GH Challenges Notes (1) PDF

GH Challenges GH Toolkit 1................................................................................................................ 1 GH Toolkit 1 - Basic Goals and Concepts RMNAC Aug 28 Agenda 1. Concepts & Context 2. Key Indicators 3. Global Burden of Disease 4. Our Global Burden...

GH Challenges GH Toolkit 1................................................................................................................ 1 GH Toolkit 1 - Basic Goals and Concepts RMNAC Aug 28 Agenda 1. Concepts & Context 2. Key Indicators 3. Global Burden of Disease 4. Our Global Burden of Disease 5. Our Global Health Agenda Global Health: How do we define it An area for study research, and practice that places a priority on improving health and achieving equity in health for all people worldwide o Health: a state of complete physical, mental, social wellbeing, not just an absence of disease (defined by WHO) o Equity: the elimination of health inequities and health disparities o Equality: o Why do we focus on equity o ALL PEOPLE: includes everyone, with a special focus on hot pops (people who are more at risk) and “hot spots” (particular areas) o WORLDWIDE: focus on domestic, international, transnational health issues, including animal and environmental health Medicine (individual level) while public health is population level Why was the HIV a security issue? o The US is interested in malaria because it wants a healthy fighting o PEPFAR and PMI Social justice – Ethical Egoism and Altruism are all intersecting Inverse care law: Julian Tudor Hart - the availability of good medical care tends to vary inversely with the need of the population served How did we get here?  - Tropical Medicine (colonial agenda) – International Health (cold war politics)– Global Health (globalization) - Global Health in Transition (critically reflective, decolonizing, demarginalizing, merging with one health and planetary health) Global Burden of Diseases WHO 1. African Region (AFRO) 2. Region of the Americas (AMRO) 3. South-East Asia Region (SEARO) 4. European Region (EURO) 5. Eastern Mediterranean Region (EMRO) 6. Western Pacific Region (WPRO) World Bank 1. Africa 2. East Asia and Pacific 3. Europe and Central Asia  4. Latin America and Caribbean 5. Middle East and North Africa 6. South Asia World Bank Income Classifications You don’t need to know the cut-offs but you need to know the WB economic classifications Low-income 1,135 or less Lower middle income 1,136 to 4, 465 Upper middle-income 4,466 to 13,845 High income – 1,313,846 or higher G8 become G7 – RUSSIA kicked out for invading Ukraine Canada France Germany Italy Japan The UK US EU Know the countries Income group Only 26 Low-Income Countries Most of the world’s poor (around 70%) live in MICs not LICs Socio-demographic Index SDI - This way of classifying countries takes into account not only income per capita but also educational attainment and total fertility rate  WHO – intergovernmental agencies All UN agencies are intergovernmental agencies World Bank is a UN agency Establishment of WHO (1948) WHO raises its money: Member dues (each member country pays its dues) MDGs - There were 8 SDGs - There are now 17 and goal 3 is Good Health and well-being - Poverty is a risk factor for poor health Key Global Health indicators Prevalence vs Incidence (make sure you know this!!!) Prevalence – total no. of cases in a specified population per 100,000 people Incidence – no. of new cases PER 100,000 PEOPLE Recovery – reduces prevalence Death Mortality rate and life expectancy Mortality rate is per 1000 people Life expectancy (LE) Disability – Adjusted Life Years DALY = Years lived with disability, illness or injury + Years of life lost DALYs – are healthy life years lost due to disability, illness, injury or death Why do you care about DALYs - Trends - Resource allocation Limitation of DALYs - Disability weight GBD by Disease Category: Globally: Group II diseases are leading In High SDI countries – group II, followed by group I In middle SDI countries – group II followed by group I (middle has a larger group I than high) In low SDI countries, group I followed by group II Group I – the unfinished MDGs agenda (3 MDGs related to group I child mortality, maternal mortality, infectious disease) Avert DALYs An intervention is cost effective to avert 1 DALY if it costs less than 3 times of the GDP of the country If it costs less than 1 times of the GDP of the country, it Is highly effective Examples: - Primary: vaccines - Secondary: cancer screening - Tertiary: exercise and medicines If we know some of the risk factors, we can change the behaviors to avoid. Disability Weights (YLD) Years lived with a disease or disability is calculated as: disease incidence x duration x a disability weight Disability weight reflects the impact of that disease on a o 0 – 1 (death)  o Different diseases have different weights Malignant melanoma o Vitamin D is linked to heart disease DALYs SDI – social demographic index o Captures income, and education Low SDI is captured by infections For