Health, Development and globalisation MPH COURSE 005

Compiled by Prof J. Mfutso-Bengo PhD

Director of Centre of Bioethics for Eastern and Southern Africa

http://www.medcol.mw/wtbioethics/index.htm

What should MPH students know about global health

• Global health principles and policies

• Know the differences between global and international health research

• Identify key challenges to global health

• Recognize the importance of information sharing in the area of global health

• Recognize the importance of preventive activities in improving global health

• Recognize the need for global networking to mobilize resources for global health locally and globally

Let us define Development, Health and Globalisation

• Development is……

• Health…….

• Globalisation…..

What is health?

Health is a social, spiritual, ethical,

psychological, cultural, gender,

economic and political issue and

above all a fundamental human

right.

The Universal Declaration of Human Rights

• “Everyone has the right to a standard of living

adequate for the health and well being of himself and his family, including food, clothing, housing and medical care.”

Universal Declaration of Human Rights, 1948

What is sustainable development? • Trading blocks

• MDGS, MPR, MDG

• WTO

• Malawi vision 2020

• GNP, GDP, HDI

• Paris Declaration, Accra Declaration, Doha declaration-Trips, Abuja Declaration

• SADC, COMESA, ACP

• Unfair trade

What is global health?

• Global health is an important new term, and an important new concept. The Institute of Medicine refers to global health as "health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.“

KEERTI BHUSAN PRADHAN once said that ,

“Nothing on earth is more International than

Disease”

Global Health content and challenge

Part A: Health for All in the 'borderless world'?

Part B: Health care services and systems

B1: Health care systems and approaches to health

B2: Medicines

B3: The global health worker crisis

B4: Sexual and reproductive health

B5: Gene technology

Part C: Health of Vulnerable Communities

C1: Indigenous peoples

C2: Disabled people

Part D: The wider health context

D1: Climate change

D2: Water

D3: Food

D4: Education

D5: War

Part E Holding to account: global

institutions, transnational corporations,

rich countries

E1: World Health Organization

E2: UNICEF

E3: World Bank and International Monetary

Fund

E4: Big business

E5: Aid

E6: Debt relief

E7: Essential health research

Part F Conclusions

What are the challenges to global health

• Discuss

There are many challenges to global health with different professionals emphasizing

different diseases.

Interdisciplinary approaches are needed to ease the burden of both communicable

and non-communicable diseases

Are there opportunities for global health in the age of globalisation

• Discuss

Challenges

• What is 10-90 gap?

• Credit crunch?

• Donor fatigue ?

• Dependence syndrome?

• Corruption?

10-90 gap is equity issue

• Define 10-90 gap

• Define equity –treat equals equally and unequal unequally

• Define all forms of justice

Digital divide: gap between haves and

have nots

One of the biggest global health

challenges is access to information

Education is the most

powerful weapon

which you can use to

change the world. Nelson Mandela

Defining and measuring

• Can we strictly define and measure equity in any standard or statistical sense?

• Precise definition and therefore measurement is challenging • Equity and justice are closely related philosophical /ethical constructs • Equity and justice are concerned with fairness, impartiality, rightfulness,

reward or penalty as deserved • Arday et al (1998) “…. health disparities or inequalities and the fairness

and effectiveness of the procedures for addressing them” • Braveman & Tarimo (2002) “Avoidable disparities in health or its key

determinants that are systematically observed between groups of people with different levels of underlying social privilege i.e. wealth, power or advantage”

Gavin Mooney (1987) definition

– “equity is a philosophical issue and not surprisingly there are many

arguments”

– “.. what might be considered as the first and most basic conclusion about equity; that it is a value laden concept which has no uniquely correct definition (in some objective and /or scientific sense)”.

Four dimensions of equity in health care by Culyer and Wagstaff (1993)

1. Equality of utilization

2. Distribution according to need,

3. Equality of access and

4. Equality of merit.

Defining and Measuring equity(smarter)

1. In spite of these difficulties of standard definition, and the fact that some of the definitions are mutually incompatible in analysis, there is not really much argument that there are local, national and international inequalities or differences in relation to health whatever approach the analyst takes, that are unfair and avoidable

2. Some of these differences are so stark as to cause problems for the international, national and local conscience

3. There are extensive reviews and descriptions of some of these problems especially between countries and regions of the world

4. There is some within country analysis literature in developed but much less literature on the subject within developing countries

Why are there inequities in global health?

1. Individual and population health is a complex function of the interaction of factors related to: – Biology – Environment – Sociology and Culture – Politics – Economics – History – Health systems – Public good

2. Increasingly countries do not exist in isolation and local, national and international factors all interact to influence health

3. These factors influence individual and group environment, privileges and behavior and thus health

4. They influence national and international policy making and choices and thus the health of individuals and groups

Global challenges of addressing these inequities

1. The interrelated multifactor nature of the causes of the problem (spider web)

2. Many of the causes may actually lie in part or even in whole outside the “bio medical sector” and be related more ethical, social or structural in nature.

