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국제보건Global Health and Medicine

2013년 5월 28일

오주환

서울의대 이종욱글로벌의학센터

의료관리학개론

수업목표

• 국제보건이란 무엇인지 간략히 설명할 수 있다

• 국제보건분야에서의 주요 현황을 안다

• 국제보건활동의 동기에 대해 이해한다

• 국제보건분야의 쟁점을 이해한다

• 국제보건분야에서 한국이 수행할 가치가 높은 역사적 역할을이해한다

Definition(s)In global health

정의: 국제보건 (proposed by Kaplan et al, 2009)

Global health is

• an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.

Global health …

• Emphasizes transnational health issues, determinants, and solutions

• Involves many disciplines within and beyond the health sciences

• Is a synthesis of population-based prevention with individual-level clinical care

Global Health is…

• Fashionable

• Provoking media, student, and faculty interest

• Has driven the establishment or restructuring of several academic programs

• Is supported by governments as a crucial component of foreign policy

• Has become a major philanthropic target

Source: Kaplan et al, 2009, Lancet

Action Plan of JW LEE Center for Global Medicine

Aug 13, 2012

Director LEE, Jong-koo MD, PhD

Global Health: Origin

• From Public Health

• From International Health (evolved from hygiene and tropical medicine)

Definition: Public Health

• “Public health

• Is the science and art of preventing disease, prolonging life and promoting physical health and efficacy

• through organized community efforts

• for

the sanitation of the environment,

the control of communicable infections,

the education of the individual in personal hygiene,

the organization of medical and nursing services for the early diagnosis and preventive treatment of disease,

and the development of social machinery which will ensure every individual in the community a standard of living adequate for the maintenance of health;

• so organizing these benefits in such a fashion as to enable every citizen to realize his birthright and longevity .”

• Source: Winslow C. The untilled field of public health. Mod Med 1920; 2: 183-91

Definition: International Health

• “the application of the principles of public health to problems and challenges that affect low and middle-income countries and to the complex array of global and local forces that influence them”.

Source: Merson MH, Black RE, Mills AJ. International public health: diseases, programs, systems, and policies, 2nd edn. Sudbury MA: Jones and Bartlett Publishers, 2006.

International Health

• Health work abroad with geographic focus on developing countries

• and often with a content of infectious and tropical diseases, water and sanitation, malnutrition, and maternal and child health

Source: Brown TM, Cueto M, Fee E. The World Health Organization and the transition from international” to “global” public health. Am J Public Health 2006; 96: 62–72.

International Health

• Limited exclusively to the diseases of the developing world (Brown University International Health Institute)

• The philosophy and content of today’s globalised health practice (Global Health Education Consortium)

Comparison of Global, International, and Public health

Global health International health Public health

Geographical

reach

can transcend

national boundaries

health issues of countries

other than one’s own

health of the population

of a particular

community or country

Level of

cooperation

global cooperation bi-national cooperation does not usually require

global cooperation

Individuals or

populations

both prevention in

populations and

clinical

care of individuals

both prevention in

populations and

clinical care of individuals

prevention programs for

populations

Access to

health

Equity among nations

and for all people

Seeks to help people of

other nations

Equity within a nation or

community

Range of

disciplines

Highly

interdisciplinary and

multidisciplinary

Embraces a few

disciplines

Encourages

multidisciplinary

approaches

14

Definition revisit: Global Health

The broadest

• Public Health and Medicine per se

The narrowest

• Public Health and Medicine for developing countries

• Developmental assistance in health

Current Healthcare Statusof developing countries

Life Expectancies at birth

Maternal Mortality Ratio

Millions miss out on needed health ser

vices

19

Source: Dr. Henk, 2012

Why help others?

