Global Health and Nursing - Chapter 11 PDF

# Chapter 11: Global Health and Nursing ## Learning Objectives - Discuss global health issues and implications to nursing. - Analyze the Sustainable Development Goals and how nurses contribute to their attainment. - Define universal health coverage and its potential impact to health and nursing. -...

# Chapter 11: Global Health and Nursing ## Learning Objectives - Discuss global health issues and implications to nursing. - Analyze the Sustainable Development Goals and how nurses contribute to their attainment. - Define universal health coverage and its potential impact to health and nursing. - Discuss primary health care as an approach to achieving universal health coverage. - Describe the work of international organizations in achieving the Sustainable Development Goals. - Identify the role of nurses in global health. ## Key Terms - global action plan - global burden of disease - global health - global health players - health systems building blocks - human resources for health - primary health care - social determinants of health - sustainable development goals - universal health coverage ## Global Health Issues Global health is about improving health of the people and achieving health equity for all. Global health issues transcend national borders and usually have global impact on politics and economics. It requires global cooperation in response, planning, prevention, preparedness, and care that reflects health equity issues among countries. The nature of these global health issues and the factors that influence them also need interprofessional and interagency cooperation from the public and private sectors. The Global Burden of Disease Study 2016 showed that deaths from noncommunicable diseases (NCDs) represented 72.3%, followed by 19.3% from communicable, maternal, neonatal, and nutritional diseases (CMNN) diseases and 8.4% from injuries. There is a global shift from premature mortality from CMNN towards deaths at older ages for causes such as cardiovascular diseases, ischemic stroke, and neoplasms. There are declining rates of CMNN across different levels of sociodemographic index (based on average income per capita, educational attainment, and total fertility). In some locations, there are increased deaths from causes such as drug use disorders and conflict and terrorism. This shift reflects the need for health systems to prepare for improving workforce capacity and higher cost of effective treatments of chronic conditions and new challenges brought by conflict and terrorism and climate change-related issues. ## Communicable, Maternal, Neonatal, and Nutritional Diseases (CMNN) * Communicable diseases decreased as a leading cause of death, brought about by the reductions in deaths caused by HIV/AIDS, malaria, tuberculosis, and diarrheal diseases. * Overall, HIV/AIDS deaths decreased by 45.8% from 1.91 million deaths in 2006 to 1.03 million deaths in 2016. This declining death rates probably reflect the successful expansion of antiretroviral therapy and the prevention of mother-to-child transmission programs. * There was also a decrease of 20.9% (1.21 million deaths) from tuberculosis, 24.2% (1.66 million deaths) from diarrhea in 2016. * Other communicable diseases that decreased in terms of total deaths included malaria (25.9%), measles (72.5%), leishmaniasis (54.1%), and intestinal infectious diseases (14.7%) from 2006 to 2016. Dengue was the only neglected tropical disease with a significant increase in cause-specific mortality, with an 81.8% increase in total deaths (37,800 deaths in 2016). * All maternal and neonatal causes of death decreased globally in terms of total deaths between 2006 and 2016. The largest decrease in deaths from maternal disorders were for other maternal disorders (35,300 deaths, maternal sepsis and other maternal infections (19 500 deaths), and maternal hemorrhage (72,400 deaths), which represented decreases of 27.4%, 26.7%, and 23.8%, respectively. Neonatal disorders decreased by 25.3% for total deaths, declining from 2.32 million deaths in 2006 to 1.73 million deaths in 2016. Deaths from nutritional deficiencies constituted 3.49% of total deaths due to CMNN causes, resulting in 368 100 in 2016. * Protein-energy malnutrition caused the largest number of deaths for nutritional deficiencies with 308,000 deaths in 2016, followed by other nutritional deficiencies, which caused 54,500 deaths. Progress toward reducing mortality rates associated with nutritional deficiencies was similar to maternal and neonatal disorders. ## Noncommunicable Diseases (NCDs) * For NCDs in 2016, the largest number of deaths were caused by cardiovascular diseases (17.6 million deaths) followed by neoplasms (8.93 million deaths), and chronic respiratory diseases (3.54 million deaths). Globally, deaths from cardiovascular disease increased by 14.5% between 