Handbook of Global Health [1st ed. 2021] 3030450082, 9783030450083

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Robin Haring Editor-in-Chief Ilona Kickbusch · Detlev Ganten Matshidiso Moeti  Editors

Handbook of Global Health

Handbook of Global Health

Robin Haring Editor-in-Chief

Ilona Kickbusch • Detlev Ganten • Matshidiso Moeti Editors

Handbook of Global Health With 362 Figures and 152 Tables

Editor-in-Chief Robin Haring Monash University Melbourne, Australia European University of Applied Sciences Rostock, Germany Editors Ilona Kickbusch Graduate Institute of International and Global Health Programme Geneva, Switzerland

Detlev Ganten Charité Foundation Berlin, Germany

Matshidiso Moeti World Health Organization, Regional Office Brazzaville, Republic of the Congo

ISBN 978-3-030-45008-3 ISBN 978-3-030-45009-0 (eBook) ISBN 978-3-030-45010-6 (print and electronic bundle) https://doi.org/10.1007/978-3-030-45009-0 © The Editors and the World Health Organization 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This Handbook of Global Health is one of the rare cases, when essence precedes existence. Initially framed as a “collection of problems, rather than a discipline,” the rapidly emerging field of global health was manifested in 2020 by the COVID-19 pandemic. The ongoing pandemic not only substantiates the definition, methods, and practice of global health, but also evidenced the interconnectedness and interdependence of major health challenges in the twenty-first century. Therefore, this timely handbook aims to provide up-to-date expertise highlighting all aspects of global health to help students, researchers, and practitioners working across a range of disciplines to translate knowledge into action. Realizing the lack of a comprehensive overview of current global health topics and challenges for global health decision-making and public policy, the genesis of the present Handbook of Global Health began in 2017 around the World Health Summit, a leading annual international global health conference in Berlin. Taking advantage of the fact that diversity is the key to success, also in global health, authorship contributions of this handbook are gender-balanced and equally promote authors from the global South as well as North. We are grateful to this diverse field of authors for their valuable expertise and would also like to thank Michael Herrmann, Tina Shelton, and Divya Nithyanandam from Springer Nature for their continuous support during the preparation and production of this handbook. Looking into a post-pandemic future, it is our sincerest hope that the Handbook of Global Health will serve students, researchers, and practitioners alike, taking a one-health approach at the human-animal-environment interface to ensure multispecies health and well-being in the twenty-first century. Berlin April 2021

Robin Haring Ilona Kickbusch Detlev Ganten Matshidiso Moeti

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Contents

Volume 1 Part I Global Health: Principles and Drivers of a Transformative Paradigm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

1

Global Health: Definition, Principles, and Drivers . . . . . . . . . . . . . Johanna Hanefeld and Hanna-Tina Fischer

3

2

Globalization and Global Health Katia S. Mohindra

..........................

29

3

Urbanization and Cities as Drivers of Global Health . . . . . . . . . . . Fatima Ghani, Emmanuel Tsekleves, and Yonette Felicity Thomas

45

4

Aging and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mihajlo Jakovljevic, Ronny Westerman, Tarang Sharma, and Demetris Lamnisos

73

5

Culture, Diversity, and Global Health: Challenges and Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Narayan Gopalkrishnan

6

Digital Transformation and Global Health in Africa . . . . . . . . . . . Gloria Ejehiohen Iyawa, Suama Hamunyela, Anicia Peters, Samuel Akinsola, Irja Shaanika, Benjamin Akinmoyeje, and Sinte Mutelo

Part II 7

8

Global Health Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . .

Epidemiological Methods and Measures in Global Health Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emmanuel Agogo and Kelly Elimian Quantitative Methods in Global Health Research . . . . . . . . . . . . . Jamalludin Ab Rahman

103 137

169

171 191

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Contents

9

Qualitative Research in Global Health Research . . . . . . . . . . . . . . Pranee Liamputtong and Zoe Sanipreeya Rice

213

10

Mixed Methods in Global Health Research . . . . . . . . . . . . . . . . . . Manmeet Kaur and Rajesh Kumar

239

11

Accountability and Aid Effectiveness Research in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elvira Beracochea

12

Global Health Project Design, Monitoring and Evaluation . . . . . . Nancy A. Scott and Lauren Schmidt

Part III

Population Health Dynamics . . . . . . . . . . . . . . . . . . . . . . . .

13

Innovations in Disease Surveillance and Monitoring . . . . . . . . . . . Jessica Espey and Hayden Dahmm

14

Population Dynamics Approaches for Research and Action in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barthelemy Kuate Defo

15

Global Migration and Population Health . . . . . . . . . . . . . . . . . . . . Brian D. Gushulak

Part IV

Global Burden of Disease

..........................

261 295

315 317

339 387

421

16

Global Burden of CVD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K. Srinath Reddy and Manu Raj Mathur

423

17

Global Burden of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . John R. Hurst and Trishul Siddharthan

439

18

Global Burden of Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Twalib A. Ngoma and Mamsau Ngoma

459

19

Global Burden of Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . Perianayagam Arokiasamy, Supriya Salvi, and Y. Selvamani

495

20

Global Burden of HIV/AIDS Frank Lule

.............................

539

21

Global Burden of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . Charlene Sunkel

587

Part V 22

Global Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tobacco as Global Health Risk Factor . . . . . . . . . . . . . . . . . . . . . . Douglas Bettcher, Juliette McHardy, Hebe Gouda, and Ranti Fayokun

615 617

Contents

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23

Global Health Risk Factors: Alcohol Consumption . . . . . . . . . . . . Jürgen Rehm, Jakob Manthey, and Kevin D. Shield

679

24

Global Health Risk Factors: Air Pollution . . . . . . . . . . . . . . . . . . . A. Kofi Amegah

719

25

The Global Pandemic of Overweight and Obesity . . . . . . . . . . . . . Donna Ryan, Simon Barquera, Olivia Barata Cavalcanti, and Johanna Ralston

739

26

Global Health Risk Factors: Physical Inactivity . . . . . . . . . . . . . . . Fiona Bull, Regina Guthold, Daniel J. Friedman, and Peter Katzmarzyk

775

27

Injuries as Global Health Risk Factor . . . . . . . . . . . . . . . . . . . . . . Jagnoor Jagnoor and Margie Peden

823

Volume 2 Part VI

Global Health Life Course Perspectives . . . . . . . . . . . . . . .

28

Life Course Approaches in Global Health . . . . . . . . . . . . . . . . . . . Claudine Burton-Jeangros

29

Infertility Among Women in Low- and Middle-Income Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mellissa Withers

855 857

885

30

Global Infant Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kasonde Mwinga, Nhimba Mwinga, and Takeshi Nomaguchi

911

31

Health of Infants, Children, and Adolescents . . . . . . . . . . . . . . . . . Fiona Muttalib, Amir H. Sohail, and Zulfiqar A. Bhutta

949

32

Health and Survival in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . Domantas Jasilionis and Dmitri A. Jdanov

993

33

Women’s Midlife Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013 Jacqueline Maria Dias, Muhammad Arsyad Subu, Mini Sara Abraham, and Nabeel Al Yateem

34

Global Health in Young Adulthood . . . . . . . . . . . . . . . . . . . . . . . . 1043 Valentina Baltag, Regina Guthold, and Susan M. Sawyer

Part VII 35

Global Health Inequality . . . . . . . . . . . . . . . . . . . . . . . . . . .

1089

Socioeconomics and the Macro- and Micro-level Determinants of Global Health Inequality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1091 Iñaki Permanyer and Jeroen Spijker

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Contents

36

Social Theories for Global Health Research and Practice . . . . . . . 1127 Garrett Wilkinson, Salmaan Keshavjee, Bridget Hanna, and Arthur Kleinman

37

Gender and Global Health Inequality Roopa Dhatt and Caitlin Pley

38

Migration, Ethnicity, and Health Inequality . . . . . . . . . . . . . . . . . . 1193 Bernadette N. Kumar and Esperanza Diaz

39

Geography of Economic Disparities and Global Health Inequality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1215 Sherine Shawky

40

Environmental Inequalities in Global Health . . . . . . . . . . . . . . . . . 1229 Paula Santana, Ricardo Almendra, Eva Pilot, Simone Doreleijers, and Thomas Krafft

41

Culture and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249 Zoe Sanipreeya Rice and Pranee Liamputtong

42

Commercial Determinants of Global Health Luke N. Allen

43

Behavioral Health Theories, Equity, and Disparities in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1311 Lauren E. McKinley, Kaylyn McAnally, Susette A. Moyers, and Martin S. Hagger

44

Technological Innovations and Social Inequalities in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1335 Daniel Weiss and Terje Andreas Eikemo

Part VIII

. . . . . . . . . . . . . . . . . . . . . . 1145

. . . . . . . . . . . . . . . . . 1275

Global Healthcare Systems . . . . . . . . . . . . . . . . . . . . . . . .

1367

45

International Health Care Systems: Models, Components, and Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1369 Honore Kabwebwe Mitonga and Anna Panduleni Kauko Shilunga

46

Comparative Health Systems Analysis and Evaluation . . . . . . . . . 1389 Carleen H. Stoskopf and Marissa A. Venn

47

Assessment of Health System Performance and Health Care Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1437 Rüdiger Krech, Agnès Soucat, and Theresa Diaz

48

Traditional and Complementary Medicine in Global Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1459 Ossy M. J. Kasilo and Charles Wambebe

Contents

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49

Long-Term Care in Ageing Populations . . . . . . . . . . . . . . . . . . . . . 1507 Sarah L. Barber, Paul Ong, and Zee A. Han

50

Global Health Systems Maithri Goonetilleke

51

Global Healthcare Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1569 Grace Achungura Kabaniha, John Ele-Ojo Ataguba, and Joseph Kutzin

52

Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1611 Githinji Gitahi and Cheryl Cashin

53

Integrated Care and Community Services in Global Health . . . . . 1651 K. Viktoria Stein

Part IX

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1541

Digital Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1665

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1667

54

Precision Global Health Antoine Flahault

55

Health Information Systems, Electronic Medical Records, and Big Data in Global Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1699 Francesca Colombo, Jillian Oderkirk, and Luke Slawomirski

56

eHealth Solutions in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . 1731 Derrick Muneene

57

mHealth Solutions in Global Health Applications and Implementation in Low- and Middle-Income Countries Smisha Agarwal, Dari Alhuwail, and Oommen John

. . . . . . . . 1747

58

Artificial Intelligence and Machine Learning in Global Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1775 Arjun Panesar and Harkrishan Panesar

59

Medical and Assistive Robotics in Global Health . . . . . . . . . . . . . . 1815 Michelle J. Johnson, Kevin Bui, and Narges Rahimi

60

Real-World Data in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . 1861 Jeffrey S. Barrett

Volume 3 Part X 61

Global Health Policy and Ethics . . . . . . . . . . . . . . . . . . . . . .

1885

Sustainable Development Goals: Concept and Challenges of Global Development Goal Setting . . . . . . . . . . . . . . . . . . . . . . . . . . 1887 Godwell Nhamo, Kaitano Dube, and David Chikodzi

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62

Health in All Policies: Concept, Purpose, and Implementation . . . 1927 Timo Ståhl and Meri Koivusalo

63

Health in All Policies: Transport, Mobility, and Health . . . . . . . . . 1949 Juan J. Castillo, Daniel Buss, and Marcelo Korc

64

Health in All Policies: Agriculture, Land Use, and Animal Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1971 Thomas D. Dulu

65

Health in All Policies: Urban Development, Health, and Health Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1985 Jason Corburn

66

International Trade Agreements and Global Health: Pathways and Politics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2009 Ashley Schram and Belinda Townsend

67

Health Promoting Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2037 David Houéto and Suvajee Good

68

Nutrition in Health Promotion Policies and Programs at the Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2063 Adelheid W. Onyango, Laetitia Nikiema, and Ruth W. Kimokoti

69

One Health and Emerging Zoonotic Diseases . . . . . . . . . . . . . . . . . 2099 Bruce A. Wilcox and Jennifer A. Steele

70

Evidence-Based Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2149 Rajesh Balkrishnan and Akhil Rekulapelli

Part XI

Global Environmental Health

.......................

2167

71

Environment, Biodiversity, and Planetary Health: Links Between Natural Systems and Human Health . . . . . . . . . . . . . . . . 2169 Suneetha M. Subramanian and Unnikrishnan Payyappallimana

72

Climate Change and Global Health . . . . . . . . . . . . . . . . . . . . . . . . 2183 Lina Taing and Kimberly Mahadeo

73

Environmental Burden of Disease David Rojas-Rueda

74

Water, Sanitation, and Hygiene in Global Health Lina Taing and Nga Dang

75

Global Impact of Chemicals and Toxic Substances on Human Health and the Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2227 Francis O. Adeola

. . . . . . . . . . . . . . . . . . . . . . . . . 2197 . . . . . . . . . . . . . 2211

Contents

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Global Occupational Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2257 Tee L. Guidotti and Ivan Dimov Ivanov

77

Planetary Health: Systems Perspectives and Impact of Climate and Environmental Change on Human and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2293 Teddie Potter

Part XII

Global Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . . .

2313

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Global Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2315 Emmanuel Chanda

79

Natural Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2335 Junaid Ahmad and Haleema Sadia

80

Whose Health Matters: Trust and Mistrust in Humanitarian Crisis and Global Health Interventions . . . . . . . . . . . . . . . . . . . . . 2347 Andrea Steinke and Sonja Hövelmann

81

Antimicrobial Resistance and Global Health . . . . . . . . . . . . . . . . . 2379 Zulqarnain Baloch, Bilal Aslam, Nafeesa Yasmeen, Amjad Ali, Zewen Liu, Abdual Rahaman, and Zhongren Ma

82

Management of Complex Emergencies in Global Health . . . . . . . . 2393 Olushayo Oluseun Olu, Dick Chamla, and Joseph Francis Wamala

83

Humanitarian Crisis and Complex Emergencies: Burden of Disease, Response, and Opportunities for Global Health . . . . . . 2437 Benjamin Schmid and Emmanuel Raju

Part XIII

Global Health Workforce and Education . . . . . . . . . . . . .

2473

84

Human Resources for Global Health . . . . . . . . . . . . . . . . . . . . . . . 2475 Ebele Mogo and Tolu Oni

85

Global Health Professionals: Education and Training . . . . . . . . . . 2503 Lisa V. Adams and Alka Dev

86

Community Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2525 Maithri Goonetilleke

87

Rural Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2535 Michelle McIsaac

88

Informal Care and Community Volunteer Work in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2553 Mirkuzie Woldie and Kiddus Yitbarek

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Occupational Risks and Health Promotion for Healthcare Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2581 Bobby Joseph and Sakthi Arasu

Part XIV

Global Health Institutions and Organizations . . . . . . . . .

2609

90

Global Health Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2611 Obijiofor Aginam

91

Global Health Partnerships and Translation . . . . . . . . . . . . . . . . . 2625 Vijay Kumar Chattu and Garry Aslanyan

92

Multilevel Cooperation and Network on Global Health . . . . . . . . . 2657 Hidechika Akashi

93

Innovation, Intellectual Property, and Global Health Jayashree Watal

94

Corporate Influence and Social Responsibility in Global Health: Evidence from India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2717 Nayan Mitra, Sumona Ghosh, and Khushboo Mehta

95

Public–Private Partnerships for Global Health . . . . . . . . . . . . . . . 2755 Hurriyet Babacan

96

Nongovernmental Organizations (NGOs) in Global Health . . . . . . 2789 Suguna Anbazhagan and A. Surekha

97

United Nations and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . 2801 Doris Kirigia and Augustine Asante

98

The World Health Organization and Global Health Gaudenz Silberschmidt

. . . . . . . . . . 2683

. . . . . . . . . . . 2833

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2881

About the Editor-in-Chief

Robin Haring Ph.D., Professor at the European University of Applied Sciences in Germany and Adjunct Professor at Monash University, School of Public Health and Preventive Medicine in Melbourne, Australia. His research interests focus on biomarker, cardiovascular epidemiology, and global health. He has published 100+ articles, several books, and book chapters, and received fellowships and funding from the Max-Planck Society, European Union, and World Heart Federation. Professor Haring is also editor-in-chief of the Springer Major Reference Work Gesundheitswissenschaften.

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About the Editors

Ilona Kickbusch Ph.D., Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva. She has had a distinguished career with the WHO, where she initiated the Ottawa Charter for Health Promotion and a range of “settings projects” including Healthy Cities. Her key areas of interest are global health governance, global health diplomacy, and health in all policies. She advises organizations, government agencies, and the private sector on policies and strategies to promote global health at all levels. Dr. Kickbusch has published widely and is a member of a number of advisory boards in both the academic and the health policy arena. She has recently launched a think-tank initiative “Global Health Europe: A Platform for European Engagement in Global Health” and the “Consortium for Global Health Diplomacy.” Detlev Ganten M.D., Ph.D., Founding President of the World Health Summit and Chairman of the Board of the Charité Foundation. He was appointed as professor of pharmacology at the University of Heidelberg in 1975 and moved to Berlin in 1991 where he became the founding director and president of the Max Delbrück Center for Molecular Medicine (MDC). He held these roles until 2004, when he became the Chief Executive Officer at the “Charité Universitätsmedizin Berlin.” His research in the molecular biology of high blood pressure, public health, and bioethics received many international awards and prizes. Dr. Ganten also functions in various scientific societies and committees, including several honors and awarded memberships. In 2009, he founded the World xvii

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About the Editors

Health Summit, a leading annual international conference in Berlin to find solutions for the challenges posed by global health. Matshidiso Moeti M.D., WHO Regional Director for Africa. Prior to WHO, she worked with UNAIDS as team leader of the Africa and Middle East Desk in Geneva (1997–1999), with UNICEF as regional health advisor for East and Southern Africa, and with Botswana’s Ministry of Health as a clinician and public health specialist. Within WHO, she served as assistant regional director, director of non-communicable diseases at the regional office, WHO country representative in Malawi, and coordinator of the Inter-Country Support Team for the South and East African countries of WHO African Region. As a public health veteran, with more than 35 years of national and international experience, she was the first woman to be elected as WHO regional director for Africa in 2015. Under her leadership, she is cultivating strong partnerships to support countries to achieve universal health coverage (UHC), improve health security, and promote better well-being to make health a reality for all people in Africa.

Contributors

Jamalludin Ab Rahman Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia Mini Sara Abraham Department of Nursing, University of Sharjah, Sharjah, United Arab Emirates Lisa V. Adams Center for Global Health Equity, Geisel School of Medicine at Dartmouth, Hanover, NH, USA Department of Medicine/Section of Infectious Disease and International Health, Geisel School of Medicine at Dartmouth, Hanover, NH, USA Francis O. Adeola Department of Anthropology and Sociology, The University of New Orleans, New Orleans, LA, USA Smisha Agarwal Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Obijiofor Aginam Law and Legal Studies, Carleton University, Ottawa, ON, Canada Emmanuel Agogo Prevention and Programme Coordination, Nigeria Centre for Disease Control, Abuja, Nigeria Junaid Ahmad Prime Institute of Public Health, Peshawar Medical College, Peshawar, Pakistan Hidechika Akashi Department of Health Planning and Management, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan Benjamin Akinmoyeje Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Samuel Akinsola Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Nabeel Al Yateem University of Sharjah, Sharjah, United Arab Emirates xix

xx

Contributors

Dari Alhuwail Information Science Department, Kuwait University, Kuwait City, Kuwait Amjad Ali Biomedical Research Center, Northwest Minzu University, Lanzhou, China Luke N. Allen Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK Ricardo Almendra Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, Coimbra, Portugal A. Kofi Amegah Public Health Research Group, Department of Biomedical Sciences, University of Cape Coast, Cape Coast, Ghana Suguna Anbazhagan Department of Community Health, MGMCRI, SBV University, Puducherry, India Sakthi Arasu Division of Occupational Health Services, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India Perianayagam Arokiasamy Department of Development Studies, International Institute for Population Sciences (IIPS), Mumbai, MH, India Augustine Asante School of Population Health, University of New South Wales (UNSW), Sydney, NSW, Australia Bilal Aslam Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan Garry Aslanyan Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization (WHO), Geneva, Switzerland Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada John Ele-Ojo Ataguba Health Economics Unit, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa Hurriyet Babacan The Cairns Institute, James Cook University, Cairns, North Queensland, Australia Rajesh Balkrishnan School of Medicine, University of Virginia, Charlottesville, VA, USA Zulqarnain Baloch Biomedical Research Center, Northwest Minzu University, Lanzhou, China Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland Olivia Barata Cavalcanti World Obesity Federation, London, UK

Contributors

xxi

Sarah L. Barber Centre for Health Development, World Health Organization, Kobe, Hyogo prefecture, Japan Simon Barquera Instituto Nacional de Salud Pública, Mexico DF, Mexico Jeffrey S. Barrett Quantitative Medicine, Critical Path Institute, Tucson, AZ, USA Elvira Beracochea Realizing Global Health, Fairfax, VA, USA Douglas Bettcher WHO, Geneva, Switzerland Zulfiqar A. Bhutta Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan Kevin Bui Department of Bioengineering, Rehabilitation Robotics Lab, University of Pennsylvania, Philadelphia, PA, USA Fiona Bull Department of Health Promotion, World Health Organization, Geneva, Switzerland Claudine Burton-Jeangros Institute of Sociological Research and Swiss NCCR “LIVES – Overcoming Vulnerability: Life Course Perspectives”, University of Geneva, Geneva, Switzerland Daniel Buss Pan American Health Organization, Washington, DC, USA Cheryl Cashin Results for Development (R4D), Washington, DC, USA Juan J. Castillo Pan American Health Organization, Washington, DC, USA Dick Chamla United Nations Children Fund, Kabul, Afghanistan Emmanuel Chanda World Health Organization, Regional Office for Africa, Brazzaville, Republic of the Congo Vijay Kumar Chattu Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada Institute of International Relations, The University of the West Indies, St. Augustine, Trinidad and Tobago David Chikodzi Institute for Corporate Citizenship, University of South Africa, Pretoria, South Africa Francesca Colombo Health Division, Organisation for Economic Co-operation and Development, Paris, France Jason Corburn School of Public Health and Department of City and Regional Planning Director, Institute of Urban and Regional Development, Berkeley, CA, USA Hayden Dahmm UN Sustainable Development Solutions Network, London, UK

xxii

Contributors

Nga Dang United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, ON, Canada Alka Dev The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA Roopa Dhatt Women in Global Health, Washington, DC, USA Jacqueline Maria Dias Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates Esperanza Diaz Norwegian Unit for Migration and Minority Health, Norwegian Institute of Public Health, Oslo, Norway Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Theresa Diaz Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland Simone Doreleijers Faculty of Health, Medicine and Life Sciences (FHML), Care and Public Health Research Institute (CAPHRI), Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands Kaitano Dube Vaal University of Technology, Vanderbijlpark, South Africa Thomas D. Dulu State Department of Livestock, Ministry of Agriculture, Livestock, Fisheries and Cooperatives, Nairobi, Kenya Terje Andreas Eikemo Center for Global Health Inequalities Research (CHAIN), Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway Kelly Elimian Department of Microbiology, Faculty of Life Sciences, University of Benin, Benin City, Nigeria Jessica Espey UN Sustainable Development Solutions Network, London, UK Ranti Fayokun WHO, Geneva, Switzerland Hanna-Tina Fischer Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK Antoine Flahault Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland Daniel J. Friedman Alfred Health, Melbourne, VIC, Australia Fatima Ghani International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia Convenor of the Design Research Society Special Interest Group on Global Health, London, UK Sumona Ghosh Department of Commerce, St. Xavier’s College, Kolkata, India

Contributors

xxiii

Githinji Gitahi Amref Health Africa, Nairobi, Kenya Suvajee Good Healthier Population Division, Department of Programme Management, WHO African Regional Office, Brazzaville, Democratic Republic of the Congo Health Promotion and Social Determinants of Health, Department of Healthier Population and Non communicable Diseases, WHO South-East Asia Regional Office, New Delhi, India Maithri Goonetilleke School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia Narayan Gopalkrishnan Department of Social Work, College of Arts, Society and Education Division of Tropical Environments and Societies, James Cook University, Cairns, Australia Hebe Gouda WHO, Geneva, Switzerland Tee L. Guidotti Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada Brian D. Gushulak Migration Health Consultants, Qualicum Beach, BC, Canada Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland Martin S. Hagger Psychological Sciences, University of California, Merced, CA, USA Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland Suama Hamunyela Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Zee A. Han Department of Maternal, Child, Adolescent Health and Ageing and Health, World Health Organization, Geneva, Switzerland Johanna Hanefeld Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK LSHTM Berlin, Department of Global Health and Development, London School of Hygiene and Tropical Medicine and Centre International Health Protection; Robert Koch - Institute, Berlin, Germany Bridget Hanna Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA David Houéto Healthier Population Division, Department of Programme Management, WHO African Regional Office, Brazzaville, Democratic Republic of the Congo Sonja Hövelmann Centre for Humanitarian Action, Berlin, Germany

xxiv

Contributors

John R. Hurst UCL Respiratory, University College London, London, UK Ivan Dimov Ivanov Division of Healthier Populations, World Health Organization, Geneva, Switzerland Gloria Ejehiohen Iyawa Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Jagnoor Jagnoor The George Institute for Global Health, New Delhi, India The George Institute for Global Health, University of New South Wales, Sydney, Australia Mihajlo Jakovljevic Department of Global Health Economics and Policy The Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia Domantas Jasilionis Laboratory of Demographic Data, Max Planck Institute for Demographic Research, Rostock, Germany Demographic Research Centre, Vytautas Magnus University, Kaunas, Lithuania Dmitri A. Jdanov Laboratory of Demographic Data, Max Planck Institute for Demographic Research, Rostock, Germany International Laboratory of Population and Health, National Research University Higher School of Economics, Moscow, Russian Federation Oommen John Senior Research Fellow, George Institute for Global Health, New Delhi, India Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia Michelle J. Johnson Department of Physical Medicine and Rehabilitation, Director of Rehabilitation Robotics Lab, University of Pennsylvania, Philadelphia, PA, USA Bobby Joseph Division of Occupational Health Services, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India Grace Achungura Kabaniha World Health Organization Country Office–India, New Delhi, India Ossy M. J. Kasilo Universal Health Coverage Life Course Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo Peter Katzmarzyk Pennington Biomedical Research Center, Baton Rouge, LA, USA Manmeet Kaur Postgraduate Institute of Medical Education and Research, Chandigarh, India

Contributors

xxv

Salmaan Keshavjee Partners In Health, Boston, MA, USA Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Harvard Medical School Center for Global Health Delivery, Boston, MA, USA Department of Anthropology, Harvard University, Cambridge, MA, USA Ruth W. Kimokoti Simmons University, Boston, MA, USA Doris Kirigia World Health Organization Regional Office, Brazzaville, Congo Arthur Kleinman Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Department of Anthropology, Harvard University, Cambridge, MA, USA Meri Koivusalo Tampere University, Tampere, Finland Marcelo Korc Pan American Health Organization, Washington, DC, USA Thomas Krafft Faculty of Health, Medicine and Life Sciences (FHML), Care and Public Health Research Institute (CAPHRI), Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands Rüdiger Krech Division of Universal Health Coverage and Healthier Populations, World Health Organization, Geneva, Switzerland Barthelemy Kuate Defo Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada Department of Demography, Faculty of Arts and Sciences, University of Montreal, Montreal, QC, Canada Bernadette N. Kumar Norwegian Unit for Migration and Minority Health, Norwegian Institute of Public Health, Oslo, Norway Empower School of Health, Gurugram, India Rajesh Kumar State Health Systems Resource Center, Department of Health and Family Welfare, Government of Punjab, Chandigarh, India Joseph Kutzin Health Systems Governance and Financing Department, World Health Organization, Geneva, Switzerland Demetris Lamnisos Department of Health Sciences, European University Cyprus, Nicosia, Cyprus Pranee Liamputtong School of Health Sciences, Western Sydney University, Penrith, NSW, Australia Zewen Liu Biomedical Research Center, Northwest Minzu University, Lanzhou, China Frank Lule HIV Prevention, WHO-AFR, Brazzaville, Republic of the Congo

xxvi

Contributors

Zhongren Ma Biomedical Research Center, Northwest Minzu University, Lanzhou, China Kimberly Mahadeo United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, ON, Canada Jakob Manthey Institute of Clinical Psychology and Psychotherapy and Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden, Germany Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy (W37), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany Manu Raj Mathur Public Health Foundation of India, Gurgaon, India Kaylyn McAnally Psychological Sciences, University of California, Merced, CA, USA Juliette McHardy WHO, Hawke’s Bay, New Zealand Michelle McIsaac Health Workforce Department, World Health Organization, Geneva, Switzerland Lauren E. McKinley Psychological Sciences, University of California, Merced, CA, USA Khushboo Mehta Sustainable Advancements (OPC) Private Limited, Kolkata, India Honore Kabwebwe Mitonga School of Public Health, University of Namibia, Windhoek, Namibia Nayan Mitra Sustainable Advancements (OPC) Private Limited, Kolkata, India Ebele Mogo MRC Epidemiology Unit, University of Cambridge, Cambridge, UK Katia S. Mohindra Subaltern Health, Ottawa, Canada Adjunct Faculty, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada Susette A. Moyers Psychological Sciences, University of California, Merced, CA, USA Derrick Muneene World Health Organization, Geneva, Switzerland Sinte Mutelo Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Fiona Muttalib Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada Kasonde Mwinga World Health Organization, Kigali, Rwanda

Contributors

xxvii

Nhimba Mwinga Dartmouth College, Hanover, New Hampshire, USA Mamsau Ngoma Ocean Road Cancer Institute, Dar es Salaam, Tanzania Twalib A. Ngoma Muhimbili University of health and Allied Sciences, Dar es Salaam, Tanzania Godwell Nhamo Institute for Corporate Citizenship, University of South Africa, Pretoria, South Africa Laetitia Nikiema Regional Office for Africa, World Health Organization, Brazzaville, Republic of the Congo Takeshi Nomaguchi World Health Organization, Kigali, Rwanda Jillian Oderkirk Health Division, Organisation for Economic Co-operation and Development, Paris, France Olushayo Oluseun Olu World Health Organization, Juba, Republic of South Sudan Paul Ong Centre for Health Development, World Health Organization, Kobe, Hyogo prefecture, Japan Tolu Oni MRC Epidemiology Unit, University of Cambridge, Cambridge, UK School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa Adelheid W. Onyango Regional Office for Africa, World Health Organization, Brazzaville, Republic of the Congo Arjun Panesar Diabetes Digital Media (DDM), University of Warwick, Warwick, UK Harkrishan Panesar Diabetes Digital Media (DDM), University of Warwick, Warwick, UK Unnikrishnan Payyappallimana UNU-IIGH, United Nations University, Tokyo, Japan Margie Peden The George Institute for Global Health, Imperial College London, London, UK Iñaki Permanyer Centre d’Estudis Demogràfics, Edifici E-2, Carrer de Ca n’Altayó, UAB Campus, Bellaterra, Spain Anicia Peters University of Namibia, Windhoek, Namibia Eva Pilot Faculty of Health, Medicine and Life Sciences (FHML), Care and Public Health Research Institute (CAPHRI), Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands Caitlin Pley Women in Global Health, Geneva, Switzerland

xxviii

Contributors

Teddie Potter University of Minnesota School of Nursing, Minneapolis, MN, USA Abdual Rahaman School of Food Science and Engineering, South China University and Technology, Guangzhou, China Narges Rahimi Department of Physical Medicine and Rehabilitation, Rehabilitation Robotics Lab, University of Pennsylvania, Philadelphia, PA, USA Emmanuel Raju Global Health Section, Department of Public Health and the Copenhagen Centre for Disaster Research, University of Copenhagen, Copenhagen, Denmark Johanna Ralston World Obesity Federation, London, UK K. Srinath Reddy Public Health Foundation of India, New Delhi, India Jürgen Rehm Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada Institute of Clinical Psychology and Psychotherapy and Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden, Germany Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation Agència de Salut Pública de Catalunya, Barcelona, Spain Akhil Rekulapelli University of Virginia, Charlottesville, VA, USA Zoe Sanipreeya Rice Independent Researcher/Scholar, Camberwell, VIC, Australia David Rojas-Rueda Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA Donna Ryan Pennington Biomedical Research Center, Baton Rouge, LA, USA Haleema Sadia Rufaidah Nursing College, Peshawar Medical College, Peshawar, Pakistan Supriya Salvi Longitudinal Ageing Study in India (LASI), International Institute for Population Sciences, Mumbai, MH, India

Contributors

xxix

Paula Santana Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, Coimbra, Portugal Susan M. Sawyer Centre for Adolescent Health, Royal Children’s Hospital; Department of Paediatrics, The University of Melbourne; and Murdoch Childrens Research Institute, Melbourne, Australia Benjamin Schmid Global Health Section, University of Copenhagen, Copenhagen, Denmark Lauren Schmidt Boston University School of Public Health, Department of Global Health, Boston, MA, USA Ashley Schram School of Regulation and Global Governance, Australian National University, Canberra, Australia Nancy A. Scott Boston University School of Public Health, Department of Global Health, Boston, MA, USA Y. Selvamani Longitudinal Ageing Study in India (LASI), International Institute for Population Sciences, Mumbai, MH, India Irja Shaanika Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia Tarang Sharma Evidence to Policy, Copenhagen, Denmark Sherine Shawky The Social Research Center, The American University in Cairo, Cairo, Egypt Kevin D. Shield Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada Anna Panduleni Kauko Shilunga School of Public Health, University of Namibia, Windhoek, Namibia Trishul Siddharthan Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA Gaudenz Silberschmidt World Health Organization, Geneva, Switzerland Luke Slawomirski Health Division, Organisation for Economic Co-operation and Development, Paris, France Amir H. Sohail Resident, Department of Surgery, New York University Winthrop Hospital, Mineola, NY, USA Agnès Soucat Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland

xxx

Contributors

Jeroen Spijker Centre d’Estudis Demogràfics, Edifici E-2, Carrer de Ca n’Altayó, UAB Campus, Bellaterra, Spain Timo Ståhl Finnish Institute for Health and Welfare, Tampere, Finland Jennifer A. Steele Global Health Group International, Kasetsart University, Bangkok, Thailand K. Viktoria Stein Leiden University Medical Centre, Leiden, The Netherlands VM Partners Integrating Health and Care, Vienna, Austria Andrea Steinke Centre for Humanitarian Action, Berlin, Germany Carleen H. Stoskopf School of Public Health, San Diego State University, San Diego, CA, USA Suneetha M. Subramanian UNU-IIGH, United Nations University, Tokyo, Japan Muhammad Arsyad Subu Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates Charlene Sunkel Global Office, Global Mental Health Peer Network, Johannesburg, South Africa A. Surekha Department of Community Health, MGMCRI, SBV University, Puducherry, India Lina Taing United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, ON, Canada Yonette Felicity Thomas Strategic Transitions, Glenn Dale, MD, USA Convenor of the Design Research Society Special Interest Group on Global Health, London, UK Belinda Townsend School of Regulation and Global Governance, Australian National University, Canberra, Australia Emmanuel Tsekleves Imagination Lancaster, LICA, Lancaster University, Lancaster, UK Convenor of the Design Research Society Special Interest Group on Global Health, London, UK Marissa A. Venn San Diego State University, San Diego, CA, USA Joseph Francis Wamala World Health Organization, Juba, Republic of South Sudan Charles Wambebe Tshwane University of Technology, Pretoria, South Africa Jayashree Watal National Law University, New Delhi, India Georgetown Law, Washington, DC, USA

Contributors

xxxi

Daniel Weiss Center for Global Health Inequalities Research (CHAIN), Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway HUNT Research Center, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway Ronny Westerman Competence Center Mortality Follow-up, German National Cohort, Bundesinstitut für Bevölkerungsforschung (BiB), Wiesbaden, Germany Bruce A. Wilcox Global Health Group International, Kasetsart University, Bangkok, Thailand Garrett Wilkinson Partners In Health, Boston, MA, USA Department of Social Anthropology, University of Edinburgh, Edinburgh, UK Mellissa Withers Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Mirkuzie Woldie Department of Health Policy and Management, School of Public Health, Jimma University, Jimma, Ethiopia Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia Nafeesa Yasmeen College of Veterinary Medicine, South China Agricultural University, Guangzhou, China Kiddus Yitbarek Department of Health Policy and Management, School of Public Health, Jimma University, Jimma, Ethiopia

Part I Global Health: Principles and Drivers of a Transformative Paradigm

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Global Health: Definition, Principles, and Drivers Johanna Hanefeld and Hanna-Tina Fischer

Contents Introduction: Redefining Global Health in Face of COVID19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tropical Medicine and Colonial Roots of the Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . From International Health to Global Health Late 1990s Onwards . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Past 2015: Sustainable Development Goals, Planetary Health, and Transformative Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Principles of Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Issues in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shifting Patterns of Disease: The Rise of Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . Preparedness and Response for Communicable Disease: One Health and Planetary Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 6 7 9 10 12 17 20 21 21 23 23 24

Abstract

Global health, as a field of study, research, and practice, has grown in prominence over the past two decades. This chapter sets out what “global health” is and outlines key principles and core concepts of relevance for the field. It goes on to J. Hanefeld (*) Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK LSHTM Berlin, Department of Global Health and Development, London School of Hygiene and Tropical Medicine and Centre International Health Protection; Robert Koch - Institute, Berlin, Germany e-mail: [email protected] H.-T. Fischer Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_1

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J. Hanefeld and H.-T. Fischer

take a historical look at the origins of global health in the fields of public health, international health, and tropical medicine, providing a brief overview of important milestones in the development of the field. The chapter ends by turning to the present day, discussing main global health challenges the world faces today and what changes in the field of global health could be leveraged to better address these. Finally, the chapter explains why global health has transformative potential and puts forward suggestions as to how this can be harnessed for the world to become a healthier and more peaceful place as set out in the sustainable development goals. Keywords

Global health · International health · Globalization · Political economy of health · Global health partnerships

Introduction: Redefining Global Health in Face of COVID19 As we were working on this chapter, the world is facing a global (health) crisis unprecedented in the last century. The COVID19 pandemic dramatically demonstrated the importance of the interdisciplinary field of global health and the extent to which the greater interconnectedness, the “global” nature of our lives, and the extent to which the very connections and our way of living have profound effects on, and are linked to, our health. The virus SARS-COV 2 has spread rapidly around the globe. Measures taken by governments to contain or limit the spread of infection have meant an unprecedented curtailment of public life in most of the 188 countries with confirmed infections. A key aspect of the lockdown measures has been that people and goods have been able to move less, including reduced international mobility. This has highlighted the extent to which mobility has become an integral part of our lives and the ways in which modern societies’ work. In many countries, production was only possible once a supply of goods could be ensured as different parts required in the manufacturing process rely to a large extent on the integrated production chains. So we write this chapter with apprehension: we are aware that global health will likely retain a key spot in the public eye, funding and politics that follow in its tail, and apprehension as we are in July 2020 in the middle of a global pandemic that shows no signs of abating and whose further development we find hard to predict. The field will continue to be shaped in its responses. Yet, at this point the pandemic has already confirmed two core truths about the field of global health. First, to improve health worldwide requires humanity to operate and work together: no man is an island. The very processes that have seen us grow closer together and increase our interactions across space and cognitive distance have also had profound impacts on population health, both with regards to infectious diseases, where new pathogens emerge more frequently – including the faster emergence of zoonoses as COVID has so dramatically demonstrated, and in the area of noncommunicable diseases where the shift in our lived environment has been concomitant to the rise in

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Global Health: Definition, Principles, and Drivers

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obesity-related diseases, for example. The increase in volume and depth of trade, for example, has been closely linked to nutrition-related ill health, while environmental degradation and air pollution have equally been linked to ill health and rises in lung disease, particularly in children (Walls et al. 2019). Second, the practice, science, and implementation required to address global health challenges need to be interdisciplinary and closely integrated. No one scientific discipline can provide the answers to the real-life challenges that we continue to face in realizing health for all. To reiterate, never has this been as drastically underlined as in the emergence and rapid but very heterogenous spread of disease around the globe. While we acknowledge the changes we will see in the field of global health and the uncertainty in the future of our discipline, we offer this chapter as a point to take stock. Global health as a self-defined field of scholarship and practice has been steadily growing in prominence over the past two decades. This has been reflected in the increasing interest the field has experienced among actors in higher education, public policy, and professional practice. Increasing demand for global health education, for example, has led to a burgeoning of university courses. In the USA alone the number of global health programs went from only 6 in 2001 to 78 in 2011, and it is estimated that over 250 universities currently offer courses in global health (Merson 2014). Politically, global health has also experienced growing recognition as a field of practice. This is evident, for example, in the way that many embassies now have health attachés. Of course, health issues have always had a global dimension – and we will explore the history of its emergence in this chapter. The word “quarantine” is set to have been derived from the Italian “quarante,” forty-days sailors were recommended to stay on board before they could disembark with their trades in fourteenth-century Venice, in recognition of the movement of disease. And since the nineteenth century, the Sanitary Conferences provided a first global intergovernmental mechanism focused on global health. For much of the twentieth century, there were two distinct disciplines: public health, a speciality focusing mainly on concerns in one specific country, and so-called “international health,” which focused on the public health in low- and middle-income countries and was part of aid and development sectors. Since the late 1990s and the early 2000s, global health issues have regularly featured the agenda of annual “Group of 7” (G7) (at one point G8 group) and “Group of 20” (G20) summits, and in 2017 the G20 health ministers convened for the first time to discuss and outline global health priorities. The same time, the late 1990s and early 2000s saw a great proliferation and diversification of actors engaged in the field of global health. Many new actors entered the field including a new breed of public– private partnerships, also referred to as Global Health Initiatives, which brought together nongovernmental actors, government, and the private sector (Buse and Walt 2000). Often shaped around vertical disease programs, these actors brought unprecedented attention and financial resources to the field and to public health challenges in low- and middle-income countries (Biesma et al. 2009). Foremost among these was the Global Fund to Fight AIDS, tuberculosis, and malaria, as was the Global Alliance for Vaccine and Immunization (Hanefeld 2014; Buse and Walt 2000). Much novel funding that became available from governments was in the context of the

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millennium development goals, agreed by the UN General Assembly at a special session on the eve of the new millennium. The other big injection of new resources was due to the entrance of the Bill and Melinda Gates Foundation and other philanthropic actors in the field of global health (Fukuda-Parr 2016; McCoy et al. 2009b). This initial growth of attention and funding was largely around three diseases, HIV/AIDS, tuberculosis, and malaria – which were also the focus of the millennium development goals. These changes to the way in which health was conducted as a previously minor field of international relations and development assistance also meant a fundamental change in power (Buse and Harmer 2004). Where previously the WHO and Ministries of Health were the main players for issues of global health, from the early 2000s these were joined by a large array of nongovernmental organizations, philanthropic foundations, private firms, and other civil society organizations (Brugha 2009). A recent review of global health system actors identified 203 independent actors engaged in global health around the world (Hoffman and Cole 2018). This myriad of new actors but also partnerships comprising many of the same actors again and again over time has also meant that the interplay of power between these actors and the accountability mechanisms or perceived or real lack thereof has remained a core and as yet unresolved question at the center of the field (Bruen et al. 2014; Kickbusch 2000; Gostin 2012). This has gone hand in hand with the importance of the governance, the legal system, and rules defining the field of global health over time (Frenk and Moon 2013). Taken together, global health is a new field of academic research, of policy and of action, which despite a much longer history, has defined itself in the last three decades. At this point it is a discipline, still loosely defined but coming of age. There is a clearer academic canon emerging, disciplines linked and a body of designated professionals working in the field. This chapter sets out the core character and principles of global health, offering a brief debate of the differing definitions offered, tracing its history and highlighting some of the key issues and debates in global health. Thus, we provide an overview of the field while also reflecting on its future.

Historical Background As briefly introduced, global health has emerged as a field of study, research, and practice roughly over the past 25–30 years. Its emergence much as the term suggests is linked to the current era of globalization, which began with a deepening and broadening of trade following the economic contraction in the late 1970s. The 1990s saw a rapid increase in global trade, its scale, speed, and scope, which enabled and saw not only a rise of trade in services but also the integration of production and commodity chains in trade, including the emerge of multinational corporations (Smith and Hanefeld 2018). These processes of integration into a global economic system also coincided with advent of great advances in communication technology. The Internet and mobile telephony enabled an increased exchange of ideas, people, and goods. This affected not only the actual movement of ideas and connections

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between people but also has enabled virtual global communities shaped around identities in addition to physical geographies. This has affected in health in many ways, including in terms of effects on mental health. Global norms, for example, have shifted in some cases becoming more uniform and leading to additional pressures on individuals with again potentially negative consequences for health. At the same time increased low-price air travel meant that people have been able to be in touch more frequently and quickly (Hanefeld 2015). These physical, temporal, and spatial changes reshaped in fundamental ways people’s interaction with one another, their environments, and pathogens, leading to essentially new ways in which these factors interplay to produce individuals health outcomes, and changing the burden of disease including a substantive rise in noncommunicable disease determined by commercial and social factors (the commercial and social determinants of health, a rise in health inequality, and also the substantive impact on climate and planet which in turn created new health crisis). It is important to consider when, where, and how the field of “global health” emerged in order to understand the factors that shaped its development and identify the factors that influence it in our present day. Global health as it is known today has its roots in the modern colonial period. Tropical medicine emerged in the nineteenth century as a discipline linked to European and American imperialism, when military, colonial administrators, civilians, and clergy were exposed to diseases endemic in the tropics (Farley 2003).

Tropical Medicine and Colonial Roots of the Field A Timeline of Global Health

• • • • • • • • • • •

1854: Sanitary Conferences 1913: Creation of International Health Commission 1948: Establishment of the World Health Organization 1978: Alma Ata World Health Assembly Declaration “Health for All” 1993: World Development Report: Investing in Health 2000: Millennium Development Goals 2001: Commission on Macroeconomics and Health 2005: International Health Regulations (IHR) 2015: Sustainable Development Goals 2018: Movement to Decolonialize Global Health 2020: COVID 19 Pandemic

In the nineteenth century, physicians in the North treating those who lived in the regions with tropical or subtropical climates began to encounter diseases they had not known before. These were diseases that did not exist in the more moderate European climate. This form of colonial medicine, or “tropical medicine” as it was called, had a narrow, clinical focus on diseases and was closely linked to the

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economic interests of economic expansion of the European colonial powers. The clinical focus has its roots in scientific developments that took place around this time including Louis Pasteur’s discovery that microbes cause disease and Robert Koch’s identification of the tuberculosis bacillus. These findings constitute part of “germ theory” that came to replace earlier theories of disease such as miasma theory, which stated that disease was caused by the effects of air, climate, and soil (Neill 2012). These roots and this era created certain important foundational aspects of the field. One was the sense that tropical disease or indeed international health was something that concerned itself with disease in “another” context or country. This also led to perceptions of colonies or people in the colonies as being vectors of disease (Berridge et al. 2011). Second is a legacy shaping the field to this day is that it meant the discipline of tropical medicine was established in the major cities of colonial powers. The Institute of Tropical Medicine in Antwerp, much like the London School of Hygiene and Tropical Medicine, was closely tied to the colonial ambitions of the Belgium king and colonial Britain. Similar developments at the end of the nineteenth century/beginning of the twentieth century led to the expansion of these discipline in the Americas. While in the USA the American Society of Tropical Medicine and the John Hopkins School of Hygiene and Tropical Medicine were linked to similar economic expansions. These roots continue to shape the field today with its legacy reflected in the fact that 88% of all degrees in global health are based at Universities in North America or Western Europe (Svadzian et al. 2020). The colonial activity resulted in the first collaboration between sovereign nations for health, recognizing the need for a transnational response to diseases and pandemics; the Sanitary Conferences were largely in response to cholera epidemics that had hit first in Bengal and then had made their way in Europe causing large numbers of deaths in 1848–1849 and in 1853–1854, respectively (Liverani and Coker 2012). A pivotal event in British public health, for example, was the Broad Street outbreak of cholera where Jon Snow traced the outbreak of cholera to the pump handle in Soho. Identifying the source of the outbreak and addressing it is what many see as a classic beginning of public health intervention. In 1851, the first International Sanitary Conference was held to discuss international quarantine regulations against cholera, plague, and yellow fever. Between 1851 and 1938, 13 additional International Sanitary Conferences were held which laid the groundwork for cooperation in international health (Lee 2009). At these conferences, conventions were agreed and codified including the International Sanitary Regulations which were a precursor to the 2005 International Health Regulations (IHR). However, they were also important events not solely for the fact what they achieved, but they were also notable for being political events attended by diplomats and politicians rather than scientists. Here there were also tensions between the idea of controlling disease and the mercantilists who needed the movement of goods and people to continue in order for economic activity to continue.

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International Health The twentieth century witnessed the establishment of a number of international organizations and institutions that focused on issues of health around the world. From Sanitary Conferences the Office Internationale d’Hygiène Publique began taking place in Paris in 1907, and following World War 1 the League of Nations Health Organization was established, which in many ways was a precursor of today’s WHO (Brown et al. 2006). At the same time in the USA the International Sanitary Office of the American Republics was established in 1902 which later became the Pan American Health Organizations (PAHO) the WHO Regional Organization in the Americas. A key actor within this was the Rockefeller Foundation which established the International Health Commission in 1913. International health was used to describe efforts made by actors in wealthier countries to improve the health of peoples living in poor regions of the world, focusing mainly on disease control. The International Health Commission worked with governments in different countries to address diseases including hookworm disease, yellow fever, malaria, and tuberculosis. The IHC was later renamed the International Health Division (IHD) and remained a main player in international health until the establishment of the World Health Organization (WHO) in 1948 (Birn and Fee 2013). What characterized the approach of the Rockefeller Foundation to global health was really a focus on technical solution, eradication, and treatment of problems in faraway places, with an inbuilt imbalance in resources and expertise. With the establishment of the United Nations (UN) at the end of World War II in 1945, the need for a specialized agency for health was identified as a continuation of the earlier collaborations described here above. Three years later in 1948, the World Health Organization was established. Every year April 7th is celebrated as “World Health Day” in remembrance of the day in which the WHO Constitution came into effect in 1948. The organization’s goal, as defined in Article 1 of its Constitution, is “the attainment by all peoples of the highest possible level of health.” The 1950s ushered in the field of international health which lasted until the late 1970s, and during which the WHO focused mainly on large vertical programs and emphasized disease elimination, with the eradication of smallpox in 1979 being a key achievement of this time, even where more detailed analysis of this now highlights a less unified image than previously has been projected (Bhattacharya 2008). Key is to point out that in the post-war era initially health systems and universalism were not a core part of the international health agenda, nor the work at WHO, which much like other UN agencies found itself between the two blocs – Soviet and American (Gorsky and Sirrs 2018). In 1978, the Alma Ata Declaration saw the emergence of primary health care and health systems strengthening as a key feature of global health. However, over the years the limitations, for example, of achieving large-scale vaccination coverage to address child health, in many low- and middle-income countries led away from this largely horizontal focus to greater attention on health systems and the focus on primary health care. The pivotal moment here was certainly the declaration of Alma Ata with the aim of Health for All by the year 2000 (Gorsky and Sirrs 2019). While certainly an enduring concept and one that many see as the origins of today’s focus on the concept of Universal Health Coverage, as well as the strategy underlying the

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Sustainable Development Goal (SDGs) 3 to achieve health and well-being for all, the commitment to universality quickly became eroded and replaced not least due to funding constraints with the concept of selective primary health care (Newell 1988). By the late 1980s and the beginning of the 1990s the World Health Organization was increasingly seen as untransparent and inefficient, lacking innovation and the ability to mobilize resources and know-how in a more adaptable form (Walt 1993). In addition, policies of structural adjustment from the 1980s onwards by the World Bank had severe consequences for the health sector in low- and middle-income countries, which was often portrayed as part of inefficient state which needed to be cut back, reflecting greater currency of neoliberal ideas as the accepted political consensus. This was underlined by the entry of new powerful players into the field of international health. Notably the 1993 World Bank Development Report focused on Health and really marked the Banks entry as a major player in this field (Rifkin 2018).

From International Health to Global Health Late 1990s Onwards The World Bank was only one among a proliferation of actors in the field of health working at a global level in the 1990s. This included not only new actors like the Bank, but also new types of partnerships and new forms of governance, notably public–private partnerships, combining nongovernmental actors, with states and the private sector in initiatives such as the Roll Back Malaria Partnership and the Global Fund to Fight AIDS, tuberculosis, and malaria. It also saw the entry of a new actor the Bill and Melinda Gates Foundation into the field of global health.

Economic Globalization and the Commercial Determinants of Health These developments in global health were closely linked or part of a new era of globalization. Following an unprecedented era of increase in volume and depth of global trade from the 1970s onwards, which saw the reduction in barriers to trade between countries, the structure of the world economy had become increasingly integrated with a key feature being the growing erosion of national boundaries in the field of business and science. This economic integration was in parallel or enabled by large advances in communication technology and the advent of cheap air travel which meant much closer immediate collaboration between people was enabled. A notable feature of this era was the emergence of multinational corporations as key actors in international relations and increasing rise of consumer economies. These structural economic developments in turn had far-reaching consequences for health and are often summarized under the term of commercial determinants of health. Given the economic size of these actors, and their reach across multiple jurisdictions, they have become hard to regulate and their political influence is significant. Cases such as the legal challenges to tobacco legislation including plain packaging have demonstrated reach, penetration, and global strategy of corporations, and their effects on health (Hawkins et al. 2020). These twin developments of the economic globalization and the emergence of new forms of governance and actors in global health were tied, and they coincided

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with a period of increasing attention on the HIV/AIDS epidemic. Many of the new global actors in health were vertically focused around specific diseases, such as HIV/ AIDS, tuberculosis, and malaria. They followed a common blueprint across countries to address specific diseases, often through implementation outside of the public health sector. The millennium development goals (MDGs), a set of targets to which the countries committed themselves at the UN on the eve of the new millennium, for example, did not reference health as an overall goal but had two health goals one centered on addressing infectious disease epidemics of HIV, tuberculosis, and malaria, and another focused on maternal and child health.

International Health Regulations It was against this backdrop of economic globalization that the world experienced the rapid spread of a new infectious disease in 2002 – the Severe Acute Respiratory Syndrome (SARS) – which caused great disruption to global travel, trade, and national economies. SARS illustrated the interconnectedness of people, goods, and nations around the world as the virus spread at an unprecedented rate. SARS also illustrated that collective defenses that had been established globally were weak and ineffective. The only international agreement related to communicable diseases that existed at the time were the International Health Regulations (IHR) that were part of the WHO’s 1951 Constitution. The IHR only applied to a small number of diseases such as cholera, plague, and yellow fever, and were thus not applicable to SARS, HIV/AIDS, or any other new and emerging infectious diseases. In the aftermath of SARS, the IHR were revised and now required that all countries to detect, assess, report, and respond to all events that could lead to international public health emergencies, or so-called “public health emergencies of international concern” (PHEIC). The regulations also outline the criteria to determine whether or not a particular event constitutes a “public health emergency of international concern.” The International Health Regulations (2005) (IHR) provide an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders. They are an instrument of international law that is legally binding on 196 countries, including the 194 WHO member states. Each country has to designate a national IHR focal point for communications with WHO to establish and maintain core capacities for surveillance and response, including designated points of entry. Additional provisions address the areas of international travel and transport such as the health documents required for international traffic. The IHR have been subject to much debate and as part of the response to COVID19, the IHR are being reviewed during 2020/2021. The 2000s then were marked by unprecedented and growing attention to this agenda of global health, and the focus on addressing targeted diseases. By 2009 the limitations of these vertical programs in the underfunded health systems of lowand middle-income countries were once again becoming apparent and the issue of health systems and their systematic strengthening was gaining increasing attention and traction, with disease-specific funders such as the GAVI Alliance and the Global Fund beginning to provide discrete budget lines to countries for the health systems and vertical approaches receiving increasing criticism.

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Global Health Past 2015: Sustainable Development Goals, Planetary Health, and Transformative Change On September 5, 2015, in a historic pledge, the world ushered in the sustainable development goals (SDGs). The SGDs consist of 17 interconnected goals that are required to “achieve a better and more sustainable future for all.” The SDGs represents a shift change in perspective and approach to the MDGs that preceded them. Whereas the MDGs focused solely on addressing problems in so-called developing and least developed countries, the SDGs are universal in scope. The SDGs are more holistic in their vision of health and well-being as they cover not only communicable and noncommunicable diseases but also violence and injuries. They no longer state goals for select diseases and instead are broader in scope, focusing on addressing health inequalities, ensuring universal health coverage, and targeting noncommunicable diseases. The aims of the MDGs were to end poverty while the aims of the SDGs are broader in that they aim to make the world a better, more peaceful and just, place. They focus on people and planet.

Sustainable Development Goals (SDGs)

1. No Poverty: “End poverty in all its forms everywhere.” 2. Zero Hunger: “End hunger, achieve food security and improved nutrition, and promote sustainable agriculture.” 3. Good Health and Well-being: “Ensure healthy lives and promote wellbeing for all at all ages.” 4. Quality Education: “Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.” 5. Gender Equality: “Achieve gender equality and empower all women and girls.” 6. Clean Water and Sanitation: “Ensure availability and sustainable management of water and sanitation for all.” 7. Affordable and Clean Energy: “Ensure access to affordable, reliable, sustainable, and modern energy for all.” 8. Decent Work and Economic Growth: “Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.” 9. Industry, Innovation, and Infrastructure: “Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation.” 10. Reducing Inequality: “Reduce income inequality within and among countries.” 11. Sustainable Cities and Communities: “Make cities and human settlements inclusive, safe, resilient, and sustainable.” (continued)

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12. Responsible Consumption and Production: “Ensure sustainable consumption and production patterns.” 13. Climate Action: “Take urgent action to combat climate change and its impacts by regulating emissions and promoting developments in renewable energy.” 14. Life Below Water: “Conserve and sustainably use the oceans, seas, and marine resources for sustainable development.” 15. Life On Land: “Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation, and halt biodiversity loss.” 16. Peace, Justice, and Strong Institutions: “Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable, and inclusive institutions at all levels.” 17. Partnerships for the Goals: “Strengthen the means of implementation and revitalize the global partnership for sustainable development.”

In 2018, two movements emerged that call for critical self-reflection within the field of global health: the movement for gender equity and the movement to decolonalize global health. These movements are based on the recognized uneven distribution of power, privilege, and priorities in the field of global health today.

Calls to Decolonize Global Health Critical reflection about the colonial past of the field of global health is now taking place among practitioners, researchers, educators, and students alike. The past 10 years has witnessed a growing number of articles published on “decolonizing global health.”

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Fig. 1 Geography of leadership of global health organizations

Recent publications that examine the architecture behind global health shed light on the uneven distribution of power that exists among organizations working in the field of global health. The latest report of Global Health 50/50, for example, highlights that global health–focused organizations are disproportionately based in the Global North, even though the activities they implement are predominantly based in the Global South. Of the 198 organizations working in the field of global health that were reviewed by Global Health 50/50, 84% are headquartered in Europe or North America and only 17% are directed by nationals from low- and middle-income countries – of which only 5% are women (Global Health 50/50 2020) (Fig. 1). Recent publications on decolonizing the practice have also examined global health interventions and how they are perceived. Hirsch (2020), for example, explores the skepticism of Sierra Leonean nationals towards the Ebola response and suggests that global health interventions need to be understood in the context of the post-colonial societies in which they are delivered. She argues that the reactions observed in Sierra Leone must be understood given the population’s experience of a conflation of care and violence in the colonial past. Similarly, Heckert (2018) points out that in many countries with a colonial history, the relationships in global health interventions mirror colonial relationships in that they are built around an unequal sharing of power. Drawing on experiences in Bolivia, Heckert describes promises of community participation in the development and execution of interventions that are not realized in practice, leaving nationals feeling subaltern. As Rasanathan and Rasanathan (2020) point out, global health practitioners are challenged to not only make adjustments to how they work but to reimagine global health as a “practice of liberation” based on genuine power sharing. Parallel to the reports and publications on decolonizing practice, students and educators have been voicing concern over the way global health is taught at universities calling for the decolonization of global health knowledge. Most notable

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among these voices are student-led “Decolonise Global Health” movements that have been growing in prominence over the past three years. These movements have fostered discussions on the “depoliticized and ahistorical” manner in which global health is taught. Conferences organized by students have taken place at numerous universities including Duke University, University of Oslo, University of Leeds, Harvard University, and Glasgow University to name a few. These movements point out that university-level global health courses are dominated by Western knowledge and a Eurocentric perspective. They also critique that global health is taught devoid of critical reflection about the neoliberal economic and political systems that are driving globalization and are central to health concerns around the globe. Numerous blogs and articles have been written as part of these movements (see Green 2019; Guinto 2019; Byatnal and Mihara 2020). In addition to students, university professors and lecturers are also grappling with the question of how university curricula can be “decolonized” (see, for example, Eichbaum et al. (2020), van Wees and Holmer (2020), and Pimblott (2020)). They critique that global health curricula currently focuses almost exclusively on health issues in low-income countries and are therefore insufficiently “global.” van Wees and Holmer (2020) suggest that a definition of global health that focuses on scope as opposed to geography should be used instead to guide teaching. In addition, suggestions are put forward in the literature for how universities in low- and middle-income countries can become more prominent in the production and dissemination of global health knowledge, providing a counterweight to the many universities in the Global North that offer global health courses (see Fonn et al. 2018). An analysis conducted by Khan et al. (2019) of gender- and ethnicity-related differences in career progression in the 15 highest-ranked universities in the world for social sciences and public health found that although the proportion of men and women was mostly equal, there are clear disparities with regards to the positions they occupied. With regards to ethnicity and disparities in the positions, ethnic-minority men and women held suggest that barriers to career progression may operate different for different groups (Fig. 2). The same trend is observed in the realm of research. The systematic lack of representation of low- and middle-income-country nationals among authors of peerreviewed journal articles is explored in a number of recent publications. A review conducted by Mbaye et al. (2019) illustrates that African authors are highly underrepresented as first and last authors in collaborative research conducted on their continent. Another review of randomized controlled trials conducted on HIV/AIDS, tuberculosis, and malaria from 1990 to 2013 in low- and middle-income countries by Kelaher et al. (2016) came to a similar conclusion. The authors found that although the total number of first authors from low- and middle-income countries increased over the timeframe, the number declined as a proportion of all authors. This is striking given that the randomized controlled trials themselves were conducted in low- and middleincome countries. A third review conducted by Hedt-Gauthier et al. (2019) found that representation for local health researchers in sub-Saharan Africa actually decreased by collaborating with researchers in high-income countries. Only half of all the studies included in the review had a first author from the country the paper was focused on.

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Fig. 2 Proportion of workforce at junior, mid-level, and senior academic grades according to gender and ethnic minority status in the 15 leading social sciences and public health institutions (Khan et al. 2019)

This lack of diversity prevails not only among journal authors, but also among editors on editorial boards of journal editors. A review of 27 specialty global health journals conducted by Bhaumik and Jagnoor (2019) identified that 73% of the editors-in-chief were based in high-income countries and 68% of editors were based in high-income countries. This suggests that the problem is not just one of lacking representation and visibility, but one of unequal partnerships and exploitation in research (Munung et al. 2017). Suggestions to address this including refining the peer review process to incorporate feedback from local actors and involving funding bodies push for greater accountability to local research communities (see Istratii and Lewis 2019). In addition to representation in research, methodologies used in research and the question of how these can be decolonized are also brought up in the literature. Keikelame and Schwartz (2019) argue that current research methodologies must be decolonized as they undermine local knowledge systems and experiences. By leveraging participatory and transformative research methods, they argue, the assets of individuals and communities can be recognized and more culturally appropriate methodologies can be applied. And lastly, academic partnership is a theme explored under decolonizing research points out that academic partnerships face a central tension in that they often embody the very inequities that they aim to address. Matenga et al. (2019) point out that this is partially due to funding mechanisms where 90% of the funding ends up with the partner from the Global North. Drawing on experiences in Nepal, Citrin et al. (2017) suggest there is potential for equitable partnerships that can drive progressive

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advocacy agendas, but these require partnerships to be regarded as relational processes that require investment, time, and flexibility, not as a state or output to be achieved quickly. It is precisely this process that Munung et al. (2017) suggests is rarely well thought through and often ill-defined which is problematic. Clarifying roles, responsibilities, and accountability mechanisms early on in the relationship is a necessary step in establishing mutually beneficial partnerships (Daftary and Viens 2020). To summarize, there have been numerous calls for global health researchers, practitioners, and educators to acknowledge the power asymmetries that accompany their work (see Abimbola 2018, 2019). Beyond an acknowledgement of the asymmetries, some argue that if global health as a profession and an academic discipline remains unchanged, it will be one of the perpetuators of health inequity around the world (see Richardson (2019)). Rather the uneven distribution of power, privilege, and priorities cannot merely be pushed aside given their historical roots, it must be proactively addressed.

Defining Global Health As briefly introduced above, global health has emerged as a field of study, research, and practice. However, given its heterogenous origins and the relatively new nature of the field it is important to point out from the onset that there is no universal, agreed, or comprehensive definition of global health. Instead, a series of definitions have been put forward over the years, each placing emphasis on a different aspect or representing a different perspective. An initial, oft-cited definition put forward in 1997 by the US Institute of Medicine defines global health as “health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions” (1997: 1). This definition focuses on the nature of the health concerns, specifying that these are transnational and implies that collaboration across national borders is required to address them. It does not, however, mention how these concerns are identified and addressed. Similarly, a definition put forward by Kickbusch (2006) defines global health as “those health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people.” Here an important element of advocacy is specified in the “call to action.” This definition puts an emphasis on health outcomes alone. Lee and Collin in (2005) offered a definition that widened the focus to processes and determinants of health “where the determinants of health or health outcomes circumvent, undermine, or are oblivious to the territorial boundaries of states and thus beyond the capacity of individual countries alone to address through domestic institutions.” Other public health scholars have also argued for including an emphasis on prevention in global health definitions and have gone so far as to suggest that global health and public health are “indistinguishable” and “represent a single field” (Fried et al. 2010).

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Provocatively, some have gone one step further suggesting global health be defined as public health “somewhere else,” critiquing that global health practitioners often practice in communities that are not their own (King and Koski 2020). With a view to the field of global health itself, this has been described as a field of study (Ablah et al. 2014), a field of research (Labonte and Spiegel 2003), field of practice with a distinct framework for action (Sheikh et al. 2016), and an idea (Frenk et al. 2014). Is it one, or the other, or all of the above? In 2009, Koplan et al. put forward a definition of global health on behalf of the Executive Board of the Consortium of Universities for Global Health (CUGH) that is comprehensive and brings these aspects together. Koplan et al’s definition emphasizes that global health is not limited to a field of research and study, but that it is also a field of practice. Moreover, the definition covers health issues and determinants of health that transcend national boundaries, it emphasizes the importance of collaboration both between countries and between disciplines – beyond the health sciences – to address global health concerns, it brings to the fore issues of health equity and health disparities, and it covers curative and preventive aspects of health care at individual and population level.

Box 1 “Global Health”

The most widely referred to definition to date of global is health is that provided by Koplan and colleagues. 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 emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention within individuallevel clinical care” (Koplan et al. 2009). Beaglehole and Bonita (2010) have put forward a “shorter and sharper” version of the Koplan et al. 2009 definition, stating that global health is “collaborative trans-national research and action for promoting health for all.” This shorter version omits the critical aspect of global health aiming to improve health and achieve health equity for all people worldwide. This has been identified as a defining feature of global health, and one very prominent way that it differentiates itself from its precursor “international health” (Abimbola 2018). However, a bibliometric analysis of the field of global health published in late 2020 by Abdalla et al. (2020) which examined academic publications as well as definitions of global health in core journals linked to the field demonstrated clearly the lack of a dominant or coherent definition of the field. This analysis over time also highlights the lack of a clearly emerging narrative, while finding differing clusters of foci on governance, infectious disease, and maternal and child health emerging together with a more recent focus on sexual and reproductive health and on research methods.

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But despite the differing definitions of global health, it now is an established field with defined features. First, as set out by Kaplan and colleagues, global health is a field of research, study, and practice. It seeks to address real-world questions and solve problems. This is important as it means global health is defined not only as a science in search of new knowledge, but equally by the practice of “doing” global health and indeed the dynamic interaction between the generation of new knowledge and its application. By implication this means that much research conducted is in the fields of operational and implementation research; however, this is not exclusively so. As the field matures and grows, the fundamental normative questions have led to greater engagement by philosophers and ethicists, and it is also a field of specialist researchers in international relations and political science. Second, global health is highly interdisciplinary and focuses on health issues that have a general global importance. Many of these transcend national boundaries however, they can also occur in one place as a result of the global factors and processes that have come to shape health. Global health recognizes the extent to which health is shaped by factors outside of the narrow field of clinical medicine, or health services and health promotion. Global health has a strong focus on the practical application of science and evidence to advance actions that improve health. It is an inherent normative/value dimension. As such the field seeks to improve health and address the injustices that have come to be associated with the injustice that causes ill health. Scholarship in this field has predominately focused on diseases and health issues concentrated in low- and middle-income countries, although this is changing, including as the result of the changes in the burden of disease which sees much greater commonality emerge across low-, middle-, and high-income countries, not least as a result of the increasing influence of the commercial determinants of health and the concomitant rise in noncommunicable diseases as discussed here below. A definition of global health in the year 2020 is therefore not just a summation of key features that define this field, it is also a set of critical junctures, debates, and disconnects that shape the current discourse on global health and delineate the fields of scholarships that self-identify within this field. The next step to “building the field” of global health will be the open, inclusive, and transparent discussion of these issues. These include the discussions about the field itself, around representation and decolonization, as well as how to forge real and equal partnerships. They also encompass the simmering debates around the underlying normative assumptions that different practitioners and fields of research hold within them and that have often been masked by different technical positions taken. Underlying these two are essential questions of who holds power and how it is expressed itself. Equally important will be the questions on the boundary of the field: while interdisciplinarity is evident and established, recent review findings confirmed the continued dominance of biomedical research within global health. Breaking the silos between disciplines and further developing interdisciplinarity in research methods and policy practice will be the key. Here establishing where the field of global health is about collaboration with other sectors and where methods form an intrinsic part of the field will form an important part of the debate.

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Principles of Global Health As set out above, the normative dimension is a definitional aspect of the field. At the same time the underlying normative dimensions have not yet been resolved. The following six key principles capture these aspects and are put forward as foundational for the field of global health.

Overview: Principles of Global Health

1. 2. 3. 4. 5. 6.

Health as a human right Health equity and social justice Solidarity Evidence-based public and global health Governance: partnership, inclusivity, and participation Resilient and responsive health systems

1. Health as a human right • Health as a human right. The basis of global health is the individual right to the highest attainable standard of health, and including the determinants of health, regardless of statehood and citizenship. This is also guaranteed, by all member states of the United Nations and thus creates responsibilities and standards that countries have to adhere to. 2. Health equity • Health equity refers explicitly to health as an issue of social justice: the differences in health status that are socially or economically determined and therefore unjust. • There is now overwhelming evidence that the majority of differences in health are determined by factors other than our biology and genes: namely by the social, commercial, and political factors that shape individual and population health. 3. Solidarity • Linked to the first two points is the principle of solidarity, inherent to the field, which further recognizes the imperative to achieve health for all and realize the right to health (and health equity) as enshrined in the UN Charter, for all humans not just people in a certain geography, class, or social location. 4. Evidence-based public and global health • Actions informed by science and evidence. Much like evidence-based medicine, global health is a field that operates in an evidence-based way. At the same time evidence itself has become politicized, as evidenced not least by the extent to which medical interventions such as vaccines have become a focus of political debate (Larson 2012). 5. Governance: partnerships, inclusivity, and participation • A core principle of a field with such a large number and different types of actors and without a clear structure or hierarchy is a networked governance.

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While this is still in flux, principles of partnership, inclusivity, and participation are essential building blocks of such an approach (Ottersen 2011). 6. Resilient and responsive health systems • Health systems remain a core determinant of health over which the sector can exert most influence. • Strengthening of systems is therefore an essential part of all interventions targeted at improving health and strengthening preparedness. • Pandemics such as Ebola and COVID19, as well as external shocks through crisis and war, climate change, and a growing burden of disease have highlighted the extent to which responses rely on systems to be resilient and their ability to transform in light of external shocks.

Key Issues in Global Health There are many key issues in global health: the rise of antimicrobial resistance, the emergence of new pathogens including zoonosis like SARS-COV-2, pandemic preparedness and responses given these threats, the rise of noncommunicable diseases, including mental ill-health, and the extent to which the planetary crisis threatens health and survival of our species in the immediate and long run. It is important to note that the factors underlying many of these issues, the causes, and the ways in which our responses to these are shaped are similar. Fundamentally these are about the distribution of power in our societies and how and by whom priorities are defined. This is why the field is so closely tied to the economic processes of globalization which have reshaped the way in which our economies and societies are organized. This is also what underlies the definition of global health advanced here above and the principles named.

Shifting Patterns of Disease: The Rise of Noncommunicable Diseases Understanding causes and rates of morbidity and mortality around the world is a prerequisite to being able to adequately address global health concerns. In 1990, a “Global Burden of Disease, Injuries and Risk Factors Study” (GBD) was initiated by the WHO and the World Bank to generate comprehensive estimates of the burden of diseases and the risk factors that cause them. Since then, the GBD study has been conducted every few years. An important metric was developed to quantify the burden of diseases, injuries, and risk factors for the GBD study, the disabilityadjusted life year (DALY). DALYs represent “the years of life lost (YLL) from premature mortality and years of life lost to disability (YLD) for people living with the health condition or its consequences” and are useful in comparing and ranking the different burdens of diseases (WHO 2020). The last GBD study conducted in 2017 shows that significant strides have been taken to improve the health and well-being of populations around the world over the past decades. Globally, life expectancy increased from 51 years (48 years for males and 53 years for females) in 1950 to 73 years (71 years for males and 76 years for

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Table 1 Leading causes of DALYs in 2017 and 1990, in order of rank 2017 Rank 1 2 3 4 5 6 7 8 9 10

Cause Ischaemic heart disease Neonatal disorders Stroke Lower respiratory infections Diarrhoeal diseases Road injury Chronic obstructive pulmonary disease HIV/AIDS Congenital birth defects Malaria

1990 Rank 1 2 3 4 5 6 7 8 9 10

Cause Neonatal disorders Lower respiratory infections Diarrhoeal diseases Ischaemic heart disease Stroke Congenital birth defects Tuberculosis Road injuries Measles Malaria

females) in 2017 (GBD Mortality Collaborators 2018). Over the same period, mortality for children under the age of five dropped from 216 to 39 deaths per 1000 livebirths (ibid.). Between 1990 and 2017, there was a 41% decrease in DALYs caused by communicable diseases and neonatal disorders as reductions were witnessed in some of the largest contributors to global mortality including HIV/AIDS and tuberculosis (GBD Causes of Death Collaborators 2018). At the same time, the GBD 2017 study highlights that there has been an equally significant increase (40%) in DALYs caused by noncommunicable diseases (NCDs) including cardiovascular diseases and cancers. These developments are in line with a predicted shift in the global burden of disease from communicable diseases to NCDs accompanying the socioeconomic development of countries. Table 1 shows the ten leading causes of DALYs in the world in 2017 in order, as well as the rank and number of DALYs in 1990. Each of the top seven ranked causes of DALYS accounted for more than one million deaths each in 2017 (GBD DALYs and HALE Collaborators 2018). This is important not only to understanding what affects the health of the people worldwide, but also as the drivers and determinants of noncommunicable disease are to some extent different, or differently accentuated to those of communicable diseases. Here the built environment and the commercial determinants of health play a far greater role, including questions such as the ability to regulate food standards and harmful substances including alcohol and tobacco (Kickbusch et al. 2016). These global trends mask striking differences by gender and at country level that highlight widening gaps in health. Life expectancy, for example, may have increased by 22 years on average overall since 1950, but this process has been varied. In Eastern and Central Europe, and Central Asia, for example, the increase in life expectancy since 1950 has only been half of the global average, at 11 years. Similarly, life expectancy in sub-Saharan Africa is only 64 years for both genders which is remarkably lower than the global average at 73 years. Relatedly, there are remarkable variations in mortality rates across countries. Young adult males, for example, have higher than expected mortality rates in Eastern Europe and subSaharan Africa (GBD Mortality Collaborators 2018). This is likely attributed to

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lifestyle and behavioral choices and to the fact that the number of deaths from conflict and terrorism increased by 118% between 2007 and 2017 (GBD Causes of Death Collaborators 2018).

Preparedness and Response for Communicable Disease: One Health and Planetary Health At the same time, even before the advent of COVID19, it is important to stress that this rise in noncommunicable diseases has not meant a disappearance of the burden of communicable diseases. With many countries facing a double or triple burden of disease and HIV and tuberculosis, as well as the rise in resistance of antimalarials overall meaning that the unfinished agenda of these diseases is likely to become more complex again. COVID 19 much like the Ebola virus disease outbreak in West Africa in 2014/15 highlights the extent to which the threat of newly emerging or re-emerging pathogens remains. It demonstrates in particular the threat emerging from zoonoses and the speed with which new pathogens and diseases travel and move from a localized outbreak to a global pandemic. From this arise a range of clear priorities and responses in global health: it highlights the need for better regulation to enable the international community to respond quicker than has happened in the past – here the ongoing review of the International Health Regulations (IHR) is an essential element. Second, the need for preparedness, including surveillance, early warning systems, building capacity for response, and strengthening resilient public health systems, has been very clearly underlined. It also shows the extent to which health of humans is connected to the health of other species and the changes in our environment on the planet. Two specific concepts have been advanced to capture these different interactions. One, the concept of One Health, which emerged in the early 2000s and gained considerable attention and increasing financial resources following 2010, and which focuses on the interaction between human, animal, and environmental health (Spencer et al. 2019). Second, Planetary Health which focuses as the term indeed highlights on the health of the planet and the concomitant effects of climate change on human and animal health (Whitmee et al. 2015). Planetary health directly speaks to many of the principles set out here above and explicitly calls on public health to become a social movement in light of the fact that the survival of the species is threatened by the challenges. Effectively, planetary health can be seen as the global health community’s evolution into a response to the existential crisis of climate change.

Conclusion As set out in this chapter, the world faces multiple global health challenges. Global health itself, while not coherently defined, is now recognized as a field of research, teaching, and practice with core competencies, a more or less defined curriculum and a set of guiding principles. We have highlighted that while a common understanding has

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emerged on some issues, perhaps more compelling are the questions, the discourse, and the disjuncture about the normative assumptions and asymmetries in power that underlie a field which has emerged at least in part from a colonial past. Global health has emerged concomitantly to the processes of globalization over the past 30 years, which have seen fundamental changes in how societies organize themselves and how humans relate and communicate, largely driven by an unprecedented process of economic integration and growth. Population health, our individual genetics aside, is a product of social, economic, and commercial determinants shaping people’s lives. To improve health globally requires therefore a focus beyond individual biology or medicine, but rather a deeper understanding of the different processes and contexts that coproduce health, wherefore the nature of the field is highly interdisciplinary. To achieve health for all and realize the right to health for all humans, the global health community needs to engage in the discourse about the roots and foundations of the field, even where these are uncomfortable. It must engage with the underlying drivers and questions of power. At the same time, the discipline could not be more relevant to address current existential challenges of the human condition, including pandemics through new pathogens or the climate crisis, all directly threatening the survival of the species, the biosphere, and the ecosystems we all depend on.

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Globalization and Global Health Impact, Trends, and Consequences Katia S. Mohindra

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalization and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalized Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalization and the Growing Burden of Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Globalization – the increasing interconnections between people, economies, and societies – is inextricably interlaced with the health of populations worldwide. The speed and reach of microbes and unhealthy commodities across the globe are challenging the global fight against infectious disease and chronic noncommunicable diseases, with important implications for health equity. Moreover, globalization-linked challenges are becoming increasingly interwoven, portending a calculus of crises. This chapter describes the harmful effects of unfettered operations of transnational and national corporations on chronic and noncommunicable diseases as well as reviews early evidence of the globalizationrelated drivers and consequences of the COVID-19 pandemic. This chapter concludes by heeding the warnings of political scientists regarding the destructive forces of multiple global crises on global health, which have heightened challenges to one of the most basic human needs – the capability to breathe. There is a need for both greater investment in “globalization and health studies” and the fomenting of a globalized resistance that recognizes the intersection of the struggles of peoples.

K. S. Mohindra (*) Subaltern Health, Ottawa, Canada Adjunct Faculty, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_2

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Keywords

Globalization · Population health · Global pandemics · Transnational corporations · Health equity · Multilateralism

Introduction Black rats, fleas, ticks, cattle, mosquitoes, dromedary camels, pigs, ducks, chimpanzees, and bats. These are just a few of the species that can host microbes which may spillover to humans infecting us with devastating diseases. Microbes cross borders easily and at increasing speeds, aided by land clearing, damn building, resource extraction, air travel, international wildlife trade, migration, tourism, climate change, industrial food production systems, poverty, and inequalities. Microbes are not, however, the only culprit linking globalization and population health. There are also more nuanced pathways involving unhealthy commodities, such as trans-fats, fast food, cigarettes, opioids, sex-detection technologies, and hazardous waste. And yet, globalization is not inherently bad for health (Feachem 2001). Opportunities for better health have emerged: transnational movements advancing human and health rights, telemedicine connecting remote communities with primary and specialized, border crossing drones delivering blood, vaccines and essential medicines to hardto-reach areas, and global governance structures that mobilize knowledge and resources to improve world health. However, the nature of globalization and its underpinnings have tended to exacerbate existing global inequalities, reducing opportunities for good health among those “expelled” by the global economy (Sassen 2014), including the poor, the Subaltern, and marginalized communities. After providing an overview of globalization and health, this chapter focuses on the links between globalization and infectious diseases (through the lens of the current COVID-19 pandemic), followed by how transnational corporations are a key driver of noncommunicable, chronic diseases. We concluded by discussing the perils of multiple global crises on global health and offer a pathway out.

Globalization and Health Simply put, globalization encompasses the increasing interconnections between people, economies, and societies (Box 1). Similar to feminism, it is a contested, variably defined term and can be viewed as having “multiple waves.” Globalization’s first wave corresponds largely to the colonial era: European colonists seized and occupied, Indigenous lands across the globe, bringing with them a slew of pathogens, while enforcing their imperial systems of mercantilism (fueled by the African slave trade), governance, and cultural worldviews (Trask 1993; Williams 1944). The second wave, or “contemporary globalization,” is often dated back to the 1970s. Contemporary globalization is especially marked by the development of a global marketplace – the engine, which influences economic and noneconomic

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aspects of globalization and the resulting pathways to population health (Labonté and Schrecker 2007). The global marketplace is entrenched in neoliberalism (Box 1). Box 1 Definition of key terms

Globalization While variably defined, globalization tends to be defined by public health scholars as a process in relation to the global economy. This view recognizes that economic conditions are increasingly shaped by global conditions (including powerful global actors) and that transnational goods, services, capital, technology, and even labor can be linked to the global marketplace. For example, the global branding of Coca-Cola ® may be part of a cultural phenomenon, but it is ultimately profit driven. Source: Labonté and Schrecker (2007). Health equity There are two key components to health equity: (1) improving average health of countries and (2) eradicating avoidable (therefore unacceptable) inequalities in health. Improving health equity requires addressing imbalances in the distribution of power and economic arrangements. Source: Commission on Social Determinants of Health (2008). Neoliberalism Neoliberalism can be viewed as a “political project” that aims to establish the necessary conditions for capital accumulation, restoring power to economic elites. Neoliberalism arose with force during the 1970s in a variety of ways across the globe ranging from the use of military force in Pinochet’s Chile to democratic means in Thatcher’s Britain but has since become entrenched in everyday experience. Theoretically, individual freedoms are meant to be liberated through unfettered markets, free trade, and private property rights. However, in practice free enterprise has been captured by economic elites leading to widening social inequalities, environmental degradation and the concentration of income and wealth among few (“the 1%”). Source: Harvey (2005).

Whether or not we are experiencing a third wave of globalization is unclear. The current global pandemic of COVID-19 has set global financial markets crashing, slowed air travel and highlighted the drawbacks of a country’s access to food and critical goods (e.g., personal protective equipment, medicine) being enmeshed in global supply chains. The slow-down of economies has also demonstrated salutogenic effects in some communities, including reductions in air pollution, booms in bicycle sales, and redesigning urban areas into green, community-oriented spaces. Ultimately, changes to how we live, work, and play may involve elements of: “de-globalization.” Globalization creates a system of “winners” and “losers” with important implications for health equity (Box 1). Globalization is associated with global flows that have multiple direct and indirect effects on population health (see Box 2).

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Box 2 Important Global Flows

Increased pathogen flows: COVID-19 has demonstrated the speed and reach of a pathogen in today’s world, especially if governments are unprepared, unconcerned, or denounce scientific approaches. There were multiple warnings, including severe acute respiratory syndrome (SARS), which spread from the Guangdong province in China to affect people in 37 other countries within weeks. SARS was the impetus for new International Health Regulations and multilateral health collaborations. Even global health and development actors can contribute to pathogen flows: United Nations peacekeepers originating from South Asia inadvertently brought Vibrio cholerae to Haiti during a postearthquake reconstruction mission, following Haiti’s 2010 earthquake – previously cholera had never been reported. Increased information flows: Advances in computing and telecommunications have shaped modern globalization, increasing the spread of health knowledge and technological innovation, the reach of multinational firms, and the rise of transnational solidarity and protest movements. Disparities in access to the internet exist both between countries (in 2020, only 1 in 4 Africans had access to the internet) and within countries (many rural and remote areas continue to lack stable connectivity even in high-income countries). The use of social media operates not only as a tool to democratize health information, it has also become a channel for propagating misinformation and “fake news.” Examples include promoting antivaccinations, misinformation of the Zika virus, and false advice for preventing and treating diseases, including Ebola and COVID-19. Increased trade flows: Economic integration has accelerated the flow of traded good and services, transforming labor markets, job opportunities, and employment conditions. For some, this has translated to gains in wealth and health. However, others have been squeezed by employment insecurity and precarious employment arrangements, exacerbated by inadequate health, social, and environmental protections. Poorer populations often are forced to work in unhealthy, unsafe, and even violent workplaces. Furthermore, energy requirements for global production chains and increased release of fossil fuels associated with transportation are contributing to climate change emissions. International trade agreements have been expanding their scope and reach, thereby widening public health implications. Yet, more recent turbulence in global affairs, including rising authoritarianism and nationalism, as well as the global pandemic of COVID-19 is leading to unchartered trade waters. Increased financial flows: Finacialization has expanded the role of money over the livelihoods of individuals and households. The exchange of assets or financial instruments across countries has increased, notably through the easing of restrictions on (continued)

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Box 2 Important Global Flows (continued)

foreign direct investment (FDI) and more recently through short-term financial flows. Financial flows are uneven, for example, FDI is less prominent among LICs compared to MICs. While FDI can promote economic opportunities for countries, it can also contribute to poor working conditions, degrade local environments, and promote dominance of foreign culture over host country culture. An increasingly financialization of the global economy has heightened risks for financial crises, including severe ones, such as the 2007 global financial crisis and the impending crisis currently forecasted as the worst one since the Great Depression. Increased people flows: The number of people living elsewhere from where they were born has tripled since the 1970s. According to the 2020 World Migration Report, there was an estimated 272 million international migrants. The number of refugees and internally displaced people has doubled over the past 10 years. While migration’s pull factors – opportunities for education, employment and family reunification – have been a steadfast dimension of globalization, migration’s push factors are gaining traction as people migrate to escape violence, conflict, and environmental degradation driven by climate change. During the travel period, the transmission of pathogens across zones is a key global public health concern, especially if there are multiple transit locations. Irregular migrants face a range of health risks during their travel, depending on their mode of transport and the security of their route – the Mediterranean Sea remains the deadliest route. Upon arrival, the health of migrants is variable. Some experience a “healthy migrant effect.” Others, notably people whose arrival was due to forced migration may face a range of challenges including food and housing insecurity, mental health challenges, inadequate access to health and basic services, and xenophobia. The illegal flow of populations through trafficking has also risen. The slowing of migration due to xenophobic policies in some countries and the COVID-19 pandemic has created further challenges, including drastic reduction in international remittances. Adapted and updated from Labonté et al. (2011b). Additional Sources: Lapavitsas (2013); Friel et al. (2015); Labonté (2019). Caulfield et al. (2019); Internet World Stats ( n.d.); Orata et al. (2014); Wang and Jolly (2004); Zimmerman et al. (2011).

