal mortality and mental retardation globally. In anemic children, iron supplementation combined with other micronutrients improves health and hemoglobin levels. In children, iron deficiency compromises learning capacity, and emotional and cognitive development.

Iodine deficiency is the leading cause of preventable mental retardation. As many as 50 million infants born annually are at risk of iodine deficiency. Pregnant women who are iodine deficient should be included in the target population for this particular intervention because pregnant women with iodine defiency increases the chance of miscarriages and also lowers the development potential of the infant. Global efforts for universal salt iodization are helping eliminate this problem.

According to Lasserini and Fischer et al., zinc deficiency may increase the risk of mortality from diarrhea, pneumonia and malaria. Almost 30% of the world's children are estimated to be zinc deficient. Supplements have been shown to reduce the duration of diarrhea episodes.

Interventions to prevent malnutrition include micronutrient supplementation, fortification of basic grocery foods, dietary diversification, hygienic measures to reduce spread of infections, and promotion of breastfeeding. Dietary diversification aims to increase the consumption of vital micronutrients in the regular diet. This is done by education and promotion of a diverse diet, and by improving access to micronutrient-rich and locally produced food.

Violence Against Women

Violence against women is a major global health crisis that affects every society in every nation. According to The World Health Organization(2005), "Violence against women is a major threat to social and economic development" (p. 3). The United Nations General Assembly (1993), defines violence against women ( as cited in The United Nations Population Fund(UNFPA)) “ [as] physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state."

Although statistics can be hard to accurately capture because so many cases of violence against women go unreported, according to The World Health Organization, (2005) "It is estimated that one in every five women faces some form of violence during her lifetime, in some cases leading to serious injury or death". In the publication "Ending Violence Against Women" (1999), authors Ellsberg and Gottemoeller state, "In addition to causing injury, violence increases women’s long-term risk of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression" (as cited in Ellsberg and Heise, 2005, p. 9). The World Health Organization (2011) Fact Sheet states, " Risk factors for being a perpetrator include low education, past exposure to child maltreatment or witnessing violence between parents, harmful use of alcohol, attitudes accepting of violence and gender inequality. Most of these are also risk factors for being a victim of intimate partner and sexual violence" (2011, para. 1).

To combat the issue of violence against women there must be changes made on a global scale. According to the World health Organization (2005) this begins with working towards reaching the Millennium Development Goals (MDGs) (World Health Organization, 2005, p. 1). The WHO (2005) states that, "The MDGs are currently the highest-level expression of the international community's development priorities. They commit the international community to an action agenda which emphasizes sustainable, human development as the key to fulfilling social and economic progress" (p. 5).

According to Joseph Millum a bioethicist who is a Research Fellow at the Clinical Center Department of Bioethics/Fogarty International Center, United States National Institutes of Health, "Health and human rights are...inextricably linked. Therefore the fight for equality of women must be at the forefront when combating the problem of violence against women around the globe. Stopping the violence against women can only happen if societies are made aware of their importance in eradicating adversaries that hinder prosperity among nations and the protection of basic human rights.

Surgical disease burden

While infectious diseases such as HIV exact a great health toll in low-income countries, surgical conditions including trauma from road traffic crashes or other injuries, malignancies, soft tissue infections, congenital anomalies, and complications of childbirth also contribute significantly to the burden of disease and impede economic development. [4]. It is estimated that surgical diseases comprise 11% of the global burden of disease, and of this 38% are injuries, 19% malignancies, 9% congenital anomalies, 6% complications of pregnancy, 5% cataracts, and 4% perinatal conditions. The majority of surgical DALYs are estimated to be in South-East Asia (48 million), though Africa has the highest per capita surgical DALY rate in the world.

As discussed above, injuries are the largest contributor to the global surgical disease burden with road traffic accidents (RTAs) contributing the largest share. According the WHO, more 3500 RTA related deaths occur daily with millions injured or disabled for life. Road traffic accidents are projected to rise from the ninth leading cause of death and DALYs lost globally in 2004, to the top five in 2030. This would place injuries ahead of infectious diseases by 2030. [5]

Health care workforce

Main article: Health human resources

The World Health Organization (WHO) estimates that the world faces a shortage of 4.3 million health professionals required for delivering essential health care services to populations in need. According to the WHO's 2006 World Health Report, 57 countries face severe shortages in their health care workforce, mostly in sub-Saharan Africa. The WHO Global Code of Practice on the International Recruitment of Health Personnel was developed in a context of raising awareness of international health worker migration and addressing global imbalances in health workforce distribution. The World Health Assembly adopted the Code in 2010 to facilitate the strengthening of health workforces with skills relevant to population needs.