3. Simple linear interventions may in some cases create a new set of problems rather than a sustainable solution (the solutions of today become the problems of tomorrow)

4. This makes interventions difficult in many cases and requiring cross disciplinary /sector, and multi factor thinking and solutions

Global Challenges of addressing Health Inequities: The Spider Web

Global challenges of addressing these inequities

1. Balancing short term and long-term planning

2. The need to contextualize rather than adopt a one size fits all approach

3. Lack of responsible politics

4. Lack of evidence based approach in problem solving

Role of Health Policy and systems research:

1. Information generation

• Describing /Measuring the problems and their extent

• Comparison

• Cause analysis

• Interventions and solution identification and evaluation

2. Information dissemination for utilization

Think globally and act locally

1. An illustration of some of the difficulties in interpretation the little information available and making decisions related to resolving inequities

2. Data to support decision making, monitoring and evaluation, capacity, teasing out what works in a situation of complex variables,

3. Many decisions are not evidence based

4. Solution are copied without adopting them to the local context

Global Health / Public Health

1. In developed countries – The rate of infectious diseases decreased through the 20th

century largely due to broad public access to water and sewage systems, sanitation, immunizations and economic prosperity.

– Public health then began to put more focus on chronic diseases such as cancer and heart disease.

2. In developing countries – People remain plagued by largely preventable infectious

diseases, exacerbated by malnutrition and poverty.

Global health systems

• WHO

• WTO -

• Global Fund

• Global policy for global health e.g., Paris Declaration

• Grand challenge-Gates and Melinda

• UNAIDS

• SWAPS

• Funding systems-World Bank, IMF, DIFID,EU

• International partnership for health

• International paternalism

• International political will

What is a Global health system?

1. It is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health.

2. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction.

3. It needs to provide services that are responsive and financially fair, while treating people decently.

Where are the gaps?

1. Problems with health systems are not confined to poor countries.

2. Some rich countries have large populations without access to care because of inequitable arrangements for social protection.

3. Others are struggling with escalating costs because of inefficient use of resources.

4. Can you give example

My growing rowing recognition 1. Systems matters more than leadership

2. Good leaders create & leave efficient & working systems

3. Good leadership without good systems nothing works

4. Good systems without good leadership something works

5. Overall there is a growing recognition that to maintain and improve the health of the world’s people

6. Governments must create sufficient, efficient & equitable health systems

7. That government should provide effective disease prevention and treatment to all women, men and children, no matter who they are or where they live.

The role of government and its leadership

• Stewardship

• Health Financing

• Provision of workforce with proper knowledge, attitude-skills

• Proper & working health information management systems

• Drugs and technology-access, availability, quality, efficacy, safety and rational use of drugs

• Discovery-development and delivery

• Sustainable health development

• Promoting professionalism and good governance

Politics of health & diplomacy

• Define Health diplomacy

• Social determinants of health (See WHO documents)

Importance of PESTEL (STEEPLE)

• It helps in becoming aware of internal & external factors or Forces of Health systems

• It facilitates realistic planning and thinking

WHAT DOES PESTEL MEAN?

• P-Political

• E-Economic

• S-Social

• T-Technological

• E-Ethical

• L-Legal

The uses of PESTEL

• Strategic planning

• As part of SWOT analysis

What are political factors

• Financing, funding, grants

• Peace or Conflict

• Political leadership

• Political trends

• Governance Issues

What are economic factors

What are social factors?

• Demographics, • Immigration • Role models • Attitude • Population Shift • Age • Social Mobility • Work/career/attitudes • Health Conscious • Living condition • Media Views

What are technological factors?

What are ethical factors?

• Transparency

• Accountability

• Honesty

• Integrity

• Responsibility

• Respect

What are legal factors?

Health, Politics and Diplomacy

• Global health is also determined by political diplomacy, advocacy & disease global impact

• Health and political diplomacy led to the establishment of WHO

Birth of the WHO

• April 1945

• 7th April 1948-Formal Existence

• World Health Day-7th April

• Specific theme each year

WHO OBJECTIVE

1. The attainment by all peoples of the highest level of health

2. Act as the directing and coordinating authority on all International health work

3. Prevention and Control of specific Diseases

4. Development of Comprehensive Health Services

5. Family Health

6. Environmental and occupational Health

7. Reproductive health

WHO Support

1. An increase in effective services to all people in need, including service delivery management and support

2. Improved patient safety, efficacy of services and financial protection

3. Increased efficiency and building of financial, human, institutional, and knowledge capacities

4. Coordinated, participatory and accountable policy formulation and implementation.

Structure

1. World Health Assembly

2. The Executive Board

3. The Secretariat

Regions

1. South East Asia-New Delhi

2. Africa-Harare (Zimbabwe)

3. The Americas-Washington D C (USA)

4. Europe-Copenhagen (Denmark)

5. Eastern Mediterranean-Alexandria (Egypt)

6. Western Pacific-Manila (Philippines)

7. SEARO: (Bangladesh, Bhutan, India, Indonesia, Korea, Maldives, Timor-Leste, Myanmar, Nepal, Srilanka, Thailand)

Who is the Director General of WHO?

