1. Global health?

2. GH principles 3. Health needs Physical and psycho-Socialpotential developed and fulfiledIf unmet : physicalhandicaps, chronicstress, lonelyness, anxiety,depre ssion Safety needs : from infections, toxic agents, unhealthy diets andsendentarism, accidents and violence If unmet : infectious diseases, intoxications, cardiovascular andmetabolic disorders, cancer, trauma. Basic physical needs : water, air, nutrition. If un met : malnutrition, dehydration, respiratory conditions.J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 5 4. Basic needs : enough water and food10050 45 90 40 8035 30 70 25 6020 5015 10 405 30 01990 2010 19902010 19902010 20 Developed Developing Totalcountriescountries 10 Underweight1.91.428.715.8 25.416.20StuntedLICL-MIC H-MICHIC All6644 29.2 39.726.7 1990Wasted 0.90.7 10 9.6 98.6 5771 899977 Obese7.912.9 3.7 7.24.2 9.1 20086786 95100 87J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 6 5. Safety needs% DALYs and health potential lost, by unmet safety needs60.0%50.0%40.0%30.0%20.0%10.0% 0.0%air/wat air- water- vector- airtemper er biocheillicit Unsafe borne borne bornetotaltraumatotal pollutiofat diet tobacco alcohol total atureparticlem drugssex infectio infectio diseasens ns ns stortalsafety Physicalchemicalbiologicalunmetneeds%DALY 17.5%2.5% 12.0% 3.0% 20.9%4.0%1.0% 7.0% 4.1% 4.0% 0.8%10.0% 5.1% 0.7% 4.0% 0.3% 48.4%% Potential health lost 3.7% 0.5% 2.5%0.6% 4.4% 0.8%0.2% 1.5% 0.9% 0.8% 0.2%2.1%1.1% 0.2% 0.8% 0.1% 10.2% J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice7 6. Health fulfillment needs : physical, psychosocial70.0%60.0%50.0% 16.00%40.0%30.0%14.00%20.0%10.0%12.00% 0.0%10.00%worldHCUMIC LMIC LIC % DALYs26.3% 51.4%44.2%36.1%15.6% 8.00% %deaths53.3% 66.3%64.6%56.6%41.1% 6.00% 4.00% 7.00 6.00 5.00 4.002.00% 3.00 2.00 1.00 0.000.00%WORLDHIC UMIC LMIC LICworldHCUMIC LMIC LIC Physical inactivity0.50 0.640.91 0.44 0.44 % DALYs 9.00% 14.00% 10.00% 9.00% 7.00% Overweight and obesity 0.44 0.701.12 0.40 0.40 % health potential lost 1.89% 2.94%2.10%1.89% 1.47% High blood pressure1.17 1.402.19 1.18 1.18 High cholesterol 0.41 0.480.81 0.32 0.32 High blood glucose 0.53 0.580.77 0.44 0.44 Low fruit and vegetable0.26 0.210.46 0.28 0.28 intakeTotal sedentary effects 3.30 4.016.26 3.06 3.06J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice8 7. Risk combinations of ill health Unmet basic needs10% of ill -health Unmet fulfillment Unmet safety needs needs 48% of ill-health(59,3% if safe delivery added)35% of ill-health J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 9 8. Present and potential health capacity 85 years LE2 % health potential?Healthier lifestyleslost/year Best country(Japan)83 years LE 5 % health potential? lost/year HIC (average HICs) 80 LE 12% health potential World average lost/year (average HICs) 62 LELICs 21 % health potential lost/year57 years LE 30,3% health Lowest health potential lost/yearstate Zimbabwe 42 years LE82% health potential lost/year J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 10 9. J Garay, Challenges for EU and US policies in Global health : Global Health is Global11 Justice 10. Global Health Equity Most consistent stratifying variable : income Best standards at country level : Upperquintile Best standards at global level : High incomeregion. Narrow disparities, improve global averagesand best standards. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 12 11. Health disparities90dispersion of life expectancy11.0008010.500Life expectancy7010.000menwomen 60 9.500ally = 6.3959Ln(x) + 12.433R2 = 0.704150 9.00040 8.5001990 2000 200830 0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 years GDP pc PPP 2008 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice13 12. Different risks and forms of ill health30.00%25.00%20.00%InjuriesNeuropsychiatric disorders + self injuriesNCDs -MH/Injuries15.00%Infectious diseasesNutritional deficiencies10.00%Perinatal conditionsMaternal conditions 5.00% 0.00% WORLD LICsLMICsUMICs HICs J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 14 13. Excess ill-health vs. best regional standards 1800000 1600000 1400000 1200000 1000000800000600000400000Injuries200000mental health 0 -200000NCDs -MH/Injuries -400000LOW INCOMELOWER MIDDLE INCOME UPPER MIDDLE INCOME Infectious diseasesInjuries 214203549165 130480Nutritional deficienciesmental health-23750 -119174 2064Perinatal conditionsNCDs -MH/Injuries63441 385607 167824Maternal conditionsInfectious diseases696672382814 259105Nutritional deficiencies 54884 61483 15694Perinatal