Globalized Infectious Diseases If there was a prize for a disease that most epitomizes globalization, it would be awarded to coronavirus 19 (COVID-19) – from the dizzying speed of the virus’s spread across the world to the chaotic social response, involving among other things,

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quasi gangster (read government) wars over personal protective equipment (PPE). First reported in China’s province of Wuhan on December 31, 2019, the virus has since spread to every continent outside of Antarctica. Predictions of a global pandemic involving a novel virus had been made by numerous health experts across the globe (Bruine De Bruin et al. 2006; Garrett 2019; Global Preparedness Monitoring Board 2019; Public Health Agency of Canada 2006). And yet, countries were ill prepared (although some societies have been faring better than others, see Box 3 for the case of Senegal). Moreover, many countries are failing to implement effective strategies to curb the spread of COVID-19. COVID-19 has unleashed immeasurable suffering and death worldwide, while also shining light across society’s fractures, including ageism, disablism, racism, weaknesses in mental health systems and wealth disparities within and between countries. COVID-19 has demonstrated the unequitable distribution of the severity and survival rates of the disease among different social and occupational groups, as well as disproportionate burdens of living through lockdowns (Table 1). Advantaged groups include those with available financial and technical resources (e.g., money to pay for delivered food, devices and services required for social connectivity), capacities to adopt public health practices for avoiding the spread of COVID-19 (e.g., access to water and soap, ability to socially distance) and opportunities to engage in daily activities. Meanwhile, “pandemic profiteering” has led skyrocketing profits among some of the largest corporations, in sectors, such as pharmaceutical, technology, social media, and retail. Box 3 COVID-19 Response in Senegal

Senegal’s response to COVID-19 ranks 2nd out of 36 low, middle, and highincome countries, according to Foreign Policy’s COVID-19 Global Response Index. The index encompasses policy responses in three areas – public health action, financial support, and science-based public communication – is based on data collected between and December 31, and August 31, 2020. Senegal launched an early, vigorous response with clear, science-based government messaging, drawing on experience from handling the 2014 Ebola outbreak. Senegal has been a leader in COVID-19 testing, including developing and evaluating their own rapid test. The Senegalese Institute of Pasteur of Dakar is one of the partners in a broader African coalition, the African Task Force for Coronavirus Preparedness and Response (AFTCOR), led by the African Centres for Disease Control and Prevention (Africa CDC). AFTCOR has mobilized and coordinated African Union states to promote supplies of affordable test kits and boost testing capacities. Source: Foreign Policy (2020); Ondoa et al. (2020). Global pandemics create chaos and distraction – fodder for political maneuvering. During the Black Death of the fourteenth century, the aristocrats and

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Table 1 Selected populations with elevated vulnerability to COVID-19 and to the effects of lockdowns Population Front line health care providers and emergency response teams

Long term care residents

Populations deprived of their liberty: Those in jail, prison, detention centers

Vulnerable to COVID-19 Health care providers on the front-line face direct exposure to the virus, particularly when ill equipped with personal protective equipment (PPE) as has been the case across both the global south and the global north due to stresses on global supply chains making them unreliable. The global south was further hampered by European and north American countries who mobilized PPE through economic, political, and strategic powers. Health care providers have faced abuse, threats and in some cases violence while attempting to test or provide care for people. Overworked with highly stressful conditions, including losing patients and making decisions related to allocation of scarce health care resources, such as ventilators creates Residents of long-term care facilities in many high-income countries faced high infection rates and death rates due to age and/or co-morbidities, as well as living in close proximity to other residents. However, the main issues appear to be neglect and poor conditions of facilities, inadequate staffing, and lack of any oversight at many facilities. Conditions were so atrocious in some cases that armies were brought in The spread of infectious pathogens can be amplified in places of detention due to close proximity of inmates and challenges related to physical distancing. People living in prisons tend to have a greater underlying burden of disease and more risk factors to COVID-19 (e.g., smoking, poor

Vulnerable during lockdowns As front-line health providers continue to work during lockdowns there is no specific vulnerability, although many providers have chosen to choose alternative lodgings in order to avoid potential COVID-19 transmission in their household

In many cases, long-term care residents were isolated in their rooms for long periods of time without access to adequate cleaning of rooms, assistance for bathing and hygiene and social interactions. Families were often barred from entry compounding residents’ social deprivations and supportive care

Suspended or limitations on prior privileges, including phone calls, visitations with community members and legal representation and access to commissionaires (soap, food). Reduced guards and heightened tensions have contributed to prison riots and escapes in some countries (e.g. Italy, Brazil, (continued)

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Table 1 (continued) Population

Indigenous people

Homeless people

Vulnerable to COVID-19

Vulnerable during lockdowns

nutrition, drug use disorders), compared to general population. Detention centers that are overcrowded (almost 60% of prisons worldwide), unhygienic and lack access to health care exacerbate risks

Venezuela). “Decarceration” has been adopted by some countries (e.g., Canada, Ethiopia, Iran, USA), although lack of community services for re-integration into society is challenging for those released who lack housing, social support, and income Historical trauma, rooted in colonialism, experienced by many Indigenous communities enhance vulnerabilities to social pathologies associated with lockdowns, including heightened family violence, drug and alcohol abuse. Disruptions to cultural, collective practices and traditions impedes salutogenic properties of Indigenous culture and community resilience

Globally, Indigenous populations tend to be more susceptible to infectious pathogens due to a constellation of factors, including social determinants of health (e.g., poverty, inadequate access to water and soap, crowded conditions, poor housing, food insecurity), underlying co-morbidities (e.g., diabetes, hypertension), inadequate access to care and collective lifestyles (e.g., extended family residences, food sharing). Prior experience with epidemics has also facilitated early action by Indigenous communities themselves to prevent infections through restrictions access of nonresidents to communities, self-imposed travel restrictions, mandatory quarantines of returning residents and producing their own masks People experiencing homelessness are vulnerable to infectious pathogens due to their higher burden of co-morbidities, including immune deficiencies and respiratory illnesses. Furthermore, there are challenges related to prevention of COVID-19: Self-isolation when demonstrating symptoms, challenges to regular handwashing and hygienic practices, lack of access to mobiles and technologies for

Lockdowns have forced shelters, soup kitchens, and drug rehabilitation centers to downsize or shut down completely. Closing down coffee shops and restaurants has further reduced opportunities for people experiencing homeless to acquire food, coffee and access to bathrooms. Heightened risks of evictions due to inability to pay rent and perceived risks of certain tenants spreading COVID-19, such as frontline (continued)

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Table 1 (continued) Population

Vulnerable to COVID-19

Vulnerable during lockdowns

virtual health care visits. Physical distancing is also challenging as mutual aid, for protection, socializing and sharing food. Among the sub-set of the population that are drug dependent, semi-permanent settlements may be formed, such as Cracolândia in Brazil, where over 1,000. Residents buy and sell drugs, share needles, crack pipes, and cigarettes

health care workers, have created new categories of people without homes

Source: Akiyama et al. (2020); Banerjee and Bhattacharya (2020); International Migration Organization (2019); Jozaghi et al. (2020); Kaplan et al. (2020); Lum et al. (2020); Power et al. (2020); Sánchez et al. (2020); Simpson and Butler (2020); WHO (2020); Wood et al. (2020)

gentry used Parliament to implement laws that lowered wages of peasants despite the critical labor shortages (Cantor 2001). To paraphrase Winston Churchill, governments across the globe have not been letting the current global pandemic go to waste. The current crisis has led governments to engage in a variety of anticitizen acts, including the implementation of draconian laws, acts contravening democracy, rolling-back on previously promised public action, and impinging on human rights (see Box 4 for examples). The public health strategy of mandating physical distancing has been inadvertently operating to constrain public protests, one of the most critical tools of civil society. This public policy strategy is captured by Alberta’s Energy Minister, Sonya Savage’s blunt statement on a podcast hosted by the Canadian Association of Oilwell Drilling Contractors “Now is a great time to be building a pipeline because you can’t have protests of more than 15 people.” COVID-19 has demonstrated that untangling the effects of globalization and health involves understanding not only the distribution, but also the severity of an illness a dimension of health that tends to get neglected. COVID-19 illuminates the full spectrum from being asymptomatic to fatal or near fatal cases requiring ICU and potentially a ventilator. The “messy middle” to the spectrum of effects is also alarming – ranging from mild cold-like symptoms to incapacitating fevers, aches, body racking coughing, body weakness, and unending fatigue, to internal organ damage that is barely noticed by the sufferers. Moreover, there is increasing evidence of a significant proportion of patients demonstrating postacute COVID19 (“long COVID”) (Greenhalgh et al. 2020). Even once the COVID-19 pandemic is finally under control, the chronic implications will remain a future global health challenge.

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Box 4 Examples of anti-citizen acts by government during the COVID-19 pandemic

Canada: A National Action Plan promised to address the findings of the Missing and Murdered Indigenous Women and Girls (MMIWG) by the Government of Canada was delayed indefinitely due to COVID-19 – a crisis that has been enhancing gender-based violence against Indigenous girls and women. China: National Security Law 66 was implemented on June 30, 2020 giving Beijing unprecedented powers (including curtailing public protests) over Hong Kong in the move towards “one country, one system.” While this law may have been in the pipeline for some time, the pandemic has provided China a “golden opportunity” to implement the law, while many countries are enmeshed in their own struggles and may want to keep doors with China open for their own economic recoveries. Hungary: In early spring, Hungary’s Prime Minister Viktor Orbán was granted wide ranging emergency powers enabling him to rule by decree, which was switched to ruling under “a state of medical crisis” until mid-December, which enables a range of decrees, but no laws can be changed. India: A number of Indian states (e.g., Gujarat, Madhya Pradesh, Rajasthan, Uttar Pradesh) amended labor laws during the COVID-19 lockdowns that constrained worker’s rights, which included extending workdays to 12 hours per day and enabling employers to fire workers at will. Source: Bayer (2020); FAFIA and Palmater ( 2020); Indian Express (2020); Shen (2020).

Globalization and the Growing Burden of Noncommunicable Diseases Despite the lack of government and intergovernment preparedness for dealing with COVID-19, the globalization of infectious diseases has received relatively greater research and policy attention compared to chronic, noncommunicable diseases (NCDs). In the realm of politics, the privileging of infectious diseases can be attributed to the relative immediacy of a threatening pathogen to both the health of populations and threats to a nation’s security and economy (Labonté et al. 2011b). Microbes are identifiable and generally more straightforward to contain as opposed to the multiple, inter-linked determinants that influence NCDs. Yet, greater attention to NCDs from a globalization perspective is critical to global health. The growing global burden of NCDs is massive. In 2019, 7 out of 10 causes of death in the world were attributed to noncommunicable diseases (WHO 2020). While infectious diseases remain the main cause of death in low-income countries

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(LICs), people living in middle-income countries (MICs), similar to those in high income countries (HICs), are more likely to die from a NCD. Furthermore, there has been a steady rise of NCDs affecting the daily lives of people in low- and middleincome countries (LMICs), leading to a situation of a “double burden” of disease (or a triple burden of diseases if injuries are also considered). The rise of NCDs in LMICs and the need for a global response has increasingly been recognized by the international community, as flagged by the 2011 UN high level meeting on NCDs. How to address the global burden of NCDs is not straightforward and will require multiple approaches. One issue that cannot be neglected is the role that globalization is and will continue to play. The main unhealthy commodities driving the rise in NCDs are tobacco, alcohol, and highly processed food and drinks. The main vector of global transmission of these products is through transnational corporations (TNCs), large global firms which have expanded their reach of these products via liberalizing international trade flows and increased demand for the products through expanded capacities to advertise and promote the consumption of these products (Labonté et al. 2011a; Moodie et al. 2013). As a result, TNCs are powerfully shaping epidemiological patterns in new ways. For example, the nutrition transition and rising obesity levels are deeply entrenched in the globalization of agrifood systems (Hawkes 2006). Unfettered market powers have led to “industrial epidemics” of diseases, such as cirrhosis of the liver, certain cancers, heart disease, and diabetes (Hastings 2012). The coca-colonization of nations is one of the first trends to be observed (Zimmet 2000) and continues to present day taking on new, powerful forms (Box 5). Box 5 Case – NCDs and Coca-Cola ® politics in Mexico

Over the past 30 years, there has been a steady rise of diabetes and obesity in Mexico, especially in poor, rural areas with large proportions of Indigenous peoples. While there have been general shifts away from traditional, plantbased diets to meat-based, calorie dense diets, the sharp increase in the consumption of Coca-Cola ® has been particularly marked. Globally, Mexico is the largest consumer of Coca-Cola ®, which has not only become a staple drink, but has become embedded in the everyday lives of many communities, including some traditional practices. In San Cristobal de las Casas, Chiapas – an area with inadequate supplies to safe drinking water – Coca-Cola ® is the major extractor of ground water, which it bottles and sells globally (including to the residents of San Cristobal de las Casas). A recent political analysis of this situation highlights the complex ways in which Coca-Cola ® was able to maintain such as powerful market presence, despite recent efforts of public policies aims to address NCDs. This analysis revealed that while corporate economic power was important, the key influence was the company’s admittance to the corridors of political power, including lobbyists access to congressional and bureaucratic institutions, as well as the historic ties with (continued)

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Box 5 Case – NCDs and Coca-Cola ® politics in Mexico (continued)

presidents. An anthropological critique further observed that during Vincente Fox’s presidential term, extraction of community groundwater for TNCs soared. And while Fox had been President of Mexico’s Coca-Cola ® company, he had been assessing the subsoil waters and extraction technology. Sources: Gómez (2019); Nash (2007).

National companies and TNCs also influence the health of peoples living in highincome countries. For example, one of the main drivers for the opioid epidemic in North America has been pharmaceutical companies who both manufactured and aggressively sold drugs through strategies, such as promoting physician overprescription of the drugs (Case and Deaton 2020). Global supplies channeled through illegal drug suppliers furthered the international reach of opioids and other drugs. Globalization has not only contributed to the supply of drugs, an imbalanced global economy has helped create an environment that increased the demand for opioids. The impact of flooding the market with new drugs was magnified in poor and rural communities that had experienced severe job losses due to globalization and automation, making them vulnerable to “deaths of despair” – deaths attributed to suicide, drug overdose, and alcoholism (Case and Deaton 2020). Deaths of despair are also growing globally. The Global Burden of Disease Study observed a growing global burden of alcohol and drug use, particularly in certain geographical areas (Fig. 1). Moreover, this burden was strongly associated with socioeconomic development; diseases of poverty, such as tuberculosis, were found to be exacerbated by substance use (GBD 2016 Alcohol and Drug Use Collaborators 2018). Greater attention is required to understand potential linkages between globalization and deaths of despair in LMICs. This includes ensuring pharmaceutical companies are prevented from pursuing predatory expansion of opiate markets to poorer countries.

Conclusion “. . .you feel breathless and you understand it may be your last breath.” Graziella Sonzonni, COVID 19 survivor in Bergamo, Italy, February, 2020 “Please. I can’t breathe.” George Floyd, Minneapolis, USA, May 25, 2020 “We can’t breathe.” Protestors against air pollution in Ulaanbaatar, Mongolia, January 2017

The capability to breathe is being challenged by a range of toxins spewed up by an imbalanced global economy that goes beyond a single pathogen. Globalizationlinked challenges are becoming increasingly interwoven, portending a calculus of crises. We have entered what some have labeled as the “pandemic era” that requires

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Fig. 1 Age-standardised DALYs per 100000 people attributable to alcohol and drug use for both sexes by country in 2016, in 195 locations (A) DALYs attributed to alcohol use. (B) DALYs attributable to drug use. DALYs¼disability-adjusted life-years. ATG¼Antigua and Barbuda. FSM¼Federated States of Micronesia. Isl¼Islands. LCA¼Saint Lucia. TLS¼Timor-Leste. TTO¼Trinidad and Tobago. VCT¼Saint Vincent and the Grenadines. Source: Reprinted with permission. All rights reserved. GBD 2016 Alcohol and Drug Use Collaborators. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;5:987-1012

greater attention to the warnings by infectious disease specialists and virologists about threatening pathogens specifically and the virosphere more generally. Furthermore, we need to be paying closer attention to political scientists who have been raising the alarm about multiple global crises, involving food security, climate

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change, and finance in relation to threats to global health equity (Schrecker 2012). The intersections of pandemics and other global crises create untenable burdens on populations. The current pandemic is being faced by societies who are also fighting back wildfires, floods, locust invasions, hunger, obesity, job losses, air pollution, structural racism, and state violence, to name just a few. Global health setbacks from these multiple crises are and will be immense, requiring an appropriate social response. Just as cholera outbreaks slowly propelled nineteenth-century metropolitan areas to restructure their community infrastructures to improve housing, water, and sanitation (Shah 2016); this global pandemic requires a major restructuring of our global economy. Even before the pandemic hit, avowed capitalists have been increasingly recognizing the failures of neoliberal policies (Case and Deaton 2020; Rodin and de Ferranti 2012). For example, the rolling back of user fees in health systems and the promotion of universal health coverage has become the new common sense in global health among the proponents of earlier neoliberal policies (Rodin and de Ferranti 2012). Moving the global health equity agenda forward requires a “globalization of resistance.” These struggles require more than the intertwining of bodies and experiences, we need a comprehensive lens that views the “intersectionality of struggles” (Davis 2016). Dr. Martin Luther King’s famous speech, I have a dream, was much more than a rallying call for Black Americans – King was establishing the interconnections of the Black liberation movement and the campaign to end the Vietnam war. Understanding the pathology and epidemiology of diseases that affect populations worldwide is necessary but not sufficient for global health knowledge. There is a need to connect the dots related to multiple crises and the distribution of opportunities to be in good health (Schrecker 2012). As a field, “globalization and health” studies have been acquiring prominence and should be increasingly pursued with the best intentions for planetary and human health.

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Urbanization and Cities as Drivers of Global Health Fatima Ghani, Emmanuel Tsekleves, and Yonette Felicity Thomas

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urbanization and the SDGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges to Achieving Sustainable Development in Cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Synergies and Trade-Offs Between and Within Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health in All Policies: A Multisectoral Approach to Urban Development . . . . . . . . . . . . . . . . . . . . . Monitoring Progress Towards Healthy Cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing Policy Relevant Urban Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leaving No One Behind in Urban Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Natural, Built and Social Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global North and Global South Divide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inequalities Within Cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gender Gap in Urban Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the Gender Gap in Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Addressing the Gender Mobility Gap: Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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F. Ghani (*) International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia Convenor of the Design Research Society Special Interest Group on Global Health, London, UK e-mail: [email protected] E. Tsekleves Imagination Lancaster, LICA, Lancaster University, Lancaster, UK Convenor of the Design Research Society Special Interest Group on Global Health, London, UK e-mail: [email protected] Y. F. Thomas Strategic Transitions, Glenn Dale, MD, USA Convenor of the Design Research Society Special Interest Group on Global Health, London, UK e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_3

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Abstract

Urbanization, urban planning and population health are closely related and interdependent. This chapter provides a multidisciplinary perspective of cities as drivers of global health. It presents a historical introduction of urbanization and highlights the challenges to achieve the Sustainable Development Goals (SDGs) in the context of cities, particularly SDG 11 (sustainable cities and communities) as interlinked with SDG3 (health and wellbeing). It mentions synergies and tradeoffs between the goals and the importance of incorporating health in all policies as a multisectoral approach to urban development in both the Global South and Global North, with the need to engage not only decision makers, urban planners and researchers, but also the voices of community and advocacy groups to ensure no one is left behind. It also examines inner-city inequalities as well as gender differences in urban mobility, including recommendations for gender-responsive interventions. The importance of developing policy-relevant urban indicators to measure progress towards achieving SDG 11 is also highlighted. Lastly, several urban health case studies are presented, providing insight into the relevant drivers of global health challenges. Keywords

Urban health · Urbanization · Smart cities · Sustainability · Gender · Mobility

Introduction Evidence indicates that the spatial planning of human settlements has a profound effect on the health of populations. Early settlements played an essential role in supporting human life and culture and were strategically located near food and water sources. They also provided a centralized public space for trade and social interactions around which individuals would choose to live, often within convenient walking distance. These public spaces were accessible through well-connected, grid-like streets providing several pedestrian routes to destinations, and instigated socioeconomic developments in pre-industrial cities by attracting new residents through opportunities for trade, employment and education (Talen and Koschinsky 2013). As urban centers increased in residential density, so did the level of investment require for their functioning. The city fringe kept expanding, reflecting population and economic growth. The industrial revolution introduced technological developments (such as motor vehicles) in urban centers, reducing the amount of physical work required to perform many activities of daily living. Rapid changes in motorized transportation led to modern urban planning forms (Giles-Corti et al. 2016). While many pre-industrial urban centers maintain features of the original walkable design, new residential developments sprawled in the periphery. These postindustrial urban developments are designed mainly for vehicular transportation

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(characterized by low residential density and less connected streets with monotonous uniform houses with separation of land uses), and are often poorly serviced in regards to public transport and other amenities, making walking impractical due to long distances. These urban forms, common in many cities of the Global North and South, promote sedentary and unhealthy car-dependent lifestyles to the detriment of active forms of travel (such as walking, cycling or public transport) as well as unsustainable development. They have also created a contextual disadvantage based on the location of residence; the value of residential property in modern cities typically reflects the distance from the urban center (or Central Business District), displacing low income earners from well-serviced areas into less desirable neighborhoods further away, creating clusters of disadvantaged residents within particular neighborhoods (Talen and Koschinsky 2013). Over the past decade, researchers have confirmed that neighborhoods influence the health and wellbeing of residents through structural, socioeconomic and compositional characteristics. In particular, the daily conditions in which people live significantly influence their health outcomes through either facilitating or inhibiting healthy behaviors and lifestyles, such as opportunities for regular physical activity, exposure to environmental pollutants or differential access to fresh nutritious food. Ultimately, urban disparities (which might reflect neighborhood-level disadvantage) are detrimental to all city inhabitants. For instance, pedestrian unfriendly environments generate unsustainable development, noise and traffic pollution, congestion, and in the worst cases, crime and social unrest (Giles-Corti et al. 2016). Public health researchers play an important role in producing evidence that enables communities to have increased control over their health outcomes by advocating for better neighborhood environments, and informing urban and transport planning policies, infrastructure and services that promote population health and narrow socioeconomic and health disparities across demographic groups everywhere, targeting the effective integration of health and urban planning (Barton and Grant 2013). Vulnerable demographic groups such as women and older adults are predisposed to inactivity, and often face more individual and environmental barriers (perceived and objective) to active transportation and recreation than men and younger adults (Giles-Corti et al. 2016).

Urbanization and the SDGs Rapid population growth has been concentrated in urban centers, increasing the pressure on essential urban infrastructure, resources, services and natural ecosystems. Growing concern about the implications of ecosystem loss – within and beyond cities – for social and economic development has prompted the formulation of global commitments (Maes et al. 2019). The United Nations (UN) adopted in 2015 an Agenda acknowledging that social and economic development depends on the sustainable management of natural resources. The Agenda comprises 17 Sustainable Development Goals (SDGs) and 169 SDG related targets for the year 2030

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for all nations, providing a unique opportunity for achieving both human and planetary health (United Nations 2015). Socio-ecological models depict the complexity of the multiple levels of influence on the health of individuals living within the ecosystem on which they ultimately depend. These cultural, social, political, economic and environmental influences are determinants of health that shape and are shaped by spatial urban planning. Since global issues are being addressed at a local level, cities are leading progress toward many SDG targets and goals (Corbett and Mellouli 2017; Barton and Grant 2013), as well as translating the broad and globally focused SDG Agenda into specific decision-making contexts – an important practical challenge for decision-makers across sectors (Maes et al. 2019). Identifying key targets and actions that create cobenefits across the SDGs, and particularly SDG 11 and 3, could support the more efficient prioritization of resource allocation to achieve better population health and well-being outcomes in the context of limited resources. While SDG 11 relates to the development of inclusive, safe, resilient and sustainable cities, this goal is strongly interlinked with SDG 3 (population health and well-being). The expression healthy city highlights the impact of urban design and policy on public health. However, the drivers for urbanization and sustainable development (e.g. transport, housing, urban design, and energy provision) have not been a traditional focus of health policy-making (Neira et al. 2017).

Challenges to Achieving Sustainable Development in Cities Multiple SDGs are relevant to urban environments in interconnected ways, and integrated strategic planning is therefore required to ensure environments are inclusive, safe and resilient to climate change (Lowe et al. 2015). Addressing issues such as socioeconomic growth, equality and good governance are prerequisites for the sustainable management of urban environments. Translating these interlinkages into a strategy supported by key stakeholders is paramount for achieving sustainable management of the urban environment (Maes et al. 2019). The importance of involving and supporting key stakeholders (policy makers, academics, communities and advocacy groups) is highlighted within the Healthy Cities Europe initiative. The initiative’s primary mission to prioritize health within the social and political agenda of cities remains a challenge for cities and municipalities in both the Global North and South (Tsouros 2015). The clear alignment of SDG 11 and transportation strategies with other SDGs, including SDG 3 and gender-equality-related SDG 5, supports the promotion of integrated health and global development. For instance, reducing mortality from air pollution exposure is referenced as a progress indicator under SDG 3. Prerequisites to reduce such mortality – such as increased access to clean household fuels and technologies and reduced urban ambient air pollution exposure – are indicators of the SDGs for energy (7.1.2) and cities (11.6.2), respectively. These indicators reflect the interrelations between environmental risk and health effects (Neira et al. 2017).

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Synergies and Trade-Offs Between and Within Goals Understanding the interlinkages between the SDGs and environmental factors remain a practical challenge at the local level for researchers and decision-makers across disciplines. While urban environment management can reinforce or undermine action to deliver the SDGs, it is unclear how SDG targets relate to urban environments (Maes et al. 2019). The links between urban development, the environment, and local health are complex. While urban development should aim at producing mutually beneficial outcomes for global and local health, some policies might have potential trade-offs. For instance, while high-density urban developments might reduce motorized transportation and pollution worldwide, they might also negatively impact local health as result of overcrowding, reduced green space for outdoor activities and psychological stress (Fisher et al. 2017). Urban developers could mitigate the negative impact that the construction of the built environment has on biodiversity by integrating biodiversity conservation into all development projects, policies and strategies. Investing in active transport presents significant cost-effective opportunities for sustainable cities and urban green spaces conducive of healthy lifestyle choices (cycling, walking and public transport) as well as creating more wildlife friendly urban environments. Such investments have additional benefits such as enabling ageing in place for city dwellers, reducing traffic congestion and improving air quality. Smart investment in active transport infrastructure (such as separated bike lanes and well-designed pedestrian infrastructure) positively impacts the health and wellbeing of city dwellers by increasing their physical activity levels, provided that potential risks (e.g. exposure to air pollution or risk of accidents) are mitigated (Fisher et al. 2017). Case Study: Building the Resilience of Cities to Address the COVID-19 Pandemic

Several SDG targets across SDG 11 and SDG 3 refer to addressing local and global health crisis, including 3.D Strengthen the capacity of all countries, particularly developing countries, for early warning, risk reduction and management of national and global health risks; 11.5 significantly reduce mortality and morbidity attributed to direct economic losses relative to global gross domestic product caused by disasters while protecting the vulnerable; and 11. B increase the number of cities adopting and implementing integrated policies and plans towards inclusion, resource efficiency, mitigation and adaptation to climate change, resilience to disasters, and develop and implement holistic disaster risk management at all levels (United Nations 2015). Mobility is linked to every aspect of life in cities (employment, education, entertainment, shopping). The COVID-19 pandemic is changing the way people move within cities worldwide, mainly attributed to the decreased used in motorized transportation (both public and private) as result of worldwide city lock-downs to contain the outbreak among urban populations. A reduction in motorized transport could be facilitated by addressing issues (continued)

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relating to housing, public services and work culture. Previously high commuting levels may no longer be necessary if individuals can work from home, services are distributed equally across geographies or people can afford to live within walking or cycling distance from their work (Perry 2020). Measures such as travel bans and street closures are decreasing carbon emissions, enabling some environmental recovery. They also provide cities the opportunity to favor social distancing by promoting active, clean and sustainable transportation modes (cycling and walking) enhancing the active living of urban populations. Making healthier and more sustainable options more efficient, accessible, affordable and convenient might require the retrofitting of street space for bike lanes and walkways. As travel restrictions are eventually lifted worldwide, some cities are planning to support active transport alternatives to facilitate social distancing such as cycle lanes alongside implementing reduced speed limits and widened pavements for pedestrians. Such moves suggest a possible shift towards more sustainable forms of transport in the long term, catalyzed by the pandemic. Cities that use the opportunity to improve active transportation infrastructure during the time that takes to produce and distribute a vaccine, may not only recover but thrive into the future with improved air quality and better public health (Perry 2020). Reducing air pollution and climate degradation is a priority for the new Global Mayors COVID-19 Recovery Task Force, coordinated by C40 Cities, a collaborative effort of mayors worldwide to achieve a climate-friendly economic recovery from the pandemic (C40 Cities 2020).

Health in All Policies: A Multisectoral Approach to Urban Development Planning for healthy, livable and sustainable communities has potential co-benefits across all sectors and requires the active engagement of multidisciplinary fields including public health, urban planning and the environment (Lowe et al. 2015). Population health and health equity can be enhanced by urban and transport planning informed by multisectoral approaches that systematically consider the health consequences of decisions and interventions, explores synergies, and reduces adverse environmental impacts (referred to as Health in All Policies). These considerations should be integrated into local decision-making processes in the context of urban policies to promote public health interventions aimed at achieving targets across SDGs (Ramirez-Rubio et al. 2019). Health in All Policies initiatives are guided by evaluation tools such as health impact assessments (HIAs). HIAs audits are increasingly being undertaken in high income countries integrating city-level quantitative burden of disease and health economic assessments (Ramirez-Rubio et al. 2019). They provide an

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opportunity to integrate a multisectoral approach by establishing mechanisms to ensure the active participation of key stakeholders, including city dwellers, urban planners, policy makers and academics, as well as relevant methods to guide the incorporation of health recommendations into urban policies (Ramirez-Rubio et al. 2019). The processes should be documented to inform how different disciplines work together, how to incorporate citizen and stakeholder opinion into quantitative HIA modelling for urban and transport planning, how different modelling and measurement methods can be integrated, and how a public health approach results in positive changes in urban and transport planning (Nieuwenhuijsen et al. 2017). Conducting HIAs in the urban and transport development of cities in Low-and Middle-Income Countries (LMICs), where urbanization rates are highest, the burden of Non-Communicable Diseases (NCDs) is the greatest and where many cities are undergoing rapid urbanization, might provide the greatest public health benefits by avoiding the mistakes made by developed countries. However, contextual challenges include limited data, clarity on future health necessities, and governance and institutional strength (Ramirez-Rubio et al. 2019).

Monitoring Progress Towards Healthy Cities Monitoring the SDGs is a significant task and strategic opportunity for stakeholders and beneficiaries involved with achieving the Agenda 2030 at all levels of government. A comprehensive SDG index was built to track overall progress across multiple targets and indicators. This index was improved by accounting for differences within and between goals as well as across the economic, social, and environmental dimensions of sustainable development. It was also refined by capturing synergies and trade-offs among indicators. The index revealed crucial differences in scores and rankings that illustrate the value of more flexible and integrated measures for guiding policymakers and monitor overall progress (Biggeri et al. 2019). Designing and building healthy, livable urban environments is a global priority, and good examples can provide benchmarks against which to monitor progress towards policy reform and enable comparisons between and within cities (Lowe et al. 2015). Livability indicators cross a range of policy domains governed by state and local governments, with varying involvement of the national government. They also cover policy domains such as housing, led by the private sector; and community services, strongly influenced by the non-profit sector. Urban and transport planning policies have large impacts on public health (via air and noise pollution, climate impacts, green and open public spaces, motorized accidents and physical activity) but these are not often well understood or quantified, partly due to lack of comprehensive models, methods and tools (Nieuwenhuijsen et al. 2017). Cities play a key role in the achievement of the SDGs target activities, and the information systems community must be an active partner in these efforts (Corbett and Mellouli 2017).

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Developing Policy Relevant Urban Indicators SDG 11 aims at making cities and human settlements inclusive, safe, resilient, and sustainable and has 11 related targets, with can be measured via indicators. There are several challenges regarding the selection of indicators and their practical use as a tool to improve cities including: the poor availability of standardized, open access and comparable data; the lack of reliable city data collection institutions to support monitoring for SDG 11; and the limited uptake and context-specific application of the goal by diverse actors in widely varying cities (Klopp and Petretta 2017). The smart cities movement present opportunities to solve the data problem but also raise new challenges. Despite these challenges, the SDG 11 framework can potentially encourage and guide needed city reforms, but only if rooted in local mechanisms and initiatives guided by transparent, inclusive and contextually responsive data collection and monitoring (Klopp and Petretta 2017). Case Study: Emerging Technologies and Smart Cities

The term smart cities involves the deployment of innovative media technologies in urban settings to improve city infrastructures and personalize the experience of the city, and has gained traction in academic, industry and policy debates in recent years (Lange and Waal 2017). A conceptual model has been developed to illustrate how an Integrated Information Ecosystem facilitates connections between three interrelated domains (administrative, political and sustainability) to promote the growth of smart sustainable cities. Moving from theory to practice, two real-world exampled (two green information systems used to manage water quality and green space) were used to illustrate the applicability of the model, and define an action framework for cities as well as identify areas for future research. This call-to-action provides a much-needed foundation for future research and practice leading to a sustainable future for all (Corbett and Mellouli 2017). Digital media enabled qualitative shifts in the way the public can be engaged with, and act upon collective concerns, allowing many citizens to organize and take ownership of issues through decentralized grassroots networks and initiatives. Digital technology provides an opportunity to directly involve civil society (or at least those who have access to such technologies) in co-creating the urban social and built environments in a culturally responsive manner, broadening the role of emerging technologies in urban design from a city management role to a social or city making role. Urban designers might be able to design accessible and inclusive public urban interfaces that engage citizens with particular matters and allow them to organize themselves and act (Lange and Waal 2017).

An assessment of two main UN frameworks that monitor SDG 11 progress (the SDG 11 indicator framework and HABITAT’s Action Framework for Implementation of the New Urban Agenda) (Giles-Corti et al. 2019), noted the following:

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• Most existing data related to SDG 11 are at country – rather than city – level. There is limited understanding of the contribution of the SDGs to spatial planning of healthy cities. A more robust and systematic set of indicators should be routinely collected for cities to monitor progress towards achieving the SDGs and enable comparisons between and within cities. Disaggregated spatial indicators are required to detect inequities in access to infrastructure and resources (by age, gender, ethnicity and socioeconomic status at least) and linked to health and other outcomes to inform urban planning across cities and areas requiring investment (Giles-Corti et al. 2019). • The creation of policy-relevant indicators (on the existence or absence of urban policies such as a transport policy designed to promote public transit and/or active modes of transport) is crucial in enabling a wider range of cities and countries, particularly LMIC, to report their progress in implementing policies towards achieving the SDGs (Giles-Corti et al. 2019). – A city policy database is a critical resource for comparing city-level performance data to large-scale comparative policy data to facilitate the detection of effective and ineffective policies in achieving SDG 11 (Rozhenkova et al. 2019). – The current monitoring system could be improved by engaging regional policymakers to pursue municipal laws and strategies from all major cities. Policymakers around the world should work collaboratively to obtain municipal policies and legislation and identify best practices, local laws and regulations to be adapted to different contexts. By combining city policies with data on outcomes, decision makers can gain valuable insights that can shape local government debates (Rozhenkova et al. 2019). Current livability indicators do not often relate to policy outcomes, and there is no agreement among decision-makers or scholars on which measures are most valuable for informing urban policy development and implementation. More effective and consistent use of livability indicators is required to promote the creation of healthy, livable and sustainable cities, achieved by integrating planning across different levels of government, as well as the private and community sectors (Lowe et al. 2015). – Current livability indexes are aggregated at the city-level, do not represent geographic variability within cities, and are therefore not aligned with policy or health outcomes. A Melbourne study incorporated health-related policy-relevant metrics into the Urban Livability Index (ULI) and explored its correlation with adult travel behaviors. The ULI offers an evidence-based and policy-relevant indicator of urban life that demonstrates an important, near-linear association to adult travel activities in Melbourne. The ULI can be used to measure progress in adopting policies aimed at generating more livable cities, identify geographical inequities and analyze health and wellbeing links (Higgs et al. 2019).

Leaving No One Behind in Urban Contexts Leaving no one behind is a central objective of the transformative 2030 Agenda across the SDGs, recognizing that socioeconomic inequalities that result in health inequalities not only prevent overall growth and human development, but also

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undermine the dignity and human rights of individuals as well as shared norms, values, and people’s inherent sense of fairness. Translating these commitments into concrete actions to tackle global poverty, eliminate inequalities, counter discrimination and accelerate development for those left behind requires a detailed understanding of target populations. While the disaggregated data sets required to address the needs of vulnerable groups (women, the young and old, people with disabilities and those living with HIV, the gender nonconforming or LGBTQ+, indigenous peoples, refugees, internally displaced persons and migrants) are limited, they indicate that the benefits of development are not equally distributed across and within cities. Analysis of data disagregated by age, gender, income level and location of residence (among other characteristics) could highlight differences between population groups and geographic areas to better inform urban planning initiatives that promote health (United Nations 2015).

Natural, Built and Social Environments Natural Environments Nature is a cost-effective tool for planning healthy cities. Urban Green Spaces (UGS) are public resources providing a range of physical, mental, and social benefits, contributing to the achievement of multiple SDGs (Ghani and Tan 2020). However, there is limited information on how specific elements of nature deliver health outcomes, which restricts their possible use for enhancing population health. A framework for identifying direct and indirect causal pathways through which nature delivers health benefits has been proposed, and a new research agenda is required to test causality integrating the ecology and health disciplines to inform costeffective and tailored solutions that enhance population health and reduce health inequalities (Shanahan et al. 2015). The quantity and quality of natural environments provide the basis for healthy communities, which can in turn support ongoing ecological sustainability (for instance, by engaging communities in active and public transportation which benefits local and global natural environments) (Lowe et al. 2015). Evidence shows that UGS enhance the quality of life and health of city dwellers (SDG 3: Health for all) by facilitating opportunities for: physical activity and recreation via outdoor activities such as walking, jogging and bike riding; social interaction by offering places for residents initiate and sustain social ties; and contact with nature and release from stress, promoting mental health and wellbeing at minimal or no cost (Sugiyama et al. 2018). UGS have been shown to increase attention, mood and physical activity, and reduce risk factors for morbidity and violence as well as mortality (Kondo et al. 2018). Built Environments Urban planners face the crucial task of providing equal geographical access to affordable accommodation, transit networks and accessible public spaces for city

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dwellers while pursuing sustainable development. These concerns are connected to environmental justice, health equity and related geographic inequities, and their solutions require the participation of key actors, including urban planners, public health practitioners and local residents to achieve a balance between local health policy and global environmental sustainability (Rozhenkova et al. 2019). A literature review on the health impacts of city planning through transport mode choices identified several integrated regional and local interventions that, when combined, encourage walking, cycling and public transport use, while reducing private motorized transport. These include destination accessibility, equitable distribution of employment across cities, reducing the availability and increasing the cost of parking, designing pedestrian and cycling friendly movement networks, achieving optimum levels of residential density, reducing distance to public transport, and enhancing the desirability of active travel modes (creating safe neighborhoods and affordable, convenient public transport). These combined interventions can create healthier and more sustainable compact cities which reduce a range of risk factors that affect lifestyle choices such as cardiovascular diseases, traffic and noise pollution, and crime (Giles-Corti et al. 2016; Ghani et al. 2018).

Social Environments The social environment comprises residential features related to the social interactions among its residents, important in promoting healthy cohesive communities. Social environment features relate to the livability indicators which make a community desirable to live in. Livability indicators align with the social determinants of health currently examined within social-ecological frameworks to inform healthy urban design and policy (Giles-Corti et al. 2016). Social environments (social capital/social cohesion, safety from crime or neighborhood physical disorder) reflect socioeconomic developments, and can vary widely within – and between – cities, having a differential impact on the residents’ health related behaviors, such as walking for recreation or transport, which has been shown to vary by age and gender (Ghani et al. 2019). The planning of social infrastructure requires further attention both in research and policy, given its influence on health and wellbeing. Having access to social infrastructure positively influences the health and wellbeing of residents, and research pn this topic increases the understanding of the influence of social infrastructure planning, service delivery, quality and capacities, and demographic needs on the health and wellbeing of urban populations. For instance, several Latin American cities (such as Curitiba, Bogotá and Mexico City) have introduced comprehensive bus rapid transit networks and cycling-sharing addressing transport inequity and expanding access to public facilities (health care) and job prospects, as well as promoting physical activity. Moreover, affordable housing projects also reduced the percentage of residents living in slums and deteriorated regions and improved exposure to safe water, hygiene and transportation (Giles-Corti et al. 2016).

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Overview: Innovative Initiatives Reclaiming Public Spaces to Reinvigorate City Centers

Originally from Bogota, and now expanded to several Latin American cities, the Ciclovías initiative closes streets to motor-vehicles and opens them to individuals for leisure activities. Ciclovías are socially inclusive programs that promote physical (walking and cycling) and social activity, with routes connecting low-middle- and high-income neighborhoods, and engaging minority populations. They are environmentally sustainable and can easily be adapted to different contexts and scaled up. Their implementation requires government support, partnerships, community ownership, champions, operational capacity, flexibility, perceived benefits, and funding stability (Sarmiento et al. 2017). The Barcelona Superblock model is an innovative urban and transport planning strategy aimed at restoring public space for city dwellers, reducing motorized transport, promoting sustainable mobility and active lifestyles, providing urban greening, opportunities for socializing and business, and alleviating the effects of climate change. The Superblocks have helped reduce harmful environmental exposures (air pollution, noise, and heat) while simultaneously increasing physical activity levels and access to green spaces, thus providing significant population health benefits. To maintain an equal distribution of health benefits, the Superblocks should be implemented consistently across the city. By adapting the Superblock model, similar health benefits are expected for other cities experiencing similar challenges of environmental pollution, climate change vulnerability and low physical activity levels, (Mueller et al. 2020).

Global North and Global South Divide A progress evaluation of SGDs across European countries via Voluntary National Reviews showed evidence of good governance, surveillance, leaving no one behind policies and multisectoral collaboration, but less signs of health determinants, safe environments, health literacy, and investment in health. Indeed, the health sector had limited political influence on interventions that have an effect on wider determinants (or health co-benefits). The WHO Europe SDG Roadmap offers a pathway for overcoming these limitations, with health practitioners working within communities across the dimensions of sustainable development (Bickler et al. 2020). The health sector must promote integrated multisectoral urban planning that prioritizes health, sustainability and livability outcomes, especially in rapidly developing LMICs (Giles-Corti et al. 2016), where urban resilience theories have failed to address issues of equity, justice, and power (Bickler et al. 2020). Nevertheless, City Resilience Approaches from Global North and South noted that large urban experiments could foster distributive equity on a global scale by

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applying the program-level selection criteria and the equity-based funding model (rather than equality). At project level, they should advocate the use of measures such as the Equity Indicators as a critical first step in the planning process (Fitzgibbons and Mitchell 2019). Health systems in LMICs face several challenges in responding to rapid urbanization, including the rise in NCDs within the context of the socioeconomic determinants of health as well as the need to improve urban health governance to enable multisectoral responses that provide accessible, affordable and reliable primary healthcare and prevention. Urban health systems should be underpinned by relevant data analyses that inform multisectoral solutions beyond the health sector that impact on the socioeconomic determinants of health and engages communities via participatory and accountable decision-making processes that integrate the expertise of health service providers (Elsey et al. 2019).

Challenges of Conducting Research in Global South Contexts Conducting and applying research in a Global South context poses several challenges typically associated with funding, as well as organizational constraints on research partnerships, with potential negative consequences at institutional and individual levels (Godoy-Ruiz et al. 2016). The issues include the selection and training of local personnel, the recruitment of participants, sampling challenges, participants’ compensation, survey methods and implementation, elicitation methods, the literacy rate of the population, and security/safety issues in developing countries (Durand-Morat et al. 2016). The most frequently mentioned challenges in conducting research in Global South contexts relate to data access and data collection issues, regional diversity, language barriers, and lack of research support infrastructure (Lages et al. 2015). A main challenge Global North researchers face when working in a Global South context is assuming that the same conditions will prevail when expanding their activities into developing countries (Durand-Morat et al. 2016). However, the contextual factors are very different, with power dynamics between the North and South collaboration/partnership posing additional challenges. More precisely, the literature suggests that asymmetry between partners remains the principal obstacle to productive research collaboration. It is estimated that 90% of health research is undertaken in countries with 10% of the world’s health problems, and there is a mismatch between the disease burden and the technical and human capacity for research in developing countries (Atkins et al. 2015). In the context of North– South global research partnerships, asymmetries in power have been linked to perceptions of unequal knowledge, competence and resources that confer advantages to Global North partners (Olivier et al. 2016). These include inequitable access to information, training, funding, conferences and publications, leading to a disproportionate influence of Northern partners in project administration and budget management. This usually results in the research agenda being dominated by the Global North partner researchers and agencies, with funding directed primarily towards international salaries, rather than the salaries of local researchers (Godoy-Ruiz et al. 2016).

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Inequalities Within Cities Health inequities might widen, particularly in LMICs, unless adequate consideration is given to the integration of land usage, transport, housing and infrastructure regulations, and planning. While limited resources and the fast pace of economic and societal shifts can present challenges for integrated planning in LMICs, proactive planning may optimise the use of existing resources and help prevent unintended effects, particularly in large-scale projects which should be well evaluated both before and after implementation (Giles-Corti et al. 2016). Urban planners can potentially narrow gaps in health inequalities and ensure no one is left behind by designing urban environments that ensure equal accessibility, safety and inclusivity, particularly the vulnerable demographics (children, elderly, women, those who are socioeconomically disadvantaged, people with disabilities) (Sugiyama et al. 2018). This includes investing in environmental features that enhance the quality of the user’s experience and conduce to regular physical activity and social participation for all demographic groups (Ghani et al. 2016; Sugiyama et al. 2018). The choice of environmental features should be informed by community consultations to understand and address the needs of residents across their lifespans (Corbett and Mellouli 2017; Sugiyama et al. 2018). Urban planning and traffic conditions in LMICs have challenges associated with urbanization, such as climate change, growing inequality and rapidly changing cities (Thynell 2016). Transport networks are important for sustainable growth. Equitble access to goods and services by efficient means of transport and connectivity is critical to reduce poverty. Worldwide, cities should be designing and building safe and environmentally friendly transport infrastructure that minimizes vulnerability to climate change and natural disasters based on zero tolerance to congestion, pollution and traffic accidents (Thynell 2016). SDG target 11.2 to be achieved by 2030 focuses on providing access to safe, affordable, accessible and sustainable transport systems (improving road safety, expanding public transport) for everyone, particularly vulnerable demographics such as women, children the elderly and those with disabilities (United Nations 2015). A well-designed transport system supports walking, cycling and public transit use for all demographic groups so they can fully participate in community life, and creates safer, cleaner, healthier and more social places (Thynell 2016). Case Study: Using Innovation in Participatory Engagement to Address Urban Transport Inequalities Within Cities

Populations are growing and ageing globally, and they concentrate in urban centers, placing greater pressure on city infrastructure and resources. Life expectancy is increasing worldwide, mainly attributed to better nutrition and advancements in health care. The UN estimates that 1.4 billion people will be over 60 years by 2030 (United Nations 2016). Developing nations, such as (continued)

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Malaysia, are also facing the challenges of accommodating ageing populations. Projections indicate that people aged 60 years and above in Malaysia will almost double, from 3.1 million currently to 5.8 million (15.3% of the total population) in 2030 (Ministry of Health 2011). Policies focused on healthy ageing are becoming a priority for several governments across the world, with a total annual global expenditure of USD 6.5 trillion for health (WHO 2018). Additional costs include time and societal burden on existing social and welfare systems. This makes healthy ageing and ageing in place policies an important multisectoral strategy beyond health, including urban planning. Healthy ageing has become a priority in the global North and is being incorporated into ‘Health in All Policies’ (RamirezRubio et al. 2019). Furthermore, following global trends, most senior citizens live in urban environments, which creates additional challenges for the design of urban environments and services, such as transportation. The ProtoPolicy project explored innovative approaches to promoting healthy ageing such as speculative design to enable citizens and governments in developing countries to engage in policy agenda setting on ageing in place in urban settings, with a focus on health and wellbeing.

Methodologies for Policy and Public Service Development Design innovations are incresingly being used in the public sector to develop more user-friendly services and as a process to jointly develop policy with citizen engagement. There are a growing number of devolved government units in the UK using innovative design for policy and public service development, such as the Cabinet Office Policy Lab, who partnered with the UK Government Office for Science on the first ever speculative design project. Focused on the Future of Ageing, the project explored the challenges and opportunities of an ageing society (Government Office for Science 2015). Speculative design is an approach that enables thinking about the future prospectively and critically (Dunne and Raby 2013). The prime objective of speculative design is to incorporate an aspect of the future into the present so that it demands a response. It negates the status quo and iniciates the discussion of possible future scenarios via confrontation with a tangible object or process, providing an ideal vehicle for establishing an innovation’s necessity, and its viability and benevolence within society. It generates narratives for these possible futures in a variety of formats – such as provocations, prototypes, products, images and films – to express the urgency of change required and to focus debate around the actions that could be taken. Speculative design can be used to explore citizens’ views, concerns and generate debate on policy issues advocated by governments and to genuinely reimagine the relationship between government, community groups and the public. ProtoPolicy Asia employed a co-design research methodology for the development of the speculative design concepts over 10 workshops over 6 months with

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community-dwelling senior citizens (typically 15–20 participants per workshop) living independently; and with researchers, NGOs and policy makers (typically 10–15 participants per workshop). During these workshops, participants engaged in creative design research activities to define their needs, aspirations and challenges, faced within the urban environment context. Several themes emerged during this process, including transportation, health services, food and nutrition. These themes were further explored in additional workshops to develop speculative design concepts with future scenarios. Case Study: Speculative Design Process to Improve Urban Public Transport for Senior Citizens

A speculative design process was developed to explore the challenges senior citizens face when using urban public transport and to generate discussions. The discussions highlighted the importance of transport for older adults’ social identity and self-perceptions of independence. Some emerging themes included finding individual independence, assurance and self-esteem while undertaking their transport journey. The proposed speculative designs were intended to increase confidence in running daily activities within their own capabilities as well as raise community awareness around considering the elderly’s needs in public areas. The speculative design included the concept of a 2025 service operating in Kuala Lumpur (Malaysia) referred to as the Malaysian High Priority Bus (MHPB), with its Transport Payment and Priority Seating Allocation System (TPAPSAS). Over 60% of the TPAPSAS seats are dynamically allocated seats to registered senior citizens once they board the bus. If these seats are occupied by non-senior citizens (i.e. young adults), the seat issues an alarm and activates an airbag system that ejects them from the seat and issues an electronic fine, to make the seats available for senior citizens. The speculative design stimuli included a visual user guide, a terms and conditions poster, a list of twitter feeds of customer reactions to the service and a Vox pop video of customer interviews about their service experiences. These speculative designs were showcased at five senior citizen community centers in Kuala Lumpur and at two public events at Sunway University for feedback. Although the former events focused on senior citizen reactions to – and feedback on – the speculative design stimuli, the latter public events were targeted at people in their early twenties. The findings indicated that speculative design is a useful tool for: raising awareness, engaging with policy makers and civil society, promoting empathy and generating debate about urban transportation for senior citizens. The exercise raised awareness among the Malaysian younger participants and the general public about the challenges faced by senior citizens when using public transport. Furthermore, it provided a tool for senior citizens and (continued)

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people with impaired mobility to engage in increasing general public awareness of their rights and needs; and being more considerate, supporting the development of an ageing society that observes and addresses the needs of seniors. It also facilitated reflection on Malaysia’s societal values regarding limited awareness of the mobility needs of senior citizens. This exercise demonstrated an alternative potential future; should seniors continue to be disrespected when travelling, Malaysian public transport agencies might have to intervene to forcefully remove younger travelers from seats allocated for seniors. The exercise increased local government awareness of senior citizen’s needs, opening further discussions and cooperation with the Ministry of Transport via feedback on the projected future, which could lead to improved public transport planning. The exercise enabled senior participants to consider current and future related policies, which provided them with a policy making perspective. Inclusive urban public transport policies benefit from policy makers empathizing with public transport user groups. The TPAPSAS speculative design raised issues related to the design of services that prioritize senior citizens, as this may segregate younger travelers and lead to reduced social interaction between different generations. Furthermore, to facilitate better public transport planning, public transportation policy makers should work more closely with town planning departments. The exercise facilitated discussion about future technologies and services and their impact on people’s independent mobility and convenience. For instance, senior-friendly buses will impact e-taxi services usage by seniors, (Grab services in Malaysia). Thus, governments should anticipate the impact of new technologies on urban mobility and use foresight methodologies such as speculative design.

Gender Gap in Urban Mobility The term gender refers to the social and cultural relationships between – and socially conditioned characteristics of – males and females. In this context, gender commonly reflects unequal power dynamics occurring within structures of power, including laws, policies, and other social, political and economic systems which often imply that, or result in, women have fewer freedoms and rights than men (Loukaitou-Sideris 2016). Transportation refers to the moving of goods or people, while urban mobility implies the ability to freely travel between places or spaces to access amenities and services, and is often linked to opportunities for the enjoyment of a better, more empowered life (Thynell 2016). How people move (including purpose, location, frequency and timing of travel between settings) is linked to autonomy and freedom,

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and varies widely across demographic and socioeconomic groups within cities (Loukaitou-Sideris 2016). Mobility implies having access to places required for living a healthy life (e.g. shops, employment, education, health care, community centers, parks, public transport), and can vary greatly within the same city for different population groups, resulting in individual and spatial inequities. Living by a bus stop with infrequent services or driving a car in a congested city indicates limited mobility. Reliable quality transportation options – defined by availability, timeliness, affordability, safety, acceptability, accessibility and appropriateness – are critical for improving the mobility of urban dwellers. SDG 5 refers to achieving gender equality and empowering all women and girls. Mobility-related SDG 5 targets include 5.1 ending all forms of discrimination against all women and girls everywhere; 5.2 eliminating all forms of violence against all women and girls in the public and private spheres; and 5.5 ensuring women’s full and effective participation and equal opportunities for leadership at all levels of decision-making in political, economic and public life (United Nations 2015). While there has been progress towards achieving these targets, many challenges remain.

Understanding the Gender Gap in Mobility Intersectionality Gender and mobility intersect in complex ways. Transport options and uses relate to gender identities and norms of mobility. For instance, private motorized vehicles are often associated with masculine identity, whereas public transport is linked to feminine identity. However, most transport systems are shaped by male users and masculine norms, with few countries enabling women to actively influence or work in the transport sector. Understanding how mobility is gendered is critical for identifying interventions that close the gender gap in mobility by improving women’s position in society and generating equality in the transport sector, where masculine norms prevail (Thynell 2016). The mobility conditions of women vary widely between countries and within cities, reflecting different geographical contexts regarding sociocultural norms, economic resources and policies. The mobility barriers and needs can vary further among different women based on their age, race/ethnicity, income, religion, cultural and educational background, gender identity, sexual orientation and/or physical mobility restrictions as well as individual characteristics, such as personality traits and life stage (Loukaitou-Sideris 2016). Mobility barriers intersect and mutually reinforce each other, shaping experiences of privilege and disadvantage within the context of places and spaces, and reflecting power structures (Kapilashrami and Hankivsky 2018). For instance, socioeconomically disadvantaged women experience lower levels of mobility and autonomy regarding transport choice (public over private) and travel time, and this disparity is further compounded by disability and old age (Loukaitou-Sideris 2016).

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A gender analysis of women’s preferences, needs, incentives, constraints (and other intersecting characteristics listed above) across different contexts, is a prerequisite for informing the design of gender-transformative urban and transport policies (Thynell 2016).

Gendered Travel Patterns Limited information is available regarding how women interact with transport systems and their socioeconomic and cultural contexts, particularly in the rapidly evolving cities of the Global South, where gender inequalities are more evident (Thynell 2016). While the Global North contributes to most current understanding of gender mobility, it focuses on travel patterns, neglecting the study of what has been referred to as mobility of care (e.g. women’s mobility as a function of their dependents) which should be acknowledged and considered in transport policies (Loukaitou-Sideris 2016). Evidence suggest that women use urban trips rooted in sociospatial contexts to participate in social life and improve their quality of life by accessing formal/ informal education and/or employment opportunities (Thynell 2016). In general, as well as undertaking domestic chores, women are often the primary caregivers for children, elderly and vulnerable relatives. Such responsibilities shape their mobility, reflecting more complex travel patterns than men, and relate to family activities, their place in the labor market and their access to cars. Women’s relatively lower financial power makes them more likely to use public transport, take more frequent but shorter trips usually at off-peak hours, travel shorter distances for work (as they seek jobs closer to home, despite being offered better work or higher earnings elsewhere) and use the same trip for multiple purposes (household errands on the way to work/ home). Their trips often involve dependents, and are combined with household duties (e.g. buying groceries and/or travelling with strollers) which limits the flexibility for leisure activities and impacts on job accessibility (Loukaitou-Sideris 2016). Such patterns have planning implications; for instance, ensuring easy and safe access to a range of destinations enables women to perform their mixed demands. In the Global North, women undertake more trips than men for parental or domestic chores, though the gender gap in mobility is shrinking, partly due to the rise in the number of women participating in the workforce, which is shifting social roles (men are increasintly assuming domestic duties) and family structure (single person/single parent households) (Loukaitou-Sideris 2016). However, in urban areas of both the Global North and South, women are more likely to use public transportation than men, particularly vulnerable women who have no other means of transport. Women working in the Global South typically have lower wages and face more mobility barriers than men, partially due to the cost of safe and secure transport. Socioeconomically vulnerable women favor walking as a free and accessible transport mode and thus, are more influenced by travel distances (Thynell 2016). In these contexts, women walk more for transport than men, and are less likely to own a car, hold a driver’s license, or ride a bicycle, further limiting their mobility. While travel

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patterns vary across countries, in some cities of the Global South women spend more time travelling than men on average (Loukaitou-Sideris 2016). The widespread use of mobile communications has facilitated the collection and analysis of mobility patterns and travel activities across spaces. Marked gender mobility gaps were identified in a Chilean sample of mobile phone users over three months, with women moving less than men, and in a smaller radius of movement, concentrating their time in a smaller set of locations. These trends relate to lower average incomes and fewer public and private transportation options. Higher fertility rates and larger households were positively associated with greater gender mobility disparity. Public transport options improved the mobility of both men and women, although they did not significantly reduce the gender gap in mobility (The Govlab 2017).

Barriers to Mobility Urban environments shape the experiences of its users, and women face particular barriers, including physical, economic, sociocultural, psychological and safe mobility barriers, reflecting gender power dynamics both in the Global North and South (Loukaitou-Sideris 2016). Poorly designed built urban environments characterized by extreme separations of land use, limited or disconnected transport networks and limited pedestrian friendly design features favors an over-reliance on private transport, and disadvantages women in performing their paid and unpaid responsibilities. Meanwhile, religious and/or cultural norms that specifically forbid women from traveling alone, drive, cycle or use transit, uphold the societal expectations about women as helpless and in need of safety, further restricting their mobility and independence (Loukaitou-Sideris 2016). Economic barriers such as differential access to means of transport have a significant impact on mobility. Employed women are more likely to be in parttime or temporary positions, and have lower incomes than men. Transport costs affects women’s transport choices, making them less likely to drive and more likely to use public transport or walk. This situation is further exacerbated for unemployed women living in deprived communities. Improving the frequency of buses, routes and stops might not entirely address women’s needs, as affordability of public transport is a major concern for women (Thynell 2016). Women in the Global South are further marginalised, as mobility barriers are compounded by more significant gaps in access to education, employment and economic opportunities, relative to men. In Africa, for example, only a small fraction of women participate in the paid labor force (Loukaitou-Sideris 2016). These factors interact with women’s psychological barriers such as safety concerns. Urban environments shape the safety experiences of its users (Ceccato 2017). Fear and anxiety over potential victimization in public spaces and transport hubs impact women’s travel mode, timing and destinations, limiting their autonomy and prospects (Loukaitou-Sideris 2016). Women might feel unsafe wandering particular streets at night, enjoying leisure spaces or using certain transport modes, further restricting their mobility. Women’s use of public spaces or public transport is often discouraged by public displays of harassment or violence (Thynell 2016).

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Fear and anxiety are amplified for particular women (ethnically/racially/sexually diverse or with limited physical mobility) who might be enduring deprivation and social and spatial marginalization in high crime communities and are at higher risk of Gender-based Violence (GBV) (Loukaitou-Sideris 2016; Meth 2019). The gender mobility gap is linked to socioeconomic and health disparities. Structural discrimination against women from low-income households place them at greater risk and such discrimitation should be assessed and addressed in transport policies (Thynell 2016). Being poor and physically impaired generates double disadvantage affecting how one perceives and experiences the environment and expresses fear and anxiety, which is reflected in decisions about travel, especially to unfamiliar destinations (Ceccato 2017).

Women’s Preference for Public Transport Women’s mobility is often compromised due to inadequate, costly, inconvenient, unsafe, inefficient and poorly maintained formal and informal public transport networks (Thynell 2016). This situation is more pronounced in cities of the Global South, where there is a wider gap in gender inequality indicators. This difference implies that a significant number of women have comparatively limited access to non-public means of travel, which leave them disproportionately reliant on public transport. Governments have been either unable or unwilling to respond to safety concerns, failing to upgrade local routes and means of transport predominantly used by women (Loukaitou-Sideris 2016). In rapidly growing Asian cities with worsening transport problems, including traffic congestion and deteriorating infrastructure, the demand for public transport is projected to increase significantly. Gender equality in urban mobility remains a challenge in such settings, amidst poor urban planning and weak law enforcement (Thynell 2016). Women may develop strategies to mitigate the risk of becoming a victim of crime by avoiding certain routes, neutralizing feelings of fear, rescheduling trips, or travelling with a partner. Some cities (such as Mexico City, Cairo and Tehran) segregate gender in public transit to mitigate harassment and violence. However, these measures perpetuate gender differences, rather than tackling systemic gender inequalities embedded in decision-making and transport planning (Thynell 2016). The neglect of women’s safety concerns in transport planning contributes to unpleasant experiences for women, which might range from intimidation via intrusive stares, to sexual harassment such as unwelcome physical contact or more serious abuse such as rape or murder (Loukaitou-Sideris 2016). Such urban manifestations of gender-based violence (GBV) occur regularly in public spaces (streets, public transit, schools and workplaces, markets, public toilets, parks) to women and girls across cities in both the Global North and South, but remain an overlooked problem. Gendered experiences of violence and safety across cities operate at multiple overlapping levels and law enforcement responses. Within cities, GBV is a multidimensional issue with varying forms and spaces including domestic violence, harassment, and cyber-related gender violence (Meth 2019). These realities restrict women’s freedom of movement and their ability to participate in school, work and public life (UN Women 2019).

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Addressing the Gender Mobility Gap: Policy Implications Mobility and accessibility are important rights for all urban dwellers, but at times these rights are compromised for women due to poor urban and transportation planning. Women’s mobility needs, challenges and travel patterns differ to those of men, and should be considered in design, planning and operations. They move at different times, for different reasons, and in different ways (Loukaitou-Sideris 2016). Women are more affected than men by restrictions to their mobility, reflecting social norms and/or lack of resources, which leads to their exclusion in certain public spaces and reinforces the pattern of inequality between genders (Loukaitou-Sideris 2016). The intersection of mobility barriers with individual characteristics limits women’s ability to participate in public spheres resulting in their under-representation and a tendency towards confinement in domestic spaces (Loukaitou-Sideris 2016). This section outlines the extent to which policy and practice in the Global North and Global South has responded to women’s needs and concerns, highlining some next steps and future directions. It has been suggested that existing urban indicators informing current urban and transport policies both in the Global North and South are predominantly gender biased, favoring men’s needs over those of women, with transport authorities often neglecting to consider how women travel within cities in their urban planning. The over-representation of men in the transport sector leads to gender imbalances in decision-making (Loukaitou-Sideris 2016). For instance, bus drivers and train conductors across the world are predominantly male, from executive to administrative levels in transport agencies (Ceccato 2017). When urban planners neglect designing gender-responsive solutions to overcome existing cultural, infrastructure, resource and safety concerns, they unwittingly widen the gender mobility gap (LoukaitouSideris 2016). The resulting poor transport services and facilities in urban environments present lost economic opportunities for women and their communities. Since women’s paid and unpaid responsibilities contributes to productivity, cities should be designed to support women’s mobility via flexible transport systems that enable them to undertake these responsibilities. Poverty and gender inequities could be mitigated by developing transit infrastructure that optimises women’s socioeconomic capacity (Thynell 2016). Gender-sensitive transport policies can narrow the gender gap in mobility while addressing the SDGs. However, it remains uncertain how gender-sensitive policies will be developed to meet women’s mobility needs in fast-growing cities of LMICs. Urban and transport planning Ministries and city administrators face challenges in translating international recommendations into practical strategies at the local level, partly due to the limited information about how women act and interact with transport networks, the natural environment, and the socioeconomic and cultural contexts in the rapidly evolving cities of the Global South (Thynell 2016).

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The historical gender data gap in travel planning is partly attributed to the unintended omission of women’s different needs by mostly male planners and decision makers (Loukaitou-Sideris 2016). Women’s needs have yet to be understood and integrated as much as men’s needs into policies that promote gender equality (Loukaitou-Sideris 2016). In the Global South, the policy-initiated gender imbalances in mobility are very acute, favoring automobility and rapid intercity transit over intra-city, non-motorized means of transport that are critical to many women, such as local roads, buses and bus stops. Achieving equal urban mobility requires an understanding of the perceptions, interests, needs and priorities of both men and women, so that they have equal weight in planning and decision-making (Thynell 2016). More context-specific research is required to identify and prioritize appropriate design and policy elements that can promote mobility and accessibility for both men and women (LoukaitouSideris 2016). This understanding is critical to inform effective decision-making, planning and interventions, as these issues are interlinked and might hinder SDGs’ progress. While the gender mobility gap can vary considerably among cities and between neighborhoods in the same city, and there are no universal standards for transportation systems, urban planners should consider the core components of the New Urban Agenda, a global strategy for sustainable urban development that promotes gender equity, welfare and shared prosperity, adopted by the 2016 United Nations Conference on Housing and Sustainable Urban Development (referred to as HABITAT III). This Agenda includes the achievement of “gender equality to empower all women and girls by ensuring: (1) women’s full and effective participation and equal rights in all fields and in leadership at all levels of decision making; (2) decent work and equal pay for equal work, or work of equal value, for all women; and (3) preventing and eliminating all forms of discrimination, violence and harassment against women and girls in private and public spaces” (2017 Habitat III Secretariat, United Nations). Urban planning presents an opportunity to address the gender mobility gap. Public infrastructure can be design or retrofitted to avoid discrimination, spatial exclusion and fear of victimization for women. Environmental programming can prevent GBV risks by incorporating women into organizational priorities and policies across budget cycles; raising awareness and capacities, and building strategic alliances across sectors and partners to expedite action. However, there are challenges in measuring safety at the neighborhood scale (data is mainly collected at the metropolitan scale and is gender biased, underestimating crimes such as sexual harassment) (Hawken et al. 2020). Addressing the gender gap in urban mobility by ensuring parity in transport needs and mobility choices via investments in transport infrastructure has transformative potential in promoting cultural acceptance of women’s autonomy and empowerment as well as enhancing environmental sustainability and transport safety for other vulnerable groups, such as children and the elderly (Thynell 2016). The engagement and collaboration of men is also essential for transforming gender relations (Thynell 2016).

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Moving Forward: Designing More Gender Inclusive Spaces for Everyone to Change Social Norms The UN Women’s Safe Cities and Public Spaces initiative is an example of collaborations involving policy makers, women’s rights organizations, researchers, and other practitioners committed to creating safe and empowering public spaces with, and for women and girls, to help prevent and respond to sexual harassment. This international collaboration involves global and local partners in developing, implementing and evaluating practices, tools, policies and comprehensive approaches to prevent and respond to GBV in urban environments. These women-led solutions include addressing gaps in data, establishing strategic multisectoral partnerships, addressing women’s safety in public spaces by developing and strengthening laws and policies, incorporating diverse needs into urban and transport plans, and developing initiatives to transform social norms (UN Women 2019). Overview: Recommendations for Closing the Gender Gap in Urban Mobility

Research women and men’s specific needs to better inform the planning of transport systems that cater to all users, particularly women-friendly transport policies. Health policy at all government levels should consider how the responsibilities, attitudes, practices and incentives of males and female are based on different power dynamics, amplifying health inequities and intersecting with other inequality drivers such as race, poverty and conflict. Applying an intersectional approach is essential to informing transformative urban and health policy actions, as well as systems research at all levels of administration (Kapilashrami and Hankivsky 2018). Further research should identify how complex environments impact the intersection between gender and mobility, develop effective data collection methodologies to understand the needs of different groups, and disseminate the findings beyond academic communities, informing the design of appropriate contextual transport policies, particularly in the Global South (Thynell 2016). Urban planners should integrate gender considerations (also referred to as gender mainstreaming) in every stage of the policy process (design, implementation, monitoring and evaluation) regarding urban systems to promote equality between women and men. Women should be involved in decision-making processes, from collecting gender disaggregated data in urban mobility and conducting gender analyses of transportation activities, to conducting gender impact assessments and developing equality indicators. The scope and nature of changes should be structural, tailored to particular sociospatial contexts and should include research, design, transport policy and technology (Loukaitou-Sideris 2016). Public infrastructure should be designed or retrofitted to avoid discrimination, spatial exclusion, and fear of victimization for women. Safety (continued)

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and gender impact assessments have been used by various groups in different countries and should be adapted to the characteristics and needs of local contexts (Loukaitou-Sideris 2016). Appropriate urban design should enhance access to neighboring amenities, shorten trip lengths, and render public transport safer and more convenient. Since women are more inclined to walk, particularly in the Global South, pedestrian friendly routes and connectivity, including high-quality pathways, shade, street lighting, garbage collection and disposal would facilitate their mobility. Mixed land usage, amenities such as toilets and transportation connections would also facilitate woman’s multipurpose trips. Designing safe transit vehicles, stops and facilities would reduce instances of abuse and aggression as well as primary psychological obstacles to transit usage. Women’s-friendly urban design would also improve accessibility to public facilities and resources for everyone, particularly vulnerable populations such as children, the elderly, and the mobility impaired (Loukaitou-Sideris 2016). Incorporate new technologies in data collection and interventions. Further research on the differential impact of emerging digital technologies on the mobility of different groups (e.g. high-speed trains, hybrid cars, ride sharing programs and smartphones) should be undertaken to inform the reduction of gender mobility gaps. For instance, real-time updates on public transport timetables accessed by transit users via smartphones could improve mobility and safety for those with access to the technology (Loukaitou-Sideris 2016).

Conclusion As urban environments continue to evolve in response to population growth and urbanization, significant challenges remain, affecting the health and wellbeing of urban dwellers. From climate change to urban mobility, cities are facing unprecedented challenges that require a more integrated and participatory approach to inform interventions and solutions. Furthermore, addressing the urban mobility needs of different vulnerable demographics, including the ageing population and women, generates new challenges for redesigning cities in an more inclusive and accessible manner.Urban liveability can be improved by designing ‘20-minute neighbourhoods’ that facilitate the local daily living routines of city dwellers within a 20-minute walk from home, with access to safe cycling and local transport options. Urbanization processes determine not only the health of city dwellers, but also global health, and the collective achievement of the SDG Agenda by 2030. More practical urban health research and related indicators are required to inform healthy urban policies, both in the Global North and South. This requires

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the multidisciplinary participatory engagement of policy makers, urban planners, public health experts, and civil society groups via coordinating mechanisms at the local, regional, national and international levels, and at the urban planning, implementation and evaluation stages. Strategic public engagement via white papers and accessible guides for communities of interest and practice regarding their urban environment as well as methodologies for unpacking where, when and how particular urban design forms impact different demographics can inform our collective understanding and the urban design of places and spaces that promote the healthy lifestyle everywhere and for all urban dwellers, regardless of their age, gender, health and socioeconomic status, improving global health.

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Aging and Global Health Mihajlo Jakovljevic, Ronny Westerman, Tarang Sharma, and Demetris Lamnisos

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Impact of Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased Early Childhood Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Worldwide Gains in Longevity and Life Expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Revolution and Absorption of Women into Labor Markets . . . . . . . . . . . . . . . . . . . . . . . . . Demographic Evolution during Accelerated Globalization of the 1990s and 2000s . . . . . . . . Political Implications of the Demographic Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legacy of Colonial Age Leading to a Demographic Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rise of the Emerging Markets: BRICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occurrence of Geo-Economic World Multipolarity Since 2010s and Impact of New Silk Road . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social and Health Policy Reforms Addressing Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO Policies to Combat Population Aging and UN Millennium Goals . . . . . . . . . . . . . . . . . . . Global Health Impact of Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Early Childhood Prevention of Infectious Diseases and Maternal Morbidity . . . . . . . . . . . . . . .

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M. Jakovljevic (*) Department of Global Health Economics and Policy The Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia e-mail: [email protected] R. Westerman Competence Center Mortality Follow-up, German National Cohort, Bundesinstitut für Bevölkerungsforschung (BiB), Wiesbaden, Germany e-mail: [email protected] T. Sharma Evidence to Policy, Copenhagen, Denmark e-mail: [email protected] D. Lamnisos Department of Health Sciences, European University Cyprus, Nicosia, Cyprus e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_4

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European Commission Focus on Health Cost and Long-Term Care Projections for All EU-28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences of Migrations for the Demographic Landscape and Survival of Nations . . . Long-Term Medical Care for the Elderly and Family Caregiving . . . . . . . . . . . . . . . . . . . . . . . . . . . Demographic Data Sources and Their Transnational Comparability . . . . . . . . . . . . . . . . . . . . . . . . Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expansion of Morbidity, Compression of Morbidity, and Dynamic Equilibrium . . . . . . . . . . . Evolution of Mortality Driven by Evolving Lifestyle and Mega-Scale Urbanization . . . . . . Role of Nutrition and GMO Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perspectives of 4.0 Industries and Applied Robotics in Home Care for the Elderly Citizens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Underlying Factors Contributing to Global Spreading of Demographic Trends . . . . . . . . . . . . Health Expenditure Dynamics Driven by Aging in Contemporary Societies . . . . . . . . . . . . . . . Prominent Role of Dementia and Neuromuscular Disorders in Elderly Age . . . . . . . . . . . . . . . Reform of Social and Health Policy Agenda to Raise Fertility Rates and Exploit Benefits of Migrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disbalance in Historical Roots, Stage, and Speed of Aging Between Rich OECD and Emerging Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flagged Emerging Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Population aging became a globally widespread phenomenon during the last decades. Its core underlying causes are extended life expectancy at birth, improved early childhood survival, education, absorption of women into the labor markets, and consequences of sexual revolution leading to decreased female fertility. The scale of this demographic transition is unique in the entire history of mankind including a profound societal change that is now taking its toll on most countries, rich and poor alike. Shrinking of capable labor force coinciding with the expanding share of elderly and retired citizens continues to happen as a long-term trend. Thus, long-term financial sustainability of public social and health insurance funds becomes more and more questionable. Health expenditure growth continues to accelerate worldwide, with increases mostly on demand side. To a large extent, it is attributable to the needs of elderly citizens for home-based medical care. Last year of life phenomenon confirmed that almost entire life span medical consumption of an individual citizen is equal to the last 12 months of costs of treatment of expensive autoimmune, malignant, or vascular diseases. Most national and transnational authorities seem to be forced to consider reform of the current healthcare financing pattern inherited from the demographic growth era. Such exit strategy is necessary to make the financial burden of population aging bearable for modern-day universal health coverage and retirement policies. Ultimately, without bottom-up rethinking of universal health coverage and social support legacies, burden of global population aging might remain virtually unbearable for the most of modern societies. Keywords

Population aging · Global health · Health expenditure · Demography · Fertility

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Introduction “Silver Tsunami” or population aging is a unique phenomenon in demographic history of the mankind over the past eight millennia. Traditional societies used to be young societies with abundance of youth and children dominating proportion of elderly. This was truth regardless of the dominant ethno-religious pattern or the way of life of ancient civilizations such as Buddhist, Hindu, Mandarin, Orthodox, Roman-Catholic and Protestant Christianity, Islam, communism or modern-day secular, and postindustrial societies. All of these communities had at least 15% of children younger than 5 years, while the portion of elderly aged over 65 was significantly less than 5%. In contemporary momentum of 2020, the growing portion of senior citizens and the decreasing portion of children are meeting a melting point. As per UN demographic sources, humanity has actually already passed a crossroad point for the first time ever in history. How could such tremendous change be possible? The social background matrix and way of life have changed essentially beginning with the dawn of First Industrial Revolution of the 1740s. The French nation as a convenient example exposed shy roots of the early female fertility fall process more than two centuries ago, roughly after the Fall of Bastille back in 1789. Yet complex demographic transition remained unnoticed almost until the late Cold War decades. Ultimately serious and stable fall of female fertility was caused by combined effects of the sexual revolution, female education, and the absorption of women into the labor markets across the globe. Social circumstances have created effective financial incentives for women to give birth to fewer children. Innovation in modern medical technology was raising public demand for advanced diagnostics, treatment, and rehabilitation procedures. Early childhood survival gradually became much more successful. It has led to the great extension of human longevity ranging from Japan to Nigeria. Joint effects of extended life expectancy at birth coupled with lower fertility led to the increase of median age. In medieval and even during recent centuries, European agricultural nations had a median population age significantly beneath 20. Such demographic landscape today is visible among the very few remaining countries, such as Afghanistan or the region of Sudanese Africa. Such nations were designated by the United Nations Population and Social Affairs Division as 18 “demographic outliers.” Unlike these few still juvenile communities, vast majority of nations around the world belong to the dominant aging pattern. The process itself began with the earliest historical shift across industrialized Northern Hemisphere. Now as we speak the median population, age of most contemporary societies is either approaching or slightly crossing the 40 years threshold.

Global Health Impact of Population Aging Increased Early Childhood Survival Major advances in public health measures globally have contributed to increased early childhood survival in the world. These substantial improvements can be quantified such that the total numbers of under-5 deaths globally have declined

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from 12.6 million in 1990 to 5.3 million in 2018. However, still on average, 15,000 children below of age of 5 are dying daily which is an improvement with the under-5 mortality dropping by 59%, from 1990 to 2018. It is essential that there is a provision of an environment for young children such that they can achieve their full developmental potential which is their fundamental human right and a requirement for achieving the sustainable development goals. It is critical to give children the best start in life, and therefore more is needed to ensure this trend continues going forward. However, with this trend more people are able to reach adulthood than ever before, which also then contributes to the current public health and demographic challenges that we see today.

Worldwide Gains in Longevity and Life Expectancy Life expectancy is increasing almost linearly in most developed countries, and it has risen by 3 months per year since 1840 (Oeppen and Vaupel 2002). Globally, life expectancy at birth has increased from 48.1 years in 1950 to 70.5 years in 2017 for men and from 52.9 years to 75.6 years in 2017 for women (Dicker et al. 2018; Rau et al. 2008). The largest gain in life expectancy since 1950 was in North Africa and the Middle East where life expectancy has increased from 42.4 years to 74.2 years. On the other hand, the smallest gain in life expectancy was in Central and Eastern Europe and Central Asia where life expectancy has increased by 11.1 years since 1950 (Dicker et al. 2018). Among the 13 counties with a population greater than 100 million in 2017, Russia has the smallest gain in life expectancy since 1950 with 5.7 years net gain for men and 7.7 years for women. The largest gains in life expectancy among the 13 most populous countries were in Bangladesh with 32.1 years for men and 31.7 years for women and Ethiopia 31.1 years for men and 30.6 years for women. China has also made steady progress since 1950, and in 2017, life expectancy was 74.5 years for men and 79.9 years for women. Among the world’s most populous countries, Japan has the highest life expectancy for men and women since 1963 and continues to do so in 2017. In 2017, the life expectancy at birth for men in Japan was 81.1 years while for women was 87.2.

Sexual Revolution and Absorption of Women into Labor Markets The role of women as homemakers has persisted over time, perpetuated through religious and cultural norms and beliefs. At the end of the Second World War, there was a substantial increase of women entering the labor market, which was then further propelled by the sexual revolution of the 1960s and 1970s. The development of the contraception pill has been attributed to be the public health contribution to this sexual revolution, which permitted women to delay pregnancy until they chose it, bringing with it their opportunities to enter and remain longer in the labor market (Allyn et al. 2016). There is general agreement that the active participation of women in the workforce brought with its economic growth for the countries (Luci 2009).

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However, gender-specific disparities in employment persist, and through empirical studies, we know that these still have a strong impact on a country’s macroeconomic growth in terms of GDP per capita (Fortin 2005). There is still a long way to go in terms of equality in pay for women and the convergence of the gender-pay gap (Blau 1997). Moreover, there persists a clash between traditional family roles and values and egalitarian perspectives, that is often manifested as an inner conflict for many women, that is noted as “mother’s guilt,” and which acts as a further obstacle to gender equality in the labor force.

Demographic Evolution during Accelerated Globalization of the 1990s and 2000s Since the 1990s, the global economy entered a new phase of development which was characterized by an “acceleration of globalization.” This new phase was characterized by the rapid spread of information and communication technology (ICT) and a further increase in global economic integration (Haraguchi et al. 2018). One of the main characteristics of this era was the economic migration. This economic migration caused the intra-regional migration from Southern Europe to Northern and Western Europe (Nicolae-Bǎlan and Vasile 2008), while the USA experienced a migration inflow from Latin America and Asia (Sintserov 2019). As a result of this, economic migration was a new population structure. The migration was favored on one hand by minimizing the global distances due to modern infrastructure and transportation, of developing communications and Internet, and, on the other hand, by the development of regulations that facilitate the mobility, such as transfers between national insurance systems and social and medical assistance (Nicolae-Bǎlan and Vasile 2008).

Political Implications of the Demographic Transition Legacy of Colonial Age Leading to a Demographic Transition World economic history following Renaissance era has led to some established patterns alongside geographical distribution of development. Out of four consecutive industrial revolutions, three of them mostly took place among the nations of Northern Hemisphere. These were mostly European colonial forces and their descendant cultures. Aligned with consequences of European conquest of the New World, Africa and Asia, most of the nations of Global South even today remain among “developing” or low- and middle-income countries (LMIC) as per World Bank Atlas measurement of economic productivity. Typical North-South axis meant that goods and services were manufactured by investors from the North employing skilful, educated, and affordable labor force of the Global South. Without surprise most consumers of these same expensive goods or services came back from the Norther Hemisphere. Economic dominion of Western Europe and its colonial descendant cultures was essentially challenged during nineteenth and twentieth century only by

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Imperial Russia and later USSR. Soviet 5-year development plans based on entirely different economic models were exceptionally successful in terms of economic output. Real GDP growth rate of USSR as the core indicator of economic productivity heavily outperformed most of world’s rapidly developing economies during most of 1928–1971 period (Allen 2005: 315–332). People’s Republic of China much later adopted 5-year plan strategy, and these plans were clearly one of the cornerstones of Chinese welfare success story. It is less known fact that during most of the Cold War era, USSR was ranked the second global economy. This was grounded in purchasing power parity terms according to the Bretton Woods Financial Institutions such as International Monetary Fund and the World Bank observing the late 1940s to early 1980s horizon. Relying on Agnus Madison’s historical estimates, the USA became the richest country as per purchase power parity GDP terms around 1875. Surprisingly this crown was not taken away from the British Empire but instead from Chinese Empire led by Qing dynasty. Epilogues of both world wars supported further growth of US share of world economy reaching its peak somewhere in around 1960 with roughly 40% of world’s economic output. Demographic history taught us that US census population never crossed the 4% threshold of entire mankind population size; thus the huge scale of such development in North America is better understood. Cold War era lasted approximately from 1947 to 1991. Accelerated globalization era began from 1989 and experienced sudden slow down during recession triggered by bankruptcy of Brother Lehman 2008–2016. Most recently economic globalization even came up to a certain, probably temporary but unique hold, due to corona pandemic which caused world economic recession in spring 2020. Through the most of past three decades, Western-Japanese led multinational companies, inclusive of those typical for the health sector known as the Big Pharma which harvested most of profit in international arena due to beneficial circumstances. Yet, there appears to be a significant hidden underlying trend which mostly passed unnoticed. “Collective or Political West” share in world’s economic output continued to shrink and contract during the most of 75 post-Second World War years. Appearance of this profound change was first measured in purchase power parity terms and far later in nominal terms. This crucial evolution was actually happening gradually for decades while accelerating rapidly since the late 1990s. Movement of world’s geo-economic heavy weight from the West toward the East Asia – Western Pacific Region – appears to be steady but irreversible process. North American contribution to the world economy was contracting further in the long run, throughout all the upsides and downs of previous decades. Contemporary US share is exactly 15.11% in GDP in PPP terms according to the latest data release of 2019. According to the International Monetary Fund’s “World Economic Outlook,” this value is going to be at 13.71% in 2024. Convenient to compare, USSR share in world economy in the same terms during the peak of its power was 16.5%. Even more surprising results appear if we observe the EU28 (prior to Brexit, as of May 2019) contribution to the world economy. Their joint output on both sides of Iron Curtain back in 1989, communist and capitalist alike, was

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around 33%. In the meantime, geopolitical maps evolved substantially. In last yearending fiscal 2019, all these same EU nations (including UK) contributed with only 16.02% to the global GDP. Most reliable long-term forecasts predict this is going to fall further to approximately 9% in 2050, regardless of the political landscape that might change. Macroeconomic global recession 2008–2016 brought upon years of stagnant or weak real GDP growth in most high-income OECD nations. Serious vulnerabilities of the neoliberal globalization model became apparent and publicly declared even by heads of state of G7 nations. Probably a milestone threshold event was the September 2014 recognition of the People’s Republic of China by the International Monetary Fund as the largest world economy in purchasing power parity. Deeper knowledge of Asian economic convinces this is no surprise neither a sudden swift in tectonic geopolitical movements. Insight into the historical archives reveals that the roots of today’s world economic order can traced back to where it was a century and a half ago. Going back to the Medieval Age and Antiquity, we face the very similar “old world” landscape dominated by either India’s or Chinese imperial statehoods.

Rise of the Emerging Markets: BRICS Aforementioned explanation of some core drivers of world economic history admits existence of the “Rich North – Poor South” as during the Colonial Age in terms of trade and investment flows. Bipolarity of the Cold War effectively ended the legacies of Western European empires. The Non-Aligned Movement formally established by India, Egypt, and Yugoslavia was a contributor accelerating this evolution. Prominent Third-World leaders, Mahatma Gandhi, Nelson Mandela, Fidel Castro, and Patrice Lumumba, played a role in the transformation and fall of classic European colonialism. Perestroika was introduced in the USSR in the 1980s, and Deng Xiaoping Chinese reforms began in 1978, but real profound changes were looming on the horizon since 1989. Impact of these reforms was not clearly understood when they happened. Ultimately the Russian recession ended in 1998, and Chinese-accelerated development was getting its momentum. Goldman Sachs analysts recognized the rise of “newly established” economies and designated them as the emerging markets. They had inherited different inner governing practices, but all where located outside the elite club of traditional high-income, welfare economies of the 1960s. Several acronyms have been introduced to group them, such as EM7, MIST, Next Eleven, and others, but the one getting the broadest recognition in academic literature was the BRICs referring to Brazil, Russia, India, and China. South Africa as a much smaller member joined BRICS later, which together constituted a formal geopolitical alliance since 2008. All of these nations were developing much faster before, during, and after world economic recession 2008–2016. Brookings Institute recently designated contribution of EM7 nations (BRIC + Mexico Indonesia and Turkey) to the real GDP growth worldwide (2017–2020 horizon). It has vastly exceeded the share

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of G7 (USA, Japan, Germany, UK, France, Italy, Canada) comparing 50% attributable to EM7 to 25% of world’s GDP brought upon by G7.

Occurrence of Geo-Economic World Multipolarity Since 2010s and Impact of New Silk Road Chinese milestone event on Tiananmen Square in 1989 marked the threshold year for rapid further development. India and Brazil also changed the traditional North-South polarity in world economic order. Middle class continues to grow among the BRICs states (Kravets and Sandikci 2014). This trend is entering its third decade now in BRICs, with China being the overachiever lifting 800+ million people from poverty (Jakovljevic 2015). Also, the purchasing power of this middle class is growing rapidly as well, particularly in rich coastal and industrial areas surrounding capitals and megacities. The 11th formal meetings of BRICS heads of state took place in Brasilia in March 2019. Its agenda was largely devoted to the coordination of health strategies. One Belt, One Road Initiative appears to be probably the largest scale infrastructural investment project in mankind history. Chinese Imperial legacy as “the Middle Kingdom” is actually filled with prominent examples of large-scale coordinated efforts of huge number of people (Rossabi 1983). Probably among the most well-known ones are the Great Wall legacy of early statehood of the seventh century BC and the buildup of a large naval fleet for early Ming dynasty treasure voyages (1405–1433 AD) exploring the shores of Indian Ocean and Africa. Contemporary China differs in several core aspects with its historically preceding statehoods in the sense that it has been long absorbing the dominantly foreign-born knowledge and technologies. People’s Republic of China in a much different international circumstances followed Japanese Meiji 1868 reform example. Modern Chinese development refers to the successful delivery of social justice in many spheres of life and controlling the gap between the rich and the poor as measured via Gini index. Socialism with Chinese characteristics are now well-known as a mega-scale industrialization, unseen urbanization, and birth of megacities with Shanghai conurbation recently becoming the largest city on Earth. Probably the most glorious recent examples are satellite landing on a dark side of the moon and essential technological breakthroughs in 5G cellphone networks. Therefore, Chinese society, academia, and industry sector alike have clearly developed their ability not only to absorb the knowledge and reproduce industrial techniques patented by other nations but as well to move the cutting edge of science creating new authentic knowledge and technologies. Yet, brand-new Chinese geo-economic behavior is this new policy of opening to the world. Society which traditionally perceived itself as the Middle Kingdom had no essential drive to civilize barbarian tribes across its frontiers like most other imperial civilizations. This new strategy of building bridges in spirit of mutual benefit and confidence among primarily the nations of Asia, Africa, and Europe is indeed a new one. Chinese-accumulated wealth, given the new circumstances in world trade affairs, needs foreign investment to consolidate its export-oriented

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economy. National industrial capacities by far exceed domestic needs, and such an engagement primarily in surrounding foreign countries and later in Eastern Europe beyond Russia, Middle East, and Eastern Africa appears to be justified from the economic point of view. Chinese economic growth model is now entering a transition period, leading to the gradual decrease of real GDP growth rates. In year 2019 national GDP was entering its lowest value over the past 27 years. This was largely attributable to the trade war with the USA. Inner reforms aim to transform China into a mature economy driven by domestic consumption, replacing export-based one. This ambitious process is likely to take years to consolidate. Yet the accumulated wealth and abundance of foreign currency and gold reserves serve as a guarantee of China’s ability. It is likely to go further beyond ambitious architectural plans alongside many of the New Silk Road high-speed railway routes, airport terminals, and large naval capacities intended to serve core ports of Indo-Pacific maritime trade. The architects of BRI have recently founded the New Development Bank and Asian Investment Bank surprisingly supported by competitive large Western European economies. Visible consequence of BRI is induced connectivity among Asian, European, and African nations of a scale. Collaborative efforts are visible in terms of huge energy projects, high-speed railways and trade, but also accelerated access to the 4.0 industries, advanced robotics, and artificial intelligence.

Social and Health Policy Reforms Addressing Population Aging WHO Policies to Combat Population Aging and UN Millennium Goals The United Nations (UN) Millennium Declaration was adopted in 2000, where all world leaders committed to jointly work together to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women (World Health Organization 1999, 2017a, b, 2018, 2020a, b). The United Nations Millennium Development Goals (MDGs) were derived from this declaration and prioritized eight goals that the UN Member States agreed to try and achieve by the year 2015. The targets were therefore set for 2015, and indicators were mapped to monitor the progress from 1990 levels. With many of these goals having a health perspective, some countries were able to make progress in achieving their targets, but others were unsuccessful. Some targets were achieved, whereby already by 2010, the MDG targets for access to safe drinking water were achieved (though the sanitation overall target was not). Progress was also seen in the nutrition targets of children, whereby in developing countries, underweight children below the age of 5 years fell from 28% in 1990 to 17% in 2013. The under-five mortality fell from 12.7 million in 1990 to 6.3 million in 2013. Success was also seen in HIV where new HIV infections declined by 38% between 2001 and 2013 globally and existing cases of tuberculosis also declined during this same period. More countries now have high levels of immunization coverage within 66% of all UN Member States managing at least 90% coverage in 2013.

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Some targets were sorely underachieved, despite a significant reduction in the number of maternal deaths; the rate of decline was less than half the target. When we unpick it further, though the proportion of women receiving antenatal care at least once during pregnancy was about 83% for the period 2007–2014, the recommended minimum of four or more visits was only achieved by 64%. From 2000 to 2013, the incidence of malaria and mortality rates attributed to it fell globally by 30% and 47%, respectively, but the numbers are still high, and there is a long way to go still. To keep that momentum going, in 2015, all the countries that are members of UN adopted the 2030 Agenda for Sustainable Development. These are 17 Sustainable Development Goals (SDGs), which consist of 169 targets, that are now being monitored (World Health Organization Regional Office for Europe 2020). Once again, they are drafted to support the end to poverty and inequality globally as well focusing on improving the health of people and justice and prosperity. The SDGs versus the MDGs also have targets to protect the planet and are also not only looking at developing nations but the world globally. This is to ensure that all people are treated with dignity and are based on values of human rights and equity noting that new ways of working and innovation will be needed to achieve these. Goal 3 is to ensure healthy lives and promote well-being for all at all ages, but this is very much crosscutting, and therefore its progress impacts on other goals as well as other goals which contribute to goal 3, in promoting and achieving universal health care (UHC). One of the key elements that are captured by the SDGs is the evolved nature of the global population since the 1990s. There are many unpredictable health challenges that emerge; however, one health trend that is certain is that the global population is rapidly getting older, and this demographic shift to aging is certain. The World Report on Ageing and Health published in 2015 helped shape the SDGs and supported the focus on healthy aging globally (Beard et al. 2016). The concept of “healthy aging” is about creating an enabling environment, i.e., adapting housing, transportation, public spaces, services etc., as needed to permit maintenance and preservation of mental and physical capacity, as we age, such that people can continue do what they value. The WHO developed a global strategy and an action plan which was adopted by its member states in 2016, which supports this by creating a policy framework to ensure the lofty ambitions of healthy aging within the SDGs are met. There are key ten priority areas that the World Health Organization (WHO) recommends and are the key priorities to focus on for improving health of the elderly, and they are summarized in Box 1 (World Health Organization 2017c). Health of the elderly is vital to ensure that people at older age have a good quality of life and that they can continue to make active contributions to society. Box 1 The Top Ten Priorities for Healthy Aging

Priority 1: Establishing a platform for innovation and change. Igniting change for healthy aging by connecting people and ideas from around the world through use of platforms permitting exchange and network. (continued)

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Box 1 The Top Ten Priorities for Healthy Aging (continued)

Priority 2: Supporting country planning and action. Providing countries with the capacity to get the skills and tools they need to create evidence informed policies that enable people to live long and healthy lives. Priority 3: Collecting better global data on healthy aging. Focusing on collecting accurate up-to-date and meaningful data on healthy aging to ensure that we can measure and act to support the initiative. Priority 4: Promoting research that addresses the current and future needs of older people. Researching the questions that are relevant to older people through innovative ways such that we gain valuable knowledge for healthy aging. Priority 5: Aligning health systems to the needs of older people. Evolving health systems of countries to ensure that older adults get the health care they need and where and when they need it in formats that they can access. Priority 6: Laying the foundations for a long-term-care system in every country. Supporting countries to create equitable and sustainable systems that provide older people and caregivers the care and the support they need to live with dignity and enjoy their basic human rights. Priority 7: Ensuring the human resources necessary for integrated care. Creating enabling environments through training and development of workforce such that people have the skills to deliver quality health and longterm-care services for older people. Priority 8: Undertaking a global campaign to combat ageism. Changing how we think, feel, and act toward age and aging to stigma and discrimination globally toward the elderly. Priority 9: Defining the economic case for investment. Understanding better the costs and opportunities of healthy aging as the starting point for sustainable, equitable, and effective responses. Priority 10: Enhancing the global network for age-friendly cities and communities. Creating cities and communities around the world that enable older people to do the things they have reasons to value. WHO recently put forward their draft proposal for the “Decade of Healthy Ageing 2020–2030,” which has put the elderly people at the center and brings together governments, civil society, international agencies, professionals, academia, the media, and the private sector to improve the lives of older people, their families, and their communities. It has noted that for the first time in 2020, people above 60 will outnumber children under 5 years, and by 2030 the people above the age of

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60 will be 34% higher, and by 2050, there will be twice as many people over 60 as there are children under 5 years globally. Additionally, by 2050, people over 60 years will also outnumber adolescents and young people aged 15–24 years. With this pace of growth, more action is needed to ensure that older people can live with dignity. Already there are more than 1 billion people over the age of 60 globally, with many living in LMICs, so this has come timely to support countries with a way forward.

