1. Introduction to Global Health

2. Health: Definitions and Concepts
“Health”- is one of those terms which most people find it difficult to define.
Many definitions of health have been offered from time to time, among them are the following:
‘the condition of being sound in body, mind or spirit, especially freedom from physical disease or pain’ (Webster).
‘Soundness of body or mind; that condition in which its functions are duly and efficiently discharged’ (Oxford English Dictionary).
c. ‘ a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic and environmental’ (WHO 1957).
d. ‘a modus vivendi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world’ (Dubos 1968).
e. ‘ a state of equilibrium of body form and human function which results from its successful dynamic adjustment to forces tending to disturb it.
Examples include infectious diseases (SARS, TB, avian influenza, malaria,) non infectious diseases (diabetes mellitus, tobacco related diseases) and other health risks (global warming, conflict, nuclear power) etc.

3. Health: Definitions and Concepts
… It is not passive interplay between body substance and forces impinging upon it, but an active response of body forces working toward readjustment’ (Perkins).
WHO Definition:
WHO definition (1948)- is the widely accepted definition of health stating:-
‘ Health is a state of physical, mental and social well being and not merely the absence of disease or infirmity’.
Health- is central to the concept of quality of life
Health – involves individuals, state, and international responsibility.
Health and its maintenance is a major investment and
Health –is a world-wide social goal.
This new philosophy of health points to dimensions of health for promoting health and well-being
Examples include infectious diseases (SARS, TB, avian influenza, malaria,) non infectious diseases (diabetes mellitus, tobacco related diseases) and other health risks (global warming, conflict, nuclear power) etc.

4. Health: Definitions and Concepts….
Dimensions of Health
Physical
Easiest to understand- focuses on the notion of “perfect functioning” of the body.
Conceptualises health biologically as a state in which every cell and organ is functioning at optimum capacity with rest of the body-however the term optimum is not definable
Signs of physical health in an individual include- good complexion, clean skin, bright eyes, lustrous hair, firm flesh, not too fat (normal BMI), sweet breath etc
2. Mental
State of balance between an individual and the surrounding world, a state of harmony btwn oneself and others, a coexistence btwn the realities of the self and that of other pple and that environment
3. Others are Social, Spiritual, Emotional and Vocational
Examples include infectious diseases (SARS, TB, avian influenza, malaria,) non infectious diseases (diabetes mellitus, tobacco related diseases) and other health risks (global warming, conflict, nuclear power) etc.

5. Health: Definitions and Concepts- Historical Development of Global Health
Public Health: Developed as a discipline in the mid 19th century in UK, Europe and US. Concerned more with national issues.
Data and evidence to support action, focus on populations, social justice and equity, emphasis on preventions vs cure.
International Health: Developed during past decades, came to be more concerned with
the diseases (e.g. tropical diseases) and
conditions (war, natural disasters) of middle and low income countries.
Tended to denote a one way flow of ‘good ideas’.
Global Health: More recent in its origin and emphasises a greater scope of health problems and solutions
that transcend national boundaries
requiring greater inter-disciplinary approach

6. Health: Definitions and Concepts
What is global health?
Health problems, issues, and concerns that transcend national boundaries, which may be influenced by circumstances or experiences in other countries, and which are best addressed by cooperative actions and solutions (Institute Of Medicine, USA- 1997)
Discuss health problems, issues and possible solutions
Examples include infectious diseases (SARS, TB, avian influenza, malaria,) non infectious diseases (diabetes mellitus, tobacco related diseases) and other health risks (global warming, conflict, nuclear power) etc.

7. Global Health Issues
Refers to any health issue that concerns many countries or is affected by transnational determinants such as:
Social and economic status
Demographic dynamics
Climate change
Urbanisation
Malnutrition – under or over nutrition
Or solutions such as:
Polio eradication
Containment of avian influenza
Approaches to tobacco control
Targeted/high –risk strategy in disease in handling global health issues.