Resource mobilization for global health: the role of WHO

• PLEASE DISCUSS

The challenges of attracting donor aid

• PLEASE DISCUSS

TRIPS

• What is TRIPS

• What is the relationship between TRIPS and DOHA Declaration

What is TRIPS

TRIPS is is:

1. Agreement on Trade Related Aspects of Intellectual Property Rights

2. an international agreement administered by the World Trade Organization (WTO) that sets down minimum standards for many forms of intellectual property (IP) regulation. It was negotiated at the end of the Uruguay Round of the General Agreement on Tariffs and Trade (GATT) in 1994.

Doha declaration

• In 2001, developing countries concerned that developed countries were insisting on an overly-narrow reading of TRIPS, initiated a round of talks that resulted in the Doha Declaration: a WTO statement that clarifies the scope of TRIPS; stating for example that TRIPS can and should be interpreted in light of the goal "to promote access to medicines for all."

Why did African countries delayed in implementing Doha Declaration

• Compassionate use of patented drugs

• Production and use of generic drugs

The problem of aid effectiveness

1. Contradictory policy of the northern partner (problem of

coherence).

2. Power imbalance between donors and recipients

3. Donor-oriented development agenda

4. Lack of systems of global governance of global aid

5. How to measure impact of development aid + its

strategies and methods?

6. Technical questions of development cooperation are not fully resolved

Paris Declaration on AID EFFECTIVENESS

1. Ownership-contextualization

2. Harmonization

3. Alignment-Maximising the use of country systems

4. Performance-action plans-targets

5. Mutual accountability-M +E

Strategies for getting donor aid?

1. Right based approach

2. Shock therapy approach

3. Moral persuasion

4. Beggars approach

Landscape review of AID: From Paris

declaration towards Accra

1. Aid is increasing

2. Aid is still underperforming

3. There is a need for change

Change, why change?

60

When is Aid Effective?

1. When it helps countries achieve their own development goals.

2. Three conditions are needed:

– Predictability.

– Accountability.

– Cost-effectiveness.

61

Is Aid Effective?

1. Levels of aid are increasing (with international Commitments and new donors)…

2. but aid is still underperforming

62

Contents

1. What is Aid Effectiveness?

2. Monitoring the Paris Declaration: Has Progress Been Achieved?

3. High Level Forum on Aid Effectiveness and the Accra Agenda for Action: What can we expect?

63

What is the Evidence?

1. Aid is Effective when countries achieve their own development goals. Three conditions are needed:

Predictability

Accountability

Cost Effectiveness

2. 2006 Survey in 34 countries showed significant challenges

64

42% of aid was recorded in countries’ budgets

GOV.

BUDGET

ESTIMATES

AID DISBURSED

AFGHANISTAN ZAMBIA MOZAMBIQUE

65

800

750

700

650

600

550

450

Vietnam (791)

Cambodia (568)

Honduras (521)

Mongolia (479)

Uganda (456)

Aid is Costly: 10 453 missions in 34 countries in 2005

Number of donor missions in 2005 66

Try Managing this ….

Source; Don De Savigny & COHRED

67

Aid Fragmentation: too many donors contributing too little?

Number of donors together providing just one tenth of a country’s aid

(Gross disbursements of CPA, 2005-06)

68

2008 Survey: 56 Countries

Asia & Pacific

Tanzania Mozambique Yemen

Afghanistan Benin Nigeria Latin America

Bangladesh Burkina Faso Togo Haiti

Cambodia Burundi Madagascar Colombia

Indonesia Cameroon Ethiopia Peru

Mongolia Cape Verde Côte d’Ivoire Bolivia

Nepal CAR Ghana Honduras

Vietnam Chad Kenya Nicaragua

Philippines P NG

DR Congo Morocco

Liberia Sierra Leone

Dom. Republic

Tonga Gabon Malawi ECIS

Lao PDR Mali Arab States Albania

Africa Mauritania Egypt Ukraine

Uganda Niger Jordan PSG Kosovo

Zambia

Senegal

Sudan Moldova Kyrgyz Republic

69

Out of the Starting Blocks…

1. 2008 Survey process and increased dialogue at country level

2. Evidence of better aid coordination

3. Some instances of improved predictability

70

What is Accra HLF 3 ?