Global Health Impact of Population Aging Early Childhood Prevention of Infectious Diseases and Maternal Morbidity There is strong connection between maternal morbidity/mortality and early childhood infectious diseases. Regarding maternal mortality only ten countries have achieved the UN Millennium Development Goal 5 (MDG5) with reducing the maternal mortality by three quarter between 1990 and 2015 (GBD 2015 Maternal Mortality Collaborators 2016). Also 24 countries remain on the high maternal mortality ratio level (per 100 000 live births) greater than 400 in the same time period. On the other hand, there are global important improvements for the UN Substantial Development Goals 3.1 like increasing life expectancy, the reduction of maternal and child mortality, and fighting against leading communicable diseases. These goals have been realized by 122 of 195 countries. As a highlight the reduction in child deaths is the major milestone for improving global health, while the annual global number of deaths of children under 5 years of age (under 5) has declined from 19.6 million in 1950 to 5.4 million in 2017 (GBD 2017 Mortality Collaborators 2018; Burstein et al. 2019). Nevertheless, there are still major challenges for maternal health during pregnancy that impacts birth outcomes and early childhood health to continue this success story. Preeclampsia is a pregnancy-related hypertensive disorder that affects 2–8% of all pregnancies and remains a leading cause of maternal and fetal/neonatal morbidity (Duley 2009). Approximately 12–25% of fetal growth restriction and small for gestational age infants as well as 15–20% of all preterm births are attributable to preeclampsia (Jeyabalan 2014). Major prevention strategies reveal on blood pressure monitoring, medication (low-dose aspirin), and dietary supplementation with calcium (Gülmezoglu et al. 2016). Maternal sepsis is associated with pregnancy complications and is still the leading cause of maternal mortality worldwide. It occurs before or during the delivery and has directly impact of newborn mortality. Annually about one million of all newborn deaths are caused by maternal infections. The major prevention strategies focus on avoiding direct risk factors including unsafe abortion, intrapartum vaginal examination, and prolonged or obstructed labor (Gülmezoglu et al. 2016). Another strategy is the improvement of hygienic standards for the delivery. As an example, the global maternal sepsis study (GLOSS) evaluates criteria for possible severe maternal infection and maternal sepsis. Important prevention strategies are early identification and management of maternal sepsis; further understanding of mother-to-child transmission of

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bacterial infections; the assessment of the level of awareness about maternal and neonatal sepsis among healthcare providers; and the establishment of a network of healthcare facilities to implement quality improvement strategies for better identification and management of maternal and early neonatal sepsis (Bonet et al. 2018). HIV infections are remaining global health threats affecting mother and children via mother-to-child transmission. Antiretroviral therapy (ART) with triple drug regimens is most effective first-choice medication to prevent vertical mother-tochild transmission (Ciaranello et al. 2011). In summary, improving hygienic conditions, monitoring blood pressure through delivery, and effective medications are major prevention strategies to improve mother and early childhood health.

European Commission Focus on Health Cost and Long-Term Care Projections for All EU-28 The 2018 Ageing Report from the European Commission broaches the issue to health cost and long-term care projection for all EU-2018 member states. There are totally 12 different assumption-based scenarios that face at least 1 of 3 main inputs: (1) demographic structure and the population level, (2) age-related expenditures profiles modelled as unit cost, and (3) assumptions regarding the development of unit cost over time with macroeconomic variables. All scenarios estimate changes in life expectancy, healthcare costs in the last years of life, income elasticity of demand for health care, different patterns of unit cost development, and the cost-convergence of age profiles for all EU-2018 member states (EU Commission 2018). The scenarios one to four remain always on debate for health policy because of their importance. With the first scenario known as “demographic scenario,” there will be the assumption about constant morbidity rates over time. This scenario is also sustained by the expansion of morbidity hypothesis that assumes all future gains in life expectancy will be spent in bad health. The second scenario defined as the “high life expectancy scenario” (a variant of the demographic scenario) is more optimistic by assuming that the life expectancy at birth will be higher by 2 years in 2070. The compression of morbidity hypothesis will be reflected with the third scenario as “healthy aging scenario.” That scenario implies that the number of years spent in bad health will be constant over the projection period and all gains in additional life expectancy are almost spent in good health. The fourth scenario known as “the postponement in health care spending” followed as a result of the shift of the excess mortality to higher ages. The other eight scenarios mostly contain macroeconomic assumptions about income elasticity, EU-28 cost convergence, labor intensity, sector-specific composite indexation, non-demographic determinants, increases in healthcare expenditure AWG reference, AWG risk scenario, and the total factor productivity risks. As only one example, the “demographic scenario” postulates an increase of the gross domestic product (GDP) from 6.8% to 7.9% in the period of 2016 to 2070. The

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public expenditure on health care will be also increase from 1.0% to 1.7% of the GDP in the same time period (EU Commission 2018). Again for Germany the projected change in age-related expenditure in health care will be about 4.2% of GDP. That is accounted as the highest growth in the EU. The two examples support the main drawback of the assumption-based healthcare projection scenarios because of its idea of “what if thinking.” Thus, the results must be interpreted with caution because of the large uncertainty. The EU-28 health cost projection scenario captures also a long-time period about 54 years that allows also variations of specific indicator beyond the defined framework (Jakovljevic et al. 2018). Case “The Great Exemption of India’s Delayed Onset of Aging and Its Demographic Dividend”

Aging in India has always been defined by increased fatigue and decline in functional capacity. From the early Hindu scriptures, the concept of retirement from family life or “Vanaprastha” was prescribed from the age of 50 onward. The Government of India amended that to be 60 years for retirement from public service. It is estimated that in the coming one and half decades, 44% of the total health burden in India will be borne by adults aged 60 and above. This is a staggering number for which the country needs to prepare for, but one of the key barriers is that the Indian healthcare infrastructure is dominated by the private sector, making affordability an issue. This is especially pertinent as it was established that socioeconomic differences in health and access to health care are key issues in India. 19% of the elderly population noted health problems in 2015, with majority being those from a poorer economic background. Therefore, pro-poor policies that go broader than health are needed to improve the lives and well-being of the elderly in India.

Case “Latin American Migrations to the USA and Canada”

By the beginning of the new millennium, Latin America is one of the main regions of population migration to the principal economies of the developed world (USA, Europe, and Canada). In 2000, there were 19.2 million who lived in a country outside Latin America (Canales 2011). This Latin American emigration was driven by the extended economic crisis during the 1980, the poverty and the lack of economic opportunities in the Latin American countries (Durand and Massey 2010), as well as the changes in the production structure and labor markets in the developed economies (USA, Europe, Canada, and Japan) (Canales 2011). In some cases, such as Mexico, those who emigrate are drawn primarily from the lower sectors of society, the workers or peasants (Durand and Massey 2010). In other cases, such as many South American nations, migrants are drawn mainly from the middle (continued)

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and professional classes. In general, Latin American migration incorporates both men and women, although in certain cases, such as Peru, Brazil, and the Dominican Republic, female migrants dominate (Durand and Massey 2010).

Consequences of Migrations for the Demographic Landscape and Survival of Nations A third demographic transition is considered to be underway in Europe and the USA (Coleman 2006). According to this demographic transition, several population nations will radically and permanently alter their ancestry as a result of the high levels of immigration and the persistent sub-replacement fertility (Coleman 2006). The low fertility combined with high immigration are changing the composition of national populations and thereby the culture, physical appearance, social experiences, and self-perceived identity of the inhabitants of nations. If current trends continue, the population of indigenous origin of many countries would be equivalence or even inferior to recent immigrant population or mixed origin (Coleman 2006). According to a demographic forecasting of population projections, the proportions of foreign-origin populations will reach the 45–50% by the 2060s in several European countries, in the case that the persistent large-scale immigration continues with the current trend (Lanzieri 2011). That would be an ultimate “replacement migration” of a kind not previously seen over large geographic areas without invasion of force. Whether or not this will be the reality depends on the amount and duration of in-migration as well as the fertility levels of the destination countries.

Long-Term Medical Care for the Elderly and Family Caregiving One quarter (23%) of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (
60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, respiratory, and infectious disorders (Prince et al. 2015). The leading contributors to disease burden in older people are cardiovascular diseases (30.3% of the total burden in people aged 60 years and older), malignant neoplasms (15.1%), chronic respiratory diseases (9.5%), musculoskeletal diseases (7.5%), and neurological and mental disorders (6.6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. The hospitalization rates among 65 years and older are more than four times their younger counterparts, while their visits to a GP annually are more than double the rate of under 65 years old individuals (McPake and Mahal 2017). Healthcare requirements of the elderly are also more complex because of their high levels of multi-morbidity.

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Data from the Australian Health Survey (2014–2015) show that the reporting of three or more chronic conditions was 29.3% among the age group 65+, and this was almost double that of the 45–64 age group and nearly 12 times higher than that of the 0–44 age group (McPake and Mahal 2017). The most common cases of multimorbidity in the age group 65+ involved some combination of hypertension, hyperlipidemia, and osteoarthritis. Disability is also an important issue related to aging that requires the response of the health system. Family caregiving plays a crucial role in delaying and possibly preventing institutionalization of chronically ill older patients. When the patient is mildly or moderately impaired, a spouse or adult children often provide care, but when the patient is severely disabled, a spouse (usually a wife) is more likely to be the caregiver (National Alliance for Caregiving and the AARP Public Policy Institute 2015). Approximately 34 million Americans, more than 10% of the US population, were estimated to have served as caregiver for someone age 50 or older in the year 2015 (National Alliance for Caregiving and the AARP Public Policy Institute 2015). The amount and type of care provided by family members depend on economic resources, family structure, quality of relationships, and other demands on the family members’ time and energy. Family caregiving ranges from minimal assistance (e.g., periodically checking in) to elaborate full-time care. Caregivers of older adults report that 63% of their care recipients have long-term physical conditions and 29% have cognitive impairment (National Alliance for Caregiving and the AARP Public Policy Institute 2015). Caregiving for older adults with neurocognitive disorders is known to be particularly intense and burdensome and to have harmful effects on caregivers.

Demographic Data Sources and Their Transnational Comparability For demographic research there are many data sources available provided by different stakeholders like the 2019 Revision of World Population Prospects by the United Nations, WHO Global Health Observatory data repository, and the population estimates from the Global Burden of Diseases Study by the Institute of Health Metrics and Evaluation, University of Washington. The remaining challenges are the comparability of data collection techniques, the quality of statistical methods for data preparation, and even the access and data courtesy on very high level. A good example is the Human Mortality Database that includes all population (countries) with virtually completed census data and death registration. That scientific endeavor contains population and mortality data for 37 developed countries and 46 populations also on sub-national level (Barberie et al. 2015). The HMD has strict selection criteria for the inclusion of any country. The country’s death registration must be complete with 99% coverage of all deaths. Furthermore, the HMD process birth counts as the annual counts of live births by until the available longest time period. The death counts are available for sex, the completed age, year of death, and year of birth. For deaths of unknown age, the HMD uses redistributions methods for specific age range and aggregated deaths. The population size will be captured with census data as the annual population estimates by sex and age. For data gaps in annual

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population estimates, the HMD uses the intercensal survival method that includes linear interpolation, in case of the territory changes, the period death rates around the time of a territorial change, and the cohort mortality estimates around the time of the territory change. The death rates are accounted for periods and cohorts and will be defined as the ratio of deaths to exposure to risk in matched intervals of age. The HMD also provides standardized life tables by single calendar year and single year of age and multi-year and abridged life tables. This allows reliable cross-country comparisons for life expectancy and age-specific deaths between countries. Another success story is the Human Fertility Database (HFD) that also refers to official data on live births and population counts from national statistical offices. As similarity to the HMD, the HFD also has strict data quality requirements that involve only countries from developed countries with full coverage of vital statistics. For comparability the HFD also plans to include the same countries, territories, or populations provided in HMD. Currently fertility data for 27 countries and 5 sub-national populations is available with the longest possible continuous time series (Jasilioniene et al. 2016). Both database show that comparability can be only achieved with high data quality standards, harmonized methods for data processing, and even the longtime series with annual data. For the global demographic phenomenon, the further efforts should be the accessibility of fertility and mortality data for less developed countries with lower data coverage less than 99%.

Noncommunicable Diseases Noncommunicable diseases (NCD) are mostly chronic conditions that account to more than 80% of all premature deaths. Within NCD there are four top diseases that excess to premature mortality with cardiovascular diseases (17.9 million deaths annually), cancers (9.0 million deaths annually), respiratory diseases (3.9 million), and diabetes (1.6 million) (GBD 2015 Risk Factors Collaborators 2016). The incidence of NCDs also continues to increase over time and become one of the most global burden for human health. The burden of NCD can be reduced with different prevention strategies that must be implemented in primary healthcare settings. One important factor is education that essentially should improve the knowledge about certain diseases and their corresponding risk factors. Beyond the educational programs about primary prevention and a better understanding for behavioral risk factors (e.g., tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol) and the metabolic risk factors (raised blood pressure, obesity, hyperglycemia, and hyperlipidemia), the access to effective treatment should be provided for everyone regardless their socioeconomic status, nationality or ethnic group (Gouda et al. 2019). Low- and middle-income countries (LMICs) especially in sub-Saharan Africa currently experience the rapid epidemiological transition as a shift from communicable diseases and childhood illnesses to the increasing predominance of chronic noncommunicable diseases. Although the burden of communicable, maternal,

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neonatal, and nutritional diseases (CMNN) successfully decreased in sub-Saharan Africa with essential improvements to healthcare access and successful treatment with, e.g., antiretroviral therapy for HIV infection, there might be a link to elevated cardiovascular risks (Triant 2013). Comorbidities of emerging NCD prevalence with remaining infectious diseases like HIV or malaria gain more importance for NCD epidemiology in sub-Saharan Africa. Another example is diabetes mellitus (DM) with increased risk of tuberculosis (TB). Individuals with diabetes mellitus have three times the risk of developing tuberculosis. Currently there are more individuals with TB-DM comorbidity than TB-HIV coinfection. Other chronic infections, for example, with Helicobacter pylori (H. pylori), human papillomaviruses (HPV), hepadnaviruses (HBV), and flaviviruses (HCV), are responsible for approximately the 5% of all human cancers (De Flora and La Maestra 2015). Infection-related cancers can primarily be prevented with avoiding the spread of chronic infections to protect the host organism with vaccination. A positive example is the national vaccination programs for HPV during adolescents in Rwanda that mainly contributed to the decline of HPV infections and dropped the HPV infection-related cervical cancer incidence in young women. There are remaining local variations in social and economic development between rural and urban areas in sub-Saharan Africa that might hinder to embark on the specific health challenges and outcomes for each country. Some smart solutions to overcome these regional gaps in the undercoverage of healthcare access are, for example, people-centered health systems to forward country-specific needs (Gouda et al. 2019).

Expansion of Morbidity, Compression of Morbidity, and Dynamic Equilibrium The theoretical framework behind the epidemiological transition in modern societies reveals to three competing hypotheses: the expansion of morbidity, the compression of morbidity, and the dynamic equilibrium. The expansion of morbidity hypothesis (Gruenberg 1977) postulates that the decreasing mortality level in human populations will be forced by the systematically drop of the disease-specific fatality rate with simultaneously increasing prevalence and incidence of that specific diseases. That means living longer with higher morbidity and disability. All medical interventions will contribute to the longevity with remaining chronic disability without improving the personal health state. Again, the increased survival means also higher shares of elderly people being more frailty to chronic diseases. Chronic diseases may be also additional risk factors for other comorbidities. The opposite idea is the compression of morbidity hypothesis (Fries 1980; Fries et al. 1989) that assumes that morbidity and disability will be shifted to higher age of onset with faster pace than the mortality can excess younger age groups. Fries argued that the life expectancy is limited by a biological maximum, so the time with diseases would be compressed into a shorter period at the end of life.

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A compromise between the expansion and compression scenario is disclosed with the dynamic by equilibrium hypotheses by Manton (1982) where healthy life expectancy grows with the same rate as the total life expectancy. This healthy aging approach also supposes that the number of years living with diseases remains constant over time. Authors tried to replicate all three theories with mixed empirical outcomes and no clear conclusions about coherence for any hypotheses. While ground-breaking medical innovations will continuously improve health, the focus about some diseases might be also changing. High levels of disabling conditions like musculoskeletal diseases and dementia correspond with decreasing prevalence rates of chronic respiratory diseases and cardiovascular diseases at the same time. Thereof it remains challenging to predict concisely the correct levels of morbidity and the needed potential demand for health service for the next recent decades.

Evolution of Mortality Driven by Evolving Lifestyle and Mega-Scale Urbanization There are three chronic drivers that stimulate the modern evolution of mortality: stress, physical inactivity, and the consumption of high-caloric food and beverages. Regarding psychosocial stress, about three or more stressful life events can significantly increase the risk for mortality in the population (Rutters et al. 2014). That effect will be strengthening by other coexisting risk factors like smoking, type 2 diabetes, and cardiovascular disease. Chronic stress is present in everyday life for many people because of the individual challenging motivation to manage family life with work-related requirements in combination with traffic or job commuting without any adequate compensation in mental and physical health. Nearly full-time sedentary lifestyle is also common risk factor for unhealthy behavior and elevated mortality risks for many modern industrialized societies. That physical inactivity often corresponds with high-caloric intake of food and beverages like a permanent high-carb diet that also included high-processed food and high sugar-sweetened beverages. Such energy imbalance between physical inactivity and poor diet makes people more susceptible for lifestyle disease like obesity, type 2 diabetes, or cardiovascular diseases.

Role of Nutrition and GMO Food Poor dietary is responsible for more deaths than any other risks globally and is a major risk factor for noncommunicable diseases worldwide (Afshin et al. 2019). Globally, in 2017, dietary factors were responsible for 11 million deaths and 255 million DALYs. The leading cause of diet-related deaths was cardiovascular diseases (11 million deaths), followed by cancer deaths (9.1 millions) and type 2 diabetes (3.4 million deaths) (Afshin et al. 2019). More than half of all diet-related deaths were attributed to three components of diet, the high intake of sodium, low intake of whole grains, and

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low intake of fruit (Afshin et al. 2019). Low-income countries are disproportionally affected from the diet-related deaths (Afshin et al. 2019).

Perspectives of 4.0 Industries and Applied Robotics in Home Care for the Elderly Citizens Industry 4.0 is often described as digitization or full-scale automation. It is also sometimes defined in relation to emerging technologies – advancements in Internet of things, big data and data analytics, robotics, autonomous systems, sensors and automation, and production methods, such 3D printing (Stankovic et al. 2017). Forward-thinking countries like Japan are allocated a significant proportion of the government’s budget to develop “carebots” which are robots specifically designed to assist elderly people, and it is an industry with high growth (Muoio 2015). The global personal robot market, which includes carebots, could reach $US17.4 billion by 2020, according to a Merrill Lynch report. One example is Honda’s Asimo robot which is an autonomous, humanoid robot that could help the elderly by getting them food or turning off lights. The Panasonic Resyone carebot is a robotic device that transforms from a bed to an electric wheelchair, eliminating the need for multiple caregivers. Like Resyone, a humanoid robot called Robobear could also eliminate the need for multiple caregivers by helping transfer seniors from the bed to a wheelchair. Sales of robots designed specifically to assist elderly people are expected to increase substantially in the future, according to the Merrill Lynch report. Apart from the carebots, smart homes, which incorporate environmental and wearable medical sensors, actuators, and modern communication and information technologies, can enable continuous and remote monitoring of elderly health and well-being at a low cost (Majumder et al. 2017). Smart homes may allow the elderly to stay in their comfortable home environments instead of expensive and limited healthcare facilities. Healthcare personnel can also keep track of the overall health condition of the elderly in real time and provide feedback and support from distant facilities (Majumder et al. 2017).

Underlying Factors Contributing to Global Spreading of Demographic Trends The demographic dividend must be seen as “boon and bane” for recent global demographic trends. This population momentum is accounted with a higher proportion of working-age people (15–64 years) related to lower share of people in the non-working age (14 years and younger and 65 years and older). While the proportion of working people in the total population is higher, there might be greater potentials of productivity for the whole population that generates massive growth of the economy. The demographic dividend is also a chance to improve education over age structure for seeking higher human capital especially for younger people. These trends reflect mostly nearly industrialized countries. More pessimistic are the current

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trends in the old-dependency ratio for many high-industrialized countries that harm the monetary inter-generational fairness, while less people in the working ages have to compensate the welfare and pension for the growing oldest-age group. The demographic dividend also draws a phenomenon of the “economic refugees” mostly in low-income countries that force people to leave their home countries to seek mostly unskilled and low-paid jobs in the new destinations. That brain drain in the descent countries can potentially result in the “loss of generations” being not forthcoming for the economic growth and prosperity in these developing countries. These trends can be only inverted if local governments will systematically improve the access to job markets with substantial economic policy strategies. That should create equal income distribution for many people. Consequently, such mechanism obligates more people to stay in their home country because they are now able to get along with their living expense there.

Health Expenditure Dynamics Driven by Aging in Contemporary Societies Societal need of traditional young communities in health care substantially differs from the ones in postindustrial old societies. This is easily observed if we compare exemplary nations of sub-Saharan Africa with Western European ones, such as Tanzania with Denmark. Thus, we come up to entirely different morbidity and mortality structures. The first is dominated with mostly curable or preventable communicable infectious medicines. The latter one is dominated with noncommunicable chronic prosperity diseases, mostly lifetime illnesses very expensive to treat. This is also visible from different WHO lists of essential medicines for such countries which refer to the dominant challenges in the sphere of morbidity. Thus, we come up to the ground economic equations of demand and supply for medical goods and services in aging nations (Jakovljevic et al. 2016, 2017). Today we well know that labor markets are shrinking. Ever growing share of elderly citizens mostly retired and with limited work ability presents a challenge for the pension funds. At the same time, share of work capable young people is narrowing and therefore tax base of employees capable of paying taxes to support the elderly is shrinking as well. This combined imbalance has raised the issue of long-term financial sustainability of national health systems (Jakovljević 2017; Ogura and Jakovljevic 2018; Rancic and Jakovljevic 2016; Reshetnikov et al. 2019). Since 1893 we had establishment of German Bismarck-style health insurance system. It is frequently cited as one of the earliest nationwide risk-sharing agreements in Europe. Yet it is important to know that it was actually limited to the very narrow targeted social layer of industrial workers and their families. At that time following unification of many monarchies into Germany back in the 1870s, it was mostly an agricultural society dominated by peasant families and land economy. The English Beveridge system appeared in 1911 at the eve of First World War although improved being far from any sort of health insurance for entire population. Surprisingly for scholars less acquainted to economic history, world’s first pioneering

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universal health coverage for the entire nation inclusive of the poor was the Soviet Union as early as back in the early 1930s with its renowned Semashko system. PostSecond World War period was characterized by massive industrialization of a scale, primarily in the USA and Soviet Russia. Much later and to a lesser degree, this trend was followed by Western Europe throughout the administration of Marshall Plan. Most of the old EU15 countries, North America and Japan, effectively reached the welfare state during the 1960s. Common political approach to fund hierarchical contemporary health system was to create broad mandatory revenue base. This means to direct the source of financing toward health insurance funds while sharing burden of contribution among the employees and employers alike. Either in social insurance based or the general taxation model, most healthcare funding strategies today rely on a massive pool of employed citizens. Given the deflation and devaluation of pension-retirement funds, citizens of working life age are essentially supporting the needs of elderly and retired citizens. A variety of such financial strategies were historically established in late nineteenth or early twentieth century. European nations were then largely in population growth mode with fertility rates comparable to Afghanistan or Nigeria today. These old strategic thinkers and creators of early health financing systems had one crucial axiom. Bottom younger floors of the demographic pyramid that sustain the weight of the heavy upper floors consisting of senior citizens shall always prevail in population size. To these decision-makers living three to five generations ago, population aging was virtually unknown and impossible to predict, since it is almost never present in natural plant and animal communities. Unfortunately, today we witness putting this assumption to the test. Lower floors of work-capable citizens are becoming ever thinner and weaker. Simultaneously upper floors consisting of elderly citizens are becoming more massive. The labor force is contracting, while the pool of retired pensioners as net receivers consuming most of available social benefits is expanding. The second additional determinant refers to testified high medical needs in last years of life. The seminal literature gives us an abundance of evidence that senior patients tend to suffer from expensive chronic disorders such as diabetes, cancer, cardiovascular, autoimmune, or mental diseases. These patients regularly do frequent laboratory testing, imaging examinations, have more outpatient physician visits, frequent and lengthier hospital admissions, and consume more prescription and over-the-counter medicines. In a latter step, health economics literature documented that needs for medical implants, rehabilitation, and psychotherapy are far greater. On top of all described medical spending patterns comes the last year of life phenomenon. This last year of life is unfortunately associated with the oncology care, intensive care unit admissions, and expensive treatment of autoimmune and neuromuscular disorders with targeted biological medicines. There is growing body of academic evidence that this year of consumption usually costs as much as that individual citizen’s entire lifetime medical consumption.

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There is one more cost driver which lies well beyond entire hospital sector. It is frequently heavily underestimated home-based medical care. Convenient example of such demand is the pandemic of dementia with prominent case of Ireland. Canada, Japan, and many Southeast Asian nations expose the same vulnerability because traditional family caregiving is dying out due to law fertility much beyond simple replacement levels. This is compensated so far by the professional facilities and nursing staff at the great social opportunity cost. Faced with similar challenge, European Commission invests heavily into the robotics research and developments programs particularly targeted for the medical care of the elderly citizens. Difficult burden of family caregivers remains hard to properly assess. We know that commonly reported values are usually only the tip of the iceberg. Israeli example witnesses the massive pool of citizens taking daily care for a sick or old family member. At the same time, they remain employed at full-time jobs leading to personal exhaustion and opportunity costs. Global health spending landscape is rapidly transforming. Low- and middleincome countries continue to take over an increasingly growing share of the world’s health expenditure. Most of these nations face the double burden today. They continue to struggle with yet non-liquidated pool of communicable infectious diseases. This burden is coupled with the growing incidence and prevalence of expensive chronic noncommunicable disease. India and Brazil are probably two best examples of such deep change. Historical timeline that was needed to double the portion of citizens aged above 65 from 7% to 14% took place over the 114 years in France and only 21 years in Brazil. Implications of this huge acceleration of population aging process worldwide are yet to be seen.

Prominent Role of Dementia and Neuromuscular Disorders in Elderly Age Dementia accounted for ten million disability-adjusted life years (DALYs) in older people in 2010, 44% of the burden arising in low-income and middle-income regions (Prince et al. 2015). Dementia is characterized by progressively disabling impairment of several cognitive functions. The behavioral and psychological symptoms of dementia affect the quality of life, and they are an important cause of carer strain (Prince et al. 2012) as well as a common reason for institutionalization (De Vugt et al. 2005). Incidence of dementia doubles with every 5.9-year increase in age, from 3 per 1000 person years at age 60–64 years to 175 per 1000 person years at age 95 and older (World Health Organization and Alzheimer’s disease International 2012). Early diagnosis allows patients affected to participate in advanced-care planning, while they still have capacity to do so (Prince et al. 2011). Musculoskeletal disorders accounted for 43.3 million disability-adjusted life years (DALYs) in older people in 2010, 66% of the burden arising in low-income and middle-income regions, and this is forecast to increase by 70% by 2030. The main contribution from musculoskeletal disorders arises from low back pain (19.1 million DALYs) followed by osteoarthritis (7.5 million DALYs) (Reveille and

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Weisman 2013). The WHO Scientific Group on Rheumatic Diseases estimated in 2003 that 10–20% of the world’s population aged 60 years or older have significant clinical problems attributed to osteoarthritis (Woolf and Pfleger 2003). Prevalence of osteoarthritis increases with age, since it is progressive and cumulative (Woolf and Pfleger 2003).

Reform of Social and Health Policy Agenda to Raise Fertility Rates and Exploit Benefits of Migrations Among the 201 countries or areas with at least 90,000 inhabitants in 2017, it is estimated that 83 had low levels of fertility, as the fertility of the population was below the level required for the long-term replacement of the population (United Nations 2015). Globally, 28% of governments have adopted policies to raise the level of fertility. Europe (66%) has the highest proportion of countries seeking to increase fertility, followed by Asia (38%). Specific measures to increase fertility include baby bonuses, family allowances, maternal, paternal, and parental leave, tax incentives, and flexible work schedules. The highest fertility rate in Europe is observed in France, and this country’s success is partly attributed to the benefits and facilities provided. In addition to the allowances distributed by French allowance funds, the public authorities also provide direct payments to families for the care of children and other related benefits. Some of these provisions interconnect with policies in other areas such as housing, education, employment, and the fight against poverty. Apart from “classical” family cash benefits, families also cumulate a number of other advantages under the heading of housing benefits, tax benefits related to the specificities of the French tax system, and deferred benefits such as retirement. Moreover, France has adopted early childhood strategies which can be categorized into three groups: (a) increased child-care facilities (nurseries) and better financial support for them, (b) increased benefits to provide partial cover of the cost of child care by registered childminders, and (c) paid parental leave for a parent who withdraws, either partly or entirely, from the labor market. Migrants and refugees, including economic migrants, can bring significant benefits to the countries that host them, including improved demographics and heightened economic activity and productivity. Moreover, the adaptation of health (and other) services to make them inclusive and migrant friendly not only ensures that migrants’ health problems are adequately treated but also has positive impacts on the quality, efficiency, and effectiveness of the services for all in the society (M8 Alliance expert meeting 2017). The health of migrants is subject to several risks during their journeys. The approach to addressing the health needs of migrants and refugees needs political, strategic, and technical measures that work along two tracks. This first track refers to the coping with the incoming people and adapting in periods when there are exceptionally high numbers arriving at borders. This should include prophylaxis, screening, and triage at the borders and in reception centers and involve health assessment and vaccines for people coming from countries affected by endemic infections and/or

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because of exposure to infectious agents during their journey (M8 Alliance expert meeting 2017). The second track refers to providing longer-term equitable access to health promotion, disease prevention and care, including health care in camps and transit or detention centers for migrants, as well as provisions for access to health services in the community (M8 Alliance expert meeting 2017).

Disbalance in Historical Roots, Stage, and Speed of Aging Between Rich OECD and Emerging Nations The proportion of the global population aged 60 years or over increased from 8.5% in 1980 to 12.7% in 2017 (United Nations. World Population Prospects: The 2017 Revision). It is projected to continue to rise over the coming decades, reaching 16.4% in 2030 and 21.3% in 2050. Population aging is a universal phenomenon, and every country is projected to see an increase in the proportion of people aged 60 years or over by 2050. Population aging is an inevitable consequence of the declines in fertility and increases in longevity that characterizes the demographic transition and is usually associated with social and economic development. Europe was the first region to enter the demographic transition, having begun the shift to lower fertility and increasing longevity by the late nineteenth or early twentieth centuries in almost all areas (Jakovljevic and Laaser 2015). As a result, today’s European population is the most aged, with 25% of the population aged 60 years or over in 2017. Europe is projected to remain the most aged region in the coming decades, with 34% of the population projected to be aged 60 years or over in 2050, followed by Northern America (28%), Latin America and the Caribbean (25%), Asia (24%), and Oceania (23%). Many countries in Africa remain in the early stages of the demographic transition; some have begun to see reductions in fertility fairly recently, while others have yet to see a decline in fertility. As a result, the aging process is just beginning to emerge in the region, and older persons accounted for just over 5% of the population of Africa in 2017, but that proportion is projected to nearly double by 2050.

Flagged Emerging Issues When we think of older people, the stereotypes are prevalent, whether they are the ones distorting public opinion or skewing policy debates or becoming an economic and social burden to society. When we use economic dependency ratios, which assumes that everyone over the age of 65 years or is unproductive or the use of disability-adjusted life years which explicitly increases the disability by age, we are creating a narrative which is negative. Technology provides this sector with new hope as assistive technologies will possibly play a huge part in care for the elderly in the future. The changing demographics globally require new innovative ways of working to create enabling environments for the elderly for their well-being and quality of life to be sustained. A recent realist review identified potential

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technologies that can support the elderly in their daily life difficulties in key three domains of (i) independent living, (ii) social isolation and dementia, and (iii) medication taking. One of the key challenges identified was the adoption of these new technologies by the healthcare system and by the elderly people. Therefore, there needs to be appropriate development of information and communication technologies (ICT) to create these enabling environments for the elderly to allow for greater independence and self-determination by the older people in the longer term. That said, with that comes ethical considerations around gradual loss of privacy with limited knowledge of what happens with the monitoring data and the pushing of care back to the individual versus social responsibility which should not be taken lightly. However, with the introduction of more technology to support care, there comes a greater possibility to increase health and access inequalities. There already available assistive technologies, but in some parts of the world, the elderly have minimal or no access to them. For LMIC only 5–15% people who need them have access to them. These numbers are expected to grow exponentially in the coming years; therefore there is a need for a comprehensive, integrated health and social system approach to increase the current availability of these technologies for aging populations in LMIC. A critical approach is therefore needed that acknowledges the complex nature and the uncertainties that persist with self-monitoring and self-care technologies for people as well as for healthcare providers. We expect digital health to become a key aspect of contemporary and future healthcare policies and healthcare delivery systems in the future, but with that comes a different set of responsibilities and ethical considerations which should be unpicked and solutions sought before making this mainstream.

Conclusion Population aging ultimately became a widespread global phenomenon and one of the landmarks of late twentieth and early twenty-first century. Extended longevity although desired has led to tremendous growth of medical care demand in most modern-day communities. From a historical perspective, contemporary health systems were established relying on demographic growth model. From these roots, it appears these systems are incapable to combat with exponential tide of medical expenditures. To a large degree, it remains attributable to the long-term care needs, expensive last year of life, and family caregiving undergoing extinction in many modern nations. Decades long shrinking of purchasing power of middle class in rich OECD nations raises the affordability line issues. Western European, North American, and Japanese health spending still remains much higher compared to emerging and LMICs nations in per capita nominal terms. Affordability of medical services and pharmaceuticals among the elderly even in high-income nations is getting lower, while insurance premiums are becoming more restrictive. The new epicenter of biomedical innovations is steadily moving its frontier toward emerging Asia.

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“Big Pharma” seeks her return on investment deriving market access strategies more and more tailored to suit needs of rich citizen elites in the emerging nations. Political reality of providing access of aging population to the prescription medicines, particularly targeted oncology and biologics, brings huge budget impact. This financial burden is almost unbearable even to the richest of societies with Japan being prominent example (Ogura and Jakovljevic 2014). To the most of governments and multilateral agencies, it became obvious that existent social support, health insurance, and retirement systems are no longer financially sustainable. They were historically established on a model of demographic growth with peoples of nineteenth century blossoming in youth and fertility. Today there are entirely different realities. Medical expenditures, largely driven by needs of expanding share of senior citizens, are almost twice exceeding the GDP growth rates. The affordability frontier of medical services is contracting in the Western Nations and expanding in the East Asian ones. As in the examples of France and Russian Federation, fertility gains and certain degree of rejuvenation seem still to be possible. Yet adoption of policies to support healthy aging might be able to release some of the financial pressure. Genetically personalized medicine coupled with innovative pharmaceuticals and home-care robotic technologies is promising arenas as well. Involvement of cost-effectiveness criteria in priority allocation of medical resources throughout health technology assessment framework is already contributing a lot to more effective spending. Ultimately, without bottom-up rethinking of universal health coverage and social support legacies, burden of population aging might remain virtually unbearable for the most of modern societies.

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Reshetnikov V, Arsentyev E, Bolevich S, Timofeyev Y, Jakovljević M (2019) Analysis of the financing of Russian health care over the past 100 years. Int J Environ Res Public Health 16(10):1848. https://doi.org/10.3390/ijerph16101848 Reveille JD, Weisman MH (2013) The epidemiology of back pain, axial spondyloarthritis and HLA-B27 in the United States. Am J Med Sci 345:431–436. https://doi.org/10.1097/ maj.0b013e318294457f Rossabi M (1983) China among equals: the middle kingdom and its neighbors, 10th–14th Centuries. University of California Press Rutters F, Pilz S, Koopman AD et al (2014) The association between psychosocial stress and mortality is mediated by lifestyle and chronic diseases: the Hoorn study. Soc Sci Med 118:166–172. https://doi.org/10.1016/j.socscimed.2014.08.009 Sintserov LM (2019) Geography of international migration in the modern age of globalization. ИЗВЕСТИЯ РАН СЕРИЯ ГЕОГРАФИЧЕСКАЯ 31–40 Stankovic M, Gupta R, Figueroa J (2017) Industry 4.0 – opportunities behind the challenge Triant VA (2013) Cardiovascular disease and HIV infection. Curr HIV/AIDS Rep 10(3):199–206. https://doi.org/10.1007/s11904-013-0168-6 United Nations (2015) Transforming our World: the 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20S ustainable%20Development%20web.pdf United Nations (2017) World population prospects the 2017 revision Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81:646–656 World Health Organization (1999) Ageing, W. H. O. ageing: exploding the myths. no. WHO/HSC/ AHE/99.1. World Health Organization, Geneva. https://apps.who.int/iris/bitstream/handle/ 10665/66330/WHO_HSC_AHE_99.1.pdf World Health Organization (2017a) World report on ageing and health. https://apps.who.int/iris/ bitstream/handle/10665/186463/9789240694811_eng.pdf?sequence¼1 World Health Organization (2017b) Global strategy and action plan on ageing and health. World Health Organization, Geneva. https://www.who.int/ageing/WHO-GSAP-2017.pdf?ua¼1 World Health Organization (2017c) 10 Priorities: towards a decade of Healthy Ageing. https://www. who.int/ageing/WHO-ALC-10-priorities.pdf?ua¼1 World Health Organization (2018) Factsheet on Millennium Development Goals (MDGs). 19 February 2018. https://www.who.int/en/news-room/fact-sheets/detail/millennium-develop ment-goals-(mdgs) World Health Organization (2020a) Factsheet: children: reducing mortality. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality World Health Organization (2020b) Improving early childhood development: WHO guideline. World Health Organization, Geneva. https://www.who.int/publications-detail/improving-earlychildhood-development-who-guideline World Health Organization and Alzheimer’s disease International (2012) Dementia: a public health priority. World Health Organization/Alzheimer’s Disease International, Geneva/London World Health Organization Regional Office for Europe. Sustainable Development Goals. 2020. http://www.euro.who.int/en/health-topics/health-policy/sustainable-development-goals

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Culture, Diversity, and Global Health: Challenges and Opportunities Narayan Gopalkrishnan

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture and the Experience of Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Etiology and Experience of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health-Seeking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stress, Coping, and Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impacts on the Healing Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Racism and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ways Forward: Toward Inclusive Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intercultural Frameworks of Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research and Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Pluralism and Integrative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Based Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

In an increasingly globalized world, we continue to face dramatic health disparities that impact adversely on Indigenous, migrant, and refugee populations as well as other minority ethnic populations in most of the countries of the world. Culture plays an important role in how people experience health and illness, and how they access and experience health care. It impacts on the healthcare professionals as well as on their patients and the communities, modifying the healing relationship and presenting both barriers and opportunities for better health outcomes. This chapter will explore some of the key ways in which this happens with a view to highlight the opportunities that they represent. These include issues N. Gopalkrishnan (*) Department of Social Work, College of Arts, Society and Education Division of Tropical Environments and Societies, James Cook University, Cairns, Australia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_5

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such as how the etiology of disease is perceived, health-seeking behavior, issues of racism, stigma and discrimination, as well as the impacts of stress, coping, and resilience. Finally, this chapter presents specific suggestions for improved healthcare systems that are more inclusive and that work toward more equitable health outcomes for culturally diverse communities. Keywords

Culture · Cultural diversity · Cultural competency · Health disparities · Health care

Introduction Culture is a broad term that can be viewed as a set of values that the members of a given group hold, and includes their beliefs, norms, normative practices, roles, patterns of communication, and other forms of social regulation (Giddens 1993; Kreuter et al. 2003; Spencer-Oatey 2008). It is certainly dynamic, changing in context, and adaptive. For the purposes of this chapter, the focus will remain on culture as expressed through ethnic identity, or the ascriptive group identity shared around factors like religion, language, historical origin, and the social construction of race (Spencer-Oatey 2008; Haque 2010; Gopalkrishnan 2018). The terms “cultural diversity” and “ethnic diversity” will be used to refer to the fact that there are diverse cultural groups in the population while the terms “culturally diverse groups,” “cultural minorities,” and “ethnic minorities” will be used to refer to those groups that have less power and access in a population due to their cultures. Cultural diversity across the world is changing dramatically, especially in the context of increasing migration. If we just consider the case of migration to the highincome countries (HICs), there are significant changes in demographics that are characterized by low fertility rates, and aging population, and high immigration rates (Bélanger et al. 2019). The term “Super-diversity” is sometimes used to denote the extraordinary level and complexity of diversity that emerges from migration in an increasingly globalized world (Vertovec 2007). There are currently over 272 million migrants globally, increased from 150 million in 2020, and equally about 3.5% of the global population (IOM 2020). It is important to recognize that migration is not just into the HICs but also to low- and middle-income countries (LMICs). Iran, for example, has over 2 million foreign immigrants from countries like Afghanistan, Iraq, and Pakistan (Amiri et al. 2015). In the context of the HICs, migration accounts for two-thirds of the total population growth, well ahead of natural factors (Bélanger et al. 2019). Further, the additional variables in the migrant population, such as diverse immigration status and related entitlements, divergent labor market experiences, discrete gender and age profiles as well as diverse patterns of spatial distribution lead to forms of diversity that are dynamic and very complex. These variables also impact on the ways that health and health systems are experienced in these countries (Ahmad and Bradby 2007; Vertovec 2007).

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The legal frameworks of a country can play a very important role in the ability of ethnically diverse communities’ to access health care. This is particularly true of migrants and refugees, who may have limited entitlements to health care and may, in some cases, be excluded from accessing healthcare systems at all (Luiking et al. 2019). In Iran, for example, most immigrants cannot access health care because of the cost of treatment, and if they are illegal immigrants, hospitals will not admit them. This has resulted in high levels of chronic disease among immigrants (Amiri et al. 2015). Situations like this are replicated in many countries, where legal status has dramatic impacts on health status. Migration and refugee status often combine with low socioeconomic status to affect the ways that these populations experience health and illness. Different patterns of migration can place immigrants at different socioeconomic levels and the attendant health experiences (Vertovec 2007). For example, most Indian immigration to Australia has been through skilled migrant streams, and the population has a high proportion of educated professionals with good incomes. The entry of other groups from South Asia such as those from Nepal and Bhutan have been in Humanitarian Entrant streams, placing most of them in completely different income brackets and more at risk in terms of health status. The impacts of immigration on health are so apparent to migrants themselves that, for example, Koreans in Australia refer to many serious health problems as “immigrant disease” (Han and Davies 2006). These impacts on the health profiles of immigrants are even more evident in countries without universal healthcare systems, like the United States, where health access can be quite limited based on SES status (Williams and Sternthal 2010). For these reasons as well as others discussed later, migrants continue to remain at risk for less than appropriate health care in both HICs and LMICs (Amiri et al. 2015; Coleman 2019). Refugees and asylum seekers are particularly at risk in terms of health care as they often have a history of trauma and hardship that impacts adversely on their health profiles. Prior to reaching their countries of resettlement, they often begin their journeys by experiencing physical and emotional trauma though war or natural and other disasters. This can be exacerbated through the refugee journey as they experience loss of homes, assets and livelihood, separation from family and friends, disease and epidemics, lack of food and appropriate nutrition, and even the further risk of torture and death. Many refugees and asylum seekers also experience lengthy stays in camps where lack of food, exposure to violence and disease can further compromise their health (UNHCR 2015). The lucky few who make it to a HIC as recognized refugees face further challenges in terms of the experience of racism and discrimination while seeking to survive as a minority in an alien culture (VFST 2007). Almost two-thirds of refugees experience mental health problems such as post-traumatic stress disorder (PTSD), anxiety, depression, and panic attacks besides the physical health issues that they may have (Khan and Amatya 2017). Cultural diversity in most countries is not just a product of immigration. Many countries have significant Indigenous populations, with their own cultural traditions and healing systems that may be quite different from the mainstream, and who are often marginalized through these differences. While the World Health Organization

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(WHO) has estimated the global population of Indigenous peoples as around 370 million, the Indigenous populations of many countries remain invisible due to lack of disaggregated data on their situations (WHO 2007; UN 2019). Just in the HICs, the United States recognizes over 2 million people in 565 federally designated tribal nations while Canada has over 1.2 million people Indigenous people (Gone 2013). These populations represent an extraordinary cultural and linguistic diversity as well as possessing invaluable resources in the form of traditional knowledge and sustainable practices (Hernandez et al. 2017). However Indigenous populations across the world “suffer from lower life expectancy, high infant and child mortality, high maternal morbidity and mortality, heavy infectious disease loads, malnutrition, stunted growth, increasing levels of cardiovascular and other chronic diseases, substance abuse, and depression” (Valeggia and Snodgrass 2015). Anderson et al. (2016) examined the data across 23 countries and 28 populations to provide evidence of poorer health and social outcomes for Indigenous populations as against non-Indigenous populations. They argue that the social determinants of health explain many of the patterns of Indigenous health in these countries. These differences are particularly well documented in countries like the United States, Canada, Australia, and New Zealand, where processes of colonization, loss of land and cultural continuity, and language barriers have led to historical trauma and the current health gaps between the populations (Valeggia and Snodgrass 2015; Kirmayer and Brass 2016). All of these historical issues have impacted on Indigenous population health through the effects of Historical Trauma, a term first coined in the context of Holocaust survivors but now used to refer to the collective complex trauma experienced by Indigenous populations. Besides Indigenous populations, many countries are culturally diverse based on a range of differences such as language, religion, caste, and historical origin to name a few. The health differences between the minority populations and the majority are often to the detriment of the minority groups. In the small country of Laos, for example, there are not less than 49 ethnicities grouped into five ethnolinguistic groups, among whom minority groups like the Mon-Khmer have much poorer health than the majority communities, poorer health that is mediated through higher levels of morbidity and less health care (Andersson and Lundin 2015). Similarly, castebased social segregation in India, while apparently decreasing with increasing globalization and mobility, continues to impact negatively on both the physical and mental health profiles of people belonging to the so-called backward castes, scheduled castes, and scheduled tribes (Vart et al. 2015). The scheduled castes, those who were formerly referred to as “Untouchables” constitute 17% of the Indian population and yet continue to demonstrate much poorer health outcomes across a number of health indicators such as neonatal mortality, infant mortality, severe anemia, and maternal mortality, even where differences in socioeconomic status are controlled for (Patel et al. 2018; Dutta et al. 2020). In the same way, the life expectancy of a Dalit (another term for castes that are discriminated against) in Nepal is 20 years less than the average, and a Dalit child is twice as likely as a Brahmin child to die in the first year (Thresia 2018). Health disparities are also visible in large

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cultural populations that have experienced dispossession and historical oppression such as the Palestinians and the Kurds in the Middle East. In Israel for example, Arabic people have a much lower life expectancy than Jewish people and have considerably higher age-adjusted mortality from heart disease, infectious disease, and diabetes (Baum 2013). Culture, especially when related to issues of marginalization and attendant socioeconomic status, is one of the key factors that influence global health inequality and also how equitably health problems and resources are distributed (Ortega and Wenceslau 2020). The disease risk profiles of ethnic minority groups in HICs is a case in point where, in Europe for example, there is a higher prevalence of coronary heart disease among those of South Asian descent, higher prevalence of depression among those of Turkish descent, higher prevalence of stroke among those of African descent, and higher death risks from infectious disease among all ethnic minorities (Stronks et al. 2013). Similar health disparities can be seen in the United States where African Americans and Native Americans have much higher death rates from the 15 leading causes of death than their Caucasian counterparts, even where socioeconomic factors are controlled for (Williams and Mohammed 2009). In this context, Fiscella and Sanders (2016) present figures from the 2014 National Healthcare Qualities and Disparities Report to demonstrate that 60% of measures of quality of care (2010–2014) showed worse care of African Americans than Caucasian Americans. Manuel (2018) too reviews a range of studies to posit that racial/ethnic minorities in HICs are less likely to have a usual source of care, fewer physician calls, and less expenditure on health. Even where socioeconomic factors are controlled for, the evidence shows that healthcare disparities continue to negatively affect the health profiles of culturally diverse populations as against the general population (Williams and Sternthal 2010). With appropriate health systems in place there, culture should not prove a barrier to accessing health care. Accessing health care should be considered a human right, and not compromised by cultural factors (Lood et al. 2015). However there are a number of factors that impact on these cultural differences and these are described very well in the United States Surgeon-General’s report on culture race and ethnicity in mental health as: The meaning of an illness refers to deep-seated attitudes and beliefs a culture holds about whether an illness is “real” or “imagined”, whether it is of the body or the mind (or both), whether it warrants sympathy, how much stigma surrounds it, what might cause it, and what type of person might succumb to it. Cultural meanings of health and illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment. (USDHHS 2001a)

Over the last century, the health needs of culturally diverse communities has generally been met through mainstream health theory and systems which have largely emerged from Western cultural philosophy and thinking and clearly reflects Western understandings of the human condition. Some of the key elements of this

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form of cultural thinking in health care include Cartesian notions of mind-body separation, as well as notions of positivism, reductionism, and the predominance of the scientific method and evidence based medicine (Sarafino 2008; Fernando 2015). The term biomedicine can be used to refer mainstream Western medical systems that are built on these cultural values. While these understandings of health are relatively monocultural, these biomedical approaches have been extremely successful in terms of alleviating the impacts of both “physical” and “mental” illness. Biomedicine has particularly been successful in working with the impacts of infectious diseases with single causal agents, and reducing the attendant mortality rates. In Australia, for example, the infectious disease mortality rate dropped from 12.6% in 1907 to 1.3% in 2000. Interestingly enough, the mortality rates due to circulatory diseases in the same period, went up from 20% to 38.6% (AIHW 2005). The global burden of disease is increasingly shifting from acute infectious disease to chronic and degenerative disease, with a number of such diseases relating to lifestyles and exposure to stress (Libster 2001; Friedman and Adler 2007). On the other hand these successes also highlight the fact that the biomedical model is not able to respond effectively to many of the cultural factors that are integral to the emerging health issues of the present day, and point to the need for a more inclusive approach to medicine. This is particularly an issue as Western cultural approaches to health are “predicated on a model that focuses on individual intrapsychic experience or individual pathology, while other traditions may be based more on community or familial processes” (Tribe 2005). Biomedical approaches can be very problematic when they involve working with non-Western cultures and the attendant complexity that the intercultural context involves (Aroche and Coello 2004; Hernandez et al. 2017). The cultural traditions that biomedicine has emerged from have significant implications on every aspect of health care, such as what qualifies as a disease, as evidence, what is worthy of investigation and treatment, how this takes place, who is seen as a “good” patient, and how they are treated in the system (Conrad and Barker 2010). The notion of healing itself can have very strong cultural roots, and Kirmayer (2013) describes it as involving “a basic logic of transformation from sickness to wellness that is enacted through culturally salient metaphorical actions.” Health and illness are not just biological phenomena, rather they are socially constructed labels placed on biological symptoms and experiences. When working across cultures these labels would shift and change, often impacting adversely on different aspects of health and illness management (Nowakowski and Sumerau 2019). As described in this section, cultural diversity has significant influences on the experience of health and illness, including the perception of health and illness, the perception of health systems and practitioners, health-seeking behavior, the perception of clients by practitioners and its impact on the healing relationship, access and barriers to health systems, and a number of other aspects of global health. In many ways culture influences what is defined as the problem, how it is understood, and what solutions are acceptable (Hernandez et al. 2009). In the next section some of the key culture-based elements that impact on the experience of health and illness are explored.

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Culture and the Experience of Health and Illness There are a number of key considerations that transform the ways that culturally diverse populations experience health and illness. Culture can change the way that the causes of the disease are perceived. It can impact on how people perceive the separation of the body and the mind, or even the separation of the individual from the community. Notions of stress, coping, and resilience also vary across cultures and it has significant impacts on the therapeutic relationship. Language is also an important aspect of culture that can support or marginalize culturally diverse patients. Culture also modifies health-seeking behavior, and related factors such as racism, discrimination, and the experience of stigma have implications on the experience of health and illness. This section seeks to unpack some of these elements of culture with an objective of drawing on them to point to the ways forward that can be more inclusive and supportive of culturally diverse patients.

Etiology and Experience of Disease The perception of the etiology of disease is a very important component of the ways in which diverse cultures manage health and illness (Helman 2007; Kirmayer 2013). Helman (2007) delineates these differences in a framework of illness causality across the individual, the natural world, and the social world and explains that every culture views these differently. For example, research with West African refugees settled in Australia identified a range of potential influences on disease that were not immediately visible to Western eyes, such as ancestral influences, hereditary curses, disruption of customs and taboos, possession, influences of gods, and influences of families (Nyagua and Harris 2008). Similarly, notions of the evil eye, black magic, and imbalances of heat and cold (among other forms of imbalances) are all identified as causes of disease among both Indigenous and migrant populations (Culhane-Pera et al. 2007; Saethre 2007). Religion and spirituality also play a role in the perception of the causes of illness, often juxtaposing a higher order good with present hardship (Kreuter et al. 2003; Hechanova and Waelde 2017) and thereafter providing religious and spiritual solutions such as healing temples and pilgrimage sites. Nyagua and Harris (2008) make the argument that “any explanations of sickness, whether Western and traditional, are embedded in ways of believing and seeing, social values, philosophies and artistic expression.” They go on to suggest that if the way the patient sees the problem is not known, their response will not be known and we fail to see, acknowledge, and account for important aspects of clients’ experiences. Even the widely accepted traditional health systems like Ayurveda and Traditional Chinese Medicine (TCM) identify the causes of diseases differently. Ayurveda ascribes disease to factors such as interconnection and/or a lack of balance of Vata, Pitta, and Kapha (the tridosha, or bioenergies), or Karma (one’s actions), Vayu (air), or swabahava (one’s nature) (Kirmayer 2004; Haque 2010; Mukherjee et al. 2017). TCM also focuses on interconnection between the person and their environment, and the lack of balance between Yin and Yang (Chang and Lim 2019). An important

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aspect of many of these traditional health systems is that they do not emphasize the differences between the body and the mind and mostly tend to work with the patient as a whole and in the context of their environments. These broad cultural differences in terms of the perceptions of the causes of disease also highlight the need for health responses that are adaptive and pluralistic and allow for the inclusion culturally appropriate forms of healing that will be discussed later. Further, illness is not just a biomedical issue and has significant cultural and experiential dimensions (Conrad and Barker 2010). The subjective ways in which illnesses are experienced vary dramatically across cultures, and these differences can provide direction for effective healthcare management if they are understood properly. A case in point is that many culturally diverse groups do not necessarily make the same distinctions between body and mind and/or the individual and the community and the ill person and the well person in the same way that Western Biomedicine does. Research among Afghan refugees in the Netherlands, for example, found that most of the participants did not differentiate between mental and physical health (Feldmann et al. 2007). While modern scanning technology and areas of study such as psychoneuroimmunology and psychosomatic medicine are increasingly demonstrating the need to work across body and mind in the context of environment (Nguyen and Bornheimer 2014), the health systems largely continue to work with distinct silos of physical health services and mental health services. This can prove quite inadequate with working with cultural groups that do not make this distinction. The health of the individual and that of the community are also not necessarily as distinct as they are perceived in Western systems. In Native American medicine for example, such as Navajo medicine, illness is viewed as a mark of social disharmony and the healing rituals and ceremonial chants involve many community members, not just those immediately impacted (Trotter 2000). In many ways, these cultural views of health align well with the WHO’s description of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). Cultural responses to emotional expression are also a factor in health and illness. Some cultures feel that talking about painful issues would lead to further painful feelings, which is quite the opposite of which Western talking therapies seek to do (Hechanova and Waelde 2017). This reluctance to engage with therapists is evidenced in research with refugees from Africa as well as from Southeast Asia (Haque 2010; Gopalkrishnan 2012) (Fig. 1). Kirmayer (2013) argues that the material and symbolic effects of healing should be considered as part of an interacting system, particularly because healing interventions will have effects based on the meanings they have for the patient and others with whom they interact. He draws on the literature on the placebo effect to posit that symbolic stimuli and psychological attitudes and expectations can have significant effects on physiology and facilitate healing or aggravating disease. Scholarship in the field of the placebo response also highlights the need for a broader understanding of health, one that is relational and integrates the body and the mind into one system. As Pohlman et al. (2013) expand on these views by stating that the responses to

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Fig. 1 Culturally distinct approaches to health

Body/Mind Binary Bin

Individual/ Community Binary

Illness/ Wellness Binary

Holistic Approaches placebos, at times comparable to that to recommended drugs or at least statistically significant in many other cases, calls for methodological pluralism and integration of diverse forms of knowledge.

Health-Seeking Behavior Migrants and refugees, particularly those in HICs, continue to be at risk in terms of seeking health care later and in more acute stages of both physical and mental ill-health. Choi (2008), while researching Marshallese immigrants in Hawai’i, found that they only sought professional help if the pain that they were experiencing was “unbearable” and that minor levels of pain were ignored. Similarly, Indian Americans are far less likely to use preventative services like cancer screening, and far more likely to use self-treatment before getting professional help than the general US population (Gupta 2010). These findings are replicated in the mental health field where all the research shows that migrants and refugees, especially those from diverse cultures tended to seek help much later than people from the majority communities, and that they tended to present at acute stages of distress (FECCA 2011). Differences in health-seeking behavior are visible in many cultures across the world. Biswas et al. (2016) discuss this in the context of India, where they found that patients seeking help from the health system tended to present more often with somatic symptoms, while those in the United States tended to present more with cognitive symptoms. Another example is the Roma people in Romania who hesitate to seek help from medical institutions because of the perception of impurity attached to these institutions (Roman et al. 2012).

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There are many reasons why culturally diverse communities do not seek mainstream health care at the same rates as the general population, one of which is cultural mistrust. This is particularly an issue in countries with a history of colonialism, but is also applicable to other countries where minority groups have experienced dispossession and oppression from mainstream society. The healthcare needs of First Nations people across the world are compromised by their histories of intergenerational trauma and attendant mistrust, and as Nelson and Wilson (2017) state, they bear a “disproportionate burden of mental and physical illness.” Healthcare professionals can be viewed as part of the problem in this context, both from a historical context and because of their current roles within the State (Bessarab and Crawford 2013). Research among African Americans and Latino communities in the United States similarly shows cultural mistrust of clinicians stemming from histories of persecution as well as current issues of racism and discrimination (USDHHS 2001a, b). And the result of this mistrust is the delayed utilization of health services as well as later and more acute care presentations. Another causal factor is the notion of shame, especially in the context of mental health. Hampton and Sharp (2013) describe shame as an emotional state that individuals experience when they fail to meet internalized social standards of morality, competence, or aesthetics. Shame can cause people to seek help later for several reasons. There may be a fear of being seen as “crazy” by people within and outside the culture, or the patient may be reluctant to open out to strangers due to a number of reasons such as “loss of face” or the fear of revisiting and exacerbating the pain already experienced. The desire to protect the family honor and reputation may also cause the patient to ignore the condition or treat themselves rather than approach a professional (Hechanova and Waelde 2017). This can be particularly the case in collective cultures, such as among Asian Americans, where the shame can be seen as concerning both the individual and the family (Tung 2010). Shame can be viewed to as related to stigma, which can be described as a “mark of shame, disgrace or disapproval which results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society” (WHO 2001). Stigma can restrict a sufferer’s access to health care, reduce the support that they can get from their social networks as well as reduce their own capacity to manage the disease. Stigma can cause people to hide symptoms and not to seek treatment because of the shame that they feel (USDHHS 2001a, b). Particular illnesses are also stigmatized, such as leprosy, cancer, STDs, and a vast range of mental disorders. Illnesses and disorders do not have anything inherent that make them stigmatized, and as Conrad and Barker (2010) argue, it is the social and cultural meaning ascribed to the disease that tends to become dominant, causing stigmatization and having independent consequences on the patients as well as the health systems. Drawing on the literature in this area of research, they recommend a shift from the biomedical “fixing” of individuals to a broader approach of changing the social and cultural context that stigmatizes illnesses. Stigma is particularly concerning in the context of LMICs where government support systems may be minimal, and the family and/or community may be the only safety net that is available to the individual. If the person experiencing illness loses the support of

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the family and the community due to the associated stigma, it can lead to isolation, neglect, and a rapid worsening of the impacts of disease (Fernando 2014). The experience of medical plurality is another reason why minority groups delay seeking biomedical care. Many cultures access healing systems depending on the perception of the nature and acuteness of the disease. If the illness is not perceived to be very acute, the first step is often home treatment with herbal remedies, massage, or other Complementary and Alternative (CAM) approaches. Among Indian Americans, for example, Gupta (2010) points to the use of a wide range of modalities as part of their self-treatment, including Ayurveda, Homeopathy, herbal medicine, massage, and diet. The second step is accessing help from spiritual and other mind-body treatments. The perception of the etiology of the illness can play a key role in this decision. If the disease is perceived to be of supernatural causes, as many psychological and psychiatric issues often are, the modality of recourse is often that of the traditional healer or the traditional healing system. Abubakar et al. (2013) draw on the research evidence from different parts of Africa to point out that this use of traditional medicine is still very prevalent there and that traditional medicine has come to play a limited but complementary role to the mainstream health system. As a corollary to this, they also suggest that traditional healers also play a part when biomedical systems are perceived to have failed in dealing with the illness. Medical plurality is one of the possible considerations when looking at ways forward and will be discussed later in this chapter.

Stress, Coping, and Resilience Stress plays a very important role in the experience of health and illness. At one level, stress can impact adversely on emotional states, giving rise to psychological distress and attendant negative health. Secondly stress can lead to the adoption of adverse coping mechanisms such as drug and alcohol dependence as well as the reduction in healthy behaviors like exercise. And stressors and the body-mind responses to stress can adversely impact on physiological systems such as the neuroendocrine, autonomic, and immune systems, leading to the experience of new illness or the exacerbation of existing conditions (Williams and Sternthal 2010). An understanding of the ways in which adversity is managed by diverse cultural groups has implications for the promotion of health, prevention of illness, and the nature and severity of health problems (USDHHS 2001a, b). Coping and resilience are important aspects to be explored in this context. Coping styles are those ways in which people cope with both the everyday and the more extreme stressors in their lives, including health stressors. Coping is defined by the social space in which it takes place and emerges through people’s interactions with their social and cultural spaces (Potter et al. 2018). Resilience is also worth consideration, where resilience is the ability to do well despite facing adversity. Much of the literature on resilience focuses on the traits and characteristics of individuals and does not take sufficient note of the systemic and/or ecological roots of resilience. Kirmayer et al. (2011) discuss this in the context of the First Nations Peoples in Canada, arguing that

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resilience in their context is embedded within cultural values, cultural identity, collective history, language, and collective action. Culture affects the experience of stress by impacting on the types of stressors that a person may experience, then affects the appraisal of that stress and the related choice of coping strategies, and finally provides institutional arrangements to enable people to cope with the stressors (Aldwin 2004). So cultures may designate certain stressful events as normative and ritualized and as such most people from that culture would expect to experience these events as part of their lives. Examples of these could include puberty rituals, bereavement rituals as well as retirement rituals, wherein distress is mitigated through the rituals, the normative approach as well as the relationship with other social institutions such as social groups, religious counselors, Elders, or professional counselors. Cultures also may differ in terms of what is viewed as a stressor. While there are more visible differences such as the breaking of taboos, there are also more subtle differences such as the response to individual achievement in a more collective culture (Aldwin 2004; Hechanova and Waelde 2017). Cultural differences in terms of dealing with stressors can be protective or risk factors. The ways in which collectivist cultures respond to illness can be seen as a protective factor, where healing is a product of interdependence and the health of the group is seen as at least as important as that of the individual (Hechanova and Waelde 2017). The family and the social group are central to all aspects of life within these cultures. And supportive extended families and strong sibling relationships can act as protective factors in these contexts (Dawes and Gopalkrishnan 2014). However, this very response can be a risk factor when the individual goes against group norms and loses the support of the culture. Women from collectivist patriarchal cultures, for example, who may seek to escape from a domestic violence situation, can often find themselves socially isolated and without any support in terms of accessing appropriate health care. In cases like this, perceptions of stigma, marital discord, and breaking of norms can be major risk factors (USDHHS 2001a, b; O’Mahony and Donnelly 2007). Similarly, religion can be viewed as a protective factor that can enable people to cope with disease (Hechanova and Waelde 2017). However, when the attribution of that disease or the disease itself is stigmatized within that religious context, it becomes a risk factor. Sexually transmitted diseases and mental illnesses are cases in point. Similarly, culturally relevant schema such as the Strong Black Woman framework endorsed by many African American women can be protective in terms of the focus on pride and resilience, but can also lead to risky coping methods such as postponement of self-care and emotional suppression (Belgrave and Abrams 2016).

Impacts on the Healing Relationship Culture can perform an integrative function when it brings people together within a group around shared values and norms. In the same way it can perform an exclusionary function when two diverse cultures interact, as within many clinical

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relationships. In mainstream healthcare literature, the challenges of providing appropriate health care to culturally diverse populations are often ascribed to the cultural needs and issues of the patients (Diaz and Kumar 2018). However, the cultures of the practitioners and the health systems are as much at play in this context as the cultures of the patients. The ways in which the cultures of both the client and the clinician/ therapist impact on the therapeutic alliance or relationship are very significant considerations in working with culturally and linguistically diverse cultures. The best possible situation would be where the healthcare professional and the client are from the same culture and have a shared cultural understanding (Marsella 2011). But even in these circumstances, the healthcare profession brings with them a “professional” culture that can prove a barrier to working with their clients (USDHHS 2001a, b). The factors that are implicit within this notion of “culture of the profession” can create a power relationship, lack of flexibility, and distance that do not allow for effective communication. “Power distancing” can work the other way too in the context of diverse cultures. Hechanova and Waelde (2017) make the argument that when the patient is from a culture that is hierarchical and where power distancing is the norm, the problems arise when she or he interacts with a therapist from a culture where power distancing is not practiced and the client perceives this as incompetence or indifference. Han and Davies (2006) reiterate this in terms of their research with Korean migrants to Australia, where they discuss the authoritarian stance of doctors in Korea and its impact on patient-doctor relationships in Australia. In practice, there are many clinical interactions where the clinician and the patient come from very different cultural, and maybe linguistic, contexts. This can lead to situations where professionals are making assessments that do not have linguistic, conceptual, and normative equivalence and can lead to inappropriate decisionmaking (Marsella 2011). In the field of mental health, Fernando (2015) makes the point that the lack of equivalence in assessment is the reason why certain cultural groups are overdiagnosed with particular mental disorders. This is described as the negative impact of culture on the healing relationship where “health practitioners overlook, misinterpret, stereotype, or otherwise mishandle their encounters with those who might be viewed as different from them in their assessment, intervention, and evaluation-planning processes” (Kline and Huff 2007). Ortega and Wenceslau (2020) draw on the term “silencing of culture” to refer to the ways in which culture is often ignored or misrepresented in health services and practices and highlight that this silencing is underpinned by contempt toward popular cultures and beliefs, regarding them as less sophisticated and rough. Language differences are also an extraordinarily important aspect of culture that modify the healing relationship, as language is a central part of communication. Linguistic diversity can impact dramatically on culturally diverse groups’ experience of healthcare systems especially where the healthcare professional and the client do not share the same language. Luiking et al. (2019) raise this issue in the context of migrants, but the issue is just as valid for Indigenous communities and other ethnically diverse communities if they speak a language other than that spoken by the mainstream. Many HIC countries, like Australia and the United Kingdom, have policies in place regarding the use of interpreters in healthcare settings, and yet there

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are numerous examples where interpreters are not utilized appropriately or at all (FECCA 2011). The use of bilingual children to interpret for their parents is one such example of inappropriate interpreting that been quite common globally even in the HICs. Even where the client’s English may be sufficient for everyday encounters, the specialized nature of the clinical consultation and the complexity of information to be shared make the use of interpreters critical to situations involving linguistic diversity (Wallace et al. 2019). Alpern et al. (2016) cite several research studies to substantiate the argument that most resident doctors do not regularly use professional interpreters despite the evidence that the use of professional interpreters improves patient communication, satisfaction, and outcomes. Stereotyping is a process that can also impact adversely on the therapeutic relationship. All members of a given culture or subculture do not necessarily follow the cultural norms the same way and do not necessarily act the same way, and fit a stereotype (Coleman 2019). Migrants, for example, are shaped by their culture of origin, the culture of the country they settle in as well as their life experience and, as such, have diverse needs that do not necessarily fit within stereotypes (Luiking et al. 2019). This is true of all people of culturally diverse backgrounds, that while they may share certain aspects of their culture, they also have unique and personal needs that are not necessarily shared by everyone belonging to that culture. This process of stereotyping is something that people of all cultures can do, but it is especially an issue when those in powerful positions, such as healthcare professionals, resort to stereotyping. Medical professionals can often fall into the trap of believing themselves beyond culture or “cultureless,” in effect making themselves the neutral standard to measure others. This, while clearly untrue, can lead to ethnocentric judgments and behaviors that impact adversely on their patients of diverse cultures (Diaz and Kumar 2018). The term “othering” to refer to how healthcare professionals may perceive migrants in particular as “others” as different to “them” and thereby be at risk of acting based on prejudicial attitudes. Interventions based on stereotyping of minority cultures can be inadequate and/or inappropriate and cause further marginalization of these groups (Luiking et al. 2019). Cultural health capital is another concept worth exploring in the context because of its impacts on the healing experience. The reasons for this are explored by Sointu (2017) in her longitudinal study exploring medical students’ experiences in the United States. She draws on Bourdieu notion of “cultural capital” to understand the reasons why doctors gave preferential treatment to “good patients” who shared their values and language (cultural health capital) while providing those without cultural health capital with less reassurance, listening, and empathy. She further points out that cultural health capital is seen to go together with perceptions of good moral character. This argument is particularly worrying in the context of minority ethnic and Indigenous communities across the world as, while having significant social capital among their own communities, they often lack cultural health capital, which includes the “repertoire of cultural skills, verbal and nonverbal competencies, and interactional styles that can influence health care interactions at a given historical moment” (Shim 2010). Minority groups that end up under-serviced by healthcare services because of their lack of cultural health capital are also less likely to be able

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to cope with health related stressors (Potter et al. 2018). The reasons for this lack of cultural health capital include aspects of linguistic diversity, colonial history, dispossession, and ongoing racism and discrimination.

Racism and Discrimination Racism is a social construct that impacts on the health of cultural minorities across the world. Traditionally the term referred to ideologies that supported the notion of biological “races,” ranked them as superior or inferior and allocated societal goods and resources preferentially based in these rankings (Babacan and Gopalkrishnan 2007; Williams and Sternthal 2010). Modern science has debunked many of these old views of race but many of the ideas of biological race and racial superiority continue to flourish, while been supplemented by new forms of racism built on ideas of cultural superiority. These ideas are then used to discriminate against people belonging to the “inferior” cultures and denying them resources in the process. Racism has dire impacts on minority groups, often leading to social alienation, fear of public spaces, and loss of access to health services. Racism leads to discrimination at the individual and at the institutional levels. Racial minorities can experience racism and racial discrimination at the individual level through behaviors in face-to-face encounters or even through the media. The direct and overt aspects of racism, involving physical violence and/or open discrimination, are relatively easy to identify and are often challenged in public spaces (Hollinsworth 2006). The more covert forms of individual and institutional racism are much harder to identify and accordingly more difficult to combat. As discussed by Holdaway and O’Neill (2007), open expressions of racism are reducing, to be replaced by covert racism and hidden institutional racism. Institutional racism and racial discrimination, while hard to pinpoint, can be embedded in the ways organizations operate, often controlling and denying access and resources to particular minority groups. The insidious aspect of institutional racism is that it can be experienced as everyday racism and discrimination and can be easily viewed as the “normal” way to be. Racism and racial discrimination form a major source of stressors that impact on the health outcomes of ethnic and other minorities. Williams and Mohammed (2009) carried out a systematic review of literature on discrimination and racial disparities in health to conclude that “the consistency of an inverse association between discrimination for an increasingly broad range of health outcomes, across multiple population groups in a wide range of cultural and national contexts is impressive, and lends credibility to the plausibility of perceived discrimination as an important emerging risk factor for disease.” The research studies that they reviewed delineated elevated levels of stress exposure due to the impacts of discrimination on stigmatized ethnic groups in the United States, Europe, Africa, Australia, and New Zealand. The term “minority stress” can be used to describe how the health of minority cultural groups is impacted on by the stresses of institutional, structural, and interpersonal discrimination (Belgrave and Abrams 2016). These stresses are particularly intense when

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the minority groups are quite easily identifiable, as with Muslim women who may wear the Hijab or where the skin color of minorities is quite different from the mainstream (Andermann 2010). Both systemic and individual discrimination have long-term implications on the health of ethnic minorities. Not all of these factors lie within health systems, as much of the discrimination may be experienced in the broader context while still impacting adversely on the health of the individual. For example, Baum (2013) discuss the systemic discrimination impacting on Arab Israelis as “pervasive, long-term and deeply entrenched discrimination by government bodies that resulted in poor living conditions, inadequate public services, and insufficient health care facilities and services in Arab communities.” The significant factors that have been highlighted in this section point to the opportunities to further develop healthcare systems so that they are more supportive and inclusive of culturally diverse communities. Some of these are already incorporated into healthcare systems such as the Biopsychosocial approach, the Recovery approach, and the notion of person-centered care. Each of these provides opportunities for inclusive work with individuals and communities, which could include working with culturally diverse communities (Green et al. 2006; Kirmayer et al. 2017). As there is extensive literature available on these more general approaches, the focus in this chapter will remain on approaches that are directly applicable to the context of working across cultures, and these are explored in the next section.

Ways Forward: Toward Inclusive Health Care Intercultural Frameworks of Practice The single most popular framework of practice in terms of working across cultures in health care is arguably Cultural Competence. As a case in point, Barone (2010) maintains that culturally competent care remains a high priority for biomedical healthcare facilities in the United States due to the twin influences of changing demographics and federal legislation. This framework has been described as referring to “the awareness, knowledge and skills and the processes needed by individuals, professions, organizations and systems to function effectively and appropriately in culturally diverse situations in general and in particular, encounters from different cultures” (Bean 2006). It is widely used in diverse settings such as from schools and colleges to hospitals, community organizations, the military, and the corporate sector. A comprehensive review of the cultural competence literature by Alizadeh and Chavan (2016) delineates that the healthcare sectors in many countries are challenged by the growing cultural diversity of their clients, and lack the cultural competence to be able to manage the intercultural issues that often arise. They go on to emphasize that there is consensus around the term “cultural competence” as well as in its three main components, cultural awareness, cultural knowledge, and cultural skills. Ortega and Wenceslau (2020) posit that cultural competence strategies can assist practitioners to interpret symptoms in ways that can lead to more appropriate and culturally meaningful interventions. The research

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literature in the field of cultural competence substantiates the use of this framework in healthcare interventions. One systematic review found that training in cultural competence not only improved the capability of the providers but also improved patient satisfaction in five of the seven studies included in the review (Govere and Govere 2016). Similarly, another review by Horvat et al. (2014) found that there was positive, if low-quality, evidence that there were improvements in the involvement of CALD patients as a result of cultural competence education for health professional (Fig. 2). However, cultural competence has also significant issues in terms of practice. The single most important issue, especially in the context of marginalized Indigenous communities and other ethnically diverse communities, is the lack of acknowledgment of issues of power and racism. In this framework, culture is seen as value neutral and, in effect, allows issues of racism and oppression to disappear into the background (Sakamoto 2007). This is especially a problem where communities have experienced long histories of oppression and are often struggling to make their voices heard, a framework that ignores these histories and their impacts is more likely to become part of the problem than part of the solution (Pon 2009). All of these issues raise the need for frameworks that incorporate notions of anti-oppressive practice and challenge some of the issues of power and historical dispossession that many minority communities have to deal with. Cultural humility is one such approach that appears to be gaining popularity in medical education. Rockich-Winston and Wyatt (2019) describe cultural humility as emphasizing positionality and relationship between the practitioner and the community member, using self-reflection and self-critique toward personal quality

Fig. 2 Elements of cultural competence

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improvement, as well as learning from patients, building partnerships and a lifelong commitment to appreciating the clients’ cultural contexts. Cultural Safety is also an important framework to consider, especially when working with Indigenous peoples. It emerged from the work of Maori nurses among the Maori community in New Zealand and sought to work toward cultural change by addressing power imbalances and reducing the impact of power and racism in health care, education, and research (Cox and Simpson 2015). This is described by Kirmayer (2012) as emphasizing the clinician’s limited access to insider cultural knowledge and the need to be respectful and open to the clients’ cultural understandings. The process of evolving toward cultural safety as a framework of practice could be perceived to begin with cultural awareness, involving an understanding of the differences between cultures, through to cultural sensitivity, where these difference are seen to be legitimate, to cultural safety where there is no longer a challenge to culture and its dimensions (Ramsden 2002). In countries with histories of colonization, such as Australia, New Zealand, Canada, and the United States, there is considerable opportunity for the utilization of cultural safety in the healthcare spaces so as to improve the health outcomes of Indigenous peoples. A framework that brings together the disparate elements of cultural competence with the anti-oppressive aspects of a framework like cultural safety would be far more inclusive of cultural minorities and would work more effectively toward equitable health outcomes. A possible framework of cultural partnerships has been explored elsewhere (Gopalkrishnan 2019) but has been summarized here in the following figure (Fig. 3). As delineated above, cultural partnerships incorporate the core framework of cultural competence as practiced in a culturally safe environment and bring in the further element of mutual learning and cultural transformation. It emphasizes the fact that all cultures are dynamic and transform through the process of intercultural interaction. Another very interesting health framework that is used to work across cultures in Bolivia and Ecuador is interculturalidad (interculturality) and is based on the notion that healthcare systems are simultaneously social and cultural and there needs to be an honest exchange of beliefs and practices leading to mutual growth and enrichment (Hartmann 2016). Several countries in Latin America with histories of colonization are incorporating the biomedical approach with their own decolonization experience to develop frameworks of health systems that are appropriate to their contexts (Hickling 2020).

Research and Evidence As discussed earlier, the health systems as well as the frameworks that they are based on are largely Western and quite monocultural. Much of the current direction of health care emerges from the processes of evidence based practice (EBP) which can be described as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patients”

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Fig. 3 Culturally dynamic partnerships

(Sackett et al. 1996). Evidence-based practice involves questions, interventions, and planned outcomes that are all culturally determined and potentially biased and/or inappropriate. Further, they do not necessarily recognize cultural ways of knowing that do not rely on the observation and experimental methods that EBP relies on (Kirmayer 2012; Coleman 2019). Health as it applies to Indigenous people and ethnically diverse groups in countries across the world remains an area that is very understudied with significant implications in terms of health outcomes for these groups (Lood et al. 2015). A very common reason for this lack of research is the exclusion of people of diverse cultural and linguistic backgrounds from clinical trials. Language barriers are a commonly cited reason for this underrepresentation, as they require additional investment of time and resources (Quay et al. 2017). Hussain-Gambles et al. (2004) provide several further reasons why this underrepresentation may happen. Firstly, they suggest that the health researchers may be unaware of the importance of representational sampling, or because of historical practices and/or paternalistic attitudes. The costs of inclusion of “extra variables” such as people from ethnically diverse groups, and language inclusion costs are also factors mentioned in several studies (Rubincam et al. 2016). Healthcare provider attitudes are also a factor, where lack of confidence in their abilities to communicate to CALD groups, dependence on stereotypes and

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cultural myths, and other negative perceptions can lead to lack of minority representation. Besides these reasons, they also discuss fear and mistrust, consent issues, and sociocultural barriers, to conclude that the “exclusion of people from ethnic minorities from clinical trials is not only poor science because it challenges the external validity of trial findings, but it also raises issues around equity in healthcare provision” (Hussain-Gambles et al. 2004). Secondly, much of the research conducted among these groups is in those conditions where minority groups have an increased prevalence of a disease as compared to the mainstream population. While this may seem to be an appropriate emphasis, it does not necessarily reflect the real priorities in terms of the groups’ needs. As Ahmad and Bradby (2007) discuss, this could mean that research could focus on a disease with a higher relative prevalent rate, like tuberculosis, as against focusing on cancers, which may have higher actual rates among the population but lower relative rates. And finally, a number of factors impact on how culturally diverse individuals and groups are meaningfully informed in research. These include differences in understanding of disease, conditions that may limit the voluntary nature of consent such as limited access to health services, mistrust regarding the means and the ends of research, and distrust that may be part of the historical context of the study country (Rubincam et al. 2016). The aspect of historic abuse of power as a result of colonial research methods is of particular note here as it has implications in how research is accepted in countries with a history of colonization such as Australia and the United States (Sibbald et al. 2016). Fassin and Schneider (2003) raise this point in the context of HIV prevention work in South Africa, where they argue that the experience of apartheid remains with many South Africans and explains much of the mistrust of Western science and medicine. The need for increased inclusion of culturally diverse groups and Indigenous populations in research is clearly required if the evidence produced through research is to have any relevance to these client populations. As Hussain-Gambles et al. (2004) describe it, “[t]he exclusion of people from ethnic minorities from clinical trials is not only poor science because it challenges the external validity of trial findings, but it also raises issues around equity in healthcare provision.” Adoption of appropriate intercultural frameworks and ensuring adequate training of healthcare research professionals in these frameworks would be one step forward in this context. It would certainly help in terms of reducing the mistrust that culturally diverse and Indigenous communities have of mainstream systems. Secondly, ensuring inclusion of local workers and/or Elders in the research, including involvement in decision-making, will improve community acceptance as well as improve project processes (Rubincam et al. 2016). This is also an advantage in that local worker may have access to networks that may be denied to other researchers (Quay et al. 2017).

Education and Training Many health professionals lack appropriate training and resources to work with migrant and refugee populations, as well as other culturally diverse groups, and

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continue to struggle with providing appropriate health care to these populations (Baum 2013; Diaz and Kumar 2018). As Alpern et al. (2016) find in their research, “resident physicians’ current training is inadequate, and highlights the need for targeted didactics that cover issues that disproportionately and specifically affect immigrant and refugee populations.” One of the main reasons for this is the global structure of healthcare education which is often directed toward being homogeneous, striving toward Western standards, focused on Western-style training and assessment and using Western scales and measurements, all in the English language (Gosselin et al. 2016). This of course means that the clinician emerging from the educational system is quite alienated from the cultural ways of being and knowing in their own countries, and often out of touch with local needs and contexts. When they have to go into practice with culturally diverse populations, this can lead to many of the cross-cultural issues that have been discussed earlier. One of the ways of responding effectively to an increasingly diverse population is to build elements of cultural competence or other intercultural practice frameworks into the curriculum of healthcare degrees or provide cultural competence training to practicing healthcare professionals. However, much of the cultural competence training remains in the form of one-off interventions and lack the ability to make for sustained change. Diaz and Kumar (2018) makes the point that healthcare educationists need to explore and address the discrepancies between formal and informal curriculum and the ideas supported by role models in everyday clinical practice, what is referred to as the hidden curriculum, if they wish to make for learning that make for positive change in the long term. Rockich-Winston and Wyatt (2019) support this when they point out that transformative approaches to learning may be based on a global health outreach, rotation opportunities, and/or servicelearning opportunities. The cross-over between the understanding of issues of global health and those of cultural competence is an important element that also needs to be incorporated into the curriculum of healthcare education, which can be further supported through an emphasis on increasing the diversity of faculty and students is another purposeful way of responding to the increasing cultural diversity in the client population (Mews et al. 2018; Rockich-Winston and Wyatt 2019).

Medical Pluralism and Integrative Medicine Medical pluralism is a promising approach in terms of providing healthcare systems that respond effectively to culturally diverse groups. This has become way of life in many countries where conventional biomedical approaches and conventional and other health systems such as traditional medicine are used in tandem with each other (WHO 2005). The WHO uses the term Traditional and Complementary Medicine (T&CM) to refer to the healthcare systems other than the conventional biomedical approach and suggests that these are “and important and often underestimated health resource with many applications, especially in the prevention and management of lifestyle-related chronic disease, and in meeting the needs of ageing populations” (WHO 2019). However, presently healthcare systems across the world are built on

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the primacy of Western biomedical systems, with other systems rendered subordinate as Indigenous medicine or Complementary and Alternative Medicine (CAM). The dominant position of biomedicine is generally established through law, while other systems have varying statuses depending on the country and the legitimacy granted to them (Baer 2007) (Table 1). CAMs are already increasingly popular in the West with over 36% of all adults in the United States and 63% of all adults in Australia using some form of CAM to manage their health (NCCAM 2010; Steel et al. 2018). In research involving 875 family physicians in Canada, Fries (2008) delineates that a number of approaches such as acupuncture, massage therapy, chiropractic care, relaxation therapy, biofeedback, and spiritual or religious healing were effective when used in conjunction with biomedicine to treat chronic or psychosomatic conditions. At the governance level, WHO reports an excellent proportion of countries with national T&CM programs including 91% in Southeast Asia, 72% in the Africa Region, 41% in the Western Pacific Region, 37% in the Region of the Americas, and 19 and 13% in the Eastern Mediterranean and European regions (2019). Regulatory bodies are also increasingly established in many countries such as Office of Complementary Medicine within the Therapeutic Drugs Administration in Australia, The Ministry of AYUSH regulating Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy in India, the Directorate of Traditional Medicine and Intercultural Development in Mexico, and the National Administration of Traditional Chinese Medicine in China. Some of the approaches that are labeled CAM, in the HICs at least, are often Whole Medical Systems (WMS) with both legal standing and popular acceptance among large populations, such as Ayurveda in India and Traditional Chinese Medicine in China. Additionally, many Indigenous peoples and other ethnic minorities Table 1 Classification of approaches in Complementary and Alternative Medicine (CAM) Major domains of each CAM Whole medical systems/alternative health care systems: These cut across more than one of the other groups Mind-body medicine, taking a holistic approach to health that explores the connection between the mind, body, and spirit Biologically based practices: Use substances found in nature such as herbs, foods vitamins, and other natural substances

Manipulative and body-based practices Energy medicine: Biofield therapies intended to influence energy fields of the body Energy medicine: Bioelectromagnetic-based therapies using verifiable electromagnetic fields WHCCAMP 2002; NCCAM 2010

Examples under each domain Traditional Chinese medicine; Ayurveda; homeopathy; naturopathy; chiropractic; native American medicine Yoga; meditation; music therapy; dance therapy; hypnosis; prayer; and mental healing Herbal therapies; special diets such as macrobiotics; orthomolecular medicine such as megavitamin therapy; individual biological therapies such as shark cartilage or bee pollen Massage; Feldenkrais; Alexander technique Qigong; reiki; therapeutic touch Magnet therapy

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have traditional healing systems that they have used for many generations. Gone (2013) makes this more explicit by stating that the widespread use of culturally specific practices such as talking circles, pipe ceremonies, and sweat lodges in the federal Indian Health Service in the United States serve both therapeutic and political purposes leading to shifts in collective identity and meaning. As healing is a process of the sentient body responding to therapeutic encounters, healing rituals, and caregiving practices, local Indigenous knowledge can provide a valuable guide to the development of health systems that are relevant to the cultures of the client populations (Pohlman et al. 2013; Boksa et al. 2015). However, while working with traditional health systems it must be recognized that many cultural healing systems used to be embedded within specific cultural traditions and communities, and do not necessarily fit when taken completely out of context (Kirmayer 2013). We exist in a globalized world where hybridity and transformation are endemic in systems, emphasizing the need to research the effectiveness of cultural healing traditions in their new contexts. Interestingly, integrative medicine is a term gaining ground in terms of the shared practice of biomedicine with WMS and indigenous medicine or other healing systems. While Baer (2007) sees this as a case of biomedicine subsuming other systems to maintain its dominance, it certainly provides opportunities for therapeutic approaches other than the mainstream to respond to the needs of culturally diverse populations. Traditional and Complementary Medicine systems present enormous opportunities to work with the communities in integrative ways that support each other and provide the best possible outcomes. A very significant reason for an integrative approach is “that T&CM has additional knowledge and interventions on preventative and curative health promotion” (Baars and Hamre 2017). The preventative aspect in particular can play a key part in reducing the expanding costs of the global burden of disease, especially of non-communicable diseases (NCDs) which is expected to be anything from US$ 30 trillion to US$ 47 trillion by 2030 (Bloom et al. 2011). There are increasing examples of successful integrative medicine interventions across the world, such as the treatment of elephantiasis with Ayurveda and biomedicine in India, the treatment of depression with yoga in the same country or the use of yoga along with biomedicine for supporting older adults in Japan (Baars and Hamre 2017). The development of intercultural models of primary health care that integrate biomedicine with Traditional medicine in several Latin American countries such as Brazil, Ecuador, and Guatemala are also interesting examples of the integrative medicine paradigm in practice (Hernandez et al. 2017). Even in HICs, there are significant numbers of clinicians who refer ethnic minority clients to T&CM practitioners such as those using acupuncture for pain relief or the Korean “Hambang” tradition for chronic fatigue (Han and Davies 2006). Similarly, Cohen et al. (2006) report that 80% of the General Practitioners that they interviewed had referred patients to a complementary therapy at least a few times a year. While much of the literature explores the issues of culture as a barrier to healthcare management, there is a dire need for approaches that view culture as an asset, one that provides points of resilience or community strengths on which

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healthcare systems and processes can be built (Rubincam et al. 2016). Many cultures have positive resources within them, such as Elders, religious leaders, priests, and traditional healers. Arguably, health approaches that incorporate these positive resources would be likely to have greater acceptability and outcomes, especially as they are tapping into what people in the community want and value (Fernando 2014). These resources can be intrinsic to healthcare approaches through collaborations, partnerships, and community-based responses.