Global DALYs – years lived with disability Non-communicable diseases Heart disease, cancer, Risk factors: hypertension, alcohol, smoking, alcohol, diet Responding to non-communicable disease in Zambia: a policy analysis Policy is externally driven without having stakeholders involved Walt and Gilson’s Policy Triangle Framework Protective factors – exercise Risk factors (you can’t control) - Air pollution The proximal/distal paradigm Proximal risk factor (“downstream” directly affects health eg. smoking Distal risk factor (“upstream”): indirect impact on health eg. Taxing tobacco  Biopsychosocial Model of Health Status: Health as an “Ecological” Complex of Determinants: Bio o Genetics o Sex o Age Psycho o Mental Health o Experience o Stress o Resilience & coping skills Social o Location o Race and ethnicity o Sexual orientation & gender identity o Socioeconomic status o Education o Occupation Six Additional Overlapping Paradigms Expand The Model Into A “Web of Causation” 1. Networks o Individual o Interpersonal  o Community o Society 2. Barriers o Sociocultural o Structural o Financial 3. Structural violence o Inequity (of all types) o Vulnerability (higher risk of risks) o Constrained agency (‘agency’ is independent action, free will) o Barriers to access & care o Discrimination & “othering” o Poverty 4. Global Transitions o DEMOGRAPHIC shift from high birth/mortality to low birth/mortality o URBAN shift from rural to urban regions in a world of 9.6 billion people by 2050 o NUTRITIONAL shift from cereals, fiber, vegetables to animal foods, high fat, sugar o EPIDEMIOLOGIC shift from infectious to chronic diseases (hence LMIC dualdisease burden) 5. Health - Wealth Gradient o Health and wealth strongly correlated 6. Status o Social position impacts health outcomes Environment as a Determinant Outdoor Air pollution Water, Sanitation, Hygiene Air, water, soil account for 16% of global deaths Increase co2 levels reduce nutritional levels of crops, especially iron, zinc, and protein. Malnutrition: Two types Toolkit III The “Global Health System”: There isn’t one Global health is a landscape of actors who share the common mission of improving global health outcomes o Actors work independently, collaboratively, multi-sectorally. A  o Actors takes place within context of evolving norms, laws and legally binding instruments, strategies, relationships, sectors, frameworks, “hard power – threats eg. Sanctions), and soft power (eg. Diplomacy, negotiations) o Vaccination ceasefire – humanitarian ceasefire Focus varies: o Local, national, regional, global o Primary, secondary, tertiary o Horizontal, vertical, diagonal ▪ Vertical – disease specific program eg. PEPFAR, PMI ▪ Horizontal – system wide ▪ builds systems to tackle multiple conditions, e.g., strengthening primary health care [PHC] is a horizontal intervention ▪ Diagonal – combination of the two o Direct or indirect impact on health The “Power” of Global Health o Framework prevention of tobacco control (second world regulation) o Why counties do not comply: No resources for screening Lack of awareness Other treaties have more weight No camp Mechanisms for compliance Police patrol – formal inspection Fire alarm – individuals. CBO creating a place for resource – sharing Community Most GH Decisions happen at the policy level Health Policy; Decisions, plans, and actions that are undertaken to achieve specific health care goals within a society The Landscape of Actors: A Typology The H8 - Need to know six building blocks and goals of Health Systems How health is funded/health is financed? Private out-of pocket spending General government financing Employment taxes Official development assistance How much of total health spending in low- and middle-income nations come from aid?  LICs – 27% of health spending in form of ODA 3% of spending in LMICs is from ODA What can get us to think about - Themes that emerge from the cases o Partnerships and coalitions o Evidence-based interventions o Incentives o Focusing on the wors-off gives the best outcome Case 20: 280,000 deaths each year 1/5 global diarrhea burden Inadequate sanitation is to blame for one-fifth of the global disease burden Indonesia context o 27% of Indonesians praticed open defecation in 2005 o 37% in rural areas o 120 million diarrhea associated illnesses annually o 50,000 deaths annually o 6.3 billion in annual economic losses Initial interventions o 1920s – Dutch colonial sanitation campaigns o 1960s - Construction of free and subsidized toilets o 1990s – World Bank funds communal and private sanitary facilities Considerations leading to new adaptation o Behavioral change o Equity Community-led total sanitation (CLTS) What group of diseases were addressed? Was the intervention cost effective? Financing: Mobilizing, pooling, and purchasing Preparation and Risk Management Regulations (e.g. water control, building codes) Community education/preparedness Access to first aid and first responder training Strong emergency medical systems, transport mechanisms, treatment centers Forward staging of medicines/equipment