Global Health introduction

Definition of global health

• Collaborative trans-national research and action for promoting health for all
• Achieving health equity by study, research and practice

Cost effectiveness is a very important aspect of Global Health.

Career in Global Health

• National representative
• Netherlands course in Global Health and Tropical Medicine, 28 months

Determinants of health

Health

• WHO: a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity → practically impossible to achieve
• S. van der Geest: the proper functioning of the body
• M. Hubert: the ability to adept and self-manage

Determinants

• Determinant: a factor that decisively affects the nature or outcome of something

Models of determinants of health are:

• Lalonde framework: assumes no interaction between determinants of health
• Skolnik model: more complex model used in this course

Different determinants influence each other. Health care has a relatively low impact on health status. Social determinants of health are particularly important for the wellbeing of patients.

According to epidemiologists Wilkinson and Pickett, “equality” in itself is a determinant of health.

Long and healthy life is a precondition for development, which stimulates participation in the society. Generally, high income relates to a good health status. Therefore, economic development is a precondition for a long and healthy life.

However, the Blue Zone Project shows that there are additional factors such as social cohesion and lack of stress that stimulate a long and healthy life.

Health indicators

Indicators

Indicator: measure that tells something about the state or level of something. Health indicators are often ratios or rates with a numerator and a denominator.

• Ratio: compares two measures of the same dimension
• Rates: compares two measures of different types

Key Health Status indicators:

• Life expectancy at birth: the number of years a newborn baby would live if subjected to the present mortality risks prevailing for each age group in the population
• Child mortality: low income countries have a high child mortality under 5 years due to malnutrition
  • Categories: perinatal, neonatal, postneonatal, infant, under 5 years
  • Infant mortality rate: the number of deaths of infants under age 1 per 1000 live births in a given year
  • Neonatal mortality rate: the number of deaths to infants under 28 days in a given year per 1000 live births in that year
  • Under-5 mortality rate: the probability that a newborn baby will die before reaching age 5, expressed as a number per 1000 live births
• Maternal mortality ratio: the number of maternal deaths per 100.000 live births
• Maternal mortality rate: the number of maternal deaths per woman of reproductive age per time period
• DALY: disability adjusted live year, YLD + YLL
  • YLD: years of life lost due to disability → number of incident cases, average duration, how severe the disability is
  • YLL: years of life lost due to death → number of deaths and age of death
• HALE: healthy life expectancy, average number of years that a person can expect to live in full health by taking into account years lived in less than full health due to disease or injury

Describing a population:

• Number of inhabitants
• Age distribution/median age
  • Median age: 50% of the population is older than this age, 50% of the population is younger than this age
• Male/female distribution
• Population pyramid
• Growth rate: can be caused by a higher birth rate or by migration trends
• Total fertility rate: TFR, the average number of children that would be born to a woman over her lifetime if:
  • She were to experience the exact current age-specific fertility rates through her lifetime
  • She were to survive from birth through the end of her reproductive life
• Age dependency ratios: the total number of people 0-14 and >65 divided through the total number of people 15-65
  • Can be high due to a high child age or old age → Jordan and Nepal have a low old age dependency ratio, while Japan has a very high one
  • Globally there is a tendency of increasing old age dependency ratio
• Crude birth rate: number of births per 1.000 population during one year
• Crude death rate: number of deaths per 1.000 population during one year
• Standardized/adjusted birth/death rate: corrected for the age distribution

Social Determinants of Health

Social Determinants of Health: social factors that influence our health.

For example what we decide to eat, which may be based on income, which is influenced by social determinants such as unemployment, education or disability. Bad eating habits may cause heart disease.

Information may be collected via surveys, social service or the judge system. This information can be given to health researches to examine health-related issues. Because the information is very confidential, it is made anonymous before being handed to researches.

By influencing social determinants and going beyond the health care system, the health and wellbeing of the population can be improved.

DALY explained

Definition

DALY: Disability Adjusted Life Years, a standardized quantitative measure of the burden of disease.

DALY is a single tool to combine the negative effects of early death and morbidity, a universally recognized and respected method to comprehensively quantify disease burden for a specific disease. DALY is a common metric with the following characteristics:

• Allows direct comparison of the burden across diseases
• Sums burden across diseases
• Permits comparing treated and untreated diseases
• Compares different disease interventions

Score

DALY = mortality + morbidity

• Mortality: life expectancy – age of death → YLL (years of lost life)
• Morbidity: disability rate x disability adjustment → YLD (years lived with disease)
  • Disability rate: 0 = fully healthy, 1 = 100% disabled
  • Disability adjustment: for how many years the disability is present

Discounting

Discounting: DALY estimates are adjusted for timing → future events are treated as having less value from today’s perspective. This can significantly reduce the DALY.

Averting

Treatment can reduce both the mortality and morbidity of a disease. The amount of DALY’s reduced by treated is the “averted” amount of years. Programs try to avert DALYs.

QALY

QALY: quality adjusted life years. Considers the same values as DALY, but from another perspective → quantifies health instead of disease burden. Therefore, bigger QALY values are better while smaller DALY values are better.

RC Measuring health around the world

Facts

Demographic composition: for example whether a population is very old or young.

