20 Proposed Global Health Challenges for 2022 and Beyond PDF

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/358595910 20 proposed global health challenges for 2022 and beyond Research Proposal · February 2022 DOI: 10.13140/RG.2.2.26629.83686 CITATIONS READS 0 3,208 1 author: Federico G de Cosio Pan American Health Organization (PAHO) 38 PUBLICATIONS 2,489 CITATIONS SEE PROFILE All content following this page was uploaded by Federico G de Cosio on 14 February 2022. The user has requested enhancement of the downloaded file. 20 proposed global health challenges for 2022 and beyond “For every challenge, there is an opportunity. Let us seize the momentum to launch a global solidarity effort to tackle them so that we can enjoy a healthier world” by Federico Gerardo de Cosío Part 1: List of Global Health Challenges without an order of priority Part II: Making a case for each of the Global Health Challenges............................................... 2 1. Reimagining Global health for a healthier world................................................................... 2 2. Underfunded global health governance mechanisms........................................................ 2 3. Sustainable Development Goals (SDGs) in times of crisis..................................................... 4 4. Building back better health systems and services by supporting development within the scope of humanitarian aid......................................................................................................... 4 5. Universal Health Coverage (UHC) in the COVID-19 era is in jeopardy............................... 5 6. Access, availability, and affordability of medicines are bumpy roads that limit UHC and can lead people to financial hardship and poverty............................................................. 7 7. One Health Approach as an instrument of global health and coordination, but widely overlooked worldwide....................................................................................................................... 8 8. Antimicrobial resistance: time is running out to solve a deadly problem.......................... 9 9. Vaccination coverages worldwide are at their low. Let us bring them back to COVID- 19 pre-pandemic levels as preventable diseases by immunization outbreaks risks are more real than ever.................................................................................................................................... 10 10. HIV, tuberculosis, and malaria: an unforeseeable crisis under the perils of the unintended effects of COVID-19.................................................................................................... 10 11. The Supply chain disruption is a crisis that costs lives, money, drives inflation, and jeopardize the progress of the health services............................................................................. 12 12. Technology and digital health: unequal digital health within and between countries in the era of the digital transformation technopole.................................................................... 12 13. Information systems for Health (IS4H) are far from providing evidence-based to support health monitoring and policy- and decision-making.................................................... 14 14. Noncommunicable diseases (NCDs) in the era of COVID-19 and beyond are in a bleak and complex landscape...................................................................................................... 15 15. Migrants' health within the scope of “disease knows no border.”................................ 17 16. Mental Health within the scope of global health: a neglected problem on everyone’s lips................................................................................................................................... 17 17. Epidemic preparedness and response under the framework of "disease knows no borders".............................................................................................................................................. 18 18. Nutrition...Malnutrition, a challenge of global health without an endpoint................ 20 19. COVID-19: a time to end the “me first” approach: a time for more coordination and solidarity............................................................................................................................................. 21 20. Synthetic data in the health artificial intelligence revolution......................................... 22 Part II: Making a case for each of the Global Health Challenges 1. Reimagining Global health for a healthier world “Consider ourselves as coordinators among equals,” Dr. Tedros Adhanom Ghebreyesus, WHO Director-General,i commented while he was laying out the priorities for the next five years. If we agree with this statement, let us help strengthen WHO's role. In times of crisis, we need to reimagine global health. Reimagining global health calls for a transformation of its governance mechanism to better respond to current and future health events and threats. It also calls for recognizing the role of non-governmental organizations and the support of outsiders of the health sector. Reducing asymmetries of power and privilege among the main actors, including decolonization of global health, may create an environment that addresses issues of governance structures and processes aimed at a real change that considers diversity and inclusion.ii Rethink global health diplomacy within the framework of “health” as a right and public good. Global health diplomacy plays an essential role in building solid structures and partnerships to address global health challenges.iii Complete and implement the global health governance reform or transformation to strengthen the role of those who lead the process. All of us are accountable for the result. The answer to how much reform the leading players are willing to accept is more relevant now than ever. 2. Underfunded global health governance mechanisms It is hard to imagine that WHO, PAHO, other multilateral and bilateral organizations, and International NGOs can deliver without the appropriate financial, human, and technological resources. The G20 members and other global donors did not respond to the level expected to address the challenges of the COVID-19 global crisis to provide financial support to the multilateral organizations. According to the Official Development Assistance (ODA) statistics, in 2020, the development aid across all sectors grew by 3.5%, which corresponds to 0.06% of the USD 13.7 trillion of all national government fiscal measures implemented to address the pandemic.iv COVID-19 has unmasked the weaknesses of the sources of finance for global health. The Center for Global Development estimates that to cope with the most pressing needs, the world requires around USD 50 billion to respond to the COVID-19 pandemic and another USD 10 billion annually for sustained preparedness. These amounts do not include financial resources to bring the health system back to pre-pandemic levels.v 2 OECD countries borrowed USD 18 trillion in 2020, equal to 29% of their GDP, which is 60% more than 2019, and expected to grow if additional fiscal policies measures to contain the economic crisis are ineffectivevi vii. Some economists argue that excessive public debt levels are a barrier to economic and development growth. It may reduce investments in health, education, and global health because they will use the financial resources to pay the debt. vii Of the approximately USD 13.7 billion globally donated to support countries during the COVID-19 crisis in 2020, the International Monetary Fund (IMF) estimated that USD 11.8 billion (87%) went to high-income countries (with only 16% of the world’s total population)iv. Furthermore, In 2021, wealthy developed countries borrowed more than emerging economies, meaning they “can pay back more easily, and it is less risky to take loans than raising taxes,” so they boost