Chronic disease

Main article: Non-communicable disease

The relative importance of chronic non-communicable disease is increasing. For example, the rates of type 2 diabetes, associated with obesity, have been on the rise in countries traditionally noted for hunger levels. In low-income countries, the number of individuals with diabetes is expected to increase from 84 million to 228 million by 2030. Obesity is preventable and is associated with numerous chronic diseases including cardiovascular conditions, diabetes, stroke, cancers and respiratory diseases. About 16% of the global burden of disease, measured as DALYs, has been accounted for by obesity.

In September 2011, the United Nations is hosting its first General Assembly Special Summit on the issue of non-communicable diseases. Noting that non-communicable diseases are the cause of some 35 million deaths each year, the international community is being increasingly called to take important measures for the prevention and control of chronic diseases, and mitigate their impacts on the world population especially on women, who are usually the primary caregivers. Current non-communicable disease efforts include global oncology.

Health interventions

Many low-cost, evidence-based health care interventions for improved health and survival are known. Priority global targets for improving maternal health include increasing coverage of deliveries with a skilled birth attendant. Interventions for improved child health and survival include: promotion of breastfeeding, zinc supplementation, vitamin A fortification and supplementation, salt iodization, handwashing and hygiene interventions, vaccination, treatment of severe acute malnutrition. In malaria endemic regions, use of insecticide treated bednets and intermittent pharmacological treatment reduce mortality. Based on such studies, the Global Health Council suggests a list of 32 treatment and intervention measures that could potentially save several million lives each year.

Progress in coverage of health interventions, especially relating to child and maternal health (Millennium Development Goals 4 and 5), is tracked in 68 low-income countries by a WHO- and UNICEF-led collaboration called Countdown to 2015. These countries are estimated to account for 97% of maternal and child deaths worldwide.

To be most effective, interventions need to be appropriate in the local context, be timely and equitable, and achieve maximum coverage of the target population. Interventions with only partial coverage may not be cost-effective. For example, immunization programs with partial coverage often fail to reach the ones at greatest risk of disease. Furthermore, coverage estimates may be misleading if not distribution is taken into account. Thus, mean national coverage may appear fairly adequate, but may nevertheless be insufficient when analyzed in detail. This has been termed 'the fallacy of coverage'.

Although health intervention programs are in place, there are paradoxes affecting their capability to make a difference. As Farmer states in his article, many populations are facing the ‘outcome gap’ meaning that some populations have access to medical treatment while others due not. The reason for this is that the countries supporting these populations do not have sustainable infrastructure. The unfortunate problem with this is that a more effective treatment will leave many untreated solely for the reasons that their country does not have sustainable infrastructure to support it. Human rights is central with this problem because sustaining health in a population should be universal and accessible to all. It is also noted in the article that lack of infrastructure is commonly referenced to for a lack of healthcare in a country, demonstrating its prevalence in global health. In making progress with health interventions, taking into account the 'outcome gap' is vital to a programs success and whether or not treatments will be able to reach those who need it. It is important to note that although we do have these interventions in place, many external factors influence how effective (if at all) a program can be.

Journalist Laurie Garrett argues that the field of global health is not plagued by a lack of funds. There are many funds available to the global health field at the present time through many different agencies. But more funds does not always translate into any positive outcomes. The problem lies in the way these funds are allocated to different issues; they are very narrow in their approach where the focus is on one single disease. This stove-piping approach disregards other dire health issues in global health, particular disease can more funds due to interest of the donors and not to what is actually needed. Efforts need to be coordinated rather than focusing on single disease. Most money that is given comes with strings attached clauses where the money is spent at the wishes of the donor. More money is needed where there are no conditions attached. Donors must figure out how to build not only effective local health infrastructures but also local industries, franchises, and other profit centers that can sustain and thrive from increased health-related spending.

While investments by countries, development agencies and private foundations has increased substantially in recent years with aim for improving health intervention coverage and equitable distribution, including for measuring progress towards the achievement of the Millennium Development Goals, attention is also being increasingly directed to addressing and monitoring the health systems and health workforce barriers to greater progress. For example, in its World Health Report 2006, the WHO estimated a shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide, especially in sub-Saharan Africa, in order to meet target coverage levels to achieve the Millennium Development Goals 4 and 5.

