global public health
TRANSCRIPT
Global public healthA discussion on the interrelated facets of global public health, and its consequences on the
international population
Babajide Okesola
Global Public Health
10:832:440
11/18/2015
Question 1. The global political and economic architecture
Global public health is concerned with the health of the populace in a global context, and
involves international populations, regulations, organizations and multi-national corporations.
Two frequently discussed elements in global public health are the IFC and international taxation.
The International Finance Corporation (IFC) is a part of the World Bank Group that fosters
sustainable growth in developing countries by assisting in financing private sector investments,
consulting, and management. The IFC has been continuously criticized for its neoliberal
procedures and for its direct involvement with the adverse effects of globalization within Low-
and middle-income countries (LMICs). The Health in Africa initiative, announced in 2007, is
one of the IFC’s most recent failed recipes for increasing the access of quality healthcare for the
poor. This campaign seeks to use the funding from investments and equities in order to develop
projects that will serve the ‘underserved’ by ‘strengthening the private sector, thus improving
health outcomes for the poor’ (GHW4, D6, 310). Yet, this initiative has been criticized for its
lack of effectiveness to increase healthcare access for poor people in Africa, and also for its
unprofessionalism in measuring the impact of these investments on population health.
International taxation is a hot topic in global public health because it discusses the
potential of public funding for healthcare programs that can be invested in developing more
equitable healthcare systems globally. Tax havens are a channel for tax evasion that has made it
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possible for a number of wealthy corporations to pay little to no income tax. An estimated one-
third of Gross Domestic Product is held offshore in tax havens, a large sum of money that should
be made available for the use of the public sector and investments in public goods (Brock, Ch.23,
276). This form of corruption is not only present in international taxation but also within
international pharmaceutical companies.
Pharmaceuticals have long been one of the central components of health care systems,
and a vital ingredient to the health care practice. Pharmaceuticals are compounds manufactured
for use as a medicinal drug that are used to cure, treat, diagnose or prevent disease. Every year
millions of people rely on pharmaceuticals to help cope with their health issues and hopefully
fully recover. Nearly 7 in 10 Americans take prescription drugs (Mayo Clinic, 2013), which is a
testament to the previous notion on the dependence of drugs in our society. Knowing this, one
can conclude that a lack of access to these life-saving/life-prolonging drugs would have a
negative impact on the health of a population. This nightmare is occurring in numerous LMICs
in Sub-Saharan Africa, South America, and East Asia. Human beings are being condemned to
death simply because of trade agreements and the monopoly established by pharmaceutical
companies. Intellectual Property (IP) patents are established by pharmaceutical companies to
secure investments and increase profits, which has been a consistent strategy used by them to
maintain their dominance in the international medicinal market. This monopoly was made
possible by the Trade Related Intellectual property Rights (TRIPS) agreement in 1994, which
allowed for pharmaceutical companies to patent their drugs, and have control over the pricing of
their patents. Furthermore, LMICs do not have access to these essential medicines because they
are set at a price that is unaffordable for them. The uses of ‘flexibilities’, which were asserted
by stakeholders from LMICs during the inception of TRIPS, have also been restricted due to
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numerous realities (GHW4, D4, 288). A lack of manufacturing capacity, pressures from High
Income Countries (HICs), unsubstantial regulatory systems, and obstacles formed around the use
of compulsory licenses have all thwarted LMICs’ attempts to circumvent the TRIPS agreement.
The pharmaceutical industry in the UK makes a significant contribution to the nation’s
economy, and is lauded for its elite innovations. The UK also has about 46,310 registered
pharmacists that are located in either community pharmacies or hospital settings. The access to
drugs in the UK fares very well when compared to other HICs with comprehensive drug benefit
programs that have low copayments. Less than 3% of the population had out-of-pocket costs of
$1,000 or more for prescription drugs (Kennedy, Morgan, 2010). The healthcare system reform
in 2010 introduced value based pricing (VBP) in the UK, which has helped to set the prices of
drugs at a level that correlates to the benefits each drug brings to the healthcare system, patients
and society (Izmirlieva, Ando, Bharath, 2011). Compared to the previous practice of free pricing,
people in the UK are gaining more access to pharmaceuticals. Despite these arrangements to
better the access of pharmaceuticals to patients, there have been consistent shortages of drugs in
the UK. In 2012, 57% of pharmacists reported that one or more of their patient’s health had
suffered because of drug shortages, marking a 12% rise from last year (Mckee, 2013). There is
certainly an issue with the supply of drugs in the UK, and it is causing direct harm to patients
affected by it. The Medicines & Healthcare products Regulatory Agency (MHRA) is the
equivalent to the FDA in the U.S., in that it is responsible for ensuring that drugs and medical
devices are safe to use. The National Institute for Health and Clinical Excellence (NICE) helps
determine the safety of medical substances and also determining its cost-effectiveness. The
MHRA, NICE, and the UK Department of Health must work together to find a solution to the
burden of drug shortages caused by free markets.
