The Global Health Context and Who Plays | Essentials of Global Health with Richard Skolnik

Welcome. This will be the last of our introductory sessions. After that, you'll be ready to jump right into some of the questions that most concern you, such as what is it that people get sick, disabled, and die from? Which people does this happen to? Why does this happen? Why should we care? And what we've learned can be done to address these health problems. By the end of this session, you should be able to comment on the sustainable development goals that relate to health, outline the different types of actors involved in global health, articulate the role of key actors in global health, and note the regional groupings of the World Health Organization and the World Bank and how data is organized by those groupings. Let's begin by speaking about goals that have been agreed globally for improving health. In the year 2000, the global community got together and agreed to help achieve by 2015 a set of international development goals called the Millennium Development Goals, or MDGs. A number of these goals concern health, including pledges to reduce child mortality, improve maternal health, and reduce TB, HIV, malaria, and other communicable diseases. These goals were also associated with a number of specific targets. The MDGs expired in 2015, and the global community has now agreed to a set of sustainable development goals, or SDGs, which are to be achieved by 2030. Many of the SDGs, as you can see in this graphic, relate directly to health, such as Goal 2, zero hunger, Goal 3, good health and well-being, and 6, clean water and sanitation, which although it's an indirect, it's a really powerful indirect relationship with health, as you know. Many of the other goals, as you can also see here, have important indirect links to improving better health, such as ensuring better access to quality schooling, achieving gender equality, promoting equitable economic development, reducing inequality, and combating climate change. Some of the SDG targets that relate most directly to health include, by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births, by 2030, end preventable deaths of newborns and children under 5 years of age, by the same year to end the epidemic of AIDS, TB, malaria, and neglected tropical diseases, to reduce by one-third premature mortality from the non-communicable diseases, to ensure universal access to sexual and reproductive healthcare services, and by 2030, as well, to achieve universal healthcare coverage. The SDGs also call for ending all forms of malnutrition, including achieving by 2025 the internationally agreed targets on child stunting and child wasting, strengthening the capacity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks. In principle, the sustainable development goals should motivate greater concern within countries for health. In addition, the global community has pledged to work together on a regular basis to monitor and evaluate progress toward the achievement of these goals. Now, another important piece of background information on global health concerns the key actors in the global health arena. One important point to note is that there are many, many actors, and the number of key actors has grown in a way by leaps and bounds, as we say, over the last several decades. To make sense of who these actors are, I want to suggest that you group actors by type of organizations that they represent, and by the type of activities in which they engage. There are individuals, communities, and governments, UN agencies, multilateral organizations, such as the World Bank, owned in common by many countries, bilateral development organizations, which represent the links between one country and countries with which they're working, international partnerships, I'll speak more to all of these foundations, national research and health oversight organizations, universities, consulting firms, product development partnerships, pharmaceutical firms, and nongovernmental organizations. It's also helpful to think about the roles that different actors play. This could include a focus on one or more of the following, research, policy, program development and implementation, program financing, standard setting, or advocacy. In fact, let me now comment very briefly on a few of the many actors so that we can both see what kind of organization they are, and the kinds of activities in which they engage. Let's begin with the World Health Organization. The World Health Organization, or WHO, is in a sense at the summit of all of the global actors who work on health. It's located in Geneva, Switzerland. Its membership is universal, and WHO is responsible in a way for standard setting, for policy making, for advocacy with others, and also engages in substantial amounts of research on a range of global health topics. It's important to note, however, that the World Health Organization is a technical agency. It's really not a substantial financing agency. UNICEF is a specialized agency of the United Nations system. UNICEF, whose original name was United Nations International Children's Emergency Fund, is that part of the UN system, which is responsible for the health and well-being of children throughout the world. UNICEF engages in policy work, research work, and advocacy work, but UNICEF is also an important financier of investments in improving the health of children and their families in a wide range of countries. UNAIDS is a partnership of a number of other organizations. UNAIDS sits in Geneva, Switzerland as well. It's right across the street from the World Health Organization, and UNAIDS is that global organization which is responsible for overseeing the world's work on HIV and AIDS. UNAIDS engages in standard setting, research, policy making, advocacy, and also provides some financing for investing in efforts to address HIV and AIDS. The World Bank is the largest of the multilateral development banks. These are international cooperatives, in a way, owned by all of their member countries, which take the money that they raise through grants to them or through sales of bonds, un-lend that money and try to help countries in doing so in investing in a range of activities, including health. And in the health domain, the World Bank has, for a long time, been the largest actor among all of the multilateral development banks. The World Bank engages in research work in health, in policy making in health, in, and when I say policy making, I should say, I don't mean they're literally making policies. I mean they're doing work on policy related matters that can help to enable the global community to think harder about what are the most sensible, most cost effective, most appropriate investments, et cetera. So the World Bank is involved in policy making activities, in research, in advocacy, and it's also a substantial financier of activities in health in a number of its member countries. DFID, or the Department for International Development of the United Kingdom, is one of many what we call bilateral organizations. This is the development assistance agency of the United Kingdom. They work closely with a number of countries, and in the health sector, they provide assistance both technical and financial to the countries with which they're working. Now, DFID, like most other important bilateral actors, also supports work on research, supports work on policy making, and is engaged often in agenda setting activities with other actors as well. Gavi, here, and the Global Fund were developed around the year 2000, in a sense, out of some frustration by the global community at the relative slowness of addressing some of the most critical global health issues. Gavi and the Global Fund, in a sense, are international