their economies.” viii The United States, European Union, and the United Kingdom are the top three borrowers. viii This crisis calls for a bold action to support the highest-burden low- and middle-income countries with less restrictive conditional loans and low-interest rates. Furthermore, the debt crisis also coincides with the rise in interest rates, making the payment of loans more expensive. Moreover, this is one of the reasons many economists are recommending a moratorium on the IMF surcharges. viiibis Low- and middle-income countries' debt levels were a primary concern even before the COVID-19 pandemic, with a global average record at 84% of GDP in 2019, and by 2020, reached 97% of GDPix. The IMF reported that about 60% of low-income countries are in debt distress.x The World Bank has expressed growing concerns that these debt levels are unsustainable, meaning potentials “disorderly defaults.” ix If this happens, increasing funding for global health will be a significant challenge. In 2021, the IMF allocated USD 650 billion worth of Special Drawing Rights to low- and middle-income countries so they could respond to the COVID-19 health and economic crisis.xi However, only $ 21 billion went to low-income countries of the total amount. Because of this pressing situation, the IMF will funnel resources through the Poverty Reduction and Growth Trust to help countries restructure their debts burdens; however, it is unclear if there will be conditions or not These countries are forced to choose between many options: COVID-19 response and its collateral non-COVID-19 health problems, SDGs, education, nutrition, climate change, violence, governance, economic, and social instability, and yet they have to continue to pay their debt loans. The leading global lenders should consider the possibility of debt forgiveness, or at least debt relief, and a moratorium on increasing interest rates so that these countries can continue addressing the burden of diseases and saving lives. 3 3. Sustainable Development Goals (SDGs) in times of crisis SDGs are in the midst of a global health crisis, accompanied by an economic and social upheaval that hinders their progress. According to the OECD, the COVID-19 pandemic has produced a “scissor effect” of the SDG financing (increasing needs and declining resources). The estimated SDG financing gap is USD 2.5 trillion, plus a 1 trillion gap in COVID-19 emergency and responsexii to support developing countries. OECD estimates that developing countries face a shortfall of USD 1.7 trillion to keep the SDG on track. The impact of COVID-19 has resulted in the collapse of external private financing by USD 700 billion compared to 2019.xii As long as the global COVID-19 crisis lasts, the achievement of the SDGs will remain off track. Certainly, COVID-19 is one of the main drivers of the SDGs crisis; but, without an interdisciplinary and collaborative problem-solving effort, just as the United Nations has stated, “the progress of one goal depends on the simultaneous development in other goals.” To ensure that "no one is left behind," we must put in motion a global effort that involves the wealthy and the emerging and developing countries, multilateral and bilateral organizations, the private and public sector, and leading international donors in a coordinated effort to maximize the impact of the work. OECD proposes that shifting 1.1% of the total financial assets held by banks, institutional investors, or asset managers (equivalent to USD 4.2 trillion) would be enough to fill the SDG gap for sustainable development. xii. 4. Building back better health systems and services by supporting development within the scope of humanitarian aid Humanitarian aid alone saves lives, but humanitarian aid does not promote sustainability to strengthen health systems and services; development does. The idea of including the development approach within the scope of the humanitarian crisis is not to promote a radical transformation but to undertake the process through proposed incremental xiii improvements to: o Continue working on urgent needs, saving lives, and supporting the maintenance and strengthening of the operational capacity of the services and public health programs to prevent, mitigate, and control the adverse health events that have resulted from the crisis; o We must acknowledge that resources given for humanitarian aid can also support development, such as strengthening the operational capacity of the health services and laboratories, health information systems, and epidemiological surveillance; o As Levine et al. (endnote xiii) have stated, “Humanitarian programs have not addressed resilience holistically”; 4 o The strengthening of health systems and services resiliency needs to consider the following three elements: assets (e.g., infrastructure), access to services of quality, and skills of the workforce; xiii o We also need to understand that donors may not be inclined to provide resources for development issues; however, we must make the case to encourage them to look beyond the crisis, and not only from a mere humanitarian aid scope. Development helps foster more sustainable actions, reduce inequities and save more lives; o There is an imperative need to foster the health technology capacity of the health systems and services to improve 1) healthcare delivery to support the achievement of Universal Health Coverage, 2) health surveillance, 3) health systems and services management, 4) health education, and 5) clinical decision-making, 5) behavioral changes related to public-health priorities and long-term diseases management.xiv However, despite the COVID-19 pandemic, most middle- and low-income countries have severe limitations in accessing health technology, including information technology (IT) infrastructure, software, hardware, internet, staff technologically literate, and more. o One of the critical elements for health systems to function properly is the amount and quality of their workforce. xv However, several middle- and low-income countries face a shortage of health workers. Even when there is no shortage, most countries do not have an equitable distribution, so the services are not accessible. Another challenge is whether they have the needed competencies to provide quality public health and healthcare services at an appropriate and acceptable level. o Primary health care (PHC) in the COVID-19 era suffered substantial cuts in budget and staffing. Even before the COVID-19 pandemic, there was an uneven distribution of funds and human resources, which is even worse now. There was a redistribution of financial and human resources to secondary and tertiary levels, leaving PHC underfunded and understaffed. Therefore, funding agencies, multilateral agencies, and Ministries of Health and Economy must strengthen PHC in primary health care, where more than 80% of the health problems are addressed. Failure to enhance PHC will increase complications that will result in higher healthcare costs at the secondary and tertiary levels, with an unquantifiable social and economic cost. 5. Universal Health Coverage (UHC) in the COVID-19 era is in jeopardy The global community is struggling to keep up the pace towards UHC. For some people, UHC is at a stage of one step forward and two steps back due to the global economic and health crises that each country is experiencing. We must help bring back more robust and resilient health systems and services to continue moving towards the UHC to make the dream a reality. 