Community Based Responses Community based approaches are far more effective than hospital and expert-based approaches in taking health care to where it is most needed. They are much more likely to improve healthcare access for ethnic minorities, Indigenous communities, and other marginalized groups (Hartmann 2016). A major barrier to health care among ethnic minorities is the stigma and discrimination that can be associated with mental health issues. People with mental health issues, especially in LMICs, are far less likely to seek treatment from mainstream health systems because of the shame they feel and the discrimination that they may come to expect (Fernando 2014). Integration of mental health services with the primary health system is an emerging and practical way of closing the mental health gap, especially in countries with limited resources (Ng et al. 2012). This integrated approach has been implemented across large populations such as over 1.3 million people in the PRIME project in Sehore district in India (Shidhaye et al. 2016). Similar approaches also have possibilities of improving healthcare interventions in HICs like Australia where the mental health needs of Aboriginal and Torres Strait peoples still remains unmet in many areas and stigma continues to impact on healthcare access (Isaacs et al. 2010). Community-based ethno-cultural services can play an essential role in responding effectively and equitably to the health needs of ethnic minorities and Indigenous populations, especially if they are supported by community networks and have strong local support (Marsella 2011). These forms of approaches can work within or in tandem with local faith-based and other community institutions to provide care that is culturally appropriate and is set within a familiar context. Belgrave and Abrams (2016) reiterate that these kinds of programs have already been successfully used to screen, recruit for, and deliver healthcare interventions among African American women. Similarly, one such project in the LMICs is the work conducted by the National Institute of Mental Health and Neurological Sciences (NIMHANS), India, at the Muthuswamy healing temple in Tamil Nadu. The temple has a history of healing, particularly in the area of mental health, and the researchers were interested in the effects of a collaborative approach utilizing the temple’s healing system along with Western biomedical approaches. The patients at temple showed a significant reduction in psychiatric rating scores post the intervention, and the researchers concluded that “[h]ealing temples may constitute a community resource for mentally ill people in cultures where they are recognized and valued. . . [and the] potential for

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effective alliances involving indigenous local resources needs to be considered” (Raguram et al. 2002). Collaboration has to be a central part of community-based approaches, bringing together all the key stakeholders, especially those who are of cultural significance to the community. Collaborative partnerships would enable more equitable and sustainable relationships to be built, transforming from hierarchical to interdependent relationships (Bhugra 2004; Chen 2015). These could include partnerships between healthcare organizations and the communities, also partnerships between healthcare providers and traditional healers and healing systems, and even looking at the relationship between the clinician and the client as a cultural partnership. These could also be supported by recruiting health workers from the community who would act as the bridge between the different worldviews. Community health workers are often the linchpins of community-based approaches, especially the programs in LMICs. As an example, the community health worker program has attended to more than 129 million people in Brazil, which is almost 67% of the population (Ortega and Wenceslau 2020). The integration of community health workers and community mental health workers into the front line of health care is supported by the process of task shifting which involves moving tasks from experts back into the community, while building up the capacities of the workers through training and upskilling. The drivers for community based task shifting in LMICs are often economic as task shifting has been demonstrated to “achieve cost savings and improve efficiency for activities related to top global health priorities, emerging global health issues, and neglected tropical diseases, but the evidence base is mostly limited to PHC and community-based care” (Seidman and Atun 2017). However, these cost and efficiency drivers also present an opportunity to provide health care in an accessible and culturally appropriate way to ethnic minority communities. The community health workers can act as mediators between the cultural groups and the biomedical systems, developing a dialogue between the two worldviews and seeking to find an area of consensus (Ortega and Wenceslau 2020). Effective communication strategies are also central to healthcare activities at the community level. Kreuter et al. (2003) posit that there are five kinds of strategies that could be adopted to communicate across cultural and linguistic barriers. The first are peripheral strategies that seek to give programs or materials the appearance of cultural appropriateness by packaging them in ways that may appeal to that cultural group. Examples may be the use of favored colors, images, or particularly evocative language to convey relevance. Next they discuss evidential strategies that present evidence in the form of epidemiological or similar data to substantiate the impacts on particular cultural groups. Third are linguistic strategies present health education programs and materials in the appropriate language of the target community. However, it must be emphasized that providing material in the language of the cultural group may not be sufficient in itself. Especially in the context of migration, the client population may lack a basic understanding of the healthcare system itself, raising the need of providing healthcare information that adapted to the different needs of the migrant population (Luiking et al.). Fourth are constituent-involving strategies that draw on members of the target group to involve in delivery of programs, providing

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substantive and necessary training to community members and thereby building community participation. And finally, they discuss sociocultural strategies as those that discuss health issues in the context of the broader social and cultural context of the concerned community.

Conclusion As discussed in this chapter, cultural diversity is a significant factor that influences global health inequality and the distribution of health problems and resources. Countries across the world have culturally diverse populations that include Indigenous peoples, migrants, and refugees as well as those divided on caste, religion, language, and historical origin. These cultural differences can, in many circumstances, deprive some groups of access to appropriate health care while privileging others. The evidence clearly shows that Indigenous and other culturally diverse groups have poorer health outcomes across a range of indicators including life expectancy, infant and child mortality, infectious disease loads, coronary disease as well as a number of mental health indicators (Stronks et al. 2013; Valeggia and Snodgrass 2015; Patel et al. 2018). A number of aspects of culture impact on how culturally diverse communities and individuals experience health and illness and on how they access health care. The perception of the causes of disease differ widely across cultures ranging across those ascribed to the natural world, the social world, and the individual, and this perception then impacts on the health-seeking behavior of the individual and the community. Mainstream health system binaries such as body/mind and individual/community may not be intrinsic to many culturally diverse communities, and this can also have an impact on health outcomes (Trotter 2000; Kirmayer and Brass 2016; Gopalkrishnan 2018). Many culturally diverse groups continue to access health later and in more acute stages than the general population in many countries. The reasons for this vary from cultural mistrust to notions of shame, the impacts of stigma, racism, and discrimination as well as these openness to medical plurality to meet their healthcare needs (Conrad and Barker 2010; Gupta 2010; Tung 2010; Nelson and Wilson 2017). Culture also modifies how people experience stress, how they cope with the stressors in their lives, and how resilient they are in terms of dealing with stressors (Aldwin 2004; Hechanova and Waelde 2017). Besides these factors, the relationship between the clinician and the patient is modified by culture in several ways. Language is one of the most important factors here especially because of the specialized nature of the information being shared in this encounter. It is absolutely essential that healthcare professionals use appropriately trained interpreters in these situations to ensure that communication happens in an appropriate and accurately communicated manner (Alpern et al. 2016). Further healthcare professionals also need appropriate training in the use of interpreters and appropriate cultural frameworks (FECCA 2011). Processes of stereotyping and “othering” based on the perception of the patient’s culture are aspects that healthcare professionals need to be wary of to ensure that they do not make ethnocentric

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judgments or behave in ways that marginalize particular cultural groups (Luiking et al. 2019). The notion of perceived cultural health capital is also worthy of consideration as it can change professionals’ attitudes and behaviors toward particular patients (Sointu 2017). These cultural factors point toward the need for intercultural frameworks of practice that would enable marginalized cultural groups to be included equitably in health care and have better health outcomes. One of the most popular approaches is cultural competence which, with its framework of knowledge, awareness, and skills, does provide an easily replicable model to train healthcare workers. However, this framework does suffer from not addressing any issues of power, racism, or historical dispossession, which makes it a flawed framework when working with cultural communities that have been adversely impacted on by these issues (Sakamoto 2007). Alternative frameworks such as cultural humility, cultural safety, and interculturality have emerged with the promise of addressing these concerns. The possibility of merging some of these approaches is one worthy of consideration. The research that guides healthcare offerings also needs to change to be more inclusive. Minority ethnic and Indigenous peoples are often not included in research for reasons such as the additional costs of inclusion, the inability to communicate across languages and cultures, and fear and mistrust (Hussain-Gambles et al. 2004; Rubincam et al. 2016). If equity is to be ensured in healthcare provision, these hurdles will have to be actively managed and the inclusion of culturally diverse communities ensured in the research process. The education and training that healthcare professional undergo also needs to be more inclusive and allow for opportunities to develop the knowledge, awareness, and skills to work across cultures (Diaz and Kumar 2018). Integration of biomedical approaches with Indigenous medicine and other CAM approaches is a promising way to improve the health outcomes of culturally diverse communities. The evidence clearly reflects that the use of approaches other that biomedical is steadily increasing and they are getting better legal standing as well as regulation across the world (WHO 2019). Many Indigenous communities and other culturally diverse groups have histories of availing of medical plurality, where they access one system or the other depending on the perception of the acuteness or etiology of the disease. Adopting a system that formally brings together these approaches provides a whole new platform in terms of providing the best and most cost-effective options for communities (Baars and Hamre 2017). Finally, the notion of community-based health interventions is a tried and tested one in many countries. Community health workers who are from the culturally diverse communities themselves can provide unique opportunities for healthcare interventions that are modified to the needs of the local community. They can mediate between two distinct worldviews and provide healthcare interventions at the point where the community needs it (Ortega and Wenceslau 2020). Collaborative partnerships between healthcare organizations and local institutions will also support the process of providing health care in a culturally appropriate way and at the right location (Belgrave and Abrams 2016). All of these provide opportunities to respond more effectively to the needs of culturally diverse communities and create a more inclusive global healthcare system.

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Digital Transformation and Global Health in Africa Gloria Ejehiohen Iyawa, Suama Hamunyela, Anicia Peters, Samuel Akinsola, Irja Shaanika, Benjamin Akinmoyeje, and Sinte Mutelo

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health and Universal Healthcare: Why It Matters to Africa . . . . . . . . . . . . . . . . . . . . . . . Digital Transformation and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digitalization: Case Study of Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digital Health: Case Study of Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digital Divide in Developing Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digital Health for All Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mobile Phone Ownership and Use in Africa and Namibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Information and Communication Technology (ICT) Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digital Transformation – Pitfalls and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non-Communicable Diseases and Disease Outbreaks: Digital Health Support for Africa . . . . Public Health Reform: Initiatives in Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Digital transformation has made a significant impact on all sectors of the economy, requiring the need for different countries to embrace the adjustments that come with it. This is particularly relevant in the healthcare sector where digital technologies have revolutionized how healthcare services are provided. This chapter explores the digital transformation within the healthcare sector with a focus on the current state G. E. Iyawa · S. Hamunyela · S. Akinsola · I. Shaanika · B. Akinmoyeje · S. Mutelo Faculty of Computing and Informatics, Namibia University of Science and Technology, Windhoek, Namibia e-mail: [email protected]; [email protected]; [email protected]; [email protected] A. Peters (*) University of Namibia, Windhoek, Namibia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_6

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of affairs in Africa. First, an overview of the digital transformation in the context of Africa will be provided, followed by a discussion on digital health in African countries with a special emphasis on Namibia. There has been significant progress made on digital health in some African countries, however, there exists various challenges inhibiting effective implementation in these countries. While digital health presents a viable approach to supporting healthcare in African countries, other proactive measures need to be explored such as the implementation of innovation ecosystems within the healthcare domain to support healthcare practices enforcing digital health. This chapter also explores opportunities for universal healthcare in Africa and provides an analysis on human resources, such as healthcare workers and technology experts, for curbing and controlling disease burden and outbreaks in Africa. Finally, this chapter discusses necessary reforms to support digital transformation within the African context. Keywords

Digital health · e-health · Digital transformation · Universal healthcare · Africa

Introduction Health is wealth and it is critical to the survival of any individual, home, community, and nation. Every nation is therefore seeking sustainable ways of implementing cost-effective strategies that could make healthcare services accessible to all its citizens, particularly those residing in rural communities; who are often neglected due to poor road and transportation infrastructures. The advent of information and communication technology and the internet is enabling the facilitation of healthcare services digitization and provision to people living in the rural and remote locations of developing countries. Experience around the world indicates that the advent of internet resources such as websites, mobile apps, social media networks, Artificial Intelligence (AI), Big Data, and Blockchain have been applied to create platforms for the facilitation of online vehicle registration, tourism, citizen complaints, online voting, subscriptions to government’s newsletters and databases, business investment promotions, electronic tax filing, digital health, and the like. Moreover, the application of digital resources has been overwhelmingly described as a more convenient and cost-effective platform for gaining access to services. Health officials in nations where digitization has been effectively implemented find them more flexible when distributing information to different categories of audiences (personalization) both within and outside the country. Whereas the usual reliance on interfacing with health officials through personal visits, mail delivery, and phone calls do not only exclude those that have no adequate resources to meet the demand of time and capacity required, it does also put enormous pressure on health officials in attending to details of requests and answering calls without fail. The healthcare domain is a multi-stakeholder consisting of various interest groups including healthcare practitioners; research and academics; technologists; suppliers; policy makers and government; pharmaceuticals; hospitals, and users or patients’

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community (Fichman et al. 2011). They can be described as a group of people who are informally related with commonly shared interest and expertise for healthcare activities. It is important to know that while the focus of individual members of this community may be at variance with each other, their collective goal is to provide sustainable healthcare service delivery of which the principal beneficiary would be the patient. Knowledge support is an integral component of any service-oriented organization. This is because provision of efficient and effective services depends on adequate knowledge of prospective service-consumers’ requirements and needs. On the other hand, the consumers of services also do often require knowledge support for services adoption, adaptation, and utilization. For instance, a patient may desire to know the healthcare facility closest to his or her neighborhood. However, in a multi-stakeholder services provision, knowledge support provisions may be fragmented, heterogeneous, and without adequate coordination. Making informed decisions in the midst of fragmented and heterogeneous sources of knowledge is a challenge, particularly for those with limited understanding within a given context. Application of knowledge within any domain often than not requires previous experience of a “native” of the context to be successful. In other words, knowledge support could be considered as any activity or use of tools that can enable an individual to make informed decisions at the point of need. Maps and other navigation tools are examples of knowledge support devices for drivers, medical practitioners’ advice and encouragement to patients are examples of related activities of knowledge support. A student with excellent high school grades may require knowledge support during the process of making decisions on what career path to pursue. The need to disseminate healthcare provision, services, and related challenges of knowledge and innovation among patients’ communities to extend it beyond the sources of generation is never in doubt, particularly, when such knowledge and innovation is aimed at providing the needed awareness that would enhance societal understanding of the situational severity and the applicable measure and control. Sources of generation as indicated here refer to individuals or institutions that originate knowledge or innovation (including academic institutions, research institutes, laboratories, and so on); these sources as it is related to this study are the multistakeholders’ community of healthcare service providers. Widespread healthcare problems, especially serious outbreaks of diseases, precautionary knowledge, and adverse economic conditions that may have effect on healthcare services production and delivery require that patients be given the needed support to overcome such difficulties or to adapt to the evolving reality.

Global Health and Universal Healthcare: Why It Matters to Africa Global Health strives to provide quality healthcare worldwide rather than focusing on one region or country. There are several definitions of Global Health and at times these definitions can become contentious. The most frequently cited definition is from Koplan et al. (2009):

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Box 1 Definition Global Health

“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 emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of populationbased prevention with individual-level clinical care.”

However, the shortened form of this definition is captured by Patel (2014) who described global health as a practice of research that primarily aims to improve health by achieving equity in health for all people worldwide. Global health is not a standalone field but is a collection of initiatives that take into account both medical and non-medical disciplines, such as epidemiology, sociology, economic disparities, public policy, environmental factors, and cultural studies (Healthcare trends 2020). In addition, Jacobsen (2014) clarified that global health should not be viewed as a health program in developing countries but rather as health challenges encountered by the human population as a whole. Thus, global health emphasis is on researchers and governments of countries working together toward developing best health practices, curing and prevention of disease outbreaks. Jacobsen (2014) supports that, due to the complexities of infectious disease, mental health and other health-related issues, there is a need for countries to work beyond regional and national borders. WHO (2020) defines Universal Health Coverage (UHC) as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.” Essentially UHC means that all people should have access to affordable healthcare services anywhere and at any time. UHC also presupposes a strong people-centered health services provision with primary healthcare as foundation. WHO (2020) further places emphasis on three interrelated objectives: • Equity in access to health services – those who need the services should get them, not only those who can pay for them • 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 striving toward UHC for all by 2030 is aligned to the United Nations’ Sustainable Development Goal (SDG) target 3.8. Although many African countries have integrated UHC into their national health strategies, common challenges remain across African countries (World Bank 2020).

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Global Health and Universal Health Coverage are complementary to each other. One optimistic point for the achievement of UHC and Global Health is the opportunities created by the rapid advances in Information and Communication Technologies (ICTs) and the proliferation of mobile networks across the continent.

Digital Transformation and Global Health The rise of new technologies and platforms such as mobile technologies, AI, Big Data, Internet of Things, Blockchain, Cloud computing, and social media networks have significantly changed how business operations are conducted in many parts of the world (African Development Bank 2019). This suggests a drastic change to the traditional methods of manually capturing and accessing information, diagnosing and detecting diseases as well as decision-making processes.

Digitalization: Case Study of Africa The early digital transformations experienced on the continent could also be traced back to some sectors of the economy such as banking and telecommunication that experienced changes in government regulations to motivate digital innovations (Ndung’u 2019). These sectors stimulated an increase in financial services inclusion for unconventional demographics and introduced enhanced access and use of digital technologies across the continent according to financial services, skills learning opportunities, and access to job opportunities (GSMA Youth Employment Report 2020). These developments inspired the proliferation of technology and innovation hubs in different sectors of the African continent as private entrepreneurs or social entrepreneurs (Jimenez and Zheng 2017). Some of these rapid digital developments can also be attributed to different corresponding factors, some of which are the roles international development agencies and donors played in spurring digital innovation adoption and many pilot implementations (Zheng 2015). All of these efforts culminated in some disruption to other sectors of the economy such as agriculture, education, aviation, and health, PwC Report (2016) stated. In agriculture, for example, manual processes have been automated to improve production output. Studies point to the impact digital transformation could significantly have on economic growth and employment opportunities in different parts of the world including Africa (Ndemo and Weiss 2017). Ndemo and Weiss (2017) reported a massive boost to the mobile market in Africa with an increase in GDP by 7.7%, which can be attributed to the increase in the use of smartphones in Africa. The invention of mobile money platforms such as mPesa in Kenya led to the rise of other similar inventions across Africa leading to improved living conditions of micro entrepreneurs (Asamoah et al. 2020), reduced transaction costs, and increased efficient financial transfers (Alhassan and Koaudio 2019). The Fourth Industrial Revolution, also described as Industry 4.0, focuses on the fusion of cyber physical systems and the use of big data, AI, machine learning and

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deep learning, Internet of Things, Blockchain, nanotechnologies, and increased cybersecurity needs (Schwab 2016). In short, digitalization is capable of revolutionizing various industries. Mrugalska and Wyrwicka (2017) refer to the role of Fourth Industrial Revolution in industries as: Box 2 Definition “Industry 4.0”

“The modern and more sophisticated machines and tools with advanced software and networked sensors can be used to plan, predict, adjust and control the societal outcome and business models to create another phase of value chain organization and it can be managed throughout the whole cycle of a product. Thus, Industry 4.0 is an advantage to stay competitive in any industry. To create a more dynamic flow of production, optimization of the value chain has to be autonomously controlled.”

This definition explains the value that comes with the Fourth Industrial Evolution as well as a mechanism for managing the revolution. It is in particular a disruptor for the healthcare industry where AI and Blockchain are important advances. As such, this will have an impact on how organizations function as well as employment opportunities (African Development Bank 2019). While this change is inevitable, African countries have been urged to take active measures to meet the demands and disruptive changes that will arise as a result of the Fourth Industrial Revolution (African Development Bank 2019). Despite the apparent rise in digital technologies within the African context, Africa still lags in terms of diffusion of digital technologies (Manda and Backhouse 2017). Ndemo and Weiss (2017) are of the opinion that skills development and training presents one approach in improving Africa’s adoption of digital technologies and the transformation that comes from such inventions. Governments in Africa are taking measures to develop skills that will meet up current demands that come with digital transformation (Manda and Backhouse 2017). Thus, it is necessary for higher institutions of education to focus on incorporating digital skills into curricula. The WHO (2016) stated that the prevalent existence of siloed systems in developing countries continues to hinder progress in achieving healthcare information exchange. Digitalization of healthcare services holds huge promises to transform healthcare services delivery to developing nations. Benefits associated with digitalization of healthcare services includes the potential to address the need for nurses and doctors and the challenges related to healthcare services in low-resource areas of developing countries and accessing healthcare data in real-time (Herselman et al. 2016). Digitization of healthcare services has the prospect to enable exchange of clinical and administrative healthcare information including medical records and images. In an effort to harness the benefits of digitalization of healthcare services, in Southern Africa alone, efforts from healthcare stakeholders have been directed to simplifying the process as well as designing of tech innovations. Herselman et al.

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(2016) on the ecosystem for digital healthcare innovation argued that technological innovation should be designed with the user’s involvement. Similarly, Iyawa, Herselman, and Botha (2019) urged the Namibia healthcare custodians to consider an inclusive ecosystem in the design, implementation, and evaluation of digital healthcare innovations. As the digitalization of healthcare processes continue to evolve, there is an increased need for interoperability, standardization, e-health policy, and evaluation of healthcare solutions (Hamunyela and Iyamu 2013). The latter are necessitated by the various sources of healthcare data and technology spheres that have emerged, e.g., social media, mobile technologies, grid computing, and AI and the frontier technologies. According to a recent report by the International Telecommunications Union (ITU) (ITU 2019), 4.1 billion people are said to be currently connected to the internet, which suggests a 53% growth since 2005. As shown in Fig. 1, Africa is the continent with the lowest level of internet connectivity compared to the rest of the world. Handley (2019) reports that, by 2025, the majority of the world’s population will access the internet through mobile devices. This is supported by the recent ITU report (ITU 2019), which suggests that computers are not necessary to establish internet connectivity in different parts of the world including Africa. As shown in Fig. 2, there is more access to the internet compared to computers.

Fig. 1 Global internet connectivity (ITU 2019)

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Fig. 2 Internet connectivity and computer access (ITU 2019)

The purchasing cost of mobile broadband in developing countries is a major setback affecting internet connectivity. As shown in Fig. 3, mobile broadband is cheaper in other parts of the world compared to Africa. In most cases, internet connectivity drives digital transactions. For example, most banking apps require internet connectivity to be able to send money to other parties. This could be challenging for people living in African countries, as internet connectivity is expensive. For digitalization to fully take place in Africa, there is a need for cost reduction in terms of providing internet connectivity.

Digital Health: Case Study of Africa Box 3 Definition Digital Health (Mesko´ et al. 2017, p. 1)

“The cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care.”

This definition emphasizes the use of digital technologies in healthcare to promote patient involvement in the healthcare delivery process. Digital technologies in this

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Fig. 3 Cost of broadband across the world (ITU 2019)

context refer to mobile technologies, wearable technologies, telemedicine, social media platforms, electronic health records, electronic medical records, health analytics, cloud computing, and AI (Iyawa et al. 2016; Shin 2019). Digital Health technologies are particularly relevant in African countries where access to medical services is low. For example, wearable technologies can be worn by patients in rural communities, to monitor glucose levels, and the results can be sent directly to the doctor’s mobile phone in a remote location. A recent review, however, suggests that the majority of Digital Health initiatives within African countries remain a test bed (Adeola and Evans 2018). Adeola and Evans (2018) further explain that despite the slow progression of Digital Health implementation and inclusion into the African health space, there is a great potential in improving health outcomes with the use of Digital Health technologies. One of the African countries making progress in the Digital Health space is South Africa. With major success stories emanating from the MomConnect program, women in South Africa are able to sign up with the Department of Health to receive information about pregnancy and childcare (Pillay and Motsoaledi 2018). Successful implementation of the MomConnect program can be attributed to several factors: government involvement in the implementation process, the inclusion of relevant stakeholders across various sectors, the use of technologies relevant to a wider population, addressing the language barrier, and continuous monitoring and evaluation (Peter et al. 2018). A key lesson for African countries is that there is a greater

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chance for successful Digital Health projects when government efforts are combined with that of relevant multiple stakeholders across different sectors, which is necessary for integration into the healthcare delivery system. A systematic review suggests that one of the key factors for successful Digital Health projects is being able to adapt the technology to the needs of the local context (Aranda-Jan et al. 2014). Another key lesson to be gleaned from the MomConnect program is the adaptation to local context in terms of technology and platform (mHealth) and the use of local languages; as such, MomConnect met the needs of a wide range of population. Various text messaging interventions have been evaluated in South Africa. Text messaging intervention was also evaluated for use in adherence to diabetes care in rural areas and to support women who had undergone medical abortion (Owolabi and Ter Goon 2019; Constant et al. 2014). While text messaging interventions have proven to be successful and effective in improving health outcomes, some challenges were also identified. These challenges include the lack of security of messages sent through the internet on the SMS system, slow speed, and cost (Brown III et al. 2018). Although these challenges were addressed in the study, this suggests that even low-cost solutions could come with challenges. As such, when implementing simple digital solutions for healthcare purposes in African countries, issues of security, speed, and cost should not be overlooked as these could hamper the effective use of digital solutions. Mobile apps have also been effective in improving the knowledge of patients regarding their health. Various mobile apps have also been evaluated within the South African context. This includes miPlan, a mobile app used by women while waiting to receive counseling on contraceptive use (Hebert et al. 2018). The outcome of the intervention showed that it improved the knowledge of patients regarding contraceptive use. There are enormous benefits that come with counseling through the use of mobile apps within the South African context; relevant stakeholders believe this could be beneficial because this could lead to improved communication between healthcare providers and efficient allocation of resources (van Heerden et al. 2017). Telemedicine has been used in healthcare settings in South Africa. Definitions of telemedicine have been provided at varied times. Box 4 Definition “Telemedicine” (WHO 1997)

“The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”

The WHO definition provides a comprehensive detail about what telemedicine should be about, its purpose, technology involved, and the participants (“all

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healthcare professionals”). While this description is concise, it provides more emphasis on distance. This is particularly relevant to African contexts where access to medical services in rural communities is low. Telemedicine, thus, provides a viable approach in which people in rural areas can access healthcare services despite the lack of healthcare facilities in rural communities. Telemedicine has been used in South Africa since the 2000s. This is exemplified in a study conducted by Johnston et al. (2004) in the form of teleophthalmology to improve eye treatment of patients in South Africa through services provided by UK experts. The key point of this study is cost reduction. This contributes to the evidence that telemedicine can greatly reduce healthcare costs and at the same time provide quality care to patients. However, this further raises the discussion on internet connectivity and the cost of providing internet connectivity in rural communities. The benefits of telemedicine are enormous, ranging from a reduction in providing healthcare services (Johnston et al. 2004) to accessing healthcare services that are not available in local areas. Telemedicine requires some amount of internet connectivity to work, which comes with its own cost. While presenting telemedical solutions to address the needs of people living in medically underserved communities, it is important to highlight the availability and reliability of telecommunications systems and internet connectivity. Kenya is another classic example of African countries continuously striving to include digital tools in the provision of healthcare services and to support healthcare delivery services. The use of mobile technologies in Kenya is not new; with wellknown innovations such as mPesa, mHealth has proven to be a simple yet useful resource in the delivery of healthcare services within the Kenyan context. Text messaging interventions, text message reminders, and mobile phone apps. Text messaging, in combination with incentives, has also been used to improve adherence to immunization in Kenya (Gibson et al. 2017). However, when developing text messaging interventions for sensitive cases like HIV, it is important to investigate the preference of patients (Ronen et al. 2018). Mobile apps have also been developed and evaluated to provide eye testing in schools (Rono et al. 2018). These low-cost strategies provide evidence supporting the use of Digital Health technologies for healthcare in different settings within developing countries. Interestingly, a pilot study on the use of Digital Health technologies, such as telemedicine, did not only improve access to healthcare services, but had an economic impact on local citizens through income generation (Holmes et al. 2014). This points to other areas where digital health technologies are used and explains that digital health technologies can be beneficial not only to the healthcare system, patients, healthcare workers, and healthcare providers, but to the society at large where the socioeconomic status of citizens can be improved. While this is relevant, it is important to conduct more studies on the economic and social impact of digital health technologies. This will be particularly beneficial to African countries where there is a need to improve the socioeconomic status of citizens, especially those living in rural communities. Similar to Kenya, Uganda is another east African country that has made significant progress in the application of digital technologies in healthcare. Text messaging interventions and computer-assisted personal interviewing are examples of common mHealth initiatives that have been reported in Uganda.

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Text messaging interventions have been performed to evaluate the impact on the treatment of diseases such as tuberculosis and malaria mostly in rural communities (Babirye et al. 2019; Cohen and Saran 2018). These studies revealed that the use of low-cost interventions such as text messaging could also prove effective in lowresource settings. While tuberculosis is common in Africa and adherence to treatment is usually poor, constantly reminding patients to adhere to medications has also proven effective in Ugandan contexts (Musiimenta et al. 2019). Manually capturing health-related information could be cumbersome, especially when dealing with a large number of people. Supporting healthcare workers with data capturing in a more efficient manner is paramount to improving not only the data collection process but improving the quality as this will reduce human errors as well as illegible writing. In Uganda, a study investigated whether the use of a computer-assisted personal interviewing could be useful for survey data collection related to healthcare in rural Uganda (Mercader et al. 2017). This shows that Uganda is taking active measures to incorporate digital technologies in various healthcare programs. The use of a toll-free telephone service also proved to be important in improving communication with the healthcare provider (Mwase et al. 2020). This shows that even mundane tasks in the health sector can be digitalized to improve services. Furthermore, research emanating from the Ugandan context shows that even the low-cost technologies are being considered in the phase of digitizing health systems within the country. Nigeria is a West African country with approximately 72,000 doctors; more than 50% work outside Nigeria leading to the country’s brain drain in terms of medical expertise and as a result, there is a shortage of medical expertise in the country (Abang 2019). Recent reports show that the doctor– patient ratio in Nigeria is 4:10,000, which is far below the standard set by the WHO (Adegoke 2019). There has been no better time when Digital Health technologies can be presented to support healthcare in Nigeria. There has been significant progress in the introduction of Digital Health technologies in the healthcare sector; however, like many African countries, full-scale implementation is still challenging. Examples of Digital Health development and evaluation in Nigeria include text messaging and mobile applications. Kenny et al. (2017) conducted a study on healthcare workers’ attitude to the use of mHealth in Nigeria. The findings suggest that, while healthcare workers are open to the use of mHealth, more efforts have to be placed on educating people on the importance of mHealth in Nigeria. This suggests that awareness of the benefits of mHealth is paramount to the effective adoption of mHealth in developing countries like Nigeria. This is particularly true when the majority of the population receiving these services is uneducated and located in rural areas. Developing technologies that healthcare workers and patients do not understand could hamper its effective use, hence, the benefits of these apps may not be utilized to the full potential. Appointment reminders through the use of text messaging seem to be one of a low cost approach toward reaching people in healthcare settings. This could be as a

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result of the simplicity of text messaging and the availability of text messages with the use of basic phones. This means that text messaging is available to populations with a basic phone that can be adopted by a large number of people. However, Iyawa and Hamunyela (2019) suggest that text messaging intervention may be a simple approach; however, language barriers could greatly hamper the effective use in healthcare. Iyawa and Hamunyela (2019) suggested voice-based systems incorporating local languages to support people in rural communities. Based on a study conducted by Adanikin et al. (2014), a text messaging approach was adopted as part of an intervention to improve appointment attendance of postpartum women. The findings showed that there was lesser number of people who missed the appointment compared to people who were not sent text messaging reminders. Text messaging has proven to be effective in ensuring patients’ adherence to treatment for mental health disorder (Adewuya et al. 2019). Using mobile phone communication for supporting patients with mental health disorders is relevant and nonadherence to treatment is a common problem, not just in mental health or in the Nigerian context, but across various areas in medicine and in different parts of the world (Kane et al. 2013). A mobile phone application that was developed as part of the m4Change project in Nigeria was evaluated in a clinical setting to support health workers providing care to patients (McNabb et al. 2015). The findings suggest that there was a boost in the quality of treatment provided as a result of using the app. Incorporating smartcard technology into mobile apps has proven to be a great potential in addressing the challenges of internet connectivity hampering the effective deployment of mHealth and rural communities, where access to internet connectivity is low (Gbadamosi et al. 2018). Gbadamosi et al. (2018) designed a mobile application that incorporates smartcard technology to securely store data, which can be used in healthcare settings without internet connectivity. Ghana, a West African country, has evaluated Digital Health technologies in different scenarios. For example, mHealth and telemedicine have been used within healthcare settings in Ghana (Amoakoh et al. 2019). A study on the use of mobile technologies (text messaging, voice messaging and calling patients, and interactive voice response system) by Laar et al. (2019) was conducted in Ghana. The study found that the use of mobile technologies as follow-up tools motivated patients and they found it as an acceptable method for carrying out follow-ups in healthcare settings. The use of Interactive Voice Response system (IVR) was also evaluated in Ghana, and the prospects of using IVR in healthcare settings are positive (Vogel et al. 2016). The study also found unstable electricity and inadequate network communication as barriers to implementing mHealth in healthcare. Similar to South Africa, telemedicine has also been evaluated in Ghana. Telemedicine has been evaluated in the provision of care to patients with stroke which had a positive impact (Sarfo et al. 2018). Post-evaluation of an mHealth intervention showed improvement in monitoring the blood pressure of stroke survivors (Nichols et al. 2019). However, after the intervention was concluded, there was a decline in blood pressure monitoring, which indicates a need to incorporate such mHealth applications into clinical care settings.

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Overview: Key Strategies for Scaling Up Digital Health Involving Mobile Technologies in Africa (Kenny et al. 2017, p. 814)

1. 2. 3. 4.

Highlighting the relevance of the solution Outlining the benefits of the solution Describing strategies to mitigate threats and barriers Communicating the aims and functionality of the solution

It is, indeed, important for the users of technology to understand its benefits and relevance. This is not only necessary in solving problems but also important for adoption. People are able to adopt technology when they fully understand its impact on their lives. Technology comes with its own benefits and challenges; however, it is important to identify the challenges early on and find ways to mitigate these challenges to aid adoption. When users do not fully understand why a technology was developed and the purpose for such technology, adoption becomes difficult. It is therefore important for users to be involved in design phases when developing Digital Health solutions. The WHO (2020) recognizes that Digital Health is an essential component in a country’s strategy but could also be an elusive goal to achieve in developing countries. WHO (2020) thus recommends emulating the successes recorded on a global landscape and incorporating them into local contexts, emphasizing collaboration with developed countries in terms of diffusing the relevant skills needed to implement digital health projects. This concept has already been conceptualized in the current literature, with recent studies exploring concepts such as digital health ecosystems, digital health innovation ecosystems, and digital health innovation (Iyawa et al. 2019). Digital Health ecosystems supports multi-stakeholder environments in which medical practitioners, patients, academics, researchers, healthcare institutions as well as government and nongovernment organizations can take part in provision and delivery of healthcare services (Iyawa et al. 2016). This concept is further explored by Herselman et al. (2016) who suggest the inclusion of innovation in such an environment where the healthcare ecosystem is facilitated by digital innovations that in turn lead to innovative solutions. Digital Health Innovation Ecosystem is a broader concept compared to the concept of digital health ecosystem in the sense that the former incorporates the concept of innovation in practice. Box 5 Definition “Digital Health Innovation Ecosystem” (Iyawa et al. 2016, p. 249)

“A network of digital health communities consisting of interconnected, interrelated and interdependent digital health species, including healthcare stakeholders, healthcare institutions and digital healthcare devices situated in a digital health environment, who adopt the best-demonstrated practices that (continued)

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Box 5 (continued)

have been proven to be successful, and implementation of those practices through the use of information and communication technologies to monitor and improve the wellbeing and health of patients, to empower patients in the management of their health and that of their families.”

A Digital Health Innovation Ecosystem not only provides an interconnection of key stakeholders and technologies in the healthcare space, but also supports best practices in the medical field. To establish a Digital Health Innovation Ecosystem within African contexts, three elements are necessary: digital health, innovation, and digital ecosystems as emphasized in the definition provided by Iyawa et al. (2016). This suggests that acquiring, developing, and implementing technologies are not the only means to which transformation of healthcare systems will be successful in Africa. Other proactive measures need to be taken. These measures include forming a close network of people involved, also referred to as the ecosystem. People involved, in this context, relate to the stakeholders including patients. To remain connected in the modern day world, technologies have a role to play. This suggests the need for digital ecosystems where the stakeholders remain connected through a digital ecosystem platform. Based on the definition of Iyawa et al. (2019), a Digital Health Innovation Ecosystem could proliferate the interaction of patients and healthcare providers where patients become actively involved in the management of their own health. One of the most active measures that can be taken in healthcare settings is getting patients involved in managing their health. Patients are able to participate in the innovation process since they are in a position to explain what works and what does not work. They could, in this process, provide insights into innovative approaches for managing their health. Treatment and care for patients can be more personalized when patients are directly involved in their own health. Patients in this context not only refer to the patients who are sick, but also refers to the families of the patients who are receiving treatment. In cases where patients are incapacitated or are unable to care for themselves, they often rely on families and private personal care givers for support. In these cases, caregivers need to actively take part in the process, in place of the patient. A Digital Health Innovation Ecosystem could also leverage its network to supplement skills (e.g., medical) lacking in a particular setting in order to address global health challenges. For example, particular skills could be lacking in various cities in Africa and at the same time be present in other cities in and outside of Africa. In these cases, a Digital Health Innovation Ecosystem could help identify the location of these experts who are connected to the ecosystem. To implement and adopt a Digital Health Innovation Ecosystem to support healthcare systems in Africa, efforts need to be made at national government levels within countries. Although a guide for implementing a Digital Health Innovation Ecosystem has been provided in the literature (Herselman et al. 2016; Iyawa et al. 2017), it will entail governments taking active measures to plan and define how a Digital Health

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Innovation Ecosystem should be run. Contextualizaton is key when implementing Digital Health Innovation Ecosystems as best practices, and techniques should be relevant within the context it is being implemented.

Digital Divide in Developing Nations The digital divide is prevalent in Namibia. It can be described as the gap between people who have access to the internet and those who do not. Globally, the digital divide between the sub-Saharan African region and the rest of the world is much more pronounced than the divide within the region (ITU 2019). The problem is even extensive in Namibia, given the fact that the majority of the population reside in rural areas. Moreover, the large number of actors in a fully functioning health information system is an indication that high-level leadership and coordination are critical to avoid overlap and duplication of efforts as well as to ensure efficient collection and use of data (WHO 2011). This serves as a motivation for performing evaluations for the existing systems. Assessment can help to determine impacts and benefits in terms of attaining the country’s goals in the Fifth National Development Plan (NDP5) and Vision 2030 documents respectively. Case Study: The Namibian Healthcare System

The Namibia healthcare system has a distinct background resulting from the country’s political background and religious context. During the colonial era of the Germans and the Boers in the then South West Africa (now Namibia), several private and public healthcare centers were constructed. The German and Finnish missionaries constructed these facilities to serve the local communities. In total, there are several healthcare facilities in Namibia; the figures include: the hospitals, health centers, clinics, stand-alone VCT centers, and sick bays (MoHSS and Marco 2011). The facilities are under various management authorities such as government, private-for-profit, missionary, NGOs, Ministry of Defense (NDF), and the Police. A common feature in all these facilities is that they aim to deliver reputable healthcare services to the communities (MoHSS and Marco 2011). This implies that the health system in Namibia is reputable and functioning. Furthermore, the country’s healthcare system is managed by the Ministry of Health and Social Services (MoHSS) as per the Namibia Constitution Article 95. Thus, the state is required to maintain the welfare of the people by putting in place a legislation that seeks to provide affordable and effective healthcare to the people (MoHSS 2014). Hamunyela and Iyamu (2013) proposed a readiness assessment for the HIS in Namibia. The models comment the readiness assessment at different levels of operation of the country’s health sector; these are at the community, district, regional, and national levels. The Namibian government, for example, in its (continued)

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2015/2016 medium-term expenditure framework indicated that N$7 billion had been set aside for the healthcare programs and developments. It is evident in the medium-term expenditure for 2016/2017 that the government is capable of financing the implementation of HIS. The allocated budget for the MoHSS rose to 7.2 billion. Much remains unknown in the healthcare environment as technology increases and as stakeholders’ demands from the sector grows. Despite numerous efforts toward transforming the healthcare sectors, service delivery remains a challenge especially in the presence of silo systems. This is a setback for the services that the MoHSS provides to the communities in the country such as: distribution of the HIV treatment; immunization against contagious disease outbreaks; and daily medical consultations between physicians and patients. Worse still, the manual approach significantly delays centralization of processes and activities (Hamunyela and Jere 2018). This indeed is dangerous to patient needs, particularly those who are in need of intensive care, patients with chronic diseases, and nomadic patients. Namibia is one of the numerous examples of developing countries, which faces challenges when deploying Health Information Systems (HISs). In other words, Namibia could be seen to represent a common African context, mainly because of its limited exploit of HIS, and the efforts invested in HIS-related activities. Most African countries have achieved very little in terms of HIS activities regardless of the resources allocated to the health sector. The continuing challenges in the development, implementation, and use of HISs in Namibia can benefit from academic discourses such as research publications. Namibia consolidated it healthcare systems and developed a National EHealth Strategy in the second half of 2019.

Digital Health for All Users Mobile Phone Ownership and Use in Africa and Namibia A recent study of mobile phone ownership in sub-Saharan countries suggest a high mobile phone ownership in the region with South Africa, Ghana, Senegal, Nigeria, and Kenya taking the lead (Elliot 2019). On the other hand, Namibia records 113% mobile phone penetration rate in terms of mobile subscription (Statista 2020). In terms of healthcare, Iyawa and Coleman (2015) found that the majority of patients accessing healthcare services in rural communities in Namibia have access to mobile phones. This suggests the potential of mobile phones in reaching a wide range of population in the Namibia healthcare system. Mobile phones could thus be used as a strong tool to disseminate health messages and enable patients to access healthcare services in distant locations. While there is a dearth of published research on the application of mHealth in the Namibia healthcare sector, Iyawa and

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Hamunyela (2019, p. 8) conducted a systematic review on mHealth apps and services for maternal health in developing countries and suggested mHealth solutions to address maternal health challenges in Namibia. Some of the solutions include: 1. Tailored short message service 2. mHealth solutions for maternal health incorporating different Namibian languages 3. Information about maternal health and childbirth, prevention of mother to child HIV transmission through the use of mobile phones 4. Appointment reminder 5. Exclusive breastfeeding programs 6. Mobile apps as a supplement to short message services especially for nurses and midwives 7. Diagnosis of health problems during and after pregnancy through the use AIdriven mobile apps 8. Mobile apps supporting health management during and after pregnancy

Health Workers Health workers are a critical resource for quality healthcare provision in any country. In Namibia, health workers range from medical doctors, nurses, paramedics, pharmacists, psychologists, and physiotherapists, just to mention a few. In the context of this study, healthcare workers can be defined as professionals who perform tasks related to providing care to patients. Based on various health workers’ knowledge and skills, sickness and illness are being treated at various public and private hospitals. According to recent reports, the doctor–patient ratio in Namibia is 1:5.000, which is less than the WHO recommended ratio of 1:1.000 (Southern Times 2019). This indicates the shortage of medical practitioners in the Namibian context. The last conducted Workload Indicators of Staffing Needs (WISN), a human resource for health tool developed by WHO to evaluate human resource for health needs in 2013, found shortages of health workforce among doctors and pharmacists; while there were sufficient number of nurses, it revealed uneven distribution of workload across hospitals, region, and needs (McQuide et al. 2013). In Namibia, health workers are faced with various challenges that are hindering them from providing effective and efficient service delivery. Kamati, Cassim, and Karodia (2014) asserted that challenges facing health workers include: lack of skills, insufficient health professionals, low morale, and demotivated staff. According to Aluttis, Bishaw, and Frank (2014), African countries are faced with shortages in health workers and due this patients either stay long in queues or are sent back home without being examined by medical specialists. Kamati, Cassim, and Karodia (2014) reported that the pool of skilled health workers in Namibia is unevenly distributed as many are working in the private sector compared to the public healthcare sector.

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Thus, in Namibia, due to shortages of health workers in public sectors some of the patients seek assistance from private sectors and in some cases patients are sent outside the country for treatment. Aluttis, Bishaw, and Frank (2014) reported that in Africa shortages of the health workforce could also be attributed to emigration of qualified personnel to developed countries. The African healthcare system is severely affected by the migration of their health professionals to developed countries (Abang 2019). According to Kamati, Cassim, and Karodia (2014), health workers migrate to other countries due to factors such as poor payment incentives.

Information and Communication Technology (ICT) Workers It must also be noted that the healthcare setting is complicated and Information and Communication Technology (ICT) workers regularly experience interdepartmental conflict with the traditional hospital records units (Zali et al. 2018). However, building health records officers’ capacity in ICT seemed to address these challenges in most cases. Proper governance structure in hospitals can help address these situations as well as digital health compliant job description for healthcare cadres, accountability mechanisms, and better communication strategy in healthcare settings. It would be difficult, if not impossible, for the healthcare sector to function without ICT workers. ICT workers play a critical role in healthcare services delivery as they enable and support effective and efficient operations of ICT infrastructures. To ensure quality service delivery, collaboration between ICT and healthcare workers is vital. Through collaborations, ICT workers and healthcare workers share insights and information required to develop and implement innovations and solutions that leads to improved healthcare. ICT workers in healthcare consist of digital health specialists, health informatics managers, and the full range ICT specialists tasked with development, support, and security. However, being an emerging field within the African context, there is a need to build capacity in this area. Institutions of higher education in African countries should take active measures in developing expertise in this area to support healthcare workers. Trained ICT experts in this domain are needed to support the current African healthcare workforce. Developing ICT skills to support healthcare workers will facilitate the development of relevant technologies with the healthcare domain applying current technology trends.

Emerging Technologies It is widely believed that developing countries could leapfrog in terms of technology (Sovtech 2019; FAO 2019). Specifically in Africa, many countries such as Rwanda, Kenya, Namibia, and South Africa have worked tirelessly on closing the digital divide gap and have advanced in terms of mobile technologies. As a result, these

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nations are leading and have the potential of leapfrogging in terms of frontier technologies. Despite technological advancement in some parts of the Africa region, most nations are facing challenges that are foundational to the advancement of technology such as a low standard of education and economic matters to enable all citizens to reap the benefits of frontier technologies (Sovtech 2019). For the developing nations to leapfrog, it is imperative that the foundational steps are catered for and necessary precursors are done in order to ensure successful deployment of these technologies. Part of the foundational steps includes investment in Research and Development, adoption of an entrepreneurial innovation ecosystem, having the right regulatory environment for business, having technology infrastructures at underresourced areas, and improving technology skills (FAO 2019; World Bank 2017). Risks to a leapfrogging nation while missing foundational steps might be greater than anticipated. There is a need for an ecosystem that addresses the need for policy directed to the deployment of frontier technologies. There is also a need to raise awareness among frontier technologies and educate users on possible ethical and social issues associated with frontier technologies. Furthermore, risk toward a leapfrogging nation while lacking adequate foundational steps may affect sustainability of frontier technology innovations as well as cause lack of enough evidence to assess the impacts of the developmental potentials of the technology. The pathways to achieving human development through the impacts of frontier technologies in developing countries can be measured by the rate of technology adoption at different societal structures of the country (Blimpo et al. 2017). Another variable widely emphasized to aid in determining the impact of frontier technologies is literacy (Blimpo et al. 2017). Literacy is key to maximizing technology impacts. Most developing countries are struggling to achieve quality education, with depreciating quality of educators in higher education institutions, and primary and secondary schools. Finally, and most importantly, technology innovations emerging from developing countries are directed to unique societal challenges. For example, in the healthcare industry alone, we have witnessed major transformations from traditional healthcare systems of paper records to smart-connected healthcare systems, healthcare devices, and mobile applications. The evolution of the healthcare industry through technology is phenomenal but scantly discussed with a focus on unique community needs in developing countries. This means that less is discussed regarding the highs and lows involved in the process of designing and developing the industry changers. Frontier technology solutions should aim to solve critical organizational and societal challenges pertaining to user demands (Khalifa 2013). Therefore, the need to consider frontier technology adoption rates, usability, and the rate at which technological innovations are emerging from the developing countries has become imperative to developmental agencies such as the UN and WHO. This paper posits that the most critical step toward sustainability and accelerating leapfrogging of frontier technology innovation in developing countries is user engagement through training and community information sharing initiatives. An inclusive ecosystem is required to ensure frontier technologies address the challenges of developing nations.

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Digital Transformation – Pitfalls and Challenges • Expertise: As public health in Africa embraces digital transformation, it also created a demand for new skills sets and capacity to manage the new platforms and technologies from digital policy advocates, to digital transformation strategy implementers; skills initially required for these functions were from donors or western countries-based consultancies. Open Source software communities, communities of practice, and peer learning have been instrumental to capacity development in Africa digital transformation. It will continue to play a crucial role. The current curriculum for the health ICT workforce is limited and there is an urgent need for updates with current realities. It requires development of novel skilled roles for the health sector. • Donors: Many of the digital health interventions on the continent have been donor-driven and with these offers come sociopolitical agenda of the donors (Khan et al. 2018). Apart from this, there is also a limited number of donors but there is an increasing number grant seeking organizations, and needs across the continent. The increasing demand for support from the different sectors gradually shrinks the available resource for digital interventions. There are few donors dedicated to digital interventions, and a small number focus on digital health compared to other health needs areas. In most cases, digital health is used to address challenges of other health areas. Donors often require the government to collaborate and take ownership of digital interventions, beyond the project period stipulated in donors’ mandate. DIAL report indicated that many donor investments in technology are often based in their head offices and barely diffused to the local offices in their countries of implementations (DIAL Baseline report 2018). There is also donors’ emphasis on results and value for money that sometimes may not be at the interest of the local beneficiaries of the system. • Donor disparate systems “dumping” standards: Many of the systems introduced in public health in Africa have originated from donor agency countries and there are policies that encourage adoption of such tools. Examples of such cases are the use of expensive proprietary software in some cases. Since there is no global coordination of donors sometimes, it is possible to have different types of systems installed within countries and regions, thereby limiting inter-exchange and interoperability of these platforms. However, lately there has been a tremendous effort to create standards such as the “Principles of Digital Development.” • Facilities: In public health, in many African countries, there is need for provision of digital facilities, such as electricity, digital equipment to support hospital care and Internet access. • Governance: The WHO (2018) stated that “health system governance is governance undertaken with the objective to protect and promote the health of the people.” Governance includes setting strategic direction and objectives; making policies, laws, rules, regulations, or decisions; and raising and deploying resources to accomplish the strategic goals and objectives. Wang and Guo (2015) write that governance recognizes the capacity to get things done without relying on the power of the government to command or use its power. They

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emphasize that, in modern society, the government is moving its responsibilities to private sector organizations and NGOs groups, which are undertaking responsibilities that were formerly in the hands of the government. MoHSS in the government of Namibia is led by the Office of Prime Minister (OPM) as a government Ministry in the governance of Information systems. According to Van de Pas et al. (2017), governance for global health refers to the organizations and tools recognized at both the national level and regional level to contribute to global health governance and governance for global health such as strategies or regional strategies for global health or agreements by a group of countries. The definition of governance for global health highlights the involvement of players on legitimacy, accountability, and transparency. Governance for global health requires the commitment of all actors, which can be a challenge to digital transformation and global health since each state individually has its own policies and procedures though in the guidance of the WHO. In addition, Van de Pas et al. (2017) highlighted six key challenges on governance for global health covering opportunities for policy innovation and institutional development in the form of questions: – How can competing interests and fragmentation be overcome? – How can a greater commitment by countries for providing global public goods for health (GPGH) be ensured? – What role should corporations and their foundations play in global health, and how can the private sector become more accountable? How can reliable funding be ensured for global health initiatives and organizations? – How can political support be gained for addressing the political, social, and commercial determinants of global health? • Funding: Funding for digital health is lagging behind, as many African countries have limited resources to support such interventions independently. Some early implementations of digital health lack sustainability frameworks to keep the system going. ICT implementation is cost-intensive with constant requirements to maintain infrastructure, and many African healthcare systems are financially constraint. Hence, after initial investment to implement, digital health becomes cumbersome when cash calls for Internet subscription, ICT equipment accessories, and service providers’ fees are required. • Education: Inclusion of digital health training into the training curriculum of Healthcare practice will be essential for the digital transformation of Global Health in Africa, but more importantly as more learning resources become readily available in Healthcare IT, Digital Health, and further democratization of knowledge especially through the Internet. Appropriate incentives should be provided for universities in Africa to offer Digital health inclined programs. While users or customers experience improved services in sectors that have been fully transformed by ICT, such as banking and airline services, they demand similar improved services in any other settings. However, developing countries are generally challenged in implementing ICT initiatives as opposed to developed countries (Pereira 2015). The challenges facing developing countries include a lack of physical resources such as network and telecommunication infrastructure,

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lack of ICT experts, unreliable internet connection, and access to ICT facilities (Zewge et al. 2015). Khalifa (2013) identifies six main categories of barriers as follows: The first is human-related barriers. This sums-up people’s beliefs and behaviors. The other barriers are financial, legal and regulatory, organisational, technical and professional. This is because of the nature of the healthcare industry, the complexity of the activities, and processes in healthcare in which this challenge is experienced.

Non-Communicable Diseases and Disease Outbreaks: Digital Health Support for Africa In the last few years, there has been a significant increase in the number of deaths arising as a result of non-communicable diseases. A recent review of the literature suggests that there has been a 67% rise in non-communicable diseases in subSaharan Africa since 1990 (Gouda et al. 2019). As a result, there is an increased strain on healthcare systems in Africa as a result of the burden caused by noncommunicable diseases. There is also a high prevalence of diabetes recorded in developing countries (Animaw and Seyoum 2017). Hypertension and diabetes are both contributing factors to life-threatening conditions such as heart attacks and stroke (World Health Organization 2018). In Namibia, non-communicable diseases such as hypertension and diabetes, contribute approximately to 100,000 cases of Disability Adjusted Life Years (DALYs) (WHO 2016). With the vast majority (85%) of Namibians reliant on services provided by the public health sector while the remaining population rely on the private healthcare sector (Iyawa and Coleman 2015). A previous study suggests that patients accessing healthcare services in rural Namibian communities have access to mobile phones (Iyawa and Coleman 2015). As a result, research on how digital tools can be used to strengthen access to medical services among underserved populations with non-communicable diseases can be significant in Namibia. Digital tools can also be used as intervention strategies to support patients in rural and medically underserved communities. Interventions such as text messaging, mobile apps, telemedicine, and wearable technologies can be used to employ low-cost strategies to provide support for people suffering from non-communicable diseases, thereby reducing the workload of health practitioners in the Namibia healthcare sector. Cases of disease outbreaks and epidemics have been recorded even before the fifteenth century. Disease outbreaks could be new or recurring. However, the proliferation of Digital Health technologies can act as support tools during these times. With recent outbreaks such as the Ebola virus epidemic, Zika virus epidemic, and more recently, the coronavirus pandemic, there is a need for improved healthcare systems in Africa. Digital Health can be used as supportive tools in such cases. For example, various digital technologies have been used as support tools during disease outbreaks. During the Ebola virus disease outbreak, mobile technologies played an important role in educating healthcare workers in Nigeria (Olu et al. 2019). In a bid

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to reduce the spread of the outbreak, the Department of Health in Western Australia implemented an SMS-based system that monitors people who have traveled to highrisk countries for 21 days (Tracey et al. 2015). The system sends automated messages to patients about their health and temperature and if a negative response is provided, a medical officer is contacted who then calls the individual for further checks. Although African health systems have not been severely strained by the pandemic compared to experiences in other continents such as Europe, Asia, and North America, there is a need to establish a concrete plan to prepare Africa for handling such outbreaks in the future. This could be through technologies for early warning, alert systems, disease surveillance, monitoring apps, and AI-driven techniques to predict and detect outbreaks.

Public Health Reform: Initiatives in Africa Levin (2018) noted that the idea of public health reform would comprise two features, a focus on determinants of population–health disparities, especially those that are rooted in inequities and injustices resulting from social structure and policy and priority given to factors responsible for the greatest morbidity and underutilization of preventive care. One important motivation for Health reform is to improve the efficiency of service delivery, and the behavior of workers is one of the key elements of productivity. Latin America healthcare system reforms have formed a different approach to worldwide health coverage; underpinned government financing enabled the introduction of supply-side intervention to expand insurance coverage for uninsured citizens (Atun et al. 2015). Furthermore, health reform statements noted to improve both access to healthcare by adolescents and young adults (AYAs), and healthcare providers’ delivery of developmentally appropriate healthcare for these patients through the presentation of an overview of the issues. Exact recommendations for financing AYAs include practical actions healthcare practitioners can take to advocate for appropriate payments for providing healthcare to AYAs (Marcell et al. 2018). In India, Shankar (2015) argued that it is crucial to immediately reform the content of the public health system and make it more diverse. To reform the healthcare system in India, Shankar (2015) proposed a long-term strategy involving radical changes in medical education, research, clinical practice, public health, and the legal and regulatory framework needed to innovate India’s public health system and make it both integrative and participatory. Five sub-Saharan Africa countries adopted healthcare reforms to rebuild their health systems destroyed during the war that brought destruction to public health, affected the health of women and children, and contributed to maternal issues (Chol et al. 2018). Evident governance on health reforms through five sub-Saharan countries that propose that the decentralization platform – the transfer of power, funding and decision-making to lower-level governments and communities – may have

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enabled initiatives that contributed to the decrease in maternal mortality in their countries (Chol et al. 2018). • Angola implemented district-level fiscal decentralization and a district health strategy to build municipalities’ capacity to improve primary healthcare services. • Eritrea established a decentralization policy before its independence from Ethiopia by designing policies such as the Post-Independence Macro-Economic Policy Framework (MEPF). • Ethiopia’ decentralization from the regional to the district. For example, maternity care provided at three levels: health posts offer first aid; health centers provide primary essential maternity care, and district hospitals offer comprehensive emergency obstetric care. • Mozambique undertook steps to decentralize its health system. It introduced policies to devolve its health system to provinces, districts, and then to municipalities. • Rwanda designed the Twubakane (Let’s build together) program to strengthen decentralization of the health system at local government levels. The program included initiatives such as family planning and reproductive health in collaboration with international partners. Furthermore, health system reforms made an important effect on the delivery of maternal health services and aimed to address vulnerabilities in municipal health policy and healthcare in both the public and private sectors, to improve access to healthcare facilities in all five sub-Saharan countries. Namibia’s primary healthcare is provided through the Ministry of Health and Social Services established in 1990. The Ministry’s mission and vision is to provide integrated, affordable, accessible, equitable, quality health and social welfare services that are responsive to the needs of the population, and to be the leading country of quality healthcare and social services according to international set standards (Ministry of Health and Social Services 2020). Although the Ministry has its mission and vision in place, healthcare reform is still vital in other area service delivery especially when it comes to health systems. Hamunyela and Dlodlo (2017) noted that integration of Information Systems is vital to provide reliable information care throughout the Namibia health sector. Again added that at the time Namibia’s HIS is implemented by external partners and thus difficult to maintain and integrate. Furthermore, Mutelo (2019) noted that with the silo systems in place health sector decision-makers will face challenges obtaining data or timely information for decision making. The Namibia health sector must deal with factors that motivate healthcare service delivery to realize its mission and health reform is crucial for this. Like the subSaharan countries Namibia health sector need to look at the following during the health form process: • Decentralize health services to local regions because services like dialysis and organ transplantations are only available from private medical centers in the

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Khomas region and accessible to those with medical aid and excludes lowerincome citizens. • Integrate health information system to avail health information data decisionmakers get access to real-time information. • Implement Namibian customized systems by experts in Namibia for easy maintenance and upgrade. • Lower medical referral to the hospital far from the citizens and reduce the death rate and costs due to distance travel by availing medical experts to local hospitals and clinics in remote areas. It must be noted that Namibia reduced many of their systems in an effort at consolidation and developed a National E-Health Strategy in the last half of 2019.

Conclusion Global health is a phenomenon that is relevant in addressing healthcare challenges. However, supplementing digital health with global health could make a significant impact on healthcare systems worldwide. This chapter provided an overview of Digital Health in Africa. Although African countries have been making significant progress in the introduction of Digital Health in healthcare settings, there was limited evaluation of Digital Health technologies. In Africa, compared to most parts of the world, the healthcare systems are weak, unstable, and lack the infrastructure to provide quality healthcare. This is further exacerbated by the lack of expertise to support healthcare systems. It was noted that African countries, in reality, have sufficient healthcare workers. However, migration of these workers to high income countries has led to a dearth of healthcare workers in these countries. It is recommended that healthcare systems should provide sustainable and attractive systems in place to support healthcare workers in Africa. Digitalization can improve the healthcare process and, as a result, address the challenges of healthcare systems in Africa. Examples of African countries that have evaluated digital technologies for healthcare in Africa include South Africa, Nigeria, Kenya, Uganda, and Ghana. Simple technologies such as the combination of mobile phones and text messaging have been used to provide support for healthcare in Africa. While digital health technologies do not replace healthcare workers, it can greatly reduce disease burden. This calls for more research emphasizing on developing, evaluating, and implementing Digital Health technologies including simple tools such as text messaging, mobile apps, and telemedicine. Africa has also experienced many cases of disease outbreaks including infectious diseases and non-communicable diseases. Thus, further research is needed in the area of developing and evaluating interventions for behavioral health change using digital technologies. Introducing digital technologies to support patients and healthcare workers in providing and receiving healthcare services will be valuable in reducing the burden caused by these diseases. Finally, Digital Health Innovation Ecosystems will be critical for the successful

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digital transformation of healthcare systems worldwide and African countries could develop initiatives to incorporate them as support platforms into existing healthcare systems.

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Part II Global Health Epidemiology

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Epidemiological Methods and Measures in Global Health Research Emmanuel Agogo and Kelly Elimian

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiological Methods in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiological Measures of Disease Burden in Global Health Research . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Global health is an evolving field with increasing significance because of the increasing interconnectedness of the world. The demographic and epidemiological transitions that are occurring globally lend themselves to empirical research. This chapter outlines the basic epidemiological methods used in public health research and demonstrates their applicability in the context of global health problems with examples from resource-rich and resource-constrained settings. The importance of robust epidemiological research in understanding disease occurrence, health inequalities, and designing appropriate interventions is critical to the progress in global health. Keywords

Global Health · Epidemiology · Incidence · Prevalence · Disability-adjusted life year (DALY)

E. Agogo (*) Prevention and Programme Coordination, Nigeria Centre for Disease Control, Abuja, Nigeria e-mail: [email protected] K. Elimian Department of Microbiology, Faculty of Life Sciences, University of Benin, Benin City, Nigeria e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_8

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Introduction Global health is relatively a new and evolving field, and what it means has proved elusive and even contentious (Beaglehole and Bonita 2010; Koplan et al. 2009; Abimbola 2018); in fact, a harmonious interpretation of what global health may not emerge over time (Abimbola 2018; Taylor 2018). From an epidemiological perspective, global health could be described as consisting of health issues whose causes or redress lie beyond the capability of any one nation state (Taylor 2018). According to the definition by Koplan and colleagues, 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” (Koplan et al. 2009). However, this definition has been considered wordy and uninspiring by Beaglehole and Bonita (2010) who defined global health thus: a “collaborative trans-national research and action for promoting health for all.” Complementary to on the definition by Koplan et al., this definition has the advantage of being more action orientated and more encompassing, with an emphasis on the critical need for collaboration. Irrespective of the varying definitional approaches, one of the main achievements in global health is the substantial reduction in health inequalities between rich and poor countries, especially in the context of the Millennium Development Goals from 1990 to 2015; this underpins optimism about the possibility of a world where there is a levelling of major health issues, largely in the fields of infectious disease and maternal and child mortality by 2035 (Jamison et al. 2013). However, it is worth noting that as traditional infectious diseases – which have contributed significantly to the proportion of morbidity and mortality – are reduced to comparable global lows, the burden of noncommunicable diseases, such as hypertension, diabetes, and mental health conditions, is increasingly being recognized (Taylor 2018). Global health promotes multidisciplinary collaboration, including epidemiology, mathematical modelling, anthropology, political sciences, sociology, and economics (Alba and Mergenthaler 2018). While some of these methods rely on qualitative research methods, others are more quantitative in nature. In summary, the priority of global health is to improve health and achieve equity for all. Achieving this ambitious goal will require concerted efforts across diverse stakeholders, including national governments, donors, technical agencies, public health professionals, and civil society (Alba and Mergenthaler 2018), and, equally important, robust epidemiological evidence to inform planning and interventions. For the purpose of clarity, epidemiology is a research tool with which researchers identify the distribution of diseases, factors underlying their source and cause, and methods for their control. Epidemiology is a special science in that it requires an understanding of how political, social, and scientific factors intersect to influence disease risk (Nature Communications 2018). Indeed, epidemiology is playing a critical role in the growth of global health, as evidenced by a significant increase in epidemiology-based research across low- and middle-income countries (Nachega et al. 2012). Essentially, epidemiology is considered the cornerstone of global health (Alba and Mergenthaler 2018). However, like any other discipline, epidemiological studies are susceptible to malpractices, thereby misguiding policy and practice as

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well as undermining community’s trust (Alba and Mergenthaler 2018). From the authors’ perspectives, the quality of an epidemiological research is hinged on the design of the methodology and use of appropriate measures of effect. Thus, the primary focus of this chapter is to explore relevant epidemiological methods and measures in the context of global health. The remaining section of this chapter will be covered by providing an overview of epidemiological methods and measures, providing a definition of key terms as needed, and using evidence in the literature to illustrate the concepts being discussed while also underlining the importance and limitations of each area.

Epidemiological Methods in Global Health Epidemiological methods are central to the emerging and ever-expanding field of global health. As with all research areas, the diverse problems inherent in global health need to be identified, quantified, and monitored (Quinn and Samet 2010). The diversity of global health focus is exemplified by the variety of research subjects being addressed by epidemiologist, including HIV/AIDS, injury and road accidents, malaria, maternal and child health, family planning, environmental health, noncommunicable diseases and mental health, and infectious disease outbreaks (e.g., novel coronavirus, Ebola virus, influenza virus, cholera etc.) of global health relevance. These topics provide only a very small snapshot of the multidisciplinary approach to global health and the variety of issues facing us in promoting health on a global basis. Nonetheless, application of epidemiological methods and principles is relatively constant. Generally, there are three broad types of epidemiological study design commonly used in global health; these include (1) descriptive studies, (2) observational studies, and (3) experimental studies. Each of the epidemiological method is explained below.

Descriptive Studies These studies are traditionally suited for the investigation of a disease distribution and in some cases possible determinants of the disease within a defined population. Over time, these studies have been used by researchers to explore the distribution of a disease in terms of time, person, and place, information that can be useful to public health professionals in identifying changes in morbidity and/or mortality associated with a disease or to comparing the incidence or prevalence of a disease in various geographical locations or between groups of individuals with different characteristics. Descriptive studies typically rely on routinely collected surveillance or health data, especially infectious disease notifications in many developing countries. A series of descriptive studies on cholera outbreaks in Nigeria and other endemic countries, including Haiti, Yemen, and Mozambique, have used surveillance data to provide evidence on both the distribution of cholera cases by person, time, and place and the impacts of some context-specific factors, such as armed conflict and seasonality. For example, Elimian et al. (2019) used records from the surveillance unit at the Nigeria Centre for Disease Control to describe the distribution of 43,996

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cholera cases and 836 cholera-related deaths during the 2018 outbreak in Nigeria while also underlining the impact of Boko Haram insurgency activities on increased cholera cases in the northeast region of the country. Likewise, Camacho et al. (2018) used surveillance data from the Yemen health authorities which included cholera cases and sociodemographic variables to conduct descriptive analyses of cholera cases at national and governorate levels, as well as to explore the impact of seasonality on cholera transmission. Overall, descriptive studies are useful in generating hypotheses about the causes of certain disease patterns, but are limited in being able to test hypotheses regarding the effect of an exposure on a particular disease outcome (Blumenthal et al. 2001).

Analytical Studies Analytical studies are purposely planned investigations aimed at testing specific hypotheses and can be generally categorized into four study designs: (1) ecological study, (2) cross-sectional study, (3) cohort study, and (4) case-control study. Ecological Study This is also referred to as correlational study and is sometimes considered a descriptive study in some locations – e.g., in the USA. This study design is primarily concerned with the study of associations between an exposure(s) and a disease or a health outcome using groups of people, rather than individuals. In other words, the unit of observation in ecological studies is the population rather than individuals. Because aggregated data are utilized, the relationship for individual patients is not directly explored, although individual relationships may often be inferred from such population-based analyses (Saunders and Abel 2014). In assessing the public health problem of violence across 169 countries, Wolf, Gray, and Fazel (2014) adopted an ecological study design, wherein they utilized crime statistics from the United Nations Office on Drugs and Crime and indicators from the Human Development Report published by the United Nations Development Programme to examine country-level associations of violence with socioeconomic and health-related factors. The main finding from the study was that income inequality was related to violence in low- and middle-income countries, an indication of the need for global action to moderate income inequality in order to decrease the global health burden of violence. The inability to link individual exposure to individual disease risk and to control for possible confounders are major limitations of ecological study design, limiting its usefulness in many contexts, especially for an exposure that changes over time and where the risk factors for the disease under investigation are diverse. Moreover, using this study design has the potential to bias an epidemiological investigation if the ascertainment of disease or exposure or both differs by location. Despite the limitations associated with this epidemiological method, research where healthcare organizations or health facilities within a district rather than individual patients are the primary focus of investigation consider ecological studies very appealing tool. For example, a study looking at the features of a Lassa fever outbreak with high case fatality rates in a country such as Sierra Leone may be “more concerned” with the

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surveillance or laboratory system at an organizational level than with individual cases. This epidemiological method also allows researchers to look at a public health problem nationwide or globally, thereby providing evidence that is potentially more generalizable than from studies considering individuals but often in only a small geographical area. Another advantage of ecological studies is the ease with which data sources are readily available, thus minimizing the cost and time required for data collection, and using publicly available data means there is little or no problems with data confidentiality as the data may have been published or are in the public domain. Overall, ecological studies are at best hypothesis generating when considering individual-level associations, and care should be taken to avoid the risk of ecological fallacy: assuming the associations observed at the population level is the same as those at the individual level. Another point to take note of is the issue of unmeasured confounding variables that may affect the findings from an ecological study.

Cross-Sectional Study A cross-sectional study is often focused on the association between a health outcome or a disease and other variables of interest in a defined population at a single point in time or over a period of time – e.g., calendar year. In other words, cross-sectional studies can provide a “snapshot” of the frequency of a disease or other health-related characteristics in a population at a given point in time; they are often used to assess disease burden or health needs of a population and are particularly useful in informing public health planning and allocation of health resources. The common outcome measure from a cross-sectional study is prevalence, but is unable to measure incidence which may be more informative for public health planning. A cross-sectional survey may be purely descriptive and used to assess the burden of a disease in a defined population, or it can be analytical, such as the association between a risk factor and a health outcome. The study design is applicable to the investigation of health issues of national and global health relevance. To explore the role of many distant macrostructural factors affecting maternal mortality at the global level, Sajedinejad et al. (2015) used a cross-sectional study design. The study found that, among other factors, education, private sector and trade, and governance were the most important macrostructural factors associated with maternal mortality, indicating that effective tackling of maternal mortality would benefit from addressing factors (political will, attention to the expansion of the private sector trade and improving spectrums of governance) other than individual determinants. Still using the same study method, but this time at the national level, Berg et al. (2015) in 2011 assessed the prevalence and correlates of tobacco use among a representative sample of 11,260 participants in Chennai, Delhi, and Karachi states of India. Authors found that, overall, lifetime (ever) tobacco use prevalence was 45.0%, 41.3%, and 42.5% among males and 7.6%, 8.5%, and 19.7% among females in Chennai, Delhi, and Karachi, respectively. Overall, the findings underlined the need to focus public health interventions on persons of lower socioeconomic group in order to effectively address high prevalence of tobacco use in the study setting.

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When adopting this epidemiological method to address a global health problem, researcher should be mindful of a notable drawback – ability to draw valid conclusions regarding the association between risk factors and a health outcome (temporal relationship). This is because the risk factors and outcome are measured simultaneously; hence, it is difficult to determine whether the risk factors preceded the disease. Other limitations associated with this method include the requirement for large sample sizes (for conditions with very low prevalence) and potential bias due to exposure and disease misclassification as well as differences in reporting by the study participants. Nonetheless, cross-sectional study design is the most commonly used epidemiological method by researchers in addressing global health issues, particularly in developing countries. Cohort Study In a cohort study (also referred to as longitudinal study), the population under study is individuals who are at risk of developing a disease or health outcome. In the simplest design, a sample or cohort of subjects exposed to a risk factor is identified along with a sample of unexposed controls; the two groups are then followed up prospectively, and the incidence of the outcome or disease in each cohort is measured. By comparing the incidence rates, attributable and relative risks can be assessed (The BMJ 2020). However, allowance can be made for suspected confounding factors either by matching the controls to the exposed subjects so that they have a similar pattern of exposure to the confounder or by measuring exposure to the confounder in each group and adjusting for any difference in the statistical analysis. In general, prospective cohort studies differ in size, complexity, and duration. For example, in the cohort study of the office of population censuses and surveys, a 1% sample of the British population that was initially identified during the 1971 census were prospectively followed up. This allowed outcomes such as mortality and incidence of cancer to have been linked with employment status, housing, and other variables measured at successive censuses. In assessing the association between breastfeeding and intelligence, educational attainment, and income at 30 years of age in Pelotas, Brazil, Victora et al. (2015) adopted a prospective cohort study of neonates. Information about breastfeeding was recorded in early childhood in 1982, but authors studied the IQ, educational attainment, and income of the participants at 30 years of age. Of the 3,493 participants with information on IQ and breastfeeding duration at follow-up between June 2012 and February 2013, the duration of breastfeeding was found to be positively associated with IQ, educational attainment, and income. Moreover, in the confounder-adjusted analysis, participants who were breastfed for 12 months or more were found to have higher IQ scores, more years of education, and higher monthly incomes than did those who were breastfed for less than 1 month. While cross-sectional or ecological studies cannot provide this level of association as demonstrated by Victora and colleagues, one of the limitations of a cohort study when applied to the study of chronic diseases or an outcome that takes time to occur, such as IQ in the previous example, is the requirement for follow-up of a large number of people before sufficient cases can be analyzed to provide

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statistically meaningful findings. The difficulty is further increased when there is a substantial period between first exposure to a risk factor and the eventual manifestation of disease, such as with many carcinogens. Moreover, cohort studies are often complex and difficult to manage, with the duration running into decades, depending on the research question. The study therefore can be expensive, which might be unrealistic for researchers in developing countries with limited financial resources. One possible approach to address some or the majority of these challenges is by following up the study participants retrospectively – this is referred to as a retrospective cohort study. For instance, in developing ideas about the fetal origins of coronary heart disease, it was possible to find groups of individuals born in the county of Hertfordshire in England prior to 1930 whose fetal and infant growth was documented. These individuals were then traced, and the cause of death was ascertained for those who had died, thereby making it possible for death rates from coronary heart disease to be related to weight at birth and at 1 year old. Of course, successfully adopting this retrospective approach is only possible when the outcome or disease under investigation can be measured retrospectively and not acute, such as asthma. A further requirement for this methodological approach is to ensure that the selection of exposed people is not determined by factors connected to their subsequent morbidity. For example, to assess whether there was an association between residency in public rental housing – an indication of socioeconomic status – and mortality in Singapore, Seng et al. (2018) adopted a retrospective cohort study design. All patients who utilized the healthcare facilities under SingHealth regional health services in 2012 were recruited. Of the 147,004 patients included in the study, 7,252 (4.9%) died during the study period; and they had higher utilization of healthcare resources in the past 1 year and a higher proportion lived in public rental housing. After adjustment for demographic and clinical covariates, residency in public rental housing was found to be associated with increased risk of all-cause mortality. Another approach commonly used to address some of the aforementioned challenges with prospective cohort studies is the use of existing disease rates in the national or regional population for control purposes, rather than following up a selected control group. However, this approach is only feasible when exposure to the hazard in the general population is negligible. For instance, suppose in a cohort study of persons exposed to ethylene oxide (a sterilant gas and a material for the manufacture of antifreeze), exposure in the general population would be minimal, in which case national death rates can be used as the reference population. The numbers of deaths in the cohort will then be compared with the numbers that would have been expected if subjects had experienced the same death rates, as per age, sex, and duration, as the general population. Case-Control Study As mentioned in the previous section, one of the limitations of a cohort study design for a health outcome or a disease with low incidence is the requirement for large and lengthy studies in order to give adequate statistical power. An alternative is the case-control study design. Here, patients who have developed

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a disease, such as cervical cancer, are identified, and their past exposure to suspected etiological or risk factors, such as engaging in an unprotected sex or use of contraceptives, is compared with that of a control population who do not have the disease. This allows estimation of odds ratios – but not of attributable risks – while also allowing for the measurement and adjustment of potential confounding factors in the analysis. The statistical adjustment of confounders becomes even more efficient when cases and controls are matched for exposure to confounders by certain characteristics including age and sex. However, the matching process does not on its own completely mitigate confounding effect; hence, statistical adjustment is still required. In November 2014, researchers of the Nigeria Field Epidemiology and Laboratory Training Programme were notified of an increase in suspected cholera cases in Gomani, Kwali Local Government Area in Nigeria. Dan-Nwafor et al. (2019) investigated the outbreak by using an unmatched case-control study, with a view to verifying diagnosis, identifying risk factors, and instituting appropriate public health control measures in response to the outbreak. Authors defined a cholera case as any person aged 5 years or older with acute watery diarrhea in the community, from where controls were also selected. A total of 43 cases and 68 controls were recruited, while structured questionnaires were administered for the collection of information on potential risk factors. Compared to controls, cases were 14 times more likely to have drank from a community river and almost 6 times more likely to be living in households with more than 5 persons; good hand hygiene was found to be protective, decreasing the odds of cholera infection by as much as 97%. Although cholera is an acute infection, authors were able to identify the source of disease transmission in the community and instituted appropriate public health interventions. The starting point of case-control studies is the identification of cases, which relies significantly on a suitable case definition, as shown in the study by Dan-Nwafor and colleagues above. Importantly, there is a need for caution to minimize the occurrence of selection bias from the way in which cases are selected. For instance, a study of small-cell lung cancer might be biased if cases were identified from hospital admissions and admission to hospital was influenced not only by the presence and severity of disease but also by other variables like socioeconomic status. As such, using incident cases is preferred over prevalent cases as the latter tend to be influenced not only by the risk of developing disease but also by factors that determine the duration of illness. Contrary to expectation, the selection of controls can be more challenging than selecting cases in a case-control study (The BMJ 2020). Ideally, selected controls will need to meet two important criteria. First, within the constraints of any matching criteria, exposure of the controls to risk factors and confounders should be representative of that in the population “at risk” of becoming cases – i.e., individuals who do not have the disease being investigated, but who would be included in the study as cases if they did. Second, the exposures of controls should be measurable with similar accuracy to those of the cases. In reality, however, it is often difficult to fulfil both criteria. Nonetheless, a common source of controls in the general population is the hospital where exposures of the controls are likely to be representative of those at risk of

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becoming cases. However, assessment of exposures in controls may not be comparable with that of cases, especially if the assessment is achieved by personal recall process. In general, cases may be more likely to find out what caused their illness and are therefore better motivated to recall details of their past exposures than controls with no special interest in the investigation (i.e., recall bias). Thus, assessment of exposure can be made more comparable by selecting patients with other diseases as controls, especially if subjects are not told the specific objective of the investigation. For example, findings from a case-control study of bladder cancer and smoking can be biased if controls were selected from the chest unit at the health facility. If other patients are to be used as controls, it is better to adopt a range of control diagnoses rather than a single disease group, thereby making sure that if one of the control diseases happens to be related to a risk factor under study, the resultant bias will not be too significant to bias findings from the investigation. When cases and controls are both freely available, then selecting equal numbers is feasible and likely to make the study efficient. However, in most cases, the number of cases that can be studied is often limited by the rarity of the disease under investigation. Hence statistical power can be increased by taking more than one control per case. As a rule, it is usually not effective to go beyond a ratio of four or five controls to one case as a law of diminishing returns easily sets in after this number. Rocha et al. (2019), for example, investigated 58 cases of microcephaly in newborns with Zika virus infection and 116 controls without microcephaly identified in the vicinity of the residence of each case in Brazil. Overall, case-control studies have the advantage of requiring smaller sample sizes, fewer resources, less time, and less money and can be the most appropriate epidemiological method to study rare diseases of global health relevance. The difficulties are in appropriate study design to minimize bias, including the selection of appropriate controls and the control of confounding variables and minimizing recall bias.

Experimental or Intervention Studies While the analytical epidemiological study designs (ecological, cross-sectional, cohort, and case-control) can provide evidence to aid understanding of global health issues, experimental randomized controlled trials or intervention studies remain the best means of ascertaining whether or not a health intervention has benefits or may work (The Lancet 2019). In observational studies, the study participants exposed to a risk factor may differ from those who are unexposed, which independently influences their risk of disease. Being able to identify such confounding role on time is crucial as adjustment can be made in the design and analysis of the study. However, there is always a possibility, regardless of how small, of unrecognized confounders that could influence findings from the investigation. This is why experimental studies are very important as they are less prone to confounding influence or selection biases. The random allocation of exposure in experimental studies ensures that the distribution of various intraindividual traits and potential confounders between study groups is similar, thereby making as comparable or making the effect of unknown confounders statistically unlikely (The BMJ 2020). Briefly, a single cohort is randomized into two groups; one group is then assigned to exposure to the

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factor under study, while the other group is the control. The health outcomes for the two groups are compared. Randomized controlled trials usually begin with the definition of a set of inclusion or eligibility criteria. Like other epidemiological studies, researchers need to ensure that the selected participants are representative of the target population in whom it is anticipated to apply the findings. Individuals who meet the inclusion criteria are asked to consent to participation in the study, although the representativeness of the study will need to be carefully considered for a high refusal rate. The participants who agree to participate in the study are then recruited and randomized to the various study arms or treatments under comparison, with the aid of either published tables of random numbers or random numbers generated by computer. To minimize the occurrence of bias, it is important to ensure there is no prior knowledge of the group to which the participant will be allocated at the time of recruitment, an approach referred to as concealment. When outcome is likely to be influenced by other aspects of a participant’s management, as well as by the treatments being compared, it is often advisable that those responsible for participants’ management be “blinded” to treatment allocation. Based on ethical principles, however, plans should be put in place to permit rapid “unblinding” should possible complications of treatment occur. Furthermore, the criteria for withdrawing a participant from treatment or a study group should be specified at the outset of the study, although final decision is often the responsibility of the study managers or health professionals caring for the participant. However, even if a participant is withdrawn from a study treatment, follow-up and assessment of outcome may continue depending on willingness of the patient. Randomized controlled trials tend to be conducted robustly to ensure that the effectiveness of an intervention is indeed true and reliable. That is, the study involves concealing the allocation of study participants, blinding the researchers, the researched, and other persons involved in the trial as needed, analyzing data according to intention-to-treat approach, and using sufficient sample size. Thus, randomized controlled trials are considered the gold or reference standard for assessing causal relationships between interventions and outcomes as randomization process helps to eliminate much of the bias inherent with other study designs (Hariton and Locascio 2018). Gill et al. (2018) used randomized controlled trial to evaluate the revised SMS-based continuing medical education (CME) intervention among HIV clinicians in Vietnam, with a view to reducing the high cost associated with the traditional CME approach. Authors enrolled HIV clinicians from three provinces near Hanoi, with the intervention of 6 months consisting of daily short message service, multiple-choice quiz questions, daily linked readings, links to online CME courses, and feedback messages describing the performance of the participant compared to the control group, who only had access to the online CME courses. Eighty-eight percent of the 121 HIV clinicians participated in the study, with 48/53 intervention and 47/53 control participants completing the evaluations. Compared to controls, intervention participants were found to be more likely to use the CME courses and increase self-study behaviors over controls in terms of use of medical textbooks, consulting with colleagues, searching on the Internet, using specialist websites, consulting the national HIV/AIDS treatment guidelines, and

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searching the scientific literature. Having addressed most of the limitations inherent in observational studies, authors were able to improve, with high level of certainty, self-study behavior, medical knowledge, and job satisfaction among clinicians in the study setting. Despite their successes in producing robust evidence in both medical and social domains, randomized controlled trials are often critiqued by scientists on philosophical, epistemological, political, and methodological grounds. According to a recent commentary by The Lancet, trials are often severely restricted, with little ability to plan for changes across the study (i.e., adaptive) and being ready for unforeseen decision-making at a huge cost and effort. Moreover, issues with generalizability of findings can arise if the study participants are not similar to patients for whom RCT results will be used in the future. Other challenges that can also affect the validity of intention-to-treat analyses in randomized controlled trials are loss to follow-up and missing data. By intention-to-treat analysis, it means analysis of study participants in the groups to which they were randomized (Hariton and Locascio 2018). Another challenge to randomized controlled trials is ethical constraints given that it is not acceptable to expose individuals deliberately to potentially serious hazards or deny them of care with proven benefits; thus, the application of this epidemiological methods in the investigation of disease etiology tends to be limited, although it may be possible to evaluate preventive strategies.

Epidemiological Measures of Disease Burden in Global Health Research This section focuses on key epidemiological measures that are commonly utilized in global health while also offering epidemiological critique of each measure as needed. Typically, the most common epidemiological measures of disease burden are prevalence, incidence, and case fatality (mortality) rates.

Incidence The incidence of a disease is the rate at which new cases of the disease occur in a population during a specified time. For example, the global incidence of anaphylaxis in children worldwide was found to range from 1 to 761 per 100,000 person-years for total anaphylaxis and 1 to 77 per 100,000 person-years for food-induced anaphylaxis (Wang et al. 2019). However, when the population at risk is roughly constant, although unlikely in real world, incidence is measured as: Number of new cases : Population at risk
time during which cases were ascertained Indeed, assessment of incidence tends to be complicated due to the dynamic or changing nature of the population at risk during the period of a case ascertainment. Common causes of a change in a population include births, deaths, migrations, or natural and man-made disasters. However, this challenge can be overcome by

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relating the numbers of new cases to the person-years at risk, assessed by adding together the periods during which each participant of a study population is at risk during the period of investigation. It is worth noting that once a participant is classified as a case, he or she is no longer eligible to become a new case and therefore will not be contributing further to the person-years at risk. However, the same event or disease can occur more than once to the same individual. In the course of a study, for example, a patient may have several episodes of malaria infection, especially in a country that is endemic for the disease – e.g., Nigeria and Democratic Republic of Congo. To ensure that the estimated incidence from such a scenario is not biased, definition of incidence is better restricted to the first event or episode of a disease, although there are times – e.g., study of infectious diseases – when it is more appropriate to count all episodes. In fact, an epidemiological study aimed at estimating incidence should be transparent by stating whether incidence refers only to first episode or to all episodes so as to minimize any form of ambiguity. For example, Lassa fever notification rates in Nigeria are increasing dramatically, especially since 2018, but the extent to which this is due to more people getting infected or to the same people getting infected more often is yet to be verified by researchers.

Prevalence The prevalence of a disease is the proportion of a population that is affected by the disease at a point in time. For example, the prevalence of human papillomavirus screened by the Pap smear in 8,101 women aged 30 years from December 1998 to December 2000 in Germany was found to be 6.4% (Klug et al. 2007). Estimation of a disease prevalence is more appropriate if the disease is relatively stable, that is, it is inappropriate for the estimation of an acute disease burden. Even in a chronic disease, the manifestations are often intermittent; thus, a “point” prevalence, based on a single examination, at one point in time, tends to underestimate the disease’s total frequency. If repeated or continuous assessments of the same individuals are possible, a better measure is the “period” prevalence, which is the proportion of a population that are cases at any time within a stated period. For instance, in a crosssectional study of 828 adults with a mean age of 39 years in Illinois, Texas, Utah, and Wisconsin, USA, the point prevalence of low back pain reported on the day of enrolment was 20.8%, while the 1-month period prevalence was 44.0% (Thiese et al. 2014). Overall, the approach taken for assessment of prevalence depends on the research objective and pragmatic reasons (e.g., funding and time). Prevalence is often used as an alternative to incidence in the study of rarer chronic diseases such as multiple sclerosis, where the accumulation of large numbers of incident cases would be difficult. Mortality Apart from the morbidity measures (incidence and prevalence), mortality rate is also commonly used in measuring global health burden. Mortality rate can be defined as the number of deaths occurring in a population during a specified period of time. The three key components for estimating any mortality rate are the total number of deaths (i.e., the numerator), the population in which the deaths occurred (i.e., the

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denominator), and the time interval during which the deaths occurred. Mortality rate is therefore a composite indicator derived from these variables rather than simply counting deaths in a population. Analysis and careful interpretation of mortality details serve as an important tool in explaining the global health trends (Kanchan et al. 2015). As such, mortality rates are considered as one of the most important public health indicators. One of the most commonly used mortality rates is case fatality rate (CFR), which is the ratio of deaths occurring from a particular cause or disease to the total number of cases due to the same cause or disease. It is calculated as follows: CFR ¼

Number of deaths due to a particular disease
100 Total number of cases due to the same disease

Following the first incidence of an outbreak of pneumonia of unknown cause in Wuhan, Hubei province, China, in December 2019, a series of investigations led to the isolation of a novel coronavirus (CoV) from patients by January 7, 2020; and this became an infectious disease outbreak of global importance. As of January 23, 2020, the epidemiological analysis by Wang et al. (2020) suggested that there was a total of 835 cases with laboratory-confirmed 2019-nCoV infection in China, with 25 deaths and a case fatality rate (CFR) of 3.0%. The epidemiological profile (affected population and geographical spread) has changed since these findings were reported by Wang and colleagues. However, estimation of the CFR associated with the viral outbreak has proven useful in understanding the burden of the disease as it serves as an indicator of the lethal effect of the outbreak; it also plays an essential role in informing preventive health strategies (Kanchan et al. 2015) and monitoring of disease outbreak and public health interventions (World Health Organization 2017). In another context, for example, CFR of more than 1% from a cholera outbreak is indicative of limited access to proper healthcare for the most vulnerable people and insufficiencies in healthcare systems, including limited capacity of the surveillance system to inform a timely response (World Health Organization 2017). It is worth noting that CFR is different from the other mortality rates in that the time component in the assessment of mortality rate is not considered in the calculation. In fact, CFR is predominantly estimated for acute infectious diseases such as cholera and Lassa fever. This means its relevance in chronic diseases is limited, due to the long and variable period from symptom onset to death (Gordis 2014). Additional Measures of Global Health Burden Historically, the indicators outlined in the previous sections, including incidence, prevalence, and mortality rates, have been used for estimating disease burden in public health; however, they lack some salient information required to assess the overall well-being of a population (Gold et al. 2002). In other words, these indicators are not comprehensive enough as they focus solely on the outcome without taking into consideration the effects of being sick, say, for several years, prior to death or recovery. In reality, individuals do bear additional burden to that commonly recorded using the traditional measures of disease burden. Health-adjusted life years (HALYs)

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are measures – largely considered as economic-based – that are often used in estimating global burden of diseases given their capacity to combine both the effects of disability or disease (morbidity) and death (mortality) concurrently. HALYs allow for comparisons to be made across illnesses, interventions, and populations, and their findings are normally presented by age, sex, and region (Gold et al. 2002). To estimate the HALYs of a disease, the following general steps need to be satisfied by researchers (Gold et al. 2002): 1. Description of the associated state of health or disease condition 2. Development of numerical values or weights for the health or disease condition 3. Combination of the numerical values of each health state with the estimated life expectancy The morbidity components of HALYs are referred to as health-related quality of life (HRQL) and are represented on a scale of 0 to 1. Two common measures of HALYs include quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Based on evidence in a systematic review of the literature, QALYs are more commonly used in the USA and the UK, while DALYs dominate in Africa and Asia (Rios-Diaz et al. 2016).