2006 and 2016. Ischemic heart disease and cerebrovascular disease (stroke) combined accounted for more than 85.1% of all cardiovascular disease deaths in 2016. Total deaths from ischemic heart disease rose by 19.0%, increasing from 7.96 million deaths in 2006 to 9.48 million deaths in 2016, which largely accounts for the overall increase in total deaths from cardiovascular diseases. * The absolute number of deaths and the total years life lost (YLLs) from diabetes both increased between 2006 and 2016 by 31.1% and 25.3%, respectively. Deaths from neoplasms increased globally by 17.8%, rising from 7.58 million deaths in 2006 to 8.93 million deaths in 2016. * From 2006 to 2016, increases of greater than 30% occurred for several neoplasms that were large causes of deaths: prostate cancer (30.8%, to 381 000 deaths); pancreatic cancer (30.2%, to 405 000 deaths); and other neoplasms (30.0%, to 431 000 deaths). Both lung cancer and breast cancer deaths increased from 2006 to 2016, from 1.44 million deaths to 1.71 million deaths for lung cancer and from 466 000 deaths to 546 000 deaths for breast cancer. Chronic respiratory diseases contributed 8.96% of NCD deaths in 2016, with chronic obstructive pulmonary disease (COPD) leading to the most deaths from these conditions (2.93 million deaths). ## Injuries * Total injury deaths were largely unchanged from levels in 2006. Unintentional injuries accounted for the most injury deaths in 2016, with 1.80 million deaths composed mainly of deaths from falls (678 000 deaths), drowning (302 000 deaths), and exposure to mechanical forces (155 000 deaths). Unintentional injuries were followed by transport injuries (1.44 million deaths), and self-harm and interpersonal violence (1.21 million deaths). Deaths from physical violence by firearm were the largest portion (41.2%) of overall interpersonal violence in 2016. Self-harm by firearm constituted 8.26% of global deaths from self-harm. * The largest decreases in injury deaths from 2006 to 2016 occurred for exposure to forces of nature (49.2%, to 7060 deaths) and drowning (19.0%, to 303 000 deaths), while the largest increase was for conflict and terrorism at 143.3%, (from 61,900 deaths to 150 000 deaths). ## Patterns of Global Health Are Changing * Patterns of global health are changing with more rapid declines in CMNN conditions than for NCDs and injuries. This is a result of the global focus on reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases in the Millennium Development Goals (2000-2015). * The continuing challenge posed by major NCDs and injuries suggest the need for more effective programs and policy interventions to reduce mortality from these causes. Moreover, public policies and sustained government commitment are required to gain substantial impact. * Global health issues are problems of high complexity; influenced by many factors, such as poverty, inequality and social determinants of health. As defined by the World Health Organization (WHO), the social determinants of health are the conditions in which people are born, grow, live, work and age. * These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries (WHO, 2014). ## Nursing's Role in Global Health * Nursing as a profession is ideally placed to engage its members as actors in both human rights and global health diplomacy efforts (Breda, 2012). * Nurses can engage in interprofessional collaborations to improve health and to enhance human rights and international relations efforts. * As health issues become more global and move beyond health to include foreign policy, security, and trade agreements, nurses can also take on leadership roles to examine health in the context of the global order of political and economic power. ## Sustainable Development Goals * In 2015, The United Nations General Assembly adopted the Sustainable Development Goals (SDGs), which aims "to ensure that all human beings can fulfill their potential in dignity and equality and in a healthy environment." * The SDGs lay the foundations for supporting global health and international development work from 2015 to 2030. There are 17 goals and 169 target indicators that require multisectoral and multi-stakeholder partnerships and involve embedding in national plans and policies and building capacity. ### SDG 3: Good Health and Well-being * One goal particular to health is SDG 3, which aims to "ensure healthy lives and promote well-being for all at all ages" and covers the unfinished MDGs and newer challenges such as NCDs, health security, tobacco and injuries (WHO, 2017). ### Other SDGs Related to Health * SDG 3 is linked to around 50 health-related targets across the SDGs. These SDGs include core health targets, contribute to health and well-being and commit to "leave no one behind." * **SDG 1:** Extreme poverty/ Vulnerability to economic, social & environmental shocks and