conditions 26055023104329470Maternal conditions55229 438026810 InjuriesMaternal conditions 25%3% Perinatal conditions 14% Nutritional deficiencies 4% NCDs -MH/Injuries 17%Infectious diseases37%J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 15 14. Excess burden of disease vs. HICs 100% 90% 80% 70% 60% 50%rest of burden 40%Excess burden 30% 20% 10% 0% LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE INCOMETOTAL EXCESS BURDEN OF DISEASErest of burden 11840344577872 1158219 6920125Excess burden13212291534741 6114463467415 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 16 15. Distribution and trend of lifeexpectancyJ Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 17 16. Distribution of child and adult mortality J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 18 17. Excess deaths due to health inequity 25000000 2500000020000000 2000000015000000 1500000010000000 10000000 50000005000000 0 1990 20002008 Upper middle15490171912015 1792779 0 income 199020002008Lower middle11180365 11759717 10716957Avoidable 15-60720907790079418921937 incomeAvoidable 100 global initiatives Advocacies by problems, isolated funding gapanalysis (consolidated > 30 b!), verticalapproaches, duplication and opportunity cost The case of a safe delivery : basic service Vs. divided into? : MDG 4 : reducing neonatal death MDG 5 : SRHRs : reducing maternal deaths MDG 6 : AIDS : PMTCT Malaria : AN PrTx Tb : BCGJ Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 41 40. J Garay, Challenges for EU and US policies in Global health : Global Health is Global42 Justice 41. Mozambique Health Financing 2001-2008 350 300 250Paris? Which 200Paris?Budget 150 100 500 2001 20022003200420052006 2007 2008 YearGovernment budgetCommon Funds Vertical Funds 42. J Garay, Challenges for EU and US policies in Global health : Global Health is Global JusticeAid effectiveness example: predictability and longevity of ODA must be improved Donor Commitments for Health as % of Total Health Donor Commitment for Health as % of Total HealthExpenditure Expenditure10060.0080 50.00 Mauritania Guinea 40.0060Benin Tanzania30.0040Burundi Mali20.00Liberia20 10.00 Eritrea 00.001997 1998 1999 2000 2001 1997 1998 1999 2000 200144 43. Ext Health aid vs Pot Fin Gap 600Niue -1003/551 500 400 Palau 651/323 3007,8 BnMarshall, Micronesia, Nauru200 11,5 BnIsrael - 1001700/50 0-3500 -3000 -2500 -2000-1500 -1000-500 0 500J Garay, Challenges for EU and US policies in Global health : Global Health is Global 45 Justice 44. J Garay, Challenges for EU and US policies in Global health : Global Health is Global46 Justice 45. A new global solidarity framework? Resources for Minimum country dignity : 3300 Maximum to keep average : 19000 46. 0-1 1015 2025 30 0 5 30 0000- 00 1 -4 200 000 400 000 600 000 800 000 1 000 000 1 200 000 1 400 000 1 600 000 1 800 000 030 000 0060 00 0-4 0060 00- 00 090 70000 0 90 -70- 00 0 0 12 10000 012 -1000- 0000015 13 0 000 015 -13 0- 000 00 16 0 01818 -1600 00000 000- 0 021 19 021 -1900 000 000- 0 0 024 22 024 -2200 000 000- 0 0 0272527 -2500 00000 00 0 0 0-30 28 030 -2800 00 00 0 0 0 0- 033 -3133 31 000 00 00 0 0 0 0- 0 GDP frequency/populationGDP frequency/countries363436 -3400 00 00 000 0 0 0-39 -3739 37 000 00 000 0 0 0- 042 -4042 40 000 00 000 0 0 0- 045 -4345 43 000 000 0 000 0- 048 -46484600 00 0-000 000 490- 00 49 000 0Countries and poulations under mDp 47. GDP gap, public financing gap 2,235 Trillion 20% public financing gap : 447 Bn GPGs (1,5 % GDP at global level?) : 700 Bn 1,147 Bn 75% direct GDP SS : 1,11% GDP 25% indirect GlTr SS : 1,9% GlTr 48. Global SS vs. ODA100%90%80%70%60%Gap50%ODA40%30%20%10% 0% Level Predictable Alligned Equitable Gap 10475 8550 ODA 100 1 1550 49. US vs. EU on Global Health Social values : Internationalism (EU > US) should deal with its own problems and let other countries deal with their problems as best they can Exceptionalism (US > EU) their culture is superior to that of other nations Role of the state (EU > US) it is more important for everyone to be free to pursue their lifes goals without interference from the state J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 51 50. US vs EU constitution concept of rights : the U.S. Bill of Rights is a list of individual rightsAGAINST the interference of the state, the EU Charter of Fundamental Rights (Part II ofthe Treaty) includes a long list of rights to servicesprovided by the state, including education, paidmaternity leave, social security benefits and socialservices, preventive health care and high levels ofenvironmental and consumer protection. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 52 51. Health ODA and equity in the last decade (for all?)Inequity deaths 1990 vs MDG targets Focus on MDGs 20000000180000001600000014000000 Emphasis on Results 12000000 Non MDG Total MDG 610000000 MDG5 target 8000000 Target MDG 4 6000000 Boost of health ODA : 4 to 16 Bn $ 4000000 2000000 0Low incomeLower middle Upper middle Totalincome income Progress : 4 m Tx AIDS Commitments 14.000,00 Distortion/restriction : 12.000,00MDG 6 GH inequity remains 10.000,00Other H ODA H systems remain weak +distorted by diseuse-8.000,00 approaches?6.000,004.000,002.000,00J Garay, Challenges for EU and US policies in0,00 200220032004 200520062007 Global health : Global Health is Global53 Justice 52. Federailsm 7 6 5 4 3 2 1 0US EUFederal/EC 3.7 0.16States and local 3.1 6.3 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 54 53. US vs EU economy and income equalityIndicator USEUGDP pc (PPP)46970 30973Ratio US/EU GDP pc1,4GDP/employed1,3 GDP/hour1,09Employment (1970, 66 80 70 672005)Income distribution(top 20%/ low 20%, R :45/4.8, R : 9.8 38,5/8,3, R : 4.7ratio)GINI index52.540J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 55 54. US vs. EU fiscal policies USEUTax revenue from GDP 24,839,6Tax on income and9,8 11,4profitsTax on property2,3 1,5Tax on goods and 4,5 11,8servicesContributions to social6.6 11.8security J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 56 55. US vs. EU healthy lifestyles?4035302520United States of America15European Union10 5 0 Adults aged 15 years who are obeseAlcohol consumption among adults Prevalence of smoking any tobacco (%)aged 15 yearsproduct among adults aged 15 years (litres of pure alcohol per person per (%) year) J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 57 56. US vs. EU child mortalityNeonatal and under five mortality rate EU-US 14.0 12.0 10.08.06.04.02.00.0 1990 200020081990 2000 2008 1990 2000 2008 1990 2000 20081990 200020081990 2000 2008MaleFemaleBoth sexes MaleFemale Both sexes Neonatal mortality rate (per 1000 live births)Under-five mortality rateUnited States of America 11.0 8.07.0 8.07.06.0 10.0 7.07.013.0 9.09.0 10.0 8.07.011.0 9 8European Union 10.5 6.64.7 8.25.33.79.3 5.94.412.6 7.85.7 10.0 6.44.511.46.9 5.1 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice58 57. US vs. EU adult mortality rates Adult health EU-US50045040035030025020015010050 0 19902000 20081990 2000200819902000 2008 20042004 Male Female Both sexesCD NCD Injuries CDNCD Injuries Adult mortality rate (probability of dying between 15 and 60 yearsA-S mortality Life years lostper 1000 population)United States of America 172 144 135918379 132 11410736.0450.050.0 9.0 73.0 18.0European Union 167.1 141.3122.577.566.958.3122.9 104.690.7 27.0456.237.7 5.7 82.6 11.7 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice59 58. US vs. EU health systemsHealth financing EU-US8070605040302010 0 2000 20072000 2007 2000 2007 2000 2007 2000 20072000 20072000 2007Social securityGeneral GeneralTotalPrivateexpenditure onOut-of-pocketPrivate prepaidgovernmentgovernment expenditure on expenditure on health as % of expenditure as % plans as % ofexpenditure onexpenditure onhealth as % of health as % of generalof privateprivate health as % ofhealth as % of gross domestictotal expendituregovernment expenditure on expenditure on total expenditure total governmentproduct on healthbexpenditure on health health on healthb expenditurehealthUnited States of America13.4 15.7 43.2 45.5 56.8 54.5 17.1 19.5 33.5 27.925.5 22.660.3 63.5European Union8.18.874.9 76.2 25.1 23.8 13.8 15.1 50.6 51.270.7 68.121.3 21.4 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice60 59. US vs. EU health spending Health spending per capita, EU-US 8000 7000 6000 5000 4000 3000 2000 1000 020002007 2000200720002007 20002007 Per capita total expenditure Per capita total expenditurePer capita governmentPer capita government on health at average on healthexpenditure on health atexpenditure on health exchange rate (US$) (PPP int. $)average exchange rate (US$) (PPP int. $)United States of America47037285 4703728520323317 20323317European Union15183182 1864275411642463 14192119 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 61 60. Signed and ratified international treatiesInternational treaties USEU (all EU member states directly, by EU or acquis)CESCRNOYESCCPR YES YESCCPR-OP1 NOYESCCPR-OP2-DPNOYESCERD YES YESCEDAWNOYESCEDAW-OP YES YESCATYES YESCRCNOYESCRC-OP-ACYES YESCRC-OP-SCYES