Spectrum of natures in global health

• Religion/Humanism

• Professionalism

• Health Diplomacy

• Long-term investment

• Health Security

• Short-term investment

• Entrepreneurism

• Imperialism

Altruism

Self-interest

Spectrum considering various actors

Religion/Humanism

Professionalism

Health Diplomacy

Long-term investment

Health Security

Short-term investment

Entrepreneurism

Imperialism

Altruism

Self-interest

Individual/Community Market/ Corporate Nation-State

Selp-interest

Imperialism in Global healthPublic health programs have been the

humanitarian partner of American

imperialism for more than 60 years.

In 1954 John C. McClintock, an assistant

vice president of United Fruit Company,

neatly summed up the relationship between

health and profits that has been a concern of

these programs in the tropics:

"In the under-developed areas where

American companies have gone, where they

have brought great enterprises into fruition,

where they are continuing, one of the

primary factors was to establish conditions

of health were people could not only exist but

also could work. “

(Source: Brown ER, 1976, AJPH)

Self-interest based international engagement : 3 key US interests

• Protecting America’s population

• Enhancing the economy

• Advancing America’s international interests

Source: Institute of Medicine (1997) America’s Vital Interest in Global Health

Self-interest based international engagement: Canada

• Withdrawal or disengagement make no sense in this globalized world

• Global pollution & Climate change

• Changes to the role of the nation-state

• Refugees, Ethnic hostility, Violence, & Mass migration

• Growing poverty

• Intractable disease that does not respect national borderline

Source: Strong et al (1996) Connecting with the World: Priorities for Canadian Internationalism in the 21st Century

Health Security: complementary to domestic action

• Although domestic(national) action remain vital, transnational action needs to complement “domestic” initiatives

(e.g.) mad cow disease in the context of exported feedstuffs

(e.g.) Anti-smoking policy in the context of global tobacco marketing strategies

Yach et al (1998) The Globalization of Public Health, Am J of Pub Health, Vol 88(3) 738-741

Health Security: complementary to domestic action

• International monitoring system are already evolving for many health threats such as

Infectious disease

International risk assessment of the cross-border food trade

Trade of harmful commodities

Yach et al (1998) The Globalization of Public Health, Am J of Pub Health, Vol 88(3) 738-741

International public health law

• Left behind even though better use of international legal instrument in public health would encourage the development of national health legislation

• E.g.) UN Convention on the Rights of the Child

• E.g.) GLOBE (Global Legislators for a Balanced Environment)-carbon tax

Interdependency

Converging self-interest & altruism

• Increasingly interdependent world makes self-interest and altruism converged

• Continued wealth in industrialized countries is not sustainable against a backdrop of poverty, disease, and warfare in many of the world’s poorest countries

Source: Strong et al (1996) Connecting with the World: Priorities for Canadian Internationalism in the 21st Century

Am J of Public Health

개발도상국 보건의료에 기여하는 이유: 순수한 도움 vs 자기 이익

개발도상국 보건의료에 기여하는 이유: 새로운 외교수단, 국제사회 리더쉽 획득

International relations

Past

• War and peace

• Economics and trade

[Hard Power]

Present

• War and peace

• Economics and trade

• Environment

• Health

[Hard Power and Soft Issue]

Global Health Diplomacy

(Definition by Anthony Fauci)

Winning hearts and minds of people in poor countries by exporting medical care, expertise and personnel to help those who need it most

(Source: Fauci AS. 2007. The expanding global health agenda: a welcome development. Nature Medicine 33: 10)

Global Health Diplomacy: New phenomena

• MoFA hires health experts

• MoH hires diplomats

• Establishing “national global health strategy”, frequently at the initiative of the international departments in the MoH

• Developing joint strategic approach to global health by the Departments of the Interior and the Department of Foreign Affairs (Switzerland)

Three major strands of global health diplomacy

1. Normative health issues, international agreements and cooperation, global outbreaks of diseases and pandemics

2. The commitment to health in the context of assistance towards development

3. The policy initiatives in other sectors such as foreign policy and trade

PEPFAR

• The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is the U.S. Government initiative to help save the lives of those suffering from HIV/AIDS around the world.