disasters * **SDG 2:** Malnutrition * **SDG 5:** Violence against women and girls/ Sexual reproductive health and rights * **SDG 6:** Safe and affordable drinking water/ Sanitation and hygiene * **SDG 8:** Safe and secure working environment * **SDG 11:** Housing and basic services/ Air quality, waste management in cities * **SDG 13:** Climate-related hazards and natural disasters ### Achieving Health in the SDGs * Achieving health in the SDGs means addressing barriers to access to health services, whether financial, physical, geographic, educational or cultural, especially those faced by socially excluded and disadvantaged groups. * It is a whole-of-system approach to improving health system performance and sustaining health gains. It focuses attention on people and communities, calling for health systems that are of good quality, efficient, equitable, accountable, resilient and responsive to the needs of diverse population groups, including in particular those left furthest behind (WHO 2017). ## Universal Health Coverage * The 2030 Agenda for Sustainable Development views health as a central component of development (Le Blanc, 2015). Among the health targets for SDG 3, Target 3.8 emphasizes the importance of universal health coverage to attain equitable and sustainable health outcomes and improve the well-being of individuals and communities. * WHO’s view of Universal Health Coverage (UHC) means that all individuals and communities receive the health services they need without suffering financial hardship. Such services include the full spectrum of essential, quality health services from health promotion to prevention, treatment, rehabilitation and palliative care. (WHO, 2019). * By making quality health services accessible to everyone, people will not run the risk of losing their money, savings and assets when they suddenly become ill. * UHC enables countries to achieve their health targets towards other economic and development goals. UHC is measured by a country’s health service coverage and financial protection. ## Health Service Coverage and Financial Protection * UHC progress is monitored using two indicators: (1) health service coverage or the proportion of population that can access essential quality health services and, (2) financial protection or the proportion of the population that spends a large amount of household income on health (Fig. 11.3). * WHO (2019) uses 16 essential health services in four categories as indicators of the level and equity of coverage in countries: * Reproductive, maternal, newborn and child health (RMNCH) which include services on family planning, antenatal and delivery care, full child immunization and health-seeking behavior for pneumonia. * Infectious diseases covering services for tuberculosis treatment, HIV antiretroviral treatment, hepatitis treatment, use of insecticide-treated bed nets for malaria prevention and adequate sanitation. * Noncommunicable diseases that include services for prevention and treatment for raised blood pressure and blood glucose, cervical cancer screening and tobacco smoking. * Service capacity and access to basic hospital and health worker services, essential medicines and health security. ## Challenges to Universal Health Coverage * At least half of the world’s population still do not have full coverage of essential health services. * About 100 million people are still being pushed into extreme poverty because they have to pay for health care. * Over 930 million people or around 12% of the world’s population spend at least 10% of their household budgets to pay for health care. ## Strengthening Health Systems * Countries who have made strides towards UHC realized that the work requires increasing the resilience of their health systems to respond to local and global health threats. * Kieny et al. (2017) defines health system strengthening as a significant and purposeful effort to improve the system's performance and should embody the intermediary objectives of the national health policies, plans and strategies which are quality, equity, efficiency, accountability, resilience and sustainability. * *Six building blocks contribute to the strengthening of health systems.