European priorities for global health action must engage all actors, including donor and recipient countries beyond the EU. These include all the agencies noted in this glossary and academic, business and civil society networks. It is important to bear in mind that global health is not solely concerned with health threats in or arising from resource-poor countries; these may also arise in rich countries (as in the case of Creutzfeldt-Jakob disease (CJD) and global warming), middle income countries (as in the case of avian and swine flu) or poor countries (as exemplified by HIV and AIDS and tuberculosis).
Priority-setting for global health action is driven by many factors and, until recently, has lacked a coherent approach between European countries, between European organizations and between different parts of the EU. In general, policy responses have tended to be issue based and responsive; they have been varied, reflected changes in the global burden of disease and in the wider impact of health on global political stability and economic development. They have also vacillated due to different perceptions of the impact of global health issues on Europe, the national interests of EU member states, the relationship with other partners such as the US, and the lobbying or advocacy of non-state actors.
The recent European Health Strategy has laid the groundwork for a more consistent policy, which will be defined by long-term investments in health infrastructures, action on health determinants and intergenerational health sustainability. The strategy recognizes that huge inequities in access to basic healthcare and exposure to the determinants of ill health are a significant destabilizing factor in many countries, and that this results in an increased global spread of both communicable and lifestyle-related disease, which causes human suffering for both EU and non-EU citizens. In other words, addressing the health challenges facing European citizenry is inextricably linked to tackling health challenges beyond Europe’s borders. This requires a shift away from ad hoc policy solutions to longer-term commitments and sustained interest from leadership.
- strengthening global health security
- promoting global health equity
- enhancing good governance for global health
In responding to these challenges, Europe can provide a unique contribution to: strengthening health systems to enable them to identify and respond to global health risks as well as providing better health and care, developing and sharing skills and knowledge to improve services, and helping to train, develop and retain the health workforce they need.
There are, of course, many other ways in which Europe can contribute to global health, including:
- strengthening health governance at global and national level to ensure better use of resources and to reduce corruption
- addressing trade constraints to development and health as well as illegal trade harmful to health
- ensuring access to essential medicines
- supporting research, development and delivery of health solutions and drugs that meet the needs of resource-poor countries
- developing exchanges and twinning between health communities
- addressing the health needs of women
A process to engage the many different actors and networks in this field in developing a European Strategy for Global Health could help establish a more coherent basis for action in addressing such complex issues.
More on European Priority-Setting for Global Health
Strengthening global health security
The EU has responded more urgently to issues of health security and the threat of global pandemics and outbreaks that could affect the health of EU citizens, than to the poverty, equity and development challenges. There has been, for example, a long-term accord between the EU and the US to work together to strengthen global health surveillance, initially focused on communicable diseases but now with a wider remit. Since 1998 the EU has funded its own health surveillance programme. Coordination within the EU in preparing response plans for health emergencies has also been emphasised in EU policies and has been strengthened in response to the avian influenza and the threat of a global influenza pandemic. In 2005 the European Centre for Disease Prevention and Control came into operation. This new agency provides a point of coordination and technical support for the many European public health agencies and laboratories that provide international health surveillance and support for response to health emergencies. It has grown from a small agency with 50 staff to its current staff of some 300 people including seconded experts from EU Member States. While its remit is focused on the protection of EU citizens, this necessarily requires it to play a role in the wider European neighbourhood and globally.
The introduction of the International Health Regulations which requires countries to recognise, monitor and respond to international threats to health, provides an opportunity to work with resource poor and middle income countries, particularly where they represent a specific threat to health within the EU, to define their health risks and to strengthen their capacity to respond to threats.
Promoting global health equity:
The “Programme for Accelerated Action on HIV / AIDS, malaria and TB in the context of poverty reduction” adopted by the Commission and endorsed by the Parliament attempts to establish a balanced programme of action across these diseases and in relation to broader issues of poverty and disease. The Millennium Development Goals (MDGs) have been declared by Development Commissioner Louis Michel to be central to EU policy, and were recently reaffirmed as such in the June 2008 European Council endorsements of the “EU Agenda for Action on the MDGs”. However, while in 2007, for the first time since the AIDS epidemic began, the number of people newly infected in a year declined, malaria nets were being distributed much more rapidly and more vaccines were reaching more children than ever before-the international community is still not making enough progress on the health of women and children generally, and on maternal and newborn health in particular. Similarly, despite unprecedented financial commitments having been made-it is still the case that the health MDGs (4, 5, & 6) are grossly under-funded in relation to their impact and importance for human development. Furthermore, a consensus is now forming that while there has been enormous support for programming to tackle specific infectious diseases, the capacity of under-funded and understaffed developing country health systems to deliver medicines, vaccines and preventive measures is not being adequately addressed. Consequently it is unlikely that the MDGs will be attained in most of Sub-Saharan Africa and several Asian countries unless programmes focus more on strengthening health system capacities and providing equal access to them.