5 During the kick-off of the campaign leading up to the 2023 high-level meeting on UHC,xvi participants agreed that international, multilateral, and global leadership collaborations could support effective health systems that can deliver affordable and quality health care, including the need for gender equality and investment in robust health systems. The main challenges identified were: o Leaders continue working to end the pandemic and the disruptions that it is causing to systems, societies, and economies, including strengthening the global health architecture and supporting all countries to invest in strengthening the foundations of their health systems, especially primary health care (Dr. Tedros Adhanom Ghebreyesus, Director-General, WHO) o Promote equitable, affordable, timely, and universal access to vaccines and medicines; Tackle the problem of underinvestment in healthcare infrastructures and services; and UHC must be highlighted as part of post- COVID-19 response strategies (Mr. Don Pramudwinai, Deputy Prime Minister and Minister of Foreign Affairs (Thailand) o Emphasize the need for partnership and collaboration to prepare for future pandemics and strengthen health systems through partnership. The post-COVID era needs to achieve a resilient UHC that contributes to global health security. Work through broader, multi-disciplinary partnerships not limited to the health sector alone (Mr. Toshimitsu Motegi, Minister of Foreign Affairs, Japan) o Focus on the interconnection between health security and UHC policies and interventions to make health systems fully resilient to health emergencies by investing in public health infrastructure and strengthening health security programs (Ms. Tamar Gabunia, First Deputy Minister of Internally Displaced Persons from the Occupied Territories, Labor, Health & Social Affairs, Georgia) o Even before the COVID-19 pandemic, we were not on track to achieve the UHC targets for 2030. We must foster national action and multilateral collaboration, so it is possible to accelerate a joint effort on UHC, climate change, and transforming food systems for COVID-19 recovery plans (Ms. Amina Mohammed, Deputy Secretary-General of the UN) o The intergovernmental role in promoting UHC and translating it into national policy, stating that “COVID-19 has demonstrated forcefully that health systems do not exist in a vacuum. Our global goals require political commitment, national implementation, and international coordination to ensure good health for all and global health security (Dr. Frank Anthony, Minister of Health, Cooperative Republic of Guyana.) o The question on how to translate the political vision of UHC into practical steps, calling for more ambitious and fast-paced implementation and highlighting “the need for national action and multilateral collaboration through the SDG Action Platform (Dr. Faisal Sultan, Special Assistant to Prime Minister, Ministry of National Health Services, Regulations and Coordination, Pakistan) 6 o Keep in mind the importance of primary health care as “a pillar of UHC, ensuring the continuum of care and the provision of essential health services in line with humanitarian principles (Mr. Alexey Tsoy, Minister of Healthcare, Republic of Kazakhstan) o Furthermore, we need to ensure more and better-aligned resources for health systems, based on a primary health care approach that reinforces health service delivery, essential public health functions, and emergency risk management, while considering the system as a whole (Ms. Gabriela Cuevas Barron, Co-chair of the UHC2030 Steering Committee) o For “high-quality essential health services to support better mental and physical health for everyone, everywhere, without fear of financial hardship, we need health systems with robust, integrated public health functions that combat all forms of malnutrition, deliver adequate water, sanitation, and hygiene services, and help prevent, detect and respond to local and global health threats (Ms. Wendy Morton, Minister for European Neighborhood and the Americas at the Foreign, Commonwealth and Development Office, United Kingdom) o The need to ensure UHC is universal and stating that “strong health systems need transparent and accountable governance, including communities and civil society in every step of the decision-making (Ms. Anamaria Bejar, Civil Society Engagement Mechanism, UHC2030 Member of the Advisory Group. 6. Access, availability, and affordability of medicines are bumpy roads that limit UHC and can lead people to financial hardship and poverty The United Nations Human Rights Office of the High Commissioner acknowledges that access to medicines is a fundamental component of the full realization of the right to health. xvibis Limited access to medicines increases disease complications, disabilities, and deaths. It is one of the main barriers to achieving UHC. Lack of access to medicines has been associated with the principles of equity, non-discrimination, transparency, and accountability. It is also linked to poverty. Intellectual property rights are one of the main barriers that prevent access to medicine at affordable costs. Patent protection somehow determines the prices of medicines, which without competition results in unaffordable costs, thus preventing access to life-saving medicines.xvii Since the creation of the World Trade Organization (WTO), medicine intellectual property rights have been at the forefront of the debate agreements, being the Trade-Related Aspect of Intellectual Property (TRIPS) one of the most important. xvii TRIPS establishes the standards for the protection and enforcement of intellectual property rights, with a minimum term of patent rights of 20 years, and confers a temporary or time-limited monopoly to allow the inventor/producer of the pharmaceutical product to 7 recover costs of investments in research and development and earn a profit in their production and sale. This process creates incentives for continually innovating and developing essential medicines. xvii However, WHO has stated that there is a need for other incentives and financial mechanisms that promote more equitable and affordable access to diagnostic tools, vaccines, and medicines; otherwise, they may severely affect the developing world. xvii Pharmaceutical Regulatory Agencies have granted patents to particular products even if the protection has expired because they made slight modifications or implemented trivial changes such as form or color. xvii There is an urgent need to make at least essential medicines affordable for the treatment of HIV, hepatitis C, malaria, diabetes, cancer, tuberculosis, cardiovascular diseases, vaccines like COVID-19, and others priority health conditions. The debate is ongoing for more flexibility to make medicines more accessible and affordable. In some instances, when there are “reasons for public interest or the need to correct anti-competitive practices justify it, the government may allow a third party to use the invention, without the patent’s holder consent, under a compulsory license.” xvii Various types of HIV drugs are an example of a compulsory license issued by Germany, Thailand, Brazil, and South Africa for instance. There are intellectual property rights involved in manufacturing the COVID-19 vaccines, which has limited the production of vaccines and timely access to these vaccines at an affordable cost. Some countries like India and South Africa, along with many more countries, are sponsoring a request to the WTO that intellectual property rights related to the coronavirus should not be enforced for humanitarian reasons. How this will play out remains to be seen.xviii 7. One Health Approach as an instrument of global health and coordination, but widely overlooked worldwide The “One Health Approach” provides an opportunity to undertake collaborative multisector, multidisciplinary, and transdisciplinary coordinated efforts to go beyond the pandemic scope. xixxx Although the “One Health Approach” promotes integrated, multisectoral, and holistic concepts (animal health-human health-environmental factors) and a transdisciplinary-integrated tactic for disease prevention and control.xxi, xxibis However, it is not easy to implement it without robust global health or national governance and stewardship that can lead the process. The approach facilitates the design and program implementation, policies, legislation, and research to achieve public health outcomes with a better chance of success. Some areas of work in which the “One Health Approach” is relevant are COVID-19, food safety, the control of zoonoses (e.g., flu and rabies), antibiotic resistance, and many other public health threats. 