YESMWCNOYESRPDNOEU and all 27 MSsJ Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 62 61. US vs. EU development policiesCommon featuresUS specificities EU specificitiesStructure Coordination across relevant Development Policy under Development Policy undersectorsNational Security: development foreign policy/partly as a central pillar of US national independent.Policy coherence security policy, equal to diplomacy and defense.Director of Developmentagency (USaid and Europaid) in Interagency DevelopmentJoint EU coordination and jointcharge lf development policies Policy Committee aimed atprogramming.and reports to US Secretary of coherence across allState/EU Foreign Office chief. Government departments US Global Development Council for consultation with stakeholdersPrinciplesEconomic growth as main pull US leadership and effectiveDevelopment aid is a priorityeffect for development partnership and a modern for EU external action in architecture that elevates support of EUs interests for aCountry ownershipdevelopment and harnessesstable and prosperous world. development capabilities (in support of common Inclusive and sustainable objectives).economic growth is crucial tolong-term poverty reduction and USAID as the worlds leading growth patterns are as important development agency.as growth rates. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 63 62. US vs. EU development prioritiesPriorities Good governance"Game-changing" initiatives Energy : Address pricesuch as vaccines for neglectedvolatility and energy security. Public administration anddiseases, weather-resistant seedLink to climate change, service delivery varieties, and clean energy including access to low carbontechnologies, technologies. Access to secure,affordable, clean and Sector reforms Global Health Initiative : High sustainable energy services.priority given to targeted health FTT/sustainable agriculturechallengesSocial cohesion : share target (but see different approaches)for social inclusion and humandevelopment of at least 20% of Attention to climate changeEU aid : Support sector reformsthat increase access to qualityhealth and education services,mainly through sector reformcontracts with intensifiedpolicy dialogue.Different approaches on some Agriculture and food security: Comprehensive approach to foodAgriculture and food security:priority areassecurity by accelerating economic Safeguarding of ecosystemgrowth and raising incomesservices, priority to locally-through greater agriculturaldeveloped practices and focusingproductivity, increasing incomeson smallholder agriculture andand market access for the rural rural livelihoods. Strengthenpoor and enhancing nutrition. nutrition standards, food securityEstablishment of the Global governance and reducing foodAgriculture and Food Security price volatility at internationalProgram (GAFSP) based at thelevel.World Bank designed to help J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justicepoor farmers grow, market and 64earn more. 63. Agriculture, food security and aid modalitiesAid modalities Selective sectors and countriesRenew the US leadership in the In line with the Operationalmultilateral development banks Framework on Aid Effectiveness. Ownership of country prioritiesand the G20 (seen as the premierforum for US international A new element is the increasedeconomic cooperation)differentiation between Donor coordination Millennium Challenge developing countries as severalCorporation MCC- (aligned partner countries (notably the Leverage private funds support-sector budget support- BRICS) have become donorslike), more connected to while others are facing increasing Aligned support to country infrastructures and water- fragility. systems : EU GBS, US MCC sanitation, based on governanceand corruption assessments. General Budget Support (GBS): Leverage to private investments.aligned, untargeted and predictable support to Ministries Attention to fragile contexts of Finance. Now called through LRRD-like approaches. development contracts Strengthen key multilateral Blending instruments. capabilities. Sector reform contracts. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice65 64. US vs. EU development aid levelsEU and US development aid levels900008000070000Million dollars6000050000400003000020000100000 20032004 2005 20062007 2008 2009 2010 EU DAC members41427.53 47290.44 60063.5 64741.92 67560.25 76433.07 71098.44 73733.23 US18257.49 20604.13 28750.3224531.56 22690.52 27414.13 29659.18 31159.3J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 66 65. EU and US ODA as % of GDP0.06000.05000.0400ODA % of GDP0.03000.02000.01000.000020032004 20052006 200720082009 2010 US ODA/GDP0.01650.0175 0.0229 0.01840.0163 0.01930.0214 0.0216 EU(DAC) ODA/GDP 0.03560.0386 0.0468 0.04650.0457 0.04970.0472 0.0479J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 67 66. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 68 67. US vs. EU ODA distribution Ratio LDCs/allEU and US distribution by income regions0.6100%90%0.580%70% 0.460%50% UMICs 0.3LMICs40% other LICsLDCs0.230%20%0.110% 0% US EU US EU US EU US EU US EU US EU US EU US EU0 US EU US EUUS EU US EU US EU US EU US EU US EU 200320042005200620072008 20092010 2003 2004 2005 2006 2007 2008 2009 2010 Ratio LDCs/all 0.38 0.45 0.31 0.41 0.22 0.42 0.33 0.39 0.35 0.42 0.41 0.43 0.43 0.38 0.48 0.44J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 69 68. Share bilateral/multilateral of EU and US ODA100% 90% 80% 70% 60% 50% 40% 30% 20% 10%0% US EUUS EUUS EU USEU USEU USEU USEU US EU 2003 2004 2005 2006 200720082009 2010Multilat 1671 1343 3466 1697 2363 1750 2380 1927 2895 2333 2992 2610 3667 2617 3775 2655Bilat1658 2799 1713 3031 2638 4256 2215 4546 1979 4423 2442 5032 2599 4492 2738 4717 70 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 69. Compliance with aid effectiveness 2005 20072010 Average Target USEU USEU US EUInd 3 : disbursed/estimatedaid 665873 62 64 6141 85Ind 4 : TA coordinated withcountry programming 473654 50 37 5057 50Ind 5a : Use of countrysystems :PFM10413404 5648 55Ind 5 b : use of countrysystems : Procurement 12425364 5544 55Ind 6 : Reduction ofprogramme Implementationunits (2005 baseline)00 048 04 6130 60Ind 7 : Aid Disbursementspredictable and captured bynational budgets295137 63 30 6043 71Ind 8 : Untied aid 70 80 79 86 80 92 86 89Ind 9 : Programme-basedsupport51 27 47 36 59 48 45 66Ind 10 : Donor missionscoordinated28 349 376 25 19 40Ind 11 : Country analysiscoordinated40 45 37 90 39 59 43 66 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 71 70. US vs. EU policies on global healthFeaturesEU-US GH policyUS GH specificities EU GH specificitiescommonalitiesPrinciplesCountry ownershipGender focus. EquitySupport to health systemsResearch and innovation Governance Monitoring frameworks CoherencePriority areasSpecial attention to MDG5AIDS (80% of theUniversal health coverage programmed support) through aligned support (50%Health system strengthenning use of country systems and Malaria 66% through programme based apporaches). Neglected tropical diseases Governance through increased core support to WHO (>50%). Mother and child care Coherence in trade, migration, Nutrition security, food security and climate change.TargetsInputs : Financial allocations. Process : aid affectiveness and governance. Impacts : Patients prevented or treated. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 72 71. US vs. EU levels of HDA 8000 7000 6000 5000 4000 3000 2000 10000EU USother1207Nutrition112 75SRHR 280 455Basic health care602Mother and child care495Malaria 60 382Tuberculosis35 162HIV/AIDS 5645509J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 73 72. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 74 73. US HAD equityEquity distribution of US GH pc 50 45 40 35 30 25 20 y = -0.003x + 4.887R = 0.025 15 1050-2500-2000-1500 -1000 -5000 500J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice75 74. EU HDA equity 20 18 16 14EU pc health aid 12 10 8 6 y = -0,0031x + 0,9267 2 4 R = 0,0078 2 0 -250,00 -200,00 -150,00 -100,00 -50,00 0,00 50,00potential pc public health financing gap J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 76 75. Challenges for EU and US on GHE PERTINENCE Health development aid (hereafter HDA) does not address the main root causes of the mainchallenge in global health: stagnant global health equity. These causes are related to high incomedisparities within and between countries. HDA follows the MDG framework, which only targets 60% of the overall gap of global healthequity, when under the main stratifying variable, that of income, the upper regional quintile (highincome region) is considered the best standard. Countries with lower public spending per capita should maximize their potential of fiscal revenue(to at least 20% of GDP) and the public budget allocation to health (to some 15% , as the OECDaverage and the Abuja commitments for Africa). The gap remaining after those increased domesticrevenues are estimated, affects the 44 countries listed in annex 4, for a total of over 100 Bn ayear, that is, some 6 times higher than the present levels of HDA. Besides lower than required levels of HAD, the distribution is not equitable in relation to thementioned public financing needs. Only 30,9% of ODA goes to countries that are under thisfinancial gap. Both, the EU and the US show low HAD equity levels. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 77 76. Challenges for EU and US on GHE COHERENCE overall development aid is poorly aligned and predictable, as committed in the aideffectiveness agenda and the Paris commitments, hence having very little effect on therequired transformations or reforms of policies to meet people needs. The same fragmentation and undermining effect of sovereignty takes place with the globalgovernance role of the United Nations, especially in the case of health with the World HealthOrganization, suffering from weak, fragmented and biased governance. The US has not ratified the Covenant on Economic, Scoial and Cultural Rights and its comment14 in year 2000, which gives the right to health an operational nature acknowledging the dutyof the state and the wide scope of services and basic and security needs for health to which allpersons are right holders. There are many concerns on how the EU and the US are approaching trade and migrationagreements, among others, which may have a significant effect in the availability of vitalresources for health care, such as qualified health professionals and essential medicines. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 78 77. Economic frameworks: The present economic order leads to growing income disparities within and betweencountries. Such dynamic requires of regulations ensuring minimum income levels (that guarantee theminimum conditions of dignity of all human beings) and avoiding excess income levels(which, in a world with limited resources, result in deficit for others). Beside regulations (ex-ante), the economic dynamics require of fiscal policies that have atleast an effect on redistribution of resources that the market rules have in concentration ofresources in privileged groups. Fiscal policies require a minimum rate of fiscal revenue and an adequate distributionbetween indirect and direct taxes and the progressive nature from basic to luxury goods andspeculative transactions, and from lower to higher salaries. At global level, such direct taxes (on GPP) and indirect taxes (on international transactions)should also be established in a legal framework and with the objective of minimum levels ofredistribution to avoid gaps and their effects in human lives. This concept (of global justice) needs to gradually replace the present concept ofdevelopment aid. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 79 78. Social frameworks :Social governance needs to guarantee basic services which enableequal basic opportunities for all (health, education, justice) inrelation to social rights. This concept is being slowly developed by the UN under theframework of the social protection floor. It is in close relation with the fiscal policy outlined above andrequires a definition of universal social security basicservices, linked to a legal framework. Such concept will also need to be translated at global level througha global social governance which may identify the minimum socialservices all human beings are entitled to for their basic dignity. The UN agencies should work towards those definitions, which, inthe case of health, should include a minimum basic healthpromotion and care package.J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 80 79. Ecological governance At the present rate of use of resources, the EU and the US, as mostOECD countries, have unsustainable models of development. This challenges the very concept and definition of development. The countries that use natural resources at a renewable rate (e.g.1,8 hectares per person and year) and manage to have health andeducation standards (to be better defined and measurable, as inhealth-see above), should be the models of sustainable (and hencetrans-generational equitable) development. The progress of those economies with resources below theminimum levels required for decent living conditions and thoseothers with abuse of global natural resources should find waystowards the equitable and sustainable development models. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 81 80. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 82 81. Thank you! Y hasta muy pronto!J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 83