Methods to measure health status in a LMIC:

• Censuses
• National household surveys (verbal autopsies)
• Data from health facilities
  • Are often paper-based records in LMIC, instead of electronic
  • Often there is missing information, or wrongly categorized information

Data from LMIC in general is a very rough indication of the real situation.

DALYs are subjective, the YLD is determined by experts who discuss about this.

Demographic transition

Major terminologies of the transition framework:

• Demographic transition: shift from a high to low fertility and mortality
• Epidemiological transition: shift in population growth due to change of disease patterns, for instance from infectious diseases to non-communicable diseases
  • Characteristics
    • Sudden and stark increase in population growth rates
    • Due to medical innovation in disease or sickness therapy and treatment
    • Followed by a re-leveling of population growth, declines in fertility rates
    • Change in disease patterns
  • Historically there are 3 stages
    1. Age of pestilence and famine: started 10.000-1.000 years age
    2. Age of receding pandemics: started 200 years ago
    3. Age of chronic diseases: started 50 years ago

These transitions have 4/5 phases which all have an impact on health, and which can be displayed in a demographic transition model. Often these models are based on the fact that there is no immigration in a population.

Double burden of disease

Many LMIC suffer from both non-communicable diseases and infectious diseases. Some groups claim that there is a triple burden of disease in LMIC, adding injuries to the burden.

Development measured by HDI

The HDI is an index of development, not only of health. The HDI is developed by the World Bank and consists of several elements:

• Health: measured by life expectancy at birth
  • Morbidity is not taken into account
• Education: measured by the mean years of schooling and the expected years of schooling
• Living standards: measured by the gross national income per capita
  • Different countries can be compared by converting currencies into international dollars, correcting to what you can buy in a country and taking inflation into account

Atlas method

Atlas Method: corrects for exchange rates between different currencies

Purchasing Power Parity

Purchasing Power Parity: what you can actually buy with an international dollar. An international dollar has the same purchasing power over the GNI as a US dollar.

Trends

The HDI had a trend of increasing globally over time. The progress of the HDI since 1990 has not always been steady, but the general tendency is an increase in de HDI. Some countries suffered reversals due to conflicts, epidemics or economic crises.

Inequality between countries

A country can be very high in the non-corrected HDI, but low on the corrected HDI. The corrected HDI takes inequality into account. Countries with a low corrected HDI have very high rates of inequality in schooling, income and access to health.

GINI Index

GINI index: measures the extent to which the distribution of income or consumption expenditure among individuals or households within an economy deviates from a perfectly equal distribution. It ranges between 0-1. If the GINI-index is 0, there is complete perfect equality within the population. If the GINI-index approaches 1, there is a lot of inequality in different groups. A Lorenz curve plots the cumulative percentages of total income received against the cumulative number of recipients, starting with the poorest individual or household. The GINI-index measures the area between the Lorenz curve and a hypothetical line of absolute equality.

Gender Inequality Adjusted HDI

GII: an index for measurement of gender disparity.

SDI

SDI: Social Demographic Index, an index to measure the overall development and wellbeing without taking health into account. It takes the following factors into account:

• Average income
• Fertility
• Education

Global Income Distribution

Gapminder: the size of the bubble indicates the size of the population

Hans Rosling: the founder of Gapminder. He divided the world into 4 income levels:

• Level 1: <$2 a day
• Level 2: $2-$8 a day
• Level 3: $8-$32 a day
• Level 4: >$32 a day

When put in a graph, this displays the Global Income Distribution.

Global child mortality

The under-5 child mortality (U5M) is a very important indicator to look at global health. The trend of under-5 child mortality is very good. However, this trend is not equally distributed among the countries. Countries in Eastern and South-Eastern Asia have made the most progress, with an 80% decline in under-5 deaths. Sub-Saharan Africa is worse off → these countries are also called the bottom 20%.

Building blocks of a health system

A health system has 6 building blocks:

• Leadership/governance
• Health care financing
• Health workforce
• Medical products and technologies
• Information and research
• Service delivery

Goals and outcomes of these building blocks are:

• Improved health
• Responsiveness
• Financial risk protection
• Improved efficiency

Insufficient numbers of health care workers

Factors responsible for the insufficient numbers of health care workers in LMIC:

• Shortness of HCW and a limited number of training facilities
• Unequal distribution of HCW within countries
• Migration of HCW to high-income countries → “brain drain”
• Migration of HCW to better paying private sectors or NGO’s

Development

Definition

Development: the desired change from a life with many sufferings and few choices to a life with satisfied basic needs and many choices, made available through the sustainable use of natural resources.

Sustainable development goals

Sustainable development goals are 17 goals to transform the world. The UN aims to have achieved the sustainable development goals by 2030. Multiple countries have signed and are committed. Each goal has a different number of targets, which each have several indicators.

GNI

Gross national income: total domestic and foreign value added claimed by residents (GDP) + net receipts of primary income from nonresident sources.

The World Bank has categorized countries into low, middle and high income countries based on the GNI. Middle income countries can be split into low middle and high middle income.