Quality-Adjusted Life Year (QALY) QALY is a statistical value ascribed to health outcomes by looking at both the quantity and quality of life generated by healthcare interventions (e.g., medication). Developed in the late 1960s by economists, QALYs are mainly used for the assessment of cost-effectiveness of health interventions as well as improvements in social welfare (Gold et al. 2002). The QALY is the arithmetic product of life expectancy and a measure of the quality of the remaining life years (Phillips 2009). That is, it is a measure of the number of years lived and the quality of life lived during those years that can be attributed to an intervention. When combined with the cost of providing a health intervention, QALYs are used to develop cost-utility ratios required to generate a year of “perfect health” – this is a notion of life without pain or disease (Gold et al. 2002). Moreover, QALYs measure the “utility” of an intervention – its potential effect on quantity and quality of life – in the context of limited resources and are often used by policymakers to determine where finite resources should be allocated (Gold et al. 2002; Phillips 2009). In estimating QALY, the utility values (i.e., HRQL) are based on individuals’ opinions about their own health state (patient weights) or on the judgments of others (e.g., health professionals, a population sample, or researchers) about a particular health state (community weights) rather than on specific diseases (Gold et al. 2002). In estimating HRQL, respondents are asked to generate health state values by indicating what they would be willing to forgo in order to return from a state of poor health to perfect health, where a year of perfect health is worth a value of 1 and death is considered to be 0. If the year is not spent in perfect health (i.e., the individual has to endure chronic pain), the value assigned is between

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1 and 0. This score considers five quality of life indicators including (1) mobility, (2) self-care, (3) pain or discomfort, (4) anxiety-depression, and (5) usual activities (Phillips 2009). Thus, QALY estimates combine both biomedical and psychosocial components of a disease burden. QALYs can measure both the effectiveness and the cost-effectiveness of a health intervention; e.g., it can compare an intervention that can help prolong life but with serious side effects (permanent disability from chemotherapy for cancer) with one that improves quality of life without prolonging it (palliative pain management). The estimate can give a sense of how many additional period (months or years) of life of reasonable quality of health a person might gain with each intervention (Neumann et al. 1997).

Disability-Adjusted Life Year (DALY) The DALY was developed in 1990 by researchers at the World Bank and Harvard University to quantify the burden of disease and disability in populations. It measures the difference between the present health status of a population and a perfect situation (i.e., where everyone attains the standard life expectancy in perfect health). This approach is underpinned by an assumption that time is the most appropriate measure of a disease burden, including the time lived with disability and the time lost due to untimely death (Young 2005). Taken together, DALY is equal to the years of life lost due to premature mortality (YLL) plus the years lived with disability (YLD) (Fig. 1). The YLL is calculated by multiplying the number of deaths by a standard life expectancy. The formula is: YLL ¼ N
L where: N ¼ number of deaths L ¼ standard of life expectancy at age of death (years)

Fig. 1 Pictorial representation of DALY. Wikimedia Commons is an online repository of free-use images; hence, there was no need for permission prior to usage

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The YLD is calculated by multiplying the number of disability cases (incidence cases) by the average duration of the disease/disability and weighted representations of disability (disability weight) (Young 2005). The formula is: YLD ¼ I
DW
L where: I ¼ number of incident cases DW ¼ disability weight L ¼ average duration of the case until remission or death (years) There are however instances when prevalence is used instead of incidence. For example, the 2010 GBD study used a YLD calculation based on prevalence rather than incidence of disability (Lajoie 2015). Thus, the formula is: YLD ¼ P
DW where: P ¼ number of prevalent cases DW ¼ disability weight Disability weights are used to represent the HRQL in DALYs based on nonfatal health outcomes in line with the International Statistical Classification of Diseases, Injuries and Causes of Death (Roth et al. 2018). In describing a health condition/ disability, non-desirability is assigned a value on a scale from 0 and 1, where 0 represents perfect health and 1 represents death (this is the opposite of the scale used for QALYs). As with QALYs, HRQL weights for DALYs are assessed by asking the study participants to assign disability weights to a specific disease or health condition by using one of various trade-off techniques. In addition to disability weights, DALY estimates have also tended to include a weighting for age, in which young adults who are considered productive and contributing to the economy are given preference over the very young and older adults, who tend to be more dependent. However, based on ethical grounds of the approach devaluing the lives of the so-called “nonproductive” members of society, these age weights are rarely used. In addition to disability and age weights, other factors that could potentially influence how and why DALYs and other HALY estimates are made include: “How long should people live?,” “Is a year of healthy life gained now worth more to society than a year gained sometime in the future?,” “Are lost years of healthy life valued more at some ages than at others?,” “Do all people of the same age lose the same amount of health when they die?,” and “Are all people equal?” (Young 2005; Murray et al. 1996). Given the controversies about the values given to these social questions, not all DALY estimates include disability weights. With ongoing development in global health, the required information for the assessment of HALYs can be obtained from a variety of sources: vital statistics, data

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from reportable diseases, healthcare utilization data, country censuses, national and local surveillance data, hospital records, national or regional surveys (e.g., household health survey), records with security agencies such as the police, death certificates and mortuary records, and, in countries where they are used, verbal autopsies. However, as with all research areas, data from a number of these sources are invalid, untimely, derived from unknown sources, and not disaggregated by age and sex, thus potentially biasing research findings (Roth et al. 2018). Detailed steps to addressing these challenges are available in Lozano et al. (2012).

Strengths and Limitations of DALYs and QALYs Although QALYs provide an indication of the benefits gained from a health intervention as per quality of life, their usefulness can sometimes be questioned. For instance, the definition of a “perfect health” is a major issue. It has also been suggested that some health states might be worse than death, a perception that is subjective to prevailing sociocultural societal factors. QALYs have also been found to lack sensitivity when comparing two competitive but similar drugs or when evaluating treatments for less severe health problems (Phillips 2009). The effects of chronic diseases, where quality of life is compromised but survival is not, are also difficult to assess using QALYs; hence disease-specific measures of life quality, such as DALYs, are considered more suitable. Furthermore, because QALYs depend on age, context, and responsibilities in different life stages, they can be difficult to quantify if a preventive intervention will not have an effect on health outcome in the short term. Another criticism of QALYs is the lack of weight associated with emotional or mental health and the impact of these problems on quality of life for individuals and relatives (Phillips 2009). Unlike QALYs, DALYs are associated with a specific disease, rather than with a state of health. This approach helps to get a better estimate in a population that may have a high mortality rate but with a tendency to not describe their health as poor for certain reasons, such as cultural norms (Gold et al. 2002). However, DALY estimates do not capture a disease burden in its entirety as psychological effects of disease on caregivers or relatives of a patient are often omitted. Notably, age weighting is considered the most controversial societal value in DALY. When including age weights as a criterion for priority setting, a year of healthy life at younger and older ages is given less weight than a year of health at other ages; that is, a year of life in young adulthood is valued more than a year of life in childhood or old age (Murray et al. 1996). In many settings, this expresses an interest in productivity and a return on investment in the education of children. In fact, one of the main concerns about DALY is that it is mostly an economic measure of productive capacity for the affected individuals. Thus, some global health stakeholders do not agree on this principle or on the magnitude of the difference between the ages and therefore omit age weighting (Young 2005). Furthermore, the use of discounting (comparing the value of a healthy year lived now to the value of a healthy year in the future) has been criticized as a social value choice given its perceived subjectivity. Overall, when comparing burden of disease estimates, it is important to know which social values have been included in the analysis as results may differ according to the weights included.

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Conclusion This chapter has outlined the basic epidemiological concepts and explained important measures for understanding epidemiological measures in global health while contextualizing these with examples from studies conducting the LMIC context. Epidemiological methods depend on the research question, whereas it is important to ensure that the statistical approach carefully addresses confounding and potential biases in the study design, collection of data, analysis of data, and interpretation of findings. Moreover, sample size should be estimated adequately, preferably in consultation with a medical statistician, especially in a randomized controlled trial where ethical considerations are of utmost importance. By exploring typical (incidence, prevalence, and mortality rate) and atypical (QALYs and DALYs) epidemiological measures concurrently, this chapter provides a broader view of disease burden estimation in global health. Proper skills and expertise in epidemiological research methods, including data collection and analysis, provide the necessary evidence for decision-making, planning, and interventions in global health.

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Kanchan T, Kumar N, Unnikrishnan B (2015) Mortality: statistics. In: Encyclopedia of forensic and legal medicine. Elsevier, Amsterdam Klug SJ, Hukelmann M, Hollwitz B et al (2007) Prevalence of human papillomavirus types in women screened by cytology in Germany. J Med Virol 79:616–625 Koplan JP, Bond TC, Merson MH et al (2009) Towards a common definition of global health. Lancet 373:1993–1995 Lajoie J (2015) Understanding the measurement of global burden of disease Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2095–2128 Murray C, Lopez A, Harvard School of Public Health et al (1996) The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Cambridge, MA Nachega JB, Uthman OA, Ho Y-S et al (2012) Current status and future prospects of epidemiology and public health training and research in the WHO African region. Int J Epidemiol 41:1829–1846 Nature Communications (2018) Epidemiology is a science of high importance. Nat Commun 9. https://doi.org/10.1038/s41467-018-04243-3 Neumann PJ, Zinner DE, Wright JC (1997) Are methods for estimating QALYs in costeffectiveness analyses improving? Med Decis Mak 17:402–408 Phillips C (2009) What is cost-effectiveness? Hayward Medical Communications, London Quinn TC, Samet JM (2010) Epidemiologic approaches to global health. Epidemiol Rev 32:1–4 Rios-Diaz AJ, Lam J, Ramos MS et al (2016) Global patterns of QALYand DALYuse in surgical costutility analyses: a systematic review. PLoS One 11. https://doi.org/10.1371/journal.pone.0148304 Rocha S, Correia L, da Cunha A et al (2019) Zika virus infection and microcephaly: a case-control study in Brazil. Ann Glob Health 85:116 Roth GA, Abate D, Abate KH et al (2018) Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392:1736–1788 Sajedinejad S, Majdzadeh R, Vedadhir AA et al (2015) Maternal mortality: a cross-sectional study in global health. Glob Health 11. https://doi.org/10.1186/s12992-015-0087-y Saunders C, Abel G (2014) Ecological studies: use with caution. Br J Gen Pract 64:65–66 Seng JJB, Kwan YH, Goh H et al (2018) Public rental housing and its association with mortality – a retrospective, cohort study. BMC Public Health 18:665 Taylor S (2018) “Global health”: meaning what? BMJ Glob Health 3. https://doi.org/10.1136/ bmjgh-2018-000843 The BMJ (2020) Quantifying disease in populations. BMJ The Lancet (2019) Where next for randomised controlled trials in global health? Lancet 394:1481 Thiese MS, Hegmann KT, Wood EM et al (2014) Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskelet Disord Victora CG, Horta BL, de Mola CL et al (2015) Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health 3:e199–e205 Wang Y, Allen KJ, Suaini NHA et al (2019) The global incidence and prevalence of anaphylaxis in children in the general population: a systematic review. Allergy 74:1063–1080 Wang C, Horby PW, Hayden FG et al (2020) A novel coronavirus outbreak of global health concern. Lancet. https://doi.org/10.1016/S0140-6736(20)30185-9 Wolf A, Gray R, Fazel S (2014) Violence as a public health problem: an ecological study of 169 countries. Soc Sci Med 104:220–227 World Health Organization (2017) Cholera case fatality rate: situations and trends. WHO Young T (2005) Population health: concepts and methods, 2nd edn. Oxford University Press, New York

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Quantitative Methods in Global Health Research Jamalludin Ab Rahman

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Is Quantitative Research? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Initiation Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phrasing Research Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sampling Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sample Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning for Data Collection and Data Dictionary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning for Statistical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning for Report Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Collection Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reporting and Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intellectual Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Quantitative research is the foundation for evidence-based global health practice and interventions. Preparing health research starts with a clear research question to initiate the study, careful planning using sound methodology as well as the development and management of the capacity and resources to complete the whole research cycle. Good planning will also ensure valid research outcomes. Quantitative research emphasizes a clear target population, proper sampling techniques, adequate sample size, detailed planning for data collection, and J. Ab Rahman (*) Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_9

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proper statistical analysis. This chapter provides an overview of quantitative research methods, explains relevant study designs, and presents considerations on all aspect of the research cycle along four phases: initiation, planning, data collection, and reporting phase. Keywords

Methodology · Quantitative research · Health research · Data dictionary · Statistical analysis

Introduction 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 (Koplan et al. 2009). It is a new term. It sounds straightforward, but it does not yet have a definitive meaning. What we know so far is that it covers all issues related to health that affects beyond the boundary of a country. The objectives, however, remain the same, which is to improve health and to achieve equity in health. So, as far as a research methodology is concerned, the main characteristics of global health that matter is which population the study will represent. Research on health at the global level requires special consideration on all aspects of its conduct and methodology. The challenges may include heterogeneity of the study population, complex sample size calculation, absence of sampling frame, difficulty in defining study variables, and limited resources for data collection.

What Is Quantitative Research? Research methodology can be divided into qualitative and quantitative studies. While the quantitative method may answer the question of “How many people are suffering from depression?” qualitative research will try to answer, “Why many people are depressed?.” If we look from this angle, we may say qualitative research is the extension of quantitative research, but quantitative research can also become the extension of qualitative research. When we do a Focus Group Discussion (FGD), we may get a few responses that trigger us to study the magnitude of its occurrence by surveying a representative study sample, which is in this case, a quantitative research. The quantitative study is about numbers. The outcomes of the study are numbers, and sample size plays one of the essential criteria in determining the validity of the study. The quantitative study is also about being standard and structured. The method should be repeatable and reproducible; the objectives are specific, and responses during data collection are expected and countable. Most quantitative studies aim at determining causality, i.e., how changes in a variable can affect the changes in another variable (Hill 1965). One criterion that is

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Idea

Initiation

Planning & strategize (proposal)

Justify

Explore

Strategize

Data collection

Collect

Reporting & sharing

Analyse

Study design Sampling plan Sample size determination Plan for data collection Plan for statistical analysis

Report

Publish

Fig. 1 Steps in doing research

essential to decide on causality is temporality, which means that the cause or exposure should precede the outcome. Research can be done in four phases (Fig. 1); initiation, planning, data collection, and reporting phases.

Initiation Phase The first phase is where the research question emerges. It may come when facing specific problems that raised questions and queries. The idea of research can develop instantaneously. In one of the clinical-pathological conferences, an orthopedic surgeon presented a few cases of oil palm thorn granuloma of the joints and recommended to do thorough debridement to all cases of such injury presented to the emergency unit. While the recommendation is clinically relevant, it may pose an unnecessary higher workload to Emergency Departments’ staff and doctors if the prevalence of the injury is high, but the actual complication is low. So, a study was done among the oil palm fruit harvesters to ascertain the prevalence of the injury. Over 550 oil palm fruit harvesters surveyed, 61% of them had a history of at least one injury ever, and 17% went to the health facility to obtain additional medical care. Among those who went to the health facility, only 3.3% or three were admitted to the ward. This simply shows that serious complication from oil-palm thorn prick injury is low; hence policy on thorough debridement for all oil-palm thorn prick injury is not necessary. Research is about solving problems and benefitting the community. To have an idea or suitable research question for global research, one may need to think about problems and solution for a broader target population. United Nations lays out 17

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goals for the world to act through its Sustainable Development Goals (SDG) (https:// www.un.org/sustainabledevelopment/). This could be the right direction and target in doing research at the global level.

Planning Phase This is the most technical phase in doing research. Once we have an idea of what to do, we have to start planning. It begins by justifying that the topic chosen is essential and merit research. It depends on the experience of the principal researcher or the research team. If experts or those authorities in the subject matter are part of the research team, it will be easier to justify its importance. A lot of readings and literature reviews are needed if the researchers do not know the subject well. However, this should not be the case when designing a global level research collaboration, as there should be many experts involved.

Phrasing Research Objectives Research objectives are the backbone of research. It describes the purpose of the study. It provides direction and affects the conduct of the research. Use SMART criteria when constructing the objective. The objective must be specific. For example, when measuring the burden of noncommunicable diseases, statistics used to measure the burden must be mentioned clearly. It can be prevalence, incident, or even risks. Avoid using vague action verbs like, to find, to understand, or to illustrate. Use measurable verbs like to measure the prevalence, to describe the association, and to determine independent risk factors. The research should be achievable. The study should be able to be completed within the available time, resources, and expertise. The expectation of the outcome should be realistic and the study should be timebound. Milestones and progress indicators must be identified and monitored. For the study done on a specific population, it is also good to mention the target and study population explicitly. A study done among people with diabetes on insulin is not the same as diabetic as a whole. If sub-analyses are done, the denominator should be defined as well. Significant research may have multiple objectives. Therefore, it is vital to sort the objectives in a logical sequence, usually arranged chronologically. This will guide us on what to do first.

Conceptual Framework The whole idea about the study is best summarized using a visual diagram or conceptual framework. The diagram describes the main concepts, assumptions,

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Fig. 2 A multivariate model consisting of three variables

Dependent Variable

Independent Variable

Confounder

expectations, beliefs, and theories that support and explain the research. It can derive from literature review or even from the researcher’s hypothesis. It is based on some theories, constructed around the research idea that needs to be proven. It can also be used to justify the study. Concept and theories can be further improved based on literature review. This means that the conceptual framework may change to suit new information obtained from the literature review. There is no specific format on how to construct or draw the diagram. In a quantitative study, many are conducted to prove or at least to support causality. It can be multifactorial where more than two variables are involved. In such a study, it is essential to distinguish which one is the dependent variable, independent variables, and confounders (Fig. 2). The drawing can become more complicated when there are presence of third factors, like mediation and moderation (Fig. 3). A study was conducted to describe the association between snoring and cardiovascular disease (CVD) among more than 70,000 women (Hu et al. 2000). After 8 years of follow-up, it was found that occasional and frequent snorer had an odds ratio of 1.20 (95% Confidence Interval, CI 1.01–1.43) and 1.33 (95% CI 1.06–1.67) and therefore a higher risk of CVD, compared to no snorer, respectively, after adjusted for age, smoking, body mass index (BMI), alcohol use, physical activity, menopausal status, family history of myocardial infarction and diabetes mellitus, cholesterol level, hours sleeping, and sleeping position. In this straightforward example, the dependent variable is CVD, and the independent variable is snoring. All other variables are treated as confounders. To explore potential mediation effects, for example, between depression, victimization, and substance use, a theoretical diagram could summarize relevant relationship clearly (Fig. 4) (Luk et al. 2010) and helps readers to understand the study aim and design.

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Dependent Variable

Confounder

Independent Variable

Mediator

Moderator

Fig. 3 Model illustrating the presence of confounder, mediator, and moderator

Fig. 4 Theoretical model showing the mediation role of depression. (Adapted from Luk et al. 2010)

Study Design For quantitative research, the study can be divided into observational and experimental design. The difference between these designs is the presence of intervention or treatment in the experimental study (Fig. 5). Observational study means that there will be no intervention assigned to any specific group of the sample. Investigator just observes what is happening. This can be further divided into a

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Fig. 5 Type of study design

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cross-sectional study, case-control study, and cohort study. These designs differ in term of the relationship between exposure (independent variable) and outcome (dependent variable).

Cross-Sectional Study The cross-sectional study measures exposure and outcome at the same time. For example, in a study about hypertension, we may get the blood pressure reading as well as dietary history at the same sitting. Even though we know from the textbook that high-fat diet is one of the causes of hypertension, in a cross-sectional study we will not be able to prove that the unhealthy diet comes first before the onset of hypertension because maybe the diet history is reflecting the lifestyle after the diagnosis of hypertension. For such instance, we cannot prove causality as there is no clear separation of the timeline to support it. Both outcome (in this example, is the hypertension status); and exposure (in this example, is the diet history); are measured at the same time. In other words, it lacks temporality. However, this does not mean that a cross-sectional study cannot be used to study association at all. Many researchers are still using it for such purpose, even though it should not be the main reason for one to choose cross-sectional study. For example, in 2015 a study done by Sajedinejad et al. (2015) using data from 179 countries shows that education, private sector, and trade and governance were found to be the most critical macrostructural factors associated with maternal mortality. The cross-sectional study is among the most frequently used designs in healthcare research. It is the best design to measure the prevalence or burden of illness. That is why it is also known as a prevalence study. Usually, the cross-sectional design involves a large sample size and is also known as a survey, especially when it is done to represent a particular population. Can this design be applied to the global population? Of course, it can! A group of researchers (Souza et al. 2016) used a cross-sectional design to come out with global reference for Caesarean Section rates using data from 38,324 women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing. The tool can estimate the expected Caesarean Section rate in health facilities based on the characteristics of the population that they serve. The model has been published on the WHO’s website (https://www.who.int/ reproductivehealth/publications/maternal_perinatal_health/c-model/en/). Case-Control Study The case-control study consists of case and control groups. The case is the dependent variable and is defined as a subject with the outcome of interest, while control is the subject without the outcome of interest. The number of subjects is determined earlier and usually fixed. Usually, the ratio is similar, but we can opt for more cases or controls depending on the desired statistical power (Hennessy et al. 1999). For both case and control groups, their exposure (independent variables) to certain risk factors will be measured. In other words, we fix the outcome, and we measure the exposure, unlike in cross-sectional study when both exposure and outcome variables are measured at the same time.

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INTERSTROKE is a case-control study studying risk factors for stroke in 32 countries worldwide (O’Donnell et al. 2016). Cases were patients with acute first stroke within five days of symptom onset and 72 hours of hospital admission. Controls were hospital-based or community-based individuals with no history of stroke and were matched with cases, recruited in a 1:1 ratio, for age and sex. They discovered that previous history of hypertension or blood pressure of 140/90 mm Hg or higher, regular physical activity, apolipoprotein (Apo)B/ApoA1 ratio, diet, waistto-hip ratio, psychosocial factors, current smoking, cardiac causes, alcohol consumption, and diabetes mellitus were associated with all stroke outcome. These factors contributed 90.7% of population attributable risk for all stroke worldwide. They also found that the factors were consistent in all countries and differed only at the importance when looking at the magnitude of the Odds Ratios. We use case-control study for few reasons: (1) to determine the association between two variables, (2) when the outcome is rare, and (3) we are interested in studying multiple factors (exposures) that are related to the outcome. In the above example, the outcome variable is all stroke, and the interest is to determine the factors that caused the stroke. Cross-sectional is not a good option here because it does not have a temporal relationship and therefore, will not be an excellent design to determine causality. Stroke is rare. To conduct a prospective study and wait for a group of people to develop stroke will take a long time and therefore, not the right choice of study design. A case-control study is then the best method for this situation.

Cohort Study Both the cohort study and case-control study are called longitudinal studies. It is because they consider element of time in the design. Exposure and outcome variables are separated by a certain time period. Exposures are identified at the inception, and the study progresses to measure the outcomes. This makes the cohort study as a good study to determine causality. Previously in the case-control study, the variable to be observed or measured is the exposure. In determining causality, exposure (or cause) should precede outcome (or effect). That is why the case-control study is known as a retrospective study. In the INTERSTROKE study, the outcome was a stroke, and the study was observing risk factors for the stroke. The Framingham Heart Study is one of the most popular cohort studies. It was initiated to discover the cause and risk factors of CVD. Framingham, which is a city in the Commonwealth of Massachusetts in the United States, was neither a random nor entirely representative sample, it was chosen among others because it was a convenient and stable place where the population can be observed for an extended period of time with adequate medical facilities to monitor the outcomes repeatedly. Cohort study involves following up the study population over a period of time. They need to be examined at specific intervals to observe for the occurrence of outcomes of interest. This should be the main criteria when selecting the suitable study population for a cohort study. Because of this purpose, it is not easy to have a cohort study involving many countries. It is not easy to follow up a specific group of people from many countries over a long period of time.

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Experimental Study Experimental study design requires intervention, unlike observational studies. The effect of the intervention between groups will be compared. Experimental study or trial can be applied to animals (animal trial), human (clinical trial), or community (community trial). The animal trial is usually the first initial phase of a clinical trial. Efficacy and safety of specific drugs are being tested in animals. Once considered safe, it will be tested in a small number of volunteers. If safety has been further assured, the study will be conducted in a more significant number of the human sample before eventually it will be conducted at multiple centers all over the world. The main strength of an experimental study is its ability to measure causality. Statins are essential in the secondary prevention of heart diseases. Scandinavian Simvastatin Survival Study (4S), which recruited 4444 patients with known CVD and hypercholesterolemia were randomized to simvastatin and placebo groups. Simvastatin therapy led to a 35% reduction in low-density lipoprotein (LDL)cholesterol, an 8% increase in high-density lipoprotein (HDL), and a 10% reduction in triglycerides after a mean follow-up of 5.4 years. There were 182 deaths in the simvastatin group compared to 256 deaths in the placebo group. Simvastatin reduced 30% in overall mortality. These findings support the use of statins for CVD patients (Scandinavian Simvastatin Survival Study 1994). A more recent study was done in Scotland, Ireland, and the Netherlands, where 5804 elderly with CVD were randomized to pravastatin and placebo groups (Ford et al. 2002; Shepherd et al. 2002). After an average of 3.2 years follow-up, pravastatin was found to reduce the risk of coronary disease in elderly individuals. These long-term follow-up experimental studies have changed the way clinicians treat their patients. When the study covers many countries, its effectiveness can be measured in a more diverse characteristic, and therefore its application can be generalized to a broader population.

Sampling Techniques Rarely a study involves universal sampling, where the entire study population will be selected. Instead, only a portion of the intended population will be sampled. There are two broad types of sampling, random sampling and nonrandom sampling. However, in both methods, the sample must be able to represent the study population very well.

Random Sampling Random sampling requires a sampling frame, which is a list of sampling units, or a list of eligible subjects or entities for sampling. The entity to be sampled does not have to be the individuals, but it can even be the villages, schools, or houses. It is almost impossible to conduct a study that is able to represent the entire world. We can prepare a list of suitable countries and select some countries randomly. This technique is called simple random sampling. All the countries will be considered as homogeneous and will have an equal chance to be selected. However, by doing so, it

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is not impossible that we might end up selecting none from specific regions. If we want to make sure all regions are equally represented, we use stratified random sampling. Countries are first stratified into groups, e.g. Asia, Europe or America, known as a stratum. All the strata will be chosen. However, please take note that within the stratum, not all the countries will have to be chosen. Usually, we may want to assign the number of countries per stratum proportionately to the size of the total population. Those selected will have to represent those not selected within the stratum. This part of the sampling is known as clustered random sampling. In summary, in stratified random sampling, all strata will be chosen, but in random cluster sampling, not all clusters will be sampled. So to represent the world based on WHO Regions; America, Africa, South East Asia, Western Pacific, Eastern Mediterranean, and Europe we may sample all the regions by applying stratified random sampling, but we may sample only some of the countries in each region by applying cluster random sampling. Anything that does not involve a simple random sampling is known as complex sampling. Some adjustment to the statistical analysis, especially to its variances, must be made as well as the consideration of the expected design effect in the sample size calculation.

Nonrandom Sampling In studies where sampling frame cannot be predetermined, researchers can opt for nonrandom sampling. Nonrandom sampling may not be able to represent a particular population by its location, but it is still able to represent the population by their characteristics. In a clinical trial among people with diabetes, for example, as long as the subjects are recruited based on criteria that are able to represent the people with diabetes, even though it was not selected randomly, the samples still represent the people with diabetes. However, if the sampling was done haphazardly, with no clear selection criteria, it will not be able to represent any specific population. So as long as there are certain selection criteria, regardless how the sample is being sampled, e.g., until it reaches the certain quota, or based on a voluntary basis, or by using a snowballing technique, it can still represent specific population.

Sample Size Sample Size Calculation The next important step in a quantitative research is the estimation of sample size. The most practical reason to calculate sample size is to estimate how many resources we need. The bigger the sample size, the more research enumerators required to collect data, more time need to be allocated and obviously more money must be prepared. Nevertheless, the bigger the sample is, the smaller will be the variances observed, and more accurate the results will be. Enough sample is also necessary to obtain the statistical power to detect a significant difference. An 80% power means 80% probability to make a correct decision, which in statistical words means the

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ability to reject the null hypothesis when it is false. What does this really mean? Imagine we would like to measure the difference in the prevalence of hypertension between two countries. If the truth is, one is higher than the other, but our samples are small, we may not be able to represent the countries well, and we may end up having no significant difference after statistical analyses. If we could increase the sample size per country, we then are able to represent the countries good enough to really detect a significant difference. Thus, a larger sample size gives more statistical power to detect a true association. However, we may also need a smaller sample size than assumed. The sample size needed for a study to detect a difference in prevalence between 50% and 60% is not the same as a study to detect a difference between 40% and 60%. The smaller the expected difference, the bigger the needed sample size. We also need to calculate the sample size for the purpose of research logistics. If we know how many samples are required, we can plan appropriately in terms of how many days are required to complete the data collection based on how many staff we have. In fact, if we have a specified duration to complete the data collection, we may then need to increase the number of staff to help with data collection.

How to Calculate the Sample Size? Sample size calculation depends on the research objective. If we plan to compare two proportions, we use the formula to compare two proportions. If we plan to compare two means, a formula to compare two means can be used. If the main objective is to measure survival curves between two treatments, we use the formula that compares overall survival times. As long as we know why we want to analyze, and we have their estimations, we can calculate the minimum required sample size needed. For example, let us use the sample size calculator OpenEpi, available in www. openepi.com, an online, free open source, web-based application. Say, we want to conduct a study to compare the prevalence of hypertension between countries. When we compare, it means that there will be two values at one time. Therefore, we can use a formula that compares two proportions. In OpenEpi, we can use either formula for unmatched CC (case-control) or formula for Cohort/RCT (Randomized Clinical Trial) (Fig. 6). The formulae given are using the same method from Kelsey, Fleiss, and Fleiss with continuity correction. If we wish to compare prevalence of 40% versus 50%, at 95% CI and 80% power, we precisely need a total sample size of N ¼ 778, 776, and 816 based on the three different methods. When calculating sample size, it is essential to note that, it is done a priori, and calculated based on plausible assumptions. Therefore, the sample size needed is always an estimate. Since there are estimates (based on 40% and 50% expected differences), we can cite around 800 participants needed in total. If we anticipate 20% may not respond to our invitation to participate in the study, we can increase the sample size to another 160 cases, and this may roughly bring us to 1000 participants needed per country.

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Fig. 6 Using OpenEpi to calculate sample size

Top-Down Versus Bottom-Up Approach There are two options when we calculate the sample size for a large populationbased study. We can calculate how many participants are needed for the whole country and then distribute the participants among all the states (top-down), or we can also calculate for each state first and combine the values for the country’s figure

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(bottom-up). The latter approach will yield a large sample size for the country, but by doing so, the study is also able to provide the prevalence for each state. A top-down approach will be able to give a national estimate, but sub-analysis by state may not have sufficient statistical power. The same approach can be used when we calculate the sample size for a study involving a few countries. Ideally, the number of participants per country should be determined by its total population. Larger countries may need more participants. However, in many global studies, we observe that similar minimum sample sizes were assigned to each country. For example, in the Global Adult Tobacco Survey (GATS), a minimum of 8.000 participants are required for each country with equal distribution for urban and rural areas (Palipudi et al. 2016).

Planning for Data Collection and Data Dictionary Identification of Variables We should not create a questionnaire or record form without careful planning. Only relevant variables identified earlier in a literature review, and likely to answer the research question, should be collected. We should not collect variables on the basis of “just in case” or “to analyze those variables later if needed.” Each variable cost a substantial amount of resources, from data collection to data entry into the database, data cleaning, and analysis. Each question or variable measured also requires considerable time and resources during the planning stage. Therefore, every individual variable must be carefully selected and justified. Data Dictionary A data dictionary defines and describes all of the variables used in a study. In global research, where the research culture and research environment may vary, a clear description of what the variables are and how they will be collected is essential. A data dictionary can be considered the extension of a codebook. A codebook is a document to describe all the variables, but mainly in terms of the meaning of each code used and a description of the responses. A simple example is the variable sex. We may assign “1” for male and “2” for female. If the variable is numerical and no dummy code assigned, the information about its unit used or how precise it will be recorded will be described. Data dictionary will explain more than just that. It may state how the question shall be asked if the questionnaire is used as a face-to-face interview, and it may contain definitions used for that variable. The National Health and Nutrition Examination Survey (NHANES) is a series of surveys to investigate the health and nutritional status of adults and children in the United States since the 1960s (https://www.cdc.gov/nchs/nhanes/about_nhanes. htm). Just like studies done at the global level, NHANES need to make sure the variables are being measured consistently over time for a different population. Therefore, they produce their own data dictionary (https://wwwn.cdc.gov/Nchs/ Nhanes/2015-2016/DEMO_I.htm) to describe variables collected for each series of the survey. In the example shown in Fig. 7 below, for variable on “Education Level,”

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Fig. 7 Description for Education Level collected in NHANES 2015–2016

the description includes the variable name as in dataset, the label used, the English text, the instruction on how to obtain the information and to whom the question is relevant. Also included is the code value, value description (value label), and their frequency. The data dictionary also has a column to state how many codes skip specific values. Since the data dictionary was made after data had been collected, they were able to include a number for each value.

Data Collection Form Once the variables to be measured had been identified and described clearly, we can design the form for data collection. Basically, we have two options, using the traditional paper and pen; or using an electronic form. The electronic form can be further divided into real-time data entry or offline entry. Not every country has good internet infrastructure. Some may have good internet penetration, but many still struggle even to provide basic landline internet access. Therefore, it is very crucial that the data collection form method chosen is practical to be used in the participating countries. Development of an electronic data collection form requires advanced technical expertise. Investigators need to identify suitable information technology (IT) expert or vendor to design and create the form. It is a trend now to use the form using a tablet or any mobile device. It this way, data can be captured immediately into the

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database and will avoid another possible step for error, i.e., data transfer from the form to a database. The electronic form also allows the investigator to include validation rules. This can further improve the quality of data collection. For example, when entering data on age, it would be ridiculous if someone is 200 years old. A typographical error can happen if the system is not able to detect a simple mistake like this. In electronic form, we can set confirmation warning every time enumerator enters any age above 100 years old. The electronic form also allows us to set the skip question properly. If the respondent is male, any question specifically for female will be hidden and will not be asked. Similarly, questions pertaining to occupation and income will not be asked to children if we assume children do not work. There are few articles or books that describe designing data collection form in great detail (Bourque and Clark 1992; Higgins et al. 2019; Worthington 2016). Once the form is ready, it is crucial to check and test it. A small sample of respondents, preferably with the same characteristics of the study population, should be selected for this exercise. The aim of the exercise is to identify problems faced by respondents as well as the numerator, as well as to detect any bug in the software developed. It can be repeated many times until investigators are satisfied with its quality.

Online Versus Offline Data Collection Going from house to house to collect data is time-consuming and expensive. However, the sampling frame is easy to be determined and able to represent the target population. The main problem with online data collection is the difficulty to have a sampling frame or to obtain samples that are able to represent the study population. Most studies opted for unrestricted self-selected surveys (Fricker 2017). Online data collection is also biased toward a population that can access the internet. It may also have selection bias toward younger generations. Nonetheless, given the current global advancement and coverage of the internet, the online survey is the way forward. Logistic Planning It is now time for us to plan the logistic requirements for data collection. The logistic planning for house-to-house survey requires careful planning (Table 1). We should start by knowing who the study population is and where they are. People live in different types of dwellings. Some reside in single-unit houses, some in terrace houses while others in high rise apartment or condominiums. They may live in

Table 1 Information required for the logistic planning of house-to-house data collection 1. Number of respondents. 2. Location and type of residence. 3. Number of enumerators needed. 4. Number and dates for the training sessions. 5. Time and duration for the actual data collection. 6. Legal and safety issues during data collection.

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urban areas, and many are in rural as well. We also should know how much time we have to complete the data collection because this will allow us to calculate how many enumerators are needed. Frequency and dates for training is a part of the planning process. This is an excellent exercise to gauge the workload and the time needed for the actual data collection later. Finally, before all numerators go to the designated houses, the community and local authorities must be notified. If the data collection is to be done using an online platform, there will be fewer data enumerator needed. We still need to identify a suitable study population. For a probability-based internet survey, the sampling unit is their online identity, such as email address. The other approach is to do an open public survey. The number of samples is based on the selection criteria defined earlier and may apply purposive sampling to get the representative samples.

Data Management The result of any data analysis is as good as the data entry: Garbage in, garbage out. Quality of data must be assured from the identification of variables, data collection process, analysis, and reporting. When managing data at the global level, it is paramount to use existing standards. There are at the moment two popular standards, Open Data and FAIR Data Principles. Both are about sharing and collaborating data. Open Data is “data that can be freely used, re-used and redistributed by anyone – subject only, at most, to the requirement to attribute and share alike” whereby in FAIR Data Principle refers to data being Findable, Accessible, Interoperable, and Reusable (Table 2) (Wilkinson et al. 2016). While Open Data concerns on data being Table 2 The FAIR Data Principles To be findable: F1. (meta)data are assigned a globally unique and persistent identifier F2. Data are described with rich metadata (defined by R1 below) F3. Metadata clearly and explicitly include the identifier of the data it describes F4. (meta)data are registered or indexed in a searchable resource To be accessible: A1. (meta)data are retrievable by their identifier using a standardized communications protocol A1.1 The protocol is open, free, and universally implementable A1.2 The protocol allows for an authentication and authorization procedure, where necessary A2. Metadata are accessible, even when the data are no longer available To be interoperable: I1. (meta)data use a formal, accessible, shared, and broadly applicable language for knowledge representation. I2. (meta)data use vocabularies that follow FAIR principles I3. (meta)data include qualified references to other (meta)data To be reusable: R1. meta(data) are richly described with a plurality of accurate and relevant attributes R1.1. (meta)data are released with a clear and accessible data usage license R1.2. (meta)data are associated with detailed provenance R1.3. (meta)data meet domain-relevant community standards Adapted from Wilkinson et al. (2016)

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available to everyone, FAIR Data believes in standard sharing data process between relevant parties.

Planning for Statistical Analysis Quantitative research emphasizes on numbers either to measure the magnitude of the estimates (descriptive statistics) or to compare different estimates (analytical statistics). If we are interested in measuring how many people in a housing area have hypertension, only one variable, i.e., hypertension status (Yes or No), is involved. We can describe the data using count and percentage. If there are 1000 people in the study area and we managed to sample everybody, and if 300 of them have hypertension, the prevalence of hypertension among that 1000 people is 30%. We have successfully described the prevalence of hypertension in the area. The analysis becomes inferential statistics when we wish to determine the relationship of the prevalence with other variables. For this purpose, more than one variable involved, and we need additional information to support the decision. If two variables are involved in the analysis, it will be known as univariate analysis, and multivariate analysis for more than two variables (Fig. 8). Univariate analysis is an examination of the relationship examining the relationship of one independent variable on the outcome. We are interested in studying how

Fig. 8 Planning for statistical analysis

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changes in one variable can affect the changes in another variable. For example, how certain diet can affect the changes in blood pressure. In this example, diet is the exposure, and blood pressure is the outcome. In real life, there is not only one variable that causes changes in blood pressure. Blood pressure can be affected by age, sex, lifestyle, psychosocial factors, and underlying diseases. Therefore, a more appropriate analysis would be a multivariate analysis. From the multivariate analysis, we could identify what significant variables related to changes in blood pressure are. We can even measure the strength of association between the different variables. While qualitative research can identify relevant variables regarding the issue being studied, quantitative research would be able to measure their importance. A proper statistical analysis plan should be developed based on each specific objective of the study. The plan should include the variables involved, their level of measurements, the null hypothesis if the analysis is analytical, the statistical test used, and dummy tables to present the findings.

Planning for Report Writing The planning stage will not be complete until we plan how we report the study findings. We start by identifying the target audience and what content to share. We should also identify the platform that we will use to share the report and findings.

Data Collection Phase Most of the time and resources are spent at this phase. The effectiveness of the research plan prepared will be tested. Therefore, it may be helpful to perform some field trial or pilot testing of prepared protocols before initiating full data collection. Once data collection is started, continuous monitoring and documentation are needed to check the progress and status of each process. The progress must be monitored appropriately using prespecified milestones. Each task must have the estimated duration for completion and deadline. Furthermore, efforts must be made to ensure the quality of data collection is maintained during the whole data collection phase. Failure to ensure excellent and correct data collection will result in more serious problems later in the research cycle. It must be done right at all time.

Data Analysis Data analysis is the continuation of data management. Good data entry will ensure good results. A good statistical practice is about avoiding mistake and misunderstanding from the moment the data is being measured to eventually reported

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(Preece 1987). The analysis should follow the statistical analysis plan, which was prepared earlier, and any deviation from the plan must be recorded and reported to the monitoring committee.

Reporting and Sharing The reporting phase starts after data collection and analysis is finished. Each report must have a clear objective. Are we reporting to justify the budget given by the sponsor? Or are we reporting to inform the research community or change health policy? The impact of any study is increased by proper reporting and data sharing. The findings must be shared and disseminated to all stakeholders or people who can benefit from the study. At this, the amount and depth of the information shared should be right for the right target audience. Most important of all, the study must benefit the community. Therefore, the findings should not be deliberated and discussed among professionals, but engagement should be done with the people who are affected by the study. To correctly report research findings, use one of the available guidelines at the EQUATOR network website (http://www.equatornetwork.org/library/) (Fig. 9).

Intellectual Property Global collaboration needs special attention regarding the intellectual property issue. Rules and regulations with regard to data and research output sharing are often complex without international standards. Furthermore, research approval processes may differ from one country to another and even from one institution to another. Most often legal advice is needed, to draft a proper research agreement.

Conclusion Quantitative methods for global health research should be carried out in an organized, precise, and transparent manner. It is a technical endeavor and requires detailed planning. Proper planning should produce the following four outputs: (1) clear conceptual framework as the product of literature review, (2) SMART objectives, (3) detailed data dictionary, and (4) a dummy table for expected statistical analysis of each objective. Planning for quantitative health research is tedious and requires a walkthrough vision of the study planned. When many collaborators are involved, modifications may be necessary, and a more generic approach is inevitable.

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Fig. 9 EQUATOR Reporting Guideline

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References Bourque LB, Clark VA (1992) Quantitative applications in the social sciences: processing data. Hist Soc Res. https://doi.org/10.4135/9781412985499 Ford I, Blauw GJ, Murphy MB, Shepherd J, Cobbe SM, Bollen ELEM et al (2002) A prospective study of pravastatin in the elderly at risk (PROSPER): screening experience and baseline characteristics. Curr Control Trials Cardiovasc Med 3(1):8–8. https://doi.org/10.1186/14686708-3-8 Fricker R (2017) Sampling methods for online surveys. In: The SAGE handbook of online research methods, pp 162–183. https://doi.org/10.4135/9781473957992 Hennessy S, Bilker WB, Berlin JA, Strom BL (1999) Factors influencing the optimal control-tocase ratio in matched case-control studies. Am J Epidemiol 149(2):195–197 Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (2019) Cochrane handbook for systematic reviews of interventions. Wiley, Hoboken Hill AB (1965) The environment and disease: association or causation? Proc R Soc Med 58(5):295– 300. Retrieved from https://pubmed.ncbi.nlm.nih.gov/14283879. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC1898525/ Hu FB, Willett WC, Manson JE, Colditz GA, Rimm EB, Speizer FE et al (2000) Snoring and risk of cardiovascular disease in women. J Am Coll Cardiol 35(2):308–313. https://doi.org/10.1016/ S0735-1097(99)00540-9 Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN (2009) Towards a common definition of global health. Lancet 373(9679):1993–1995. https:// doi.org/10.1016/s0140-6736(09)60332-9 Luk JW, Wang J, Simons-Morton BG (2010) Bullying victimisation and substance use among U.S. adolescents: mediation by depression. Prev Sci: The Off J Soc Prev Res 11(4):355–359. https:// doi.org/10.1007/s11121-010-0179-0 O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H et al (2016) Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 388(10046):761–775. https://doi.org/10.1016/ s0140-6736(16)30506-2 Palipudi KM, Morton J, Hsia J, Andes L, Asma S, Talley B et al (2016) Methodology of the global adult tobacco survey – 2008–2010. Global Heal Prom 23(2_suppl):3–23. https://doi.org/10. 1177/1757975913499800 Preece DA (1987) Good statistical practice. J Roy Stat Soc Ser D (The Statistician) 36(4):397–408. https://doi.org/10.2307/2348838 Sajedinejad S, Majdzadeh R, Vedadhir A, Tabatabaei MG, Mohammad K (2015) Maternal mortality: a cross-sectional study in global health. Glob Health 11:4. https://doi.org/10.1186/s12992015-0087-y Scandinavian Simvastatin Survival Study, G (1994) Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 344(8934):1383–1389. https://doi.org/10.1016/S0140-6736(94)90566-5 Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM et al (2002) Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 360(9346):1623–1630. https://doi.org/10.1016/s0140-6736(02)11600-x Souza JP, Betran AP, Dumont A, de Mucio B, Gibbs Pickens CM, Deneux-Tharaux C et al (2016) A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG 123(3):427–436. https://doi.org/10.1111/1471-0528.13509 Wilkinson MD, Dumontier M, Aalbersberg IJ, Appleton G, Axton M, Baak A et al (2016) The FAIR Guiding Principles for scientific data management and stewardship. Sci Data 3(1):1–9 Worthington R (2016) Best practices for designing data collection forms. Retrieved from http:// www.kwantu.net/blog/2016/12/26/best-practices-for-designing-data-collection-forms

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Qualitative Research in Global Health Research Pranee Liamputtong and Zoe Sanipreeya Rice

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Value of Qualitative Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Qualitative Inquiry and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Qualitative Inquiry and Evidence-Based Practice in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . Qualitative Research and Its Salient Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inductive Approach and Theory Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodological Justification: Methodological Framework(s) Is Essential . . . . . . . . . . . . . . . . . Multiple Ways for Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Source of Data in Qualitative Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analytic Strategies and Qualitative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trustworthiness and Qualitative Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Qualitative Researchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Empirical Example of How We Conduct a Qualitative Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter discusses the contribution of qualitative research and its value in global health. Qualitative research alludes to “a broad approach” that qualitative researchers adopt as a means to examine social circumstances. The inquiry posits that people use “what they see, hear, and feel” to make sense of social experiences. There are many features that differentiate qualitative research from the quantitative approach. Fundamentally, it is interpretive. The meanings and interpretation of the participants are the essence of qualitative inquiry. Qualitative P. Liamputtong (*) School of Health Sciences, Western Sydney University, Penrith, NSW, Australia e-mail: [email protected] Z. S. Rice Independent Researcher/Scholar, Camberwell, VIC, Australia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_10

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research is valuable in many ways. It offers researchers to hear silenced voices, to work with marginalized and vulnerable people, to address social justice issue, and to contribute to the person-centered healthcare and the design of clinical trials and plays an important role in evidence-based global health. Qualitative researchers are seen as constructivists who attempt to find answers in the real world. Fundamentally, qualitative researchers look for meanings that people have constructed. In this chapter, we discuss the value of qualitative research, qualitative inquiry in global health, qualitative research, and evidence-based practice in global health. The chapter also discusses in great depth some distinctiveness of the qualitative research, in particular the inductive nature of qualitative research, methodological frameworks, purposive sampling technique, saturation concept, qualitative data analysis, and the trustworthiness of a qualitative study. We also provide a concrete example of how a qualitative study was undertaken using details from the research project that we have conducted. Keywords

Qualitative inquiry · Meaning · Interpretation · Evidence-based practice in health · Methodological framework · Saturation · Trustworthiness · Qualitative researcher

Introduction Words, especially when they are organized into incidents or stories, have a concrete, vivid, meaningful flavor that often proves far more convincing to a reader – another researcher, a policymaker, or a practitioner – than pages of summarize numbers. (Miles et al. 2015, p. 4)

Qualitative inquiry alludes to “a broad approach” that qualitative researchers adopt as a means to examine social circumstances. The inquiry is based on the position which argues that people use “what they see, hear, and feel” to make sense of their social experiences (Rossman and Rallis 2017, p. 5). Fundamentally, qualitative research contributes to the social inquiry which aims to interpret “the meanings” of people’s actions and behaviors (Bradbury-Jones et al. 2017). It is a type of research that embodies individuals as the “whole person living in dynamic, complex social arrangements” (Rogers 2000, p. 51). The focus of qualitative is on the social world. The approach offers in-depth explanations for “social actions” (Rossman and Rallis 2017). In the social world, we deal with the subjective experiences of individuals. In different social situations and over time, people’s perceptions of their reality can change (Dew 2007). This makes qualitative research different from researching the natural world, which can be treated as “objects” or “things” (Taylor et al. 2016). In order to capture and understand the perspectives of individuals, qualitative research relies heavily on words or stories that these individuals tell researchers (Patton 2015; Creswell and Poth 2018; Liamputtong 2020). Thus, qualitative research has also been recognized as “the word science” (Liamputtong 2017, 2020).

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Qualitative research has been adopted extensively in the social sciences, particularly in anthropology and sociology. We have also witnessed the wider adoption of a qualitative approach in health and medicine. In the past decade or so, qualitative data or interpretive information has been gradually accepted as a crucial component in our understanding of health (Liamputtong 2017, 2019a, b, 2020). In the new public health that recognizes the need to “understand” people, qualitative research is needed since it offers “considerable strength in understanding and interpreting complexities” of people’s behavior and their health issues (Baum 2016, p. 201). In this chapter, we will discuss the contribution and nature of qualitative research in global health. In particular, we discuss the value of qualitative research, qualitative inquiry in global health, qualitative research, and evidence-based practice in global health. The chapter also discusses in great depth some distinctiveness of the qualitative research, in particular the inductive nature of qualitative research, methodological frameworks, purposive sampling technique, saturation concept, qualitative data analysis, and the trustworthiness of a qualitative study. We also provide a concrete example of how a qualitative study was undertaken using details from the research project that we have conducted.

The Value of Qualitative Research Qualitative research is adopted because there is a global health problem or issue that needs to be explored (Creswell and Poth 2018). This is particularly when the health problems or issues cannot be easily counted with statistics and when “silenced voices” need to be heard. Qualitative inquiry permits researchers to ask questions, and to find answers, that can be difficult or impossible with the quantitative approach (Hesse-Biber 2017; Liamputtong 2020). For example, What makes many people unable to adhere to medicines? How do Chinese-Australians deal with racist remarks and discrimination of a recent outbreak of the novel coronavirus in Australia? How do Asian Australians feel about the label of a “Chinese virus” on the front page of the Herald Sun newspaper? How does the recent coronavirus impact the everyday life of Asian people in the globe? Why are people in poor nations afraid of going into hospital? Why are breast cancer screening programs underused by women from ethnic minority groups? What contributes to stigma and discrimination of HIV/AIDS despite extensive media and educational campaigns in the country? Why do women with low incomes have many children? How do young refugee people deal with social exclusion? Why do some health programs or interventions do not work? What makes some of these programs/interventions succeed? These are some examples of what qualitative research can find answers for health and social care policy-makers and professionals. Qualitative research is crucial for research involving marginalized, vulnerable, or hard-to-reach individuals and communities in the globe (Liamputtong 2007, 2010, 2020; Taylor et al. 2016; Flick 2018). This is particularly so when they are “too small to become visible” in quantitative research (Flick 2018, p. 452; Yin 2016). More importantly, due to their marginalized, vulnerable status and distrust in research,

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most of these individuals tend to decline to participate in research. The nature of qualitative inquiry will permit qualitative researchers to be able to engage with these individuals. Qualitative research has increasingly received interest in evidence-based practice in healthcare and the patient-centered care (Olson et al. 2016; Liamputtong 2017). This is mainly because qualitative inquiry can cultivate great understanding of the beliefs, attitudes, and behaviors of the patients and consumers (Liamputtong 2017, 2020; Olson et al. 2016). These in-depth understanding will permit health professionals to better accommodate health interventions to suit the needs of the consumers. In the areas of HIV/AIDS, for example, HIV/AIDS is a global public health concern, and antiretroviral therapy (ART) has saved many lives worldwide. However, non-adherence to ART is still a huge issue in most parts of the world (Liamputtong et al. 2015). Qualitative research can contribute greatly to our understanding the non-adherence of combination antiretroviral therapy (ART). Qualitative inquiry provides a unique means for understanding the complex factors that influence adherence (see Sankar et al. 2006; Liamputtong et al. 2015). According to Sankar et al. (2006), qualitative inquiry offers persuasive means for exploring adherence to ART. Often, there are many factors that influence adherence among individuals including culture, stigma, medication beliefs, and access. Sankar et al. (2006, p. S54) argue that “a disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions.” Sankar et al. (2006, p. S65) also contend that thus far qualitative research has been essential in studies concerning ART adherence as it has unfolded “key features and behaviors that could not have been identified using quantitative methods alone.” Qualitative research can contribute effectively to the design of clinical trials in health care (Toye et al. 2016). Qualitative inquiry helps trial researchers to know their trial participants better. It can also help the researchers to apprehend the successes and failure of trial interventions, which can save money on trials that might not work (Toye et al. 2016). Essentially, the qualitative inquiry can “show the human faces behind the numbers, providing critical context when interpreting statistical outcomes,” as well as make sure that “the numbers can be understood as constituting meaningful changes in the lives of real people” (Patton 2015, p. 179).

Qualitative Inquiry and Global Health There has been an increasing interest to amalgamate the qualitative approach into traditional biomedical research in global health. In global health, social surveys tend to be used to determine the social determinants of health. However, social surveys often neglect to catch “underlying pathways of pathogenesis” which can only be captured by discerning the immeasurable meanings, perceptions, and beliefs held by local people; in Adams et al.’s words, “a notion of the social that is not assumed” (Adams et al. 2019, p. 1395).

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It is argued that qualitative research can help us to understand the meanings and interpretations of health and illness of individuals and communities, why the implementations of some programs and interventions are successfully or fail and how to make them work, how do people seek healthcare, and what are the challenges to healthcare delivery in the local area (Liamputtong 2020). As presented in earlier chapters in this handbook, there are many emerging global public health issues that impact on the lives of many individuals and communities. For example, the HIV/AIDS epidemic has entered its fourth decade and continues to pose a major public health problem worldwide (Carlson 2019). Although earlier it affected people ranging from intravenous injecting drug users and sex workers to heterosexual men, it has now affected a large number of women around the globe (UNAIDS 2017). Many of these women are also mothers with young infants. According to Carlson (2019), in 2018, there were 37.9 million people worldwide living with HIV/AIDS. In 2018, 770,000 people died of AIDS-related illnesses (Carlson 2019). Among young women in developing countries in particular, the rates of infection are increasing rapidly. The majority of people living with HIV resided in low- and middle-income countries, about 68% living in sub-Saharan Africa. Among this group 20.6 million are locating in East and Southern Africa, and in 2018, there were 800,000 new HIV infections (Carlson 2019). In 2015, there were 25.6 million people with HIV/AIDS in sub-Saharan Africa (the region most heavily affected by HIV), and women comprised more than half of this number (UNAIDS 2017). Overwhelmingly, the HIV/AID pandemic has disproportionately affected women of reproductive age (UNAIDS 2014). However, according to Carlson (2019), young women are particularly at risk. Approximately, among young people aged 15-24, there are 6,200 new infections each week (UNAIDS 2019). In sub-Saharan Africa, four in five new cases of HIV are among girls aged 15–19 years. Young women aged 15–24 years are twofold more likely to be HIV-positive than men. Children and young people are also affected badly by the HIV/AIDS epidemic. In 2017 about 1.7 million children young people aged 10–24 years were living with HIV/AIDS (UNAIDS 2017). Although the number of children living with HIV has declined in recent time, in 2018, there were still 160,000 new infections among children globally (Carlson 2019). Despite the recent reduction of number of people infected by HIV/AIDS in the globe, it is suggested that the number of individuals living with HIV/AIDS will continue to grow in sub-Saharan Africa (UNAIDS 2014; Carlson 2019). It appears that women and children tend to suffer from the adverse impact of HIV and AIDS more than men (Liamputtong 2013a, 2016). Qualitative research will allow researchers to understand the meanings and experiences of individual living with HIV/AIDS as well as their families and communities. In the research conducted by Liamputtong, Haritavorn and KiatyingAngsulee with HIV-positive women in Thailand (2015), they examined adherence of antiretrovirals (ARVs) among these women. They argued that antiretrovirals (ARVs) have been seen as life-saving for HIV-positive people. However, ARVs have a darker side resulting from side effects of the medication. Since 2000, many HIVpositive people in Thailand have received antiretroviral (ARV) treatments, but the

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understanding of ARVs and practices of medication-taking among HIV-positive women have not received much attention. In their study, Liamputtong and colleagues discussed local discourses employed by HIV-positive women and health work by these individuals in their attempts to adhere to ARVs restrictions. The local discourse of ARVs was ya tan rok AIDS: medications that could resist HIV/AIDS. ARVs provided hope for the women. Although the women were affected by the side effects of ARVs, they continued to take their medication to be able to live longer and perform their duties as mothers and caregivers. They were more concerned about the practice of medication-taking. Understanding why these women were adherent to their ARVs offers insights into the social impact of these ARVs on their lives. Antiretrovirals (ARVs) have provided hope for HIV-positive people. ARVs act as part of “people’s ‘quests’ to regain control, create order, reduce dependence on others, and to feel ‘normal’ again” (Russell and Seeley 2010, p. 376). However, it is crucial to pay attention to how individuals experience and deal with the challenges associated with ARVs in their everyday life within a local context. Liamputtong et al. contend that a good understanding of the local discourse, motivation, and concerns about ARVs may assist in the expansion and sustainability of ARV therapy within the sociocultural context of the locality. Their research was based on qualitative research. The findings cannot necessarily be generalized across Thai population. However, their findings contributed to theoretical understanding about the meanings of ARVs and medication-taking practices from one low-income location and had implications for health policy relating to the provision of ARVs. As Thailand continues to expand its ARV programs, it is essential to examine factors that are associated with medication-taking practices and ARV adherence so that future implementation attempts can succeed. Additionally, a better understanding of issues that are meaningful to HIV-positive women may assist healthcare providers in their attempt to provide appropriate ARV services to them and allow policy-makers to make policy that meets the needs of women living with HIV/AIDs in Thailand and elsewhere. Their findings also contribute to future research regarding ARV therapy and women living with HIV/AIDS in different sociocultural contexts.

Qualitative Inquiry and Evidence-Based Practice in Global Health Attempts have been made in the last few decades to provide more evidence-based healthcare to individuals and communities in the globe. Thus, we have witnessed a large number of research projects carried out in the health area, and often this involves the use of quantitative methodology including experimental design, epidemiology, and systematic reviews of interventions. But will this research reflect the realities of people? Particularly, what does this mean to people who do not have opportunities to contribute in research that can be used as “evidence” in healthcare? Evidence-based practice in global health and the need for qualitative inquiry is discussed in this section. As in healthcare in general, evidence-based practice has become an important practice in global health (Olson et al. 2016; Fan and Uretsky 2017; Liamputtong

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2017, 2019a). The turn to evidence-based practice and its beliefs in “numbers” in global health has surfaced as a result of the emergence of evidence-based medicine (EBM). In particular, the trust in randomized controlled trials (RCTs) and the “production of scientifically valid results as the gold standard for evidence of efficacy” (Fan and Uretsky 2017, p. 158) have intruded into the domain of global health as well. Evidence-based global health has been referred to as “an approach that promised to create standards across all phases of the ‘production, distribution, and consumption of evidence’ grounded in ‘legitimate’ forms of statistical results” (Fan and Uretsky 2017, p. 158). Evidence-based global health is perceived as a decisionmaking process that health practitioners adopt to identify and use the best intervention strategy to address the health issue for specific individuals and groups within their local context. Evidence-based global health requires the use of “scientific research” for developing effective practices (Hess et al. 2014; Liamputtong 2017, 2019a). Thus, similar to evidence-based medicine, evidence-based global health is based on a hierarchy system, where quantitative methods (objective data) and systematic review are located at the top level and qualitative evidence (subjective data) is at the lower end. The hierarchy of evidence-based global health suggests that “subjective perceptions” are subordinated to “objective quantification” and “description” is less important than “inferential testing” (Giacomini 2001, p. 4). Within this model, the contribution to evidence-based practice of findings from qualitative research is undervalued and discounted (Olson et al. 2016; Liamputtong 2017, 2019a). According to Fan and Uretsky (2017, p. 207), within the world of the evidencebased practice, measurements are given priority over people’s lived experiences, thus “producing programs fit for a ‘bare life’ that strips people and communities of the individual identities that cloud the population-level measures that inform good global health interventions.” For global health practitioners, evidence is generated from research data (Brownson et al. 2011; Hess et al. 2014; Liamputtong 2017, 2019a). However, this data includes not only quantitative data but also qualitative data, which can be used in decision-making about health programs, interventions, and policies (White et al. 2014; Olson et al. 2016; Liamputtong 2017, 2019a). Although evidence-based global health might have been claimed to stipulate clear responses to messy and difficult problems and would provide “certainty” in the uncertain world we are living in, dealing with people also needs a passion for humanity,” as well as “a belief in human potential” (McLaughlin 2012, p. 97). This is what data from qualitative inquiry can indeed offer (Patton 2015; Liamputtong 2017, 2019a). In the words of McLaughlin (2012, p. 101), “not everything that is valuable is measurable and not everything that is measured is of value.” Increasingly, global health programs have reacted to criticism of the “top-down approaches” used in international health by emphasizing the necessity of “local ownership” and “partnership with key stakeholders” (Brown 2015). Partnership with local players can be done through “collaborative mode of engagement” (Fan and Uretsky 2017, p. 207). This is what qualitative research can significantly contribute.

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It is argued that the hierarchical model of evidence is only one way of organizing different types of evidence. It can be very useful for some global health practices (e.g., in therapeutic and medical science). It is important for global health researchers and practitioners to appreciate this, so that they can evaluate the quality of evidence that can be found with respect to a specific global health issue in a particular context. Global health practitioners need to consider the relevance and feasibility of evidence and whether the evidence accords with the values and preferences of the clients (White et al. 2014). What is required in global health is “the best evidence available not the best evidence possible” (Brownson et al. 2011, p. 6). And this is what this chapter advocates – that we need to consider different types of evidence and that this evidence can be derived from the findings of different types of research. All too often, little is known about particular health problems of some population groups or about intervention options that are not empirically based (Olson et al. 2016; Fan and Uretsky 2017; Becker et al. 2019). Although there is research evidence that global health practitioners may find in existing literature, there are still many health issues that remain unknown to us (Liamputtong 2017, 2019a). Additionally, efficacy research on health promotion and prevention is not readily available in global health. Therefore, it is often difficult to find a systematic review of global health interventions. More importantly, global health practitioners may need evidence other than that which relates to the efficacy of interventions to inform their practice (McLaughlin 2012; Olson et al. 2016). Some health topics or issues in global health (such as the health impact of domestic violence or the effects of smoking cessation on lung cancer mortality) are not appropriate for an intervention. Not all interventions can be done through randomized controlled trials (Hess et al. 2014). For example, interventions in psychological issues may be difficult to “randomize (because they must be tailored to individuals), and blind (because psychosocial treatments may require explicit awareness, engagement, and commitment from patients for efficacy)” (Kirmayer 2012, p. 250). Evidence-based global health has also been criticized for its limited application for diverse cultural groups (Kirmayer 2012). Currently, evidence-based global health does not apply to many of the health issues of certain population groups (e.g., certain ethnic minorities and indigenous groups, recent immigrants and refugees, transgender individuals, gay men and lesbians, people with disabilities, children, older people, rural people, and people with uncommon or particularly challenging health problems) (Fan and Uretsky 2017; Liamputtong 2017, 2019a). Evidence derived from the qualitative approach can help global health practitioners to understand the issue and to use the findings in their practice. Qualitative research provides evidence that may not be obtainable from quantitative research or from a systematic review of quantitative research (Olson et al. 2016; Liamputtong 2017; Becker et al. 2019). Within the dominance of evidence-based global health, qualitative research can be a vehicle for practitioners to bring the consumers back to healthcare. Qualitative research allows global health practitioners to gain a better understanding about newly emerging as well as chronic illnesses. Qualitative research provides insight into barriers and facilitating factors that can influence the

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development and implementation of effective global health programs, interventions, and policies (White et al. 2014). Numerous researchers have argued that findings of qualitative research can enhance evidence-based practice (White et al. 2014; Olson et al. 2016; Becker et al. 2019). In their recent research, Becker et al. (2019) contend that around the globe, there has been an increased attention on the improvement of access to evidence-based mental healthcare. This has particularly been in areas where there is also a high burden of HIV among the nations’ population. Due to the experience of marginalization that people living with HIV has had, qualitative research that can help to better understand the perceptions of and reactions to mental illness within the local areas are crucial to successfully increase evidence-based mental healthcare and integrate such care with HIV care. Stigma attached to mental illness and HIV/ AIDS occur in all societies but the meanings and context of stigma differ in different societies (Liamputtong 2013b). To successfully address stigma, portrayal of the culture-specific meanings of stigma is essential. Becker et al. (2019, p. 1567) suggest that “as stigma is embedded in cultural beliefs, characterization of local conceptual models of mental illness can provide a rich basis for understanding fundamental roots of stigma processes.” Below, we provide an example of the use of qualitative research in an evidencebased practice in health promotion program.

The “Body and Soul” Program in the Samoan Community in Hawaii

Churches have a great capacity to promote overall health and to reach marginalized individuals and communities to reduce their health inequalities. Churches, for Samoan migrants living in the USA, are established, trusted, and well-attended organizations which have an ability to address the wellbeing of their community. In this study, Cassell et al. (2014) qualitatively examined the adaption of “Body and Soul” (a proven faith-based, health promotion program) for use in Hawaii’s Samoan churches. The findings from their research showed the value of qualitative research methods to inform the adaptation of evidence-based health promotion programs for communities experiencing health inequalities. Additionally, this research pinpointed possible intervention strategies that could work with other migrants from distinct Pacific Island jurisdictions who experience similar poor health outcomes to Samoan migrants in the USA. According to Cassell and colleagues, qualitative interviews with Samoan community members helped to reveal “underlying socioecological factors” that significantly contribute to obesogenic trends in Samoans living in Hawaii. These factors included “changes in the vocational structure of Samoan society, combined with influences because of migration and acculturation into Western societies, modified cultural norms surrounding the adoption of Westernised diets, and the prominence of Western foods within (continued)

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cultural practices” (p. 1668). The authors suggest that the use of qualitative approach was an “efficient approach” that assisted in the implementations of health promotion interventions to suit a particular group of people (Cassell et al. 2014).

Qualitative Research and Its Salient Characteristics In the following sections, we will discuss some salient characteristics of the qualitative inquiry in great details.

Inductive Approach and Theory Generation Qualitative research is inductive. Instead of “theory testing” as practiced in quantitative research, the qualitative approach adopts “a logic of ‘theory generation’” (Hesse-Biber 2017, p. 11; Wilson 2019). Inductive reasoning allows researchers to adopt particular understandings and develop a general conceptual understanding of the issue they examine (Taylor et al. 2016; Rossman and Rallis 2017). Typically, qualitative research projects start with the collection of particular data and follow with the analysis that will allow the researchers to form a more general understanding of the issue they investigate (Berger and Lorenz 2016; Merriam and Tisdell 2016; Hesse-Biber 2017). Thus, guiding questions that they use to collect their data are open-ended that will allow multiple meanings to surface. Usually, the questions that researchers ask in qualitative research commences with words like “what,” “why,” or “how,” rather than questions about “how much” or “how many.” For instance, What prejudice and discrimination that transwomen of color experience in their everyday life? Why do many working mothers experience struggles to continue breastfeeding? and How do women living with breast cancer cope with their health condition during chemotherapy treatment? Nevertheless, despite being inductive, often qualitative researchers commence their study with some conceptual frameworks that shape their decisions in undertaking their research. However, this framework is adjustable. It can change as the study is being conducted (Rossman and Rallis 2017).

Methodological Justification: Methodological Framework(s) Is Essential Qualitative research tends to be situated within some methodological frameworks. Methodology determines a method for researchers to produce data for analysis (Taylor et al. 2016; Hesse-Biber 2017; Silverman 2017; Gaudet and Robert 2018).

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Avis (2003, p. 1003) contends that qualitative researchers need to provide their “methodological justification” by discussing the reason why they select a particular method in their research. The methods that researchers select and what they expect to get out of those methods is strongly formed by their “methodological position” (Dew 2007, p. 433). A methodological framework provides “ways of seeing” in the conduct of qualitative research. Qualitative researchers must defend the adoption of their methods based on an appropriate methodological framework (Avis 2003; Taylor et al. 2016). It is insufficient to say that we will use an in-depth interview in our research to examine the experience of living with chronic illness among our research participants. We must provide some framework to justify our method. In this case, we may say that we are interested in the lived experience of participants and hence phenomenology will be our methodological framework, and with this type of research, an in-depth interview is appropriate because it will allow participants to tell their stories in great depth (Liamputtong 2020). There are many methodological frameworks and research approaches practiced by qualitative researchers (Bradbury-Jones et al. 2017; Gaudet and Robert 2018). These include ethnography, symbolic interactionism, phenomenology, feminism, postmodernism, ethnomethodology, empathy, participatory action research, grounded theory, case study, and Indigenist methodology. According to Hesse-Biber (2017, p.10), “the diversity of the methods with which qualitative researchers work is one of the distinguishing features of the qualitative landscape, which makes for a vast range of possible research topics and questions” (see also Bradbury-Jones et al. 2017). Bradbury-Jones et al. (2017, p. 628) suggest that the diversity of approaches that are available to qualitative researchers provides “a significant benefit” as it “provides a rich pool of methodological and technical options” that researchers can employ in their research. In Liamputtong’s own writing (Liamputtong 2020), she has advocated several methodological frameworks that qualitative researchers can draw on. These include ethnography, phenomenology, symbolic interactionism, hermeneutics, feminism, postmodernism, and decolonizing methodology. Taylor et al. (2016) recommend several frameworks. These include phenomenology, symbolic interactionism, ethnomethodology, feminism, institutional ethnography, postmodernism, narrative analysis, and multi-sited, global research. In her recent book, Hesse-Biber (2017) suggests different methodological lenses including symbolic interactionism, dramaturgy, phenomenology, ethnomethodology, postmodernism, feminisms, critical race theory, and queer theory. Gaudet and Robert (2018) propose five frameworks: phenomenology, grounded theory, discourse analysis, narrative analysis, and ethnography. Different methodological frameworks offer different perspectives in the conduct of qualitative research. Each methodological framework may also be suitable for some research questions than others. Qualitative researchers must carefully consider which methodological framework will be more appropriate for their research project.

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Multiple Ways for Data Collection Qualitative research methods have been coined as “data enhancers” as they disclose “empirical reality” which cannot be revealed by numbers (Berger and Lorenz 2016). All qualitative research methods attempt to obtain “detailed accounts,” what Clifford Geertz (1973) refers to as “thick description” of a small number of people (Berger and Lorenz 2016). Traditionally, there are a number of methods that qualitative researchers use to collect empirical materials in their research. These include in-depth interviewing method, focus group, life or oral history, and unobtrusive methods. Among these methods, the in-depth interviewing method is the most commonly known technique and is widely employed by qualitative researchers (Brinkmann and Kvale 2015; Serry and Liamputtong 2017; Nathan et al. 2019). As we now reside in “an interview society” (Fontana and Frey 2000, p. 646), interviews have become essential for individuals to make sense of people’s lives (Brinkmann and Kvale 2015). In-depth interviewing method refers to “face-to-face encounter between the researcher and informants directed toward understanding informants’ perspectives on their lives, experiences, or situations as expressed in their own words” (Taylor et al. 2016, p. 102). Interviewing is a way of collecting empirical data about the social world of individuals by inviting them to talk about their lives in great depth. In an interview conversation, the researcher asks questions and then listens to what individuals say about their lived experiences such as their dreams, fears, and hopes. The researcher will then hear about their perspectives in their own words and learn about their family and social life and work (Brinkmann and Kvale 2015). Rubin and Rubin (2012, p. 3) say that in-depth interviewing “helps reconstruct events the researchers have never experienced.” It is particularly valuable when researchers wish to learn about the life of a wide range of individuals, “from illegal border crossing to becoming a paid assassin.” There are other qualitative approaches that embody some forms of qualitative method. However, they are often referred to as the method (although some may refer them to as research traditions). These include the ethnographic method, narrative research, grounded theory, memory work, autoethnography, case study, and participatory action research (PAR). It is not feasible to discuss all of these methods in this chapter. However, participatory action research has played a crucial role for global health researchers to work with local people in the world (Higginbottom and Liamputtong 2015; Liamputtong 2020). Here, we provide an example of the contribution of PAR in a global health research.

Rebuilding People-Centered Maternal Health Services in Post-Ebola Liberia

Jones et al. (2018) used PAR to work with local people to build maternal health services in post-Ebola Liberia. In Liberia, during the Ebola crisis between March 2014 and January 2016, Redemption Hospital was a holding facility for (continued)

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suspected Ebola cases and 12 hospital staff lost their lives to Ebola. This prompted violent hostility from the community in the surrounding New Kru Town, in the capital city of Monrovia. Due to this, inpatient services, including maternity care, were closed down for 6 months. When the hospital was reopened in early 2015, the utilization of the services was low, particularly birthing services. The main issue was that the community did not have trust in health workers. Due to the lack of communication and trust between community members and the formal health system, participatory action research (PAR) was perceived to be a potential methodological approach in this study. The PAR methodology seeks to generate processes which challenge dynamics of power between individuals and groups as well as to cultivate relationships between stakeholders and service providers. PAR was initiated in July 2015 to develop communication between stakeholder groups and to determine impacts of the epidemic and identified shared actions to reform the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs), and traditional birth attendants (TBAs), community leaders, and health workers. The PAR process involves two stages. Stage 1 included 2-day meetings which were held with the three subgroups separately. The meetings focused on the current experience of maternal care services, how the Ebola epidemic impacted them and the important issues which needed to be addressed to improve services. The findings of the meetings were discussed with their own wider group. Feedback was then brought to a stage 2 meeting. During the stage 1 meetings, a number of tools and activities were utilized in order to allow participation and stimulate discussions among the stakeholders. These included picture codes and pile sorting, social map, Venn diagram, EVD (Ebola virus disease) timeline, ranking and scoring/pairwise ranking, and market place. Stage 2 meetings involved 1-day meetings which included all groups to identify actions that addressed problems and improved experience of services. The group also established a coordination committee and progress markers for the action plan. The identified actions were then implemented within the 3month period. They were reviewed by the coordination committee against progress markers as well as in a wider review meeting in late 2015 to support to learning action. The findings of this PAR project suggested that Ebola worsened communityhospital relations and the preexisting weaknesses in maternal services. Findings suggest that the PAR process established evidence and improved communication as well as interaction between the community and health workers. In their conclusion, the authors contended that: “The PAR methodology uncovered significant issues, allowed community members and health workers (continued)

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to understand each other’s experiences and needs, created meaningful links, and strengthened communication between a hospital and its surrounding community.” They also suggested that “PAR methods can be used effectively in low-resource settings, but also in post-crisis contexts, where health systems need to be rebuilt in a way that makes them responsive to current needs and resilient to future crises” (p. 17).

Within the present climate of our fractured world, it is inevitable that global health researchers will engage with the vulnerable, disadvantaged, and marginalized groups as it is likely that these population groups will be confronted with more problems with their health and well-being. There are many situations where no conventional qualitative methods will work and can be alienating for some individuals. It is essential that global health researchers adopt unconventional alternative approaches. Indeed, many researchers have increasingly realized the value of more creative inquiries in working with marginalized groups. Research that involves children, for example, traditional research methods such as in-depth interviews or focus groups may be problematic. Creative methods that treat children as research participants instead of research objects will allow children to play an important role in the research. These creative methods also allow researchers to gain a deeper insight into the understanding and experiences of children. Increasingly too, there have been many global health researchers who believe in the social justice value and attempt to change the social conditions of people and communities around the globe. This is precisely what Denzin (2010) has encouraged researchers who are situated within the “moral and methodological community” to do. This has resulted in the development of and creative qualitative approaches in many parts of the globe and they are also in expansion. In the last few decades, researchers in the health sciences have started to embrace the use of visual research so that their understanding of the human condition can be enhanced. There are a wide variety of visual forms that are available to researchers. Each of these visual forms can result in different ways of knowing. Thus far, we have witnessed visual forms such as photographs, drawings, cartoons, graffiti, maps, diagrams, films, video, signs, and symbols, which have been adopted in research in the health sciences. Most often, however, health researchers use visual methods together with some form of interviewing. Images speak louder than words (Harper 2002, 2012) and there is a saying that “a picture is worth a thousand words.” A picture can be captured instantly at a glance, but those thousand words would need time to read or to listen to. The use of visual images as a data collection tools in research can assist health social science researchers in many ways. Weber (2008) suggests a few. Images can assist us to capture knowledge that is hidden, elusive, or hard-to-put-into-words which would be ignored or remain hidden without the use of visual forms. Photographs, for example, can greatly invoke “information, affect and reflection” (Rose 2007, p. 238) that written texts may not be able to do. Similarly, drawing and painting can grasp

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emotions which are not easily produced in words alone. Images can assist researchers to pay attention to things in different ways. Ordinary things can become extraordinary with the use of images. This can make us embrace new ways of doing things. Often, images can invoke new research questions and inspire the research design (Weber 2008). Teti et al. (2019) tell us that in health research and practice, visual methods are common tools. Health researchers have appreciated the values of photography as a means “to understand health issues from the perspectives of those living with health challenges, inform health interventions, and engage community members in identifying and solving health problems.” Teti and colleagues write about the application of the photovoice method to HIV/AIDS and autism spectrum disorder research and practice. Within community-based participatory action research (PAR), the method of photovoice has emerged as an innovative means of working with marginalized people and in cross-cultural research (Liamputtong 2007, 2010, Liamputtong 2020). Photovoice method allows individuals to record and reflect the concerns and needs of their community via taking photographs. It also promotes critical discussion about important issues through the dialogue about photographs they have taken. Their concerns may reach policy-makers through public forums and the display of their photographs. By using a camera to record their concerns and needs, it permits individuals who rarely have contact with those who make decisions over their lives, to make their voices heard.

The Source of Data in Qualitative Research Qualitative research is concerned with the in-depth understanding of the issue or issues under examination; it thus relies heavily on individuals who are able to provide information-rich accounts of their experiences (Patton 2015; Yin 2016; Creswell and Poth 2018). This is referred to as the purposive sampling strategy (Houser 2015; Patton 2015; Bryman 2016; Yin 2016; Hesse-Biber 2017; Creswell and Poth 2018; Liamputtong 2020). Purposive sampling is a deliberate selection of specific individuals, events, or settings because of the crucial information they can provide, which cannot be obtained as adequately through other channels (Patton 2015; White 2015; Yin 2016; Creswell and Poth 2018). For example, in research that is concerned with how women with breast cancer deal with the side effects of chemotherapy treatment, purposive sampling will require the researcher to find women who have experienced the side effects of chemotherapy, instead of randomly selecting any cancer patients from an oncologist’s patient list. The purposive sample is also referred to as a “judgment sample” (Hesse-Biber 2017, p. 62). Research participants are selected to be included in a study due to their particular characteristics as determined by the particular objective of the research (Liamputtong 2020). The powers of purposive sampling techniques, Patton (2015, p. 264, original emphasis) suggests, “lie in selecting information-rich cases for study in depth.” These information-rich cases are individuals or events or settings from which

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researchers can learn extensively about issues that they wish to examine (Houser 2015; Creswell and Poth 2018; Liamputtong 2020). The focus of decisions about sample size in qualitative research is on ‘flexibility and depth’. A fundamental concern of qualitative research is quality, not quantity. A qualitative research usually involves a small number of individuals. Qualitative research aims to examine the ‘meanings’ or a ‘process’ that individuals give to their own social situations. It does not require a generalization of the findings as in positivist science (Houser 2015; Hesse-Biber 2017; Liamputtong 2020). Qualitative research trades ‘breadth for depth’ (Hesse-Biber 2017, p. 63). The important question to ask is whether the sample provides data that will allow the research questions or aims to be thoroughly addressed (Houser 2015; Liamputtong 2020). In qualitative research, there is no set formula that can be adopted to determine the sample size rigidly (Liamputtong 2020). Often, at the commencement of the research project, the number of participants to be recruited is not definitely known. However, data saturation, a concept associated with grounded theory, tends to be adopted by qualitative researchers to determine the number of research participants. Saturation is considered to occur when little or no new data is being generated (White 2015; Liamputtong 2020). O’Reilly and Parker (2012, p. 192) suggest that saturation is reached at “the point at which there are fewer surprises and there are no more emergent patterns in the data.” The sample is adequate when “the emerging themes have been efficiently and effectively saturated with optimal quality data” (Carpenter and Suto 2008, p. 152) and when “sufficient data to account for all aspects of the phenomenon have been obtained” (Morse et al. 2002, p. 12). Saturation is usually established during the data collection process (Houser 2015; Liamputtong 2020). This means that in most qualitative research, data collection and data analysis tend to occur concurrently. This is the only way that researchers can know if they have reached saturation or not (Liamputtong and Serry 2017; Liamputtong 2020). Despite its usefulness, saturation has received some criticism, and many qualitative researchers have also questioned its use (see Morse 2015a). There are also different levels and types of saturation.

Analytic Strategies and Qualitative Data Qualitative inquiry relies heavily on words and stories; thus, how qualitative researchers make sense of their data also reflect this. Data analysis and interpretation of data are an exciting process that qualitative researchers bring meaning to the piles of data that they have gathered (Rossman and Rallis 2017, p. 227). It is a complex process and involves the following: “Organizing the data, familiarizing with the data, identifying categories, coding the data, generating themes, interpreting, and searching for alternative understanding” (Rossman and Rallis 2017, p. 237). There are several analytic strategies that qualitative researchers analyze and organize their data. These include content analysis, thematic analysis, discourse analysis, narrative analysis, and semiotic analysis method (Liamputtong 2020). Thematic analysis method seems to be the most commonly adopted in qualitative

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research. It is seen as “a foundational method for qualitative analysis” (Braun and Clarke 2006, p. 78). Thematic analysis is “a method for identifying, analysing and reporting patterns (themes) within the data” (Braun and Clarke 2006, p. 79). Nowadays, there are some software programs, such as NVivo, ATLAS.ti, and MAXQDA, that can assist qualitative researchers with the analysis. This is referred to as “computer-assisted qualitative data analysis” (CAQDAS) (Yin 2016; Serry and Liamputtong 2017; Bazeley 2019). However, the software programs do not analyze the data per se; they help to manage the qualitative data more efficiently (Creswell and Poth 2018). The researchers still have to perform “all the analytic thinking” (Yin 2016, p. 188). Another word, “the real analytical work” still “takes place in your head” (Patton 2015, p. 531). Qualitative data analysis is a time-consuming process. However, it is also “creative and fascinating.” Sufficient time needs to be dedicated to data analysis in qualitative research. Taylor et al. (2016) contend that data analysis is the most difficult thing for qualitative researchers to teach or communicate to others. Most novice qualitative researchers tend to “get stuck” when they start to analyze their data. Taylor et al. (2016, p. 168) contend that this is because qualitative analysis “is not fundamentally a mechanical or technical process; it is a process of inductive reasoning, thinking and theorizing.” For most qualitative researchers, their ability to analyze their data arises out of their experience. The best way that researchers can learn more about inductive analysis is to work with “a mentor who helps them learn to see patterns or themes in data by pointing these out” and by reading qualitative papers and studies to see how others have come up with their data. This is our recommendation as well.

Trustworthiness and Qualitative Research Qualitative research has criteria that can be used to evaluate the quality of the research. Within the qualitative approach, the term “rigor” or “trustworthiness,” which refers to the quality of qualitative inquiry, is used (Morse 2015b; Bryman 2016; Yin 2016; Rossman and Rallis 2017; Liamputtong 2020). A trustworthy research is a research that researchers have “drawn the correct conclusions about the meaning of an event or phenomenon” (Houser 2015, p. 146). In health research and practice in particular, trustworthiness means that “the findings must be authentic enough to allow practitioners to act upon them with confidence” (Raines 2011, p. 497). Lincoln and Guba (1989) propose four criteria that many qualitative researchers have adopted to evaluate the trustworthiness of their qualitative research. The criteria were invented in responses to the influence of quantitative research that relies heavily on the issues of validity and reliability (Morse 2015b, 2018). These criteria include credibility, dependability, confirmability, and transferability. Credibility relates to the question “how believable are the findings?” (Bryman 2016, p. 44). A credible study, according to Yin (2016, p. 85), refers to a study that “provides assurance that you have properly collected and interpreted the data, so the

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findings and conclusions accurately reflect and represent the world that was studied.” Dependability focuses on “the consistency or congruency of the results” (Raines 2011, p. 456). It asks whether the research findings fit the data that have been collected (Carpenter and Suto 2008). Confirmability attempts to show that the findings and the interpretations of the findings do not derive from the imagination of the researchers but are clearly linked to the data. Transferability (also referred to as applicability) begs the question of “to what degree can the study findings be generalized or applied to other individuals or groups, contexts, or settings?” or “do the findings apply to other contexts?” (Bryman 2016, p. 44). It attempts to establish the “generalizability of inquiry” (Tobin and Begley 2004, p. 392). Transferability in qualitative research emphasizes the theoretical or analytical generalizability of research findings. Transferability suggests that the theoretical knowledge that researchers obtained from qualitative research can be applied to other similar individuals, groups, or settings (Carpenter and Suto 2008). This is particularly so for research employing the ethnographic method and grounded theory research. There are several strategies that qualitative researchers employ to ensure the rigor of their study. Often, these include prolonged engagement, persistent observation, thick description, peer review, member checking, external audits, triangulation, and reflexivity (Morse 2015b; Rossman and Rallis 2017; Creswell and Poth 2018; Liamputtong 2020). Each of these strategies may not be suitable for all types of qualitative research and some strategies may create difficulties for some qualitative projects than others (see Morse 2015b). Qualitative researchers need to take into account the type of qualitative method they use and social context on which their research is situated.

Qualitative Researchers Basically, qualitative researchers look for meanings that people have constructed (Taylor et al. 2016; Hesse-Biber 2017). They are interested in learning about “how people make sense of their world and the experiences they have in the world” (Merriam and Tisdell 2016, p. 15). Qualitative researchers can be perceived as “constructivists” who “seek answers to their questions in the real world” (Rossman and Rallis 2017, p. 4) and then “interpret what they see, hear, and read in the worlds around them” (p. 5). Qualitative researchers are individuals who commit themselves to several issues. They: • See the social world holistically • Have a strong commitment to examining an issue from the participant’s perspective • Interact extensively with the participants • Employ multiple reasoning • Are sensitive to personal biography • Are reflexive in the conduct and interpretation of research

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Qualitative research is personal and sensitized to personal biography as the researcher acts as “the instrument of inquiry” (Patton 2015, p. 3; Rossman and Rallis 2017, p. 9). What brings then to their research is an important thing for most qualitative researchers. Thus, qualitative researchers tend to acknowledge who they are and how their personal biography frame their research. They value their “unique perspective as a source of understanding rather than something to be cleansed from the study” (Rossman and Rallis 2017, p. 9). Qualitative research is an exquisite sensitivity to personal biography.

Empirical Example of How We Conduct a Qualitative Research Breast cancer is the most commonly occurring cancer among women both in the developed and less developed nations (World Health Organization 2020). In 2011, worldwide, over 508,000 women died due to breast cancer. In 2018, there were more than 2 million new cases of breast cancer. The incidence of breast cancer has increased in developing countries, particularly in the Asian region (World Health Organization 2011). Although breast cancer is seen as a disease of the developed world, about 50% of breast cancer cases and 58% of deaths occur in under developed nation. Women with breast cancer are not only affected physically, but also psychologically. Breast cancer is an “emotionally debilitating disease” that affects women of all ages (Banning et al. 2010, p. 307; Liamputtong and Suwankong 2015). Research has shown that women who are diagnosed with breast cancer suffer from many emotional debilities, including anxiety, fear of dying, depression, and negative and suicidal thoughts (Liamputtong and Suwankong 2015). Breast cancer is one of the leading causes of deaths in Thai women. Breast cancer was the second leading form of cancer in women, following cervical cancer. Each year, approximately 192,000 women are diagnosed with breast cancer and the incidence of breast cancer has increased significantly in the last decade, particularly among older women. Breast cancer has also become a common health issue among Thai women in rural areas. There appears to have been little research that addresses therapeutic landscapes and the lived experience of living with breast cancer among Thai women living in Southern Thailand. In their research, Liamputtong and Suwankhong (2015) attempted to address the gap in literature in their paper. The authors were interested in rural areas as most rural people tend to rely on traditional healthcare practices in dealing with their health issues. These factors would allow them to examine therapeutic landscapes that their participants adopted for dealing with their breast cancer. Qualitative research has shown that breast cancer is an “emotionally debilitating disease” that affects the lives of women of all ages. Liamputtong and Suwankhong adopted a feminist framework as their research methodology and employed qualitative and innovative methods in their study. The therapeutic landscapes of healing involved multiple levels of landscape changes including body, home, neighborhood, healthcare, and cultural contexts. Their findings offer a particular insight into the role of emotions and cultural beliefs and practices in forming therapeutic landscapes among women living with breast cancer in Thailand. It is crucial that healthcare

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providers understand the emotional experiences of women with breast cancer and their particular cultural needs for emotional healing landscapes. Their findings could be used as evidence for developing culturally appropriate therapeutic strategies and interventions for women with breast cancer in Thailand and elsewhere.

Qualitative Research with Women Living with Breast Cancer in Southern Thailand

Liamputtong and Suwankhong (2015) adopted a qualitative approach for the research as it allowed them to learn about individuals’ lives, stories, and behavior. A qualitative approach is appropriate because qualitative researchers accept that, in order to understand people’s behavior, we must attempt to understand the meanings and interpretations that people give to their behavior. Qualitative inquiry is most appropriate when the researcher has little knowledge of the participants and their worldviews and when the researcher wishes to work with marginalized and vulnerable individuals. In this study, Liamputtong and Suwankhong situated their research within the feminist framework. Within feminist methodology, women and their concerns are the focus of investigation. An intention of feminist research is to undertake research that is beneficial for women. The ultimate aim is to capture women’s lived experiences in a respectful manner that legitimates women’s voices as sources of knowledge. Although some feminist researchers employ positivist methodology, often feminist research calls for qualitative inquiry that is less structured and more flexible than that of the positivist paradigms. Qualitative inquiry allows researchers to examine in depth the experiences of people by giving them a voice and allowing them to express themselves. The participants of this study included 20 Thai women who had been diagnosed with breast cancer in Southern Thailand. The purposive sampling method was used to select key informants who met the study’s criteria and could provide rich data relevant to the aim of their study (to examine the lived experiences of living with breast cancer among Thai women). The number of participants was determined by the theoretical sampling technique, which stops recruiting when little new data emerges. Recruitment was firstly carried out through their personal network as members of the Thai community in Southern Thailand. Liamputtong and Suwankhong initially contacted healthcare providers at the primary health center, where many women sought care after being hospitalized. Snowball sampling technique was also adopted to expand the number of participants. Snowball sampling requires that researchers initially select a few research participants and ask them for a recommendation of others who might meet the research criteria and who might be interested in participating in the research. Snowball sampling is employed extensively in sensitive research (continued)

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with groups whose members are difficult to locate or are unlikely to be willing to participate without referral from others in their own network. Liamputtong and Suwankhong contacted the women via telephone to schedule convenient interview times. All interviews were conducted in Thai language to retain the subtleties and hidden meanings of the participants’ statements. Both authors, who are Thai, conducted the interviews together at the beginning of data collection to ensure consistency. However, most interviews were conducted by Suwankhong. They used an interview guide for each woman. This interview guide comprised several open-ended questions which allowed the women to express their experiences in detail and included relevant prompts. Some of the main questions included: • • • • •

What does breast cancer mean to you? Please tell us about your own experience of breast cancer. What did you do once you were told that you had breast cancer? How did you deal with breast cancer in your everyday life? Did you receive any support from you family or other people? Please tell us more about this.