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Question 2. International assistance: the problems and the response
Of the numerous methods that can be used to assess the general health of a certain
population, measuring the maternal mortality rate is one that is more frequently referenced
amongst public health professionals because of its accurate depiction of population health. The
maternal mortality rate is the number of maternal deaths in a population divided by the number
of women of reproductive age, and does well in measuring the quality of a country’s health care
system. Because a majority of maternal deaths can be prevented, it was prioritized as a
Millennium Development Goal, aiming to reduce maternal mortality by 75% between 1990 and
2015 (GHW4, B8, 147). Although this is a global goal, results of these efforts vary
geographically. Women in LMICs have a greater chance of dying of a cause related to childbirth
than women in HI countries (GHW4, B8, 148), especially in Sub-Saharan Africa where there has
been small progress in reducing maternal mortality compared to the rest of the world. This is due
to their poor access and utilization of health facilities/resources, a weakened health system,
socio-economic inequities, and gender oppression. Efforts to ameliorate this global health burden
include universal access to reproductive and sexual health so that mothers can have the option of
contraceptives, which would remarkably reduce the number of maternal deaths, especially those
related to unsafe abortions (GHW4, B8, 149). What one must understand when discussing
maternal & reproductive health issues is that the strengthening of health systems will also need
the reinforcement of political systems and health financing to have a definite lasting effect on the
population’s health.
Another issue that will also rely on the political system is the health workforce crisis.
Maternal deaths that happen during labor usually occur because of the absence of an experienced
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health professional and a sanitary area for the delivery. This is closely associated to the health
workforce gap that is occurring between LMICs and HICs. There are currently 57 countries
undergoing a critical health worker shortage, while 36 are located in Africa (WHO: 10 Facts).
Sub-Saharan Africa accounts for 25% of the global disease burden and only contains 3% of the
global health workforce; meanwhile North/South America account for 10% of the global disease
burden and accounts for 50% of health expenditures worldwide (WHO: 10 Facts). When
comparing these two geographical areas, one can deduce why it is that there are numerous
preventable maternal deaths occurring in Africa. This inequity within the healthcare workforce is
influenced by labor migration, weak international agreements regarding health personnel
recruitment and a lack of healthcare expenditure in affecting countries. Healthcare workers in
LMICs migrate to other countries often for higher pay and other benefits, leaving behind
populations that are highly dependent on the already limited number of health professionals in
the area. These LMICs aren’t able to compete with foreign countries’ health markets, because of
neoliberal structural adjustment policies that limit them from making adequate health
expenditures to retain their healthcare workers. Furthermore, LMICs are not reaping the benefits
of their costly investment towards the education of healthcare professionals, while HICs are
attracting more LMIC native workers every year, thus perpetuating healthcare inequities. For
example, the UK benefited $ 2.7 billion from recruiting trained doctors, while Malawi lost $2.16
million in investments in 2011 (GHW4, B9, 159).
Maternal/reproductive health concerns and the healthcare workforce crisis are just 2 of
the collective of issues that are considered to be international problems because of their
detrimental effects felt throughout the world. The World Health Organization is an agency of the
United Nations that coordinates and directs authority on international public health. WHO
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recently undertook a process of reform to conduct fundamental challenges within the
organization. Since its inception, WHO’s role in the governance of global health has been
unclear at times; the reform sought to disambiguate their position and relation with other actors
in international health (WHO: Why Reform?). WHO also wanted to work on being more efficient
by initiating a managerial reform that would improve health outcomes and increase the
efficiency of the organization. Measuring the impact of WHO programs and assessing the results
will help them address global health priorities and keep all parts of the globe on a good track
towards international health goals. Financial reform and transparency was also incorporated into
the revitalization of WHO, making the organization more trustworthy and fair in its decision
making processes.
WHO’s leadership in improving the health outcomes of the world has been
supplemented by the efforts of many stakeholders in global health and international aid and
development efforts. There has been an increase of interest in global health and a more
centralized focus on Millennium Development Goals (MDGs), which has influenced the growth
of humanitarian medicine and efforts to measure the efficiency and impact of aid. Humanitarian
medicine is based on the belief that every human deserves the right to a healthy well-being, and
through the efforts of philanthropists, that can be achieved worldwide. Humanitarian aid has
shifted from a more charity-based perspective to rights-based, where people are more compelled
and see it as their duty to maximize the benefits from foreign aid to those in need (Mahmudi-
Azer, Ch.15, 173). As more aid is being distributed, one begins to question what populations and
situations are considered for assistance. Furthermore, there are concerns as to what populations
are prioritized and whether or not these decisions on prioritization are legitimate. Does one limit
aid to immediate disasters or focus on implementing protracted aid for long-term sustainability?