RC Financing health in LMIC

Dutch health system

The Dutch health system:

• Is based on accessible, affordable, good quality care. Like the definition of UHC of WHO
• It developed as a private health system and introduced public health insurance during WWII → ziekenfonds
• It was reformed in 2006 towards private insurance with market incentives of patient choice and competition for contracts
• The government applies strict regulation and pays for long-term care, mental health, preventive care and epidemics such as COVID
• Virtually all health insurance companies are not-for-profit cooperatives and profits are added to the reserves to lower the premiums
  • There are 23 insurers, which bear risks for their operations and compete for clients

Dutch insurance system

The Dutch insurance system is a mix of public and private → the government sets the public requirements, which guarantee the social nature of private insurance:

• Individuals must purchase mandatory basic health insurance of around 1400 euros per year, are free to choose their own insurer and the own annual risk is 385 euros
  • This allows the government to mandate that the health insurance must accept all people under the policy
• Health insurers are required to accept persons under their policy, irrespective of age or state of health
• Premiums for a policy offered are equal for all policyholders, regardless of their health condition, age or background
• Health insurers have a duty of care of the basic package, but excluded are dental care, very expensive treatments of rare diseases and alternative medicine
• One can pay higher premiums to insure a larger package

The Dutch health system compared to LMIC

• Dutch
  • 80% private premium + 20% user fees = around 2000 euros per year
  • Overall financing is 77 billion per year → 5500 euros/person/year and 13% of the GDP
    • This average is above the UK (11%) and below the USA (18%)
• LMIC
  • Insurance is marginal and user fees are very high (30-80% of total health expenditures)
  • Overall financing is between 2% and 8% of the GDP

In short, Dutch inhabitants are well-protected against disease and costs. 24.000 people (0,2%) are not insured by choice or social cases, but hospitals do not refuse them. In LMIC most inhabitants are uninsured. In the USA 13% of the population is uninsured.

Micro and health economics

Economy of scale and scope

• Economy of scale: cost advantages are reaped by companies when production becomes efficient. Companies can achieve economies of scale by increasing production and lowering costs. This happens because costs are spread over a larger number of goods. Costs can be both fixed and variable. An institution benefits from the increase in volume of a single product
• Economy of scope: the production of one good reduces the cost of producing another related good. An economy of scope results in a decrease in the average cost of production.

Performance based financing

PBF is a health reform strategy. A health reform strategy can only be successful if fundamental economic laws are firmly applied.

Basis economic distribution systems

The 2 basic economic distribution systems are:

• The free market system: a form of economic organization in which resource allocation decisions are left to producers and consumers acting in their own best interest with a minimum of central government intervention
• The central planning economy: central decision makers tell people how to produce, what to produce and what to consume

In central planning, decisions on all production and pricing issues represent a gigantic task, means treating a phenomenal quantity of data in complex operations. This may in fact be impossible. Most countries now are in some form of a market economy.

Ideal system

The conditions for perfect competition (the ideal system) are:

• Numerous sellers and customers: rules out collusive arrangements whereby firms work together to fix prices
  • The government must stimulate the suppliers to be competitive and assure that there are no public or private monopolies or cartels → setting up one distribution system or only government health facilities is economically inefficient
    • A monopoly would be the worst possible situation
• Homogeneity of the product: the product is identical to that supplied by any firm and consumers do not care from which firm they buy
  • E.g. the prize for a pizza from a street corner or a seaside restaurant is different, but the product may be the same
  • The same counts for an OPD consultation from a nurse with limited diagnostic equipment or in an advanced clinic run by a doctor, yet in many countries, governments set the same price
• Freedom to enter or leave the market: new firms should be allowed to compete with existing firms → “creative destruction”, which stimulates new ideas or shifts in market opportunities
  • Example of COVID: should the government always invest to protect firms, or would the firm also survive under normal circumstances?
• Perfect information among suppliers and consumers: the government should promote information about:
  • Disease, prevention through government-approved google sites
  • Information about the quality of health facilities
  • Where to open new health facilities by engaging with potential new providers

Scarcity or shortages

If nobody influences consumers or providers, the price will always settle at the equilibrium. If the government intervenes, the price will become either too high or too low. If the price becomes too low, the quantity supplied will become inferior to the quantity demanded.

A price below the equilibrium by a price ceiling typically produces:

• The persistent shortage of the concerned services
• The emergence of illegal and black-market activities
• The reduction of the quality of the services provided

Market failures

Market failures arise when there is case of:

• Positive externalities: service which does not only benefit that person alone, but benefits a third party → external benefit
  • These services should be subsidized by the government
• Negative externalities: service which has costs for a third party → external cost
  • For instance smoking → causes passive smoking
  • These services should be taxed by the government
• Public good characteristics: a service from which everybody benefits, but nobody pays
• Moral hazard: the tendency of overconsumption and overproduction when the person using the services is not the one who pays
  • E.g. a patient who knows he or she is insured, and because of that excessively uses a service
  • Both patient and provider can have a moral hazard
• Asymmetry of information: when one party in a transaction is in possession of more information than the other
  • When the provider actively stimulates demand in a patient

The problem with the health market is that there are relatively many market failures that need to be corrected. Yet, a general market should be there.