8 The approach supports collaborative work at the local, regional, national, and global levels to achieve optimal health. It helps recognize the interconnection between people, animals, plants, and their shared environment. COVID-19 reminded us that we could not ignore these interconnections between people, animals, plants, and the environment. Therefore, the “One Health Approach” is an option of many other possible strategies to address this or any other present and future global health crisis. 8. Antimicrobial resistance: time is running out to solve a deadly problem According to WHO, about 80% of antibiotics use is among healthy animals.xxii,xxiii The factors that accelerate the rate of antimicrobial resistance are: 1) overuse and misuse of antibiotics in animals and humans are contributing to the rising of antibiotic resistances, xxiii 2) agricultural use of antibiotics, 3) overconsumption of antibiotics in developing countries, 4) biological factors through mutations and bacterial evolution, 5) gaps in knowledge since statistics in health care settings and animal production are not systematically gathered worldwide.xxiv These factors subsequently contribute to taking lives because of the lack of antibiotics that no longer respond to treat infections. The United Nations (UN) estimates that currently, each year, there are more than 700,000 deaths, and by 2050, there will be 10 million antimicrobial resistance deaths if we do not find a solution to this problem. About 28.3 million people will be pushed into poverty because of antimicrobial resistance.xxv CDC estimated that in 2019, the cost of antibiotic resistance in the United States was USD 55 million per year, USD 20 billion for health care, and USD 35 billion for loss of productivityxxvi. Several studies have shown that the global GDP could decrease by 1% and in the developing countries will range between 5-7% by 2050. xxv Antimicrobial resistance is becoming a barrier to eliminating HIV, tuberculosis, and malaria. Multi-drug resistant tuberculosis is the cause of about 230,000 deaths each year, and the lack of efficient antibiotics contributes to more than 200,000 child and infant deaths. xxv Antimicrobial resistance heavily contributes to 1) increasing poverty due to high out-of-pocket expenditure by individuals, 2) slowing down progress towards the attainment of UHC, and 3) representing a threat to global security. The “One Health Approach” (Challenge 7) is a strategy that can help to address antimicrobial resistance as it establishes interconnections with people, animals, plants, and the shared environment. However, the main challenge requires the coordination of many sectors and stakeholders. Controlling antimicrobial resistance is complex and requires bold actions and innovations. CDC has proposed three measures to fight antimicrobial 9 resistance xxvi. 1) Prevent infections in the first place; 2) Improve antibiotic use to slow the development of resistance; and 3) Stop the spread of resistance when it does develop. We need collective action, political momentum, robust multisectoral collaboration, and partnerships with stakeholders worldwide to implement these actions. xxvi Without the appropriate partnership with NGOs, government agencies, researchers, providers, public health sector, pharmaceuticals, hospital administrators, policymakers, agriculture industry, health personnel, and patients, the control of antimicrobial resistance will be difficult. 9. Vaccination coverages worldwide are at their low. Let us bring them back to COVID-19 pre-pandemic levels as preventable diseases by immunization outbreaks risks are more real than ever According to WHO, global immunization coverage dropped from 86% in 2019 to 83% in 2020; 23 million children under age did not receive essential vaccines in 2020.xxvii COVID-19 reminded the world that vaccines save lives to create a healthier, safer, and more prosperous future. xxvii The WHO’s World Health Assembly has proposed to address this challenge over the next decade and save over 50 million lives through the implementation of the Immunization Agenda 2030: A Global Strategy to Leave No One Behind.xxviii The Strategy has three impact goals: o Reduce mortality and morbidity from vaccine-preventable diseases for everyone throughout the life course; o “Leave no one behind” by increasing equitable access and use of new and existing vaccines; and o Ensure good health and well-being for everyone by strengthening immunization within primary health care and contributing to universal health coverage and sustainable development. The main challenges to implementing the Immunization Agenda are 1) insufficient financial resources at the global level to support national immunization programs, 2) a disrupted distribution chain that is delaying shipments of vaccines and supplies; 3) underfunded immunization programs mainly in developing countries, and 4) a diminished operational capacity of the immunization programs to vaccinate the target populations. 10. HIV, tuberculosis, and malaria: an unforeseeable crisis under the perils of the unintended effects of COVID-19 HIV/AIDS, tuberculosis, and malaria kill more than 2 million people every year, mainly affecting the most disadvantaged, poor, lower-middle, and low- income countries.xxix In a joint statement, WHO and the Global Fund highlighted “inequities,” acknowledging them as “barriers to achieving global and national goals and targets in HIV, TB and malaria programs. However, the magnitude and extent 10 of underlying health inequalities have remained poorly documented and understood.”xxx The joint statement also points out that although “indicators have generally improved in the past decade, the poorest, least educated and rural subgroups tend to remain disadvantaged across most HIV, TB and malaria indicators.” xxx “Pandemics thrive on inequalities and exacerbate inequities: we have learned this with HIV, TB, and malaria, and we have seen it again with COVID-19,” said Peter Sands, Executive Director of the Global Fund. xxx The Global Fund Results Report 2021 highlights a devastating HIV, tuberculosis, and malaria panorama due to COVID-19:xxxi About HIV, in most countries, the UNAIDS target “90-90-90” by 2020 of testing and treatment was not attained. Compared to 2019, in 2020, the Global Fund estimated that there was: o an 8.8% increase in antiretroviral therapy despite COVID-19; o a decrease of 22% of people tested for HIV; and o a reduction of 11% of people reached with HIV prevention services. As for tuberculosis o A decrease of 18% of people treated for tuberculosis; o A reduction of 19% for people on treatment for drug resistance; o An increase of 13% of children in contact with tuberculosis patients received preventive therapy; o A decrease of 16% of HIV-positive/TB patients on antiretroviral therapy during the TB treatment; o COVID-19 suppressed tuberculosis as the world’s leading infectious disease killer; however, it remains the second leading infectious disease, with more than 1.4 million people dying of the disease in 2019 and possibly increasing to unforeseeable numbers in 2021; and o Because of the COVID-19 pandemic, it is unclear if the decrease in testing and prevention services in 2020 will lead to an increase in deaths and infections. As for malaria, the momentum was stalled by COVID, exacerbating the challenges and putting progress off track. o Mosquito nets distributed to protect families from malaria increased by 17%; o A decrease of 4.3% of people tested for malaria; o No changes in pregnant women receiving preventive therapy; and o A 29% increase of structures covered by indoor residual spraying. Addressing the uneven progress of HIV, tuberculosis, and malaria inequalities is a complex issue exacerbated by the COVID-19 pandemic. It requires strengthening people-centered primary health care, UHC, and social determinants