1. High Level political event on aid

2. Mid-term Stock-taking of the Paris Declaration mutual commitments

3. Forward looking event : road to Paris Targets.

4. 100 partner countries

5. 800 to 1000 participants

6. Strong civil society engagement

71

What does the Accra Agenda for Action intend to achieve ?

72

73

What does the Accra Agenda for Action intend to achieve ?

1. Not a new Paris Declaration

2. A political, ministerial statement, setting out a

small set of concrete actions

3. Set future direction for aid effectiveness

74

What might it look like? The AAA is likely to identify concrete actions to make

progress on: • 5 principles of the Paris Declaration • 6 priority issues for partner countries

– Predictability – Conditionality – Untying Aid – Capacity development – Incentives – Division of labour

75

CASES

• Critical Review of the book: Dead AID by Dr Dambisa Moyo from Zambia

• Brain drain of health workers and international donor response: a policy review

• Male circumcision: policy design

• Doha declaration: policy analysis for Malawi

Dr Dambisa Moyo

Her book is titled: Dead Aid

• Zambia is better off without Aid- Dambisa Moyo • Friday, April 3, 2009, 11:50 • Columns, Headlines • 2,517 views • 143 comments • • Renown Zambian author Dambisa Moyo • By Milimo Moyo, New York • Dr. Dambisa Moyo has revealed that she is scheduled to visit Zambia next week to speak to the

government about aid-related issues raised in her popular new book, Dead Aid: Why Aid is not working and how there is a better way for Africa.

• Speaking to a packed audience at an event organized by the Carniege Council in New York City on April 2, 2009, Dr. Moyo stated that the Zambian government had invited her for in-depth discussions related to reducing aid-dependence and finding alternatives for long-term economic development. Her talk at the Carniege Council was part of her high profile U.S book tour that has drawn well-deserved attention from a wide spectrum of media, charity, government and academic institutions.

• During the talk, Dr. Moyo discussed her motivations for writing the book, problems associated with the Aid model and the various ways that African countries can generate their own income thus reducing their dependence on foreign development Aid. She also decried celebrities’ tendency to speak for Africa in a manner that was couched in pity.

• “Perhaps the most of awful thing is that when they speak about Africa, they do so with pity,” she said adding that America would not tolerate a foreign celebrity telling U.S President, Barack Obama and Treasury Secretary, Tim Geitner how to fix the current credit crunch.

• Dr. Moyo, a Zambian-born economist formerly employed at Goldman Sachs and the World Bank, has caused a stir in the United States and around the world with her refreshing and forthright analysis of the problems stemming from development aid dependence in most African countries.

• In her book, Dr. Moyo makes the case that an estimated $1 trillion worth of so-called development aid to Africa in the last five decades has dismally failed to create long-term, sustainable development on the African continent. Dead Aid examines the history of the aid-model of development and outlines specific indicators of its failure including corruption, bureaucracy, civil and political strife, a lack of entrepreneurship and inflation, among others. More importantly, Dr. Moyo’s book suggests ways in which African countries could reduce their dependence on aid and generate their own income through participation in the bond markets and trade.

Critique of her book

• While Dr. Moyo’s book has been well-received by many, some critics have adopted a contentious and somewhat misleading approach to criticizing Dead Aid. Dr. Moyo told the audience at the Carniege Council that as a result of certain misconceptions, she has found herself defending her book during her tour in America. For example, the aid advocacy group ONE, has posted what it considers a critique of Dr. Moyo’s book on its website charging that Dr. Moyo’s suggestion to stop aid in five years’ time is “reckless and seems to pay no heed to the fact that millions of Africans are on life-saving AIDS medications today paid for by aid”. However, ONE ignores the fact that Dr. Moyo categorically excludes humanitarian and charity-based aid from her pejorative view of development aid to Africa.

• Despite explaining this in her book and subsequent interviews and discussions, critics have been quick to accuse Moyo of spreading an “irresponsible” message that could result in the deaths of “African babies”. One can only smile at the dramatics.

• Regardless of what some critics have said, Dead Aid is set to be a bestseller both in the west and Africa. It has captivated many people’s attention so far and is fast gaining the attention of readers everywhere. In New York City, Dr. Moyo’s book promotion events have drawn enormous crowds. She has also been interviewed by an array of prominent publications and media personalities including Charlie Rose, Bill Baher and Steven Colbert.

Comments and Information on the High Level Forum and

drafts of the Accra Agenda for Action can be found at:

www. accrahlf.net

81

ZIKOMO

• Now go and harvest more knowledge!