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Should one aim for treating a larger number of people with lower quality, or tend to a lower
number of people with higher quality? These represent the arguments raised when allocating
resources to areas of need. There are those who take more of an egalitarian approach of equal
access to aid for all, and those that are prioritarian. Prioritarians are in support of a triage form of
aid, where the worse off countries and areas of poor health get priority when administering aid.
Daniel & Sabin’s accountability for reasonableness set guidelines for fair decision making that
describes the imperative need for decisions on limits to aid be made public, for there to be
relevance of evidence and appropriate reasons with aid, improvements/revisions of aid upon new
information, and regulation on the previous elements (Hurst, Mezger, Mauron, Ch.15, 180).
Although the amount of international assistance that the UK receives is little to none, it
plays its role in assisting LMICs with aid. As the spectrum of humanitarian activities increases,
there will be more reliance on and expectation for these humanitarian efforts to address. HI
countries like the UK and those in the Organization for Economic Co-operation and
Development (OECD) want to administer aid in a way that is efficient and produces measurable
results. These countries in OECD promote Overseas Development Assistance (ODA) which is
used to provide support to the political, economic and policy improvements that will ultimately
better the livelihoods of LMIC populations (Zwi, Ch.16, 185). Non-governmental Organizations
(NGOs) are used as a vessel to implement these overseas development projects. Non-
governmental organizations, to some, are the remedy for assisting countries with deficient
health systems to attain universal coverage (GHW4, D2, 271). Recently there has been a growing
trend of NGOs adopting a more business-like model, with regards to their management practices
and their pragmatic activities, which are measurable and time bound (GHW4, D2, 276). This has
made them more appealing to donors and ODA because they can effectively execute proposals
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and meet agendas. Although these projects are constantly used, warnings of how NGOs are
associated with poor quality are identified with seven deadly sins. These ‘sins’ relate to the
inefficiencies of NGOs in reference to their imbalance of aid allocation, prideful reluctance to
terminate investments, competition amongst donors, a lack of local ownership, and failure to
evaluate (Zwi, Ch. 16, 191).
Question 3. Shaping the Future
Universal Health Coverage (UHC) is currently the most discussed subject between
international health groups on health care. This is largely due to its potential to solve a majority
of the problems of healthcare in LMICs. The definition of UHC varies amongst many
professionals but it essentially refers to strong health systems that ensure that all people are able
to attain the health services they need. The feasibility of such a monumental shift relies primarily
on sustainable health financing because effective universal coverage is costly. What is required
for an efficient universal health system would be a strong health system, access to essential
medicines/technologies, and a sufficient number of well-trained health workers )workers). The
2010 World Health Report designed the frameworks of a gradual UHC that consisted of an
increasing range of services provided to the entire population, and a growing pool of deposits to
fund healthcare (GHW4, B1, 80). Debates on the efficacy of UHC focus on the role of the public
system in administering health care services. Governments are responsible for ensuring that
health providers attend to patients’ needs cost effectively, in a way that allows all people to gain
access to healthcare. Private sector providers are notorious for blocking access to healthcare for a
large portion of the population because of their inability to afford services; hence a solution to
that would be to have the state regulate the accessibility, quality, and range of services of the
private sector. There has been a lack of proof of the efficacy of UHC and its positive impact
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(GHW4, B1, 85), but the healthcare systems seen in Thailand and Brazil show that there is
strong potential in the plan that cannot be ignored. If public systems are revitalized into universal
coverage systems, there will be less waste of capital investment, duplication of services, and
there will be more emphasis on epidemics, which would improve the health of the population.
There is a plethora of health threats that face the global community, along with an
emerging set of challenges that the world must face. In order to meet these challenges, research
is needed to develop solutions and effective interventions to maintain and improve global health.