Response  WASH (water supply, sanitation, hygiene) Food, shelter, and other necessities Interpersonal and environmental safety Psychological support Essential health services (including reproductive and child health) Infection control (esp. measles, malaria, diarrheal diseases, TB, meningiti Group 3: Injury, Violence and Disasters Injury, classified as: Unintentional Intentional (suicide) Disasters, classified as: Anthropogenic (caused by humans)  Oil spills Natural  Fracking (fracturing the rocks) to get to oil and gas, can create earthquake  Poor are always the most affected Complex (humanitarian) emergencies  the result of a combination of political instability, conflict and violence, social inequities and underlying poverty. Complex emergencies are essentially political in nature and can erode the cultural, civil, political and economic stability of societies, particularly when exacerbated by natural hazards and diseases such as HIV and AIDS, which further undermine livelihoods and worsen poverty Global Distribution of IVD: Global DALYS: The largest contributors 1. Road-related injuries 2. Falls 3. Self-harm 4. Interpersonal Violence 5. Fire, drowning, and poisoning 6. Mechanical forces IVD: A Global Impact - Poorest are hit always first and worst. Unintentional injuries 1. Traffic injuries Intentional Injuries – Violence Uneven distribution by age, sex and risk - Acid attacks on women happen in SEARO, but usually not in AMRO or EURO.  - Mass shootings, whether children or minority groups tend to happen more in the US than anywhere else in the world. IVD reduces global GDP by 1-3%, and hot spots attract less investment Related not only to physical health and economics but also to emotional health, familial stability, social cohesion, and educational opportunities for children Globalization & climate change both contribute North or South, impact of IVD falls disproportionately on the poorest and most vulnerable How can IVD affect IDs & NCDs? 1 in 8 of the world’s population live in fragile, conflict-affected or vulnerable (FCV) settings Underlying conditions in FCV settings contribute to pandemic spark risk and spread risk Pandemics can amplify existing political tensions and worsen conflict in these settings (e.g., west Africa during 2014-2016 Ebola epidemic) Intentional Injuries: Violence We define it as a disaster: when needed hazard response exceeds local surge capacity. 1. Anthropogenic disasters – events such as mining and refining, accidents, hazardous spills, nuclear plant meltdowns 2. Natural disasters – earthquakes, fires, floods, droughts, famine, tornadoes, hurricanes, 3. Complex disasters or complex humanitarian emergencies (CHE) or disasters (CHD)  a. Natural disasters can exacerbate—or initiate--Complex Emergencies b. Conflicts that create large-scale disruption and displacements of people, mass food and water shortage, and fragile or failing economic, political, and social institutions The complex burden of disasters 1. Disease outbreaks 2. Sexual violence 3. Mental health issues 4. Physical trauma 5. Undernutrition and lack of potable water 6. Destroyed social structure, institutions, resources, 7. Refugees and IDPS 8. A longitudinal conflation of group I, II and II disorders UNHCR (Office of the United Nations High Commissioner for Refugees) works to coordinate assistance to refugees (and, increasingly, IDPs as well) The UN’s Office for the Coordination of Humanitarian Affairs (OCHA) coordinates disaster relief. Refugees and IDPs Refugee: a person who has been forced to leave their country in order to escape war, persecution, or natural disaster. IDP: An internally displaced person is someone who is forced to leave their home but who remains within their country's borders stateless people: who have been denied a nationality and lack access to basic rights such as education, health care, employment and freedom of movement. Asylum seeker: someone who has applied for protection in a country other than their own, but their claim for refugee status has not yet been determined. Preparation, prevention, damage control Preparation, and risk management Preparation and Risk Management Regulations (e.g. water control, building codes) Community education/preparedness  Access to first aid and first responder training Strong emergency medical systems, transport mechanisms, treatment centers Forward staging of medicines/equipment Response WASH (water supply, sanitation, hygiene) Food, shelter, and other necessities Interpersonal and environmental safety Psychological support Essential health services (including reproductive and child health) Infection control (esp. measles, malaria, diarrheal diseases, TB, meningitis Primary, secondary and tertiary prevention of violence 1. Actions to prevent violence occurring in the first place 2. Intervening after violence has happened to stop it from happening again (protective orders, counseling) 3. Ongoing support for victims and ongoing accountability for perpetrators (eg. Support groups, batterer intervention programs) Preparation, prevention and damage control