Global Public Health Exam 2 10/22

What does a "horizontal" approach mean?

Focuses on improving the entire health care system, rather than treating one specific disease.

Driven by the affected community

How were the rural doctors of India and the "barefoot doctors" of the People's Republic of China examples of a "horizontal" approach to medicine?

India's rural doctors and China's barefoot doctors provided basic treatment and prevention in underserved communities.

Why wasn't the grand vision of "health care for all" that was promoted in the Declaration of Alma-Ata ever realized?

Lack of funding, political opposition, rise of neoliberalism, and a shift toward cheaper, selective health programs.

Primary Health Care (PHC)

Health for all; comprehensive care, prevention, sanitation, nutrition, and treatment.

Most effective way to sustainably solve today's health and health system challenges

Ex: Vaccinations, Prenatal/maternal care

Selective Primary Health Care (SPHC)

Cost-effective, targeted interventions like immunizations and oral rehydration therapy.

Ex: A program that focuses specifically on childhood vaccinations to reduce deaths from preventable infectious diseases, rather than trying to improve entire healthcare system.

What are structural adjustment programs (administered by IMF)? What types of reforms do they require?

IMF loans to struggling countries in exchange for economic reforms:

Stabilization: Reduce government spending

Liberalization: Reduce trade barriers

Deregulation: Remove government restrictions

Privatization: Shift public services/businesses to private ownership

In this analysis, how do structural adjustment programs impact health system access and neonatal mortality?

SAPs reduce health care access and increase newborn deaths (neonatal mortality). Labor market reforms are a major driver of these negative effects.

The World Bank

Provides loans + funding to developing countries to reduce poverty and improve development

Mission/focus: Reduce poverty and promote economic development.

Known for: Loans and funding for health, education, infrastructure, and development.

Critiques: Loans can increase debt; required economic reforms may reduce government spending on health/social services.

World Health Organization

UN agency that promotes global health, prevents disease, + responds to health emergencies.

Mission/focus: Improve global health and prevent disease.

Known for: Vaccination, disease eradication/control, health guidelines, emergency response.

Critiques: Limited enforcement power, dependent on member funding, can respond slowly to crises.

UNICEF

United Nations Children's Fund

Mission/focus: Protect children's rights, health, education, and well-being worldwide

Approaches/programs: Vaccinations, nutrition, clean water, education, and emergency aid

Critiques: Relies on donations, can be influenced by donors, and may overlook local needs.

How the Alma Ata and Bellagio conferences relate to global health: who was there? What key message of global health they each espoused?

Key difference: Alma-Ata = Health for All; Bellagio = cost-effectiveness.

GOBI-FFF: United Nations Children's Fund, Selective Primary Health Care Strategy

Strategy to reduce child deaths through low-cost interventions

G - Growth monitoring

O - Oral rehydration therapy (treat diarrhea)

B - Breastfeeding

I - Immunizations

F - Food supplementation

F - Female education

F - Family planning

How neoliberalism impacted public health starting in 1980s

Promoted privatization and reduced government spending.

Introduced user fees (patients pay for services).

IMF/World Bank loans required economic reforms (SAPs).

Result: Reduced health care access, especially for the poor.

Strengths of NGOs in global health

- Innovative

-More cost-effective in service delivery

-Greater ability to target impoverished and vulnerable

-Greater capacity to develop community-based institutions

-Better able to promote popular participation

-NGOs are seen as an alternative to government

-Seen as vehicles of democratization

-In the absence of the state, NGOs can fill a political vacuum

Critiques of NGOs in global health

-Dependent on donor money, often from abroad, often tied to policies of donor states

-Top-down, "Participation" is often misused

-Can be innovative at times

-Often recycle ideas from other donors

-Hasn't been demonstrated (state vs. NGO) as cost effective

- Doesn't always reach impoverished individuals

ICRC (Red Cross)

-Ensuring humanitarian protection + assistance for victims of armed conflict + other situations of violence

-Takes action in response to emergencies while promoting respect for international humanitarian law

-Strict doctrine of neutrality and discretion (necessary to operate on the battlefield, was problematic during Holocaust)

MSF (Doctors without Borders)

-Focus on medical care (and broader health efforts)

-Balance operational neutrality with a willingness to speak out

-Responds to War and conflict, Natural disasters, Outbreaks and epidemics, Refugees and internally displaced people