• PEPFAR is driven by a shared responsibility among donor and partner nations and others to make smart investments to save lives.

G8 commitment on health system strengthening in developing nations

The declaration of the G8 Toyakosummit, held in Japan in July, 2008, covered global health issues under the topic of development and Africa.

The official summary stated:

“The G8 leaders welcomed the Report of the G8 Health Experts Group, presented along with its attached matrices showing G8 implementation of past commitments, and set forth the Toyako Framework for Action, which includes the principles for action on health.”

(Source: Reich M et al, Lancet. 2008 Mar 8;371(9615):865-9.)

Brazil’s global health diplomacy

• Made WTO conference in Doha, Qatar, the health of the population as a priority over international trade

• Brazil assure delivery of the health services and drugs especially for HIV/AIDS patients via close cooperation between the MoH and MoFA

Professionalism in Medicine

has been described by the American Board of Internal Medicine as

“constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.”

(Source: Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243- 246.)

OUR Shared interest altruism

Shared global Prosperity

• Mutually assured progress

• From fortresses of military independence

• Towards shared interest in building human and social capital and reducing cross-national disparities in terms of health and disease risk

Diplomacy

• From power and prestige

• Towards peace and prosperity

Source: Cooper. The breaking of nations. Order and chaos in the 21st century. New York: Atlantic Monthly Press; 2003

Limitation

• Ideal

• But, no clear momentum yet

• Still rhetoric

Development from under-develpment

Two different perspectives in development

• Since in the process of modernization all societies will undergo by and large similar changes, the history of the presently modern nations is taken as the source of universally useful conceptualization

versus

• Both underdevelopment and development are aspects of the same phenomenon, both are historically simultaneous, both are linked functionally and, therefore, interact and condition each other mutually

Modernization perspective

Dependency perspective

Alleged obstacles in development

• Predominance of ascriptive, particularistic, diffuse, and affective pattern of action

• Extended kinship structure with multiplicity of function

• Little spatial and social mobility

• Mostly primary economic activity

• A tendency towards autarchy of social units

• Undifferentiated political structure

versus

• Dependency is a situation in which a certain number of countries have their economy conditioned by the development and expansion of another…placing the dependent countries in a backward position exploited by the dominant countries

Modernization perspective

Dependency perspective

Development can be achieved via...

Modernization perspective

• Diffusion of modern values and institutions from the early modernizers

• To be guided by the Western model adopting and adapting its technology; assimilating its values and patterns of action; importing its financial, industrial, and educational institutions

Dependency perspective

• The center is capable of dynamic development responsive to internal needs

• On the other hand, the periphery is seen as having a reflex type of development; one which is both constrained by its incorporation into the global system and which results from its adaptation to the requirements of the expansion of the center

A Dialogue of World System Theorist

World Population according to three subgroups

GDP per capita over time(10 countries: randomly chosen + Korea added)

Life Expectancies over time(countries: randomly chosen)

Life Expectancies over time(Korea + 10 countries: randomly chosen)

Optimal ODA in normative

• How much achievable: full pledging of under-developed countries with financial and technical support from developed countries?

• Can it be achieved or just rhetorical statement (based either on modernization perspective or on dependency perspective)?

Jump to health ODA: our values

• What’s the underlying perspective with respect to the Korea’s ODA or ODA we hope to establish soon?

• What is your value and way for optimal ODA commitment?

• What should be the goal of health ODA?

Lessons and/or remained question

• What can we learn from both perspectives with regard to development?

• Can professionalism work in global health in the world context beyond nation-state level?

• What does Korea need to rely on?