Enhancing good governance for global health:
Poor governance and corruption is a major cause of the failure of health systems in the least developed countries and within some European Countries. It is therefore central to any effort to strengthen health systems to address such problems. In many cases doctors and nurses are so badly paid that accepting or even demanding gratitude money or gifts from patients is almost universal practice, while many health professionals appear to spend more time in their private practice than in their health system post. At higher levels corruption may be much more significant. Such practices destroy the trust on which health delivery depends and undermine health systems.
Europe should provide a model of good governance both within national systems and in its common actions on the governance of health determinants. This must start by improving governance within national health systems and by developing common processes to address issues such as trade impacts on health.
The difficulty that the EU faces in taking action to regulate an increasingly globalised food production industry, even when the health of its own citizens is at risk, is that action could be seen as counter to the interests of EU based multinational companies or its agricultural and trade policies. This dilemma can be seen in relation to action on tobacco and health, where subsidies to tobacco growers in Europe were some ten times the total level of health promotion within the EU. Recently, excitement over potentially beneficial health implications of reforms to Europe’s agriculture subsidy regime has to some extent been thwarted by to the 2008 financial crisis and economic recession. Due to ongoing crisis in commodity prices, the European Parliament’s agriculture committee called on the Commission to scale down its proposed reform of agricultural policy. Similar conflicts between short-term EU interests and long-term global priorities arise in relation to regulation of multi-national pharmaceutical companies and in relation to the recruitment of health professionals from developing countries to the EU. Following the adoption of the Lisbon Agenda the EU has recognised the need to resolve some of the issues inherent in the EU’s position on globalisation. The 2004 communication from the Commission to Parliament on “The Social Dimension of Globalisation – the EU’s policy contribution on extending the benefits to all” points out the need to address the issues, but as of yet progress has been limited and health has not been considered sufficiently.
Health Systems Strengthening (HSS):
A health system organises and manages the actions necessary to achieve and maintain the goals of health for all. It requires the active cooperation of many people and agencies, including health and care specialists but also other branches of central and local government, business organisations, schools and communities, NGOs, foundations, families and individual citizens.
According to the WHO primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community. In 1978 the WHO and its Member States signed the Declaration of Alma-Ata which supported a universal primary health care approach to developing health systems and improving health standard worldwide. However, soon after some international organizations began questioning the feasibility of such an approach given limited resources and growing disease-burden and in its placed began pursuing a selective approach to primary health care. What this implied was that aid programming for health would focus not on building up health systems from the community level to the national level, but rather on combating specific diseases. This disease-centric or “vertical” approach to health programming has been the dominant strategy of the international community since that time. The consequences have been positive in that overtime funding has increased enormously to address the most pressing scourges of our time, such as HIV; however, in many instances the gains made have come at a cost of torpid and fragmented health systems. Today this has occurred to the extent that vertical programmes aren’t able to achieve their desired impacts due to the lack of capacity of local health systems. Some of the greatest challenges international aid for health has faced in implementation have been the inability of health systems to deliver regular services, reach target populations and to cultivate community based health competence and health literacy.
As a result there has been a renewed attention to the need to strengthen health systems and a universal approach to primary health care. This is evidenced by a lively debate on vertical vs. horizontal approaches that has occurred within the international development and health communities over the last few years, and WHO Director General Margaret Chan’s decision to center the 2008 World Health Report on the theme “Primary Health Care: Now More Than Ever.”
Health systems in poor countries, particularly those in Africa, are under increasing strain, they face a growing burden of disease, and diminishing public sector budgets. In many countries salaries are insufficient to retain clinical staff in rural areas, so they move to the cities in order to be able to supplement their income from private patients and “gratitude payments” and an increasing number migrate to Europe where they can earn more. In the context of a high disease burden the health system represents the frontline for local, regional and even global health surveillance. Therefore the strength of a health system to discover, report, monitor and combat an outbreak can quickly become the deciding factors in the level of threat faced by the populations not only neighbouring the local of an outbreak, but half-way across the world as well. This is no exaggeration, for a real life example follow the path of SARS from Guangdong province, China to Hong Kong and then to Toronto. Using Europe as an example, this raises a dilemma: the threats of infectious disease (not only those to health, but to the global economy as well) can quickly become a concern of global proportions, but the capacity to monitor global disease threats depends upon local capacity for public health and health service provision.