CRC (Red Cross) and MSF (Medecins Sans Frontiers, i.e., Doctors without Borders) similarities

-Both emerged in response to conditions created by conflict

-Both respond to suffering through a health framework (rather than poverty or hunger)

-Both provide health care and humanitarian aid during conflict

-They have their differences but often work together

CRC (Red Cross) and MSF (Medecins Sans Frontiers, i.e., Doctors without Borders) differences

-On the principals of neutrality, confidentiality, impartiality, and independence

-MSF will set up medical services as soon as it is practical, even if illegal

-ICRC normally works with legal authorities to set up medical services

-Red cross is less likely to speak up and break neutrality

Know what 4 crises currently threaten Sustainable Development Goals (SDGs) progress

1. COVID-19 pandemic - Disrupted health care and development.

2. Climate change - Threatens health, food, and water security.

3. Conflict and war - Cause displacement and instability.

4. Economic crises - Increase poverty and inequality.

What are the potential benefits and drawbacks of traditional global health training in high-income countries?

Benefits: More funding, better resources, advanced technology, and research opportunities

Drawbacks: Focuses on wealthy countries' perspectives, overlooks local knowledge, and can reinforce power inequalities between countries

What does 'global' mean? What are the advantages of a global health program?

Global: Involving or affecting the whole world, across national borders

Advantages: Countries share resources, knowledge, and funding to prevent diseases, improve healthcare, and address health inequalities

Does a global approach discourage students from high-income countries from engaging in low/middle-income countries?

How does 'global' address health inequities and disparities in HICs and LICs?

No. A global approach encourages students from high-income countries to work with low- and middle-income countries through respectful + equal partnerships

Global health addresses unequal access to healthcare in all countries, rich and poor, rather than focusing only on poorer countries

Medical Voyeurism

Treating patients' bodies or suffering as objects of curiosity or observation rather than respecting dignity and privacy

Medical Tourism

Traveling to another country to receive medical care, often because it is cheaper, faster, or unavailable at home

In what ways can students' presence in developing country contexts be drained on the health system (including on staff)?

Students can strain healthcare systems by using limited supplies, taking up staff time for training and supervision, and slowing down patient care

Know the ethical dilemmas of medical volunteering in resource poor countries

Unqualified volunteers may harm patients due to lack of training

Communities may rely on foreign volunteers instead of local healthcare

Volunteers may not respect local practices

Patients may receive temporary care without follow-up

Foreign volunteers may prioritize their own experience over community needs

Know recommendations of how to reduce negative unanticipated consequences of medical volunteering in resource poor countries

Work with local healthcare workers

Provide training to build long-term local skills

Respect local cultures and needs

Avoid creating dependence on foreign volunteers

Only perform tasks you're qualified for to prevent harm

What were the two biggest sources of DAH in 2021?

1st: United States (26.21%)

2nd: Other sources (20.81%)

What percentage of DAH funding came from debt repayments?

Approximately 70.42% within the expanded category of other sources.

Debt repayments = developing countries paying back loans to lenders such as the World Bank and IMF.

How did US DAH funding change from 1990 to 2021?

US funding increased significantly.

HIV funding exceeded $1 billion around 2001-2002 and $5 billion around 2009-2010.

How did US funding through different channels change?

WHO: Decreased overall.

UN agencies: Increased overall.

NGOs: Increased rapidly, then leveled off above $3 billion.

Global Fund: Increased substantially.

Gavi: Increased more gradually.

Know strengths and critiques of the role of NGOs in global health

Strengths: NGOs provide healthcare, reach underserved communities, and respond quickly to health crises

Critiques: Rely's on donations, lack accountability sometimes, and can create dependence on outside aid instead of strengthening local health systems

What is the overarching objective of the Millenium Development Goals (MDGs)?

To reduce global poverty and improve people's health and quality of life by 2015

Know what four crises currently threaten Sustainable Development Goals (SDGs) progress

Climate change

Conflict and war

Economic crises

COVID-19 aftermath

What social determinants of health contribute to unequal risk of being diagnosed with and dying from AIDS in Brazil?

Poverty, racism, discrimination, and unequal healthcare access

How do AIDS cases and AIDS-related deaths exemplify the concept of 'intersectionality'?

Overlapping social inequalities (race, gender, sexuality, poverty) combine to increase HIV/AIDS risk.

How much more did Johnson & Johnson (J&J) charge South Africa for COVID-19 vaccines compared to the European Union and their not-for-profit price?