All interviews occurred at each woman’s home and at a time that was convenient for each one. The interview’s duration was approximately 1.5 hours and was audio-taped for verbatim transcription and data analysis. Situated within the feminist framework, Liamputtong and Suwankhong also employed an innovative method involving drawing. Drawing helps people to see their world whether it is a simple or complex matter. The drawing method constitutes a form of visual imagery and is a contemporary method used to collect information from vulnerable people, and for sensitive topics, drawing methodology provides “a rich and insightful research method to explore how people make sense of their world,” and hence, it is suitable for conducting research with vulnerable people (including women living with breast cancer and women from ethnic minority groups). It is argued that vulnerable people tend to have difficulty expressing their emotions and understanding phenomenon through conversations or written words. Drawing provides a means for them to express their feelings and tell others how they feel about their illness. This method is often used to complement other methods such as in-depth interviews to obtain insight and understanding of the participant’s world (Liamputtong 2019b; Liamputtong 2020). In this research, the drawing method was employed after the in-depth interviews were completed. All participants were given a pack of 48 colored pens and blank flip-chart papers for the drawing session. The participants were then invited to draw the image of the meanings and experiences of breast cancer that they had. When they completed the task, the researchers asked (continued)

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participants to describe the image(s) they had drawn. The descriptions that the participants provided were audio tape-recorded for subsequent data analysis. Ethical approval was obtained from Thaksin and La Trobe University’s Human Ethics Committees. In presenting the women’s narratives, each participant was allocated a fictitious name to preserve participant anonymity. Before making an appointment for interviews, the participant’s consent to participate in the study was sought. After a full explanation of the study, the length of interviewing time and the scope of questions, the participants were asked to sign a consent form. Each participant was given 200 Thai baht (about US$7) as a compensation for their time in taking part in this study. This incentive is necessary for sensitive research because it is a way to show that research participants are respected for their time and knowledge (Liamputtong 2020). With permission from the participants, interviews were tape-recorded. The tapes were then transcribed verbatim in Thai for data analysis. The data was analyzed using a thematic analysis. This method of data analysis aims to identify, analyze, and report patterns or themes within qualitative data. Initially, the researchers performed open coding where codes were first developed and named. Then, axial coding was applied which was used to develop the final themes within the data. This was done by re-organizing the codes that they had developed from the data during open coding in new ways by making connections between categories and subcategories. This resulted in themes, and these themes were used to explain the lived experiences of the participants in their writing.

Conclusion Qualitative research is now a well-established and important mode of inquiry for the health science fields. We have suggested in this chapter that the inquiry can contribute significantly to global health. However, the field of qualitative research is ever advancing (Hesse-Biber 2017). Gaudet and Robert (2018, p. 2) suggest that “qualitative research is a never-ending journey.” This is because “there are always new phenomena to learn about, new methods to invent, and new forms of knowledge to create.” We have witnessed this many existing and emerging global health issues attest to this. Most importantly, we are now living in a fractured world, where we have, and continue to be confronted with social inequalities and injustices in all corners of the globe (Liamputtong 2019b). We need qualitative research that can help us to find better answers that better suit people, particularly those who are marginalized and vulnerable (Denzin 2015; Flick 2018). Qualitative inquiry can lead to a positive change in the life of many people. This is what Denzin (2015, 2017) has advocated.

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Denzin (2017, p. 8) puts this clearly when he calls for qualitative research that “matters in the lives of those who daily experience social injustice.” We contend that qualitative research will continue to play a crucial role in the global health in the years to come.

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UNAIDS (2016) Children and HIV: fact sheet. Retrieved http://www.unaids.org/sites/default/files/ media_asset/FactSheet_Children_en.pdf UNAIDS (2017) The global HIV/AIDS epidemic. Retrieved https://www.hiv.gov/hiv-basics/over view/data-and-trends/global-statistics UNAIDS (2019) UNAIDS data 2019. Retrived from https://www.unaids.org/sites/default/files/ media_asset/2019-UNAIDS-data_en.pdf Weber S (2008) Visual images in research. In: Knowles JG, Cole AI (eds) Handbook of the arts in qualitative research: perspectives, methodologies, examples, and issues. Sage, Thousand Oaks, pp 41–53 White AH (2015) Using samples to provide evidence. In: Schmidt NA, Brown JM (eds) Evidencebased practice for nurses: appraisal and application of research, 3rd edn. Jones & Bartlett Learning, Burlington, pp 294–319 White F, Stallones L, Last JM (2014) Global public health: ecological foundations. Oxford University Press, New York Wilson LA (2019) Quantitative research. In P. Liamputtong (ed.), Handbook of Research Methods in Health Social Sciences. Springer: Singapore World Health Organization (2011) Breast cancer: prevention and control. Retrieved from http:// www.who.int/cancer/detection/breastcancer/en/index.html World Health Organization (2020) Breast cancer: Prevention and control. Retrieved from https:// www.who.int/cancer/detection/breastcancer/en/ Breast cancer: Prevention and control. Retrieved from https://www.who.int/cancer/detection/breastcancer/en/ Yin RK (2016) Qualitative research: from start to finish, 2nd edn. Guildford Press, New York

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scientific Traditions in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of Mixed Method Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning Mixed Method Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Designing Mixed Method Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sampling in Mixed Method Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Mixed Method Sampling Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sequential Sampling Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concurrent Sampling Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiphase Mixed Method Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Field Work: Data Collection Tools and Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tools and Techniques of Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mixed Method Research Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Writing-Up Mixed Method Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Public health originated from the need to understand upstream factors that were causing or spreading diseases, to understand and address structural factors including social, commercial, and corporate determinants of health. To explore and explain the complex interplay of these determinants of health, research approaches in global health shifted accordingly with an increasing use of mixed M. Kaur (*) Postgraduate Institute of Medical Education and Research, Chandigarh, India e-mail: [email protected] R. Kumar State Health Systems Resource Center, Department of Health and Family Welfare, Government of Punjab, Chandigarh, India e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_11

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methods. This chapter introduces the philosophical and theoretical explanations of mixed method research, with research traditions briefly explained to provide principles underpinning mixed method research, the challenges, and potential contradictions of using mixed methods. Furthermore, this chapter explains how to use mixed methods, including design and sampling strategies, data collection, analyses, and writing up of mixed method research findings by using relevant examples. Keywords

Mixed methods · Research traditions · Study design · Sampling · Analyses

Introduction Public health research has mostly been quantitative and focused on epidemiology for finding out cause and effect associations. It was assumed that use of statistics will make the inferences more objective and provide generalizations to predict the future of disease progression in population which is the core to public health. This positivist tradition was followed by many social sciences as well till the last about three decades. Public health needs to address human behavior as source of epidemics. It deals with social, cultural, commercial, and corporate determinants to promote health. It needs to understand and work on the issues that emerge with the change in structure of society, the cause of causes. Understanding health behaviors and the environments in which people work and live needs to be the key component of public health. It necessitates that public health specialists look beyond the positivist to constructivist tradition and follows qualitative research approach. By the end of twentieth century, the constructivist perspective postulated that objective reality does not only exist outside humans, but reality is created by all. In the beginning of twenty-first century, scientist struggled to prove that the relationship between two variables cannot always be linear and there are patterns that determine relationship (Williams 1997). This shift in understanding on reality made it easier to think about using both quantitative and qualitative methods in one research study or project. The strong lines drawn between the logics of making methods of research more important than the research need or research question were shaken and broken. For understanding mixed method research approaches and when, why, and how to use them in global health research requires to go through the journey of development of scientific traditions, application of logics, epistemology, ontology, and methodologies required.

Research Methodology In general, research is not simply numeric, textual, or both but involves a researcher’s perspective that allows him or her to explore the problem based on their own beliefs and the ideas of scientific community they belong to. Science and

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scientific research have mostly been related to the high-school or college-level education and to those brightest students who study physics, chemistry, and biology. Therefore, the practice of science is associated with laboratory experimentation by the people in aprons. Since the human behavior cannot always be tested in laboratories and is dynamic, different methodologies outside the labs emerged, and science could no more be confined to laboratories, and it evolved to explain human social behavior. The questions being asked especially by non-researchers have never been considered as scientific research. Any inquiry that is carefully investigated and studied in detail before drawing conclusions is considered research. Such a research starts as experimentation in elementary schooling. The science or scientific research did not develop instantly and still has not achieved its goal of developing and interpreting knowledge. Science followed both evolutionary and revolutionary changes. For long, authoritarian individuals such as people holding social or political position were supposed to be having all the knowledge about the mystical supernatural world (Frankfort-Nachmias and Nachmias 1996). Scientific methods became a means to create new knowledge or verifying existing knowledge later, i.e., in the nineteenth century (Comte 1848). It was believed that knowledge derived from the rules of logic is rational and requires empirical proofs. Therefore, epistemology or the philosophy that one follows for acquiring knowledge determines the source of knowledge. Empirical observation differentiated scientific knowledge from all other approaches of gaining knowledge. The knowledge produced through by making and evaluating observations to produce new knowledge are termed methodology or methods and material to understand and describe the physical world and predict future. Research methodologies delineate the rules and procedures to generate and share knowledge. According to positivist tradition, there are three criteria for considering a study scientific (Bryman 2008). First that the research study is repeatable which means the measures used in study are reliable and consistent. It means that it is possible to repeat the measurements and get the same results under same conditions. Second criterion is replication which means that the methodology used in the study is explained for other researchers to repeat the same. The third criterion is validity, i.e., the conclusions drawn are true which means that the measures used were accurate for investigation and the causal relationship were vigorous, e.g., A causes B is sure and findings could be extrapolated even beyond the research context. Research methodology has undergone many evolutionary and revolutionary changes. Kuhn provided (Kuhn 2012) the revolutionary explanation as compared to Comte who in 1848 offered three evolutionary phases. Kuhn called “paradigm shift” which is usually abrupt and fast rather than slow and evolutionary. From Copernican Revolution to Newtonian physics and Einstein’s theory of relativity all are examples of this revolutionary approach in explaining the history of science. All scientific endeavors start with the belief that no knowledge is complete and not that all knowledge is the ultimate truth. Bindings with the methods would have made it impossible to research in some periods. While teaching research, the history and philosophy of science is often ignored, and the traditions of scientific communities are missed. This is more true for public

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health than social sciences like psychology and sociology. However, researcher in any field needs to understand the traditions and clarify the standpoint before starting any research. It clarifies one’s own school of thought and the theoretical underpinning that will lead the research. Recognizing and identifying with specific tradition determine the approach, the study design, and the methods and techniques of data collection. It has been realized that the design of research that can add to or challenge the existing knowledge is based on the researcher’s understanding of traditions in science.

Scientific Traditions in Research Scientific traditions are characterized by the logical explanation and the expression of ontology, epistemology, and methodologies. While all have been trying to understand the truth or the reality, Copernicus, Galileo, Newton, and Einstein have been considered scientists and Aristotle, Socrates, and some other well-known names as philosophers (Cushing 1998). The first question that bothered the inquisitive minds as described in ancient and medieval period of scientific development was the cosmic world (Comte 1848), the advent of science has been associated with the positive tradition, and the ones who tried to prove the facts numerically were considered the scientists. After Galileo, the French philosopher-scientist Descartes tried to describe universe, came up with mechanical philosophy, and explained that universe is not static. Newton while agreeing with Descartes and other mechanical philosophers improved the theory and gave a dynamic mechanical theory. His laws of motion and principal of gravitation culminated from the same theory. Newton explained his theory with precision and rigor. He invented mathematical techniques which are now known as “calculus.” Newton’s physics that provided the framework for science was followed for about 200 years. Comte the first proponent of positivism and many social scientists after him followed the principals of the dynamic mechanical theory that perpetuated positivism. This tradition dominated the medical and public health research for a long time. Epidemiology is an example of positivism and post-positivism dominance. Epidemiologists follow post-positivism and feel that reality or truth is outside the individual and that can be tested using statistical methods. In this tradition the inductive logic has been used to produce or reproduce knowledge. On the other hand, constructivist or interpretivist believed that reality is constructed and it is internal which a researcher cannot ignore. The conclusions drawn by these scientists are based on deductive logic. Constructivism is defined by its ontological and epistemological commitments and overlap with the other theoretical traditions. There are a good number of examples that express overlap of constructivist with other traditions. Constructivism overlaps with the liberal and is also compatible with the realist (Barkin 2003). The post-structuralist, realist, and critical realist often use abductive logic which is “observe and explain”; the explanation is near truth but not the ultimate truth

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(Pierce 1914). Since, medicine, public health, or any other social science need to explore, confirm, and explore, the integral theory has now become the bases of most of the research, and there is a shift toward critical realism. Public health most often has followed positivist and postpositivist tradition. Constructivism and realism traditions have gained ground in the past two decades and mixed method research that appears in most of the research in public health today follows critical realism. In public health, researchers do follow the critical realist approach that can best answer the research question, which means critically looking at the question and applying quantitative and qualitative research methods in a single study. Being critical realist one can follow both positivist and constructivist tradition simultaneously (Tashakkori et al. 1998). It is better to combine multiple approaches, address complexity, and bring rigor and richness in research (Denzin 2012). Researchers decide on when, why, and how to use both quantitative and qualitative approaches and paradigms to make best use of the available epistemologies, ontologies, and methodologies for their study (Creswell et al. 2003). Before using mixed method research, the researchers need to understand their own thinking. Many of the research students in public health use mixed method approach following the research question at hand. But what is their conceptualization about positivism, constructivism, or realism and why should they know about are never considered necessary. For the same reason, researchers often mix methods without mentioning the design of mixed method research. A good understanding of traditions can lead to good framing of research questions and objectives, the choice of design, framing questions for tools, and selection of techniques for data collection besides the quality of inferences. While some researchers as has been discussed above often are driven by research questions and/or purposes, others might be purist as they find the assumptions are incompatible and it is not possible to mix methods. Some use substantive theories wherein emergent codes either are embedded in or intertwined with theories (Greene 2007; Venkatesh et al. 2013). There are complementary strengths in both positivist and constructivist approaches, and the assumptions may not be fundamentally compatible but are important in different ways. Mixed method researchers need to use dialectics to address these differences by purposefully and meaningfully using both quantitative and qualitative approaches while acknowledging the differences. Most of mixed method researchers use complementarity, and few use the dialectic (critical realism). Understanding of traditions help researchers to use dialectics and allows them to follow more than one tradition in a single research study with a better understanding that using both positivism and constructivism will lead to better understanding of the factors and processes under the study (Greene and Hall 2010). Critical realists respect the existence of an objective reality but consider it to be imperfect and probabilistic (Tashakkori et al. 1998). For them objective knowledge about the truth or world may have alternative valid accounts of any phenomenon (Maxwell and Mittapalli 2010). That is why the critical realism tradition is considered apt or an ideal mixed method research studies. The

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philosophical underpinning in this tradition is congruent with the attributes of both quantitative and qualitative research (Maxwell and Mittapalli 2010). For a mixed method research study, the researcher begins with one’s own philosophical understanding of the world and the theoretical underpinning that can be interwoven with the research questions and purposes of mixed method research. Therefore, a very good understanding of the traditions and the clarity of thought why they are following the mixed method approach provides the rationale for mixing quantitative and qualitative methods in the same study (Creswell 2003).

Definition of Mixed Method Research Based on their review Johnson, Onwuegbuzie, and Turner (2007) defined mixed method research as: the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches (e.g., use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) for the broad purposes of breadth and depth of understanding and corroboration. According to this definition, mixed method research can mix two or more different methods within a single study or within a research project and that “mixing [methods] might occur across a closely related set of studies” (Johnson et al. 2007). Mixed method research enables researchers to generate theory and evaluate it at the same time and provide sound inferences than a single method or worldview and an opportunity to produce a variety of conflicting as well as complementary views (Venkatesh et al. 2013). Quantitative and qualitative methods, when used together in a study, complement each other and allow for a more robust analysis (Ivankova et al. 2006; Tashakkori and Teddlie 2008). However, mixed method research does not replace either a quantitative or a qualitative approach but draws from the strengths and minimizes the weaknesses of both methods (Creswell 2003; Jick 1979; Johnson and Onwuegbuzie 2004; Venkatesh et al. 2013). Integrating quantitative and qualitative methods seems quite simple, but when and how to integrate quantitative with qualitative or qualitative with quantitative require both theoretical and practical knowledge. Some researchers assume that there are two possible points of integration, first at analyses and second while drawing inferences (Bryman 2017). But the mixed method research can also be used at the conceptualization stage and the data collection along with data analysis and the inferential stage. Thus, integration can happen in all four stages, and thus all four stages are potential points or integration (Teddlie and Tashakkori 2009). However, researchers can follow the guidelines provided by Venkatesh et al. (2013).

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Mixed method research is a multi-strategy research. It involves different research strategies that are related to research questions. Designing a mixed method research study is quite complex. Mixed methods may form part of a long-term study, e.g., participatory action research studies which are pursued over time by one or a group of researchers applying different methods and approaches consecutively (Baum et al. 2006).

Planning Mixed Method Research Planning a research study or project remains same in quantitative, qualitative, and mixed method approaches of research. Identifying the issue and defining objectives or purpose are followed by designing of study are the initial two phases which are based on the thorough review of theories, frameworks, and literature. The third phase of preparing tools for data collection and implementing them to collect information is more critical and depends upon the design that has been selected. The framing of questions in the tools and the skills of interviewer determine the data quality. There is a lot of complexity in fourth and fifth phases of analyses and drawing inferences from both quantitative and qualitative data. Synthesizing the inferences requires a lot of indulgence in data, thoughtfulness, and writing skills.

Designing Mixed Method Research Designing a mixed method study involves rigorous process. Mixed method studies are driven both by the inductive or deductive logic. These studies may have qualitative or quantitative as essential or core component and qualitative or quantitative supplementary or additional component. Design of mixed method research needs to be developed logically and optimally from the research question. The research questions and the theoretical underpinnings determine the dominance of quantitative or qualitative method in a study. Understanding and applying the logic of enquiry is the first step for designing a mixed method study. At the outset one needs to consider whether the study primarily is inductive which means the aim is to explore and explain or deductive wherein the aim is to test hypotheses and predict or abductive which starts with an observation or set of observations and find the simplest and most likely explanation for the observations. Mixed method approach is useful where all the three types of logics are needed. At times the population-based surveys, e.g., sample registration survey or national health and family surveys, may involve inductive and deductive logics. Grounded theory, a design of qualitative research approach, may test ideas as well as generate them. At the second step, researchers need to decide ordering of quantitative or qualitative methods to be used for designing a mixed method study. Both the methods can be used simultaneously or in sequence or if any particular method or

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methods are preferable at the beginning of the research, for example, qualitative method can be used to generate representative samples from which subgroups may be selected and intensive methods of investigation can be applied. The design of study also depends upon whether qualitative and quantitative have to be used in one go, but one leading to the other in the same or different study or qualitative research will lead to statistical enquiry which has rarely been used (Ritchie et al. 2003). At times researchers ignore that the resources are scarce, and they need to decide which data can be treated as supplementary. In most studies this step is ignored, and more emphasis is put on the research question. Often such studies face problem at the writing stage and present the findings in two separate reports. Deciding on research design is no more a one-time-only activity. It may be truer for PhD plans, but even PhD plans made at the start make changes during the implementation of the study. The mixed method research designs depend upon the sequencing in use of qualitative and quantitative approach and the dominance of methods (Morse 2003). Morse in 2003 suggested the arrows to indicate sequencing of methods and the plus signs for simultaneous use of both approaches. Dominance of a method needs to be presented in CAPITAL letters. Since then, these symbols have become part of the mixed method research design. The most common methods in use are: 1. Concurrent Mixed Method Design: This design is also known as convergent/ parallel or concurrent study design. It is though difficult but quite commonly used design. Both quantitative and qualitative methods are planned at the beginning of the research study to answer the question. For example, in an ongoing vulnerability assessment study, the qualitative and quantitative data collection and analysis are being carried out simultaneously. The quantitative data is providing the prevalence and types of vulnerability, and qualitative is providing explanations for the vulnerability and how it affects their health (Kumar 2020) (Fig. 1). 2. Sequential Mixed Method Design: Mixed method research could also be sequential. Quantitative or qualitative data sets are built on the results from one over the other. Researcher may start with a qualitative exploration followed up by a quantitative analysis or a quantitative survey which the results of which need explanation and explained by a qualitative follow-up. For most of the intervention health promotion studies, the formative research starts with qualitative approach, wherein the perception of people about specific health issue under study can be understood before implementing the intervention plan. In health sciences qualitative approach helps to explaining mechanisms, e.g., whys and hows underlying the findings of quantitative data like what, who, where, and when. Qualitative methods also help in developing quantitative tools. There are examples wherein the rationale of the study itself was based on sequential use of qualitative and quantitative methods based on the need to develop a quantitative instrument from the qualitative data or to converge information to understand the research topic. For example, Creswell et al. reviewed five studies in a primary healthcare setting. Following is the diagram used in one of the studies on a multisectoral action plan in India (Fig. 2).

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Fig. 1 Concurrent mixed method design: vulnerability and health outcomes, Haryana. (Kumar 2020)

Fig. 2 Diagram for a study that used sequential mixed method design Kaur (2020)

3. Embedded or Nested Mixed Method Design: Embedded is another design that has often been used in public health. Quantitative and qualitative approaches are implemented one in the other to provide new insights. For example, in a psychosocial intervention study (Chakrapani et al. 2020) for promoting safer

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sex behaviors among men who have sex with men, qualitative formative research was used to understand the local contexts and get feedback on the proposed intervention. Intervention mapping, a systematic approach that uses information from empirical, theoretical, and practiced literature, was used in addition to outcomes and process evaluation. These were used to build understanding on the processes or mechanisms needed for intervention and to understand users’ perspectives on the usefulness of the intervention. The process evaluation employed qualitative methods such as in-depth interviews with intervention users and a consultation meeting with key stakeholders (HIV intervention implementers and government officials for HIV program). Thus, the study as a whole has adapted a mixed method approach – with an initial qualitative component to inform the components of the intervention, followed by a quantitative quasi-experimental design for outcome evaluation, integrated with a qualitative process evaluation to understand the perspectives of the intervention users and key stakeholders. The focus of the study was the experiment or trial, in which qualitative methods are embedded before, during, or after the experiment. Accordingly, this study specifically used a quasi-experimental design to evaluate the intervention, employed qualitative formative research to refine the intervention, and qualitative process evaluation to assess the perspectives and experiences of the participants and key stakeholders on the usefulness and impact of the intervention (explained through diagram) (Chakrapani et al. 2020) (Fig. 3). 4. Multiphase Mixed Method Designs: The above diagram and the diagram below are good examples of using one quantitative, one qualitative, and one mixed study, carried out over time with links in place with each other. There are many examples of using this design. For example in an unpublished study (Passi 2020) started with quantitative base line survey, planned participatory intervention and

Fig. 3 Embedded or nested mixed method design. (Chakrapani et al. 2020)

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Fig. 4 Quant baseline, participatory action, and quant end line (multiphase study). (Unpublished protocol; Passi et al. 2020)

decided to to do quantitative endline survey. The aim is to see the effect of participatory intervention on followup of blood pressure and treatment adherence among people having hypertension. The researcher is planning to use participatory action research and build the capacity of the stakeholders including community through collaborative approach. In the second phase the research started with the consultancy meetings with all the stakeolders including community members to understand the needs of community, planning the intervention, and identify the capacity building needs etc. The details of plan is available in Fig. 4. At the third phase, a survey will be carried out to identify the effect of the intervention. Creswell in 2003 identified two types of mixed method designs: concurrent and sequential, which means that studies can use both the approaches of QUAN and QUAL simultaneously or concurrently or in sequence as and when needed through the development of the research protocol. Later, Creswell et al. (2011) suggested emergent design, for example, while carrying out the study wherein one of the components is found to be inadequate and additional component of the other type can be used to answer the research question. Should research decide the mixed method design of the study before or as study progresses depends upon the complexity of research questions. In common parlance, a researcher must decide the design beforehand, i.e., which research components to include in the design and when to use so that the robust conclusions can be drawn. The developments during the implementation of research most often stimulate the researcher to decide on additional components. Since

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Fig. 5 PRECEDE-PROCEED model used to design mixed method research (Kaur et al. 2018)

science is to know the unknown and anything unexpected can emerge, the advice is to be prepared for the change. Fixing the design might not allow to plan for emergence. Therefore, despite typological approach for mixed method design helps researchers (Teddlie and Tashakkori 2003), the diversity needed for mixed methods cannot be captured in one single design is the opinion expressed by most experts e.g., Maxwell and Loomis 2003; Tashakkori and Teddlie 2003; Guest 2013. Following more than one tradition, i.e., positivist, postpositivist, interpretivist/constructivist, and critical realist, one can use a wide range of purposes of mixed method research. Creswell et al. (2011) emergent design provided an idea to expand and address the limitations of the typology approach in mixed method design. A recently used precede-proceed model for study design development (Kaur et al. 2018) will be explained in the following diagram to finally come up with cluster randomized controlled trial (Fig. 5).

Sampling in Mixed Method Research The first step in any research approach is to decide the goal of research, followed up by research questions for qualitative component and objectives for quantitative component, the design, and then sampling. The size of the sample depends upon the research questions and research design both for QUAL and QUAN component of mixed method research. In mixed method

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research, sample size is calculated using statistics for the QUAN component. The number of units is based on representation of population, variability in the estimate of interest, and probability of rejecting the null hypothesis when it should not be rejected. For QUAL component of the mixed method study, sample size decided in the beginning often changes as the concern is to saturate the information. In QUAL “saturation” is the key to decide the sample size. For example, in-depth interviews or FGDs can be stopped immediately when new information stops flowing. In mixed method research (Onwuegbuzie and Collins 2007), sample size is based on the minimum sample size required both for quantitative and qualitative research. A review provided guidelines on sampling for mixed method research (Teddlie and Yu 2007). A sampling typology of mixed method has been developed as basic, sequential, concurrent, and multiphase based on the four designs advocated for mixed method research. Basic sampling refers to when researcher divides the groups into strata (e.g., above average, average, below average, etc.) and then selects few cases for indepth understanding within each stratum based on purposive sampling. When the results of qunatitative study leads to qualitative questions and findings of QUAL are used to determine the sampling for QUAN is sequential sampling. The research question leads to the design of sequential mixed method, and then one method leads to the other. There are many examples from public health literature where this sampling has been used (Morgan 1998). Concurrent sampling is the one in which both the samples (qualitative and quantitative) are decided independent of each other to meet the requirement of the research. For multilevel sampling, one may use district purposively, but for selection of health institutions like subcenters, probability sampling can be used (Creswell et al. 2007). Sample size and sampling frames to be used in mixed method research are quite diverse. The terminology for sampling also changes from sample size and sampling framework to sampling strategies. While in QUAN probability sampling a sample which is considered to provide a most accurate representation from the population is used, in QUAL it is the purposive sampling, in which sample of population or selection unit of participants are based on the research questions. Sampling in mixed method is as complex as it is in each of QUAN and QUAL. There are about 35 sampling strategies, and a mixed method researcher can apply any of these (Palinkas et al. 2015). In a mixed method study where the design has been fixed or kept modifiable or interactive over the duration of research, it becomes difficult to fix sample size for QUAN component, and it is all the more difficult to decide the saturation under QUAL component of the study. For example, a researcher might decide to do an intervention study to reduce salt in school children. The baseline for this project needs to have both QUAN and QUAL components. The QUAN will provide actual salt intake, and QUAL will provide information on how people perceive and measure their own salt intake. The QUAN sample will be calculated statistical based on the assumption on high salt intake in the population or the estimates from the earlier studies, and QUAL will be purposive keeping in mind who cooks in the family and who influences the choice of food or whose choice matters most while cooking food.

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A mixed method researcher generates samples varying in size from a small number to a large. The two databases, i.e., numeric and narrative, include information that is complemented. It has already been mentioned that a mixed method researcher needs philosophical clarity. To achieve complementarity, unlike pure QUAN and pure QUAL in a mixed method research, study sampling needs to be considered at almost all stages of research. It starts at the conceptual stage followed up at planning, data collection or implementation, and reporting or writing stage. Following are the strategies conceptualized for mixed method research.

Basic Mixed Method Sampling Strategies Stratified purposive sampling or quota sampling is one of the most recognized basic MM sampling strategies. The stratification in this kind of sampling starts with probability sampling, followed up by small units using purposive sampling. MM researcher first divides the universe of study into strata, e.g., very young, young, and adults. Using purposive sampling small number of units from each of strata can be selected. This has also been described as “samples within samples”(Patton 2002). This stratified purposive sampling comes from (Kemper et al. 2003), and (Kaur et al. 2018) studies where in the first phase of a study six strata were generated based on two dimensions wherein three were at community level crossed by two levels of implementation of innovation. Purposive sample could be random and random sample of a small number of units from quite a large size of population (Kemper et al. 2003). Researchers often use large QUAN approach to establish the magnitude of the problem or issue in evaluation studies wherein they use random sampling, but to understand the processes that were used in interventions, they use purposive random sampling. Kalafat and Illback (1999) used purposive random sampling in a school-based family support system program evaluation study. There were almost 600 sites in this program. Even for in-depth interviews, the random sample could have been 200 cases. It was not desirable and was not resource effective to explain the processes. Using purposive random sampling, they selected 12 cases out of the total population from all the study sites. But to have a good understanding of the process, they closely followed cases throughout the life of the project. The purposive random sample added credibility and complemented the large-scale QUAN results.

Sequential Sampling Strategy In sequential mixed method design, only QUAN or QUAL are carried out to prepare the ground for the QUAN or QUAL whichever is to be followed later. The methodology and results from the first phase of QUAN or QUAL leads the methodology of the follow-up phase that could again be QUAN or QUAL. For example, to find out the reason on whether people use more sugar or salt, a researcher may decide to start with QUAL and then plan for QUAN to know how much more than

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the recommended intake of sugar and salt people take. The same process can be reversed. The final sample used in the QUAN can also be used for the sampling frame for the subsequent QUAL.

Concurrent Sampling Strategy The researchers who choose to triangulate the results from each of the QUAN and QUAL components of a single study use the concurrent MM design. It allows the researcher to cross-validate or corroborate findings which have been collected by one of the QUAN or QUAL (Creswell 2003) and combine probability and purposive sampling. In concurrent sampling strategy, probability sampling strategies are used for the QUAN component and purposive sampling techniques are used for the QUAL. Alternatively, when a sample of participants are selected through the joint application of probability and purposive sampling strategies, both closed-ended and open-ended questions are used. Million Death Study, India (Jha et al. 2005), is an example of the second type of concurrent MM sampling procedure and provides finding for QUAN hypotheses and explanations on cause of death using one openended question. The data were collected concurrently and triangulated in the final phases of the data analysis.

Multiphase Mixed Method Sampling Multiphase sampling as the title suggests is estimated and decided for each of the phase of the study. It has often been used in two phases by the researchers (Palinkas et al. 2015). It provides the researcher scope for using smaller sample to answer a question that has not been answered from the large sample or needs to revisit study participants but not all to answer the question that emerged during or after the study. This is quite different from multistage or multilevel sampling. Researchers use multilevel sampling; if the universe of the study is classified into different levels, e.g., state, district, hospitals, doctors, and patients, then multilevel MM sampling strategies are more useful. Such studies have units nested within one another. The context differs at each level; therefore, it affects the analyses and results. In such cases researchers try to get samples from different levels. Multiple sampling is used to address one of more research questions (David et al. 2000). For Kemper et al. 2003, “in research, sampling is destiny” and creativity and flexibility is important. But 1. Research questions and hypotheses need to be kept in the center before deciding on sampling strategy. (continued)

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2. Both probability and purposive techniques or only one technique may also be useful. 3. Follow the assumptions of the probability and saturation for purposive sampling techniques, and do not violate the assumptions and ensure saturation. 4. Credibility of the inferences depends upon the purpose used for sample selection and saturation in QUAL. 5. Ethics are the same as for QUAN and QUAL, e.g., informed consent, and ensuring confidentiality must be followed.

Field Work: Data Collection Tools and Techniques The design of the study is often fixed at the start, the sampling strategy and techniques and tools of data collection along with brief analyses plan in their project protocol. In the recent past, researchers are keeping their protocols evolving with each of the progressive steps of the project. It holds true more for researchers doing mixed method research. Research projects undergo design change, introducing or modifying new methods in the protocol. Until analysis it is difficult to assume that the research methods were a complete fit. There are many such studies that can be considered exemplars. Brannen and Moss 1991 focused on first-time mothers and their return to employment following maternity leave. They started with purist positivist approach, but the findings led to experiential learning explanatory questions, and the study was modified toward QUAL, i.e., moved from structured interview schedule to open-ended questions. Similarly, many large studies from India in the recent past have added QUAN and QUAL as the need emerged through the study implementation and most often after analyses of the one component. It was not to generate topic guide or structured questionnaire but to seek explanations or explorations after reviewing the findings. Even the questionnaire had been prepared to have structured questions with open-ended questions in some of the small studies. Quality of data in such studies becomes a challenge for mixed method research. Both skills to prepare questions and art of asking them are required for collecting both a valid and thick data. Data quality from a QUAN researcher is evaluated with validity and reliability, while from a QUAL it is credibility and dependability wherein the researchers’ biases are acknowledged using alternative explanations. Researchers using mixed methods need skills for preparing both QUAN and QUAL tools for data collection or need a team with a varied skill sets.

Tools and Techniques of Data Collection In QUAL studies the focus is on research questions and purpose of the study; in QUANT the objectives need to be SMART. In mixed method research,

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researcher needs to focus on research questions and use the data collection techniques appropriate both for QUAN and QUAL. The questions used in the tools of QUAL are different from that of QUAN tools. For QUAN the tools such as interview schedule, observation checklists, or scales use specific questions and provide numbers. In QUAL, researchers use topic guides for whichever method or technique of data collection, e.g., focus group discussion or in-depth interviews, leaves space for explanation and discussion to get rich thick information. Onwuegbuzie and Leech (2006), have discussed the structure and quality of questions being used in quantitative or qualitative tools. The quantitative tools need to frame the questions that can lead to quantified responses to one or more variables, for example, what is the perception of people about their salt intake: comparative, e.g., is it different in age or gender groups, or associated, e.g., if salt intake is associated with socioeconomic variables. Qualitative tools on the other hand are “open-ended, evolving, and non-directional,” i.e., more of topics and less of questions are required. Following the biomedical rather than biosocial approach till recently even for studies that require topic guides, good qualitative questions which are broad and specific have been used (Clark and Badiee 2010). “Qualitative questions generally tend to seek, discover, and explore a process or to describe experiences” (Onwuegbuzie and Leech 2006). Therefore, it is suggested to use topic guides to get the exhaustive responses rather than the specific questions in the qualitative tools.

Mixed Method Research Analysis Mixed method data requires both statistical knowledge and understanding from the nuances of textual data. The analyses of a mixed method research study depend upon its design. Many public health researchers restrain from mentioning use of mixed method research approach or sometimes overuse it. They use statistical techniques such as regression analysis, clustered samples, and multilevel modelling to begin with and qualitative methods to study groups or sites to justify other research design, e.g., case study. In such cases these case studies are carried based on findings from quantitative data and are used only for the clarification. In some other studies, the key concepts derived from the qualitative data analysis have been quantified or converted to quantifiable variables to establish correlation with outcomes. These studies use different methods and analyze the data within the same set of epistemological assumptions as from a positivistic quantitative approach and rationalized use of different methods for their “complementary strengths” and for minimizing weaknesses that are associated with only one approach. Quite often qualitative data even in mixed method research studies has been transformed into quantitative data especially those that are appearing in public health literature. The depth of qualitative data is likely to be affected by the interview approach or other method used to prompt the respondent. On the other hand, the quantitative researcher who applies a qualitative method may be wary of analyzing

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qualitative data as such since not all respondents answer questions in equal depth. An important point to ponder over here is that the computer softwares for qualitative analyses also provide findings in codes and categories. For analyses of mixed method research, it is important to involve a team of statistician and a qualitative researcher. While the quantitative data can be analyzed by applying statistical testing of hypothesis, the qualitative analysis starts with the data collection itself. The data collected through in-depth interviews, focused group discussion, or from any textual document needs to be reviewed thoroughly and regularly to fill the gaps in the data. For example, a researcher could conduct a qualitative analysis of qualitative data followed by a quantitative analysis of the qualitative codes that emerge from the qualitative analysis. In qualitative data exploratory factor analysis is often carried out of the themes that emerge from a constant comparison of qualitative data (Onwuegbuzie and Leech 2006). As has already been mentioned, the qualitative data sometimes is converted into numerical and is analyzed quantitatively (Miles et al. 1994; Tashakkori et al. 1998). Overview: Seven-steps for analysing mixed methods data (Onwuegbuzie and Teddlie 2003) 1. Data reduction: reduce the dimension of the quantitative data and qualitative data. 2. Data display: describe the quantitative and qualitative data visually. 3. Data transformation: quantitizing (quantifying the qualitative data) and/or qualitizing data (converting the quantitative data into qualitative). 4. Data correlation: correlating quantitative data with quantitized or with qualitized data. 5. Data consolidation: combining both quantitative and qualitative data to create new or consolidated variables or data sets. 6. Data comparison: comparing quantitative and qualitative data. 7. Data integration: integrating both qualitative and quantitative data into a coherent whole. Green (2007) provided four phases of analyses, the first two of which are the steps 3 and 4 provided by Onwuegbuzie and Teddlie (2003). The step 1 is analysis for drawing inferences and step 2 is to use analytical framework of one methodological tradition within the analysis of data from another tradition. Not that all the researchers quantify the qualitative data and apply statistics. There are quite a good number of studies where the categories derived from textual or visual data are used for explaining the connections between categories.

Writing-Up Mixed Method Research Writing mixed method research is somewhat similar to the report writing for quantitative or qualitative study or project. At the same time, it is quite different

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and more challenging than writing a report for quantitative or qualitative study or project. Major components of writing up findings from mixed method research: 1. Rationale of the study: It seems similar to both qualitative and quantitative study, but it is important to reflect that how and why use of mixed methods will provide robust and more useful information. 2. Research questions: The mixed method research starts with small and clear research questions. The objectives need to be mentioned for the quantitative aspect of the study. 3. Explain the philosophical approach: A brief on the philosophical approach used in the study helps the reader understand the standpoint of the researcher (Chakrapani et al. 2020). 4. Design of the study: Methods are explained in all the reports and so are designs. The design in a mixed method study needs to be carefully decided and explained. 5. Knowledge and skills of the team members: The competencies of all the team members need to be mentioned for the reader to understand how different people with different sets of knowledge and skills complemented to bring the rigor in the study. 6. Findings: Writing findings involve the understanding of purpose of using mixed methods. For example, findings of a mixed method study wherein the purpose was to corroborate, the results of quantitative aspect should be presented first to corroborate the findings of the qualitative study. If the purpose was to complement, then findings can elaborate, illustrate, enhance, or clarify the results of one over the other aspect of the study or project. 7. Rigor in the study: Rigor needs to be reflected throughout the writing. Findings from mixed method research provide divergence, convergence, and complementarity for drawing conclusions. The contradictory or opposing findings of a single mixed method research study can happen because of the methodology problems or the misuse of theoretical assumptions (Erzberger and Kelle 2003). It can be resolved by revising theoretical assumptions which had led to contradictions. Researchers have to formulate ad hoc hypotheses based on already-collected empirical data that may lead them to retain their initial theories and formulate “far-reaching speculations that lack a sound empirical basis” (Erzberger and Kelle 2003). The relationship between hypotheses and the empirical content of the initial theoretical assumptions must reflect consistency, and the hypotheses should improve the consistency of the initial theory with empirical content. The empirical test leads to new hypotheses using new data, and the newly developed hypotheses should be adaptable to other established theories related to the research (Erzberger and Kelle 2003). Researchers need to reexamine the processes used in assessments if there is any divergence in results. The divergence in findings may be because of

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quality or methodological issues in one or more of the methods used in the mixed method research study (Costa and Remedios 2014). The convergence in results wherein the qualitative and quantitative data are providing same results, the integration of results lead to arguments and questions the quality of the inferences drawn through the data. In such cases the theoetical assumptions can help in reinforcing the results. Finally, if a mixed method approach leads to complementary results, i.e., the qualitative and quantitative results relate to different objects or phenomena but are complementary to each other, then the integration provides a more complete picture (Erzberger and Kelle 2003).

Conclusion Public health generates new knowledge to address the factors that are structural. It is quite different from most medical fields including community medicine or preventive and social medicine where individual behaviors are responsible for health and treatment is the only solution. Public health has moved out of the tradition of pure positivist to the critical realist tradition to find out how structural issues affect the community and individual health. The research traditions and approaches have undergone revolutionary changes and are quite useful for public health. Therefore, the traditions other than the positivist, i.e., constructionivist, and realist can contribute more for providing evidence for public health practice. The goal of a mixed method research is to expand and strengthen the findings of public health. Mixed method studies contribute to answering research questions with heightened knowledge and validity. Finally, mixed method research approach has its own design and sampling strategies. Thus, quantitative and qualitative researchers need combined expertise and skills of data collection to answer the research questions and testing hypothesis. However, the most important feature to evaluate any research study, irrespective of the research approach used, is the rigor with which it has been carried out.

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Accountability and Aid Effectiveness Research in Global Health

11

Elvira Beracochea

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why Does Aid Effectiveness Research Matter in Global Health? . . . . . . . . . . . . . . . . . . . . . . . . . What Is Accountability and Aid Effectiveness Research in Global Health? . . . . . . . . . . . . . . . . . . What Are the Principles of Aid Effectiveness and Accountability that Guide Research? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Kind of Accountability and Aid Effectiveness Research Is Needed to Advance the SDG Agenda? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Can AAE Research Do to Contribute to Global Health Practice in the SDG Era? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How to Conduct AAE Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AAE Research Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How Would an AAE Research Department Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective Steps to Conduct AAE Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What to Do with AAE Research Results? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Accountability and aid effectiveness (AAE) research accounts for three main global health outcomes: first, the delivery of effective global health solutions; second, the efficiency or “value for money” of these solutions to donors and recipient countries; and third, the sustainability of these effective solutions to continue working towards the country’s health goals after the aid ends. AAE research is based on five principles: country ownership, harmonization, alignment, management by results, and mutual accountability. AAE research is difficutl because of the same reason that effective global health practice is difficult, that is, the global health and aid architecuture are complex and fragmented. However, it is possible to focus on E. Beracochea (*) Realizing Global Health, Fairfax, VA, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_12

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research questions at country level, measure effectiveness, efficiency, and sustainability, reduce fragmentation and duplication, and aim for cross-national effectiveness comparisons. This chapter will discuss why this type of research matters and describe examples of how effective and accountable global health practice has demonstrated to be so far. Next, we will discuss mixed research methods used to measure accountability and effectiveness. If the HIV/AIDS (Esser, Glob Public Health 9:43–56, 2014), Ebola, and 2020 COVID-19 pandemics have served for a greater purpose, it is to show that AAE research is an essential part (or at least should be) of global health practice. This chapter will show you how to design and implement this type of research and use it to improve your own performance as a global health practitioner, as well as contribute to improve the results of global health practice. Keywords

Global health research · Aid effectiveness · Accountability · Sustainability · Universal health coverage · Health systems

Teaching and Learning Objectives

The three main objectives of this chapter are: (1) to explain why accountability and aid effectiveness matters and why there is need to have a global research agenda to systematically conduct AAE research, (2) to describe what is studied in AAE research, and (3) to teach you how to conduct this type of research. The specific objectives you will achieve after studying this chapter are: 1. Understand the definition and principles of Accountability and Aid Effectiveness 2. Discuss the rationale and why these principles matter in global health 3. Discuss various approaches to AAE research in global health 4. Learn how to design and conduct research in the field of AAE 5. Learn practical application of AAE research in global health practice

Introduction Why Does Aid Effectiveness Research Matter in Global Health? Aid is effective when it achieves the desired effect or outcome (Beracochea 2015). The desired outcome of global health practice is a sustainable improvement in the health status of the population that receives the aid. If the aid does not help the country deliver better services that achieve better outcomes and the country’s health system has not been strengthened to keep delivering better services after the aid

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ends, then aid has not been effective. I am referring to development aid. The outcome of effective humanitarian aid is to save lives and prevent further worsening of the country’s health status. Effective development aid, along with stable governance (Kabir 2019), helps countries to develop. Aid solves health service delivery and management problems, improves quality of care, and expands coverage of health services. It is about hitting the bull’s eye (Wickremasinghe et al. 2018) and doing so that you can explain what worked to achieve what outcomes (Beracochea 2018). For example, aid is effective when a HIV/AIDS project increases the detection of HIV+ persons and improves the quality of the health care delivery model so patients can sustain viral suppression. In addition, the country where these persons live is able to sustain the improvement and keep delivering better HIV/AIDS quality services. In short, the project can account for improved performance of the country’s HIV/AIDS program and of the country’s healthcare delivery system. In addition, the country continues doing it after the aid ends. The aid was effective. If not, the job is not done, and aid needs to continue and demonstrate that it is showing improvement in the right direction. On the other hands, effective humanitarian aid is aid that is provided during an emergency such as an Ebola outbreak, civil unrest, war, or an earthquake or Tsunami. This aid helps implement the emergency response faster and better, reaching larger numbers of victims, and preventing negative outcomes such as diarrhea and other diseases related to lack of drinking water, food, or lack of access to medical care. Thus, effective humanitarian aid should provide quality healthcare to victims and provide basic services to those affected, such as mosquito nets to prevent malaria, children’s vaccination to prevent vaccine preventable diseases, and family planning services to prevent unwanted pregnancies. Effective humanitarian aid provides lifesaving aid without which people would die or suffer unnecessary and preventable hardship or disease. Effective aid is evidence-based by design and requires effective planning and management to deliver the maximum return on the investment by a governmental or private donor that are affected by so many factors including rate exchange (Chansa et al. 2018). In short, it is not only what a donor-funded project does but also how it is done that leads to effective results. This matters, because effective aid needs to achieve three objectives:

Overview: Threefold Goal of Global Health Practice

1. Deliver effective global health solutions that solve the identified problems 2. Be efficient, that is, demonstrate “value for money” of these solutions to donors and recipient countries 3. Be sustainable so that these effective solutions do continue working and helping the country achieve its health goals event after the aid ends

Effective aid accounts for its results and is subject of evaluation research. However, not all aid is effective and there is evidence of selective practices (Adedokun and

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Folawewo 2017). Aid that is not evaluated cannot be determined to be effective, not matter how good the original intentions of the donor or the implementing stakeholders. Effective results also help fundraising and attract more support from donors (Karlan and Wood 2017; Metzger and Günther 2019a, b). Aid is funded by a donor and provided by global health experts in various fields. These global health experts usually come from more developed and richer nation. Their goal is to help counterparts in developing ones achieve one or all of the three objectives above. This aid is essential especially in the poorest and war-torn countries such as Iraq and Afghanistan (Dalil et al. 2014). Therefore, global health practice must account for solving the challenges for which aid is provided and deliver effective development and/or humanitarian aid. AAE research is part of the practice of global health and helps demonstrate that the global health practice and practitioners have indeed solved the problem at small scale at least. In addition, the effectiveness of the role of the global health experts, consultants, facilitators, trainers, coaches, researchers, and/or evaluators in global health needs to be questioned and measured as a matter of professional accountability. The continuous and transparent assessment of the performance of those of us working in global health will ensure our work achieves the desired outcomes. Although altruistic intentions to help those in need are usually the motivation for providing aid, foreign policy and political alliances are also underlying motivations for countries to be involved in giving and receiving aid. Understanding the ultimate purpose helps explain why some countries with smaller populations receive more aid than large countries with more people and bigger needs. Finding ways to advocate for equitable distribution and allocation of aid is the job of international organizations such as the UN, WHO, UNICEF, etc., and the professionals that work in them. How transparent and effective these organizations are is also part of AAE research. This chapter will show you why you need to gather evidence of effectiveness and account for the results of aid in global health. You will also learn what aid outcomes to account for and how to research and find evidence of effectiveness and accountability. Also, you will learn how to demonstrate effectiveness in your global health work and to advocate for accountability of health outcomes of every global health interventions or projects you are involved. Global health is a great career that carries also the professional responsibility for effectiveness and accountability.

Why Does Accounting for Aid Effectiveness in Global Health Matter? International laws and treaties are the legal reason for accounting for aid effectiveness, for the results of our global health work, that is, effective and ineffective results and everything in between. In fact, accounting for the effectiveness of using aid funds is necessary to demonstrate the fulfillment of the right to development of the receiving nation. AAE research in global health measures how well aid has helped fulfill the right to health of the people in the recipient country. Accounting for aid and its results in global health includes accounting for the result of financial aid, as well as the sharing of technology or knowledge and expertise provided through various mechanisms, usually humanitarian or development projects that provide technical assistance to improve the health status of the people in the receiving country. Therefore, multidisciplinary teams are usually

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needed to conduct AAE research and make use of various research tools form their fields. It is essential that everyone on the team be aware of the purpose of AAE research and the legal basis. Having a common foundation will help you apply epidemiological and social science tools as well as financial tools to conduct AAE research studies that make use of the right mix of qualitative and quantitative methods. Quantitative research methods help quantify and account for the effectiveness of the aid while qualitative methods help us explain why aid was or was not effective in fulfilling human rights treaties and conventions, as well understand the cultural differences and expectations and perceptions of those receiving and giving aid. In short, every global health organization and the work we do is to contribute to fulfill these international legislations.

What Is the Legal Basis for Global Health Practice and for Accountability and Aid Effectiveness? The legal basis for the provision of global health aid was first created through the Universal Declaration of Human Rights (UN 1948). The rights-based nature of our work in global health was further defined in subsequent declarations and international covenants that most countries have endorsed with some notorious exceptions. In short, there is large body of international laws and treaties that your global health work will help put into practice and fulfill. Aid is provided in the context of these legal documents. Therefore, you need to remember that all you do either global health practice or research is rights-based, that is, it is based on the rights of every human being on the planet, particularly the right to health, and contributes to fulfill those rights in the most effective way. I suggest you create a folder in your computer for these documents, and even print them and keep them in a binder near your desk. You will need to refer to these documents many times in the course of your global health practice and while conducting AAE research. Global health aid is rights-based and also provided in the context of the right to health as defined by article 25 in the Universal Declaration of Human Rights (UN 1948). The Committee on Economic, Social, and Cultural Rights (CESCR) further defined the right to health in more clear terms in the year 2000 in its General Comment 14 (UN 2000), which despite its unappealing name, it states that “Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity.” General Comment 14 matters because the CESCR includes a body of 18 independent experts that monitors the implementation of the International Covenant on Economic, Social, and Cultural Rights by the UN country members. This includes the right to health. You need to read General Comment 14, print it, and keep a copy with you because it is the legal basis that will guide your global health work. Global health aid is provided in the context of humanitarian or development assistance through various treaties and agreements between countries and is – or should be – based on the Declaration on the Right to Development (UN 1986). This declaration was endorsed by most countries and established the right to

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development as a collective human right and it is centered on the right to selfdetermination of every human being. In just 10 articles, this declaration established the duty of all states to cooperate to help realize the right to development and to sustain their effort to ensure “effective international cooperation” to provide “countries with appropriate means and facilities to foster their comprehensive development.” With a sound right-based foundation, aid effectiveness and accountability are now the basis of your global health career. Now you know why we do what we do and why we account for our work. There is not a universally accepted standard code of practice in global yet. However, I hope in my lifetime, the principles and the tools of aid effectiveness and accountability you will learn in this chapter become common practice and routine in the work of the international health and development industry complex. Please keep a folder in your computer or print the documents and keep a binder to refer to them. Each is a few pages long, but you will discover every word counts and will guide your path towards more effective and accountable global health aid.

What Has Been Done About Improving Accountability and Aid Effectiveness in Global Health? You are now aware of the legal basis for working and doing in global health and for conducting AAE research in global health. There has been progress towards more effective and better accounting of global health results. However, despite the legal basis and international treaties, and the many conferences and meetings, progress towards global consensus on accounting for aid effectiveness has not been moving as fast and transparently as desired. There are a number of lessons to be learned so mistakes of the past are not repeated and what works is preserved and improved. Therefore, it is essential that you be aware of the main milestones and the lessons learned in the road towards more effective and from the past to avoid mistakes and learn from the lessons of the past 40 years as you prepare to conduct AAE research. The purpose for listing these milestones is to show you that global health professionals have been working to improve the effectiveness of our work for over 40 years with varied degree of success. The important message here is to learn from the past and not repeat its mistakes but fix them. Main Aid Effectiveness and Accountability Milestones in Global Health 1948 – UDHR. The 25th article of the Universal Declaration of Human Rights to which most countries are signatories established the right to health of every human being on our planet. How countries have gone to fulfill this right differs and for that reason, each country has different and more or less effective health system and each country’s people have different health status. Fortunately, research to compare the effectiveness of various health systems is a growing field. 1978 – HFA2000. In 1978, international conference on Primary Health Care (PHC) was held in Alma-Ata, USSR. The Alma-Ata Declaration established that PHC was essential to realize the right to health of every person and that PHC was urgent to achieve health for all by the year 2000. This strategy became known as HFA2000. However, the year 2000 came and PHC had not been yet implemented by

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most countries. Many excuses and explanations were attributed to this failure, but not formal accountability structures were in place, except the ability of the UN to ask member countries to report. 1979 – CEDAW. The Convention on the Elimination of Discrimination Against Women addressed gender inequality and most of the social determinants that affect the health of women in our planet. Despite renewed emphasis on gender, most CEDAW articles still need to be enforced and many countries have not endorsed it, including the USA. In 1994, UNFPA held a conference on Cairo that brought 113 countries and set an agenda. Research to determine the effective implementation of this agenda has not been conducted despite several meeting held since then. The health status of women was partially addressed in the Millennium Declaration in 2000 (see below) because it called for countries to reduce by 50% maternal mortality. Research has shown that this target was not met and many disparities within counties disproportionally affect certain ethnic and racial minorities. More AAE research is needed to find effective solutions to women’s health. 1986 – DRD. Declaration on the Right to Development. I believe this declaration rules our global health work. More developed countries have the duty to help developing nations develop faster and better. Research on the effective implementation of the declaration needs to be further explored. 1989 – CRC. The Convention on the Rights of the Child is another international human rights document that guides our global health work. As with the CEDAW, many countries have not ratified it, including the USA, because it implies accepting the duty of fulfilling the right to health of every child. The USA has a federal program to protect children’s access to health care: the Child Health Insurance Program (CHIP) provides low-cost health care to children who are not poor enough to be covered by Medicaid, the free healthcare program. Research has shown that there are disparities across states and racial and ethnic groups that question the effectiveness of these programs. AAE research within and across countries is still needed to determine how best to fulfill the right to health of every child. 2000 – MDGs. The Millennium Declaration was a good document that included important commitments, especially the eight Millennium Development Goals, of which three goals were specifically health-related and others also related to improving gender equality and saving lives such as reducing hunger and increasing access to clean water. The MDGs also had a list of “Quick Wins” that would help accelerate their achievement, but these were not implemented consistently to achieve impact and most countries did not meet the MDG 48 targets. Research on the effectiveness of the interventions designed to meet the MDGs did not start until after 2005, the year of the first monitoring report on the progress of the MDGs and the year of the Paris Declaration on Aid Effectiveness and Accountability. As you can see, the international machinery moved slowly and it took 5 years to start monitoring the progress of a 15-year agenda. Fortunately, the international organizations associated with the Sustainable Development Goals (SDGs) learned from that and the UN created a monitoring toolkit and the SDGs are monitored annually. Here is the latest report: https://unstats.un.org/sdgs/report/2019/The-Sustainable-DevelopmentGoals-Report-2019.pdf

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2005 – PD. The Organization for Economic Cooperation and Development (OECD) (www.oedc.org) convened a meeting in Paris that led to the Paris Declaration on Aid Effectiveness and Accountability was a turning point in the practice of AAE research. For the first time, principles for the provision of overseas development assistance (ODA) were agreed upon. Applying these principles is at the core of AAE research in aid effectiveness and in global health effectiveness (OECD 2012). As it will be shown below, ensuring that donors and recipient countries apply these principles account for effective results has not been a straightforward mandate and there are still many global health organizations and professionals that do not practice them making research even more urgent (ADB 2011). See the section on the Paris Declaration below for more detail. 2007 – IHP+ and 2016 UHC2030. The International Health Partnership was created to improve cooperation to achieve the health MDGs. In 2016, the IHP+ was transformed into UHC2030 (www.UHC2030.org) to help achieve SDG3 and focus on strengthening health systems and achieve Universal Health Coverage (UHC). UHC is the main strategy to achieve all the other health targets of improve maternal and child health and preventing and controlling diseases. UHC2030 is an advocacy and coordination stakeholder organization (Bigsten and Tengstam 2015). It is to facilitate accountability and integration of interventions to improve UHC. AAE research to find ways to monitor the expansion of coverage is needed and well as definition of what the effective ways to do so. The UHC2030 has a vision document that lists a number of principles similar to those of the PD and a number of health system performance dimensions focused on improving service delivery, financing, and governance. The principles are: 1. Leaving no one behind: a commitment to equity, nondiscrimination, and a human rights-based approach 2. Transparency and accountability for results attract beneficiaries (McGee 2013) 3. Evidence-based national health strategies and leadership as the foundations for HSS 4. Making health systems everybody’s business – with engagement of citizens, communities, civil society, and private sector 5. International cooperation based on mutual learning across countries and development effectiveness principles There are no indicators or data regarding the impact of the UHC2030 on its stakeholder’s performance or a selected number of countries is not reported in their website, nor is there a mechanism for coordinating coverage expansion activities. Therefore, the UHC2030 and its partners need to develop AAE research branch to monitor their progress towards 2030. 2010 – AAA. The Accra Agenda for Action called for accelerating progress and strengthening country ownership, a core principle of the PD. Having ownership over development by strengthening country capacity to manage development is an area of research that has not been developed in global heath yet. How effective is aid at strengthening a country’s health system, and its government

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ownership and leadership of what happens in the health sector is a question that needs answer in many countries as the study about “Hitting the Bulls Eye” (Wickremasinghe et al. 2018) described below has shown. The AAA agenda raised the costly problem of aid fragmentation (Gehring et al. 2017) and the need to increase value for money and accounting for results and recommended a number of practical actions. All these topics still require research 10 years later. In fact, global health would really benefit from have a list of evidence-based effective “Quick Wins” and effective ways to account for value for money and results. The meeting in Accra showed the limitations in health and other development sectors (Cabral 2008). There is evidence of a number of interventions that we know do work and save lives that need to be scaled up and included in every primary health care program in every country. These include vaccination, antenatal care, active management of the third stage of labor, antiretrovirals, breastfeeding, handwashing, mosquito nets, etc. 2011 – 4thHLF. Fourth High Level Forum on Aid Effectiveness. In a meeting in Busan, Korea, OECD also convened and helped reaffirm the PD principles and AAA again. The Busan meeting also produced a list of additional actions that were agreed for more effective international cooperation, particularly through South-South Cooperation and Partnerships. These actions among others included: improving the quality of cooperation, increasing the focus on results, and making effective aid part of effective and sustainable development, promoting the role of CSOs and private sector, and combating corruption (Quibria 2017). There is still need of AAE research to measure the effectiveness of the Busan commitments. 2015 – AAAA. The Addis Ababa Action Agenda was the result of the Third International Conference on Financing for Development, which called for a Global Partnership implement the Sustainable Development Agenda. The COVID-19 pandemic has made the need for an effective global partnership even more urgent. 2015 – SDGs. The 2030 Agenda for Sustainable Development included 17 Sustainable Development Goals (SDGs) approved by the UN General Assembly in 2015. The UN monitors the SDGs and while progress has not been significant in the first 5 years, there have been improvements. This progress is at risk given the current COVID-19 pandemic that might cause high mortality in itself and for other causes due to reduced access to care for other patients for all other conditions. The 2019 SDG report (UN 2019) is a general report that does show gaps in coverage but does not account for disparities within countries.

What Is Accountability and Aid Effectiveness Research in Global Health? AAE research is research based on the principles of the Paris Declaration on Aid Effectiveness and Accountability of 2005. Let’s see these principles and what type of research has been and is being conducted in the SDG era.

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What Are the Principles of Aid Effectiveness and Accountability that Guide Research? The Paris Declaration. In the year 2005, a number of donors, countries, and organizations gathered in Paris and drafted five principles of Aid Effectiveness and Accountability. The principles are interrelated and are focused on accounting for effective results. These principles are the focus on AAE research. The principles are (Fig. 1): 1. Ownership. This means that receiving countries need to lead the development process. They must be in the driver’s seat and be empowered to put in place national development strategies with clear strategic priorities. This principle is the number one requirement for increased effectiveness (Martinez-Alvarez 2018). Bypassing the government does not lead to effective results (Chasukwa and Banik 2019). 2. Harmonization. This principle means that aid is provided through harmonized programs that are coordinated among donors. Coordination structures became a must with the proliferation of donors (Pallas and Ruger 2017), all trying to help in different ways. It is agreed that donors must conduct their field missions and country analytical work together with recipient countries and demonstrate effectiveness themselves (Minasyan et al. 2017). 3. Alignment. This principle requires that countries develop reliable national fiduciary systems or reform program to achieve them and that donors must align their aid with national priorities and provide the information needed for it to be included in national budgets, allowing for gender-specific needs (Holvoet and Inberg 2014). Coordinated programs aligned with national development strategies are to provide support for the country’s capacity development. Donors are to avoid creating parallel systems and are to use the systems that already exist in

Fig. 1 Principles of the Paris Declaration

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recipient countries: for example, education and health systems, information, procurement, government administrative, financial, and HR systems. Effective public procurement can have an important impact on health outcomes (La Chimia and Trepte 2019). Aid is to be predictable and reliable so the country can count on the aid to be released according to agreed schedules, and that bilateral aid is not tied to services supplied by the donor. 4. Management by Results. Countries have transparent, measurable assessment frameworks to measure progress and assess results 5. Mutual Accountability. Regular reviews assess progress in implementing aid commitments. Research can focus on those that need help the most such as postconflict areas (Ssengooba et al. 2017) The Organization for Economic Cooperation and Development (OECD) is a policy making partnership of countries with over 60 years of experience. Their motto is “better polices for better lives” and was the leader in AAE, particularly in health since convening the Paris conference in 2005 and subsequent meetings. A number of targets and indicators have been used to measure progress of implementation of the five PD principles (Fig. 2). However, by 2010, that is, 5 years after the PD, progress had been limited. And even, since Busan in 2011, OECD and the international aid industry does not seem to focus on the PD principles as the basis for cooperation and development. OECD no longer seems to spearhead emphasis on the PD indicators, and although, as an organization, its website does not show data of how much lives have been improved by its policies, it does have a health data base (https://www. oecd.org/health/health-data.htm) that is available for researchers to use. Since 2014, the OECD produces a report on what makes aid effective. The 2019 report (https:// www.oecd.org/dac/making-development-co-operation-more-effective-26f2638f-en. htm), which presents the 2018 results, showed that progress is not too good with the 12. Mutual accountability

2010 targets

11. Results-oriented frameworks

10b. Joint country analytic work 10a. Joint missions 9. Use of common arrangements or procedures 8. Aid is untied 7. Aid is more predictable 6. Strengthen capacity by avoiding Parallel PIUs 5a. Use of country PFM systems 4. Strengthen capacity by co-ordinated support 3. Aid flows are aligned on national priorities 2a. Reliable Public Financial Management (PFM) systems 1. Operational Development Strategies -0.1

Fig. 2 Indicators of the Paris Declaration 2010 (Source: Elizabeth Sandor, OECD 2008)

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exception of improve mutual accountability and country planning, all other indicators have worsened: 1. Reaching the Sustainable Development Goals (SDGs) requires urgent action on effective partnerships, as called for in SDG 17. 2. Development partners’ alignment to partner country priorities and countryowned results frameworks is declining 3. Partner country governments have made significant progress in strengthening national development planning. 4. Forward visibility of development co-operation at country level is weakening 5. Strengthened public financial management (PFM) systems have not been matched with significantly increased use by development partners. 6. More systematic and meaningful consultations with development actors are needed both by partner country governments and development partners. 7. The enabling environment for civil society organizations is deteriorating. 8. Improving the quality of public-private dialogue (PPD) in partner countries requires increased capacity, strengthened relevance, and the inclusion of a wider range of private sector actors. 9. There is mixed progress in making development co-operation more transparent. 10. In response to the evolving development landscape and the ambition of the 2030 Agenda, mutual accountability mechanisms are becoming more inclusive. In short, there is a lot of room for AAE research and the field needs to develop to demonstrate what really works. In the context of the current pandemic, innovative approaches are now urgent. Fulfilling the PD principles in global health practice brings up a number of research questions: • What is the purpose of Aid in global health? • Does Aid work to achieve global health goals or just to improve public health programs? • Does it matter how it is used and who takes ownership? • How can one organization harmonize with what others are doing? These and other questions require a new paradigm to design and implement aid in global health, a paradigm that integrates the five principles and one that is systemic. Systemic means that aid helps develop and expand the coverage of the country’s health system and public and private health sectors.

What Kind of Accountability and Aid Effectiveness Research Is Needed to Advance the SDG Agenda? The global health agenda has been reset by SDG3, which calls for ensuring healthy lives at all ages through the achievement of Universal Health Coverage (UHC) and a

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number of measurable reductions in preventable morbidity and mortality by 2030. However, the fragmented architecture of global health practice and weak international coordination among countries has not allowed the development of a coordinated strategy and plan to achieve these targets. Most countries do not know what their baseline coverage rate is, how many of their people are not covered, and how they will be covered or with that services. Some countries have defined a basic or essential healthcare package or basket. How effectively is such package delivered is known in most developing nations. In conclusion, we do not know what the baseline is for UHC and we do not have a plan to achieve it. In addition, we are in the midst of a pandemic that has disrupted and weakened most health systems. Through its articles of constitution, the WHO is the international organization charged with coordinating and monitoring SDG3, but its funding and role have been put in question during the Ebola and Covid-19 pandemics. Strengthening the WHO might require political will and commitment to the mission of the WHO as it was defined in its constitution. In addition, more strategic AAE and transparent reporting of performance indicators of the assistance provided by WHO and other agencies of the UN facility to member countries. In addition to hundreds of bilateral and multilateral organizations working in global health, there are hundreds if not thousands of foundations and nongovernmental, faithbased, and civil society organizations that provide global health services and healthcare services. Lack of effective partnerships and stakeholder coordination makes it difficult to measure the effectiveness of various global health programs, projects, and interventions. Therefore, it is now almost impossible to attribute outcomes to either one of them or measure their contribution unless they are organized and coordinated to do and account for their contribution. For example, the outcomes of the effective coordination role of WHO with other UN agencies such as UNPD, UNAIDS, UNFPA, and UNCEF is not well understood or known yet. The evidence of the effectiveness of the World Bank’s health projects usually relies on the effectiveness of the country’s health information system, which sometimes tends to be inaccurate and incomplete. Therefore, it is confusing in this fragmented scenario how best to measure what is effective and how to account for health outcomes. If more effective coordination could be achieved across all stakeholders, AAE studies on the effectiveness of various global health programs could be done using secondary data collected in WHO’s Global health observatory (https://www.who.int/ data/gho). The GHO also depends on the quality of the data that countries’ heath information systems can produce, but with better coordination data quality problems (Breitwieser and Wick 2016) could be diagnosed and solved with the advent of digital health technology. There are probably indicators that measure hundreds for services and programs in the GHO that would allow hundreds of AAE studies. Despite data quality and system inefficiencies, the GHO and other existing databases are untapped sources of data for meta-analysis in AAE research. If aid is to help achieve SDG3, it has to be by supporting the development of effective health systems. The country’s health system must be the focus on global health aid efforts because health systems do not happen by chance. A health system is a complex organization of public and private healthcare delivery, academic and

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government organizations that need to work in a coordinated manner to meet the health needs of the country’s people. There is not a globally accepted simple paradigm that helps keep global health work simple and focused on its ultimate goal: UHC. The paradigm I have been using in my work in the last 10 years was presented in a book a number of colleague and I put together entitled “Improving Aid Effectiveness in Global Health” (Springer 2015). The paradigm is deceptively simple: project > program > system. It means that if effective health systems are the vehicle to deliver quality healthcare to every person, then, every project, initiative, or donor-funded organization working in a country must ensure that what they do contribute to designing and improving the effectiveness of the country’s health system. In short, every aid-funded project must demonstrate to have effectively improved how one or several of the country’s programs work so that the health system can deliver better quality and more services to cover as many people as possible. In addition, the project should be implemented in a manner that the health system, that is, a number of public and/or private health facilities and the local health authorities can continue to do so after the project ends. The effect should be measurable at least in the project-supported geographic areas.

What Can AAE Research Do to Contribute to Global Health Practice in the SDG Era? Let’s see a couple of hypothetical examples of global health practice to show how research would contribute to improve outcomes. First, let’s imagine an effective family planning project. It would be one that demonstrates having improved the country’s national family planning program performance, as demonstrated through a number of improved indicators of the country’s family planning program. And consequently, the country’s health system is able to deliver better and more family planning services in the project areas. In our family planning example, a significant number of healthcare providers, health facilities, districts, or even whole provinces report to deliver family planning services in accordance to the improved standard and evidence-based procedures and are able to do so after the project ends. The project was then effective and accounted for its results in terms of the improvement of the family planning program and the health system. The Project-ProgramSystem paradigm has worked well when I conduct aid effectiveness research and helps show any gaps that may have not been addressed and that will need to be solved by the next project or another stakeholder, usually by the recipient of the aid. Here is another example. There is evidence from MDG and SDG reports that aid does work to reduce malnutrition. However, it matters how aid is used because it can also have negative effects. There are missed opportunities, wastages, unsustainable results, and increased coordination and management costs for an aid-recipient country that has to manage the aid provided by hundreds of different donors or donor-funded organizations, each with their own agenda that is not aligned with the country’s policies or systems.

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Let’s imagine a country is suffering a severe drought and food shortages with the resulting famine and high acute infant malnutrition. A donor decides to help by supplying a large number of nut packets and delivers them to a local NGO for distribution. However, the donor does not provide funding for other activities except distribution of nut packets to malnourished infants. How effective is this aid? Here are some questions AAE research would answer based on the PD principles: • Ownership and Governance: Did the donor ask the local NGO to ensure that the nut packets be distributed in accordance with country’s nutrition policy guidelines? Did it happen and how well was it? How much of the time of the National Nutrition Program staff needs to be involved to make this happen? What about if this donor is one of the 47 other donors supporting the Nutrition Program and there are only five staff in this program? Should the donors adapt to the MOH or the other way around? • Ownership and Harmonization: Was the Director of the National Nutrition Program involved in the design of the distribution plan so this supply can complement what other donors and the government have bought? What about the other children in the family that may be also malnourished? How will the health staff that are not familiar with the nut treatment be able to learn to use it? • Alignment: Is the NGO working with the health facilities in the districts where the project is being implemented to ensure that their staff are trained in the country’s policies and malnourished children are rapidly detected? • Management by results: Is the NGO monitoring that the number of children that are detected and the rate of acute malnutrition is going down? What about chronic malnutrition and stunting? • Mutual Accountability: Is the NGO accounting for the results obtained to the National Nutrition Program Directorate? Was the government able to account for the nut supplies in the country’s supply chain? • Effective sustainability: What will happen after the infant recovers from the malnutrition and goes home? Will he or she be back in a few weeks? How will the country continue the program after the donor’s supply ends? What is the donor and the NGO exit strategy? Did the donor help the country’s government include the nut supply in the next year’s procurement plan? Did the donor help the government create pool resources and build a local manufacturing plant that produces nuts and other commercial peanut-based products? Was the prevention and management of acute malnutrition included in the preservice training in all the country’s academic institutions so in the future every healthcare provider is able to promptly detect and manage infant malnutrition? Progress in global health must be based on the evidence of effective global health aid and medical and health science. As the UN SDG2019 report showed, there is evidence that over the last 20 years or so, life expectancy has increased in most developing countries, infant and child mortality have decreased mostly due to community-based programs and expansion of immunization program. Access to quality health services and medicines has increased, along with poverty reduction

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(Bourguignon and Platteau 2017), although the rate at which these had been improved has slowed down. The connection between health and poverty is well known so for that reason, the 17 SDGs matter to achieving health outcomes. There has also been a modest decrease in maternal mortality and in mortality due to new and chronic conditions, but the national average hide inequality in access and life expectancy within a country. Inequity and lack of access to surgical and specialized and emergency care are still a barrier most developing countries and rural and urban areas of middle and high income countries. In 2020, the COVID-19 pandemic is raging across the world and making the ineffectiveness of health systems to meet existing and new health needs has become more evident in many countries. Aid is likely to be reduced and be focused on humanitarian assistance and/or on achieving short term results and not on UHC. Research is likely to be stopped or delayed despite the fact that now is the time to really use AAE research to invest on aid programs that do both, deliver the desired outcomes of meeting the healthcare needs of COVID-19 patients and the rest of the population, while building resilient and sustainable health systems and not bypassing them. The goal should be to conduct research on how to sustain the current systems and consistently expand its coverage to meet the needs of COVID19 patients and the effective epidemic control measures. AAE research is based on the principles of the Paris Declaration and starts with a question. Here are some research questions that ideally would need to be answered during and after the COVID-19 emergency is over: • Ownership: Is the MOH leading and coordinating the national COVID-19 prevention and control program? Do the aid-funded programs have a clear role in the program and are contributing? • Harmonization: Are all the aid-funded stakeholders using the same harmonized strategies and healthcare delivery interventions? • Alignment: Are all the aid-funded stakeholders using the same systems and reporting using the same indicators? • Results: How much has the aid-funded project or a donor improved the quality of care? Was aid used to improve coverage? Where and by how much? Has aid improved the capacity of healthcare providers to respond to COVID-19 cases? Who is performing better where? What percentage of the workforce remain to be trained? • Accountability: Are aid-funded stakeholders accountable for results in their respective coverage area? Are they sustainably strengthening the country’s institutions? Despite pandemics and especially because of them, effective healthcare coverage and its expansion also need to be accounted for by every country, not only those receiving aid. There are two main barriers to achieving UHC and delivering effective aid and health services: first, there is the limited capacity of the health system management structures and second, there is the shortage of facilities and human resources that has not been addressed despite the call for UHC. A 10% annual

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expansion would be required to achieve UHC by 2030. Accounting for effective coverage of quality healthcare has not been implemented yet and WHO does not monitor that yet. Lack of manpower (O’Sullivan 2015) is a barrier to expansion of coverage. There is already evidence that inefficient production and distribution and management of human resources has caused shortages of healthcare providers in most countries. The surge for paid and unpaid Community Health Workers to fill the gaps due to lack of facilities and trained staff has been the focus of research. The evidence shows that CHWs do help deliver health promotion and prevention services and a selected number of home-based care treatment and care services. The well-trained, supervised, and supported CHW has proven to be effective but few countries have integrated the CHW in the health system sustainably or developed a plan to train and recruit the required health workforce in adequate numbers. How effectively CHWs are sustained has not been researched in most countries yet.

How to Conduct AAE Research Now that you know why you need to conduct AAE research and what this kind of research entails, let’s see two practical scenarios so you can see how to conduct AAE research as part of your work as a global health practitioner. These are imaginary cases and any coincidence is just a coincidence. I have created these scenarios from a composite of projects from various sources. Please put yourself in the role of the lead evaluator or if that is too hard to imagine, pretend you are observing how the aid is provided. Your perspective as external research is very important to focus the research on answering the most important research questions. Scenario 1 Setting: A donor designed a project to help improve the health system of a country. The donor considers this its flagship project and expects the project to have significant impact on improving the health of the people in a number of districts. The donor has allocated several million dollars to implement this project and hired an international organization to implement the project. Three years into the life of the five-year project, the donor hired a team to conduct a performance evaluation and find out how well the project is being implemented and if anything needs to improve. AAE Research Findings: The evaluation found evidence that the project team has met all its milestones to date. The project has trained healthcare providers in a selected number of districts in the country on how to improve maternal and child health and HIV/AIDS and TB treatment and has worked with the Ministry of Health (MOH) authorities to develop a new health system improvement strategy and a new quality improvement (QI) policy. The evaluation also found that these documents are very comprehensive and meet international standards, but there is not an implementation plan for either document was not part of the project’s design. The NGO was only to help draft these documents. The QI and the new health improvement strategy

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are not part of the country’s annual health plan and budget yet, despite the documents having been approved a year ago. In fact, the new health system improvement strategy and the QI plan are not being implemented in the project-supported districts or anywhere else in the rest of the country. In terms of improving the health system performance, per their contract, the project had hired and trained over 3000 community health workers (CHW) to follow up HIV+ patients until their viral load was reduced and trace TB contacts. However, there was not a plan for how these CHWs would continue doing the job for which they had been trained after the life of the project. The project had met the target number of patients diagnosed HIV+. However, although there was an increase in the number of HIV patients diagnosed and under treatment, the percentage of patients lost to follow up was almost 40%. It had been harder to follow up HIV+ children, who almost 50% had a high viral load in their last follow-up visit. There was an average of 3% increase in the number of children immunized and a 5% increase in the number of mothers that use antenatal and family planning services but not an increase in the number of mothers that deliver in the facilities in the project-supported districts. The interviewed healthcare providers reported to appreciate the training received by the project team, but when asked how they had applied the training, they reported not have the resources to put it into practice. When asked about the lack of implementation by the trained health staff, the project said that the government supervisors were in charge of the followup. The project team reported they had strengthened the capacity of the health workforce through training, but it was out of their SOW to help supervisors implement the training in all the facilities. They also said that the project’s scope of work (SOW) was to help the government develop the new policies, but the government had failed to implement them due to lack of funding. Scenario 2 Setting: A project to improve the delivery of maternal and child health (MCH) services is being implemented by an international organization also funded by a donor. The project had achieved less than expected targets in the first 2 years, so an AAE taskforce comprised of external evaluation experts, and donor and Ministry of Health (MOH) representatives has been created to monitor and evaluate how well the project has been performing and decide if corrections are necessary. AAE Research Findings: The project has created a partnership with the MOH and helped selected MOH staff review and update the National Safe Motherhood and the Child Health policies and program guidelines, proposed updates to the data collected by the DHIS21 system and helped develop next year’s annual work plan and budget to include the new MCH priorities. The MOH MCH program managers have worked along the project’s MCH experts to design and implement a baseline study of the country’s MCH program effectiveness to find out what works and what is missing in the light of the new evidence-based MCH program

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DHIS2 is a web-based open source health information system used by many developing countries, and the main source of health statistics.

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guidelines. The AAE taskforce studied this baseline study and sampled a number of facilities and worked with the Medical Faculty Research Center to conduct data collection and analysis to find out the reasons for the slow progress of the project. The baseline study findings along with the DHIS2 data had showed a large number of women completed ANC1 but only 22% of them had ANC4. The ANC1/ANC4 ratio showed that some districts were better performing than others, so the project focused on conducting research to find out what caused the difference and how to address the performance problems. With these findings, the donor-funded project’s annual workplan was jointly developed by the project team and the country’s MCH program managers at national and district levels to solve the problems identified. The project accepted to work on the worst performing districts to bring them up to par and that explained why the progress of the project-supported districts had been lower than the others. These districts had started well below the average national ANC1/ANC4 ratio. The sustainability of the new MCH program was safeguarded because the MOH had agreed to use the same improvement strategy as the project and adapted their annual workplan to jointly and progressively expand the new MCH program to 10 new districts every year and thus reach the rest of the country’s districts. The project also worked out an agreement with the National Medical Association, the Medical Faculty, and the Nursing Council to revise their training program to include the new MCH interventions, and also in collaboration and with the support of the project experts, they developed and implemented an ongoing MCH refresher program that would annually include 20% of the nation’s workforce and in that way update the whole workforce every 5 years. This target had been achieved in the past year of the project and it was on track for the next year. Analysis These two scenarios show different aid approaches and AAE research, respectively, and how differently the PD principles were applied as well as different models of global health practice. The first scenario shows a donor-driven project that delegates implementation to a consulting organization that does not observe the ownership of the MOH or help strengthen its leadership. The project also did not align itself with the existing MOH programs and involved the country’s training institutions in their effort to develop CHW. In addition, there was no coordination with other organizations supporting the same programs with funding from the World Bank or Global Fund. The project showed to be focused on meeting all its deliverables and thus continue getting funds from the donor. The project had developed a new QI policy and health system strategy and had them approved by MOH and reached the numbers of people trained and the numbers of people tested and diagnosed, etc. However, the project was not also focused on the outcomes of those project inputs and outputs. The evaluation research did show the project had done what it was contracted to do and had the evidence to show it did meet it deliverables. In addition, the evaluation research also demonstrated there were a number of project design flaws that had prevented it from achieving the desired outcomes of those deliverables. When asked why they had not brought up these problems with the donor, they

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said a contract modification was very complex and had not pursued it. In summary, this was not an effective project. Despite the high number of patients treated, their care was not likely to be sustained after the end of the project, so the donor will have to continue providing this kind of aid for a long time or correct the design flaws. Thanks to the research findings, the design flaws were corrected, and a contract modification was signed that allowed the project to account for effective and sustainable outcomes. The second scenario shows a project that was designed to be accountable and effective. It was implemented in alignment with the MOH structures and leadership, was in harmony with other donors improving MCH, and had become a valuable partner helping the MOH improve its performance and do its leadership job better. Although the project had not met its targets in the first 2 years, it was on track to do it in the third year. In addition, impact of the project interventions had been found to be beyond the planned targets in the districts where it worked and this success had had an impact throughout the health system. The project had been accountable for its performance to the MOH and the donor. It was able to explain why it had not me all its targets and was able to show what it had done to respond to the country’s needs and get on track. The alignment with the MOH had shown the project’s impact beyond the districts it was supposed to focus and this would increase the sustainability of the project’s new MCH interventions to be sustained after the aid ended. In short, this was an effective project and the country’s MCH program is likely to continue performing well after the end of the project.

AAE Research Methodology As the scenarios above have shown and the evidence from research in the last 20 years have shown (WHO 2001), AAE research is complex requires that address numerous challenges. For that reason, you will need to use qualitative and quantitative research so that your research can account for three main global health outcomes: first, the delivery of effective global health solutions, second, the costeffectiveness of these solutions to donors and recipient countries, that is, the value for money, and third, the sustainability of the effective solutions which led to sustainable and measurable outcomes and progress towards global health goals. This is my personal approach. There is no international consensus on the most effective way of practicing global health and conducting AAE research yet. In fact, there is no consensus on applying the principles of the Paris Declaration either. Global health experts are working on this. As you already know, AAE research is an essential part (or at least should be) of global health practice. It is the way to demonstrate that global health practice actually improves the health of everyone in our planet. In fact, I believe that every global health organization must endorse AAE principles and have an AAE research department that ensures the effectiveness of their work and accounts for their results.

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How Would an AAE Research Department Work? First, an AAE research department or tram should focus on assessing and accounting for aid to the country’s health system. The Project-Program-System paradigm must be demonstrated where aid is provided. This means that a global health project needs to improve the performance of the respective country’s programs and to improve the performance of the health system in their geographic area of responsibility in terms of the four main areas of performance improvement: health outcomes, quality of care, continuity of care and coverage. Most countries have a health system to fulfill their duty and achieve varied outcomes with varied degrees of accountability and effectiveness. Internationally, the World Health Organization helps UN country members through various programs to improve their health systems in order to protect and fulfill their citizens’ right to health. In addition to WHO, there are also hundreds of donors and organizations that have their own programs to help countries improve outcomes. Therefore, the PD principles of harmonization matters. AAE research needs to measure how well each donor is contributed to improve the various building blocks of the health system (WHO 2000) (see Fig. 3) as well as improving the coordination and organization of various sectors and levels of the health system. The main sectors are: government, public and private sector providers, academia, and professional associations. The four levels are: primary, secondary, tertiary, and quaternary, depending

Fig. 3 Health system building blocks (WHO 2000)

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on various degrees of medical technology and specialization that is required. The primary levels serve the needs of the whole population and the other levels serve increasingly smaller sectors of the population. An efficient system allows for patients to move up and down the system according to their needs and ensures the continuity of care throughout the patient’s life (Rutherford et al. 2019). As the HIV/AIDS, Ebola, and COVID-19 pandemics have shown, there is no formal global coordination and accountability mechanism and no global consensus on the most effective way to practice global health, how to improve health systems, control epidemics and account for all the effort and investment made by all parties involved yet. Evidence-based AAE research is also hampered by the lack of effective health information systems and the lack of sharing of information across borders. This lack of an effective global health information system requires that AAE research gather data from primary sources which is more expensive and timeconsuming than use of secondary data to analyze trends, predict disease patterns, and assess effectiveness of various programs and interventions. Second, AAE research must “follow the money.” Research needs to find out where the aid funding is being spent and how allocation decisions are made (Easterly and Pfutze 2008). Equity is the ideal, so everyone receives what they need in proportion to their need. Again, follow the PD principles and ask: Is funding allocation donor-driven or in partnership with the country’s MOH and other government agencies? Economic aid helps countries grow (Arndt et al. 2015; Maruta 2019) even when not linked to good polices in the recipient country and even in “unfavorable policy environment.” The evidence shows that there are various ways to help the health sector improve and save more lives. In order to increase effectiveness, they are: (a) Aid as an increment to government efforts. This is not part of the national income (outside the funding pie or in parallel pie) but hopes to pick up what the government cannot do (what they don’t know or cannot afford to do). Aid is seen as humanitarian assistance and the donor is in control. This aid is usually time-limited. The purpose is to help the poorest or most affected to get pie. (b) Aid as a complement to government efforts. This aid is invested in selected programs and geographic areas of country (still aid is managed in a parallel pie, some get pie, some don’t, because aid is not usually based on need). The purpose is to demonstrate how to “do it” right to the government. The idea is that the government does not perform well because they do not know how, and they need to be shown how to do it correctly. (c) Aid to sustain and develop government efforts. This aid is an investment with unknown return (expanding the pie). The focus is on getting results, with various degrees of coordination and success. (d) Aid to develop the civil society, faith-based organizations (FBOs) and NGO sector but not the government sector, which is supposed to be working well by now. The purpose is to expand the pie for coverage expansion and improve the effectiveness of the nonprofit private sector.

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Aid is invested in the management of the health system, its health workforce, its facilities at various levels, and the coordination of the various sectors to advance the country’s health goals and policies. Aid funding is sometimes invested as part of the government basket and sometimes is provided in kind in the form of technical assistance or consulting services (Annen et al. 2016). In AAE research, our job is to show the results of various types of aid received and their effectiveness. Third, focus on gathering and analyzing existing monitoring and evaluation (M&E) data and data from the health management and information systems. Most AAE research is conducted in the context of monitoring and evaluation (M&E) studies that are funded by the donors that also provided the aid. The purpose of these studies is to measure the performance and/or the impact of a global health project (Haque et al. 2017). The donor that is funding the project and the recipient government through the MOH have different degrees of involvement in these M&E studies. Someday, hopefully not too long, data from health information systems and data collected through systems embedded in all we do in global health will be gathered by AAE research departments and AAE findings will flow as fluidly and transparently into dashboards in real time just as well as credit card records can be tracked online. But we are not there yet. There are not globally accepted AAE standards of practice yet or a central repository of consolidated results where global health professionals can find the answers to the questions that keep us awake at night: is this intervention working? Is it the most cost-effective use of aid? Is it scalable and sustainable? M&E research is usually conducted to answer a number of evaluations questions. These questions are usually developed by the donor or organization that funds the research with input from various stakeholders and not necessarily comply with PD principles. It is the evaluators’ job to ensure that. Most questions are aimed at finding out what is effective and how effective the implementing team and their project have been and not about outcomes, cost-effectiveness or sustainability. When we design and evaluation, there are, therefore, questions of effectiveness of how well the project is or has been at achieving the objectives for which it was designed, whether the original project design was effective, how cost-effective and efficient the project has been in the use of the funds received; questions of accountability and of who is accountable to whom, and questions of sustainability beyond the life of the project. In addition, like any human organization, projects have human relationship and performance issues that range from intercultural differences to personality clashes between donor and project staff, between the project and the MOH staff, and between staff within these organizations that if not detected and addressed effectively, they may hinder the project’s performance and the evaluation. Confidentiality of in-depth informant interviews will need to be maintained at all times. For this reason, the AAE team needs to be not only proficient in research methodology, be sensitive to personality and management styles, and also play the role of good brokers between donor and recipient country, and effectively facilitate the discussion of the findings and their interpretation to ensure the maximum benefit of the investment in the evaluation or AAE research.

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Effective and continuous communication between all parties involved in and affected by AAE research is much of a science as an art and requires maturity of the AAE team to not let AAE discussions derail into a blame and shame game. Objectivity and a focus on learning from successes and mistakes needs to be maintained and modeled by the AAE team at all times, from the research design stage, through the finding’s presentation and application stage. This is where transparency, integrity, and professional ethics come in. I will not dwell on these as they are beyond the scope of this chapter but remember that 20 or 30 years from now when you retire, you want to look back on every AAE assignment and have no ethical regrets. You may have lessons learned of things you would have done differently, but not regrets having been transparent and done the right thing for all involved, especially the people of the country that received the aid or were supposed to benefit from it. AAE is easier to be enforced through governmental organizations such as USAID or through international ones such as UNICEF or UNDP. However, the websites of most foundations or NGOs will not show evidence of how effective they have been in improving health in a country where they may have been working for decades or show evidence that the interventions they promote have actually achieved improved patient outcomes and are sustained after the life of their projects. Most donors do not fund “after the project” impact evaluation. I know of only one in my 30 years of global health practice, and it was a very useful evaluation that showed important design flaws that only could have been detected in hindsight. The Global Fund (https://www.theglobalfund.org/en/) is one of the few organizations that having been designed for performance, awards performance-based grants, and rates them on their website, where data and graphs on every country can be accessed. It would be great to be able to integrate these data with the countries’ data bases and conduct AAE research. In addition, these countries receive aid from other donors and foundations and NGOs that do show how they have been able to “graduate” a certain number of facilities, districts, and even whole countries. Some of these countries have been able to become donors themselves, such as Brazil, India, Russia, and China, and share their lessons learned. There is need of a coordinating mechanism and a repository of AAE research evidence. Then, the evidence could be used to inform global health practice, maybe in real time too. In health, WHO would be the natural place for such integrated AAE repository. After all, that is the mission for which WHO was created as stated in its article of constitution (WHO 1946–2006): “the attainment by all peoples of the highest possible level of health” (article 1), and “to direct and coordinate international health work” (article 2a). In fact, all the functions listed in article 2 of the WHO constitution would require the evidence gathered through well-coordinated and focused AAE research teams. M&E research is the closest we have to AAE research we have so far and there is a lot that can learned from M&E research if more meta-studies and crosscountry studies were done regularly and strategically. It is good practice to monitor and evaluate the performance and impact global health projects even if

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AAE research is not conducted. Most evaluations are performance evaluations, impact evaluations are few. In my experience, most end-of-project evaluations have the objective of gathering data to ascertain results that will serve as baseline to design the next project. In any case, M&E research is a good practice and most donor government organizations conduct systematic evaluations. Private foundations and NGOs might also conduct M&E studies, but their findings are used for internal decision-making and not shared to add to the body of global AAE evidence. For example, you can go to www.dec.usaid.gov, the USAID development clearing house and find the report of every evaluation and other documents that has been conducted of the projects in any country where USAID works. But you cannot usually find the same in the website of foundations and NGOs. Most articles are informative, share successes, and are posted for marketing purposes. It is my hope that this book you hold in your hands will set a new standard in global health practice and that AAE research be systematically coordinated and conducted and its findings implemented to help countries achieve universal health coverage by 2030. In 2009, the US government joined other countries in the G20 summit and endorsed Aid Transparency. Realizing that transparency is difficult when no one is ultimately responsible for accounting for it and there are no tools to ensure it, the US Congress passed the Foreign Aid Transparency and Accountability Act in 2016. The act led to the creation of the foreign assistance dashboard that can be found at https:// www.foreignassistance.gov/ in an effort to coordinate the development work more than 20 agencies. For some time, there were two dashboards and confusion as what each would do (Ingram and Sally 2018), but in 2020 they were consolidated. The website shows every appropriation and what is was for but not results or value for money. One still wonders: Are countries better because of these investments? And what percentage of the population benefited and what will happen to them when the funding ends? Does this funding complement what hundreds of private foundations also invest in developing nations? If yes, how? These are more questions can only be answered thought research, which will eventually and hopefully inform new policies, acts and practice. Fourth, stay up to date with AAE research reports and analyze the evidence. In the absence of a global repository of AAE research, you will need to keep your own database of evidence and bibliography, at least in your area of expertise. In most donor organizations and large NGOs, it is good practice to have a Knowledge Management Unit and that helps to keep track of what projects your organization has implemented or is implementing and what is effective. It is not good to keep doing the same thing in a country over 20 or 30 or more years without having the evidence of what does work. Someday, there will be effective knowledge management and AAE research tools that allow us to analyze large databases and compare the effectiveness of various programs and interventions across countries. Unfortunately, we are not there yet. You need to stay informed and use your judgment when reading published and unpublished AAE research findings. Read published articles in your area of expertise. When working in another country, I suggest you review the evidence from M&E studies in that country. Not all donors share reports transparently.