Solutions

Market solutions for moral hazard are:

• Patient moral hazard: corrected by co-payments and deductibles
  • Co-payments: a fixed amount or proportion of the total bill paid by the insured
  • Deductibles: own risk
• Provider moral hazard: countered through quality reviews by supervisors or peer group reviews in health facilities

Solutions for asymmetric information are:

• Inform patients about this risk and where to find as much information as possible
• Analyze patient records through peer reviews
• Punish providers in case of abuse

The state can do various things to regulate the market:

• Stimulating the proper functioning of the market and competition
• Fighting against monopolies and cartel formation of companies that seek noncompetitive power
• Financing the production of public goods such as the military, police and justice
• Preventing supplier induced demand
• Reducing inequalities by redistributing resources

Scarcity

Opportunity costs

Public resources required to meet unlimited human needs are rare. Therefore we must make choices among a range of possibilities. By choosing or purchasing one set or products, we automatically reject another set of products. This is called the opportunity costs.

Universal Health Coverage

Definition: UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

UHC is one of the Sustainable Development Goals and is based on the idea that health is a fundamental right. Yet, what does this right entail because resources are scarce? It requires each society to determine the minimum health packages at primary and hospital levels, to which citizens have access.

WHO model

UHC is often explained with this model, which shows the who, what, quality and cost aspect:

• Who is covered?
• Quality of services: which services are covered?
• Direct costs: proportion of costs covered

The criticism on this model is that it does not emphasize efficiency gains. One should also look at the efficiency of the system provided.

Non-solidarity-based health financing

Examples of non-solidarity-based health financing are:

• Fully private voluntary insurance
• Individual medical saving accounts
• Out-of-pocket payments
• Informal payments

In LMIC there is not enough public money to support tax-based free health care or obligatory insurance systems, and the above modalities remain necessary to finance quality care.

Free health care based on tax-based revenues

Free health care based on tax-based revenues evolved in the Soviet Union and Great Britain after WWII and was adopted in the PHC system of Alma ATA 1978 and chosen by several countries, including in Africa.

In Africa, theoretically, revenues came from taxes, but in practice often from donors. It resulted in inefficient health systems. Countries such as Cameroon and Nigeria only marginally benefitted from aid agencies, but also did not put into place a robust tax system and efficient public financing. It resulted in deteriorated health systems. In general, these systems have a bad reputation.

Compulsory health insurance

In compulsory health insurance, employers and employees both pay a premium. Health insurance companies negotiate reimbursements with providers for a package of health services on behalf of the insured. Compulsory health insurance is common in continental Europe since many years, and recently tested in Rwanda. Well-designed systems have co-payments and deductibles to prevent moral hazard.

Advantages of compulsory health insurance are:

• Prevents adverse selection by the patient and cream skimming by the insurance company
• When coverage is high, the administrative costs reduce
• Companies are not permitted to refuse patients and patients must be insured

Disadvantages of compulsory health insurance are that it must work perfectly, because when public payments are not regular, the system collapses:

• Governments must heavily subsidize compulsory insurance so that the premium payments remain accessible for patients
• Governments may pay for the chronically ill or for the hospital services and the poor

Voluntary community-based health insurance with premium payments

Advantages of voluntary community-based health insurance with premium payments (CBHI) are that they create a positive risk sharing effect for the insured.

Potential problems of voluntary community-based health insurance with premium payments are:

• The adherence rate rarely exceeds 30%
• CBHI systems tend to have high administrative costs due to low coverage rates
• Difficult to grasp the informal sector
• When the government invests, the system is regressive because the wealthy adhere more than the very poor

In summary, the opportunity costs of CBHI are high compared to PBF and compulsory HI.

Direct user fee payments

Advantages of direct user fee payments are:

• User fee payments have the advantage of a market transaction → the patient selects the providers and when the patient is not satisfied chooses another

Problems with fee paying are:

• Direct payments have obvious equity problems, even leading to catastrophic expenditures
• If patients pay per act, they may suffer from supplier induced demand

The proportion of direct payment of a health facility should therefore preferably not exceed 40-60%.

Summary

In summary, the following can be said about provider payment mechanisms:

• Centrally arranged tax-based systems: to provide social security
• Compulsory health insurance: in which employers and employees/other subscribers pay to provide social security
• Voluntary pre-payment system: community based health insurance systems based on the voluntary contributions of the insured
• User fee payments: either per activity or with a flat fixed fee system, voucher systems or conditional cash transfers

Performance based financing evolves into a health system that integrates elements of the above financing modalities.

Performance-based financing

The current situation in most countries is that 70% of the budget is spent at the central level, while 15% is spent at the peripheral level. PBF aims to re-invert the financial pyramid to make it point upwards.

In PBF, instead of buying inputs at the central level and giving it to the provider (the PUSH system), the government and partners pay for the performance (the PULL system). Thus, public money will be paid for a result already achieved.

