global health and medicinesnu-dhpm.ac.kr/pds/files/130528 국제보건_오주환.pdf ·...
TRANSCRIPT
국제보건Global Health and Medicine
2013년 5월 28일
오주환
서울의대 이종욱글로벌의학센터
의료관리학개론
수업목표
• 국제보건이란 무엇인지 간략히 설명할 수 있다
• 국제보건분야에서의 주요 현황을 안다
• 국제보건활동의 동기에 대해 이해한다
• 국제보건분야의 쟁점을 이해한다
• 국제보건분야에서 한국이 수행할 가치가 높은 역사적 역할을이해한다
Definition(s)In global health
정의: 국제보건 (proposed by Kaplan et al, 2009)
Global health is
• an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.
Global health …
• Emphasizes transnational health issues, determinants, and solutions
• Involves many disciplines within and beyond the health sciences
• Is a synthesis of population-based prevention with individual-level clinical care
Global Health is…
• Fashionable
• Provoking media, student, and faculty interest
• Has driven the establishment or restructuring of several academic programs
• Is supported by governments as a crucial component of foreign policy
• Has become a major philanthropic target
Source: Kaplan et al, 2009, Lancet
Action Plan of JW LEE Center for Global Medicine
Aug 13, 2012
Director LEE, Jong-koo MD, PhD
Global Health: Origin
• From Public Health
• From International Health (evolved from hygiene and tropical medicine)
Definition: Public Health
• “Public health
• Is the science and art of preventing disease, prolonging life and promoting physical health and efficacy
• through organized community efforts
• for
the sanitation of the environment,
the control of communicable infections,
the education of the individual in personal hygiene,
the organization of medical and nursing services for the early diagnosis and preventive treatment of disease,
and the development of social machinery which will ensure every individual in the community a standard of living adequate for the maintenance of health;
• so organizing these benefits in such a fashion as to enable every citizen to realize his birthright and longevity .”
• Source: Winslow C. The untilled field of public health. Mod Med 1920; 2: 183-91
Definition: International Health
• “the application of the principles of public health to problems and challenges that affect low and middle-income countries and to the complex array of global and local forces that influence them”.
Source: Merson MH, Black RE, Mills AJ. International public health: diseases, programs, systems, and policies, 2nd edn. Sudbury MA: Jones and Bartlett Publishers, 2006.
International Health
• Health work abroad with geographic focus on developing countries
• and often with a content of infectious and tropical diseases, water and sanitation, malnutrition, and maternal and child health
Source: Brown TM, Cueto M, Fee E. The World Health Organization and the transition from international” to “global” public health. Am J Public Health 2006; 96: 62–72.
International Health
• Limited exclusively to the diseases of the developing world (Brown University International Health Institute)
• The philosophy and content of today’s globalised health practice (Global Health Education Consortium)
Comparison of Global, International, and Public health
Global health International health Public health
Geographical
reach
can transcend
national boundaries
health issues of countries
other than one’s own
health of the population
of a particular
community or country
Level of
cooperation
global cooperation bi-national cooperation does not usually require
global cooperation
Individuals or
populations
both prevention in
populations and
clinical
care of individuals
both prevention in
populations and
clinical care of individuals
prevention programs for
populations
Access to
health
Equity among nations
and for all people
Seeks to help people of
other nations
Equity within a nation or
community
Range of
disciplines
Highly
interdisciplinary and
multidisciplinary
Embraces a few
disciplines
Encourages
multidisciplinary
approaches
14
Definition revisit: Global Health
The broadest
• Public Health and Medicine per se
The narrowest
• Public Health and Medicine for developing countries
• Developmental assistance in health
Current Healthcare Statusof developing countries
Life Expectancies at birth
Maternal Mortality Ratio
Millions miss out on needed health ser
vices
19
Source: Dr. Henk, 2012
Why help others?