Actors and Actions in global health

Past History of Actors/Actions in Global Health

• 19th ~ the early 20th century: New diseases in Europe• International Sanitary Conference (1851-1903)

• International Office of Public Hygiene established (1907)

• 20th century: International Organizations established• UN (1945), WHO (1948)• Elimination of particular diseases (1950s-1960s), Vertical Project

• Basic Health Service deliverysystem (1970s), Integrated project

• Declaration of Alma-Ata (1978): Health for all by the year 2000;

Primary health care throughout the world

Source; Don De Savigny & COHRED

Contemporary Partners in Health

Source: Dr. Henk, 2012

Glossary of terms in Global Health Action

Official Development Assistance (ODA) is defined

as financial flows to developing countries and multilateral organizations provided by official agencies or by their executive agencies, each transaction of which meets the following criteria:

1. It is administered with the promotion of the economic development and welfare of developing countries as its main aim

2. It is concessional in character and conveys a grant element of at least 25 per cent (in case of loan)

3. ODA is reported on a calendar year basis

Glossary of terms in Global Health Action

Multilateral ODA is defined as aid delivered in the form of core contributions to organizations listed in the DAC Statistical Reporting Directives such as WHO, WB, UNICEF, UNFPA, etc

Bilateral ODA covers all aid provided by donor countries when the recipient country, sector or project is known

1990

Bill

ions

of 2008 U

S D

olla

rs

Influx of resourcesDevelopment assistance for health (DAH) by channel of assistance, 1990-2010

NGO’s

Other

BMGatesF

GFATM

GAVI

ECWHO, UNICEF, UNFPA

WB-IBRD

WB-IDA

Regional Banks

Bilaterals

2010

26.87

5.66

Various Actors’ Contribution in Global Health

2000년 이후 Bilateral agency, Global Fund, and Private institution에 의한활동이 급격히 증가하기 시작함

Total ODA amount against ODA/GNI ratio in 2009

0.0%

0.7%

1.4%

0 5000 10000 15000 20000 25000 30000

Total ODA Amount (million USD)

OD

A /

GN

I ra

tio

(%

)

(US)

(France)

(Germany)

(UK)

(Japan)

(Spain)

(Netherlands)

(Sweden)

(Norway)

(Demark)

(Korea)

(Italy)

(Canada)

Bilateral Aid at a glance

아직은 국제보건 분야의 기여도가 낮은 한국

Where other donors spend their money?: sector versus geography

UNITED STATES OF AMERICA

UNITED KINGDOM

JAPAN

SWEDEN

AUSTRALIA

KOREA

Issues and debatesin global health

• Everyone has access to needed high quality interventions

• No one should be exposed to financial hardship because of paying for these services

1. Population Coverage

2. Benefit package, like outpatient services etc.

3. Reimbursement levels

Universal Health Coverage

76

Current Global Health Issues• Aid effectiveness

• Millennium Development Goals (2000):

MDG 4(Reduce child mortality rates),

MDG 5(Improve maternal health),

MDG 6(Combat HIV/AIDS, malaria, and other diseases)

• Paris Declaration (2005): Ownership, Alignment, Harmonization, Managing Results, Mutual accountability

• Building a new Global Partnership for Effective Development

• Strengthening health system

• Human Right for Health

Known Problems of the ODA world

1. tied aid

2. short-term goals

3. Sustainability

4. project-based thinking

5. imposed solutions

6. duplication and competition among donors:

lack of coordination

Paris declaration on Aid Effectiveness

Ownership(Partner countries) Countries se

t the agenda

1

Aligning

with country's

agenda

Using

country system

s

Alignment(Donors - Partner)

2

Harmonisation(Donors - Donors)

Establishing

common arrangemen

ts

Simplifying pro

ceduresSharing informat

ion

3

Ma

na

gin

g fo

r Re

su

lts

4

Mu

tua

l Acco

un

tab

ility

5

Development ResultsResult based aid and financing

Discrepancy between health need & health ODA

Health Need: Causes of death

Discrepancy between global ODA NEED vsODA SUPPLY

A New Potential leader of good ODA in Health

Korea: the latest member of OECD/DAC

Known ODA World Problems

1. tied aid

2. short-term goals

3. Sustainability

4. project-based thinking

5. imposed solutions

6. duplication and competition among donors:

lack of coordination

Korea, solve or follow the problems?