Eleven fundamental best practices in PBF are:

1. Separate the functions of regulation, health provision, contract development and verification, fund disbursement and community empowerment
2. Stimulate competition for contracts
3. Promote public-private partnerships
4. Regulator defines the output, quality and equity indicators, costs out public budget with equity bonuses
5. Facilities are autonomous and respond to government defined health packages and patient demand
6. Facilities must assure that revenues and expenditures are balanced
7. CDV agencies negotiate contracts, verify and coach Health Facility managers to use management instruments
8. Local community groups enhance patient interests
9. Pay cash for results, no inputs in kind and facilities have free choice to purchase inputs from independent distributors operating in competition
10. Seek economic multiplier effects by deliberately injecting cash into the local economy to generate employment, economic growth and tax revenues
11. Extend PBF towards other sectors

Equity

Targeting women and children is equality. Targeting the vulnerable is equity → some need more resources than others. Equity instruments in PBF are:

• Robust subsidies for public goods and positive externalities interventions
• Small subsidies for curative health services automatically reduce user fee tariffs because PBF provides a price signal to the suppliers
• Regional, provincial or district bonuses of 10-40% on top of the basic subsidies correct differences between poor and rich areas
• Health facility specific bonuses of 10-40% on top of basic subsidies correcting differences between health facilities
• Individual equity payments for curative indicators to exempt the vulnerable up till 10-20% of all patients
• Increased equity payment for all curative indicators in case of emergencies to exempt the affected up till 50-100% of the population
• Local initiatives through extended family, churches and benevolence

RC Health and migration

Youth health care

• Preventive branch
• Healthy population
• Prevention or early detection of disease or problems
• Proactive
• Individual care of the child, family or environment
  • Development
  • Environment
  • Upbringing
• Collective care for all children or a specific group

Asylumprocedure

• Vluchteling/refugee: iemand die uit noodzaak zijn land verlaat
• Asielzoeker: iemand die veiligheid/opvang zoekt in een ander land om daar te mogen blijven

1951 Genève Convention:

Establishes when someone is a refugee. There are various reasons to be a refugee:

• Race
• Religion
• Nationality
• Political opinion
• Membership in a particular social group
• War

Numbers:

• Refugees globally: 80 million
• Asylumseekers per year in Europe: 500.000
• Asylumseekers per year in the Netherlands: 20.000-25.000
• Children: 4.000
• Unaccompanied children: 1.000
• Receive a permit: 30%

Countries of origin:

1. Syria (40%)
2. Turkey
3. Eritrea
4. Afghanistan
5. Unknown
6. Jemen

Asylumprocedure:

1. Central reception center/centrale ontvangslocatie (COL)
   • Registration and TBC check
   • First hearing
2. Process receptor center/proces opvanglocatie (POL)
   • Rest/preparation time
   • Start of the general asylumprocedure
3. Asylum center/asielzoekercentrum (AZC)
   • Extended asylumprocedure for 6-12 months
   • Permit and waiting for municipal housing
4. When being refused a permit:
   • Freedomrestrictor location/vrijheidsbeperkende locatie (VBL)
     • The refugee has to return to his home country within 12 weeks
   • Familylocation/gezinslocatie opvang (GLO)
     • For families with minor children

AC Katwijk/Rijswijk

• AC Katwijk: familylocation for refugees with an exhausted procedure waiting for return
  • Daily report
  • Minimal allowance
  • Prohibited to pass municipal boundaries
  • Financial sanctions
  • Dutch repatriation and departure service
  • School <18 years
  • Right to stay until childer are >18 years
• AC Rijswijk: for refugees who have received a permit
  • Weekly report
  • Extra allowance
  • No restriction
  • Start integration
  • Dutch lessons
  • Work

Reasons for no return from familylocations:

• First procedure: 3 appeals
• New information or a new procedure
• Administration
• Dublin regulation
• Country of origin refusing forced returns
• Article 64 Vw: the Aliens Acts
  • Not being able to return due to medical reasons
• Children’s pardon

RC Non-communicable diseases

Global problem

Non-communicable diseases kill 41 million people annually → 71% of all deaths globally. The most common non-communicable diseases are:

• Cardiovascular diseases
• Cancers
• Respiratory diseases
• Diabetes

77% of NCD deaths occur in LMICs. 16 million people <70 years die prematurely due to NCDs, of which 85% occur in LMIC.

NCD risk factors

• Metabolic risk factors for NCDs are:
• Raised blood pressure
• Hyperlipidemia
• Hyperglycemia
• Obesity and overweight
• Air pollution
• Modifiable risk factors for NCDs are:
  • Physical inactivity,
  • Alcohol abuse
  • Tobacco
  • Unhealthy diet

Epidemiological transition

Epidemiological transition is the change in the balance of disease in a population from communicable/infectious diseases tot non-communicable diseases. In LMIC there is a co-occurrence of CDs and NCDs → double burden of disease.

Epidemiological transition is a continuous transformation process with some diseases disappearing and others re-emerging. Evident indicators of epidemiological transition are changes in morbidity and patterns of mortality. Epidemiological transition is linked to demographic changes and advance in managing infectious diseases.

Nutrition transition

Nutrition transistion: community and population shifts in dietary consumption and energy expenditure that coincides with economic, demographic and epidemiological changes.

Nutrition transition is typified by a reduction in fibre-rich foods and an increase in animal-source products, oils, sugar and energy-dense refined food. It is linked to globalization → diffuse food-markets and food distribution systems. Advances in technology and urbanization lead to a change in food culture.

Urbanization

Urbanization is the net population shift from rural to urban areas. Today 54% of the world’s population lives in urban areas. By 2050 the urban population is expected to rise to 62% in Africa, 65% in Asia and 90% in Latin America.