of health with multisectoral actions. xxix 11 11. The Supply chain disruption is a crisis that costs lives, money, drives inflation, and jeopardize the progress of the health services It is hard to predict how long the supply chain distribution crisis will last. COVID-19 exacerbated the supply chain weaknesses that existed even before the COVID-19 pandemic. For some, it was the engine driver that unmasked a hidden crisis. China's zero-tolerance COVID-19 pandemic prevention measures promote the closing of ports and manufacturing facilities once the health authorities detect a COVID-19 case. China's zero-tolerancexxxii, among other problems, impacts supply chain distribution by reducing access to supplies of any kind. Subsequently, the costs of container shipments are ten times higher than they were at the pre-pandemic levels; xxxii thus, increasing the merchandises values. The shortage of container shipments has created a high demand and short availability. China’s zero-tolerance is one of the many factors that has contributed to inflation Experts are reporting that the transport of goods is not getting any better; on the contrary, the container shipping shortage (trucks and vessels) is going back to the levels they were last summer (2021).xxxiii It also creates delays in shipping supplies. The Economist predicts that there will not be any relief in the supply chain disruption until the second half of 2022. Compared to the pre-pandemic era, in the United States, there are about 4 million workers less moving containers from the manufacturing facilities to the ports and from the docks to the end consumers. xxx Workers’ wages have increased by three folds, and yet, it is difficult to find people who want to drive trucks or work in the ports. Increases in gasoline prices have become another factor in the rise of the cost of the supply chain distribution. From the point of view of health, the supply chain disruption is creating an increase of procurement and healthcare costs and possibly costing lives, increasing complications and disabilities of health problems that are not timely cared for. 12. Technology and digital health: unequal digital health within and between countries in the era of the digital transformation technopole COVID-19 has created disruptions with the health care system, which made an unbalanced delivery of health services and interruptions in implementing public health programs. This unbalanced has put pressure to accelerate the digital transformation worldwide. xxxiv The COVID-19 pandemic has shown that it can create an ecosystem that enables digital health. However, COVID-19 taught us that we must overcome inequities as there is an uneven distribution related to access, affordability, and digital literacy; xxxv 12 The rapid transition to digital health during the COVID-19 pandemic has also brought problems like a poor understanding of the digital health risks under the concept of health systems thinking, which will help develop an agile digital health eco-system in the post-pandemic era. xxxvi Besides, the interoperability of the digital health systems is a very complex problem to address at the global and country-level. Furthermore, the legal and quality issues discussions are still in their early stages. xxxvi Harmonization of international and national strategies for regulating, evaluating, and using digital technologies is still far behind around the world; xxxvi The developing world is struggling to acquire and maintain the information technology (IT) infrastructure needed to make digital health a strong arm of health systems and services delivery. The digital transformation has brought challenges related to: o Ethical issues related to data privacy and ownership. They are an essential concern as it is not clear the role that consumer tech companies play (Amazon, Google, Apple, Facebook, or Samsung) while they collect, store, and analyze health data;xxxvii o The need for increased connected health solutions that enable connectivity and timely sharing of information creates concerns among the providers and consumers; o Although digital technology has played an essential role in response to COVID-19, the main concern is that connectivity will produce some safety and security issues. xxxv Not everyone has the protective system's antivirus and firewall in place. Most consumers in the developing world may not have the connectivity required to take advantage of the digital technology with the appropriate broadband width. Likewise, with the speed at which technology updates, it will be very difficult for providers and consumers to keep track of the changing environment. o The role of artificial intelligence (AI) raises security concerns as well. We expect that AI systems will meet high human standards; therefore, they should not make errors in theory. However, today, the algorithms developed for AI lack standards for verification and validations. xxxvi Moreover, national regulations are still weak. Perhaps, the most “advanced” law is the introduction of the European Union General Data Protection Regulation (GDPR). Nevertheless, it is far from reaching acceptable levels of AI technologies transparency and fairness. The world needs to improve education and literacy on information and communication technology (ICT) fundamentals. There is unequal access to the internet in schools and the general population, “a divide that exacerbated the pandemic.” xxxvii To grasp the opportunities from digital health technologies, we need to overcome the following obstacles: xxxvii o As there is a lack of high-level leadership and strategizing on ICT, we need firm commitments to create the environmental conditions for investments and infrastructure and human capital to meet the opportunities offered by the growing internet-using population; 13 o Leaders need to acknowledge that digitalization is a powerful tool that can support economic development, improve social inclusion, reduce poverty, and address health events and problems; o Many countries around the world have poor digital readiness. Therefore, it will be challenging to improve and foster digital readiness without investment in infrastructure, policies, human resources, developing and enforcing digital standards; o Emerging and developing countries need to ensure the availability of cybersecurity infrastructure and practices. It will require to 1) create a strong ICT sector with well-developed cybersecurity; 2) ensure that the development of infrastructure meets the demands of access to the internet and mobile services with the need broadband width and speed, and 3) establish a Cybersecurity Agency that can respond to the cyber threats; o Although there is an economic and pandemic crisis, governments cannot ignore the fact that without a solid digital transformation in all sectors, including health, countries will begin to lag behind the digital transformation of the health sector; therefore, it is imperative the allocation of more financial resources to overcome the challenges of the current times. Human resources with expertise must accompany the process; o It is not time for government budget cuts as they are not leading to digitalization; on the contrary, they can lead to poverty and socioeconomic and health development delays; o To develop and provide the infrastructure needed to enable digital health in each country, the global health organizations and the countries need to establish public/private partnerships; o Increase access to the internet with enough broadband width at an affordable cost, including easy access to WIFI and technological devices, and o Digital literacy will not be possible without access to WIFI and equipment that also responds to the needs of people with disabilities, with gender equality perspective, and accessibility to the most vulnerable populations. 