8. Disciplines involved in Global Health
Social sciences
Behavioural sciences
Law
Economics
History
Engineering
Biomedical sciences
Environmental sciences

9. Communicable Diseases and Risk Factors
Infectious diseases are communicable
But..
so are elements of western lifestyles:
Dietary changes
Lack of physical activity
Reliance on automobile transport
Smoking
Stress
Urbanisation

10. It’s the Real Thing

11. Key Concepts in Relation to Global Health
The determinants of health
The measurement of health status
The importance of culture to health
The global burden of disease
The key risk factors for various health problems
The organisation and function of health systems

12. 1. Determinants of Health
1.1 Biological deters
Genetic make up
Age
Gender
1.2 Behavioural deters
Lifestyle choices
Community influences
1.3 Socio-eco deters
Income/economic status
Education
Occupation/work conditions
Geographical location
Culture, religious
1.4 Environmental deters
Other deters
Access to health services
Health professionals
Health systems and technology
Source: Dahlgren G. and Whitehead M. 1991

13. Determinants of Health
PLUS MORE GENERAL FACTORS SUCH AS:
POLITICAL STABILITY
CIVIL RIGHTS
ENVIRONMENTAL DEGRADATION
POPULATION GROWTH/PRESSURE
URBANISATION
DEVELOPMENT OF COUNTRY OF RESIDENCE

14. Multi-sectoral Dimension of the Determinants of Health
Malnutrition –
more susceptible to disease and less likely to recover
Cooking with wood and charcoal –
lung diseases
Poor sanitation –
more intestinal infections
Poor life circumstances –
commercial sex work and STIs, HIV/AIDS
Advertising tobacco and alcohol –
addiction and related diseases
Antimicrobial resistance and residues
Building resistance against bacterial diseases
Rapid growth in vehicular traffic often with untrained drivers on unsafe roads-
road traffic accidents

15. 2. The Measurement of Health Status I
Cause of death
Obtained from death certification but limited because of incomplete coverage. Supplement with surveys and verbal autopsies
Cause of death as defnd in the ICD 10.
Life expectancy at birth
The average number of years a new-borns baby could expect to live if current trends in mortality were to continue for the rest of the new-born's life.
strongly affected by infant and child mortality
Maternal mortality rate
The number of women who die as a result of childbirth and pregnancy related complications per 100,000 live births in a given year
*The maternal mortality rate can be converted to a maternal mortality ratio (MMR⎯expressed as deaths per 100,000 live births) by dividing the maternal mortality rate by the general fertility rate (GFR) that prevailed during the same time period and multiplying the result by 100,000.

16. The Measurement of Health Status….
Infant mortality rate
The number of deaths in infants under 1 year per 1,000 live births for a given year
Neonatal mortality rate
The number of deaths among infants under 28 days in a given year per 1,000 live births in that year
Child mortality rate
The probability that a new-born will die before reaching the age of five years, expressed as a number per 1,000 live births
Disability-Adjusted Life Years (DALYs)
Express years of life lost to premature death and years lived with disability adjusted for the severity of the disability

17. The Measurement of Health Status….
Health care delivery indicators
Doctor/nurse – patient ratio
Patient – bed ratio
Population per health center
Utilization rates/ actual coverage
The proportion of people in need of a service who actually receive it in a given period, usually a year.
Affected by availability and accessibility of health services; and attitude of individuals towards ones health and the health care system.
e.g. fully immunization

18. 3. Culture and Health Culture: Traditional health systems
The predominating attitudes and behaviour that characterise the functioning of a group or organisation
Traditional health systems
Beliefs about health
e.g. epilepsy – a disorder of neuronal depolarisation vs a form of possession/bad omen sent by the ancestors
Psychoses – ancestral problems requiring the assistance of traditional healer/spiritualist
Influence of culture of health
Diversity, marginalisation and vulnerability due to race, gender and ethnicity

19. 4. The global burden of disease
Predicted changes in burden of disease from communicable to non-communicable between and 2030
Reductions in malaria, diarrhoeal diseases, TB and HIV/AIDS
Increase in cardiovascular deaths, COPD, road traffic accidents and diabetes mellitus
Ageing populations especially in high and middle income countries
Socioeconomic growth with increased car ownership
Based on a ‘business as usual’ assumption