*: * Leadership/governance and health information systems provide the basis for the overall policy and regulations of all the other health system blocks. * Key input components to the health system include financing and health workforce, while medical products and technologies and service delivery reflect the immediate outputs of the health system. * Health systems strengthening require good governance, well-functioning health information systems, a robust financing structure, sound system of procurement and supply of medicine and health technology and finally, available, accessible and capable health workers to deliver high quality people-centered integrated care. (WHO, 2010; WHO, 2019). * *The Impact of Strengthening Health Systems on SDGs*: * **SDG 1: No Poverty** * **SDG 4: Quality education** * **SDG 5: Gender equality** * **SDG 16: Inclusive societies** * **SDG 3: Equitable health outcomes and wellbeing; global public health security and resilient societies** * **SDG 8: Inclusive economic growth and decent jobs** ## Primary Health Care * It has been four decades since the 1978 Alma-Ata Declaration that Primary Health Care (PHC) was the way to achieve health for all by the year 2000. * PHC as a concept, philosophy and an approach received much criticism as it was misunderstood. In the mid-1990’s, the global health scenario characterized by the HIV/AIDS epidemic, resurgence of TB and malaria prompted the WHO to review its approaches to address these emergencies. * The start of the 21st century saw the MDGs being put forward as framework for development cooperation. * In 2010, the WHO commissioned a report on universal health coverage which became central to the SDGs. (WHO, 2017b) * Reiterating the earlier definition, PHC is an approach to health and well-being centered on the needs and circumstances of individuals, families and communities and addresses comprehensive and interrelated physical, mental and social health and well-being. (WHO, 2019). * PHC looks at the person's health in a holistic manner and not just addressing disease or illness conditions. * It also emphasizes the services being delivered in places where the people live or as close to where they live. * *WHO’s definition of PHC is based on three components:* * Ensuring people's health problems are addressed through comprehensive promotive, protective, preventive, curative, rehabilitative and palliative care throughout the life course, strategically prioritizing key system functions aimed at individuals and families and the population as the central elements of integrated service delivery across all levels of care. * Systematically addressing the broader determinants of health (including social, economic, environmental as well as people's characteristics and behaviors) through evidence-informed public policies and actions across all sectors; and * Empowering individuals, families and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services through their participation, and as self-carers and caregivers to others. ## Global Health Players * In response to the work needed in achieving health-related SDGs, twelve (12) multilateral international organizations with significant roles in health, development and humanitarian work came up with a Global Action Plan to strengthen their collaboration in support of countries. * *The Global Action Plan (WHO, 2019b) builds on existing mechanisms, including country platforms for achieving the SDGs and the ongoing process of reform in the United Nations Development System.*: * Engage with countries better to identify priorities and plan and implement together. * Accelerate progress in countries through joint actions under seven accelerator themes set out in the Plan, and through an overarching commitment to advance gender equality and support the delivery of global public goods. * Align by harmonizing operational and financial strategies and policies in support of countries where this increases our efficiency and reduces the burden on countries; and * Account by reviewing progress and learning together to enhance shared accountability. * *Global Health Players in Achieving the SDGs:* * **Gavi, the Vaccine Alliance** * **The Global Financing Facility (GFF) for Women, Children and Adolescents** * **The Global Fund to Fight AIDS, TB and Malaria** * **The Joint United Nations Programme on HIV/AIDS (UNAIDS)** * **The United Nations Development Programme (UNDP)** * **The United Nations Population Fund (UNFPA)** * **The United Nations Children's Fund (UNICEF)** * **Unitaid** * **The United Nations Entity for Gender Equality and the Empowerment of Women (UN Women)** * **The World Bank Group** * **The World Food Programme (WFP)** * **The World Health Organization (WHO)** ## Role of Nurses in Global Health * Addressing the global health issues and achieving the SDGs through the universal health coverage and primary health care require the commitment of all health workers. * Nurses being at the forefront of health care delivery system are expected to help accelerate progress towards achieving these. * Nurses have the greatest potential since they are well positioned in many settings from academic institutions, public health, clinical care, government and private agencies, possessing various roles as leaders, managers, direct carers, researchers, and policy advocates. * However, there are challenges that must be faced. * Nurses must recognize and understand how social determinants impact on health of individuals and populations. * Nurses must advocate for addressing