Spectrum of natures in global health
• Religion/Humanism
• Professionalism
• Health Diplomacy
• Long-term investment
• Health Security
• Short-term investment
• Entrepreneurism
• Imperialism
Altruism
Self-interest
Spectrum considering various actors
Religion/Humanism
Professionalism
Health Diplomacy
Long-term investment
Health Security
Short-term investment
Entrepreneurism
Imperialism
Altruism
Self-interest
Individual/Community Market/ Corporate Nation-State
Selp-interest
Imperialism in Global healthPublic health programs have been the
humanitarian partner of American
imperialism for more than 60 years.
In 1954 John C. McClintock, an assistant
vice president of United Fruit Company,
neatly summed up the relationship between
health and profits that has been a concern of
these programs in the tropics:
"In the under-developed areas where
American companies have gone, where they
have brought great enterprises into fruition,
where they are continuing, one of the
primary factors was to establish conditions
of health were people could not only exist but
also could work. “
(Source: Brown ER, 1976, AJPH)
Self-interest based international engagement : 3 key US interests
• Protecting America’s population
• Enhancing the economy
• Advancing America’s international interests
Source: Institute of Medicine (1997) America’s Vital Interest in Global Health
Self-interest based international engagement: Canada
• Withdrawal or disengagement make no sense in this globalized world
• Global pollution & Climate change
• Changes to the role of the nation-state
• Refugees, Ethnic hostility, Violence, & Mass migration
• Growing poverty
• Intractable disease that does not respect national borderline
Source: Strong et al (1996) Connecting with the World: Priorities for Canadian Internationalism in the 21st Century
Health Security: complementary to domestic action
• Although domestic(national) action remain vital, transnational action needs to complement “domestic” initiatives
(e.g.) mad cow disease in the context of exported feedstuffs
(e.g.) Anti-smoking policy in the context of global tobacco marketing strategies
Yach et al (1998) The Globalization of Public Health, Am J of Pub Health, Vol 88(3) 738-741
Health Security: complementary to domestic action
• International monitoring system are already evolving for many health threats such as
Infectious disease
International risk assessment of the cross-border food trade
Trade of harmful commodities
Yach et al (1998) The Globalization of Public Health, Am J of Pub Health, Vol 88(3) 738-741
International public health law
• Left behind even though better use of international legal instrument in public health would encourage the development of national health legislation
• E.g.) UN Convention on the Rights of the Child
• E.g.) GLOBE (Global Legislators for a Balanced Environment)-carbon tax
Interdependency
Converging self-interest & altruism
• Increasingly interdependent world makes self-interest and altruism converged
• Continued wealth in industrialized countries is not sustainable against a backdrop of poverty, disease, and warfare in many of the world’s poorest countries
Source: Strong et al (1996) Connecting with the World: Priorities for Canadian Internationalism in the 21st Century
Am J of Public Health
개발도상국 보건의료에 기여하는 이유: 순수한 도움 vs 자기 이익
개발도상국 보건의료에 기여하는 이유: 새로운 외교수단, 국제사회 리더쉽 획득
International relations
Past
• War and peace
• Economics and trade
[Hard Power]
Present
• War and peace
• Economics and trade
• Environment
• Health
[Hard Power and Soft Issue]
Global Health Diplomacy
(Definition by Anthony Fauci)
Winning hearts and minds of people in poor countries by exporting medical care, expertise and personnel to help those who need it most
(Source: Fauci AS. 2007. The expanding global health agenda: a welcome development. Nature Medicine 33: 10)
Global Health Diplomacy: New phenomena
• MoFA hires health experts
• MoH hires diplomats
• Establishing “national global health strategy”, frequently at the initiative of the international departments in the MoH
• Developing joint strategic approach to global health by the Departments of the Interior and the Department of Foreign Affairs (Switzerland)
Three major strands of global health diplomacy
1. Normative health issues, international agreements and cooperation, global outbreaks of diseases and pandemics
2. The commitment to health in the context of assistance towards development
3. The policy initiatives in other sectors such as foreign policy and trade
PEPFAR
• The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is the U.S. Government initiative to help save the lives of those suffering from HIV/AIDS around the world.