For these reasons, Europe needs to increase its investment in global health systems in partnership with developing countries. This could take many forms including: budgetary support for health ministries, support for training and staff development, further twinning and other two-way relationships between health services, cooperation on health systems research and agreement on staff exchanges and migration. While health aid is increasing, the European Development Fund has been slow to support human resources for health. And despite a recent up-swing in donors’ attention to the need to refocus programming on horizontal approaches for health systems strengthening, most of the increases in aid for health of the last decade have focused on disease-specific (vertical) programmes, which both create additional problems of coordination for health ministries and draw staff and resources away from basic health care. Some of the most prominent disease-specific aid programmes of the previous five years have also been criticised for creating parallel structures for the delivery of aid at the country level (in part to avoid corruption and inefficiency) rather than strengthening the local government’s ability to foster a sturdy health system.
The range of experience available across the European region provides a rich vein of knowledge of health system innovation and development. The European Observatory on Health Systems and Policies, which is supported by many different European institutions, provides access to this knowledge as a resource for global health. The potential exists to combine this academic knowledge with the practical experience of the leadership of health systems and training and development of staff both in Europe and in developing countries. Many hospitals and other health organisations across Europe already support some form of twinning and knowledge exchange for clinical staff. This could be extended to support leadership and human resource development for health.
Innovations in health service provision must be matched by new approaches to investment in global health and in global public goods for health. This may involve reclassifying some elements of support for health systems, currently regarded as aid, to recognise their global impact, as well as offsetting the costs of training staff that migrate to Europe. Upon proven success, innovations such as the International Finance Facility for Immunization (IFFIm), which recognises the importance of investment for health as a global public good, need to be applied for the benefit of health systems in addition to specific drugs. In fact, this trend is already in motion. Since 2006 GAVI, which is supported by the IFFIm, has been accepting application to fund programmes for HSS. The 27 which have been approved have amounted to a multi-year predictable commitment of US $403 million for HSS. Such investment must continue and also engage the private and voluntary sectors in Europe as partners in the development and funding of new health system solutions.
Europe should be a major force in supporting investment in health systems and human resources for health in developing countries. Europe’s voice in health is a crucial element in global health development. But this support need not only take the form of new investments in health systems. Europe can be a leading force in the introduction of new approaches to vertical programming which helps foster stronger health systems. Furthermore, new approaches to vertical programming and commitments to health system must be combined with renewed efforts to promote community involvement in the spirit of primary health care and country-ownership. Effective and appropriate community involvement and stable health care systems can be mutually reinforcing. This can occur through formalised structures and forums (such as district health committees, clinic committees and hospital boards), as well as informally by inculcating a culture of consultation and respect for lay people. Health care systems can also disseminate information about local health services and the rights of service users, as well as publicise disparities in key indicators such as maternal mortality ratios and immunisation coverage rates. However, because communities are in themselves stratified, community involvement cannot be viewed as simple or a technocratic fix-it requires commitment from health workers to promote equity and prevent privileged groups from gaining preferential benefits. Human resources for health include, but are not limited to health professionals. It is increasingly recognised that the majority of care and basic health knowledge is provided by individuals and local communities. Thus, support for health systems must also include consideration of how to mobilise and empower local communities and traditional health providers in developing countries.
Europe with its experience in transparent and participatory approaches to integrating cultural and public policy diversity into common approaches is an ideal advocate and partner in the effort to improve health systems world wide.
Global Health Research and Knowledge Management:
Health research is investigative work undertaken on a systematic and rigorous basis using quantitative and qualitative methods to generate new knowledge that seeks to impact on human physical, social and psychological well-being.(Queensland Health) Knowledge management for health is a set of principles, tools and practices that enable people to create knowledge and to share, translate and apply what they know to improve health and the effectiveness of health systems. It is an integral skill for health for clinical and public health practitioners.
Health research is essential for achieving and maintaining a state of good health. The spectrum of health research encompasses:
- Biomedical research: Basic research (involving the physical and biological sciences including chemistry, genetics, molecular biology, pharmacology, toxicology, etc) leads to understanding of the biological nature of diseases and the human body, while applied research and development translates this knowledge into the creation of products (drugs, vaccines, diagnostics, medical appliances) to prevent, treat or ameliorate disease states.
- Health policy and systems research: Research on policy formulation, relationship of policy to evidence, prioritisation; health systems management, functions, efficiency, effectiveness, system factors affecting access, scale-up, monitoring and evaluation.
- Social sciences and behavioural research: Research on social, political, economic, environmental determinants of health and their relation to equity, access, lifestyle and health-seeking behaviours.
- Operational research: Research on factors affecting functioning of programmes, effectiveness of targeting, impact on behaviour, disease burdens and public health.
The 1990 report of the Commission on Health Research for Development identified that far too little health research is devoted to the needs of developing countries and that every country should conduct a programme of essential national health research. The Commission recommended that developing countries should aim to spend the equivalent of 2% of their national health budgets on health research and that donors should allocate 5% of their programme support for the health sector to research and research capacity strengthening. In January 2006, a resolution (EB117.R6) of the World Health Organization’s (WHO) Executive Board recommended that member states consider implementing this, and the resolution was adopted by the World Health Assembly in May 2006.