Do we just follow the same ways of previous donors?

Or

Do we need to attempt to overcome current flaws of ODA?

Problem solving (1)

Tied aid

• Aid on condition that most equipment and supplies should be stick to the donor country producers

• The least flexibility to operate the institution in the recipient society

Un-tied aid

• No condition on the aid with respect to procurement: neither equipment nor supply

• Genuine ownership of the institution established by donor

Problem solving (2)

Short-term goals

• Mostly project focuses on easily measurable short-term goal

• Could it guarantee DEVELOPMENT of the recipient country on earth?

Long-term goals

• Need to help get the results which need some time to achieve good results especially in resource-limited countries

• Fishing compared to fish

Problem solving (3)

Volatile results

• Normally lots of vertical programs such as drug-distribution get results within a short period of time

• Mostly resumed after exit of the program

Sustainable results

• Good results should be remained in the recipient countries even after exit of donors

• Mostly sustainable result goes with system strengthening

Problem solving (4)

Project based thinking

• Small scale, fragmented components without continuum of the service provision

• Inefficient to manage lots of gap and tons of administrative works for small scale projects

Program or System based thinking

• More comprehensive scale of development assistance: maximal continuum per at-least-one agenda

• Considering health system strengthening all the time

Problem solving (5)

Imposed solution

• Donors give solution program based on their knowledge

• Developing country knowledge is functionally invisible to donor

Participatory approach

• People know themselves more than others

• It is usually monetary capacity not intellectual capacity that they lack

• Seek to find the optimal way of problem solving together between donor and recipient

Problem solving (6)

Duplication and competition among donors

• Trying to provide similar projects on the same geographical areas

• Duplication exist with gap as well

Harmonization

• Effective provision via division of role

• Cooperation among donors within same geographical area

• No competitive provision in the same agenda and same way via sector-wide-coordinating group activity

How to solve: clue or normative

• The nations get agreeing for good normative even without commitment

• Normative way such as Paris Declaration was already established; just not implemented

FORMATION OF INTERNATIONAL NORMATIVE

Revisit: PARIS DECLARATION

1. Ownership: Partner countries exercise effective leadership over their development policies and strategies

2. Alignment: Donors base their overall support on partner countries’ national development strategies, institutions and procedures

3. Harmonization: Donors’ actions are more harmonized, transparent and collectively effective

4. Managing for Results: Managing resources and improving decision-making for results

5. Mutual Accountability: Donors and partners are accountable for development results

The Paris Declaration on Aid Effectiveness, endorsed by over 100 countries in 2005, committed their countries and organizations on five key areas:

ACCRA AGENDA

Ministers of developing and donor countries endorsed the following statement in Accra, Ghana,

(4 Sept. 2008 )

to accelerate and deepen implementation of

the Paris Declaration on Aid Effectiveness

(2 March 2005)

BUSAN DECLARATION

[Two of essentials]

Establishing good governance and the role of efficient public procurement in the effective functioning of the public sector

South-South or triangular co-operation, complementing North-South forms of co-operation

North-South

Co-operation

in

Official

Development

Assistance

Infant Mortality Rates 2007

source: www.gapminder.org

Helping South-

South Co-

operation

(Triangular

cooperation)

in

Official

Development

Assistance

Where to go

Unique or different approach

Sincerely respecting international normative and recipient societies (Paris Declaration)

Way of good Samaritan: considering others as you do for yourself

Pursuing good reputation from recipient countries in long-run view rather than short-term interest under short-run view

Goal: Helping others- ODA as humanitarian ends -

Helping underserved population in the underserved countries (primary achievement)

will give us global leadership (secondary gain)

Goal: Achieving Global leadership- ODA as effective means -

• Achieving global leadership (Primary goal) will be achieved well

through helping underserved population in the underserved countries (Humanitarian means) compared to military forces.

Thank Youoh328@snu.ac.kr