Major challenges with urbanization are:

• Overcrowding → infectious disease transmission
• Inadequate housing → slumization
• Unemployment → crime and insecurity
• Pressure and WASH amenities
  • On clean water and sewerage
• Environmental pollution

Link between urbanization and NCDs:

• Air pollution
  • The second leading cause of death from NCDs after tobacco-smoking
  • Main NCDs associated with air pollution include:
    • Ischemic heart disease
    • Stroke
    • COPD
    • Lung cancer
• Urban heat
• Noise exposure
  • Increases the risk of CVD

Socioeconomic impact of NCDs

NCDs threaten SDG Target 3.4: by 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being.

There is a vicious cycle between poverty and NCDs:

• NCDs affect the effectiveness of poverty reduction initiatives
• In low-resource settings, health-care costs for NCDs quickly drain household resources → “out-of-pocket expenditure”

Kenya

Kenya is a LMIC with a population of 48,5 million. 27% of the reported deaths are from NCDs. The risk of dying prematurely (30-70 years of age) from NCDs is 13%. Currently, there is a massive rural-urban migration in Kenya.

CVD

25% of adults in Kenya have hypertension, however only 20% of this group is aware of the condition. Only <6% of the group is actually under treatment of which <3% is under control.

There is a poor or no understanding on the how and mechanisms of developing CVD. The diagnosis is late and usually by chance, and treatment is insufficient.

Certain individuals have an increased risk of developing CVD:

• Stressed individuals
  • Young mothers without support of their spouses
  • Older women without support of husbands in providing for their families
  • Women who always have to worry about the whereabouts of their drinking husbands
• People who live a good life but rarely exert themselves
  • Are “affluent and lazy”
• Victims of family conflicts
  • Especially women forced out of their homes as a result

Causes of CVD in LMIC are:

• Poverty
  • Leads to stress
• Inheritance
• Family planning or hormonal contraceptives
• Bad/toxic food
• Environmental pollution
• Poison in illicit alcohol

Many LMIC inhabitants are not sure of certain harmful effects:

• Alcohol consumption
• Physical inactivity
• Rampant insecurity
  • E.g. not enough space to move/exercise in
• Perceptions of body weight
  • A fat/big body is “evidence of good life”
  • Overweight and obesity are a female problem, arising from gender roles and choice of diet

Urban populations are disproportionately affected by CVD compared to rural populations → large sections of urban populations live in slums, where access to health care is at best limited. Slum residents have the worst health outcomes of any group in Kenya.

Barriers to seeking care and treatment

In LMIC there are barriers to seeking care and treatment on various levels:

• Individual
  • Ignorance and lack of knowledge about risk factors
  • Despair, refusal to screen for CVD
  • Men resistant to change risky behavior
  • Dismissive young people
• Community
  • Lack of family and extended support
    • Often elderly and invalid
  • Stigma towards certain diseases
• Healthcare system
  • Cost of healthcare
  • No insurance coverage
  • Lack of optimum services at facilities
  • Poor quality of care
  • Poor attitude of health care providers

Interventions

Mitigation and interventions for NCDs in LMIC are:

• Interventions in urban poor settings to consider perceptions on and understanding of interrelationships among risk factors and account for cultural and contextual issues
• Programs informed by locally-generated evidence on awareness and opportunities for CVD care and effective risk communication
• Screening for and treatment of CVD must address perceptions and concerns such as on prohibitive cost of healthcare
• Address social determinants of disease and health implicated in addressing CVD in low-resource setting

A multi-sectoral approach, reorientation of policies and rejigging of health systems is necessary.

RC Ethical Aspects of clinical research in LMIC

Categories of human rights

• Civil + political rights → protects individuals
• Economic, social and cultural rights → progressive realization for people

With respect to human rights, global civil society recognizes an individual’s or a community’s entitlement to assert that right.

1946 WHO constitution

• The enjoyment of one of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief, economic or social condition

Every nation has at least one international human rights treaty that recognizes the right to help.

Health related entitlements

• Safe drinking water
• Sanitation
• Safe food
• Healthy environmental conditions
• Health related information
• Gender equality
• Available health services

Freedom

Human rights also provide freedom from:

• Non-consensual medical treatment
• Medical experiments or research
• Forced sterilization
• Torture and degrading forms of punishments

Exploitation

Exploitation: voluntary exchange of two things of unequal value where the exploited party accepts an unfair exchange as a result of some preexisting injustice or rights violation.

Ethical issues in global health

• Responsibility for the just allocation of health care
  • Legal
    • Human rights perspective: inalienable and universal
    • 1948 UN general Assembly
    • Everyone has the right to a standard of living adequate for the health of him and his family → the right to the highest attainable health
  • Social ethic: feasibility does not determine human rights
  • Economic: health is a necessity
  • Amartya Sen: capabilities approach → there are some capabilities we all have to strive for as a country
• Responsibility for ethical medical research
• Responsibility for just treatment of immigrants in the Netherlands

Classical and social rights

• Classical rights: protection of the individual
• Social rights: progressive realization for a group of people
  • E.g. health care or education rights
  • Much more difficult to realize than classical rights → how much effort should the government make to abide by this right?

A moral question about social versus classical rights: is there a moral responsibility for high income countries to support the health of people in LMICs?

John Rawls

John Rawls (1971) was a philosopher and legal scholar who developed the theory: “Veil of Ignorance”. Because we know our position, we can never really objectively think about this question. All people are biased by their situations, so how can people agree on a “social contract” to govern how the world should work? John Rawls suggests that we should imagine we sit behind a veil of ignorance that keeps us from knowing who we are and identifying with our personal circumstances. By being ignorant of our circumstances, we can more objectively consider how societies should operate.