• PEPFAR is driven by a shared responsibility among donor and partner nations and others to make smart investments to save lives.
G8 commitment on health system strengthening in developing nations
The declaration of the G8 Toyakosummit, held in Japan in July, 2008, covered global health issues under the topic of development and Africa.
The official summary stated:
“The G8 leaders welcomed the Report of the G8 Health Experts Group, presented along with its attached matrices showing G8 implementation of past commitments, and set forth the Toyako Framework for Action, which includes the principles for action on health.”
(Source: Reich M et al, Lancet. 2008 Mar 8;371(9615):865-9.)
Brazil’s global health diplomacy
• Made WTO conference in Doha, Qatar, the health of the population as a priority over international trade
• Brazil assure delivery of the health services and drugs especially for HIV/AIDS patients via close cooperation between the MoH and MoFA
Professionalism in Medicine
has been described by the American Board of Internal Medicine as
“constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.”
(Source: Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243- 246.)
OUR Shared interest altruism
Shared global Prosperity
• Mutually assured progress
• From fortresses of military independence
• Towards shared interest in building human and social capital and reducing cross-national disparities in terms of health and disease risk
Diplomacy
• From power and prestige
• Towards peace and prosperity
Source: Cooper. The breaking of nations. Order and chaos in the 21st century. New York: Atlantic Monthly Press; 2003
Limitation
• Ideal
• But, no clear momentum yet
• Still rhetoric
Development from under-develpment
Two different perspectives in development
• Since in the process of modernization all societies will undergo by and large similar changes, the history of the presently modern nations is taken as the source of universally useful conceptualization
versus
• Both underdevelopment and development are aspects of the same phenomenon, both are historically simultaneous, both are linked functionally and, therefore, interact and condition each other mutually
Modernization perspective
Dependency perspective
Alleged obstacles in development
• Predominance of ascriptive, particularistic, diffuse, and affective pattern of action
• Extended kinship structure with multiplicity of function
• Little spatial and social mobility
• Mostly primary economic activity
• A tendency towards autarchy of social units
• Undifferentiated political structure
versus
• Dependency is a situation in which a certain number of countries have their economy conditioned by the development and expansion of another…placing the dependent countries in a backward position exploited by the dominant countries
Modernization perspective
Dependency perspective
Development can be achieved via...
Modernization perspective
• Diffusion of modern values and institutions from the early modernizers
• To be guided by the Western model adopting and adapting its technology; assimilating its values and patterns of action; importing its financial, industrial, and educational institutions
Dependency perspective
• The center is capable of dynamic development responsive to internal needs
• On the other hand, the periphery is seen as having a reflex type of development; one which is both constrained by its incorporation into the global system and which results from its adaptation to the requirements of the expansion of the center
A Dialogue of World System Theorist
World Population according to three subgroups
GDP per capita over time(10 countries: randomly chosen + Korea added)
Life Expectancies over time(countries: randomly chosen)
Life Expectancies over time(Korea + 10 countries: randomly chosen)
Optimal ODA in normative
• How much achievable: full pledging of under-developed countries with financial and technical support from developed countries?
• Can it be achieved or just rhetorical statement (based either on modernization perspective or on dependency perspective)?
Jump to health ODA: our values
• What’s the underlying perspective with respect to the Korea’s ODA or ODA we hope to establish soon?
• What is your value and way for optimal ODA commitment?
• What should be the goal of health ODA?
Lessons and/or remained question
• What can we learn from both perspectives with regard to development?
• Can professionalism work in global health in the world context beyond nation-state level?
• What does Korea need to rely on?