partnerships, and they bring together funding from high income countries, from some even middle income countries, from the private sector and foundations. And in the case of Gavi, they try to assist countries that are eligible for their assistance in strengthening their vaccine programs, both by helping to improve the coverage of the older vaccines, and by helping to expand, disseminate, and improve coverage of some of the newer vaccines as well. The Global Fund works in a somewhat similar way, but the Global Fund focuses its activities on HIV, TB, and malaria, and both of them are also located in Geneva. There are also a large number of non-governmental organizations, or NGOs, which are involved in global health activities. And one that's quite well known is Medecins Sans Frontieres, or MSF, known in English as Doctors Without Borders. These international organizations, these non-governmental organizations, can play a range of roles. The smallest ones may be involved locally with communities, and helping to enable people to live more healthy lives. The largest ones may actually even have seats at the agenda setting table with other important global health actors, and that's certainly true for Doctors Without Borders. It's also important to note that there are NGOs that grew up in some of the low income countries, like BRAC in Bangladesh, which have now themselves become very important actors, not only in Bangladesh, but in a range of other countries as well. And some of these organizations are very involved at a range of levels, from the community level to the global level, in working on a range of global health issues. Now, some years ago as well, in fact, beginning in 1997, also born of some frustration that things weren't moving fast enough, and that new drugs, diagnostics, and vaccines weren't emerging from the market as we wanted to help meet the health needs of poor people in poor countries, the global community created what we now call Public-Private Partnerships for Health, or Product Development Partnerships for Health. And the TB Alliance, or the Global Alliance for TB Drug Development, as it used to be called, is one such organization that tries to bring together actors from the global community, from individual countries, from the public and private sector, from the pharma sector and other sectors as well, to enable the creation in faster and better ways than would otherwise be possible of TB drugs that will be better than the drugs we have now, or shorter course than the drugs we have now, and that will enable people who suffer from TB worldwide to be treated more effectively and efficiently, and hopefully at low cost as well, a lower cost, than we can do today. And there are a very wide range of these Public-Private Partnerships and Product Development Partnerships for Global Health. Foundations have become very active in global health and have been for many, many years. But now, in many respects, the terrain has changed somewhat as the Bill and Melinda Gates Foundation has become so actively involved. In many respects, the Bill and Melinda Gates Foundation focuses largely on investing in the development of new technologies that can help enable better health of marginalized people in low-resource settings. But they do occasionally also support some other activities, including programs like a very important program to address HIV in India that they supported. One should also be aware that the Wellcome Trust in the United Kingdom is also another very large foundation that supports health research, some of which can enable better health in low- and middle-income countries. I could go on, and I could go on for a really long time, talking about the many actors in global health and what they do, but that's really not the point. What I really want you to understand is that this small sample of actors represents a wide range of different kinds of organizations engaged in different kinds of activities who are engaged in global health work today. To find out more about these actors, I want to encourage you to take a look at the websites of some of them, to review relevant sections of different global health textbooks, and to pursue a range of articles as well to get a feel for who's involved, how they're involved, and how, as they say, global health, in a way, is governed these days. Before ending this last introductory session, it's important to also note how global health data is organized. Two of the most important sources of data on global health are the World Health Organization and the World Bank. You should be aware that some data is organized by country income group following the methodology of the World Bank Atlas, which is republished and updated every year. Every year, the World Bank republishes the Atlas. They update their data on the per capita income of different countries and the so-called income groups into which they fall. So here, as we see, one group of countries is called high-income countries that don't belong to the Organization of Economic Cooperation and Development. And then there's another group of countries, which are high-income countries that do belong to the OECD. Then there are upper-middle-income countries. There are lower-middle-income countries. And lastly, there are what we call, what the World Bank defines as, the lowest or lower-income countries. And I remind you, this is based on a per capita income that the World Bank recalculates each year. And let's explore for one minute just some examples of the World Bank country income groups. And this won't be a surprise to most of you, but it will help you to get a little bit better feel for which countries fall into which country income group. So when we think about low-income countries, these might include Cambodia, Haiti, and Mozambique. Lower-middle-income, Egypt, the Philippines, and Vietnam. Upper-middle, Costa Rica, South Africa, and Turkey. And finally, some of what we certainly know of as the high-income countries, Denmark, the Netherlands, and Singapore. Now that we've looked at how the World Bank organizes some data by country income group, it's important to understand that some data is also organized by World Bank geographic region. And so let's look at the next graphic. And here what we see is that the World Bank has a number of geographic regions. We have first, Latin America and the Caribbean region. Second, we have the Africa region. Third, we have the Middle East and North Africa region. Fourth, we have South Asia. Fifth, we have Europe and Central Asia. And lastly, we have the region that they call East Asia and the Pacific. Data is also shown, and important data, by region of the World Health Organization. And in some respects, a little bit sadly or a little bit confusingly, the World Bank regional data is not organized the same way. As the WHO regional data. World Bank geographic regions and World Health Organization geographic regions are not the same. So in this graphic, we see the geographic regions of the World Health Organization. We saw Africa. We see the region of the Americas. Southeast Asia. The European region. The Eastern Mediterranean. And lastly, the region of the Western Pacific. So it's going to be important as you explore data on global health that you be familiar with these different regions, how they, data is not always organized the same. You'll learn to differentiate them, but also to make good sense of them as you go along. You now have a better understanding of the global goals for health. Some of the key international actors involved in global health. Some of the key activities in which they're engaged. And how some key data for global health is organized. In the next session, we'll look at how we measure health status of different communities and different countries.