This theory has been extensively used by other philosophers and governments and has been applied to health care. Rawls argues that people in the original position would agree to rules which maximize the minimum level of primary goods that they might find themselves with beyond the veil. People would thus aim to maximize the minimum amount/quality of health care they might receive.

Peter Singer

Peter Singer was a philosopher who developed the theory of effective altruism. Effective altruism has the following arguments:

• If we can prevent something bad without sacrificing anything of comparable moral significance, we ought to do it
• Extreme poverty is bad
• We can prevent some extreme poverty without sacrificing anything of comparable moral significance
• Conclusion: so we ought to prevent it

If the political reality is that the government is not likely to give more, the current level of official aid should not stop you giving what you can and should give.

Peter Singer didn’t necessarily look at the principle, but at the consequences of the principle → if a good principle has bad consequences, one should get rid of the principle. Singer was an extreme globalist → couldn’t think without involving the world. This theory is interesting because it gives mixed feelings.

Responsibility for ethical medical research in LMICs

The fundamental starting point for medical research within humans is: vulnerability of the participant. In this case, there is a history of excesses. An example is the experiments with prisoners in German concentration camps, leading to the Neurenberg Tribunal after WWII.

Other examples of why protection is needed for vulnerable populations are:

• 1898: Albert Neisser inoculation of sera of syphilis patients
• 1944-74: Fernald School in Waltham, Massachusetts → mentally retarded children were fed radioactive iron and calcium in their cereal
• 1950s-1960s: Willowbrook State School → study on the natural history of hepatitis by injection of mentally retarded children with strains of hepatitis virus

The experiments always were conducted on a vulnerable, convenient population. Sometimes detainees were researched, people with incurable illness or who otherwise would not be able to receive care. The researchers always tried to justify their research by saying there was informed consent, and that everyone eventually would get the disease anyways.

Declaration of Helsinki

After the Nazi-experiments, the first guidelines were put in the Neurenberg Code (1947). This was further developed in the Declaration of Helsinki, conducted by the World Medical Association in 1964. The core of the Declaration of Helsinki is:

• An emphasis on informed consent
• The health and wellbeing of the participant is the most important criterium
• Distinction between patients and health volunteers should be made
• Distinction between therapeutic and non-therapeutic research should be made
• In the first versions of the declaration it was the responsibility of the researcher

Due to the Declaration of Helsinki, experiments have to be based on voluntary participation and moral standards → national laws need to abide. In the Netherlands, the Declaration of Helsinki is part of the WGBO and WMO.

Development

During the years, the Declaration of Helsinki developed as follows:

• Researcher paternalism: 1940-1970
  • In the first versions of the Declaration of Helsinki, there was a lot of focus on the Nazi-experiments → it was more important not to do research than to do research
• Regulatory protectionism: 1970-1997
  • Protection by ethical review and informed consent
  • Protection of vulnerable populations
• Fairness principle: 2000-present
  • Research is also good
  • Protection can lead to injustice
  • Vulnerability is not a group characteristic per se
    • Researches started to look at vulnerability on an individual level → not at groups of children or pregnant women
      • The protection of groups has led to injustice

Ethics in LMIC

Dilemmas of health ethics in LMIC are where to put risks and burdens:

• Responsiveness to health needs
  • Research on medication that is much too expensive to be implemented in LMIC shouldn’t be done
• Post-trial access to proven therapy
  • Some proven therapy isn’t necessary or won’t even be implemented in LMIC
• Challenge of experiments that induce infections in healthy volunteers
  • This is more often done in Western countries than in LMIC → e.g. students in the Netherlands being infected with malaria
• Informed consent is culturally sensitive
  • Informed consent is a norm with a very European-American background
  • In LMIC, only a small proportion of the participants are able to correctly interpret and recall the concepts of randomization and placebos
  • Informed consent rises from certain values which we think are very important, but may be less important in LMIC
    • E.g. embarrassment or concerns about individual privacy are less important in Thai culture than sharing experiences with peers when making a decision
    • Concepts about research and individual choice that might be unfamiliar, developing country participants may be plagued by poverty, illiteracy and limited access to health care services that make it difficult for them to give valid informed consent
• Mistrust in the researcher
  • Some commentators claim Africans believe that blood obtained ostensibly for research purposes used for sorcery of is sold

Declaration of Helsinki in LMIC

The most important development in doing research in LMIC is how people think of the standard of care. Pharmaceutical companies used to research the easily accessible people in LMIC, sometimes against no treatment at all because there was no available treatment → the standard of care was “no treatment”, even if there was a treatment available in Western countries. Therefore, the following guidelines were added to the Declaration of Helsinki:

• The tested intervention must be tested against those of the best proven interventions, expect:
  • Where no proven intervention exists, the use of placebo or no intervention is acceptable
  • When for compelling and scientifically sound methodological reasons and the patients who receive any intervention less effective than the best proven one, they will not be subject to additional risks of serious or irreversible harm as a result of not receiving the best proven intervention

Extreme care must be taken to avoid abuse of this option.

Post-trial access

In advance of a clinical trial there should be provisions for post-trial access for all participants who still need an intervention identified as beneficial in the trial. This information must also be disclosed to participants during the informed consent process.