Actors and Actions in global health
Past History of Actors/Actions in Global Health
• 19th ~ the early 20th century: New diseases in Europe• International Sanitary Conference (1851-1903)
• International Office of Public Hygiene established (1907)
• 20th century: International Organizations established• UN (1945), WHO (1948)• Elimination of particular diseases (1950s-1960s), Vertical Project
• Basic Health Service deliverysystem (1970s), Integrated project
• Declaration of Alma-Ata (1978): Health for all by the year 2000;
Primary health care throughout the world
Source; Don De Savigny & COHRED
Contemporary Partners in Health
Source: Dr. Henk, 2012
Glossary of terms in Global Health Action
Official Development Assistance (ODA) is defined
as financial flows to developing countries and multilateral organizations provided by official agencies or by their executive agencies, each transaction of which meets the following criteria:
1. It is administered with the promotion of the economic development and welfare of developing countries as its main aim
2. It is concessional in character and conveys a grant element of at least 25 per cent (in case of loan)
3. ODA is reported on a calendar year basis
Glossary of terms in Global Health Action
Multilateral ODA is defined as aid delivered in the form of core contributions to organizations listed in the DAC Statistical Reporting Directives such as WHO, WB, UNICEF, UNFPA, etc
Bilateral ODA covers all aid provided by donor countries when the recipient country, sector or project is known
1990
Bill
ions
of 2008 U
S D
olla
rs
Influx of resourcesDevelopment assistance for health (DAH) by channel of assistance, 1990-2010
NGO’s
Other
BMGatesF
GFATM
GAVI
ECWHO, UNICEF, UNFPA
WB-IBRD
WB-IDA
Regional Banks
Bilaterals
2010
26.87
5.66
Various Actors’ Contribution in Global Health
2000년 이후 Bilateral agency, Global Fund, and Private institution에 의한활동이 급격히 증가하기 시작함
Total ODA amount against ODA/GNI ratio in 2009
0.0%
0.7%
1.4%
0 5000 10000 15000 20000 25000 30000
Total ODA Amount (million USD)
OD
A /
GN
I ra
tio
(%
)
(US)
(France)
(Germany)
(UK)
(Japan)
(Spain)
(Netherlands)
(Sweden)
(Norway)
(Demark)
(Korea)
(Italy)
(Canada)
Bilateral Aid at a glance
아직은 국제보건 분야의 기여도가 낮은 한국
Where other donors spend their money?: sector versus geography
UNITED STATES OF AMERICA
UNITED KINGDOM
JAPAN
SWEDEN
AUSTRALIA
KOREA
Issues and debatesin global health
• Everyone has access to needed high quality interventions
• No one should be exposed to financial hardship because of paying for these services
1. Population Coverage
2. Benefit package, like outpatient services etc.
3. Reimbursement levels
Universal Health Coverage
76
Current Global Health Issues• Aid effectiveness
• Millennium Development Goals (2000):
MDG 4(Reduce child mortality rates),
MDG 5(Improve maternal health),
MDG 6(Combat HIV/AIDS, malaria, and other diseases)
• Paris Declaration (2005): Ownership, Alignment, Harmonization, Managing Results, Mutual accountability
• Building a new Global Partnership for Effective Development
• Strengthening health system
• Human Right for Health
Known Problems of the ODA world
1. tied aid
2. short-term goals
3. Sustainability
4. project-based thinking
5. imposed solutions
6. duplication and competition among donors:
lack of coordination
Paris declaration on Aid Effectiveness
Ownership(Partner countries) Countries se
t the agenda
1
Aligning
with country's
agenda
Using
country system
s
Alignment(Donors - Partner)
2
Harmonisation(Donors - Donors)
Establishing
common arrangemen
ts
Simplifying pro
ceduresSharing informat
ion
3
Ma
na
gin
g fo
r Re
su
lts
4
Mu
tua
l Acco
un
tab
ility
5
Development ResultsResult based aid and financing
Discrepancy between health need & health ODA
Health Need: Causes of death
Discrepancy between global ODA NEED vsODA SUPPLY
A New Potential leader of good ODA in Health
Korea: the latest member of OECD/DAC
Known ODA World Problems
1. tied aid
2. short-term goals
3. Sustainability
4. project-based thinking
5. imposed solutions
6. duplication and competition among donors:
lack of coordination
Korea, solve or follow the problems?