Global health challenge

The major challenge arose from globalization is that people trained in specialized schools in developing countries as health workers are increasingly migrating to developed countries causing deficiency of local health workers to continue to grow up. Already, one out of five practicing physicians in the United States is foreign-trained and it is estimated that if current trends continue, by 2020 the United States could face a shortage of up to 8oo,ooo nurses and 200,000 doctors. The lack of local health worker is impeding improvement and foundation of global health care and the fact that developed countries are poaching health workers from developing countries is the key point where needs effective solution.

In addition, it takes appropriate conditions, health-care systems, and basic working infrastructure to improve the general health of the public in the developing countries. However, long term neglect of basic infrastructure has made hospitals, local health clinics, and medical schools with educated individuals in the health field scarce. These cash flow and funds from public and private sectors end up being spent effectively.

Furthermore, the type of aid given to improve global health is often associated with short term goals. For example, increasing the amount of people receiving specific treatment, decreasing pregnant women with HIV (aids), or increasing the number of bed nets. Few donors realize that it will take up to at least one full generation or more to substantially improve the public health, and that the focus should be less on particular diseases and more on populations general well-being.

See also

• Global mental health
• Global Pulse Journal
• Primary health care
• Public health
• Global Health Delivery Project at Harvard University
• Global Oncology at Harvard University
• Globalization and Health
• Family Health International non-profit organization
• Journal of Global Health
• MEDICC non-profit organization
• Reproductive Health Supplies Coalition global reproductive health alliance

Global health strategies and policy frameworks

• Global Strategy for Women's and Children's Health
• Global Code of Practice on the International Recruitment of Health Personnel
• International Code of Marketing of Breast-milk Substitutes
• Millennium Development Goals
• WHO Framework Convention on Tobacco Control
• Social determinants of health in poverty

References

Additional sources

• Tulenko, Kate (29 April 2012). "Healthcare’s foreign invasion". Salon.com. 
• Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M (August 2004). "Migration of health-care workers from developing countries: strategic approaches to its management". Bull. World Health Organ. 82 (8): 595–600. PMC 2622931. PMID 15375449. 
• Skolnik, Richard (2011). Global Health 101 (2nd ed.). Jones & Bartlett. ISBN 978-0-7637-9752-2. 
• "Staff Nurse — RN — U.S. National Averages". Salary.com. 
• Taylor AL, Hwenda L, Larsen BI, Daulaire N (December 2011). "Stemming the brain drain—a WHO global code of practice on international recruitment of health personnel". N. Engl. J. Med. 365 (25): 2348–51. doi:10.1056/NEJMp1108658. PMID 22187983. 
• Masoli, Matthew; Fabian, Denise; Holt, Shaun; Beasley, Richard. "Global Burden of Asthma" (PDF). Global Initiative for Asthma. 
• Spiegel, J.M.; Huish, R. (2009). "Canadian foreign aid for global health: Human Security Opportunity Lost". Canadian Foreign Policy Journal 15 (3): 60–84. doi:10.1080/11926422.2009.9673492. 

Further reading

• Jacobsen KH (2008) Introduction to Global Health. Jones and Bartlett
• Skolnik R (2008) Essential Public Health: Essentials of Global Health. Jones and Bartlett.
• Levine R (Ed) (2007) Essential Public Health: Case Studies in Global Health. Jones and Bartlett.
• Launching Global Health Steven Palmer. Ann Arbor, University of Michigan Press, 2010.
• White, F; Stallones, L; Last, JM. (2013). Global Public Health: Ecological Foundations. Oxford University Press. ISBN 978-0-19-975190-7. 

External links

• "For a Global Generation, Public Health Is a Hot Field". Washington Post. 19 September 2008. 
• "Global Health Journals," GlobalHealthPolicy.net
• Global Health Overview (Global Issues, October 2, 2010)
• GlobalHealth.gov (hosted by U.S. Department of Health & Human Services)
• Partnership for Maternal, Newborn and Child Health global partnership
• Roll Back Malaria global partnership against malaria
• Stop TB global partnership against tuberculosis
• Countdown to 2015 global partnership
• Global Health Gateway
• The Chr. Michelsen Institute - Centre for development research in Scandinavia with a subfocus on Global Health and Development.