these social determinants of health and health inequities to help individuals, families and communities achieve better health. * Nurses in the different levels of care across the health system must know how to assess, implement, and evaluate programs and policies that would better address the local, national and global health issues. * Furthermore, nurses need to become human rights advocates, political activists, engaged citizens and critical artists for global health issues and acquiring these roles requires that they have a sound understanding of globalization and the political economy of health, as well as a solid knowledge base in human rights and global health diplomacy (Breda, 2012). * There is also a need to address nursing shortage and maldistribution in many countries. * The International Council of Nurses actively participated in drafting of the WHO Global Strategy on Human Resources for Health: Workforce 2030 (White, 2016). * The Global Strategy has the vision: "Accelerate Progress towards Universal Health Coverage and the Sustainable Development Goals by ensuring equitable access to skilled and motivated health worker within a performing health system." * This was further supported by the goal: "Ensure availability, accessibility, acceptability and quality of the health workforce through adequate investments and the implementation of effective policies at national, regional and global levels, for ensuring healthy lives for all at all ages, and promoting equitable socio-economic development through decent employment opportunities.” (Global Health Workforce Alliance & WHO, 2015). * Nurses can contribute as leaders of change to help address global health issues, achieve the SDGs, implement universal health coverage and primary health care. * Nurses can contribute by becoming involved in communities and professional nursing organizations, getting involved in policy making and advocacy organizations, and active in their workplaces. ## Summary * Global health is about improving health of the people and achieving health equity for all by addressing global health issues that transcend national borders and have global impact on politics and economics. * Global burden of study 2016 showed the global shift from premature mortality from communicable, maternal, neonatal and nutritional diseases towards deaths at older ages for causes such as cardiovascular diseases, ischemic stroke, and neoplasms. * Sustainable Development Goals (SDGs) aims "to ensure that all human beings can fulfill their potential in dignity and equality and in a healthy environment." * SDG 3: Good health and well-being, which is particular to health, aims to "ensure healthy lives and promote well-being for all at all ages" and covers the unfinished MDGs and newer challenges such as NCDs, health security, tobacco and injuries. * One of the targets in SDG 3 emphasizes the importance of universal health coverage to attain equitable and sustainable health outcomes and improve the well-being of individuals and communities. * PHC is an approach to health and well-being centered on the needs and circumstances of individuals, families and communities and addresses comprehensive and interrelated physical, mental and social health and well-being. * Multilateral international organizations with significant roles in health, development and humanitarian work recognized the needed closer collaboration to help accelerate progress towards the health-related SDGs and committed to a Global Action Plan. * Nurses can contribute as global leaders of change to help address the global health issues, achieve the SDGs, implement universal health coverage and primary health care. ## Review Questions 1. The leading cause of death globally is which of the following? * A. Malnutrition * B. NCDs * C. Infectious Diseases * D. Aging 2. Common factors that influence global health issues include: * 1. Poverty * 2. Inequality * 3. Environment * 4. Socioeconomic conditions * A. 1, 2, and 3 * B. 1 and 2 only * C. 3 and 4 only * D. 1, 2, 3, and 4 3. All but one are correct statements about Sustainable Development Goals: * A. It has 17 goals and 139 targets * B. It will be implemented from 2016 to 2030 * C. It was launched by the World Health Organization to ensure quality of life * D. It aims to foster collaboration among member states of the United Nations 4. Universal Health Coverage means that all individuals and communities receive the health services they need without suffering financial hardship. Such services include: * 1. Health promotion * 2. Disease prevention * 3. Rehabilitation * 4. Curative and Palliative Care * A. 1, 2, 3, and 4 * B. 1, 3, and 4 * C. 1, 2, and 3 * D. 1 and 4 only 5. Which of the following roles can the nurse assume to promote global health? * A. Human Rights Advocate * B. Political Activist * C. Community Organizer * D. All of the above