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Effective Steps to Conduct AAE Research 1. Background documentation and desktop review Before conducting an evaluation or study in a specific country, you will need to review available background documents including online searches for published articles, evaluations, and reports in that country. Below is a list of questions to review M&E reports. You will need to adapt it to what you are looking for, but this list will help you get started. Mine the documents and reports and look for evidence that allow you to answer these questions: 1. 2. 3. 4. 5. 6. 7.

What was the purpose of the study or project? What were the outcomes of the study or the project? Did it demonstrate accountability? Did it demonstrate effectiveness? Was the project’s implementation methodology reproducible and sustainable? Did the study/project show value for money? What would you have done differently?

2. Select the research questions Most donors have already decided on the evaluation or research questions by the time the research or evaluation team is gathered. However, it is important to discuss them with the donor and all the stakeholders and make adjustments as necessary. Keeping the focus on the PD principles, the results on the health system, and various human rights treaties, the countries have been signatories is a way to get started and ensure the research is asking the minimum right questions. Below are a number of sample questions

Sample Selected Research Questions

• Are the objectives of the donor’s overall development agenda for the health sector being met progressively? • How effective has the project been at meeting its targets and objectives? • Has the project improved the performance of the related country’s health programs? • How effective has project’s contribution been to the growth and development of the country’s health system? • Has the project improved the performance of the health providers? • Have patient outcomes improved? • Has the project improved the efficient management of medicines, technologies, and finances? (continued)

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• Does/Did the project work as it was designed? Did the implementers have to make adjustments to the design? • Are the results achieved scalable and repeatable in other geographic areas of the country? • Are the results likely to be sustained by the country’s health system? • How was the project monitored? Who was the project accountable? How well did the project monitored and used the monitoring data to make decisions? • Has the project’s information contributed to improve the country’s health information system?

3. Design an effective AAE research proposal Proposal Outline

1. Background: In this section, you will summarize what is known and the current knowledge of status of health outcomes in terms of health indicators, quality of care and coverage 2. Problem Statement: This section describes what is not known and needs to be studied (a) Sample general objective: to measure the effectiveness of a certain intervention or improvement and account for results and coverage (b) Sample specific objectives: (i) To determine the effectiveness of the project and help design future improvements (ii) To identify the causes of effective or ineffective interventions (iii) To determine the degree of compliance with PD principles (iv) To make recommendations for improving effectiveness and accountability for health outcomes 3. Effectiveness Evaluation questions: (a) How effective was the project in meeting its objectives? (b) How effective was the project design to meet the desired outcomes? (c) How well was the project implemented? (d) How effectively did the project identify and solve implementation problems? (e) How sustainable are the project interventions? 4. Methodology: In this section, you will describe how the research or evaluation will be conducted. You will include the following topics. (a) Type of study: descriptive, cross-sectional, retrospective, operational research, time series, etc. (b) Population whose outcomes will be studied: if target population or denominator is available, you will be able to calculate proportions and measure progress and coverage rates. (continued)

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(c) Sampling: sample size estimation and how records or patients will be selected for study, how health worker to be interviewed will be selected, etc. If randomization is possible, it is desirable. In most cases, givent time and funding limitations, a convenience sample is used to contrast top and bottom performers or document case studies. (d) Variables are selected based on the evaluation or research questions and their definition is usually included in a table to ensure all the right variables are collected and data from various sources can be triangulated for analysis. The variable table usually also include the source of data for each variable (e) Data collection methods: The methods section of your proposal will include a mixture of qualitative and quantitative methods. The right mix will allow you to find the answers to the questions above (f) Sources of data: In this section, you will identify primary and secondary sources of data that are usually used in AAE research. Primary data are collected to answer specific questions such as How satisfied are mothers with the new maternity? Secondary sources make use of data already available, usually collected for M&E or management purposes. Having access to the country’s HIS is a great advantage, or better yet, working side by side with the HIS and HMIS teams in the MOH will help uncover the evidence and detect information quality or completeness problems to be solved. (g) Instruments: The instruments you will design to conduct your research will include: document review checklist, interview guides to interview key informants, guides for conducting and analyzing focus group discussions, and survey tools and data collector training tools may be necessary. (h) Analysis plan: AAE research and project evaluations are complex exercises. The way to avoid problems is to have a clear analysis plan for analyzing qualitative (interview notes, focus groups notes) and quantitative surveys (facility surveys, health staff interviews, community, or patient interviews) (i) Results dissemination, publication, and archiving: I suggest you plan the outline of the final report and how the results will be discussed with all stakeholders before starting the research so you can plan the enough time for everyone to get involved in this most important task. (j) IRB approval: Each country has a different approval process so becoming familiar with the process as early as possible will save time and ensure the IRB has all the documentation to make the right decision. (k) Timeline: a week by week Gantt chart helps keep everyone on the team on track and complete all the tests within time and budget. 5. References: Include previous studies with similar methodology and/or that involved the same population or health outcomes.

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4. Conduct the research Gathering the data and analyzing the findings requires planning to ensure logistics are in place, flight, and hotel or car rental arrangements have been made, interview appointments are made, and focus group participants are invited in a timely manner. Data collection quality control throughout the research needs to be maintained by the senior members of the research team. Also ensure you keep all stakeholders informed of the progress and any challenges along the way. Nobody likes surprises. The credibility of the research findings may be put in question if quality control is not enforced. 5. Data analysis By the time you get to this phase, you will already have planned what data will be analyzed by whom and even anticipated how the data will be presented in tables, graphs or charts. As with everything in life, less is more. Make sure that you use all the data collected and present the findings in a prioritized manner so they conclusions and recommendations you make can be easily understood and acted upon. It helps to validate with your findings with senior project and donor and MOH staff to ensure your conclusions make sense. A presentation of preliminary findings helps get all stakeholders on board and guides a more in-depth analysis. 6. Presentation of final report, discussion of recommendations, and planning of next steps Researchers usually prepare a long and a short PowerPoint presentation for the project and donor to disseminate the results, in particular to the MOH and staff in the project districts or provinces.

What to Do with AAE Research Results? Health is a science and as professional scientists we need to demonstrate that what we do is effective. AAE research shows how effective aid money is in global health. In most cases, the main issue is whether resources and efforts were invested in the right interventions. With the COVID-19 pandemic in 2020, the question about the effectiveness of our global health work is even more important and pressing. Asking why we conduct AAE research and finding out where money is being well used or wasted, who is or is not performing and who needs to be held accountable as well as where the gaps in the health system is more important than ever. You might be wondering what happens to those responsible for doing their job and who failed in their responsibility and who delivered ineffective solutions or implemented projects that wasted valuable resources and failed to save more lives. The answer is to ensure we all learn and share our mistakes so that others do not repeat them. Except in the case of willing corruption, most professionals just did not

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know what they were doing was not effective. AAE is not about investigating criminal charges. The truth is that we are all responsible for doing our best and admitting when we did not. This is how we learn. We all make mistakes and in hindsight, wish we had done things differently, the author of this chapter included. What matters is transparency (Arkedis et al. 2019) and learning from our not so effective experiences and not make those mistakes again. Taken together, evidence matters and our performance as global health professionals needs to be evidence-based. Effective global health professionals search for evidence and do not stop until they have figured out how to fulfill everyone’s right to health and the right to development (UN 1986) of every nation in this planet. This, any time you might be asked “Why account for aid effectiveness in global health?” you will be able to respond: “Because effective global health practice helps fulfill human rights: the right to health, that is, to receive the highest quality of health care, and the right to develop one’s country.”

Conclusion Global health practice needs to be evidence-based. Research findings need to be applied to improve results and effectiveness of global health aid projects. Some bilateral donors choose to give aid to countries based on need, some on policy partnerships. Other donors give untied aid, define specific conditionalities, or contribute to the country’s “financial basket” and provide technical assistance to improve the management of health budgets including monitoring and health information systems. Some donors choose to give the money to implementing organizations that manage the funding in alignment with the country’s health programs and priorities. Some donors invest in the country’s medical and nursing training institutions to improve the quality of their training programs and increase production, others provide the training themselves, or through NGOs or CSOs they give grants to. Some donors have an interest in supporting vertical programs such as family planning, malaria, cervical cancer, TB or HIV/AIDS, and others focus on expanding an integrated patient-centered healthcare delivery model that responds to their health needs according to their life cycle. Whatever kind of aid is provided it needs to be accounted for and the effectiveness of the investment needs to demonstrate to ensure aid helps fulfill the human rights of every citizen that is to benefit from it. AAE research is based on the principles of the Paris Declaration, improves the performance of the recipient country’s health program and health system. In this way, we ensure that every global health project contributes to improve the performance of the country’s health programs and the functioning of the country’s health system to deliver better services and achieve better patient outcomes. In the SDG era, AAE research is essential to achieve universal health coverage by 2030 and overcome the impact of the COVID-19 pandemic. Improvement in health status is essential for all the other development sectors, because no country can develop and grow without healthy people. AAE research should be conducted

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routinely by every donor organization, starting with the Paris Declaration signatories, to improve the effectiveness of the global health architecture.

References Adedokun AJ, Folawewo AO (2017) Aid selectivity practice and aid effectiveness in sub-Saharan Africa. Rev Innov Compet 3(2):43–64 Annen K, Batu M, Kosempel S (2016) Macroeconomic effects of foreign aid and remittances: implications for aid effectiveness studies. J Policy Model 38(6):1136–1146 Arkedis J, Creighton J, Dixit A, Fung A, Kosack S, Levy D (2019) Can transparency and accountability programs improve health? Experimental evidence from Indonesia and Tanzania. SSRN Electron J. https://doi.org/10.2139/ssrn.3399124 Arndt C, Jones S, Tarp F (2015) Assessing foreign aid’s long-run contribution to growth and development. World Dev, Aid Policy and the Macroeconomic Management of Aid 69(May):6– 18. https://doi.org/10.1016/j.worlddev.2013.12.016 Asian Development Bank (2011) Aid effectiveness report 2011: overall achievements on Paris Declaration Commitments. Asian Development Bank, Manila. https://www.adb.org/sites/ default/files/institutional-document/33038/files/aid-effectiveness-report-2011.pdf Beracochea E (2015) Improving aid effectiveness in global health. Springer, New York. http:// search.ebscohost.com/login.aspx?direct¼true&AuthType¼ip,sso&db¼edsebk& AN¼1060619&site¼eds-live&custid¼s9001925 Beracochea E (2018) Effective aid for hitting the bull’s eye: comment on ‘it’s about the idea hitting the bull’s eye’: how aid effectiveness can catalyse the scale-up of health innovations’. Int J Health Pol Manag 12:1155. https://doi.org/10.15171/ijhpm.2018.90 Bigsten A, Tengstam S (2015) International coordination and the effectiveness of aid. World Dev 69 (May):75–85 Bourguignon F, Platteau J-P (2017) Does aid availability affect effectiveness in reducing poverty? A review article. World Dev 90(Feb):6–16 Breitwieser A, Wick K (2016) What we miss by missing data: aid effectiveness revisited. World Dev 78(Feb):554–571 Cabral L (2008) Accra 2008: the bumpy road to aid effectiveness in agriculture. Nat Res Perspect 114(Apr):1 Chansa C, Sundewall J, Östlund N (2018) Effect of currency exchange rate fluctuations on aid effectiveness in the health sector in Zambia. Health Policy Plan 33(7):811–820. https://doi.org/ 10.1093/heapol/czy046 Chasukwa M, Banik D (2019) Bypassing government: aid effectiveness and Malawi’s local development fund. Polit Gov 7(2):103–116. https://doi.org/10.17645/pag.v7i2.1854 Dalil S, Newbrander W, Loevinsohn B, Naeem AJ, Griffin J, Salama P, Momand FM (2014) Aid effectiveness in rebuilding the Afghan health system: a reflection. Glob Public Health 9(Jul): S124–S136 Easterly W, Pfutze T (2008) Where does the money go? Best and worst practices in foreign aid. J Econ Perspect 22(2):29–52 Gehring K, Michaelowa K, Dreher A, Spörri F (2017) Aid fragmentation and effectiveness: what do we really know? World Dev 99(Nov):320–334 Haque H, Hill PC, Gauld R (2017) Aid effectiveness and programmatic effectiveness: a proposed framework for comparative evaluation of different aid interventions in a particular health system. Glob Health Res Policy 2(1):1–7. https://doi.org/10.1186/s41256-017-0029-8 Holvoet N, Inberg L (2014) Gender responsive budgeting and the aid effectiveness agenda: experiences from Mozambique. J Int Women’s Stud 2:61 Ingram G, Sally P (2018) US foreign aid transparency: how to fix dueling dashboards. Brookings (blog), 13 Jun 2018. https://www.brookings.edu/blog/future-development/2018/06/13/us-foreignaid-transpare

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Kabir AHM (2019) Development aid in stable democracies and fragile states. Palgrave Macmillan, Cham. http://search.ebscohost.com/login.aspx?direct¼true&AuthType¼ip,sso&db¼edsebk& AN¼1855061&site¼eds-live&custid¼s9001925 Karlan D, Wood DH (2017) The effect of effectiveness: donor response to aid effectiveness in a direct mail fundraising experiment. J Behav Exp Econ 66(Feb):1–8 La Chimia A, Trepte P (2019) Public procurement and aid effectiveness: a roadmap under construction. Hart Publishing, Oxford, UK. http://search.ebscohost.com/login.aspx? d i r e c t ¼t r u e & A u t h Ty p e ¼i p , s s o & d b ¼e d s e b k & A N ¼2 1 7 9 1 7 1 & s i t e ¼e d s - l i v e & custid¼s9001925 Martinez-Alvarez M (2018) Ownership in name, but not necessarily in action: comment on ‘it’s about the idea hitting the bull’s eye’: how aid effectiveness can catalyse the scale-up of health innovations’. Int J Health Policy Manag 11:1053. https://doi.org/10.15171/ijhpm.2018.72 Maruta AA (2019) Can aid for financial sector buy financial development? J Macroecon 62(Dec). http://search.ebscohost.com/login.aspx?direct¼true&AuthType¼ip,sso&db¼edselp& AN¼S016407041830123X&site¼eds-live&custid¼s9001925 McGee R (2013) Aid transparency and accountability: ‘build it and they’ll come’? Dev Policy Rev s1:107. https://doi.org/10.1111/dpr.12022 Metzger L, Günther I (2019a) Making an impact? The relevance of information on aid effectiveness for charitable giving. A laboratory experiment. J Dev Econ 136(Jan):18–33 Metzger L, Günther I (2019b) Is it what you say or how you say it? The impact of aid effectiveness information and its framing on donation behavior. J Behav Exp Econ 83(Dec). http://search. e b s c o h o s t . c o m / l o g i n . a s p x ? d i r e c t ¼t r u e & A u t h Ty p e ¼i p , s s o & d b ¼e d s e l p & AN¼S2214804318304336&site¼eds-live&custid¼s9001925 Minasyan A, Nunnenkamp P, Richert K (2017) Does aid effectiveness depend on the quality of donors? World Dev 100(Dec):16–30 O’Sullivan SL (2015) Funding conditions for aid effectiveness: a mixed blessing for the sustainable development of host-country-national employees. Can J Adm Sci (John Wiley & Sons, Inc.) 32 (3):189–202 Organisation for Economic Co-operation and Development, and Development Assistance Committee (2001) Evaluation feedback for effective learning and accountability. OECD Development Assistance Committee, Paris, France. https://www.oecd.org/dac/evaluation/2667326.pdf OECD (2008) The Paris Declaration on aid effectiveness and the Accra Agenda for Action. https:// www.oecd.org/dac/effectiveness/34428351.pdf OECD (2012) Better aid aid effectiveness in the health sector: progress and lessons (Complete edition) – ISBN 9789264178014. Source OECD Development 2012 (16):1 OECD and United Nations Development Programme (2019) Making development co-operation more effective: 2019 progress report. OECD. https://doi.org/10.1787/26f2638f-en. http://www.oecd. org/publications/making-development-co-operation-more-effective-26f2638f-en.htm. Accessed 22 Jun 2020 Pallas SW, Ruger JP (2017) Effects of donor proliferation in development aid for health on health program performance: a conceptual framework. Soc Sci Med 175(Feb):177–186 Quibria MG (2017) Foreign aid and corruption: anti-corruption strategies need greater alignment with the objective of aid effectiveness. Georgetown J Int Aff 18(2):10–17 Rutherford C, King MT, Butow P, Legare F, Lyddiatt A, Souli I, Rincones O, Stacey D (2019) Is quality of life a suitable measure of patient decision aid effectiveness? Sub-analysis of a Cochrane systematic review. Qual Life Res Int J Qual Life Asp Treat Care Rehab 28(3):593– 607. https://doi.org/10.1007/s11136Ssengooba F, Namakula J, Kawooya V, Fustukian S (2017) Sub-national assessment of aid effectiveness: a case study of post-conflict districts in Uganda. Glob Health 13(1):1–12. https://doi.org/10.1186/s12992-017-0251-7 UN (1948) Universal Declaration of Human Rights. https://www.un.org/en/universal-declarationhuman-rights/

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UN (1986) Declaration on the Right to Development. https://www.un.org/en/events/rightto development/declaration.shtml UN (2000) General comment no. 14: the right to the highest attainable. n.d., 21. http://health-rights. org/index.php/cop/item/general-comment-14-the-right-to-the-highest-attainable-standard-ofhealth UN (2019) The sustainable development goals report. https://unstats.un.org/sdgs/report/2019/TheSustainable-Development-Goals-Report-2019.pdf WHO (1946 and 2006) Who_constitution_en.Pdf. n.d. https://www.who.int/governance/eb/who_ constitution_en.pdf. Accessed 1 Sept 2020 WHO (2000) World health report. https://www.who.int/whr/2000/en/whr00_en.pdf?ua¼1. Accessed 1 Sept 2020 Wickremasinghe D, Gautham M, Umar N, Berhanu D, Schellenberg J, Spicer N (2018) ‘It’s about the idea hitting the bull’s eye’: how aid effectiveness can catalyse the scale-up of health innovations. Int J Health Policy Manag 8:718. https://doi.org/10.15171/ijhpm.2018.08

Global Health Project Design, Monitoring and Evaluation

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Nancy A. Scott and Lauren Schmidt

Contents Introduction: What Is Project Monitoring and Evaluation (M&E)? . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Justification for a Rigorous M&E Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engaging Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identifying Key Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Designing a Stakeholder Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissemination to Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Describing an Intervention or Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction to Program Design: Justification for Program Design in Evaluation . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Considering Evaluation Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction to Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Notation to Depict an Evaluation Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonly Used Evaluation Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Experimental Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Quasi-Experimental Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nonexperimental Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gathering Relevant Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Data Should Implementers Use When Developing an M&E Plan? . . . . . . . . . . . . . . . . . Developing Indicators for Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning Data Collection for the E in M&E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planning Collection for the M in M&E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sampling Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Probability Sampling and Non-Probability Sampling Techniques . . . . . . . . . . . . . . . . . . . . . . . . . Ensuring Result Use and Disseminating Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Budgeting for Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Abstract

This chapter introduces approaches for designing global health projects and methods for conceptualizing and conducting rigorous monitoring and evaluation. Guided by the CDC Framework for Program Evaluation, this chapter offers practical skills needed to effectively monitor and evaluate public health programs. Topics covered include the fundamentals of designing a project, the importance of proper stakeholder management, developing a project logic model, the basics of mixed-methods evaluation designs, developing indicators, instruments, and a sound analysis plan, and creating a dissemination strategy for both process and outcome evaluations. Keywords

Global health interventions · Monitoring and Evaluation · Evidence-based decision-making · Effectiveness · Mixed-methods

Introduction: What Is Project Monitoring and Evaluation (M&E)? While the two terms often are grouped together, monitoring and evaluation generally each seek to accomplish separate but complementary goals when it comes to understanding a project’s performance. Monitoring is the process of systematically gathering and assessing routine data about a project’s inputs and the progress of the activities being implemented. When analyzed routinely, monitoring data helps to understand how the intervention is progressing, as well as determine whether this particular program is the best way to tackle the targeted issue (Khandker et al. 2010). Project monitoring data helps implementers determine if resources are being well utilized and if activities are being carried out punctually, according to plan, and if the particular activities are yielding the expected outputs. Evaluation is a periodic assessment of an intervention that determines its impact at a population level, change in outcomes among the target population effectiveness, efficiency, sustainability, or relevance. Evaluations seek to investigate what degree of change occurs in the target population, if any, as a result of the intervention rather than external factors, or what would have happened without the intervention. The overall goal of a project evaluation is to provide feedback and generate evidence for different stakeholders to make informed decisions (Trochim 2020a, b, c). Though not always practiced, monitoring and evaluation (M&E) should be planned and incorporated from project inception, and adapted as needed.

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Definitions and Terms for Project Design, Monitoring and Evaluation

Logic model: The simplest way to map out a project in a conducive manner is through the use of a logic model. A logic model is esentially a series of “ifthen” statements that connect what is done in the project to the expected changes in the target population through a series of logical steps. A logic model visually depicts a project’s inputs, activities, outputs, and outcomes. Program monitoring: The process of routinely gathering information on aspects of the program or project to observe how activities have progressed. Program evaluation: An assessment of a program to determine its impact, effectiveness, efficiency, sustainability, and relevance. Target Population: The intended beneficiaries or end-users of the intervention. The target population can be any unit including individual, a community, or health facilities, depending on the intervention. Nontarget: Individuals or groups are essential to the implementation of the intervention and are often health workers, staff members of the implementing organization, or community outreach workers. Process evaluation: Measures how well the program is being implemented as designed. Outcome evaluation: Measures the change in knowledge (short-term outcomes), behavior (medium-term outcomes) or health condition (long-term outcomes) in the target population. Impact Evaluation: Measures the change in a health or development indicator at a population level that can be attributed to an intervention. Counterfactual: A comparison group that allows an estimate of what would have happened to the target population in the absence of the intervention

Types of Evaluation There are three main types of evaluations that implementers can conduct: formative, process, and outcome/impact evaluations. Each has a unique purpose and seeks to capture different types of information. Implementers should note that in order to conduct a truly rigorous evaluation, all three types of evaluations must be incorporated to various degrees throughout the lifetime of an intervention. Formative evaluations inform the design of the program. Essentially, they ensure that the design of an intervention is feasible and acceptable before actually being implemented. Formative evaluations are usually, though not always, conducted at the beginning of a program or when an existing program is being modified. Formative evaluations help implementers understand whether the proposed facets of the intervention are actually needed and accepted by the target population, rather than being for the sake of the evaluator (Types of Evaluation 2020). Examples of formative evaluations include community needs assessments and evaluability assessments (Types of Evaluation 2020).

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Process evaluations seek to measure how well the intervention is working and if it is being implemented as designed. These evaluations tend to focus on the nontarget population. Process evaluations assess if the intervention is reaching the correct people and are typically conducted at the start and throughout implementation (Types of Evaluation 2020). These are best used to monitor an intervention’s progress or when measuring quality improvement. Lastly, summative evaluations encompass the two previous evaluation types along with an overall outcome or impact evaluation. Outcome evaluations measure whether the intervention affected the target population, while impact evaluations assess if a population level change can be attributed to said intervention. Overall, summative evaluations seek to quantify the effects and long-term impact of an intervention on individuals, families, and communities (Khandker et al. 2010). Box: Definition “Impact Evaluation”

Impact evaluations measure the change in a development outcome at a population level that is attributable to a defined intervention; impact evaluations are based on models of cause and effect and require a credible and rigorously defined counterfactual to control for factors other than the intervention that might account for the observed change. – USAID (Opportunities for Evaluation Impact 2019)

Justification for a Rigorous M&E Plan Project M&E is critical in order to ensure effective use of limited resources and to make informed decisions on global health programming, implementation, and scale up. The Centers for Disease Control and Prevention’s “Framework for Program Evaluation” is a practical, nonprescriptive tool summarizing six key steps needed for evaluation: (1) engaging stakeholders; (2) describing the program; (3) focusing the evaluation design; (4) gathering credible data; (5) justifying conclusions; and (6) ensuring use and sharing data (Framework for Program Evaluation in Public Health 1999). In this chapter we demonstrate how to apply these steps to guide the development of an M&E plan for a global health project.

Engaging Stakeholders Stakeholders are the people or organizations invested in the project and the information generated from its evaluation. Understanding stakeholders is one of the keys to the success of both project implementation and evaluation (Summary of the Framework for Program Evaluation 1999). Stakeholders can help shape priorities

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and inform an evaluation’s design, preparation, and implementation. Engaging stakeholders early and often can increase the credibility of findings and the chances that results will be considered when adapting future iterations of the project (Salabarria-Pena et al. 2007).

Identifying Key Stakeholders Stakeholders – anyone who has a stake in the project – should be identified and consulted at the intervention’s conception, as they may provide project and evaluation input. While the list of who should be considered a stakeholder does not need to be exhaustive, there are several key groups to consider. First, there are those involved in the project’s operations such as implementing staff, government collaborators, and community leaders. Second, those who will be affected by the intervention such as community members, patients, and clients. Lastly implementers should consider stakeholders in a position of power who may use results to make decisions about the intervention, such as governments and funding agencies (Summary of the Framework for Program Evaluation 1999). Implementers should plan to engage a wide range of stakeholders with unique perspectives (Salabarria-Pena et al. 2007). An introductory meeting with stakeholders is useful to solicit early feedback for the project design and its evaluation, as well as to clarify stakeholder roles (Forman and Discenza 2012). Implementers must keep in mind that some stakeholders, such as programmatic staff, may work directly with the targeted population implementing the evaluation. Others, such as those responsible for providing funds, may be in another country and remain distant. Keeping stakeholders informed is critical but the frequency and type of communication will vary by stakeholder. Some may require bi-weekly informal written communication and updates via email or memo while others may only want to receive a budget report every six months (Forman and Discenza 2012). Illustrative List of Common Key Stakeholders Evaluators Could Identify

Departments of Public Health/ Ministries of Health at all levels Educational Institutions/ Ministries of Education at all l levels Law Enforcement Community Members Local NGOs and Community Based Organizations International NGOs National Government Leaders Faith-based Community Leaders Clients, Patients, End users of the intervention Health Advocates

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Table 1 Example of a stakeholder engagement tool

Stakeholder Funder

Ministry of Health

Influence and power Resources Role in Interest in over Engagement brought to evaluation evaluation evaluation frequency evaluation Provide High High According to funds for funder evaluation schedule Provide Medium High Quarterly Technical approval expertise and access to populations

Dissemination plan According to funder schedule Updates in form of a memo

Designing a Stakeholder Management Plan A simple table allows project implementers to organize key information salient to each stakeholder throughout an evaluation. Table 1 offers a template to track key stakeholders, identify their role and level of interest in the evaluation, their influence over the evaluation, frequency and type of engagement, the resources they provide, and in what format information should be disseminated to them.

Dissemination to Stakeholders Results should be clear and translated into recommendations for stakeholders. In addition to evaluation results, information for dissemination should include ways to improve the intervention as well as aspects of the evaluation that went well and could be considered in future adaptations (Adamchak et al. 2000). A clear dissemination plan is useful for organizing information such as the targeted audience, and the preferred modes and frequency of communication. Once initial results are presented, implementers should allow some time for additional feedback from stakeholders. This feedback can improve future iterations of the intervention and make it more likely that stakeholders will implement them (Adamchak et al. 2000). Reports should be clear, concise, and address generalizability t (Adamchak et al. 2000). If possible, implementers should include visual aids such as charts, graphs, and photographs (Adamchak et al. 2000). It is also important that reports be eyecatching and made easier to follow through the use of boxes, headings, and subheadings (Adamchak et al. 2000). Findings should be accessible to a broad audience. Additionally, press releases and now social media should be used to call attention to results (Adamchak et al. 2000). Table 2 provides an example of different stakeholders and illustrates potential, appropriate modes of communication to each.

Summary Stakeholder engagement in project design, implementation, and evaluation is a dynamic process. When stakeholders are not appropriately engaged, evaluation

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Table 2 Illustrative example of stakeholders and potential modes of dissemination Example stakeholder Government, Ministries of Health, policy makers

Funder Nontarget population/project implementers

Target population/end-users

Example dissemination mode • Policy memo • Policy briefs • Dissemination workshop • Progress report, funder template • Routine monitoring updates • Lessons learnt • Summary report • Fact sheets • Social media • Community-based meetings

findings might not be utilized to adapt and improve projects and ensure efficient use of resources. It is important for project implementers to have deliberate and clear communication with stakeholders from inception through the dissemination of results. The stakeholder analysis tool can assist implementers with effectively managing their stakeholders.

Describing an Intervention or Program Introduction to Program Design: Justification for Program Design in Evaluation In order to effectively monitor and evaluate a project, the project itself must be clearly articulated. The simplest way to map out a project in a conducive manner for developing an M&E plan is through the use of a logic model. In its simplest form, a logic model is a series of “if-then” statements that connect what is done in the project to the expected changes in the target population. A clear logic model is a useful tool to: first, align stakeholder expectations around a common understanding of the program and its expected outcomes; second, inform the scope and design of an M&E plan; third, help evaluators understand if a project has faults in its theory (it is illogical) or in its implementation (it was not implemented according to plan). A logic model visually depicts a project’s inputs, activities, outputs, and outcomes. Inputs are defined as the resources going into the program such as funding, materials, personnel, even the facilities where the program will be held. Activities are what the implementers are carrying out during intervention while outputs are the direct results of activities. For example, if the implementer conducted ten trainings of 20 people each, the output is ten trainings conducted for a total of 200 people trained. Outcomes are changes observed in the target population or project participants. In general, a short-term outcome is a change in knowledge or awareness among project participants; a medium-term outcome is a change in a behavior among project participants; a long-term outcome is a change in the health condition of project

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participants. An impact refers to the population-level change of a development or health condition that can be attributed to the intervention. A sound project logic model underpins the entire M&E plan and guides evaluation questions. An example logic model can be seen in Fig. 1. In many global health projects, it is more common than not that organizations train an intermediary such as health facility staff members or community health workers to implement the project activities with the intention of affecting change in the target population. In the scenario illustrated in Fig. 1 the top half of the logic model (circled in blue) reflects the project staff training and preparing the intermediaries to implement the intervention. The final product thus is a cadre of community health workers (the nontarget population) adequately equipped and prepared to implement the intervention; this cadre then becomes an input into the next logic model where they implement activities with the goal of changing outcomes in the end-user or target population. The logic model should be used to develop clear, answerable questions that can will guide and refine the M&E plan. Questions generally focus on process evaluations, which are answered primarily by monitoring data, or outcome evaluation, which require more episodic collection of data from the target population. Process evaluations should address the program’s operations, describing those involved with the program, what their capacity is, and how many of program activities are being implemented with the outputs the activities produced (Developing an Effective Evaluation Plan 2011). Outcome question should focus on changes in the project participants’ knowledge or awareness (short-term), behavior (medium-term), or health outcome (long-term). Comparatively, impact evaluation questions focus on a population-level change of a health outcome and include a clear counterfactual (Table 3).

Summary A logic model underpins any project evaluation. By simply depticting the rational series of steps leading to change, the logic model is a useful tool to bring stakeholders to a common understanding of the project implementation approach and its evaluation, provides a clear albeit simplified understanding of the theory of change, and offers a platform from which to develop structured process and outcome evaluation questions.

Considering Evaluation Designs Introduction to Validity When developing an M&E plan, it is critical to consider the validity of the data so that it can be collected using an evaluation design that yields meaningful and credible data. The right evaluation design may determine the effect of the intervention and can minimize challenges that may lead to inaccuracies of the intervention’s

Global Health Project Design, Monitoring and Evaluation

Fig. 1 Example logic model of a maternity homes project in Zambia

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Table 3 Example monitoring and evaluation questions Monitoring evaluation question examples To what degree was the intervention implemented as intended? What was the capacity of the (nontarget population) to implement the intervention over time?

Outcome evaluation question examples How did the intervention change the long-term outcome of project participants compared to (the comparison group)? To what degree, if at all, did the intervention (impact/change/increase/ decrease) the (medium outcome) to (the comparison group)

outcomes (Trochim 2020a, b, c). Careful decisions about study designs help mitigate these threats to validity. Validity, simply defined, is the truth in measurement. It answers the question, did the implementer measure what they wanted to measure? This chapter does not provide an exhaustive list of threats to validity, but highlights two common threats that implementers must be aware of as they think through evaluating their projects: maturation and history. Maturation is the physical, mental, or emotional growth by an individual in the target population that cannot knowingly be attributed to the intervention itself. History is defined by external events, not related to the intervention, that may have an effect on the target population. Both threats can be mitigated by enacting an M&E plan that includes data observations before the intervention begins and by collecting data from a control or comparison group.

Using Notation to Depict an Evaluation Design Evaluation design notation uses an X to depict the intervention being implemented. O’s indicate the observation points within the evaluation where data is being collected. R’s and NR’s indicate whether the study is randomized or non-randomized. An ellipsis (. . .) indicates the same units are followed over time and is particularly useful when depicting longitudinal evaluations. Examples of this notation will be seen throughout the subsections below.

Commonly Used Evaluation Designs The most common evaluation designs can be broadly categorized as experimental, quasi-experimental, and nonexperimental. Not all design options are optimal for meeting the needs of stakeholders, nor can each design mitigate all common mistakes and challenges in M&E; but each of the three is able to eliminate various threats in different ways (Framework for Program Evaluation in Public Health 1999).

Experimental Designs Experimental designs are the most rigorous, allowing for the evaluator to estimate the change in the target population compared to what would have happened in the

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absence of the program. This requires randomly assigning units to be part of the project group, those receiving the intervention, or a control group, those not receiving the intervention. Each unit has an equal probability of being assigned to either group, balancing both known and unknown confounders at baseline. This requires careful planning and stakeholder management before the project is implemented which can be challenging. As indicated in the evaluation design below, units are randomized (R) to either the intervention group (X) or the control group (_); data are collected on both groups before the intervention (O1) and after the intervention (O2), minimizing threats to maturation, history and other key validity issues. The most common example of an experimental design is the randomized control trial (RCT). R : O1 X O2 R : O1 O2

Quasi-Experimental Designs Quasi-Experimental study designs, considered mid-level rigor, are more commonly used when it is not feasible or ethical to carry out an experimental design (Harris et al. 2006). Like experimental designs, they include a comparison group, though the groups are not randomly (NR) assigned and therefore known and unknown confounders may not be balanced between the groups. Quasi-experimental designs commonly include both pre- and post-test observation points. In fact, one of the most commonly used designs is nonequivalent groups which in its simplest form are where there are pre- and post-tests implemented for both intervention and comparison groups (Trochim 2020a, b, c). NR : O1 X O2 NR : O1 O2

Nonexperimental Designs Lastly, nonexperimental evaluation designs are considered to be the weakest of the three as they lack a comparison or control group, though are the most frequently used design as they are the simplest to execute. Without a comparison group, history and maturation are major potential problems implementers must be aware of when attempting to interpret results. Implementers often use this design type when funds or time are limited, but risk incorrectly attributing change in the target population to the intervention. When comparing the post-project data (O2) to pre-project data (O1), any trend that would have happened in the absence of the intervention (maturation) or event that influenced the intervention group (history) may lead to incorrect conclusions about a project’s effectiveness. However, a longitudinal

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nonexperimental design with repeated measures (O O X O. . .O24) is the most common way to structure monitoring data being collected in the intervention group. O1 X O2

Summary Choosing the right design for an evaluation requires considerations around cost, availability of resources, whether there is a naturally occurring comparison group or if sampling techniques are needed, and the importance of being able to emulate the intervention in other settings (Framework for Program Evaluation in Public Health 1999). Different than independent research, project implementers face specific challenges when developing evaluations. Implementers must be aware of their own personal biases including where they are choosing to implement the project (easiest to reach) and why (high performers and most likely to succeed, political influences). All of these actions could potentially skew the findings.

Gathering Relevant Evidence What Data Should Implementers Use When Developing an M&E Plan? There are two categories of data that implementers could use: primary and secondary data sources. Primary data is collected by the implementer first-hand and often includes questionnaires, household surveys, interviews (generally for evaluation), and project records or registers (generally for monitoring). Secondary data, on the other hand, is data previously collected by others. Data gathered from census records or medical files can be helpful for comparison and is often utilized when resources are limited as primary data collection tends to be costly (Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide 2011). Quantitative data is useful for answering the questions relating to “how much” and “how often.” It is particularly useful when a subject is clearly defined, when a detailed numerical description of a representative sample is necessary, and when repeatability is needed (Bamberger et al. 2011). Some of the most common quantitative data collection tools include structured surveys, household surveys, record review, aptitude tests, biomarkers, and project records or registers. Qualitative data generally answers the questions “why” and “how,” providing rich information, depth, and context to the captured quantitative data. Some of the most common qualitative data collection methods utilized for project M&E include focus group discussions, key informant interviews, and in-depth interviews.

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Generally, a combination of quantitative and qualitative methods is most appropriate for understanding the complexities in which global health projects operate; thus, a mixed-methods approach should be included when developing a project M&E plan. While quantitative and qualitative data collection methods each have their own strengths and weaknesses, the combination of the two is synergistic, bringing together the breadth of quantitative evaluation methods with the depth of qualitative evaluation methods.

Developing Indicators for Measurement An indicator is a characteristic of an individual, population, or environment which is subject to measurement. In M&E, indicators are used to describe aspects of each component detailed in the logic model. Indicators are measured and tracked over time to determine if the project was implemented well and had an effect upon the target population. When possible and appropriate, indicators measuring outcomes should be aligned to existing validated indicators allowing comparisons to be made with other data sources. Often times, evaluators will need to develop their indicators, particularly when it comes to the monitoring plan. When developing an indicator, evaluators need to think SMART: specific or singular construct, measurable, achievable, realistic, and time bound. An indicator is measurable when it has the ability to be counted, observed, and analyzed, potentially in multiple ways. Indicators should be achievable meaning that what is measured can help meet the outcome. Additionally, indicators should be realistic when they measure a valid result so that it may also be linked to research. Finally, indicators are time-bound i (Doran 1981).

Planning Data Collection for the E in M&E In order to ensure that the M&E plan captures the necessary information needed to answer the evaluation questions, evaluators should link back to the target population cited in the project logic model and the evaluation questions agreed upon by the stakeholders. Table 4 illustrates how all the pieces should connect to the logic model construct, in this case a behavior change of utilization, is linked directly to the outcome question. The quantitative indicator(s) to measure that change is included, followed by the specific variables required to construct the indicator, any qualitative domains, data sources, and the frequency of data collection. The frequency of data collection should align directly with the observations detailed in the study design.

Planning Collection for the M in M&E While an outcome evaluation measures the project’s effect on the target population, results cannot be fully interpreted without also understanding the degree to which a

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project was implemented. Monitoring plans help interpret outcomes and better understand where the project can improve upon, if needed. This could lead to the project’s successful replication in the future. In general, monitoring data is collected and reviewed on a routine basis to comprehend the intervention’s implementation quality, as well as to make real-time corrections if needed. The monitoring plan, as guided by the project’s logic model, focuses on the inputs, activities, and outputs related to the nontarget population. Though they frequently entail counting in some capacity, monitoring plans are most beneficial when they capture data that allows evaluators to discern the degree and quality to which the project was implemented (fidelity), the amount of the intervention delivered to the target population (dose), any changes or modifications made throughout implementation (adaptations), and the extent to which the target population accessed the intervention (reach) (Moore et al. 2014). Additionally, in order to understand the nuances and complexities inherent in global health project implementation, monitoring plans should capture what Moore et al. describes as mechanisms of impact or the potential barriers to implementation that may arise such as difficult weather conditions or a lack of transportation (Fig. 2). Critically thinking about these issues before implementation and systematically developing a way to document them can facilitate more accurate interpretations. Table 4 can be adapted to connect the logic model, monitoring questions. Simply add columns for the framework implementation domains such as fidelity, dose adaptations, reachwith quantitative indicators and qualitative themes to explore when developing a process evaluation plan. In general, the frequency of routine data collection for monitoring tends to be higher with monitoring plans than in evaluation plans. With evaluation plans, the frequency of data analysis is generally longer and dependent on project timeline, the need for learning, and the need for reporting.

Sampling Strategies Typically, projects have registries of participants which can be used to monitor reach (e.g. #/% of eligible children enrolled) and dose (e.g. % of enrolled children attending at least 80% of classes). However, when considering outcomes, collected or episodically for an evaluation, a portion of the target population must be chosen. Sampling is the process of selecting units, such as people or organizations, from a population of interest. The hope is that evaluators can generalize their results back to the rest of the population from which the selected were chosen from (Trochim 2020a, b, c).

Probability Sampling and Non-Probability Sampling Techniques With probability sampling, every unit has a known chance of being selected at some stage. Evaluators want to make sure that the sample is representative of the target group as this enhances validity and generalizability to the target population. This is

Improved awareness of MWH

Logic model construct (long term outcome) Increased utilization of maternity waiting homes (MWH) among women living more than 10 km away

How do the awareness and perceptions of MWHs and health facility delivery change among women living more than 10 km from a health facility in the intervention group compared to the control group?

Outcome evaluation question How does the proportion of women using MWHs for health facility delivery change among women living more than 10 km from a health facility in the intervention group compared to the control group?

Change in proportion of households that have heard of a MWH

QUANT indicator % of women who stayed at a MWH before delivering the most recent baby

Table 4 Example of data collection plan to answer outcome evaluation questions QUANT variables required # of respondents that used a MWH before last delivery # of total respondents surveys Delivery location Distance # pregnancies, # live births # of households that have heard of a MWH # of household surveys Delivery location Distance Awareness of MWH Perceptions of MWH Perceptions of facility delivery

Qualitative domains Not applicable

Household survey And In-depth interview

Data source/ mixedmethod Household survey

O1 (baseline) O2 (endline) Among both intervention and control groups

Frequency of data collection O1 (baseline) O2 (endline) Among both intervention and control groups

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Fig. 2 Process evaluation monitoring plan tool. (Moore et al. 2014)

particularly important in impact evaluation, but also important to understand outcomes of program participants. Four examples of common probability sampling strategies include: simple random, systematic random, cluster random, stratified random (Table 5). Cluster sampling is useful when evaluators are trying to sample a large population that may be spread out across a wide geographical area and is often used in global health M&E. For example, a selection of project sites might first randomly be selected, then a sample of program participants within those sites would be selected for the outcome evaluation. With non-probability sampling, the chances of selection are unknown. They are more often used for qualitative methods. Four common types of non-probability sampling include: quota sampling, convenience sampling, purposive sampling, and snowball sampling (Table 6).

Ensuring Result Use and Disseminating Conclusions In order to be useful, data must be analyzed appropriately. Thus, a clear analysis plan should be developed as part of the M&E plan at the beginning of a project and included in the broader M&E plan. However, the ultimate goal of an M&E plan is to understand the effectiveness of the intervention and to either improve the

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Table 5 Common Probability sampling techniques (Bamberger et al. 2012) Probability sampling technique Simple random

Systematic random

Stratified random

Cluster random

Definition Every case has an equal chance of being included in the sample. It is typically used when the number of sampling units is small or if the frame is enumerated The first element is selected randomly from a list or from sequential files, and then every nth element is selected The population is first subdivided into two or more mutually exclusive segments called strata, based on categories of one or a combination of relevant variables. Simple random samples are then drawn from each stratum, and these subsamples are joined to form the complete stratified sample Typically used when a sampling frame is not available as is often the case with large population spread across a wide geographic area. The population is broken down into groups of cases such as states, cities, blocks. Clusters are first selected randomly and then cases in each sampled cluster are selected. Cluster samples often include multiple stages

Pros • Easy to carry out • Requires little knowledge of the population

Cons • May have a larger sampling error • Need to have population units all listed in some form

• Easy to carry out

• Need a listing or mapping of the entire population

• Prone to less sampling error • Implementers can analyze more about groups with small proportions in the population

• Need to have a list of characteristics on which you need to stratify • Costly • Not always representative of the whole population

• Cost and time effective • Requires sampling only part of the population

• Larger possibility of sampling error • Requires a larger sample of clusters for precision

intervention or the delivery of the intervention. When paired with costing data, M&E data can contribute to cost outcomes or cost effectiveness analyses. Conclusions can be used to demonstrate effectiveness, identify bottlenecks, modify intervention planning if it is going to be replicated, and justify the need for continual funding (Step 6: Ensure Use of Evaluation Findings and Share Lessons Learned 2012). Results and updates should be disseminated on an on-going basis as they may be able to help strengthen the evaluation as it is still unfolding and adjusting (Developing an Effective Evaluation Plan 2011). It is critical that stakeholders be engaged along the entirety of the evaluation including at the end.

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Table 6 Common Non-probability sampling techniques (Bamberger et al. 2012) Nonprobability sampling technique Quota sampling

Convenience sampling

Purposive sampling

Snowball sampling

Definition Intended to overcome the flaws of convenience sampling by introducing a quota to ensure that the sample represents certain characteristics in proportion to their prevalence in the population Units are selected because they are easy to find, consisting of whoever or whatever is available Each sample element is selected for a purpose, usually because of the unique position of the sample elements Units are first selected to participate in the study and then are asked to help recruit other potential participants to take part

Pros • The sample represents certain characteristics in proportion to their prevalence in the population

Cons • Can be time consuming

• Easiest to carry out

• Provides the least information

• Can target individuals who are particularly knowledgeable about an issue

• Selection bias

• May be easier to locate and contact hard to reach population

• Can run into a network which is not representative of the population implementers are looking to work with

Budgeting for Monitoring and Evaluation Building a strong budget is critical for any evaluation. Budgets are vital as they help implementers plan for the anticipated expected and the unexpected. When developing a project budget, approximately 10% should be allocated to M&E, which includes both developing and implementing the M&E plan. Budgets should include, but not be limited to, the following: development of the plan, printing of necessary data collection tools, data collection staff, data analysis staff and software, travel, and stakeholder engagement activities including dissemination workshops.

Conclusion M&E is an essential part of any global health program and should be included from a project’s inception. It is a continuous process that occurs throughout the life of a project. Project M&E is used to generate evidence to inform decisions on global

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health programming, implementation, and scale up while also ensuring the efficient use of limited resources. It is an exercise to help decision makers understand how a program or project is responsible for particular results. Monitoring should be conducted at every stage continuously while evaluations are usually implemented episodically and should be planned from the project’s onset. A logic model underpins any project evaluation. By simply depticting the rational series of steps leading to change, the logic model is a useful tool to bring stakeholders to a common understanding of the project implementation approach and its evaluation, provides a clear albeit simplified understanding of the theory of change, and offers a platform from which to develop structured process and outcome evaluation questions.

References (2011) Developing an effective evaluation plan. Center of Disease Control and Preventions. Available via Centers of Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Division of Nutrition, Physical Activity, and Obesity. https://www.cdc.gov/obesity/downloads/CDC-EvaluationWorkbook-508.pdf. Accessed 26 Feb 2020 (1999) Framework for program evaluation in public health. Center for Disease Control and Prevention. Available via MMWR. https://www.cdc.gov/mmwr/PDF/rr/rr4811.pdf. Accessed 20 Feb 2020 (2011) Introduction to program evaluation for public health programs: a self-study guide. Centers of Disease Control and Preventions. Available via Office of the Director, Office of Strategy and Innovation. https://www.cdc.gov/eval/guide/CDCEvalManual.pdf. Accessed 2 Mar 2020 (2019) Opportunities for impact evaluation. US Agency for International Development (USAID). Available via Office of Trade and Regulatory Reform Bureau of Economic Growth, Education, and Environment. https://www.usaid.gov/project-starter/program-cycle/cdcs/anticipating-evalu ation-needs/opportunities-for-impact-evaluation. Accessed 20 Feb 2020 (2012) Step 6: Ensure use of evaluation findings and share lessons learned. Center of Disease Control and Prevention. Available via Centers of Disease Control and Prevention, Program Performance and Evaluation Office. https://www.cdc.gov/eval/guide/step6/index.htm. Accessed 26 Feb 2020 (2020) Types of evaluation. Center for Disease Control and Prevention, Program Performance and Evaluation Office. https://www.cdc.gov/std/Program/pupestd/Types%20of%20Evaluation.pdf. Accessed 20 Feb 2020 Adamchak S, et al (2000) A guide to monitoring and evaluating adolescent reproductive health programs In: The FOCUS on Young Adults Tool Series. FIH 360. https://www.fhi360.org/ resource/guide-monitoring-and-evaluating-adolescent-reproductive-health-programs. Accessed 23 May 2020 Bamberger M, Rugh J, Mabry L (eds) (2011) Real world evaluation: working under budget, time, data, and political constraints. Sage, Los Angeles Bamberger M, et al (2012) Real world evaluation: working under budget, time, data, and political constraints. Sage Publications, 2nd Edition Doran G (1981) There’s a S.M.A.R.T way to write management’s goals and objectives. Manag Rev 70:35–36 Forman JB, Discenza R (2012) Got stake?: (holder) management in your project. Paper presented at PMI Global Congress 2012, Vancouver, British Columbia, Canada, 23 Oct 2012 Harris A et al (2006) The use and interpretation of quasi-experimental studies in medical informatics. J Am Med Inform Assoc 13(1):16–23. https://doi.org/10.1197/jamia.M1749

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Khandker S, Koolwal G, Samad H (2010) Handbook on impact evaluation quantitative methods and practices. Banco Mundial, Washington, DC Moore G et al (2014) Process evaluation of complex interventions: Medical Research Council guidance. BMJ 350:1258. https://doi.org/10.1136/bmj.h1258 Salabarria-Pena Y, Apt BS, Walsh CM (2007) Practical use of evaluation among sexually transmitted disease (STD) programs. Centers of Disease Control and Prevention. Available via Centers of Disease Control and Prevention. https://www.cdc.gov/std/program/pupestd/Step-1SPREADS.pdf. Accessed 20 Feb 2020 Trochim W (2020a) Introduction to evaluation. In: Research methods knowledge base. Available via Conjoint.ly. https://socialresearchmethods.net/kb/introduction-to-evaluation/. Accessed 20 Feb 2020 Trochim W (2020b) Design. In: Research Methods Knowledge Base. Available via Conjoint.ly. https://socialresearchmethods.net/kb/research-design/. Accessed 22 Feb 2020 Trochim W (2020c) Sampling. In: Research Methods Knowledge Base. Available via Conjoint.ly. https://socialresearchmethods.net/kb/sampling-in-research/. Accessed 24 Feb 2020

Part III Population Health Dynamics

Innovations in Disease Surveillance and Monitoring

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Jessica Espey and Hayden Dahmm

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Traditional Disease Surveillance Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CRVS Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administrative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existing Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Sources of Health Surveillance Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strengthening Traditional Data with New Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Point of Care Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sero-Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptomatic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Real Time Sequence Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Syndromic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non-Health Data Relevant for Disease Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non-Health Digital Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telecommunications Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modeling and Satellite Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insufficient Diagnostic Testing and Long-Term Capacity Development . . . . . . . . . . . . . . . . . . . Representativeness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Negotiating Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . National Systems Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

While there have been worldwide improvements in public health over the past few decades, new viruses and other pandemics are expected to increase as we move towards high-density, urban living. But with only 49 countries reporting high-quality cause of death data to the WHO, the exact burden of infectious diseases is impossible to know. As made clear by the COVID-19 pandemic, there is a vital need for identifying and monitoring the spread of new infectious diseases. Novel sources of data offer the opportunity to expand the geographic scope and timeliness of surveillance activities. This chapter reviews six new health surveillance approaches, such as syndromic data collection, as well as three other novel data collection methods, such as movement tracking using telecommunications data, that have the potential to offer useful health insights. However, most of these methods are in their comparative infancy and need rigorous testing and investment before a pandemic strikes so that countries are not left scrambling to innovate during a crisis period. Particularly important is that countries aim to establish an inclusive national data infrastructure, which fosters third party partnerships and innovation, with epidemic intelligence as core objective of that system. The focus should be data-driven and evidence-based decisionmaking during crisis periods as well as day-to-day policy-making. Keywords

Infectious diseases · Monitoring · Surveillance · Big data · Evidence-based public health

Introduction There have been substantial declines in the death rates for a number of infectious diseases over the past decade. In 2017, 15% of deaths were attributed to communicable diseases compared with 25% in 1990 (IHME 2020a). Yet with the growing threat of antibiotic resistance, there has been a marked increase in the number of emerging diseases (WHO 2020). Furthermore, new viruses and other pandemics are expected as we move towards high-density, urban living (UNEP 2020). But with only 49 countries reporting high-quality cause of death data to the WHO, the true burden of infectious diseases is impossible to know exactly (IHME 2017). As made clear by the COVID-19 pandemic, there is a vital need for identifying and monitoring the spread of new infectious diseases. Novel sources of data offer the opportunity to expand the geographic scope and timeliness of surveillance activities. Our knowledge about the global distribution of diseases is still limited (Hay et al. 2013). As of 2013, only 7 of 355 significant infectious diseases had been comprehensively mapped, and not knowing the geographic distribution of disease has real public health implications (Ibid.). Moreover, the Ebola outbreak, which killed over 11,300 in West Africa (Bell et al. 2016), underscored the fundamental weaknesses in

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national and international systems for disease detection, monitoring and response (Woolhouse et al. 2015), made all the more apparent by the present coronavirus epidemic. New data collection methods and data sources can improve the quality and quantity of information available for disease surveillance systems, if carefully managed, by providing: • more timely data to inform policy and decision-making; • more accurate spatial maps to support preparedness and planning; • and more data with which to derive insights on disease spread patterns and extent (Hay et al. 2013).

Traditional Disease Surveillance Practices International Health Regulations, established in 2005, define public health surveillance as “the systematic, ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for assessment and public health response as necessary” (CDC 2006a). But the data collected by such systems is not exclusively health related, it may include other demographic, socioeconomic and clinical characteristics of the population under surveillance, data on key outcomes such as disease complications and mortality, and data on potentially mitigating or aggravating behaviors or co-morbid conditions referred to as risk factors (Soucie 2012). National communicable disease surveillance systems around the world provide the majority of this critical data, although these systems have sometimes been developed unevenly, with surveillance conducted by a variety of agencies, or far from the point of action, or by academic institutions rather than by government (WHO 1999). The WHO has defined a set of core functions provided by a surveillance system: case detection; reporting; investigation and confirmation; analysis and interpretation; action; control and response; policy; and feedback (WHO 1999). Although the system as a whole covers a wide range of functions, data and information are fundamental to case identification, monitoring and evaluation. To date, health information systems continue to rely on a range of manually collected datasets at both national and regional levels (Bansal et al. 2016). The three most common sources are clinical data, civil registration and vital statistics data, and administrative data from health facilities, discussed below. The collection of data from these sources is broadly guided by the following principles, which borrow from the Principles of Official Statistics (Soucie 2012): • Surveillance must have a clearly defined objective, which will dictate what data is most relevant. • Measurement standards are critical and definitions must be clear from the start. • Standardization of the data collection is essential for comparing population groups, geographic areas, or trends over long periods of time.

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• All data elements should be clearly defined so enumerators or clinicians are all collecting comparable information. • The minimum amount of data should be collected to meet the stated surveillance objective. • Large and complex data collection tools should be limited where possible, as they can substantially increase the burden of data collection which may adversely affect both the amount and quality of the data collected. • Careful targeting of the population is essential, including a strong sampling strategy if the data are to be representative. • Data should be gathered using an appropriate information gathering style (e.g., patient interview, clinical record review) such that the responses will most likely be valid and the data reliably reflect the true status of the condition under study. • In all cases it is extremely important to apply ethical principles during the collection of data and to respect the privacy of the individuals under surveillance. • Laws and regulations concerning the confidentiality of data collected are universally available and should be adhered to as a matter of standard practice.

Clinical Data Disease outbreaks are normally detected by clinical investigations by healthcare workers (Woolhouse et al. 2015). For example, in a number of countries, “sentinel surveillance systems” have been established in health care sites such as hospitals, clinics, or care providers’ offices to monitor key disease trends such as influenza or cancer. The main purpose these provider-based surveillance systems are “to obtain timely information on changes in the occurrence of a disease or condition that can inform preventive public health activities” (Soucie 2012). Clinical surveillance data was crucial to the identification of the West African Ebola epidemic from 2013 to 2016 (WHO Ebola Response Team et al. 2014). Yet there are severe limitations to surveillance purely through clinical investigations; first it needs very strong government and institutional support, with standardized data collection techniques used by all clinicians (Soucie 2012). Second, there are medical practice challenges, such as mild symptoms not being detected in clinics or being misdiagnosed (Campos-Outcalt et al. 1991). Alternatively, clinics may be underutilized, as sick people choose not to visit a clinic because of cost or distance. For example, in parts of sub-Saharan Africa, such as Ethiopia, upwards of 18% of women do not have access to essential health services as they are more than 2 h away (as of July 2020) (World Pop 2020). Furthermore, traditionally monitoring of disease outbreaks using clinical data would involve health officials taking reports of known disease occurrence, drawing on the literature. This information would be combined with expert knowledge about environmental factors, such as temperature and rain fall, to map and predict disease risk. This process can be highly labor intensive and has often been done manually (Hay et al. 2013).

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CRVS Data Civil registration and vital statistics data (CRVS) can be a useful source of public health data. A well-functioning system records all births and deaths, including cause of death, as well as other vital events such as marriages and divorces. It is defined by the UN as the “universal, continuous, permanent and compulsory recording of vital events provided through decree or regulation in accordance with the legal requirements of each country” (UNSD in WB & WHO 2014). Unlike other sources of vital statistics, such as censuses and household surveys, the data from CRVS systems enables “the production of statistics on population dynamics, health, and inequities in service delivery on a continuous basis, for the country as a whole and for local administrative subdivisions” (WB & WHO 2014) (Fig. 1). In spite of its obvious benefits, many countries do not have comprehensive CRVS systems (more than 100 worldwide) which means that an estimated two-thirds of deaths are never recorded (WB & WHO 2014). As a result, their deaths are not included in vital statistics systems, inhibiting accurate information about the spread of diseases. Likewise, it is estimated that approximate 230 million children under five have not had their birth registered either, which means that even if their deaths are reported, there will be no record of their lives beforehand, including where they lived, what services they’ve accessed and their movements, which all have implications for monitoring disease spread (WB & WHO 2014).

Administrative Data Finally, administrative data can also be a source of disease surveillance data. Encompassing a range of data collected by the government for non-statistical purposes, administrative data often includes healthcare, insurance, and education data. Administrative data, especially related to health care, has been used to track the prevalence and outcomes of diseases. Health administrative data usually entails hospital billing records, primary and secondary diagnoses, procedure codes, provider names, admission and discharge dates, and demographic information on the individual. One example of a type of administrative data is a registry. In health these can be patient registries, medical or health ministry registries. While these tend not to include detailed clinical data, they can be a useful source of information for population wide, representative data on common diseases and conditions. Where registries and other administrative data are recorded electronically, are interoperable, and shared across government departments, they can be a particularly useful resource for monitoring national health and wellbeing.

Existing Limitations As intimated above, these traditional approaches help us paint a broad picture of disease behavior but are subject to a number of limitations.

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Fig. 1 A civil registration and vital statistics system. (Source: United Nations (2014) Principles and Recommendations for a Vital Statistics System, Revision 3, United Nations: New York)

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The first is underfunding; existing systems are not funded sufficiently to fulfil their missions (Espey 2015). CRVS and administrative data sets are often incomplete, in part due to a lack of funding that inhibits the complete collection of this data and the maintenance of systems for accessing the data. According to the last recorded estimate, produced in 2014, the cost of scaling up CRVS systems to 73 priority countries was estimated to be US$3.82 billion over a 10-year period (2015– 2024) and at the time of writing the financing gap was 52%, an estimated $1.98 billion (World Bank & WHO 2014). Recent estimates of the cost of monitoring COVID-19 in the USA suggest that surveilling that one disease across the U.S could cost as much as $3.6 billion in additional emergency funding to state and territorial health departments, suggesting huge additional shortfalls in most other countries worldwide (Watson et al. 2020). A related issue is timeliness; many traditional health data systems are not updated with enough frequency to help with disease surveillance. In order for clinical, CRVS, and administrative data to be useful in disease surveillance, they must be able to provide data as close to real-time as possible. The time lag inherent in these traditional approaches also limits their utility in helping to rapidly identify and respond to disease outbreaks. Many of these methods, especially clinical data, are collected and coded manually, leading to a delay in their availability for analysis. In terms of disease mapping, this traditional approach produces maps that are spatially continuous but only represent one point in time (Hay et al. 2013). Underreporting also presents limitations to traditional disease surveillance. Because much of the data for surveillance is based on passive reporting by healthcare providers, only a fraction of cases is ever reported. The Centers for Disease Control outlines two main reasons for underreporting – lack of knowledge about reporting requirements and negative attitudes towards reporting. If individuals are unaware of processes, if the reporting system is too burdensome or if there is distrust of the public health system, cases are less likely to be reported. Underreporting can delay treatment and lead to the spread of a disease (CDC 2012).

New Sources of Health Surveillance Data The ongoing data revolution has the potential to strengthen surveillance systems by improving the timeliness of data and bringing new sources of information to bare. This ranges from data about patient symptoms to digital data from web searches and social media, as well as telecommunications data about population movement and satellite data that can describe relevant environmental changes. Aside from new technologies, building capacity and simply changing the procedures for data collection is just as important, as with efforts by the UN to improve autopsy reporting. New data sources, including big data, have the potential to greatly improve the timeliness and availability of epidemiological data, but these new sources are intended to strengthen and supplement traditional systems, not replace them (Bansal et al. 2016).

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Strengthening Traditional Data with New Methods The most urgent demand on CRVS data in the health sector is to provide reliable, standard data on cause of death (Ye et al. 2012). Even though mortality data is essential to documenting diseases, overworked health systems can struggle to deliver this data systematically, and many deaths happen outside of the hospital setting. The WHO has established methods for conducting verbal autopsies, which are 15-minute interviews with witnesses of deaths. This data can then make needed contributions to CRVS (WHO 2017). In particular, verbal autopsies can provide information about disease incidents like malaria. The INDEPTH project (International Network for the Demographic Evaluation of Populations and their Health) has demonstrated the benefits of this verbal autopsy method in Asia and Africa. In a study of 22 INDEPTH sites classifying nearly 100,000 deaths, researchers were able to track mortality rates and causes of depth and found the results to be comparable to other sources of mortality data. Although verbal autopsies are generally not as conclusive as clinical data, in the aggregate, they provide a useful and low-cost way of identifying trends in mortality in the absence of CVRS data (Streatfield et al. 2014). This shows that we don’t necessarily need new technologies or new types of data. Alternative methods for collecting recognized data can be of great benefit. Box 1: Verbal Autopsy Methods

Verbal autopsies are a method of determining causes of death and associated health concerns in deceased individuals where there is an incomplete vital registration system. Usually a trained interviewer will undertake a questionnaire with an individual familiar to the deceased, asking about signs, symptoms, possible risk factors (like smoking), and demographic characteristics. Once collected the questionnaire responses are customarily reviewed by a physician but this can be costly and time-consuming, as such groups like IHME and Johns Hopkins have been trialing alternative review processes such as “InterVA” (a program that incorporates commonly applied physician decision points by coding them into algorithms). IHME concludes that “a great deal of research has been conducted in the past several decades about VA, but some traditional methods of implementation and analysis can be costly, time-consuming, and potentially of varying quality. Verbal autopsies are now analyzed using a much wider array of cutting-edge techniques, some of which could be less expensive or yield higher quality results than those used traditionally,” but these developments are a work in progress (IHME 2020b).

Point of Care Data Point of care (POC) data are produced by rapid diagnostic tests linked to IT systems. Results are inputted electronically by providers while care is being administered to patients. It allows for quick and low-cost diagnosis while requiring limited

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infrastructure (Kozel and Burnham-Marusich 2017). Improving detection times can be vital to disease control (Woolhouse et al. 2015) and POC data has the potential to do so in both high- and low-resource settings. Because there was no vaccine available, the main way to control the 2014 Ebola outbreak in West Africa was through containment, which required rapid diagnosis in order to isolate patients. Real time testing for the Ebola virus was developed in the early 2000s and compared with traditional methods; it took hours rather than days to obtain results. However, at the start of the outbreak, these tests had not been approved for clinical settings. New tests had to be developed for use in decentralized health care facilities with minimal laboratory infrastructure, use of minimally invasive diagnostic samples, and simple procedures. When they were made available, these new tests were able to provide more rapid results than traditional testing, leading to faster isolation of patients (Broadhurst et al. 2016). The shortage of POC tests for COVID-19 in the United States compared with countries like South Korea has shown the importance of being able to rapidly test and isolate patients. Early on in the outbreak in the United States, testing shortages meant that most of the people who were able to get tested were already very ill and that asymptomatic or mild cases were not being identified and isolated. Meanwhile, South Korea was testing tens of thousands of people per day with rapid results and the cases in South Korea have stayed low relative to the United States. These two countries’ experiences with point of care testing demonstrate its effectiveness at rapidly responding to outbreaks (Kost 2020).

Sero-Surveillance Sero-surveillance is a technique that is used to measure population level exposure (Woolhouse et al. 2015). Immunity and past exposure to diseases can be determined by testing for antibodies to a disease. Serological surveillance can detect antibodies even without symptoms or an active virus. It can provide a broad picture of population immunity and how a disease is spreading, as well as identifying immunization coverage gaps and predict outbreaks (Arnold et al. 2018). For existing epidemics, serological data shows which populations have been affected and which may still be susceptible while also providing inputs for models that can determine transmissibility and severity.

Box 2: Serological Studies on H1N1

During the H1N1 epidemic in 2009, a large number of serological studies were used to provide a picture of how the virus had spread throughout the world and determine infection rates. These studies were valuable for understanding the virus but the majority were not published until the virus was widespread. As a result, information about the disease’s transmissibility and severity were not available early on when it could have been useful in preventing the spread of (continued)

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Box 2: (continued)

the disease. Challenges involved in scaling up serological studies early on included the development of new procedures, procurement of funding, rapid deployment of training, and laboratory capacity. However, in the case of H1NH, once the serological studies ramped up, researchers were provided with information that allowed them to learn more about the virus and its spread. Lessons from serological testing during the H1N1 epidemic include adopting a common framework, methodology, and reporting system, standardizing laboratory serological procedures and planning for outbreak studies (Laurie et al. 2013).

Sero-surveillance has also been used during the COVID-19 epidemic to understand the spread of the disease and the infection rate within the population. The Centers for Disease Control plans to use this data to see how many infections have occurred at different points in time, at different locations, and among different populations. The results of this testing will help guide future control measures and healthcare needs by understanding the incidence of infection, how it spreads, and what populations are most vulnerable. It can also help identify risk factors for the disease such as age, location, and underlying health conditions. Given the shortage of testing in the United States early on in the pandemic, serology testing may also help to identify asymptomatic and mild cases that were not tested while they had the virus (CDC 2020).

Symptomatic Data Symptomatic data is data about the health symptoms reported by patients, rather than formal diagnoses. Participants are asked on a weekly basis to report on their symptoms such as fevers, cough, body aches, diarrhea or vomiting. Often, this informal data is collected electronically and can be used to detect spikes in certain symptoms among a broader population. This preliminary information can help in tracking outbreaks (Pilot et al. 2011). This type of surveillance is most often used to detect influenza via online apps and websites and are based on volunteer participants. Flu Near You uses volunteers in the USA to monitor for influenza-like-illness in which the volunteers report on the prevalence of 10 symptoms every week. A website shows the distribution of symptoms throughout the country, allowing for early detection. However, in order to be most effective, systems like Flu For Now need a large and diverse sample size (Chunara et al. 2013). Box 3: The Indian Integrated Disease Surveillance Project

In India, responsibility for disease surveillance is shared by central and local government authorities (Pilot et al. 2011). Responding to issues with (continued)

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Box 3: (continued)

variability in consistency, the Indian Integrated Disease Surveillance Project was set up, with WHO support, in 2004 to collect village level data on a weekly basis about symptomatic reports. In the city of Pune, a symptomatic screening process was set up in response to H1N1, mapping the location of patients, and identifying patterns in where patients originated (Pilot et al. 2011).

Real Time Sequence Data Real time sequence data is pathogen genome data that is time-resolved and geolocated. This technique helps us to understand and respond to the evolutionary development of pathogens. Sequence data can help track the emergence of drug resistance, and it can be combined with other sources of data to perform transmission network analysis. Moreover, sequencing can provide insights about transmission across species, as well as the spread across space and time. An effective analysis requires a large sample size on the order of hundreds or thousands. The technique has been used to assess HIV and influenza (Woolhouse et al. 2015). The 2009 H1N1 flu pandemic was the first major outbreak to be tracked in real time with virus genetic data. Since then, it has been used to track the 2014 Ebola outbreak in West Africa (Stadler et al. 2014) and COVID-19 (CDC 2020). During the 2019 H1N1 pandemic, researchers relied on data from GISAID’s EpiFlu database for real time sequence data. Launched in 2008, the EpiFlu database allowed countries to publicly share genetic data and track the evolution of the virus as it spread (Shu and McCauley 2017). Within 2 months of the first cases, researchers were able to provide accurate estimates of the evolutionary rate, date of emergence, and transmission rate using real time genetic sequencing, allowing for early characterization of the epidemic (Hedge et al. 2013). Box 4: Using Real Time Genome Data to Counter Popular Misconceptions During COVID-19

In studying the genome data of COVID-19 patients in New York City, researchers found that most of the cases were introduced from Europe and also found evidence for community spread. This countered the common belief that the virus came to the United States from China; a misconception that had informed the policy decision to shut down the border with China much earlier than that of Europe. If sequence data had been used in more real time during the early days of COVID-19 in the United States, it could have informed these border policies and may have prevented further introduction of the disease by travelers coming from Europe (Gonzalez-Reiche et al. 2020).

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Syndromic Data Syndromic data is a type of early warning system for disease outbreaks. While the type of data used by syndromic surveillance systems can vary, it centers around a systematic approach in which health departments use automated data acquisitions and alerts to monitor disease indicators as close to real time as possible (Henning 2004). These indicators can include everything from school absenteeism and increased over-the-counter medication sales to veterinary data that reveals an unexpected increase in animal deaths (Abat et al. 2016). Syndromic surveillance focuses on the early symptom periods of a disease, before clinical or lab tests can traditionally provide a diagnosis, allowing for earlier detection of outbreaks. Negatively, these alternative, non-clinical, data sources can have confounding factors that show spikes unrelated to disease outbreaks, but when combined with multiple sources, they can provide a more reliable picture (Henning 2004). A study in Madhya Pradesh, India stationed data collectors in clinics using specially designed mobile apps to collect demographic information and symptomatic data. The data was then submitted to a central server for analysis. By using cell phones, the data collectors were able to obtain syndromic data about rural India that hadn’t been previously accessible. The cell phone collection gave researchers access to data in electronic form in order to improve syndromic surveillance compared with manually entered data (Diwan et al. 2015).

Non-Health Data Relevant for Disease Monitoring While disease surveillance historically relies on health data collected through the formal health system, there are other sources of related data that offer insights. Digital big data, satellite data and telecommunications data in particular, are becoming more and more accessible for public health reporting, catalyzed by the data revolution for sustainable development (IEAG 2016).

Non-Health Digital Data The growing volumes of digital data now available are a resource for real time insights about a range of social conditions, including the spread of disease. The earliest applications of digital data for disease surveillance drew on web search data to estimate the prevalence of influenza within certain communities. This method was made famous by Google Flu Trends. However, Google Flu Trends failed to detect 2009 flu outbreak (Woolhouse et al. 2015) and the tool was ended in 2015. There is now more interest in using social media data rather than search data, but flu is still the most commonly monitored disease (Paul et al. 2016). With unprecedented numbers of users on social media (as of January 2020, Twitter had 330 million active monthly users, most outside of the USA), there are opportunities to combine this information with machine learning and natural language

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processing to monitor public health (Paul et al. 2016). Search and Twitter data have been used to track dengue fever (Paul et al. 2016). Twitter has been used to track cholera, Ebola, and e. coli and has also been considered for monitoring HIV (Stoové and Pedrana 2014). There are some difficulties when using social media data. Short text, such as Tweets, does not lend itself to natural language processing, and the colloquial language used in social media makes it challenging to search for and classify posts (Paul et al. 2016). There also needs to be a more extended consideration of the ethics involved. Although social media data may technically be public, analyzing posts can reveal private information.

Telecommunications Data Predicting and containing the spread of a disease requires an understanding of population movement. Telecommunications data provides an innovative way for estimating such population movement, and it has been used to help address disaster scenarios, disease outbreaks, and service planning. By looking at changes in where calls were received, messages sent, and other mobile network activity, it is possible to document how groups of people may have relocated over time. Location data from call data records were used as part of malaria prevention strategies (Wesolowski et al. 2012). Building on initial work, it was then proposed the approach be used for responding to the West Africa Ebola outbreak of 2014–2016 (Wesolowski et al. 2014). The rapid spread of Ebola was thought to be driven by local and regional travel, and mobility data could inform epidemiological models. During the Ebola outbreak, Sierra Leone created a containment strategy that was highly controversial, with many dismissing it as counterproductive. Traditional methods, such as self-reporting surveys, are not well suited for measuring the effectiveness of containment, though. Researchers accessed call data records following a lockdown event, and they found a 31% reduction in mobility for distances under 15 km and a 76% reduction for distances beyond 30 km, with original travel patterns returning after the lockdown was lifted. Furthermore, the impact was up to twice as great in areas with a higher disease burden, suggesting that less affected areas might not have been as inconvenienced. This experience shows the potential of anonymized, mobile data to capture complex population dynamics and movement, and inform future disease responses (Peak et al. 2018).

Modeling and Satellite Estimates Mathematical models can provide real time projections of disease spread (Woolhouse et al. 2015). There are many different approaches, but disease spread is basically modeled as an exponential process, defined by the parameters of the number of secondary people a first person will infect and the generation time.

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Risk mapping looks at various predictors of disease outbreak and spread, including elevation, vegetation, animal species present, other environmental factors, and so on (Woolhouse et al. 2015). Especially in remote areas, mapping requires satellite imagery and other supplemental data. Identifying areas of acute risk through mapping can help direct surveillance efforts and resources between outbreaks. GIS and satellite images can help monitor variables like temperature, precipitation, humidity, wind, and other variables that affect the spread of diseases. As such satellite imagery has been used in studies and forecasts of diseases such as Hantavirus pulmonary syndrome (HPS), malaria, dengue, Lyme, and Rift Valley fever (Nsoesie et al. 2015). During an outbreak, analysis of spatial data can identify the spread of the disease, show what population groups are at risk, evaluate how many facilities are available to provide healthcare within a certain distance, and assess the effectiveness of control measures (Singh and Ranjan 2015). Box 5: Using Satellite Data to Estimate Hospital Attendance

Researchers in Argentina, Chile, and Mexico used satellite imagery to monitor hospital parking lot traffic data to augment public health disease surveillance. They hypothesized that increases in hospital traffic could serve as an early indicator of social disruption resulting from disease. They used high-resolution satellite imagery collected from January 2010 to May 2013 and overlaid it with data on the incidence of respiratory virus illnesses, collected by the Pan American Health Organization (PAHO). They then developed dynamical Elastic Net multivariable linear regression models to estimate the incidence of respiratory virus illnesses using hospital traffic. The models for influenza and other respiratory viruses using hospital traffic data for select hospitals in Chile, Argentina and Mexico, performed well ‘in capturing the trends present in the data within a reasonable range of error.’ The errors were partly explained by lags in data releases from Ministries of Health, as well as PAHO. The researchers also concluded the model could not properly account for high-density parking (i.e., multistory car parks) or for socialeconomic dynamics relating to car ownership, shared usage, and so on. Nonetheless, the project demonstrated that, when combined with other information, this type of satellite data could be useful in monitoring disease trends (Nsoesie et al. 2015).

New Data Limitations New data sources provide huge possibility for monitoring health conditions and disease transmission, not least of all satellite and telecommunications data which can help us to map population movement and disease spread in real time. However, as alluded to above, each approach has its own pitfalls and is best utilized in combination with other traditional, and potentially more representative, methods. Common

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limitations affecting all of these methodologies are insufficient capacity, representative bias, ethnical concerns and the complexity of data-sharing partnerships.

Insufficient Diagnostic Testing and Long-Term Capacity Development As discussed above (2.2) diagnostics are a fundamental component of successful outbreak containment or control strategies. And we’ve seen huge advances in rapid diagnostic approaches and techniques. However, as demonstrated by COVID-19, but also recent Ebola, Zika, and yellow fever outbreaks, there are common barriers to diagnostic preparedness that occur across all epidemic situations. In the case of the 2013–2016 Ebola epidemic in West Africa, there was a 3-month delay between the index case and the identification of the causative agent; post-outbreak analyses suggest that diagnosing 60% of patients within 1 day instead of 5 days could have reduced the attack rate from 80% to nearly 0% (Haug et al. 2016 in Kelly-Cirino et al. 2019)

The primary limitation is inadequate diagnostic testing capacity at both national and community levels of healthcare, with governments loathe to invest in pandemic preparedness outside of crisis periods. Furthermore, the companies producing the diagnostic testing for pathogens need incentives to work on these outside of outbreak periods (Kelly-Cirino et al. 2019). The problem with this is that test development and validation, through field tests, only commence when the pathogen has substantively taken hold, slowing down the whole diagnostic process. These challenges are not unique to diagnostics. Few governments are investing substantially in broad national or subnational data and monitoring capacities, particularly using new or alternative techniques such as GIS, telecommunications analytics and so on, meaning national and subnational health actors, and statisticians, are ill-equipped to use these approaches during the crisis. However, with the frequency of pandemics increasing this kind of testing and capacity development is essential to ensure the ongoing health of the population. For diagnostics, other long-term investments should focus on identifying overlaps in diagnostic development needs across different priority pathogens, which would prove timelier and more cost-effective than a pathogen by pathogen-based approach (Kelly-Cirino et al. 2019).

Representativeness Another issue affecting many of the new data approaches is representativeness. Telecommunications data only provides demographic data on mobile phone users and does not differentiate between shared mobile phone usage. Digital data, such as twitter analysis, only captures the digitally connected and those actively engaged in social media (Bansal et al. 2016). And GIS data infers population characteristics

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based on other proxies such as infrastructure and roofing. It is not a representative, house to house count. As such all of these methods require triangulation with censuses, household surveys and other representative data collection sources to ensure demographic accuracy. For example, researchers have raised questions about the representativeness of mobile data used as part of the Ebola response. Anthropological studies have shown that cell phones are not used strictly as individual property in West Africa, meaning that they are not reliable beacons of individual behavior (Erikson 2018). Instead, ownership is much more fluid, with one phone possibly being shared by multiple family members, and with one individual potentially owning multiple phones. Furthermore, with patchy phone service in less urban areas and many phones not having GPS capabilities, it can be challenging to accurately locate a call. On top of these technical limitations, Ebola is spread by person to person contact, so the existing modeling assumptions for malaria that underpinned the analysis of mobile data might not translate well to Ebola. Critics also point out that there has not yet been much in the way of peer reviews of the positive claims about telecommunications data for surveillance (Maxmen 2019). And indeed, to prevent Ebola transmission, restricting overall movement is less important than isolating patients to prevent direct contact with infected fluids (Maxmen 2019). These concerns emphasize the need to fully consider the local and social context as well as the specifics of a disease before deploying novel data solutions.

Ethical Concerns The use of new data sources has raised a variety of ethical considerations that must be balanced with the benefits to public health, for example, the concern that much public health information is becoming concentrated with select, powerful companies (Kostkova 2018). As such, there is an urgent need for guidelines around the acceptable use of personal data (by both the public and the private sector) while also providing sufficient flexibility to accommodate different emerging data sources and respecting issues of global justice (Vayena et al. 2015). Already, there are growing concerns about the lack of consent involved with the sharing of data for public health applications, as well as about the fairness of algorithms built off of these data (McDonald 2016). Because of the high-resolution of spatial data used for disease surveillance, privacy is another important concern. Current safeguards focus on anonymizing individually identifiable data and the aggregation of shared data to protect privacy. However, even when data is anonymized, researchers have shown that it can be de-anonymized with very little information, enabling them to uniquely identify individuals represented in the dataset (Kondor et al. 2018). Ensuring the methodological robustness of new techniques can also be viewed as an ethical issue, not just a scientific one (Vayena et al. 2015). Epidemiological studies are prone to a wide range of methodological challenges (CDC 2006b), which may incorrectly estimate the spread of a disease leaving certain individuals and communities vulnerable to health risks, while at the same time economically

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harming, stigmatizing, or curtailing the freedoms of others without necessarily creating public health benefits. This set of ethical concerns will need to be addressed with concerted action. Privacy issues could be mitigated in part with higher levels of aggregation, lower spatial resolution, and the use of synthetic data sets (Kondor et al. 2018). Although this creates a potential tradeoff between the granularity of data and privacy protection, public health experts should consider the minimum level of granularity needed to conduct epidemiological analysis (as noted by Public Health England 2012). Regarding the wider set of concerns, it has been suggested that the epidemiological community develop best-practice standards, such as review boards to assess the potential risks and benefits for communities and to negotiate compensation in the event of accidental harm (Vayena et al. 2015).

Negotiating Partnerships Much of the innovations discussed above require collaboration between the public sector and private or third-party actors, and as such require a formal partnership or data sharing agreement. These agreements are important so that new sources of data can be validated and then integrated into traditional statistical and monitoring systems (Bansal et al. 2016). They are also important to ensure private data is maintained and can be relied upon over the medium to long term for national reporting. As mentioned above, Google Flu received widespread attention for its apparent ability to track the spread of the flu in real time through web search queries, but the tool eventually lost its efficacy and was discontinued. This example underscores the issue of volatility when data is not created for the direct purpose of public disease surveillance and there is less incentive to maintain it (Bansal et al. 2016). However, negotiating partnership agreements can be difficult and time consuming. A consortium of actors including SDSN TReNDS, NYU Gov Lab, University of Washington, and The World Economic Forum, analyzed a host of data sharing agreements and found serious inequalities in the partnership terms, very unequal capacities to negotiate the partnerships, challenges relating to citizen’s privacy and so on (Dahmm 2020). In summary, they highlight six important issues that need to be considered when embarking on data sharing partnerships; (1) Why the data is bring shared? (2) What kinds of data are being shared? (3)When the data should be shared? (4) Who is involved in the data sharing, (5) How the data is being shared, and (6) Where the data is being shared from and to? As we enter an era of more complex and multi-party data production, ownership and sharing, formalized data partnerships will be crucial but will require institutional innovations. Governments will need to designate partnership brokers, ensure adequate legal capacity, and familiarity with partnership terms. Likewise, private data actors will need to ensure their practices comply with national standards for data ownership, control and use, if they are to maintain a long-term partnership with any public authority.

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National Systems Innovation Disease surveillance data, whether traditional or new, needs to be incorporated into a system that is able to appropriately assess and respond to risk. In the early 2000s, Europe advanced the notion of Epidemic Intelligence (EI), which covers all activities for identifying new health risks (Paquet et al. 2006). This includes both structured data from routine surveillance (or “indicator surveillance”) and unstructured data from any source of intelligence more generally (or “event surveillance”). The importance of EI is now recognized globally within International Health Regulations (2005) (IHR), specifically the guidance on surveillance which aims to protect the global community from transboundary public health risks and emergencies (WHO 2005). Today a number of countries and regions around the world have advanced epidemic intelligence facilities, training, and centers (such as the UK, USA, and the European Union), but sadly this is still not the norm, with limited progress having been made in the vast majority of countries (Woolhouse et al. 2015). There is a need for investment and capacity building, and increased connections between the different components of national surveillance systems. Data sharing can bring a proliferation of data, but it can then lead to uncertainty about the quality of methods and loss of control on the part of the National Statistics Office or Ministry of Health. In 2015, SDSN TReNDS recommended the creation of Chief Data Officers; officials responsible for coordinating new data partnerships and sources, working closely with the National Statistical Office to validate the data and integrate it into a national system (Espey et al. 2017). Such capable systems are essential to managing the variety of data tools and partners now available.

Conclusion To fully utilize new data tools for disease surveillance and monitoring, there needs to be investment and strengthening of digital capacity. Tools should not be learned and deployed during a disaster, but should be made available and integrated in anticipation of such (Woolhouse et al. 2015), thereby also providing time for the tools to be assessed vis-a-vis local social context and vetted alongside alternative methods. Also important is to provide sufficient time to negotiate partnership agreements between national governments and third-party actors to ensure fair data sharing practices and sustainable arrangements. Above all, health indicators should be scientifically rigorous, and we should not forget the fundamental importance of traditional, bottomup data, even amid the hype of remote sensing and digital data tools. But used together within an improved surveillance system, the discussed data innovations can help to improve the equity of public health responses and help to ensure that no one is left behind.

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Population Dynamics Approaches for Research and Action in Global Health

14

Barthelemy Kuate Defo

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Location in Time and the Lexis Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Events, Rates, Quotients, and Analysis of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ratios and Proportions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Quotients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cohort Analysis and Period Analysis: Intensity and Calendar of Phenomena . . . . . . . . . . . . . Population Structure and Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standard Population Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standard Phenomenon Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mortality, Life Tables, and Measures of Life Expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crude Death Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mortality Structure by Age, Sex, and Cause of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Life Tables and Measures of Life Expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Natality and Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Natality, Fertility, and Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crude Birth Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specific Fertility Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Synthetic Indices of Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fertility Levels and Parity Progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rate of Population Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Population Doubling and Halving Time Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration: Intensities, Expectancies, Spread, and Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Concept of Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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B. Kuate Defo (*) Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada Department of Demography, Faculty of Arts and Sciences, University of Montreal, Montreal, QC, Canada e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_19

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Migration Measures from Two Conceptual Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crude Migration Intensities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age Standardized Migration Intensities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age Profile Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gross Migraproduction Intensities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration Expectancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration Impact on Population Growth in Cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration Globalization at the Global, Regional, and National Levels: Intensity, Spread, and Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter covers concepts and approaches in population dynamics – the branch of science that addresses mathematically the quantitative evolution of human and nonhuman populations, from a wide range of disciplinary perspectives – which are relevant to research and action in the global health context of the ever-changing size and structure of global, regional, national, and subnational populations of different species on the planet. Such concepts are often not defined or muddled, and this easily renders analyses based on these approaches vague. Given widely diverse backgrounds of the community of researchers, practitioners, policymakers, and planners involved in today’s population and global health issues, these approaches and methods are presented without the mathematical apparatus generally embedded in them, to encourage their utilization in research and action. Keywords

Population · Population dynamics · Global health · Mortality · Fertility · Migration

Introduction This study covers for the broader community of students, researchers, and stakeholders involved directly or indirectly in health-related issues, while keeping to a minimum the mathematical apparatus inherent in population dynamics methods, core population dynamics approaches. Suitable uses of these approaches will undoubtedly contribute to comparable measures, fuller understanding, and nuanced interpretation of population health problems facing the planet where populations of human and nonhuman species live and interact every day and everywhere. The concepts of “population,” “population dynamics,” and “global health” are extensively used in a wide range of disciplines in the academia as well as outside the academia (Schoen 2006; Birn et al. 2009; Farmer et al. 2013; Glassman and Temin 2016; Levine 2007; Merson et al. 2011; Perlman and Roy 2008; Skolnik 2008; Smith and Ram 2020). We restate them within the natural link of population dynamics with global health.

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A population in the most common sense of the term is a set of people living within the boundaries of a defined terrain. It refers to a group of individuals of the same species occupying a specific area at a specific time. Population usually refers to any aggregate of species (humans, plants, animals, fishes, etc.) with a clear definition of who and what belongs to it, who are residents at a given moment in a specified geographic universe, which is usually defined in terms of political (state, province, region, department, county, city, village, neighborhood, etc.) or in terms of any boundary-delimitating construct. The concept is also applied to subpopulations (e.g., the patient population of a hospital), and can be used for any aggregate or set of species chosen for study (animals, plants, fishes, humans, and so forth). Our primary focus is on human populations and human health issues. Population dynamics refers to the way in which the size and structure of populations change over time and the characterization of changes in the components of population change (i.e., increase, stagnation, or decline) in mathematical terms (Booth 2003; Brouard 2011). Population change entails natural movement due to vital events (births and deaths) and physical movement (migration). Population control for effective health policies and programs requires that the birth rate be aimed at the death rate. In the absence of migration, if the birth rate is lower than the death rate, the population will decline; if it is higher than the death rate, the population will increase. Changes in population size and structure are a function of the three core components of population change: birth, death, and migration. The population balance equation (PBE) expresses in discrete terms the components of change in population size from Pt at time t to Pt + n at time t + n, all components pertaining to the interval (t, t + n): Pt + n
Pt ¼ births (t, t + n)
deaths (t, t + n) + immigrants (t, t + n)
emigrants (t, t + n). When age is taken into account, this equation expresses the changes occurring to cohorts (persons of the same age during a given time interval). Population dynamics is about the analysis of population change coupled with the understanding of its mechanisms that have given rise to a body of methods specific to the study of any population. Therefore, population dynamics approaches are appealing to population – human, plant, animal, fish, and so on – health at the global, regional, national, and subnational levels, given their multidisciplinary nature and their utilization in a wide range of perspectives and disciplines. From an individual life course perspective, a natural question arises as to what differentiates people with respect to the probability of experiencing one or several of such events, given exposure for a particular duration since the occurrence of an earlier (reference) event. For instance, a disease/condition – diagnosed or undiagnosed – is an event in the life course of an individual, or an event in the professional life course of the treating healthcare practitioner (nurse, physician, clinical psychologist, etc.) in the healthcare system. Population scientists use techniques in the analysis of changes of status or shifts in disability status that can be used for analyzing the probability of a person’s experiencing a disease or a health professional treating that patient, and the interval between the onset of the disease and the timing of treatment or a pre-existing condition that led to it. The following are some of the research questions that population dynamics approaches can tackle

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in order to inform action to address the major health issues of global significance for all countries and territories worldwide. What attributes tend to increase the hazard of experiencing a longstanding disease like malaria (malaria is a life-threatening – preventable and curable – disease caused by parasites transmitted to people through the bites of infected female anopheles mosquitoes)? What factors explain malaria re-infection? What influential factors account for the variation in the interval between the nth and the (n + 1)th episodes during the life course of malaria patients? Which population segments (e.g., in terms of sex, gender, socioeconomic, demographic, and susceptibility traits) are at greater risks of getting malaria, and what are the population segments at greater risks of not be treated given the current healthcare system of a given country? What are the trends and differentials in the malaria attack rates? In a similar vein during an individual life course, chronic diseases (e.g., cardiovascular diseases, diabetes, and cancer) advance with time through stages, ending in the death of the person. Elevated blood pressure (hypertension) is the main risk factor of the global burden of disease since the 1990s (GBD 2019 Risk Factors Collaborators 2020). How has the makeup of chronic diseases (in terms of the stages of the disease such as hypertension or cancer of different types) changed over time (e.g., during the demographic, epidemiological or health transitions under way or experienced by various populations) and across populations/societies at the global, regional, national or local levels (Kuate Defo 2014a, b)? What accounts for the variation across such populations in the makeup of chronic diseases? What are the policies, programs, and interventions that can be devised, implemented, and evaluated in light of the evidence of the relationship between the changes in the life course epidemiology of infectious and parasitic diseases (e.g., changes in the malaria attack rates) and the changes in the life course epidemiology of chronic diseases (e.g., changes in the progression of hypertension or different types of cancer through stages), on the one hand, and the social, economic, and demographic changes of the population, on the other hand? Such time patterns of infectious/parasitic diseases or chronic disease onset and progression through the stages, alone or in combination with existing and emerging communicable diseases, are more than ever, of central concern at the global, regional, national, and local levels. From a population dynamics perspective, how aggregates of events change population size (the number of people) and structure over time and space, or with an influential variable (or covariate) such as climate change. Population studies focus on the ever-changing size (the number of species/people), composition (the makeup of species/people in terms of one or more traits such as age or sex), and spatial distribution of the species inhabiting well-defined territories (Namboodiri 1991, 1996; Smith 1992; Caselli et al. 2001, 2002a, b, 2003, 2004; Pressat 2008). The population size changes because of births, deaths, and migration. Compositional change occurs when the populations change their ascribed or achieved characteristics or when attrition (e.g., due to deaths) or accession (e.g., due to migration) occurs disproportionately in different segments (e.g., age strata) of a population (Aitchison 1986). In investigating the conditions that produce and the implications of changes in population structure (size, makeup, and spatial distribution), population scientists borrow heavily from a wide range of disciplines including mathematics, statistics,

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philosophy, biology, ecology, economics, geography, political science, psychology, sociology, anthropology, history, public health, and medicine. This is because population dynamics (population size, structure, distribution, and their changes) are intertwined with social, economic, political, disease and related condition, cultural, environmental, historical structures and changes, and therefore, population dynamics is essential to understanding health issues within and between populations on this planet. From a global health perspective, a health issue concern is about the onset, prevalence, and incidence, and spread of a disease or condition under the influence of the dynamic elements (births, deaths, emigrations, immigrations) of underlying population processes (fertility, mortality, and migration, respectively). Major global health issues have received amplified attention in recent years and with the COVID19 pandemic, so that the Lancet Editorial (2020, p. 1129) rightly argues that “It’s time for the global health community to change direction” in designing policies, developing programs, implementing interventions, and evaluating their capability at tackling “deeply embedded structural inequities in society.” These health issues include, but are not limited to the social determinants of the burden of disease, the dependence among diseases, and the influential factors of disease spread among humans and/or between humans and other living species on the planet (Braveman and Gottlieb 2014). Accordingly, a population health scientist’s attention is sometimes focused upon the structure of groups of diseased people aggregated at the global, regional, national, or local levels (GBD 2019 Diseases and Injuries Collaborators 2020); these people in turn contribute to the disease burden given their exposure to risk factors (GBD 2019 Risk Factors Collaborators 2020). For example, harmful lifestyles to health during the life course – excesses in fatty food, salt, alcohol, tobacco, obesity, physical inactivity – in the past determine the current composition of the population by chronic diseases such as cardiovascular diseases and diabetes (GBD 2016 Alcohol Collaborators 2018; GBD 2015 Tobacco Collaborators 2017; Afshin et al. 2017). Sometimes, it is the group of events that is the focus of the study (e.g., deaths or disease burden in a given year) but with reference to the structure of the population that experiences these events. For example, one might study the frequency of deaths or the burden of disease in the part of a population having a given age group (e.g., infant mortality, maternal mortality) (GBD 2015 Maternal Mortality Collaborators 2016; GBD 2017 Child and Adolescent Health Collaborators 2019; GBD 2019 Demographics Collaborators 2020). These aspects of focus in population dynamics and global health require two types of data: data of the size and structure of the population, and data on events occurring in a population. In the context of health systems (Birn et al. 2009; Farmer et al. 2013; Glassman and Temin 2016; Levine 2007; Merson et al. 2011; Skolnik 2008; Smith and Ram 2020), a population consists of health workforce who are engaged in an interdependent system of activities of the health system. The system of interdependence of activities of the health systems is extremely complex, and one of the many ways to study it is by analyzing changes in the size and structure (occupational composition) of the health workforce or the division of labor.