South Africa: $10 per dose

European Union: $8.50 per dose

Not-for-profit: $7.50 per dose

What is 'evergreening' and how did J&J use this practice to extend their drug patent? How can South Africa learn from India to help prevent this in the future?

Evergreening: When pharmaceutical companies make minor changes to a drug to extend patent protection, preventing cheaper generic versions.

J&J: Used a modified form of its tuberculosis drug, bedaquiline, to seek patent protection until 2027 instead of 2023.

India: Rejected J&J's secondary patent in 2023 because it did not meet patentability requirements.

South Africa: Can adopt stricter patent laws like India's to prevent unnecessary patent extensions and allow cheaper generic drugs.

James Love went to Washington DC to lobby US activists to support generics for Africa. He described one reason they were opposed to supporting generic drugs for use in Africa. What was it?

Some US AIDS activists feared that Africans would not take HIV medications correctly, leading to drug resistance and potentially making treatments less effective.

Know why governments of low-income countries back off from challenging the drug patents. from film

Governments of low-income countries fear economic and political retaliation from wealthy countries and pharmaceutical companies, including trade sanctions, lawsuits, and loss of foreign aid.

4 examples of how international pharmaceutical companies + governments of high-income countries blocked the ability of low- and middle-income countries to access generic HIV drugs

1. The US response when the South African government was considering generic HIV

drugs

2. The response of European leaders and pharmaceutical companies to the Indian

company Cipla's offering of HIV triple therapy for $800 per person per year

3. The U.S. response to the immediate need for Cipro to be available for treatment of

anthrax exposure. (Why is this issue brought up in regards to HIV drugs?)

4. The U.S. response to the Global Fund's plan to purchase generics

One argument for supporting drug patents is that by ensuring companies could profit from that drug for a certain number of years, it gives companies incentives to do research and development (R&D) for other new drugs. Know 3 critiques of this which were offered in the film:

1. ___________ (the % of profits spent on R&D)

2. ___________ (the % of global medication research funded by governments & public sources)

Less than 1.5% of pharmaceutical sales revenue goes toward discovering new drugs.

84% of global drug discovery research is funded by governments and public sources (only 12% by pharmaceutical companies).

Companies spend more on marketing and advertising than on R&D.

HIV

Human immunodeficiency virus detected in the body

AIDS

Having 200 or fewer CD4 cells/liter OR having an opportunisitic infection and being HIV positive

Understand how HIV causes opportunistic infections

HIV destroys immune cells, weakening the body's ability to fight germs. This allows infections that normally wouldn't make you sick to cause illness

PrEP for HIV

Pre-exposure prophylaxis: Taken daily by people at risk for acquiring HIV

PEP for HIV

Post-exposure prophylaxis: Taken ASAP after a possible exposure to HIV (within 72 hours)

ART for HIV

Antiretroviral Therapy: Standard daily treatment consists of a combination of drugs that suppress HIV replication

Goal: reduce viral load to undetectable

Prospect of a normal lifespan

What is a 'vertical' health program? Benefits and critiques

Top-down 'technical fixes' for prevention and treatment

Benefits:

Minimizes the threat of a disease in a pop

Leads to benefits of other health outcomes

Improvements in health infrastructure

Easier to get funding bc there's measurable results

Critiques:

Limited local input

Not looking at the social or policy determinants that create high rates of disease

Herd immunity

When very few people are able to carry a disease, the virus cannot find a host and therefore cannot spread in that population

Successes and failures of vaccine campaigns globally

Successes: Smallpox eradicated, polio nearly eradicated, millions of lives saved.

Failures: Unequal access, vaccine hesitancy, poverty, and conflict.

COVID-19: Disrupted routine vaccinations, increased inequality, and caused outbreaks.

Characteristics of a disease that may help make an eradication campaign successful

-Direct human-to-human contact

-Permanent immunity from a single infection or vaccination

-Short and known time between exposure and symptoms

-Case-identification is obvious

-Vaccine is effective + doesn't require temperature controlled environment

Polio eradication efforts

WHO launched a global campaign in 1988 using mass vaccination to eliminate polio

Polio cases decreased by over 99%, but it has not been fully eradicated due to conflict, limited healthcare access, and vaccine challenges

Small pox eradication efforts

WHO led a global vaccination campaign using surveillance, contact tracing, and targeted vaccination to stop the spread

Eradicated in 1980

First human disease completely eradicated worldwide

Malaria eradication efforts

WHO launched a global campaign in 1955 using insecticides (DDT) to kill mosquitoes and medications to treat malaria

Malaria was eliminated in some countries, but global eradication failed due to insecticide resistance, limited funding, and weak healthcare systems

As you read about the collaboration between Partners in Health ([PIH] an international NGO) and the Rwandan government, find examples of how the 8 aspects of PIH's Health Care Delivery Model (p. 160-161) looked on the ground in Rwanda.