CIOMS international ethical guidelines for research

CIOMS international ethical guidelines for research is an alternative to the Declaration of Helsinki that is more focused on vulnerable populations. Characteristics are:

• Scientific and social value of research
• Fair benefits of research in low resource settings
• Engagement of communities
• LMIC-participants are not vulnerable per se

CIOMS international ethical guidelines for research make available the interventions proven effective in research as part of a broader obligation to care for participants’ health needs → transition of participants to health services. Researchers are not only there to do research, but also have the obligation to care for the patient’s needs.

Conclusion

Ethical issues in Global Health are:

• Responsibility for just allocation of health care
• Responsibility for ethical medical research in LMICs

Ethical issues in global health are a field in transition. One of the most important shifts is to not see LMIC as vulnerable populations that need to be protected, but to have a true engagement with the population and local researchers and to respond to the necessities.

RC Health Systems

What is a health system

WHO: a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.

This includes effectors to influence determinants of health, as well as more direct health improving activities. Examples are:

• A mother caring for a sick child at home
• Private providers
• Behavior change programs
• Vector-control campaigns
• Health insurance organizations
• Occupational health and safety legislation

Outcomes of a health system

The goals of a health system are:

• To provide a comprehensive range of health services, accessible to all
• To generate (sustainable) resources to fund these activities
• To improve the health of populations through good governance of the HS, regulations of activities that have a direct impact on health and promotion of healthy behavior

The WHO health systems framework:

Access and coverage

• Access: the economical and/or geographical accessibility of health care.
• Coverage: the proportion of a target population that benefits form an intervention/service.

An example is that in Netherlands, there is an agreement that an ambulance should arrive within 15 minutes.

Universal coverage

Ensures that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

Objectives:

• Equity in access to health services: those who need the services should get them, not only those who can pay for them
• That the quality of health services is good enough to improve the health of those receiving services
• Financial-risk protection: ensuring that the cost of using care does not put people at risk of financial hardship

The levels of care

There are different levels of care, depending on the income level of a country:

• Primary care: in a health centre
• Secondary care: in a (district) hospital
• Tertiary care: highly specialized care for referred patients from a secondary care level

State of Health in the EU

The “State of Health in the EU” is a two-year initiative undertaken by the European Commission that provides policy makers, interest groups, and health practitioners with factual, comparative data and insights into health and health systems in EU countries.

Every even year, “Health at a Glance Europe reports” are published. Every odd-numbered year the differences and challenges between EU-countries are captured.

Youth Healthcare Physician

A Youth Healthcare Physician gives preventive Health Care for children and teenagers.

Influence of the COVID Pandemic

• Highest coverage of the HPV-vaccination ever in the Netherlands
• Disruption in the care for HIV, TBC and malaria
  • Malaria has been the most disrupted, but HIV forms the highest risk
• Low mental health
• Less children vaccinations

Only 11% of countries in Africa were able to do rapid tests and only 20% PCR tests.

Roles of a doctor

• As a leader
  • Societal expectation: physicians demonstrate collaborative leadership and management within the health care system
  • At a systems level: physicians contribute to the development and delivery of continuously improving health care and engage with others in working toward this goal

• As a health advocate
  • Physicians contribute their expertise and influence as they work with communities or patient population to improve health
    
     

Evaluation

Key terms

• Key indicators of economic/social development
  • (Inequality adjusted) HDI: index of development consisting of the elements health, education and living standards
  • Gross domestic product: total of the value of the goods and services that have been produced minus the value of the goods and services needed to produce them created in an economy
  • Gross national product/income: total domestic and foreign output claimed by residents and foreign residents, minus income of nonresidents
  • Purchasing Power Parity: what you can buy with an international dollar
  • Atlas Method: the average of a country’s exchange rate for a year and the two preceding years, adjusted for the difference between the rate of inflation in the country and international inflation, the objective of the adjustment is to reduce any changes to the exchange rate caused by inflation → used to determine the size of an economy in terms of GNI
  • GINI-coefficient: measures the extent to how much the income of individuals or households in an economy deviates from a perfectly equal distribution, it ranges from 0 (equal) to 1 (inequal)
  • Average years of schooling: average number of years of education of the population older than 25 years
  • Expected years of schooling: number of years of education the population is expected to have at birth
• Key indicators of demography
  • Population pyramid: represents the breakdown of the population by gender and age at a given point of time
  • Crude birth/death rate: number of births/deaths per 1000 population within 1 year
  • Adjusted birth/death rate: birth/death rate corrected for the age distribution
  • Total fertility rate: the average number of children that would be born to a woman over a lifetime if she were to experience the exact current age-specific fertility rates through her lifetime and she were to survive from birth to the end of her reproductive life
  • Demographic transition: shift from a high to a low fertility and mortality
  • Total dependency ratio/window of opportunity: the total number of people aged 0-14 or >65 divided through the total number of people aged 15-65
  • Epidemiological transition: shift in population growth due to disease patterns
• Key determinants of health
  • Individual characteristics: e.g. genes, gender, age
  • Physical environment: e.g. water, sanitation, air
  • Social Determinants of Health (SDH): social factors that influence our health
  • Social-economic conditions: e.g. employment, education, culture
  • Healthy behavior and coping skills