13. Information systems for Health (IS4H) are far from providing evidence-based to support health monitoring and policy- and decision-making Without robust health information systems, poor data, and outdated data will be challenging to assess the health information systems and services capacity to attain UHC and SDG. It is essential to assess the level of maturity of the information systems to develop and implement targeted strategies for their strengthening. Health information systems do not collect all health and health-related data. For example, the Civil Registration Services gathered deaths and births data in most countries. Therefore, there is a need to integrate that specific data 14 into the health information systems. There is a need to make each specific system interoperable and inter-connectable to facilitate sharing information as needed. The Pan American Health Organization (PAHO) developed the concept of information systems for health (IS4H). IS4H focuses on favoring the required level of interoperability to process, analyze and use data from the various system for the benefit of a health-related system to support informed, evidence-based decision-making and policy-making.xxxviii Data collection and analysis need the support of IS4H to strengthen surveillance, timely identification of health threats, and implementation of strategies. IS4H is a strategy for health monitoring and policy- and decision- makers. The WHO 2020 global assessment of country data and health information systems capacityxxxix found: o Over 50% of countries have a moderate or better capacity of their health information systems to collect and analyze data; o Only 51% of the countries have data disaggregation in their health information systems; o Only 28% of the countries have less than10% ill-defined causes of death codes, which means that 72% need technical support to ensure that the data they collect is of quality; o Although 84% of the countries have central units to translate data and evidence to policy, the report found that their functionality is not very clear. For example, 64% of these countries have Data Observatories; however, they do not frequently update their data and portals; o Despite that 74% of the countries have monitoring and evaluation plans, the report found that they do not meet recommended standards, and o Alongside investments in data availability, timeliness, and quality, inequality analyses and reporting should be done at regional, country, and subnational levels. 14. Noncommunicable diseases (NCDs) in the era of COVID-19 and beyond are in a bleak and complex landscape If NCDs continue unattended and underfunded, their complications will lead to poor quality of life, disabilities, and, even worse, more deaths than expected. The WHO 2021 survey about the impact of the COVID-19 pandemic on NCDs resources and services revealed a bleak panorama. Most countries reallocated financial resources to purchase COVID-19 supplies and provide healthcare services, leaving the non-COVID-19 healthcare and public health programs underfunded. Although the WHO report data was collected in 2020, the results are still valid, and possibly the NCDs services were worse in 2021 than the previous year. The report highlighted the responses of 163 countries. It states that the disruptions of the health services affected people living with any of the main 15 four NCDs (cardiovascular disease, cancer, diabetes, and chronic pulmonary disease), which have made access to health services difficult.xl The main findings are: o Nearly 94% of the countries reported that all or some of the ministry of health staff responsible for NCDs and their risk factors were reallocated to support the COVID-19 response; o About 31% of the countries do not know if there was a reallocation of NCDs funds. Only 20% of the countries that reported the reallocation of NCDs funds mentioned that the NCD program suffered more than 50% financial loss; o About 66% of the countries reported that NCDs services were included in the list of essential health services in their national COVID-19 response plan. However, it seems that the focus of the plans was put on COVID-19 cases with NCDs, leaving those non-COVID-19 NCDs cases without the proper care; o About 77% of the countries reported disruptions in providing NCDs services, being the most affected screening, suspension of mass communication campaigns, training, and implementation of services in the primary health care; o Nearly 59% of the countries reported restrictions on access to essential NCDs services at the primary, secondary, and tertiary care levels, and o NCDs were usually not part of the national preparedness plan for COVID- 19. WHO recommends the inclusion of NCDs in the response plans of COVID-19 or any other epidemic, pandemic, or significant disaster will help to “build back better.” The WHO report findings highlighted the severity of the disruptions in implementing NCDs programs. The impact of unattended NCDs is hard to quantify, but for sure, the social and economic costs will be high. Nikoloski et al. xli summarize the disruptions as follows: o Fear of infection led to avoidance of using health services; o Delays in the diagnosis of more acute conditions; o Skipping screening appointments or their cancellation due to COVID-19, and o Lengthening of the waiting lists for diagnostic and therapeutic procedures. By the year 2050, most countries of the world will have reached the “population no replacement point,” meaning that there will be a large population over the age of 60 xlibis. As the world ages, the multimorbidity of NCDs among aging individuals is a central concern, particularly in the middle- and low-income countries with limited resources to address these diseases. xlibis1 Multiple NCDs conditions among the elders are essential factors for the poor quality of life and premature mortality. Research findings have found that NCDs are a leading driver of high mortality in any epidemic or pandemic, including COVID-19. xlii Despite there is knowledge about the adverse effects of NCDs on the population’s health, 16 when there are emergencies or epidemics, we tend to underestimate the NCDs impact on the quality of life and life expectancy. 15. Migrants' health within the scope of “disease knows no border.” According to UNHCR, in mid-2021, there were 281 million international migrants and 84 million forcibly displaced worldwide; of which 48 million were internally displaced, 26.6 million are refugees, 4.4 million asylum seekers, 3.9 are Venezuelans displaced abroad, and there are 35 million children below 18 years of age.xliii WHO has alerted that COVID-19 has posed additional challenges to migrants and refugees by increasing inequities in access and utilization of health services.xliv Migrants travel with their health problems across borders, as “disease knows no borders.” Therefore, while on the move, they also seek healthcare services. Furthermore, while they strive for healthcare, they have to overcome barriers that prevent them from accessing healthcare. The UN-OCHA COVID-19 risk index that includes vulnerability and response capacity found that the ten countries with the highest risk of COVID-19 also host 17.3 million internally displaced persons (IDP). Although there is a scarcity of health data about the health status of migrants and refugees, as per a United Nations Policy Brief on People on the Move, it is estimated that:xlv o The main health risks that these IDPs face are weak health systems and travel restrictions, which usually are accompanied by severe barriers that obstruct access to humanitarian assistance; o Most migrants and refugees live in unsanitary and crowded living conditions with limited access to essential services. Because of the living conditions, the risk for malnourishment, high infectious diseases rates, poor reproductive health access and maternal and child healthcare, poor compliances with medical treatment and access to medication, higher NCDs complications, and other health problems is extremely high; o Reduction in routine health services for refugees and displaced populations may result in 1.2 million-under-five deaths just in six months, being the most at risk the children on the move and in conflict-affected countries, and o About 50% of refugee and internally displaced populations live in 8 countries facing a food crisis (Turkey, Pakistan, Sudan, Lebanon, Bangladesh, Jordan, and Ethiopia.)xlvi 16. Mental Health within the scope of global health: a neglected problem on everyone’s lips As Mental Health is a neglected problem on everyone's lips, we need to implement the required actions under the scope of a global commitment and local effort. 