It is now widely understood that the determinants of health extend far beyond the health sector and that “research for health” must encompass not only the immediate causative agents of diseases but also social, political, economic and environmental factors that contribute to the health status of individuals and populations. The Commission on Social Determinants of Health, established by WHO in 2005, is conducted studies and gathered evidence over three years and in 2008 released its final report contributing greatly to this picture and highlighting the need for research into the health impact of every sector of activity.
Globalisation has been enabled by the rapid development of information and communications technology, which has made it possible to develop and share knowledge faster than ever before. It is estimated that more than 90% of information is now accessed in electronic form, whether by broadcast, telephone or the Internet. Since 1996 there has been an investment of $1 trillion in the Internet, providing online access to information for one-eighth of the world’s population.
The explosion of information brought about by the Internet and by developments in knowledge has had a particular impact on the practice of medicine. Medical knowledge doubles every 7-10 years; in 1997 it was estimated there were 40,000 articles published each year relevant to general medicine, in 2005 an electronic library for general medicine estimated it reviewed 100,000 articles in that year. However, information resources are not equitably shared; for large areas of the developing world access to Internet information is difficult and expensive. In high-income countries, more than 40% of people use the Internet and it costs them less than 2% of average salary, but in low-income high-mortality countries less than 1% of people have access and it costs more than 30% of average salary. While some medical schools in developing countries have Internet access, in many cases the quality of connection is poor and the cost high. It is also expensive for the public to gain access to information to enable them to look after their own health.
Bamako Call to Action: The 2008 Global Ministerial Forum on Research for Health was co-organized by the Council on Health Research for Development (COHRED), Global Forum for Health Research, Government of Mali, United Nations Educational, Scientific and Cultural Organization (UNESCO), World Bank and the World Health Organization (WHO). The largest gathering on this topic to date, it was the first time the major organisers of previous conferences on this topic came together with the purpose of holding “one conference under one roof.” Over 600 participants representing 75 countries attended-including official delegations from 65 nations. What observers found most encouraging was the energetic dialogue between government ministers and members of the scientific community-two groups which in the past have had difficulties communicating. The conference was also centred on forwarding work geared toward the research needs of the developing world as expressed by developing countries and not solely by international institutions. The Bamako Call to Action reaffirms the commitments of all actors to streamlining the international architecture which governs research and knowledge management for health, as well as holding governments to their investment commitments to health research as first recommended in the 1990 commission report noted above. The Call for Action also highlights issues of gender and equity as central concerns in health research.
European has several key roles to play in supporting, underpinning and enabling health research. These include support for: basic research that addresses significant global health challenges, including attention to ‘neglected’ diseases such as tropical parasitic diseases; the development of new drugs and vaccines for neglected diseases, particularly through funding of public-private partnerships like the International AIDS Vaccine Initiative, the Medicines for Malaria Venture and the TB Alliance which are addressing specific Millennium Development Goal (MDG) targets; and capacity building to ensure that developing countries can themselves conduct the health research that is vital to improving the efficiency and effectiveness of their health systems.
While in Europe online and telephone information services for doctors and the public (i.e. “e-Health” systems) have been successful in providing access to health knowledge, these are not available in the developing world. Poor people in rural areas often have to rely upon the information they can obtain from family members and friends. They may then gather what monies they can to go and purchase what they hope is the right medicine, which they then share around in the hope that it will be effective. This is the very opposite of a knowledge-based health service; it is expensive and dangerous. Knowledge resources for poor countries could be very effective in both supporting continuing medical information and providing better health information for rural people. Technical solutions to the delivery of information with limited Internet access are available using Internet conferencing facilities and/or low-cost portable hard drives and providing access from mobile phones. Indeed such technology may hold the key to delivering medical services in areas where it is very hard to locate highly trained staff due to lack of resources and support facilities.
Health knowledge must be relevant to local culture and resources and must be organised around the needs of users. This may mean using a mixture of traditional resources such as school education materials, book-based libraries, as well as local intranet, mobile phones and hand-held computers. The starting point must be a local appreciation of health knowledge and information needs and how it can best be developed within the local health system. Thus while Europe has a great many information resources it could offer the developing world, it will be important to start by supporting local skills in knowledge management for health alongside views on the leadership and innovation of health systems as described in the previous section.
Europe needs to strengthen its commitment to all dimensions of global health research and aim to allocate 5% of its programme support for the health sector of developing countries to strengthen research and research capacity. It should take the lead in the analysis of the local and national impact of global processes as well as the study of global health policies and governance. Europe should support the development of knowledge management for health in developing countries and assist them in developing information products and services to meet the needs they identify.