Do we just follow the same ways of previous donors?
Or
Do we need to attempt to overcome current flaws of ODA?
Problem solving (1)
Tied aid
• Aid on condition that most equipment and supplies should be stick to the donor country producers
• The least flexibility to operate the institution in the recipient society
Un-tied aid
• No condition on the aid with respect to procurement: neither equipment nor supply
• Genuine ownership of the institution established by donor
Problem solving (2)
Short-term goals
• Mostly project focuses on easily measurable short-term goal
• Could it guarantee DEVELOPMENT of the recipient country on earth?
Long-term goals
• Need to help get the results which need some time to achieve good results especially in resource-limited countries
• Fishing compared to fish
Problem solving (3)
Volatile results
• Normally lots of vertical programs such as drug-distribution get results within a short period of time
• Mostly resumed after exit of the program
Sustainable results
• Good results should be remained in the recipient countries even after exit of donors
• Mostly sustainable result goes with system strengthening
Problem solving (4)
Project based thinking
• Small scale, fragmented components without continuum of the service provision
• Inefficient to manage lots of gap and tons of administrative works for small scale projects
Program or System based thinking
• More comprehensive scale of development assistance: maximal continuum per at-least-one agenda
• Considering health system strengthening all the time
Problem solving (5)
Imposed solution
• Donors give solution program based on their knowledge
• Developing country knowledge is functionally invisible to donor
Participatory approach
• People know themselves more than others
• It is usually monetary capacity not intellectual capacity that they lack
• Seek to find the optimal way of problem solving together between donor and recipient
Problem solving (6)
Duplication and competition among donors
• Trying to provide similar projects on the same geographical areas
• Duplication exist with gap as well
Harmonization
• Effective provision via division of role
• Cooperation among donors within same geographical area
• No competitive provision in the same agenda and same way via sector-wide-coordinating group activity
How to solve: clue or normative
• The nations get agreeing for good normative even without commitment
• Normative way such as Paris Declaration was already established; just not implemented
FORMATION OF INTERNATIONAL NORMATIVE
Revisit: PARIS DECLARATION
1. Ownership: Partner countries exercise effective leadership over their development policies and strategies
2. Alignment: Donors base their overall support on partner countries’ national development strategies, institutions and procedures
3. Harmonization: Donors’ actions are more harmonized, transparent and collectively effective
4. Managing for Results: Managing resources and improving decision-making for results
5. Mutual Accountability: Donors and partners are accountable for development results
The Paris Declaration on Aid Effectiveness, endorsed by over 100 countries in 2005, committed their countries and organizations on five key areas:
ACCRA AGENDA
Ministers of developing and donor countries endorsed the following statement in Accra, Ghana,
(4 Sept. 2008 )
to accelerate and deepen implementation of
the Paris Declaration on Aid Effectiveness
(2 March 2005)
BUSAN DECLARATION
[Two of essentials]
Establishing good governance and the role of efficient public procurement in the effective functioning of the public sector
South-South or triangular co-operation, complementing North-South forms of co-operation
North-South
Co-operation
in
Official
Development
Assistance
Infant Mortality Rates 2007
source: www.gapminder.org
Helping South-
South Co-
operation
(Triangular
cooperation)
in
Official
Development
Assistance
Where to go
Unique or different approach
Sincerely respecting international normative and recipient societies (Paris Declaration)
Way of good Samaritan: considering others as you do for yourself
Pursuing good reputation from recipient countries in long-run view rather than short-term interest under short-run view
Goal: Helping others- ODA as humanitarian ends -
Helping underserved population in the underserved countries (primary achievement)
will give us global leadership (secondary gain)
Goal: Achieving Global leadership- ODA as effective means -
• Achieving global leadership (Primary goal) will be achieved well
through helping underserved population in the underserved countries (Humanitarian means) compared to military forces.
Thank [email protected]