17 Even though mental health is part of the SDGs, it is also true that people unattended of their mental health problems die prematurely, they experience human rights violations, discrimination, and stigma.xlvii According to the WHO 2020 global assessment of country data and health information systems capacity, less than 50% of the countries have data for mental health disorders. xxxix WHO estimates that mental health conditions have risen by 13% globally in the last ten years. Around 20% of children and adolescents have mental conditions that lead to suicide, and they are the second leading cause of death among people15-29 year-olds. Furthermore, one in five people living in post-conflict areas has unattended mental health conditions.xlviii The WHO Mental Health Atlas 2020 found that human and financial resources for implementing policies and plans are limited, and only 19% of the countries monitor the progress of their indicators: xlix o The global median allocation of financial resources to address mental health conditions is 2.1% of the total health expenditure of the governments, being worse in low- and middle-income countries; o The median number of mental health workers is13 per 100,000 population; however, in low-income countries is 2 per 100,000 inhabitants. For example, the median ratio for mental health workers in the United States is 1 per 30,000 and in crowded areas is 1 per 20,000, meaning a shortage of mental health workers globally;l o The Atlas also reports that only 52% of WHO Member States have programs for mental health prevention. Furthermore, only 28% of the WHO Member States have mental health and psychological support integrated into disaster preparedness and disaster risk reduction components, and o Few resources were allocated to address mental health issues during the COVID-19 pandemic. About the extent of the mental health problems due to COVID-19, some studies have reported:li o About 53.8% of the population in China reported moderate or severe psychological impact characterized by depression (31.3%), anxiety (36.4%), or stress (32.4%), and o As for health workers, 50.7% reported depressive symptoms, 44.7% anxiety, and 36.1% sleep disturbances. It is vital to address the current mental health problems and the potential protracted crisis effect of the mental health conditions of the population and health workers during the post-COVID-19 era. 17. Epidemic preparedness and response under the framework of "disease knows no borders" Recent epidemics/pandemics and outbreaks (e.g., Ebola or COVID-19) have exposed the need for more resilient health systems, multi-sector engagement, collaboration among neighboring countries to address 18 strategies that can support efforts for the prevention and control of disaster and epidemics.lii Epidemic preparedness and response is uneven worldwide. The main challenges to address the weaknesses are strengthening surveillance and response, building capacity for cross-sectoral and cross-border collaborations, and responding to emergencies. The “One Health Approach” is one of the suggested strategies that can support addressing the challenges (Challenge 7.) It promotes intersectoral collaborations among the various players. lii The WHO Independent Panel for Pandemic Preparedness and Response findings of the COVID-19 pandemic international health response liii were: o Pandemic preparedness was limited and disjointed, creating the conditions for the overwhelm of health services; o There is a need for a new approach to measuring the leadership dimensions of preparedness and response, including strengthening the accountability level of those in charge of the preparedness; o It seems that the International Health Regulations (2005) are a conservative instrument that constrains rather than facilitates rapid action; o In the case of COVID-19 and possibly for other events of international concern, the declaration of a public health emergency of global concern by the WHO Director-General was not followed by forceful and immediate responses in most countries; o Countries with poor results during the COVID-19 had uncoordinated approaches (e.g., devaluated science, denied the pandemic impact, delayed a comprehensive action, allowed distrust to undermine effort), weak capacity to mobilize and coordinate with all country levels and sectors; o Failure of leadership to take responsibility and develop strategies aimed at preventing transmission, and o The combination of poor strategic choices, unwillingness to tackle inequalities, and uncoordinated response allowed the pandemic to trigger a catastrophic human and socioeconomic crisis. High-income countries and multilateral agencies should support emerging and developing countries in strengthening the health system response capacity, including laboratory/diagnosis, epidemiological and genomic surveillance, and leadership capacities building not just for COVID-19 but for any other future disaster and epidemic/pandemic. The global community must carefully review the lessons learned for the COVID-19 pandemic to close the gaps that sometimes perpetuate uneven epidemic preparedness and response. The COVID-19 pandemic is an opportunity for walking the talk in this time of crisis. 19 18. Nutrition...Malnutrition, a challenge of global health without an endpoint The world is facing a double burden of malnutrition (undernutrition and obesity/overweight.) While undernutrition prevails in developing countries, mainly in lower-middle and low-income countries, overweight and obesity are more prevalent in wealthy countries. However, both malnutrition problems coexist and are drivers associated with NCDs. Nutrition has to be a high priority on achieving UHC; therefore, we cannot underestimate financing nutrition to improve the status of malnourished children and mothers.liv FAO in the State of Food Security and Nutrition in the World 2021reports that in 2020 between 720 and 811 million people faced hunger. lv This figure is staggering because it is also a significant contributing factor in perpetuating high prevalence rates of undernourishment. The FAO’s report found that between 1999 and 2020, undernourishment climbed from 8.4 to 9.9. It also predicted that about 660 million people may face hunger in 2030, partly due to the post-COVID-19 impact. FAO also estimates that one in three people did not have access to adequate food in 2020. Furthermore, 3 billion people do not have access to healthy diets. These staggering numbers are a crucial contributor to high undernourishment among children worldwide. In 2020 the World Food Program (WFP) estimated that about 17 million children under five years of age living in 55 countries suffered from acute malnourishment. These estimations will be higher in 2021as the COVID-19 pandemic is a primary driver of economic and social crises worldwide. xlvi According to a discussion paper prepared by the World Bank Group and the Global Financing Facilitylvi, “primary health care, as part of the UHC, is essential for delivering high-impact, cost-effective, nutrition-specific interventions at scale.” The implementation of the actions should consider the life-course approach. It plays a vital role in reducing and preventing permanent physical and cognitive impairments that result from poor nutrition in children. However, it is essential to mention that there is limited research about strengthening nutrition as part of UHC. xii The main findings of the 2020 Global Nutrition Report lvii are: o The 2025 global nutrition targets are off track. Only eight countries will achieve the targets of the total 194 countries; o About 48 low-income countries spend on nutrition deficiencies USD 1.87 per person, and o The report found substantial inequities between the urban-rural divide in any country. In children under 5-years of age, wasting is nine times higher, stunting four times higher, overweight, and obesity three times higher. These three problems may have a severe lifetime impact on the children’s development and subsequently a poor quality of life during adulthood. 