1. Access to care

2. Free/affordable care

3. Community health workers

4. Comprehensive care

5. Social support

6. Training

7. Government partnership

Role of accompagnateurs in their successful treatment of HIV (p. 173).

Accompagnateurs: Community health workers who visit HIV patients at home, ensure they take medications, and provide emotional and social support.

Impact: Improved treatment adherence, reduced deaths, and helped patients stay in care.

Mutuelle health insurance plan (p. 175-176).

Mutuelle: Rwanda's community-based health insurance program where people pay affordable premiums to access healthcare.

Impact: Reduced financial barriers and increased healthcare access, especially for low-income families.

What was fundamentally different about the relationship between this NGO (PIH/IMB) and the Rwandan government compared to most NGOs?

PIH/IMB partnered with Rwanda's government to gradually transfer responsibilities and build a self-sustaining healthcare system.

Do high-income countries have a nursing shortage? What root causes (structural and workplace factors described in the article) contribute to vacant nursing positions?

Yes, high-income countries face nursing shortages.

Structural factors: Aging populations, aging nursing workforce, insufficient nursing education capacity, and underfunding.

Workplace factors: Low pay, long hours, heavy workloads, burnout, and poor working conditions.

Result: Nurses leave the profession, creating more vacancies.

According to the authors, what changes should governments and health systems enact to retain local nurses?

Governments and health systems should increase pay, improve working conditions, reduce workloads, provide mental health support, and offer career advancement to retain local nurses.

Goals and Functions of a Health System

Improve population health.

Provide fair, accessible healthcare.

Protect people from financial hardship.

3 levels of health care

1. Primary care: Basic care, prevention, and checkups.

2. Secondary care: Specialist care and hospital treatment.

3. Tertiary care: Advanced, specialized treatment (e.g., complex surgeries).

National Health Service systems

Example: United Kingdom

Funding: Government-funded through taxes.

Insurance: No separate insurance required; residents are covered through the public system.

Impact: Universal healthcare, mostly free at point of service, but sometimes long wait times.

National Health Insurance systems (public +private)

Example: Canada

Funding: Government-funded through taxes.

Insurance: Public insurance covers essential care; private insurance covers extras (dental, vision, prescriptions).

Impact: Universal coverage for eligible residents, little to no cost for covered services, but sometimes long wait times.

Out-of-pocket systems

Example: Nigeria

Funding: Patients pay directly for healthcare.

Insurance: Limited coverage; many people are uninsured.

Impact: High costs, unequal access, and people may avoid treatment because they cannot afford it.

Which type of health care system does Cuba have?

National Health Service (NHS) system — government-funded through taxes, universal coverage, and free healthcare at the point of service.

What is the Cuban health care system known for?

Strong preventive care, community-based healthcare, high doctor-to-patient ratios, and sending doctors abroad to provide medical assistance.

Know what is meant by universal health coverage (UHC) by the WHO and what two metrics the WHO is using to measure UHC

Universal Health Coverage (UHC): The WHO's goal that everyone can access the quality health services they need without experiencing financial hardship

Eradication campaign

A global effort to completely eliminate a disease worldwide

Ex: Smallpox eradication through vaccination

Alma-Ata (1978)

Alma-Ata (1978):

Who: All UN member countries invited.

Message: Health is a human right. Comprehensive primary health care (PHC) for all, with community participation.

Bellagio (1979):

Who: Only the wealthiest countries.

Message: Selective primary health care (SPHC) — focus on affordable, targeted interventions with measurable results.

Bellagio (1979)

Who: Only the wealthiest countries.

Message: Selective primary health care (SPHC) — focus on affordable, targeted interventions with measurable results.

What percentage of DAH went to different health areas in 2021?

SWAps & HSS: 10.6%

Noncommunicable diseases: 1.60%

Infectious diseases combined: 54.15%