20. Source: WHO statistics 2008

21. Trends in Global Deaths 2002-30
The upward trend in HIV/AIDS mortality and downward trend in RTIs and other infectious diseases will place HIV/AIDS as the top ranking cause of death from infectious diseases before 2020
Source: World Health Statistics 2007 21

22. Trends in Global Deaths What are some of the reasons showing an upward trend of HIV/AIDS related deaths?
The upward trend in HIV/AIDS mortality and downward trend in RTIs and other infectious diseases will place HIV/AIDS as the top ranking cause of death from infectious diseases before 2020 22

23. HEALTH PATTERNS COMMUNICABLE vs NON-COMMUNICABLE DISEASES DISEASES
GENETIC FACTORS
ENVIRONMENTAL FACTORS
LIFESTYLE FACTORS
COMMUNICABLE vs NON-COMMUNICABLE
DISEASES DISEASES

24. HEALTH PATTERNS IN RESOURCE POOR COUNTRIES
INFECTIOUS/COMMUNICABLE DISEASES PREVALENT:
VACCINE PREVENTABLE DISEASES, e.g. measles
ACUTE RESPIRATORY INFECTIONS (ARI)
DIARRHOEAL DISEASES (cholera)
MALARIA TB
HEPATITIS
HIV/AIDS
Plus:
MALNUTRITION RELATED CONDITIONS:
- CALORIE DEFICIENCIES
- MICRO-NUTRIENT DEFICIENCIES
TRAUMA/ACCIDENTS
Many of these diseases are treatable

25. HEALTH PATTERNS IN RESOURCE RICH COUNTRIES
NON-COMMUNICABLE DISEASES PREVALENT:
Causes of death (all ages):
40% Circulatory diseases, e.g. heart disease, strokes, etc.
25% Cancers
16% Respiratory diseases
5% Injuries and Poisonings
0.6% Infectious diseases
Premature mortality (<65):
25% Circulatory diseases
33% Cancers
16% Injuries (RTAs/Suicides) and Poisonings
1% Infectious diseases
Many of these deaths are related to lifestyle factors and are preventable

26. HEALTH PATTERNS IN RESOURCE RICH COUNTRIES
Lifestyle factors affecting physical and mental health:
Smoking – one third of cancer deaths related to smoking
Drinking
Healthy eating/nutrition
Physical activity
Substance abuse

27. The picture below shows a traditional “three-stone” kitchen in rural Africa. What are;
a) 3 risks to health
b) 4 diseases that can result from these risks

28. Discuss risks to health that are associated with regular consumption of the meal shown.

29. High Fertility/High Mortality

30. Declining Mortality/High Fertility

31. Reduced Fertility/Reduced Mortality

32. COMPARATIVE DATA (1) INFANT MORTALITY 45/1,000 100-190 RATE
Zambia Developing countries
INFANT MORTALITY 45/1,
RATE
UNDER 5 MORTALITY 75/1,
MATERNAL MORTALITY 398/100,
RATIO
LIFE EXPECTANCY
What are some of the some of the factors that have contributed to the above statistics?
IMR reduced from 73/1,000

33. 5. Key Risk Factors for Various Health Conditions
Tobacco use –
related to incremental in non-communicable diseases e.g. lung and heart diseases world wide
Poor sanitation and access to clean water-
related to high levels of diarrhoeal/water borne diseases
Low condom use –
HIV/AIDS, sexually transmitted infections
Malnutrition –
Under-nutrition (increased susceptibility to infectious diseases) and over-nutrition responsible for cardiovascular diseases, cancers, obesity etc.
Diarrhoea contributes to about 1·5 million child deaths and around 88% of deaths from diarrhoea

34. 6. The Organisation and Function of Health Systems
A health system
comprises all organizations, institutions and resources devoted to producing actions whose primary intent is to improve health (WHO)
Most national health systems consist:
public, private,
traditional and informal sectors:

35. KEY CHALLENGES TO HEALTH SERVICES
Increased burden of diseases associated with overcrowding, poor sanitation and hygiene
Diseases associated with air and water pollution
Lifestyle and stress related diseases, accidents/violence, substance abuse
Diseases of nutrition
Various administrative units with little coordination.
Districts and catchment not clear
Lack of grass root level structures
Inequitable distribution of health facilities
Multiple agencies/bodies providing health care
Lack of Standardization and standard treatment protocols
Lack of integrated HMIS and databases
Large segment of urban poor
In migration and floating populations
Diverse social and cultural backgrounds
Greater vulnerability of the migrating populations
Socio Demographic
Operational
Dual burden of diseases
Administrative
KEY CHALLENGES TO HEALTH SERVICES

36. Operational Challenges
Inequitable distribution of health facilities
To connect every household to health facilities is a big
challenge
Distance of first point of contact for any health need
Lack of a fully functional and well defined public outreach system
Lack of standards for
Provision of safe water and sanitation facilities
Housing and waste disposal systems
No public health bill for setting up and regulating these standards
Lack of understanding of recent demands of urban health care delivery and poor planning/implementation

37. Operational Challenges…….
Lack of infrastructure for setting up of primary health care facilities
Many slums are not having even a single primary health care facility in their vicinity
Multiple health care facilities/bodies but without coordination
Lack of community level organizations/slum level organizations and lack of adequate support to them

38. Challenges in Involving NGOs & Private Practitioners
Accountability
Sustainability
Supervision and monitoring systems
False reporting/over reporting
Co-operation and coordination among large number of service providers is challenging

39. Which is better? Vs

40. What makes private services inaccessible?
Paying more from patients to maintain competency
Vulnerable people cannot afford treatment in corporate hospitals - tend to seek treatment from quacks
Focused on curative services particularly on non-communicable diseases, Malignancies etc.
Preventive and promotive components are completely omitted

41. Operational Challenges
Lack of any campaigns to counsel people to bring about changes in health related behavior/attitudes
Absence of defined geographical / demographic population allocations.
Lack of integrated HMIS and databases
Limitations of NRHM in urban context - norms for urban primary health infrastructure are not part of the NRHM proposal
Lack of efficient mobile health teams/problems faced by them

42. Challenges faced by Mobile health teams
Security problems
Worn-out vehicles
Tired and stressed staff
Poor roads
Seasonal obstacles
Uncertainty about population movements
Erratic funding

43. Challenges of the health systems exist in terms of
Administrative issues
Policy issues
Operational issues
Involvement of non governmental service providers
Large size of the population
Discuss some of the possible solutions to the above challenges

44. Solutions to challenges faced by the health system
Ensure adequacy and reliability of health related data
For understanding the graveness of situation and for planning purposes
Need for inter-sectoral co-ordination
Sharing of successful experiences and best practice/lesson learnt models
Successful experiences from other countries can be adopted. These can be adopted with local adaptations to suit the need of the people and the current situation
Reducing the financial burden of health care through
Community health funds
Health insurance
Subsidized out patient care provision by private providers
Provision of Urban amenities to Rural Areas model to Strengthening public private partnerships
Strengthening public health care facilities
Strengthening public private partnerships

45. Conclusion on Introduction to Global Health
What strategies can reduce risks to health?
INTERVENTIONS
“Any health action - promotive, preventive, curative, or rehabilitative activity, where the primary intent is to improve health.”
Most risk- reducing strategies involve a component of behaviour change.
The population
Reduce risks in the population as a whole
The individual
Target individuals within
a particular population
Change health behaviours
of individuals through
personal interaction with a
health provider
Legislation, tax, financial incentives by government
Health promotion campaigns
Engineering solutions; e.g. safety belts in vehicles, provision of piped water

46. Global Health References
Skolnik R. Essentials of Global Health. Jones & Bartlett Publishers, Sudbury MA Chapter 1
Ed. Robert Beaglehole, Global Public Health: A new era. Chapter 1
Megan Landon Environment, Health and Sustainable Development
Bonder, B. Martin L. Miracle A. Culture in Clinical Care
Koplan J et al, Towards a common definition of global health The Lancet, Volume 373, Issue 9679, Pages