20 We must end malnutrition before those children reach the point of no return and death. We must create a momentum that cannot lose the speed; otherwise, more lives will be lost. 19. COVID-19: a time to end the “me first” approach: a time for more coordination and solidarity COVID-19 remains one of the most pressing challenges globally. The intensity of COVID-19 cases is concentrated in South America and Europe, followed by North America. lviii President Biden’s administration has requested additional funding from Congress to increase the global COVID-19 vaccines supply. The additional resources will be part of a Global Vaccines Access Initiative, or Global VAX, with an initial fund of USD 400 million led by USAID. lviiibis, lviiibis1 It is not clear if Global VAX will work independently or if it will coordinate efforts with COVAX and other multilateral agencies such as WHO, UNICEF, and PAHO. Global VAX will focus on increasing vaccination rates in low- and middle- income countries by shifting the process from vaccine supply to vaccine uptake, meaning that vaccines will get into the arms of the people. This initiative is an enormous change in the process. Global VAX does not intend to leave vaccines seated, waiting for the immunization program to put the shots in the arms of the people. Besides the possible allocation of funds from the U.S. Government, USAID will work with other donors and World Bank to mobilize resources. Global VAX will build its capacity and coordinate with the Centers for Disease Control and Prevention, Peace Corps, PEPFAR, and other U.S. experiences. lviiibis It seems that old age and NCD-related comorbidities towards COVID-19 mortality are two crucial determinants. lvii Therefore, they cannot be left unattended. The collateral COVID-19 damages have increased inequities in the healthcare and public health services, thus impacting life expectancy reduction. We must put in place the mechanism that will support the transition from the COVID-19 pandemic to the COVID-19 endemic by making available COVID- 19 vaccines, medications, and supplies available to everyone, with the support of a distribution chain and good vaccination programs at the country level. It is imperative to strengthen the implementation capacity of the vaccination programs. It is time that health services begin to provide healthcare services and implement public health programs at the same level before the start of the COVID-19 pandemic. It is time to develop strategies to support health services to transition from the COVID pandemic to recovery to bring back health services to the pre- pandemic level. 21 We need to identify and develop strategies to support countries in a health crisis in the COVID-19 era –fragile economies, political and governance challenges, food insecurity, and social distress) so the global community can provide additional support to help them cope with the social, economic, and political burden originated or exacerbated by COVID-19. 20. Synthetic data in the health artificial intelligence revolution Although synthetic health data is not a current pressing challenge for 2022, Synthetic data generation research has been around for more than 30 years. lix As AI progresses, synthetic health data generation will soon become a promising alternative for data generation. The main highlights and challenges of data generation are: o Synthetic health data aims to minimize the use of actual data by combining simulation, public population-level statistics, and domain expert knowledge bases; o Real data generation is expensive; thus, synthetic data generation may become a valuable tool; o Synthetic data can replace real data or be used as a proxy for faster research results as it can develop models faster than collecting real data; o To generate synthetic data, researchers will need to address three high- quality criteria: 1) Fidelity of individual sample levels; Fidelity of population levels; and Privacy disclosures, and o The main challenges of synthetic data are lix ▪ it requires capturing the relationships across the real diverse populations. ▪ To maintain confidentiality lix and privacy protection, including sensitive personal information, people's data cannot be disclosed in synthetic data. lx ▪ The developed algorithm may be biased based on historical data lx and human inferences and perspectives. ▪ Although in recent years, there have been increasing regulation and data privacy policies efforts (Europe GDPR and California’s Consumer Privacy Act.) lx Most of the world is far from meeting confidentiality and privacy standards. Therefore, there is a need for a global effort to address issues related to synthetic data generation before it is too late. ▪ Electronic systems need to implement higher technological standards for data protection from cyberattacks. ▪ Artificial intelligence learning takes place through self-learning and supervised learning processes. Both processes may have huge drawbacks in synthetic data generation. For example, synthetic data can rebalanced datasets reflecting a different reality that does not exist. lx ▪ According to Bertalan Meskó, Director of the Futuristic Institute, synthetic data is fake but based on real-life data.lxi However, if real-life data is of poor quality, there is a problem. 22 Endnotes i Jenny Lei Ravelo. Tedros, sole nominee for WHO chief, lays out priorities for next 5 years. Devex Global Health, 25 January 2022 ii Seye Abimbola, Sumegha Asthana, Christian Montebnegro, Renzo R. Guinto, Desmond Tanko Jumbam, et al. (2021) Addressing power asymmetries in global health: Imperatives in the wake of the COVID-19 pandemic. PloS Med 18(4):e1003604. https://doi.org/10.1371/jourbnal.pmed.1003604. iii Kerri-Ann Jones (2010). New Complexities and Approaches to Global Health Diplomacy: View from the U.S. Department of State. PloS Med 7(5): e1000276 https://doi.101371/jounal.1000276 iv Mark Miller, et al. Multilateral finance in the face of global crisis. Overseas Development Institute (ODI). 2021. v Amanda Glassman. Beyond Aid: Sources of Finance for Global Health Security. Center for Global Development, August 16, 2021. Available at: https://www.cgdev.org/blog/beyond-aid- sources-finance-global-health-security vi OECD 2021. Sovereign Borrowing Outlook for OECD Countries. Accessed on January 28,2022. Available at: https://www.oecd.org/daf/fin/public-debt/Sovereign-Borrowing-Outlook-in-OECD- Countries-2021.pdf vii Paul Hannon. Rich Countries Barrowed $18 Trillion in 2020.Few Seebn Worried About Them Paying It Off. The Wall Street Journal. February 25, 2021. viii Lucia Ventura. Countries with the most external debt 2021. Global Finance, October 14, 2021. viiibis Shabtai Gold. Should IMF be making money off of countries that are struggling to repay loans? Devex Invested. 04 February 2022. Available at: https://www.devex.com/news/should- imf-ditch-surcharges-some-economists-and-lawmakers-think-so- 102568?mkt_tok=Njg1LUtCTC03NjUAAAGCeQzxw5-jrNXdPhbJDERUonORXREG4tD67AVJ89PWn- 8SJnZROIhvTVZ1WhJhq8s7aSP8bPrdhCxXVtli1lCeWCgQqrQRPMGFS9E9K7MQH9iRNg&utm_conte nt=text&utm_source=nl_invested&utm_term=article ix Delia Cox. Opinion: Vulnerable countries need more development aid post-COVID-19. Devex Global Views, 29 September 2021. x Shabtai Gold. IMF warns of rising inflation and debt as it lowers global outlook. Devex Finance 25 January 2022. xi Shabtai Gold. IMF has allocated SDRs. Now, might they be redistributed. 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