Global health research hopes to achieve sustainable development goals of good health/wellbeing,
food security, clean water/sanitation, reduction of inequalities, and also develop new drugs to
lessen the global burden of disease. Recently the health sector has raised many issues with the
current global health research agenda, which involve the new non-traditional health problems,
and research implementation. Instead of just focusing on infectious/chronic diseases, research
must now address concerns such as climate change, food insecurity, globalization health impacts,
aging populations and antimicrobial resistance. Global health research also finds it difficult to
incorporate all of its knowledge and evidence into policy development. The “three bucket’
analogy describes the lack of effort put into policy implementation by saying that for every
dollar that goes into understanding and treating health issues, only one cent goes into the delivery
aspect (Pang, Ch.24, 286). Another issue that involves global health research is its uneven
distribution of burden and resources, with research focusing more on HIC health issues rather
than LMICs. For instance, of the 1556 new drugs that were developed between 1975 and 204,
only a mere 21 (1.3%) were for tropical diseases of the developing world (Pang, Ch.24, 285).
This leads one to question the ethics of health care research, and determining whether or not this
is serving justice to LMICs. HI countries clearly have a greater for capacity for conducting
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research, which is why most global health research targets specific issues in these countries,
compared to LMICs who have contributed only 7% of the global output of scientific literature
(Pang, Ch.24, 286). Many HICs outsource and do off-shore research and clinical trials that
generate non-universally applicable benefits to people in HICs. Not only do HICs utilize the
resources in LMICs for their own research, but they may also use the people in LMICs to take
part in these research studies. Data safety monitoring boards must oversee these research studies
to ensure the safety of the individuals and ethics committees must assess the potential
risks/benefits of the specific research. In order to guarantee ethical conduct and accountability
there must be emphasis on the evaluation, transparency and monitoring of the research. In
cooperation with these guidelines, global health research should work to outline global health
priorities and to ensure equitable access to the products of research.
One of the more innovative approaches to altering the methods and traditions of modern
global health research is the Health Impact Fund. The HIF is a proposed global agency that has a
pay-for-performance mechanism including a patent regime with incentives/rewards for new
medicine (Pogge, Ch. 20, 247-248). There is a pressing need for this kind of agency because of
the lack of access to medication that a large population of the impoverished are faced with and
ultimately perish due to their inability to obtain these drugs. The HIF would eliminate the
inefficiencies of a free market system, and allow for patents and cost-effective drugs. The HIF
would be funded by governments and would reimburse pharmaceutical innovators depending on
the impact of the drug on the population’s health (assessed by quality adjusted life years
[QALYs]) (Pogge, Ch.20, 248). This way pharmaceutical innovators are still willing to conduct
research in hopes of receiving a patent and profit, new medicines are being engineered in
accordance with global health priorities, and LMIC populations can afford these lifesaving drugs.
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The innovation of the HIF reflects the new way of thinking that is encouraged by public
health professionals. Health experts are calling for a new paradigm shift in the way we think and
perceive global healthcare issues and its stakeholders. The HIF tries to circumvent the dominant
influence of international corporations, governmental policies, and globalization ideals, which
procured the pharmaceutical pricing problem faced today. A movement towards a new ‘common
sense’ focuses on capitalism and impeding its long-term threats to social and ecological
reproduction (Bakker, Gill, Ch. 29, 329). It is evident that these global structures that have been
exploited are in need of more than moderate reforms, but of fundamental transformation. The
failures of the past Declarations of Social Progress and Development reflect the inefficacy of
using international charity and mobilization of funds towards ameliorating nutritional,
environmental, health and educational burdens in LMICs (GHW4, C1, 180). Capital is a
powerful possession, and must be democratized in order to reach a different type of economic
playing field. The world must prioritize sustainability and health by ceasing the socializing of
risks by corporations, shifting agricultural food systems from petroleum/chemical based methods
to more organic and ecofriendly substitutes (Bakker, Gill, Ch.29, 330). These new perspectives
must also be incorporated into our modern policies, by taking into account the inequalities of
social classes, genders, and race so as to achieve better health outcomes for all.
The National Health Service in the UK was established in 1948 and was, for a long time,
the exemplary model of tax-financed universal healthcare. However ever since the establishment
of the Health and Social care Act in 2012, there have been reforms within the NHS and the UK
healthcare system. The UK appears to be moving towards a more private sector oriented
healthcare system. There has been more private financing, while public financing diminishes;
this is complemented with a mixed provider’s market in which public and providers compete
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with one another (GHW4, B2, 99). The overall health expenditure of the UK is expected to
increase by 6% of GDP by 2050, which will come with more competitive market forces (Leach,
2014). Despite this, new paradigms on global health will have a significant effect on the policies
practiced in the UK. The UK has a strong pharmaceutical industry that will greatly benefit from
innovations if the HIF is eventually created. The new culture of challenging traditional
perspectives on healthcare services, delivery, and the feasibility of universal health coverage will
make a positive impact on policy makers to work towards a more equitable and universally
accessible healthcare system.
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