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Health systems can only function with health workers; improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability, and quality. WHO estimates a projected shortfall of 18 million health workers by 2030, mostly in low- and lower-middle income countries; however, countries at all levels of socioeconomic development face, to varying degrees, difficulties in the education, employment, deployment, retention, and performance of their workforce (World Health Organization 2020a). The conditions that make the health workforce change and the consequences of the change on healthcare and health systems can be analyzed using the population dynamics techniques for the analysis of compositional data (Aitchison 1986; Smith 1992; Pressat 2008). In the health systems, people are producers as well as consumers of health care. When people are producers, an important trait deserving attention is their skills; the desirable skill composition of the health workforce changes with technology. As technology develops, many health and care workers face periods of unemployment, task shifting or task-redefinition in line with computer-based technology. The fewer skills that workers have, the more likely they will face displacement. The approaches of population dynamics developed for chronic disease modeling are applicable to the analysis of the incidence, duration, and influential factors of displacement spells, for instance. Culture (all elements – materials, rules, attitudes, values, and knowledge – related to what people do as they live their lives) and technology (the practical tools and the way people use them when carrying out their activities or living in general) are influential factors of global health (Held et al. 1999). The various tools and the way they are used in different cultures across societies on the planet can be sorted and inventoried at successive points in time. Their location in time provides a picture of an ever-changing population of cultural and/or technological elements, such as the social media nowadays. This population changes in size and makeup over time: new items are constantly added, many of the existing/old ones are abandoned, and a number of the retained ones are modified; this mirrors “birth” (new items added) and “death” (abandonment of old items) in a population. In studying this population of cultural and/or technological elements, two different approaches of population dynamics are possible (Namboodiri 1996). One approach involves attaching the elements to people; each member of a population being a user of a tool, owner of a health-related consumer durable good, and so on. In this approach, the analyses of cultural and/or technological elements and of changes in them are treated as in the study of the population composition. Another approach is to focus on the cultural and/or technological elements themselves. This approach applies the life table technique (see below) to the analysis of life histories of cultural and/or technological elements. For instance, one may focus on the gestation periods of inventions: for example, the life histories of independent searches for a vaccine against HIV/AIDS yet to be found since its emergence as a global pandemic since the 1980s, or against COVID-19, the ongoing pandemic. HIV continues to be a major global public health issue. Such studies resemble the studies of waiting times of events in population dynamics.

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With respect to gender inequalities and health, social structure interconnects with gender and other influential factors of health across the life course of people as well as within and between societies in all countries worldwide. Gender refers to the characteristics of women, men, girls and boys that are socially constructed and which vary from society to society and can change over time. The intersectionality of gender hinges on the reality that gender is hierarchical and produces inequalities that intersect with other social and economic inequalities. Globally, the average life expectancy gap between men and women is 4.6 years, with women outliving men in all countries; moreover, the global burden of disease disproportionately affects men in terms of disability-adjusted life years, although women are more likely to spend a longer time living with a disability (Manandhar et al. 2018; GBD 2019 Demographics Collaborators). To address gender inequalities in global health, the social structure of the gendered-population dynamics in the characteristics of women, men, girls, and boys that are socially constructed, can be regarded as a population distributed among social positions along the lines of these characteristics that affect people’s role relations and social interactions. The same approaches in population dynamics used to study population structure, changes therein, and their determinants and consequences, can be applied to gendered-population dynamics straightforwardly. Urbanization is one of the leading global trends of the twenty-first century, with significant impact on global health. Over 55% of the world’s population live in urban areas, a proportion that is expected to increase to 68% by 2050; the growth in the urban population is driven by an overall population increase and an upward shift in urban dwellers, both of which are projected to add 2.5 billion to the world’s urban population by 2050, with almost 90% of this growth taking place in Asia and Africa (United Nations 2019). Most of the over 4.2 billion people living in cities still suffer from inadequate housing and transport, poor sanitation, and waste management, and air quality failing WHO guidelines. Today’s cities and those of tomorrow are facing a triple health burden of infectious diseases (e.g., HIV/AIDS, tuberculosis, pneumonia, dengue, and diarrhea), noncommunicable diseases (e.g., heart disease, stroke, asthma and other respiratory illnesses, cancers, diabetes, and depression), and violence and injuries including road traffic injuries. While cities can bring many challenges, they can also bring opportunities for better health, cleaner environment, and climate action. Population dynamics approaches such as compositional analysis (Aitchison 1986; Pressat 2008; Schoen 2006) can inform strong urban policies, programs, and interventions that must match those challenges since health is essential for fostering good urban livelihoods, building a productive workforce, creating resilient and vibrant communities, enabling mobility, promoting social interaction, and protecting vulnerable populations. Cities should also make use of the opportunity presented by having a single authority under a city mayor who is empowered to take cross-sectoral decisions and actions, for example on urban planning, transportation systems, purchasing, supply of energy, water and sanitation, waste management, and creating supportive and enabling environments for health. The remainder of this chapter covers population dynamics approaches which can help to have a clear understanding of what the available population realities are and

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how to use them accurately to examine the determinants and consequences of population trends on the health issues of global import for population species living on the planet.

Location in Time and the Lexis Diagram Population theories that are the basis of thought in population science find appeal in a precise geometric representation of the time-instants and time-intervals of the phenomena under study. Indeed, to be analyzed, the data produced concerning population structure and vital events must be classified according to certain criteria, especially by criteria involving time (age, duration, etc.) (Newell 1988; Pressat 2008). The German statistician Wilhelm Lexis in 1875 proposed a mode of representation for locating events through the double dimension of time (the civil calendar and age) and the various groupings useful for the analysis by age, period, and generation or cohort. The Lexis diagram is a tool used primarily in demography and actuarial science to locate events (e.g., births, deaths, marriages) and population sizes as a function of time (age, period, generation). Consider a straight line on which a succession of points are located equidistantly and the number in duration (in years), the number in calendar year of time, or age (in years). With such a scale of time, the intervals are measured as lengths of time elapsed between two points. The scale of intervals and ages may be large or small units of time, depending upon the phenomena under study. Mortality, for instance, is usually analyzed by age in days up to 1 month, then in months up to age 1 year, and so on, depending on the total or causespecific mortality studied. The Lexis diagram (Fig. 1) is a Cartesian system, the first axis of which measures absolute time (e.g., the civil calendar) and the second, relative time (e.g., age). With the two perpendicular straight lines as axes (one for calendar dates, another for ages), an individual experiencing an event under study in a given population is located by the intersection point of the two axes or lines. In the Lexis diagram, this mode of representing events is systematized, where elapsed intervals (or ages) and dates are combined. Events (births, deaths, emigrations, immigrations, marriages, divorces, etc.) are generally observed over the calendar year. It is of interest to classify these events according to two criteria: (i) the timeinterval elapsed since a previous or initial event (e.g., death according to the duration of life or age), widowed or divorce according to the duration of marriage, first births according to interval elapsed since the marriage or the beginning of exposure to the risk of conception, etc.; and (ii) the cohort of individuals to which it is natural to relate the person who has experienced the event (e.g., deaths related to the birth cohort, divorce or widowhood related to the marriage cohort, women giving birth to their first child as related to the cohort of women having being married at the same time or beginning their exposure to the risk of conception at the same time). E1 are events which took place among people of the same generation or birth cohort (the group of people born during the same calendar year) (P0) and at the same age (t + n1 years old). E2 are events which took place during the same year (P4) among people

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t+n6

t+n5 E2

t+n4 t+n3

t+n2 E1

E3

E4

t+n1

t

P0

P1

P2

P3

P4

P5

P6

P7

Fig. 1 Lexis diagram representation of events by different modes

of the same cohort (P0). E3 are events which took place during the same year (P4) at the same age (t + n1 years old). Members of the same cohort did not experience these events, since some of them took place among people born in year P2 and other events among people born in year P3. E4 are events which took place during year P6, among people of the cohort P5 and therefore aged t + n1 years old. If the events under study are deaths, the distribution of mortality points corresponding to the double classification of deaths by age and cohort is easily represented as Fig. 1 illustrates.

Events, Rates, Quotients, and Analysis of Events There are different ways of calculating the various rates of events used in population studies (Namboodiri 1991, 1996; Weeks 1999; Yaukey et al. 2007; Pressat 2008). The main idea that leads to the formulation of a rate is the idea of getting a measure that relates to a phenomena and that permits comparisons in time and in space. Getting married, becoming pregnant, having a second child, getting sick, dying, changing residence, changing occupation, and so on are all events. The presentation of different tools and techniques of analyses in population dynamics is made with an effort to facilitate the readability, understandability, and utilization of population dynamics approaches in global health, without requiring any college-level background in mathematics. Indeed, for over 25 years, we have taught these approaches

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to university students from a wide variety of disciplinary backgrounds including medicine/public health, social sciences, ecology, zoology, humanities, sciences, and international studies.

Events In the study of any of the components of population change – fertility, mortality, migration, social mobility – the population scientist is dealing with events and time intervals between events in the life course of individuals. An event is said to have occurred in the life of an individual when the individual has experienced a happening of substantive significance (e.g., birth, onset of a disease, death, marriage, entry into the health and care workforce, and exit from the health and care workforce). If the probability that a person will experience an event (e.g., birth, death, emigration, immigration) during a given time interval is greater than zero, then that person is said to be exposed to risk or at risk of experiencing that event during that time interval. The characteristics of individuals on which the probability of occurrence of an event depends are often called risk or predicting factors for the event. A fundamental paradigm in population dynamics approaches is to relate the observed event to an event that necessarily precedes it (Pressat 2008): death as logically dependent upon birth, first marriage as dependent upon survival to the minimal age for marriage, secondary infertility as dependent upon previously successful conception, birth of a child of the order n + 1 as dependent upon birth of a child of the nth order, and so forth. These illustrative examples indicate the great generality of this paradigm. This paradigm is readily transferable to the analysis of the timing and sequencing of risk factors, conditions, and common disease end-points, as well as other population health issues. Indeed, the overwhelming evidence on the relationship between risk factors, conditions, and common disease end-points indicates that chronic diseases share common risk factors and conditions. In individuals, common risk factors are generally classified into background risk factors (e.g., age, sex, level of education and genetic composition), behavioral risk factors (e.g., tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity) and intermediate risk factors (e.g., raised blood pressure or hypertension, raised blood glucose, raised cholesterol, and overweight/obesity). In communities, factors that commonly affect health include social and economic conditions (e.g., poverty, employment, and family composition), environment (e.g., climate or air pollution), culture (e.g., practices, norms, and values), and urbanization which influences housing, access to products and services. While some risk factors (e.g., age, sex, genetic makeup) are unchangeable, many behavioral risk factors are modifiable as well as a number of intermediate biological factors including high blood pressure, overweight or obesity, elevated blood lipids, and pre-diabetes. Societal, economic, and physical conditions influence, shape behavior, and indirectly affect other biological factors. The recognition of these common risk factors and conditions is the conceptual basis for an integrated and multipronged approach to chronic disease reframed in the

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global health context. Some events have among their risk factors the length of time elapsed since the occurrence of some other event. For instance, death has age (the time elapsed since birth) among its risk factors. In population dynamics, interest in the study of the probability of occurrence of events and their timing with respect to other relevant events preceding them in the sequencing of events has led to an emphasis on the concept of duration of time (the length of time that has elapsed since the occurrence of an event origin until the event destination before the end of the study – closed interval, or until the end of the study without an event destination – open interval). Approaches in population dynamics to analyses of population structure and change can be used with emphasis on intra-cohort and inter-cohort differences in these common risk factors and conditions. Such approaches are helpful in the design of effective policies and interventions for the prevention and control of chronic diseases as well as for infectious and communicable diseases, for evaluating them, and for interpreting their evolution within and between populations at the global, regional, national, and local levels.

Ratios and Proportions A ratio is the result of dividing one quantity by another, specifying its numerator and denominator. To avoid using very small numbers, a round number such as 100 or 1000 sometimes multiplies that result. Examples include: maternal mortality ratio (deaths of mothers due to causes linked to pregnancy, labor or the puerperium/live births from these mothers), fetal death ratio (fetal deaths/live births), child/woman ratio (children under 5 years/women aged 15–44), dependency ratio (dependents (usually persons under 15 years or older than 64 years)/supporters (usually persons aged 15–64)), and sex ratio (males in a population/females in a population). A proportion is a special kind of ratio in which the numerator is a part of the denominator. An example is the female proportion (females in a population/total of a population). Whereas ratios and proportions are measures that relate one quantity to another on a static basic, rates relate one quantity to another on a dynamic basis and serve a key tools in population dynamics.

Rates In order to compare the level of health problem (e.g., mortality) in a country at two points in time (t and t + n), absolute number of events (e.g., deaths) at t and t + n do not suffice, for the population of that country changed in the same period. In order to neutralize the effect of this population variation, corresponding numbers of events (e.g., deaths) per given number of inhabitants, generally per 1000 inhabitants, must be computed for the two dates; this provides the crude event (e.g., death) rates. This need to base the number of events on a given number of inhabitants appears again when one wants to compare the health problem (e.g., mortality) between countries

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with quite different populations. Crude event (birth, death, migration, etc.) rates are relative rates generally calculated for single calendar years thereby making them based on the same time reference. More specifically, the crude event rate (e.g., crude death rate) is obtained by dividing the annual number of events (e.g., deaths) by the mean population (or the arithmetic mean for the two January 1 dates that bound the year in question, as frequently the case in official statistical publications) of the country or territory under study, and multiplying the result by 1000 (or 10,000 or 100,000, etc. depending on the rarity of the events). While the crude rates measure the frequency of phenomena in the total population, rates calculated for subpopulations may allow designing better policies, implementing effective programs and evaluating their impacts (Newell 1988; Namboodiri 1996; Pressat 2008). For instance, the occurrence of many disease and condition and their associated mortality varies greatly with age and sex, calling for calculating different rates for different age groups, for male versus female subpopulations, in the population under study. Rates by age/age groups are the number of events occurring at a given age/age group divided by the mean population at that age/age group. These rates can then be disaggregated by sex (the different biological and physiological characteristics of persons, such as chromosomes, hormones, and reproductive organs) and gender (the socially constructed characteristics of women, men, girls, and boys that vary from society to society and can change over time, and produce inequalities which intersect with other social and economic inequalities). It is also common to calculate rates for all or part of the female population of reproductive age (e.g., fertility or infertility rates). If one wants to calculate an age-specific mortality rate, the first necessity is to have a very accurate count of the number of deaths occurring at the age and during the year under consideration. A similar need arises when calculating any age-specific event rates. In order to get a relative measure of reality, this absolute number of events occurring at the indicated age must be related to the mean number of the population under study which turns out to be a very fluid concept. This arises from the need to know how many people could possibly experience the event of interest (e.g., death) at the age in question during the course of the calendar year. Even if the number of people who are alive at that age varies little during the course of the year, the cluster of people who are exposed to the risk of the event of interest does not remain the same throughout the course of the year. Individuals are continuously exiting the observation field when reaching the maximum age of interest, while others are continually entering the observation field as they attain the minimum age required for being in observation. These exits and entries during the period of observation, and the resulting ambiguity in the definition of the mean number of population, occur in the course of investigation on age groups as well, though to a lesser extent. A way of avoiding this inconvenience consists in observing vital events by birth cohort, as depicted in the Lexis diagram (e.g., Po, E1 in Fig. 1). With cohort rates or cohort group rates, there is unambiguity about the study population which definition is more satisfactory theoretically (Pressat 2008). Not only are cohort rates sometimes better population-measuring instruments, they are also better analytical tools. Because they detail perfectly the role of different cohorts in determining, for

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example, the Covid-19 mortality in a calendar year, they also permit partitioning the mortality into one part that may be attributed to the conditions of the calendar year in question, and another part that may be ascribed to the nature of the different cohorts observed.

Quotients Quotients give a measure of population processes (e.g., fertility, mortality, migration) and related phenomena (e.g., nuptiality, aging) in cohorts between two exact ages, which need not be consecutive (Pressat 2008). This type of measure derives from a probabilistic approach to vital events (e.g., births and deaths). Taking mortality as an example, let us consider a birth cohort of individuals (e.g., Po in Fig. 1). Let us enumerate those who reach their t + n1th birthday: some of them will die before their t + n2th birthday. The quotient of mortality at age t þ n1 years in this cohort is defined as the proportion of individuals reaching their t + n1th birthday who die prior to their t + n2th birthday. The quotient of mortality at t + n1 years thus measures very precisely the risk of death between exact ages t + n1 and t + n2 in the group under investigation. In fact, it is the probability that any particular person who reached age t + n1 died before reaching t + n2, in the absence of migration (i.e., closed population). Concern with quotients and probabilities is particularly shown in the construction of tables, life tables being the most familiar and having the longest history. The idea of probability arises also in the conventional measure of infant mortality. The infant mortality rate is intended to measure mortality between 0 and 1 year of age. Despite its name, it is in fact the annual quotient of mortality at 0 years of age. Regarding the methods of calculating the infant mortality rate, the most common method is to relate infant deaths in the calendar year to live births in the same year. Though somewhat unsatisfactory in principle (it may relates certain deaths to births of a different period), this method quite often gives completely acceptable results; however, if variations in the number of births from one year to the next are considerable, the results can be gravely in error. In such instance, the method of constructing the divisor (the method of the weighted mean, quite common in demographic computation) (Pressat 2008) is used to compute the infant mortality rate in that year; this is done, for example, by choosing corrective coefficients based on the distribution of death during the first year of life, and see if they are of significance. All the indices – rates and quotients – calculated are based on an interval of observation of a single year and, therefore, are annual rates or quotients. Conditions of observation or the requirements of analysis may demand calculation of rates or quotients for periods longer or shorter than a year. The order of magnitude of the indices is thus affected, and immediate comparison with annual rates or quotients is impossible. Conversion of a rate/quotient to an annual rate/quotient comprises calculating a rate/quotient from deaths that would occur in a year of 365 days at the same intensity of mortality as during a shorter (e.g., 90 days) or longer

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(e.g., 460 days) length of time, the mean daily number of events-deaths during a given period. It is by multiplying this mean daily number of events-deaths by 365 that one finds the number of annual deaths. Use of the mean daily number of events is a convenient way of measuring seasonal changes in population and epidemiological processes in the context of the global health, where daily, weekly, monthly, etc. statistics are increasingly crucial to mitigate the impact of emergency health problems and pandemic like Covid-19.

Cohort Analysis and Period Analysis: Intensity and Calendar of Phenomena Cohort analysis (or longitudinal or generation analysis) refers to analysis of events happening to a single cohort; for example, data permitting a cohort analysis of the mortality of the 2000 male birth cohort in a country. The primary objective of longitudinal analysis is to study the intensity and calendar of phenomena. Period analysis (or current or cross-sectional analysis) refers to analysis of a category of events experienced by a group of cohorts during a given year (or in a period of years); for instance, deaths in the year 2000 in a country. These deaths took place among over 100 different birth cohorts, under epidemiological conditions of most countries. Table 1 shows the intensity and calendar of some phenomena affecting a population size and structure, population change, and population health. Among the events necessarily prior to the one observed, the most recent marks the beginning of exposure to the phenomenon studied. Consequently, the time elapsed since its occurrence represents the duration of exposure. Therefore, if one denotes by O the observed event and by A the most recent of the events that are necessarily prior to it, one can ask two questions about the occurrence of O. Firstly, among people who have already experienced A, what is the proportion of those who will end up undergoing O and, if so, how many times on average if O is a renewable event? Secondly, what is the distribution of occurrences of O by time elapsed since the occurrence of A? The intensity of a phenomenon resulting from a nonrenewable event (e.g., death, ranked events such as first birth, first marriage, or first migration) is measured either by the final frequency of this event, or by the complement to one of it. The final frequency is equal to the proportion of the members of the cohort, who, in the absence of disruptive phenomena, would have experienced the event considered during the existence of this cohort. The intensity of a phenomenon resulting from a renewable event (e.g., births, migrations, marriages, episodes of an illness, accidents) is measured by the equivalent of an average number of events per person, during the existence of a cohort, always in the absence of disruptive phenomena. The timing of a phenomenon is defined as the distribution over time, within a cohort, of events corresponding to the phenomenon studied. The results of a cross-sectional analysis are commonly summarized by synthetic indices called period indices as opposed to cohort indices for which the generation

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Table 1 Mode of description of phenomena in population dynamics: intensity, calendar, and synthetic indices Phenomenon Manifestation of the phenomenon (event O) Live birth Fertilitya

Latest event necessarily prior to (event A) Getting at the minimum maternity age (i.e., puberty)

Mortality

Death

Birth

Emigrationb

Departure from the country

Birth

Nuptiality

First marriage

Getting at the minimum age at marriage (e.g., legal age at marriage)

Intensity of the phenomenon

Calendar of the phenomenon

Average number of children born to a woman during her reproductive period Proportion of people who end up dying, i.e., 100% Proportion of people who end up emigrating Proportion of single people who end up getting married

Distribution of live births by maternal age at maternity

Synthetic indices of the phenomenon Total fertility rate

Distribution of deaths by age

Life expectancy at birth

Distribution of departures by age of emigrants Distribution of first marriages by age

Emigration dispersion index Synthetic marriage index for singlesc

a

Female fertility First emigration (migration has largely globalized from a destination country perspective) c The synthetic single marriage index is the proportion of men or women who would marry before their 50th birthday, depending on the marriage conditions in a given year. This measure is the sum of the marriage rates of single people by age. In nuptiality studies, single people are conventionally defined as people who have never been married and who are under 50 years of age; this age restriction at first marriage was introduced for its repercussions on fertility b

indices are a special case; these can be constructed in various ways. The following method has been at the vanguard: one attributes to a hypothetical cohort the quotients or rates observed at various ages or at various durations. This final frequency and, possibly, its complement to one, have variable names from one phenomenon to another. The concept of “hypothetical cohort” is a fundamental concept used in population dynamics approaches (e.g., life tables, see below) to study population processes and generate synthetic indices (e.g., life expectancy). The deaths in a calendar year – for example, deaths in the year 2000 in a country – involve persons belonging to over 100 births cohorts. Suppose a hypothetical cohort of 10,000 newborns who are followed through all the ages of life, assuming the deaths occurring therein at the various ages occur with the intensity that was observed at the various ages in that country in 2000. By transposing data derived

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from observations actually made upon over a 100 real and distinct cohorts onto one hypothetical cohort, the mortality situation of a single year can be restated in terms applicable to a single cohort: this is the general idea underpinning the construction of life tables and derived indices such as life expectancy (the mean length of life of a population).

Population Structure and Standardization The variation in population structure (e.g., by age structure notably) is an obstacle to the comparability of crude rates in different populations. For instance, the frequency of human death in a population varies considerably – other things being equal – with the population composition, say by age. The age structure of a population is determined by the relative size of past successive cohorts at birth and subsequent changes in size because of death and migration. The numbers of births, deaths, and migrants in the present year (or other time interval) are determined by prevailing fertility, mortality, and migration rates and the existing age structure of the population, which in turn is a result of previous demographic rates and structures; thus, the present age structure is a function of current and past demographic rates – that is, of the population’s demographic history (Booth 2003). Past changes in demographic rates lead to changes in age structure over time. Overcoming the influence of age structure by calculating rates by age or by age groups gives a collection of several measures that accurately describe the mortality situation in a population. The task becomes cumbersome for comparison of mortality levels involving several populations or countries. For this reason, two core standardization approaches exist that are useful in studying population processes and health issues in a comparative perspective: use of standard population (direct approach) and use of standard phenomenon schedule (indirect approach). The standardization as a method of comparison of phenomena is, for instance, particularly useful when one wishes to compare the global health issues at the global, regional, national, or local levels in all countries and territories on the planet. The derived synthetic measures summarize the total of global health risks at the various ages for comparative purposes.

Standard Population Approach The use of a standard/reference population is the direct approach used to standardize these rates (Smith 1992; Pressat 2008). To neutralize the effect of the structure of a population structure/composition variable (e.g., age), the standard population approach applies the age-specific rates observed in the populations that are being compared to a single population of a given age structure (standard/reference population). This standard population yields a series of number of events (e.g., deaths) by age corresponding to each set of age-specific rates used, and so provides the computation of a comparative event rate (e.g., death rate). The choice of the standard population is

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an arbitrary matter. The rates obtained have no other use than to make the desired comparisons; they have no significance regarding the population they represent. No exact rule is applicable to make the choice of the standard population; one way is to take one of the two populations (e.g., the one having the highest data quality) as the standard population and apply the rates of the other population to it. One may do the same in comparing the phenomenon under study (e.g., mortality, mortality by cause, mortality by specific characteristics such as gender, race, ethnicity, socioeconomic status, male or female infertility) in more than two populations. In this way, the actual number of events (e.g., infant deaths, maternal deaths, number of infertile men, number of infertility women) in the population chosen as standard population serves directly for the comparison without it being necessary to make such computation, as would be the case if the standard population were not one of the populations under study. It permits the calculation of standardized comparative rates on a base of a standard population. It is, however, necessary to have age-specific rates for each population, which presumes a knowledge of both the population by age and the number of events (e.g., deaths) by the population composition. The indirect method of comparison based on the use of a standard phenomenon (e.g., mortality, nuptiality) schedule is more easily employed, for it requires only knowledge of the population by age as well as the total number of events (e.g., deaths, marriages, respectively) in the countries to be compared.

Standard Phenomenon Schedule A stable population is a population with an age distribution which remains constant over time. A stationary population is a stable population of constant size. Subject to age-specific mortality and fertility rates which remain unchanged over time, a population will eventually develop a stable age distribution which depends on those mortality and fertility rates but is independent of the initial age distribution of the population (Sharpe and Lotka 1911). In nonstationary populations or changing populations, the same fertility and mortality schedules can produce different birth and death rates in populations with different age structures. The natural fertility schedule of a population is the schedule of age-specific marital fertility one would observe under conditions of no birth control practices (Henry 1961). In natural fertility (no birth control) populations, one can observe the natural fertility schedule directly; but in populations where women control their fertility, for example by practicing limitation, curtailment, and postponement of childbearing, the natural fertility schedule is masked by such practices affecting fertility rates in those age intervals in which such control is exercised (Timæus and Moultrie 2020). Let us suppose an investigation consisting of comparing Population A (PA) and population B (PB) in year t. The standard phenomenon (e.g., mortality, fertility, migration, nuptiality) schedule or indirect standardization consists of choosing a standard schedule of age-specific event (e.g., birth, death, marriage) rates and applying this schedule successively to the two populations for which the

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phenomenon under study (e.g., fertility, mortality, nuptiality, respectively) is being compared (Smith 1992; Pressat 2008). Suppose a study aiming to compare the mortality of populations A and B. The repeated application of the chosen standard schedule of mortality (age-specific death rates) yields two figures for total deaths, in PA and PB. These are then compared with two figures for the actual number of deaths, respectively, observed in year t. The two ratios: I(PA) ¼ (actual deaths in PA/ expected deaths in PA) and I(PB) ¼ (actual deaths in PB/expected deaths in PB) yield two indices allowing the ordering of the two populations, the larger index indicating the one having the higher mortality. As in the case of the standard population method, the age-specific mortality rates of one of the population being compared can be taken as the standard mortality schedule. The index has meaning only in relation to the standard schedule of mortality chosen. The utility of this method becomes apparent when it is a question of carrying out comparisons of mortality for a large number of different populations. For example, applying the rates by age and sex for the world to each of the populations of all 204 countries and territories of the Global Burden of Disease (GBD) study, for a year, will yield expected number of deaths which, compared with actual number of observed or real deaths (the relationship consisting always in dividing the observed or real deaths by the calculated or expected number of deaths), yield indices of mortality for each country or territory, by sex, relative to the world. To apply this method, suffice to know for each country or territory only the age structure of the population and the total number of deaths. The indirect method of standardization is particularly appropriate when one wishes to locate the relative level of mortality and health-related issues of quite a small human group, for which calculation of age-specific rates would make no sense because of the small number involved.

Mortality, Life Tables, and Measures of Life Expectancy The study of mortality in population has long served as a model for the study of population and epidemic processes within and between human and nonhuman species inhabiting the planet.

Crude Death Rate The crude death rate in a given population (the number of deaths at all ages during a given period in a territory expressed as deaths per year per 1000 persons in a reference population, which is usually the mean population during the same period or the population at the middle of the time interval) is a relative rate commonly used in mortality analysis. The crude death rate (i) pertains to a specific calendar time interval (e.g., calendar year 2020) and is a flow (per year) of event-deaths (ii) occurring in a clearly defined population (e.g., the Canadian population) and (iii) expressed in relation to a reference aggregate (e.g., the mid-2020 Canadian

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population). When the events (ii) and the reference population (iii) are restricted in scope, the resulting rates are reduced specific rates (e.g., age-specific and age-sexspecific death rates). When the time interval (i) is gradually shortened, the resulting rate, in the limit, is called an instantaneous death rate or force of mortality.

Mortality Structure by Age, Sex, and Cause of Death Mortality begins at quite a high level at 0 year of age and then diminishes rapidly. It reaches its lowest level somewhere in the age group 10 to 14 years. After that, the increase is uninterrupted, and the newborn child’s level of mortality is reached again at approximately 70 years of age (Pressat 2008). Mortality among infants is measured by the infant mortality rate, which is in reality a mortality quotient. Calculated on a given birth cohort, the rate of infant mortality is the ratio (usually multiplied by 1000) of the number of deaths between birth and one year of age in the cohort to the total size of the cohort at birth. Infant mortality in a given year is measured as the number of persons dying during the year at less than one year of age divided by the number of live births during the year. When there are substantial fluctuations in the number of births in the different periods, the use of weights may be needed. To take into account the fact that infants deaths in a given year occur to the newborn of two adjacent generations of different sizes, it is necessary to construct a weighted average of the two numbers of births (e.g., 2/3 or ¾ of the births in the year studied, and 1/3 or ¼ of the births in the preceding year, correspondingly). The method of weighting can be extended to other situations where one wishes to calculate the infant mortality rate for a fraction of the year (e.g., month, trimester, semester). Infant mortality rate has the advantage over the crude death rate of not being influenced by the age composition of the population. It is usually considered as an excellent index of the state of hygiene and the level of development in general (hence the influential role of sociocultural and economic conditions) and of the health system in particular (hence the influential role of medical and healthcare environments), in a country. The concept of excess mortality is applied to any population group in which general mortality, or mortality from some specified cause, is greater than that of one or several other population groups. For example, at all ages under normal circumstances, male mortality is higher than female mortality. This is the phenomenon of male excess mortality, measured by dividing the male rate by the female rate and multiplying the result by 100. This index is easily interpreted: an index of 154 for the age group 10–14 years indicates that the male rate is 54% greater than the female rate, or alternatively that for female and male populations of the same size (and at age 10 to 14 years), for every 100 female deaths there are, on average, 154 male deaths. Male excess mortality varies with age, and between and within countries, depending on the extent of child’s sex preference (e.g., usually of boys in certain societies). Elementary mortality analyses by age and sex extends to cause of death. Using measurement approaches already described, mortality rates by different causes of

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death can be calculated, and by sex and age groups. Taken into account the data quality, comparison within and between populations or analyses of changes over time can be carried out. In all countries where mortality has largely declined as the outcome of the reduction – e.g., through hygiene, vaccinations, antibiotics – of the dangers of infection, the majority of deaths are due to chronic diseases (e.g., cardiovascular diseases, diabetes, and cancer) or to old age because a greater proportion of people attains advanced age at which they are more frequently victims of chronic diseases and injuries. In countries with low mortality, pandemics such as the 1918 influenza pandemic or the ongoing Covid-19 pandemic are examples of form of mortality owing to an infectious disease, which complications are often linked with preexisting conditions such as hypertension, diabetes, immunodeficiency disorders (e.g., X-linked agammaglobulinemia (XLA), common variable immunodeficiency (CVID), severe combined immunodeficiency (SCID), or alymphocytosis).

Life Tables and Measures of Life Expectancy Life Table A life table provides a model for analysis of events contributing to population dynamics (Pressat 2008; Schoen 2006). The computation of life tables is one of the oldest techniques in population studies. Indeed, life table analysis or survival analysis has its roots in population studies since the seventeenth century, with pioneered work by John Graunt in 1662. Following this work has been the population studies of competing risks since at least 1760, indirect and direct standardization since at least 1777, and the simultaneous handling of age, period, and cohort since the 1870s with the Lexis diagram. The life table provides the most complete description of mortality and mortalitylike phenomena in any population in a variety of disciplines studying animals, plants, fishes, humans, and nonhumans. The life table technique also provides a descriptive model amenable to useful extensions to a wide range of health issues and other phenomena in different population species that are of paramount importance to global health. Knowledge of the sequence of deaths in a life table leads to a description of mortality as a demographic phenomenon following natality, in accordance with the population dynamics paradigm (see above). Starting with 1000 people born (event A) who are exposed to the subsequent phenomenon of mortality (event B), two questions arise for the entire life table. Firstly, what is the proportion of people having experienced event A who experience the subsequent event B (the intensity of mortality)? The response is 100% (see Table 1). Secondly, what is the distribution of intervals between event A and event B? This question concerns the length of life, and the distribution sought is the distribution by age (the calendar of mortality) (see Table 1). The procedure for going from death statistics to the life table is valuable because the life table facilitates calculation of prospective survivors in real populations. What in application to an individual of a given age is the probability of surviving to the next age turns out to be the right factor for estimating

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the fraction of a population surviving from that age to the next. The projected population includes the survivors among those initially alive, plus the survivors among the births during the projection period. Let us suppose that we are able to observe a given part of a cohort or of a group of cohorts (a group of individuals born during the same year or the same span of calendar years) from birth until all members have died, that is, over about 100 years. We would have good description of mortality process in this group if we knew the number of survivors at ages sufficiently close together to be comparable. That is, if we have the total number of survivors at successive complete years of age: 0 year (birth), 1 year, 2 years, 3 years,. . . 99 years, 100 years, 101 years, and so on until the oldest age (Jeanne Calment of France is the oldest person ever who lived to the age of 122 complete years). The conventional table format of a life table is composed of the following columns: exact age x (in years) corresponding to a number of completed years; total number of survivors to exact age x (lx); number of deaths between exact ages x and x + 1 (dx); annual probability of dying between ages x and x + 1 per 1000 (qx). In this table, dx ¼ lx
lx + 1 and thus lx + 1 ¼ lx
dx; qx ¼ dx/lx and consequently dx ¼ lxqx. Any life table is completed with knowledge of any one of the following three sequences: [lx], [dx], [qx]. Suppose the number of survivors at 0 year is l0, which is called the radix of the table. By convention, the radix of the table is some power of 10 (e.g., 1000; 10,000; 100,000).

Cohort Versus Period Life Tables There are two types of life tables: period or static life tables show the current probability of death (for people of different ages, in the current year); cohort life tables show the probability of death of people from a given cohort (especially birth year) over the course of their lifetime (Smith 1992; Schoen 2006; Pressat 2008). The only natural way of introducing the notion of a life table is to follow a birth cohort (or a group of cohorts) through time. However, life tables for cohorts are of only limited practical interest. Attention is more usefully given to conditions of mortality obtained during a single year or given period of years than to the effect of mortality throughout the history of a generation. There are many reasons for this. Firstly, the phenomenon studied occurs over a quite long period of time – over a century for most contemporary human populations given the prolonged longevity in humans –, which renders the complete observation difficult if not impossible. Secondly, the trends characterizing different cohorts do not seem to have many implications for their future, because the effect of selection by mortality seems minor in comparison with the presence of myriad other factors – social, economic, psychological, environmental, genetic, and epigenetic. Thus, the study of the mortality of a cohort does not clarify the analysis; by contrast, in the case of nuptiality (e.g., nuptiality life table), for example, it is not possible to separate the behavior of any given cohort at a given date from its history (e.g., future signing of postponed marriage in 2020 due to the Covid-19 pandemic). Thirdly, there is obviously considerable interest in observing the state of mortality in a given year in order to measure the effects of different non-modifiable and modifiable factors and to follow

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the changes from year to year. In summary, in the study of mortality, period analysis always takes priority. The construction of a period life table rests on the derivation of a hypothetical cohort, which is taken through all the ages of life and, at each of the various ages, is subjected to the mortality conditions observed for real cohorts in the year (or group of years) studied. The essential element for the construction of these tables is the series of mortality probabilities [qx] observed in the period studied. These probabilities are then applied according to the process indicated above. If we consider for instance the computation of annual probabilities. If we consider for instance the computation of annual probabilities (i.e., indices giving for a single cohort or groups of cohorts), the probability that persons in that cohort or group of cohorts reaching age x will die before reaching age x + 1 is qx ¼ dx/lx. Similarly, the period mortality probability can be defined for several cohorts. There are challenges in determining the probabilities of mortality at different ages, based upon all the deaths occurring in a given calendar year (or group of years) in the population studied. While it is possible to compute the mortality probabilities with the deaths of two or more calendar years, it is never possible to take into account all the deaths in the period studied. If the period covers 2 years, about half of the deaths are not taken into account; if it covers 4 years, about a quarter of the deaths are neglected; and so forth. A computation of successive mortality tables that uses the deaths “enclosed” quite exactly in a Lexis diagram (see Fig. 1) does not neglect any quantitative data about the mortality of a country, and avoids the problem of the exact determination of the current (period) conditions (Pressat 2008, p. 115).

Life Expectancy: Period Life Expectancy, Cohort Life Expectancy, and Cross-Sectional Average Length of Life Life expectancy measures the average time individuals in any population are expected to live based on the current mortality conditions. Life expectancy is perhaps the most important summary measure of mortality in any human or nonhuman population. For a cohort, it summarizes the unique set of conditions experienced by its members at different ages. It is used to assess and set a number of important policies that impact all aspects of everyday life in any population, for example targeting health policy initiatives, designing, implementing, and evaluating interventions to address health issues at the local, national, regional, and global levels. Life expectancy at birth is the most common measure of life expectancy (Smith 1992; Schoen 2006; Pressat 2008). Life expectancy at birth reflects the overall mortality level of any human and nonhuman population, and thus, is an important indicator of global health. For humans, it summarizes the mortality pattern that prevails across all age groups – including the various life stages of children and adolescents, adults, and the elderly. It is the average number of years that a newborn is expected to live if current mortality conditions represented by mortality rates continue to apply. Life expectancy (also called expectation of life) can be computed using three approaches: a cohort approach (i.e., mortality risks during the actual life

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course of a group of individuals born during the same period of time), a period approach (i.e., mortality risks experienced by different cohorts during a single period of time) (Pressat 2008), and a cross-sectional cohort approach which offers some additional insights about the dynamics of mortality (Guillot 2011). These approaches provide alternative ways for studying life expectancy and time trends in life expectancy, given their relative strengths and weaknesses in light of the extent to which interpreting period and cohort expectations of life in terms of underlying health conditions for the corresponding periods and cohorts holds. Life Expectancy A natural way of summarizing the mortality at different ages in one cohort is to compute the mean age of those in the cohort who die, which is also their mean length of life. This idea is transported without modification when what is concerned are hypothetical cohorts generated during constructions of period life tables. Besides, it is the only way of associating the concrete idea of mean length of life under the conditions of mortality of a given year or period of years. The expectation of life can be applied to any human or nonhuman population (Smith 1992; Namboodiri 1991, 1996; Schoen 2006; Pressat 2008). Life expectancy is calculated by constructing a life table. A life table incorporates data on age-specific death rates for the population in question, which requires enumeration data for the number of people, and the number of deaths at each age for that population. The potential accuracy of estimated life expectancy depends on the completeness of the census and death data available for the population in question. The completeness of that data varies from country to country. There are two core questions framed within a life table. Firstly, what is the mean length of life of the l0 newborn persons in a life table? Secondly, what is the mean length or duration of survival of the lx persons who reach age x in a life table? What is the mean length or duration of life of the l0 newborn persons (the radix of the table) in a life table? If the years lived by the group of l0 newborns were equally distributed among each of them, each newborn child would reach the mean length of life of the group. Such as definition leads directly to the method of calculating the mean length of life. Let us compute, then, the sum of the years lived by the l0 newborns. On the one hand, in living through the first complete year of life, the l1 individuals who reach their first birthday have lived a total of l1 person-years, and in living through the second complete year of life, the l2 individuals who attain their second birthday have lived a total of l2 person-years; and so forth; denoting Ω the last birthday reached by persons in the (real or hypothetical) cohort considered, the total number of persons-years lived is l1 + l2 + . . . + lΩ. On the other hand, it is necessary to take into account the fraction of years lived after the last birthday reached. To make the necessary correction, the conventional assumption is that deaths are distributed uniformly between successive birthdays, so that the total number of persons dying between age x and x + 1 (i.e., dx) have each lived a half of year on the average, or 0.5dx. The total correction through all age intervals is 0.5(d0 + d1+ d2 + . . . + dΩ) ¼ 0.5 l0. The mean duration of life, denoted e0 ¼ 0.5 + (l1 + l2 + . . . + lΩ)/l0, conventionally called expectation of life at birth (or life expectancy at birth).

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What is the mean length or duration of survival of the lx persons who reach age x in a life table? Clearly, this is a generalization from the first question. The mean length or duration of survival at age x is conventionally called the expectation of life at age x (i.e., life expectancy at age x), denoted ex. Following the method used for the first question, a computation of the years of life remaining to the lx survivors of the table gives ex ¼ 0.5 + (lx + 1 + lx + 2 + . . . + lΩ)/lx. Calculating the expectation of life at a given age x requires the summation of all survivors beginning with the last age of the table until x + 1. A certain difficulty arises in beginning this summation in settings where mortality probabilities beyond a certain age (e.g., 99 years of age) are unknown with accuracy; thus, it is not possible to reach the last age Ω and consequently to know the sum l100 + l101 + . . . + lΩ, and the estimation of the mortality of very old persons may present some challenges. It is conventional in such situations to adopt a reasonable value for the expectation of life at that age. Suppose x ¼ 100, then e100 ¼ 0.5 + (l101 + l102 + . . . + lΩ)/l100, which implies that l100 ¼ 0.5 + (l101 + l102 + . . . + lΩ)/e100. While the choice of e100 may be partly arbitrary, the effects may be quite insignificant if the life expectancy at the oldest ages varies little over time. The expectation of life is the index most often used when one wishes to summarize the mortality risk in a country. The mean length of life in a population is not, in general, identical to the mean age of those dying. This mean age depends considerably on the number of deaths at different ages, and the absolute number of deaths at a given age depends, other things being equal, on the relative size of the cohort that is exposed to the risk of mortality. The size of the cohort at the period of observation depends on its size at birth, on past mortality, and sometimes on migration. Another life expectancy calculation is healthy life expectancy (or disability-free life expectancy), which is the average number of years a person is expected to live in good health, or without disability, given current age-specific mortality rates and disease and disability prevalence rates. Calculation of those figures requires reliable health statistics as well as mortality and census data. Cohort Life Expectancy Cohort life table summarizes the mortality experience of individuals of an actual birth cohort (i.e., group of people with the same year of birth) dying at each age over the course of their lifetime (i.e., from birth until the cohort extinction at the death of the last survivor) (Smith 1992; Schoen 2006; Pressat 2008; Guillot 2011). The cohort life table is based on age-specific probabilities of death, which are calculated using observed deaths from the cohort. Cohort life expectancy is the average length of life remaining at a given age, experienced by people born in the same year. Cohort life expectancy measures the mortality experience of a particular cohort by following that cohort from birth to death (i.e., until the death of the last survivor). Since cohort life expectancy is based on the death rates of the same group of individuals over their lifetime (allowing for people leaving and joining the cohort through migration), it presents a true historical record of mortality experienced by a birth cohort. Thus, the question of “what lifespan should I expect?” is correctly answerable by using the cohort life expectancy of a specific cohort.

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A cohort life table uses a combination of observed mortality rates for past years and projections about mortality rates for the cohort in future years. The cohort life table takes into account observed and projected improvements in mortality for the cohort throughout its lifetime. Cohort figures are therefore regarded as a more appropriate measure of how long a person of a given age would be expected to live on average than the alternative measure, known as period life expectancy, which is calculated using mortality rates for a fixed period in time. It is important to understand that these are projections and not forecasts. As we do not know what the future will hold, we make assumptions about how mortality rates will change in the future. Information on how mortality rates have changed in the past is used to estimate the current rate of mortality improvement by age and sex and to make assumptions about improvements in mortality in the future. Expert judgment is often applied to decide how long historical trends will continue into the future. Cohort life expectancies, even for past years, usually require projected mortality rates for their calculation and so, in such cases, involve an element of subjectivity. Many other types of life expectancy that allow making comparisons for different population subgroups, or to look at how long people might expect to live in good health (healthy life expectancy), are calculated on a period basis. Cohort life expectancy varies over time and place as well as across species, its overall order of magnitude reflecting the underlying age-dependent biological vulnerability of humans who live on average longer than other species such as animals. These species-specific time-space influences on cohort life expectancy argue for examining the time location of these factors and their impact on age-specific mortality.

Period Life Expectancy Period life expectancy summarizes the mortality risks experienced by different cohorts (or, at different ages) during one period of time (i.e., a single year or group of years) (Smith 1992; Schoen 2006; Pressat 2008; Guillot 2011). Period life expectancies are a useful measure of mortality rates experienced over a given period. They can provide a baseline against which to benchmark cohort life expectancies. For past years, they provide an objective way of comparing trends in mortality over time, between areas of a country and with other countries. Period life expectancy is the average length of life remaining at a given age, assuming that people experience the age-specific death rates of a specific period from the given age (e.g., at birth) onwards. For example, life expectancy at birth for the period 2010–14 is based on death rates for that period, and takes no account of changes in death rates after 2010–14. Period life expectancy is therefore a hypothetical construct. Period life expectancy is a hypothetical measure that assumes that the age-specific death rates for the year in question will apply throughout the lifetime of individuals born in that year. The estimate, in effect, projects the age-specific mortality (death) rates for a given period over the entire lifetime of the population born (or alive) during that time. The measure differs considerably by sex, age, race, and geographic location. Therefore, life expectancy is commonly given for specific categories, rather than for the population in general. Life expectancy reflects local conditions.

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Period life expectancy is calculated by using hypothetical or synthetic cohorts, which, unlike real cohorts, do not gain 1 year of age every year, but hypothetically spend their entire life during one period of time. Thus, period life expectancy at birth can be thought of as the mean age at death that would be experienced by a synthetic cohort hypothetically exposed to the age-specific mortality rates of the period studied. Equivalently, period life expectancy at birth can be interpreted as the mean age at death that would be experienced by a real cohort if age-specific mortality rates observed during one period were to remain constant in the future. The use of period life expectancy is often based on the assumption that it directly reflects the mortality conditions of a certain year. Accordingly, the explanation for changes in life expectancy is typically sought in factors that have an immediate impact on current mortality conditions. It is frequently overlooked, however, that this indicator can also be affected by other powerful factors, particularly in the situation of shortterm fluctuations (e.g., cohort effects, heterogeneity effects). Period life expectancy is one of the most used summary indicators for the overall health of a population. It can be calculated for recent periods to estimate the effects of a timely set of conditions on mortality risks in the population studied. In populations undergoing steady mortality change, period life expectancy has been found to be fruitfully interpreted as a lagged measure of underlying cohort experience (Goldstein and Wachter 2006). Its levels and trends direct health policies, and researchers try to identify the influential factors of mortality risks to assess and forecast future developments. Period life expectancy uses mortality rates from a single year (or group of years) and assumes that those rates apply throughout the remainder of a person’s life. Period life expectancy is also regarded as a lagged indicator of the experience of real cohorts in populations experiencing steady improvement in mortality. This means that any future changes to mortality rates would not be taken into account. Thus, although period life expectancy is a timely and useful summary of relative mortality levels between populations (from different countries and different time periods), it will typically underestimate expected lifespans (assuming death rates continue to decline). Period life expectancies tend to be lower than cohort life expectancies because they do not include any assumptions about future improvements in mortality rates. This is because the period life expectancy figures use observed historical mortality rates, while the cohort life expectancy figures use a combination of observed and projected mortality data; the earlier the year of birth, the more observed data there are for any given cohort. Cross-Sectional Average Length of Life Cohorts that are not extinct (i.e., still have surviving members) at time t do not have a known life expectancy, since their survival history is truncated. However, they have a known survival probability, from birth until the age they reach at time t. These truncated cohort survival histories contain useful mortality information, which is ignored in both cohort life expectancy calculations (which deal only with non-truncated mortality histories) and period life expectancy calculations (which ignore cohort survivorship altogether) (Guillot 2011). Brouard (1986) first proposed

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the cross-sectional average length of life (CAL) which combines such information for age-specific death rates involved in its calculation, and Guillot (2003) further developed this mortality indicator. The CAL is the cross-sectional sum of proportions of cohort survivors at a given time. CAL is neither a cohort indicator – it involves information from many different cohorts – nor a period indicator – it uses past mortality information and does not involve synthetic cohorts. CAL thus involves a third perspective in mortality analysis termed the “wedge-period” perspective (Schoen 2006). There are two interpretations of CAL that do not involve any particular assumption about the age pattern of mortality and its change over time (Guillot 2011). Firstly, CAL is a mortality measure that summarizes the mortality history of all the cohorts present in a population at a given time. Since cohorts present in a population at time t have been exposed to past mortality levels that are typically higher than at time t, CAL(t) will typically be lower than period life expectancy at time t. Secondly, CAL corresponds to the size of a model population in which a unit number of births each year is exposed to actual, changing mortality. In that sense, CAL shows how mortality change directly influences population size. The ultimate goal of a summary mortality measure is to give an indication of a population’s underlying mortality conditions and how it evolves over time. Cohort life expectancy adequately summarizes the specific set of conditions to which one cohort has been exposed. Period life expectancy, which seeks to summarize the conditions of one period, is affected by a number of biases. The basic component of CAL is the truncated survival history of a cohort present at time t in the population. This survival history of that particular cohort, although truncated, adequately reflects the set of conditions to which the cohort has been exposed up to time t, even in the presence of cohort influences and heterogeneity. Combining this information for all cohorts present in the population at time t, it can be said that CAL adequately summarizes the average conditions to which cohorts have been exposed to. This implies that increases in CAL do not only reflect improvements in cohort mortality rates, but they also reflect improvements in cohort mortality conditions. Perhaps the most obvious sign that mortality conditions are improving in a population is the fact that these improvements generate population growth: more people are surviving. This is precisely what CAL seeks to measure. Similarly, if CAL is higher in population A than in population B, this reflects the fact that cohorts in population A have experienced more favorable mortality conditions, on average, than in population B. Similar statements cannot be made with period life expectancy. While a link can be made between CAL and underlying mortality conditions, one needs to keep in mind that the time and age location of the conditions that CAL seeks to summarize is unusual. Thus, these conditions refer to the past, even though they refer to a more recent past, on average, than the conditions reflected in the most recent cohort life expectancy that can be calculated at time t (Guillot 2011). In sum, cohort life expectancy and CAL are two summary measures that adequately reflect the mortality conditions they seek to capture, without any further corrections or adjustments. Therefore, much can be gained by using these indicators as a basis for studies of mortality levels and trends. Their main drawback, however,

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is that they refer to conditions of the past. For many purposes, especially in the area of health policy, it remains important to capture conditions of the present. Because period life expectancy is an imperfect reflection of current conditions, appropriate corrections need to be implemented. Two main approaches have been generally used (Guillot 2011). The first approach focuses on cohort influences and consists of establishing relationships between past health conditions and their impact on current mortality rates. Once these relationships are established, information on historical changes in health conditions allows us to purge current mortality rates of the lagged effect of past conditions. The second approach focuses on heterogeneity and recognizes that the imprint left on an individual as a result of past exposures should in theory be observable as part of the individual’s current characteristics. This approach thus consists of studying current characteristics associated with mortality at the individual level and how they vary in response to current conditions. If one could find a set of variables that adequately identifies these underlying characteristics, and study how they interact with the current conditions to produce current mortality patterns, period life expectancy could be corrected through the use of synthetic cohorts that take this heterogeneity into account. The multistate life table approach is one example of such an attempt. The advantage of this approach, compared to the first approach, is that it is based only on current information and thus does not require information about past health conditions. However, this approach poses important methodological challenges, because it requires the identification of the correct individual characteristics summarizing an individual’s current level of frailty, and also necessitates data from longitudinal surveys which are complex to carry out. Nonetheless, these two approaches show that corrections of period life expectancy are theoretically grounded and empirically possible, even if incomplete. Future research should seek to develop and systematize ways to improve the measurement of current mortality conditions, net of past influences. While life unfolds on a cohort basis, health policy operates on a period basis. Thus, indicators that correctly reflect current conditions would better guide health policy.

Natality and Fertility Natality, Fertility, and Infertility Natality as a phenomenon connected to birth may be considered from the perspective of the individuals who are born, or from the perspective of mothers who give birth to a child, or from the perspective of couples who have a child. Studying human procreation in more detail hinges on studies of fertility as a component of population change in population dynamics (Caselli et al. 2001, 2002a; Smith 1992; Yaukey et al. 2007; Pressat 2008). Fertility represents the actual childbearing experience of individuals, couples, subpopulations, or populations. Fertility care encompasses the prevention, diagnosis, and treatment of infertility. Equal and equitable access to fertility care remains a challenge in most countries, particularly in low- and middle-income countries and fertility care is rarely prioritized in national universal

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health coverage benefit packages. Besides the summary statistics given the number, sex, and other characteristics of newborn infants, there are statistics permitting the analyses of the fertility of the couples: births by age of mother, by duration of marriage, and by birth order. The births in any given year are to mothers of all ages and of diverse durations of marriage or exposure to the risk of conception; this heterogeneity of the group makes analysis difficult. But comparison of the observations for consecutive years permits following the development of fertility within groups that are homogenous with respect to age, duration of marriage, cohort membership, etc. Fertility is the manifestation of the ability of women or couples to conceive (fecundity). Regrettably, infertility – a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse – is a global health issue affecting between 48 million couples and 186 million individuals of reproductive age worldwide (World Health Organization 2020b). Primary infertility (inability to have any pregnancy) and secondary infertility (inability to have a pregnancy after previously successful conception) of couples or individuals have an impact on their families and communities. Of the many primary and secondary causes of infertility in both women and men, infertility may occur due to male factors, female factors, and a combination of male and female factors or may be unexplained (World Health Organization 2020b). In the female reproductive system, infertility may be caused by a range of disorders of the ovaries (e.g., polycystic ovarian syndrome and other follicular disorders), uterus (uterine disorders could be inflammatory in nature such as such endometriosis, congenital in nature such as septate uterus, or benign in nature such as fibroids), fallopian tubes (tubal disorders such as blocked fallopian tubes are in turn caused by untreated sexually transmitted infections or complications of unsafe abortion, postpartum sepsis or abdominal/pelvic surgery, and the endocrine system, among others), or disorders of the endocrine system (hypothalamus and the pituitary glands) causing imbalances of reproductive hormones (common disorders affecting this system include pituitary cancers and hypopituitarism). In the male reproductive system, infertility is most commonly caused by obstruction of the reproductive tract causing dysfunctionalities in the ejection of semen (the blockage can occur in the tubes that carry semen such as ejaculatory ducts and seminal vesicles, and blockages are commonly due to injuries or infections of the genital tract); absence or low levels of sperm due to hormonal disorders leading to abnormalities in hormones produced by the pituitary gland, hypothalamus, and testicles (hormones such as testosterone regulate sperm production, and example of disorders that result in hormonal imbalance include pituitary or testicular cancers) or due to testicular failure to produce sperm ascribed for instance to varicoceles or medical treatments that impair sperm-producing cells (such as chemotherapy); or abnormal sperm function and quality (conditions or situations that cause abnormal shape (morphology) and movement (motility) of the sperm negatively affect fertility, such as the use of anabolic steroids which can cause abnormal semen parameters such as sperm count and shape). For both women and men, environmental and lifestyle factors such as smoking, excessive alcohol intake, and obesity can affect

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fertility. In addition, exposure to environmental pollutants and toxins can be directly toxic to gametes (eggs and sperm), resulting in their decreased numbers and poor quality, leading to infertility. The significance of fertility studies in global health hinges on the fact that fertility (especially changes in fertility over time) is the most significant factor in determining population structure, which in turn determines the age patterns of disease and needs for care across the life course. Through the initial effect on any population structure, an increase in fertility, even temporary, changes population size and structure for many years later; more permanent changes in fertility as well as changes in mortality and migration have similar effects on population structure (Booth 2003; Pressat 2008).

Crude Birth Rates The crude birth rates permit a brief view of natality within and between all countries of the world. The crude birth rate refers to the relationship between live births in a given calendar year and the mean population of that year. It is usually computed as the total number of live births in a given year per 1000 total population at the middle of the year. It is a measure of the gross rate of increase of any population by births. Many other factors differentiate crude birth rates, including conditions affecting procreative ability, especially in settings where fertility is largely marital fertility, precocity and intensity of primo-nuptiality (marriages of never married people), biological and health-related factors, and extent of contraceptive practices. In nearly all countries around the world, an important distinction between crude birth rates and crude death rates is that populations may vary greatly in their proportions over age 50 or 65 where mortality is concentrated and driven by chronic diseases, but most tend to be similar in the proportions at ages 15–44 where fertility concentrates (Smith 1992). In fact, only a small portion of the female population is in a position (or choose) to give birth to children. All other things being equal, the level of the birth rate will depend, then, on the relative size of women in the groups at fertile ages. Moreover, the diversity of the population composition is shown by the differences in the relative size of adult age groups in general and women of reproductive age groups – which influence natality – being smaller in the more advanced age groups – which influence mortality. Therefore, the heterogeneity of population composition is a factor not as important in the variability in the crude birth rate as it is in the crude death rate (Pressat 2008). The similarity of proportions at the fertile ages in the proportions tend to hold across nearly all countries, allowing to characterize relationships between fertility measures and make comparisons across populations in a way that is not possible for mortality measures. Another aspect of fertility that is common to populations across countries of the world is the sex ratio at birth (male births to parents across all of the fertile ages/ female births to parents across all of the fertile ages). The sex ratio is higher at conception, but is brought down by excess male mortality at early ages; it also declines slightly with birth order (Smith 1992; Pressat 2008).

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Specific Fertility Rates In the attempt to analyze the natality at the global, regional, national or subnational levels, specific rates of birth are regularly computed, relating to all or part of the female population of childbearing age; they are the fertility rates. In doing so, the extent to which the natality at the global, regional, national, or subnational levels is attributable to the fertility of women is measured more specifically, while the effects of age composition are eliminated more or less totally, depending on the rates computed. Fertility rates are generally computed as period indices. However, nothing prevents computation of age-specific or age group-specific fertility rates for a cohort of women, by taking account of married years of life lived by the group in the different age categories and of the births related to it. The general fertility rate is computed for the total number of women of childbearing age (usually 15–49 years of age), by relating the births of a given year to the mean total number of women of childbearing age. It indicates in part the extent to which the natality of a country is attributable to the age composition of its population. However, the appropriateness of this rate is limited: in most circumstances, its computation is not called for, because it makes only an insignificant correction in the birth rate, the relative size of adult (and therefore fertile) categories varying but little from one population to another (Smith 1992; Yaukey et al. 2007; Pressat 2008). The use of the general fertility rate, then, offers no real interest except when one is concerned with populations having quite dissimilar age compositions. It is particularly useful in the case of studies and comparisons of small human groups (e.g., small geographic units) of quite variable composition, where, in addition, the computation of more refined indices (e.g., age-specific fertility rate) is impossible, given the small totals. Age-specific (or age group-specific) fertility rates and the marital fertility rates were for a long time the only analytical tools used in population studies and continue to be used for the study of fertility. Female fertility and age are connected in several ways (Caselli et al. 2002a; Pressat 2008). Firstly, they are connected by the onset of fecundity at adolescence and its disappearance at varying ages, often near the age of menopause. Secondly, in many societies, there are social rules fixing sexual customs that are closely associated with age; in the majority of cultures, fertility is predominantly marital fertility, and the customs connected with nuptiality (more or less frequent, and more or less precocious marriages) have a direct impact upon fertility. Thirdly, in societies in which birth control is practiced, more or less effective voluntary infertility appears after the couple has had the number of children desired or for birth spacing reasons. Fourthly, socioeconomic factors (e.g., education, employment, income) and social mobility affect the connection between female fertility and age, contributing to delayed fertility or absence of it. Therefore, it is natural to seek to measure the total incidence of these factors by computing age-specific fertility rates. Fertility rates by age are affected by all these factors. In particular, they depend on marriage, the preponderant factor in human fertility, and on the relative incidence of fertility outside of marriage. It is useful to specify

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separately the two forms of fertility: marital fertility and non-marital fertility, and compute their corresponding age-specific rates. Age-specific fertility rates (ASFRs) give the proportion of women at various ages who give birth during one year, usually using 1- or 5-year age intervals from 15 to 44 or 15 to 49. At most ages, 5-year intervals substitute well for single year ages. For the women during their fertile ages x, ASFRx ¼ B(x, x + n)/N(x, x + n), where B(x, x + n) represents annual births to women aged between x and x + n and N(x, x + n) is the mid-year female population at the same ages. When investigating teenage or adolescent fertility (fertility at ages 10–19 or 15– 19), the teenage age group of interest is commonly separated into subintervals 10– 14, 15–17, 18–19, or into single years.

Synthetic Indices of Fertility Combining the rates of each of the series above (age-specific (or age group-specific) fertility rates, age-specific (or age group-specific) marital fertility rates, etc.) provides synthetic indices of fertility (Smith 1992; Pressat 2008). All these indices are usually computed as period or cross-sectional indices, primarily because of the nature of the data generally available. The total fertility rate and the gross reproductive rate are derived from the sum of the age-specific (or age group-specific) fertility rates. The values of these indices are generally highly correlated with those of the crude birth rate. The better way to present the total fertility and gross reproduction rates is to consider the rates included in the computation as applying to a hypothetical cohort. Let us consider a country’s ASFRs of the year Y. Let us take, hypothetically, 1000 girls aged 15 years through all the ages of the fertile lifespan – from 15 to 50 years of age – without mortality, attributing to them, at each age, the number of births given by the age-specific fertility rates (there are 35 ASFRs) in year Y. The total number of births that would result is obtained simply by adding the 35 rates; this gives the average number of children per woman and denotes the total fertility rate. Keeping only the daughters and expressing the number of daughters per woman, yields the gross reproductive rate. The total fertility rate (TFR) is computed by summing across the ASFRs and adjusting for the number of years of age each ASFR span: TFR ¼ xP þn Bðx, x þ nÞ=Nðx, x þ nÞ . For instance, when each ASFR is for a 5-year age x

interval, the TFR is found by summing the ASFRs and multiplying by 5; if 35 single year intervals (n ¼ 1 year) was used – assuming the fertile ages spanning from 15 to 49 years – instead of six 5-year intervals (n ¼ 5 years), the TFR would be the sum of the 35 single year rates. With abortion, later marriages, smaller proportions of women marrying, and higher divorce rates, and changes in family configurations and types, pregnancy, and marriage have gradually become less closely related and nonmarital fertility continues to expand. The use of marital fertility by age is appealing to the extent that the greatest part of fertility still occur in marital settings within many countries where fertility levels remain high such as in sub-Saharan

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Africa. The fertility level in sub-Saharan Africa is the world’s highest, as fertility decline is highly unlikely where women enter first unions at very early ages like in most populations of sub-Saharan Africa (Hertrich 2017). In such populations, the behavior of the married couple is generally not determined by the age of the woman; thus, it is more appropriate to use marital fertility rates by age (or by age groups) according to the age (or age group) of the woman at marriage. This is because it is only in populations not practicing birth control that marital fertility rates by age (or age group), calculated without reference to age at marriage, is of interest. The marital TFR can be computed to introduce a link between total fertility and fertility within marriage. Since marital status change over time, one can also estimate total fertility rates for ever married and never married women. An appropriate combination of the marital fertility rates by age (or age groups) beginning say, 20 years of age in populations practicing birth control, gives the mean number of children per marriage of the woman married at that age. In a population not practicing birth control, the computation of the mean number of children per marriage requires the use of rates by age and age at marriage. The TFR is a measure of completed family sizes of women or of men surviving to the end of the reproductive age interval. To determine whether the population will increase, remain constant, or decrease gradually over time, the TFRs needs to be adjusted to births of one sex and adjusted for survival. When the TFRs are computed with adjustments for daughters (N(x, x + n)F), female births (B(x, x + n)f) replace total births (B(x, x + n)) and fertility rates for daughters (ASFRFs) replace rates for all children (TFR). Summing the fertility rates for daughters (ASFRFs) and multiplying by 5 (if the 5-year age intervals are used) yields the gross reproductive rate (GRR), or lifetime female births per 1000 women. Alternatively, multiplying the TFR by the overall proportions of births that are female gives a good approximation of the GRR. The GRR is usually computed by the latter method, using the TFR and the proportion of the total births that are female, since the TFR is normally available and the proportion of births that are female is nearly constant across ages. A limitation of the GRR is that it estimates the number of daughters born per woman in the absence of mortality. To measure population replacement, mortality needs to be taken into account; this is done by multiplying the ASFRs for daughters by the survival probabilities from birth to the mother’s age at delivery. The appropriate life table terms are the L(x, x + n) values (i.e., the number of women at ages x to x + n per l0 births) and l(0, n) (i.e., the number of births in n years), from which the L(x, x + n) survivors arise. The survival probability from birth to the interval x to x + n becomes L(x, x + n)F/l(0, n). These values from a life table complete the computation for the net reproduction rate (NRR) or generational replacement rate: NRR ¼ R0 ¼

xP þn Bðx, xþnÞ f Lðx, xþnÞF N ðx, xþnÞF lð0, nÞ x

ffi GRR 

Lðx, xþnÞF lð0, nÞ:

Since the survival probabilities vary in relatively small amount over the main fertile ages, the NRR can be approximated using the GRR and an estimate of the survival probability to about a midpoint of the fertility distribution in the population

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studied. For a population to exactly replace itself, the NRR must be 1.0, meaning that each woman (man) averages one surviving daughter (son). For instance in the United States in 1980, the NRRs was 0.876 for females and 0.964 for males, which are lower than unity (Smith 1992); this suggests that in the absence of migration, this population should be declining from one generation to the next. The distribution of ASFRs can be used to estimate an approximate mean fertile age. One can also include the number of males and females at each age as weights, to find the mean age of parents for births in the calendar year. Of more interest in population dynamics are the ages of the life table population of parents (i.e., the age distribution associated with the NRR) than the actual ages of parents which change every year. To compute the mean age in the life table population, suffice to replace the terms N(x, x + n) in the computation of the mean fertile age by the life table population L(x, x + n). The child-woman ratio (CWR) is another fertility indicator of interest in population dynamics. The CWR is defined as CWR ¼ N(0, 5)/N(15, 45)F, where N(0, 5) represents the midyear population of children of both sexes aged 0 to 4 completed, and N(15, 45)F is the midyear female population aged 15–44 completed. The value of the CWR as a fertility measure is that it can be estimated from a census and there is no need to know the number of annual births (Smith 1992). Children 0–4 are used instead of children aged 0 because data quality problems are worse at age 0 than at 0– 4. If a life table for the population studied is available, one can also use the CWR to estimate the NRR directly, by the approximation NRR(Thompson) ffi CWR/CWR(life table). The approximation is known as the Thompson’s Index (Smith 1992). It holds because the life table can be used to generate a stationary population. The ratio of the actual to the life table CWR is thus a measure of the difference in family sizes between the actual population and one with similar mortality rates that exactly replaces it. The life table CWR (CWR/CWR(life table)) is computed as: CWR/CWR(life table) ¼ [(B(0, Ω)m/B(0, Ω)f)* L(0, 5)M + L(0, 5)F]/L(15, 45)F, where L(15, 45)F is the life table female population at ages 15–44 completed (in 5-year interval life tables, the sum of the terms L(15, 20)F + L(20, 25)F + . . . + L (40, 45)F), the term (B(0, Ω)m/B(0, Ω)f) is the sex ratio at birth for the actual population.

Fertility Levels and Parity Progression An important component of fertility differences between populations is the range over which usual family sizes vary: this can be measured through the number of children already born. A simple measure of the variation in family sizes is the parity progression ratio, which refers to the number of children born by a woman. Knowledge of parity progression ratios permits a quite expressive and natural description of the fertility of a group of women: a birth of a given order, say, the second birth order, is the event subsequent to a birth of the preceding order, which here is the first. The complete description of the movement from one event to a succeeding event requires answers to two questions. First, among women who have had their first live birth,

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what is the proportion who have a second live birth? The response to this question is given by the parity progression ratios. How are the birth intervals between the birth of the first and the second child distributed? Birth spacing analyses answer this question.

Rate of Population Change Since the net reproduction rate (NRR) represents generational replacement, it can be converted to an estimate of long-term annual population change (increase or decline) in the absence of migration if the generation length is known (Smith 1992; Pressat 2008). This is done using the exponential relationship NRR ¼ exp.(rT), which gives r ¼ ln (NRR)/T, where r is the annual rate of population change (increase or decrease) and T is the generation length (Smith 1992). The generation length is near the mean fertile age computed from ASFRs; in most human populations, the generation length T is usually set at about 27.5 years. The rate r is the eventual rate of population growth in the absence of migration, assuming that fertility and mortality remain essentially constant. In other words, r is intrinsic to the fertility and mortality distributions of each population. The actual growth rate for a given population, the crude growth rate (CGR), will be the difference between the crude birth rate (CBR) and the crude death rate (CDR) plus the crude migration rate (annual immigrants – annual emigrants) (CMR), divided by the midyear population: CGR ¼ CBR + CMR – CDR. For populations with relatively constant mortality and fertility rates over several years, the intrinsic rate of increase estimated from the NRR will be similar to the rate estimated from the difference between CBR and CDR. For most low- and middle-income countries, the two estimates are quite similar, but will diverge over time as the size of parenting population stabilizes (Smith 1992; Caselli et al. 2001).

Population Doubling and Halving Time Estimates In the absence of migration, the intrinsic growth rate r can be used to estimate the number of years it would take a population to double or, if the NRR is below 1, to decline to half its initial size. The doubling time is simply the number of years y that it would take for the population to increase from N persons to 2 N persons. The value of y is found by setting exp.(ry) ¼2, which gives y ¼ ln(2)/r ffi 0.693/r. Since growth rates are usually expressed as percentages, this formula implies that for a population growing at 1 per cent per year, the doubling time is 69.3 years or about 70 years. If the intrinsic growth rate r is negative, halving times substitute for doubling times and yields y ¼ ln(0.5)/r ffi -0.693/r. The growth rate of the population of Japan in 2020 is negative, with r ¼
0.3%; this implies that in the absence of migration, the Japanese population would decline by half in about
70/
0.3 ¼ 233 years.

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B. Kuate Defo

Doubling and halving times estimates are long-term values for the fertility and mortality rates that determine the intrinsic rate of growth of a population. They would not hold if r changed or if migration (immigration or emigration) occurred, and might not be realized for a generation or more, even with fixed r and no migration, because they do not take into account the age structure of the population.

Migration: Intensities, Expectancies, Spread, and Distance The Concept of Migration Migration is inherent to human population history, being one of the three components of population change (fertility, mortality, and migration). Migration is a special type of geographic mobility referring to the change in the location of where people live, involving the change from the usual place of residence and change in the physical and/or social environment over a defined time interval, irrespective of the distance over which the change can take place or the time interval (Skeldon 1997; Rees et al. 2000; Bastia and Skeldon 2020; Czaika and de Haas 2015). To facilitate data collection and analysis of human migration, international migration is defined as a residential change across political boundaries. An internal migration is a residential change which has both its origin and destination within the same country. Migration, both international and internal, plays a major role in population dynamics, especially in the distribution and redistribution as well as on fertility (through marriage or reproductive behavior of migrants) of any population on the planet. Births and deaths affect only one population, whereas migration affects two simultaneously, the origin population – reducing it – and the destination population – increasing it. Migratory changes and the number of children a woman bears may range from none to many. Births and migrations are renewable events and can be ordered (first, second, third,. . ., nth birth/migration), whereas deaths are nonrenewable events. Thus, having children and moving residence both have sequential nature. The size of the spatial units used to define the boundaries over which a person must move and the time that a person needs to remain at a destination in order to be defined as a migrant must be spelled out. With the increasing integration of societies in international migration systems, more and more countries are experiencing significant volumes of immigration and emigration, and global migration patterns have become more complex (Czaika and de Haas 2015). In this global context, growing social, economic, and cultural interconnectedness is facilitating migration in ever-greater numbers between an increasingly diverse and geographically distant array of destination and origin countries. The diversification of migration in terms of composition of immigrant populations (i.e., people living outside their country of origin) in terms of countries of origin as well as in terms of migration categories would increasingly coexist. As migration patterns become more complex, fluid, and transnational (Paul and Yeoh 2020), there is an urgent need to use comparable indicators (Rees et al. 2000; Czaika

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and de Haas 2015; Paul and Yeoh 2020) for studying these migration processes in the global health context.

Migration Measures from Two Conceptual Frameworks Migration is normally measured using one of two conceptual frameworks: as a transition or as a movement (Rees et al. 2000; Caselli et al. 2003; Bastia and Skeldon 2020). The transition concept involves comparison of a person’s location at one point in time with a person’s location at another point in time (transition between time points). Migrants are people making a transition and the count of transitions is the same as the count of migrants. The movement concept in a given time interval – within a time interval, migrants can make more than one migration – defines migrations as counts of events. Counts of transitions/migrants or of movements/ migrations are related to suitable populations at risk. The population at risk depends on the migration concept used (Rees et al. 2000). The ratios of migrants to populations at risk are referred to as transition probabilities. The population at risk used in computing transition probabilities is the starting populations of origin corresponding to the migrant count numerator. Care must be taken to ensure that all migrants in the numerator are included in the denominator. Equally important is that the denominator be confined to people who could validly appear in the numerator. The ratios of migrations to populations at risk are referred to as movement rates (occurrence-exposure rates). The population at risk used in computing movement rates will be the population exposed over the time interval to the risk of migration. Because this usually cannot be measured directly, a number of alternative estimates are employed. Of these, the linear average of start and end populations or the mid-interval population is the most common. The intensity of migration measures the frequency with which a population engages in migration, and encompasses both transition probabilities and movement rates. When the time intervals of measurement are infinitesimally small, probabilities and rates converge on the same intrinsic values. Migration data can be derived from censuses to yield transition data that can be used to construct migration intensity measures. Where movement data exist, the standard set of intensity measures based on the occurrence-exposure paradigm can be used. A migration flow can be a count of transitions from origins to destinations or a count of movements between before-move and after-move locations; thus, migration intensities can be defined as the ratios of migration flows to populations at risk.

Crude Migration Intensities Crude migration intensities (CMIs) provide basic measures of total migration. Like other crude rates, a crude migration intensity is a measure summed over all ages and sexes, ignoring the influence of age and sex structure. Crude migration intensities

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can be computed in two ways, depending on which type of migration data are input (Rees et al. 2000; Bastia and Skeldon 2020). If transition data are used, the crude migration probability (CMP) is computed as CMP ¼ k(T/PAR), where k is a scaling constant usually set to 1000; T is the count of transitions/migrants; and PAR ¼ P(t), that is the estimated population at the start of the time interval over which migration is measured. If movement data are used, the crude migration rate (CMR) is computed as CMR ¼ k (M/PAR), where PAR ¼ ½ (P(t) + P(t + n)); M is the count of movements/migrations occurring in the time period (t, t + n); P(t) is the population at the start of the time interval over which migration is measured; and P(t + n) is the population at the end of the time interval of n years. To calculate the crude migration rate, the estimated population at the start of the time interval over which migration is measured includes both persons who die and persons who emigrate in the interval that follows. Such probabilities confound the risks of mortality, emigration, and internal migration: a high-mortality and high-emigration country will have a depressed migration probability compared with a low-mortality and low-emigration country, even if the pure chances of making an internal migration are the same. Rees et al. (2000) proposed a refined definition of the CMI which eliminates these problems: CMP’ ¼ k (T’/PAR’), where T’ is the count of transitions/migrants existing in the country at t who survived and were enumerated in the country at t + n, and PAR’ is the total population in the country at t who survived and were enumerated in the country at t + n. The appeal of this corrected migration measures is that they can be derived directly from the Census. The number of intercensal migrants recorded at the Census, at time t + n, has already been reduced by mortality, emigrants are excluded from the national Census, and immigrants can be separately identified by their place of residence at t. Thus, P(t) ¼ P(t + n) – I, where I is the count of immigrants in the interval surviving at the end of the period. Calculating migration intensities in this way, conditional on survival and remaining in the country, has the advantage of maintaining consistency between the numerator and denominator, especially if movers and stayers are from the same data set. The calculation of crude migration intensities done at the national can be extended to subnational levels. When crude migration probabilities, conditional on survival and staying in the country are computed for a region j within a country, the estimated population at the start of the time interval over which migration is measured for region j is Pj(t) ¼ Pj(t + n) – Ij, which yields the destination count of survivors in region j. To calculate the migration probabilities for flows or for total out-migrants, one needs to know the populations of origin of survivors staying in the country, obtainable from origin-destination matrices of migrants.

Age Standardized Migration Intensities Like crude rates of the other two components of population change (natality/fertility and mortality), the problem with crude migration intensities is that they are sensitive to the age-sex structure of the population (Rees et al. 2000; Bastia and Skeldon 2020). The normal solution is to adopt a standard population and use this with

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country or region-specific age-sex migration intensities to compute an expected number of migrations or transitions that would occur if these intensities were applied to the standard age-sex schedule (see standardization above). The standardized migration intensity when transition probabilities are used is the age-sex standardized migration probability (SMP); here, the probability of migration is conditional on survival and staying within the country for age group a and sex s, and Sas is the standard population at risk (the total population surviving and staying in the country). The equivalent standardized migration intensity when movement rates are used is age-sex standardized migration rate (SMR); here, mas is the occurrence-exposure rate of migration at age a for persons of sex s, and the standard population plays the role of a weighting function.

Age Profile Measures It is well known that migration intensities vary substantially with age. The shape of the curves of migration probability by age profiles is well documented: the schedule has a peak in the earlier 20s, associated with entry into higher education or the labor force; the migration probability falls to a minimum in late middle age and then rises after retirement; the childhood probabilities mirror those of adults some 25–35 years older; and the infant probability is lower, because of the smaller exposure time (Rees et al. 2000; Bastia and Skeldon 2020).

Gross Migraproduction Intensities The most obvious summary measure of migration is the area under the age-specific migration schedule (Rees et al. 2000; Bastia and Skeldon 2020). Because migration data for all types of residence change are more easily available from censuses than from registers, a transition probability formulation of the gross migraproduction intensities (GMR) is generally used, with clear indication of the source of the data used in P its computation. The general formula for computing the GMR is simply P GMR¼ mx or px, where mx is the migration (movement) rate for age x and px is x

x

the migrant transition probability for age x.

Migration Expectancies Migration expectancy is the number of moves that a person can expect to make in his or her lifetime, making allowance for the effect of mortality. Migration expectancy can be used to compare the intensities of migration across time within and between countries around the globe. The measure is analogous to the net reproduction rate in fertility studies, the expected number of daughters that a woman will have over her reproductive lifetime, allowing for mortality. Migration expectancies are computed

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by using an appropriate life table together with single year interval age-sex specific migration rates for the populations of interest. To do so, there are a number of methodological issues to be resolved, particularly when comparing expectancy measures between countries (Rees et al. 2000; Bastia and Skeldon 2020). Firstly, whether migration expectancies should be calculated using movement data or transition data must be elucidated. Ideally, one would need a data source that counts all migrations and classifies persons by sex and age at time of migration. In practice, migration measured in national population censuses using a fixed interval question is used, which yields the number of persons reporting a different address 1 year ago. Dividing this count of migrants by the appropriate population at risk gives the probability that a person makes a transition over the next year. In this context, the measures of migration expectancy computed above are expectancies of the number of years with one or more migrations rather than expectancies of the number of migrations per se (Long 1970). Thus, to make an estimate of the number of migration events and calculate a migration occurrenceexposure rate using transition data from a census, one would need to know the average number of migrations in a year made by persons making a transition (Rees et al. 2000). Secondly, choice must be made about the populations at risk to be used in calculating the migration intensities for the migration expectancy calculation as well as how immigrants and emigrants should be treated, as discussed above. Thirdly, the age-time observation plan of the data used in the migration intensity calculations and the age-time observation plan of the life table should be matched for the migration expectancy calculations to be performed. Migration expectancies are computationally the most complex of the migration measures, but they have a number of advantages (Rees et al. 2000; Bastia and Skeldon 2020). Migration expectancy is easily understood and relatable to an individual’s experience. Like other summary/synthetic measures (e.g., total fertility rate and life expectancy) of other components of the population change (fertility and mortality, respectively), migration expectancy is independent of the age-sex distribution of the population. Hence, the measure can be converted into an age-standardized annual rate by dividing migration expectancy by the life expectancy, and into average residence duration by dividing life expectancy by migration expectancy. Synthetic measures for fertility (e.g., total fertility rate) and mortality (life expectancy) can be computed using single-year or multi-year intervals; migration expectancy has the limitation of being computed using only single-year interval data, and multi-year interval computation of migration expectancy (e.g., using fiveyear transition data) are compromised by a failure to take into account multiple moves within the observation interval.

Migration Impact on Population Growth in Cities With more than half of the world population living in cities, city health is crucial goal for global health students, scholars, policymakers, planners, and various global, national, and city stakeholders (Bastia and Skeldon 2020). This is because

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population growth is taken increasingly place more in urban than rural settings, and societies are growing ever more concentrated in urban systems. Important aspects of cities like urban spread, infrastructure development, or transport planning depend on the population evolution over time, which in turn affects population health. Verbavatz and Barthelemy (2020) have developed a stochastic equation for modeling population growth in cities, in order to address the most fundamental problem of understanding the hierarchical organization of city population and the statistical occurrence of megacities. Their model considers that the growth dynamics of a system (such as a country) of cities i of size Si can be decomposed into the sum of an interurban migration term between metropolitan areas and an “out-of-system” term that combines other sources of growth. These sources include the natural growth of the population through births and deaths, as well as the international migrations and exchanges with smaller towns that occur outside the system of cities. Using empirical analysis of recent datasets from Canada, France, the United Kingdom, and the United States, this model reveals how rare, but large, interurban migratory shocks dominate city growth. At a practical level, this result highlights the critical effect only of interurban migration flows, but also more importantly, their large fluctuations which are ultimately connected to the capacity of a city to attract a large number of new citizens.

Migration Globalization at the Global, Regional, and National Levels: Intensity, Spread, and Distance Measuring the volume, diversity, geographical scope, and overall complexity of migration under the influence of broader globalization processes contributes to situate the impact of migration on population health issues around the globe by synthesizing standardized indicators for analyzing the evolution of global migration patterns and changes in the direction, intensity, geographical spread, and distance of international migration. These indicators allow to assess the extent to which international migration has become more intense, spread, and geographically distant on a global, regional, and national level, as well as the extent of particular increase in migration from low- and middle-income countries to high-income countries (Czaika and de Haas 2015; Bastia and Skeldon 2020). Migration globalization is the aggregated measure of the intensity, diversity, and distance of migration into one composite measure (Czaika and de Haas 2015). It is conceptualized as functionally related processes of emigration dispersion and immigration diversification. If the globalization of migration hypothesis holds, growing emigration dispersion and immigration diversification are expected, with more countries simultaneously experiencing accelerating immigration and emigration from and to an increasingly diverse and geographically distant array of origin and destination countries. If immigration diversification increases, emigration dispersion is expected to increase and vice versa. Globalization defined as the widening, deepening, and speeding up of worldwide interconnectedness (Held et al. 1999, p. 2) is theoretically rooted in Zelinsky’s (1971) and Skeldon’s (1997)

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Table 2 Theoretical dimensions of migration globalization Dimensions Intensity Spread Distance

Perspective of the country of origin Emigration dispersion Emigration intensity Emigration spread Emigration distance

Perspective of the country of destination Immigration diversification Immigration intensity Immigration spread Immigration distance

Source: adapted from Czaika and de Haas 2015, p. 292

conceptualization of migration as a spatiotemporal diffusion process. This conceptualization of migration reflects the idea that more people will start moving in increasing numbers and over increasingly long distances because of population growth and concomitant economic and urban transitions as development unfolds. These theoretical dimensions of migration globalization are presented in Table 2. The migration diversification hypothesis is that all three dimensions of migration diversification (migration intensity, migration spread, and migration distance) have increased under conditions of globalization (Czaika and de Haas 2015). Immigration diversification refers to growing immigrant populations diversifying by coming from an increasingly geographically distant and diverse array of origin countries. From an origin country perspective, emigration dispersion refers to growing numbers of emigrants dispersing to an increasingly diverse array and geographically distant array of destination countries. These indicators are designed to simultaneously capture changes in the geographical spread, distance, and intensity of migration and distinguish between immigration and emigration patterns without relapsing in crude distinctions between emigration and immigration countries, elaborating country-level indices for emigration dispersion and immigration diversification. A growing intensity or acceleration of migration means that migrants constitute an increasing percentage of a population, reflecting an acceleration of migration rates. There is a distinction between global migration intensity and country-level emigration and immigration intensity (see above), because a stationary global migration rate may conceal important changes in country-level migration levels (Czaika and de Haas 2015; Bastia and Skeldon 2020). Global spread of migration differentiates between the spread of the global immigrant and emigrant populations in terms of origin and destination countries, respectively (Czaika and de Haas 2015). The previous measures assess the spread of the world migrant population across destination and origin countries on a global level. The values of the Hirschman–Herfindahl index on migrants’ concentration in bilateral corridors range between 0 (no concentration) and 1 (full concentration). As the interest is in an indicator of spread (and not of concentration), one subtracts the concentration score from 1; thus, the spread (diffusion of migration) is defined as unity minus the Herfindahl-Hirschman index of concentration. Thus, the global spread of migrants across all possible bilateral (country-to-country) migration corridors can be calculated as one minus the sum of squares of the shares of the global migrant populations for each corridor in the world. The global spread of migration is a measure ranging from 0 to 1; higher values indicate that the global migrant

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population is scattered “relatively” equal across all migration corridors (Czaika and de Haas 2015; Bastia and Skeldon 2020). At a country level, the emigration spread (ESi) and immigration spread (ISi), calculated using the Herfindahl-Hirschman index of concentration, indicate for each country i the extent to which bilateral emigrant (EMij) and immigrant populations (IMij) have become more diverse or concentrated across destination and origin countries, respectively. On average (weighted at the country level), immigrant populations have become less concentrated, which seems in accordance with the globalization of migration hypothesis; also, national emigrant populations have become more spread across destination countries, although this increase has been lower than the growing immigration diversification (Czaika and de Haas 2015; Bastia and Skeldon 2020). The global emigrant spread and average emigration spreads at country levels measure something different. While the former measures the extent to which migrants are spread across destination countries irrespective of their origins, the latter is the (weighted) average of country-level emigration spread values. This means that while from an individual origin country perspective, emigrants have gone to an increasingly diverse array of destinations, on a global level, these destination countries increasingly overlap; that is, they represent a decreasing pool of major immigration countries on which global migration has increasingly focused. The geographical distance is measured as an “average migrant” (estimated by the distance between origin country and current country of residence) (Czaika and de Haas 2015). By calculating the reciprocity within bilateral migration corridors, one can assess whether over time within-corridor imbalances have increased or not. This is done through calculating bilateral net stocks, that is the number of people born in country j living in country i subtracted by the number of people born in country i living in country j, which indicates net movements per bilateral corridor. Czaika and de Haas (2015) explored the hypothesis on the globalization of migration at the country level, combining measures of a country’s level of dispersion of its emigrant population and the level of diversification of its immigration population. They propose a methodology for a migration globalization index (MGI), which is an index that combines two composite subindices, the emigration dispersion index (EDI) and the immigration diversification index (IDI). These two subindices are geometric means with equal weights of respective measures on intensity (emigration intensity (EI) and immigration intensity (II)), spread (emigration spread (ES), and immigration spread (IS)), and distance (emigration distance (ED) and immigration distance (ID)). Geometric aggregation ensures limited compensation (substitutability) between its components. This ensures, for instance, that for a country with no immigration at all, that is, an immigration intensity of zero, the respective immigration diversification index is equally zero (and not positive). Furthermore, weighting of components (subindices) is a crucial decision in the compilation of any index. For the EDI and IDI, we use equal weights for all three dimensions, which are supported by the fact that rank robustness of each index is rather high. This implies that any alternative weighting scheme does not lead to a strong change or even reversal of the overall rankings (Czaika and de Haas 2015).

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Both subindices are scaled from zero to one, making straightforward comparisons between the EDI and IDI scores possible. Finally, the migration globalization index (MGI) is then calculated by the geometric mean of the EDI and IDI scores which indicates a country’s level of “integration” into global migration processes.

Conclusion Population dynamics is about the size (the number of people) and structure (its composition by age, sex, migration status, marital status, ethnicity, disease or health condition, and so on) of any population change (increase, decline, or stagnation) because of experienced changes in events (births, deaths, location shifts, or qualitative changes in status – marriages or termination of marriage) that take place among its members. This chapter has provided some core approaches for the analyses of the components of population change (mortality, fertility, and migration) which are relevant to students, researchers, and the broader community of practice in global health. The attempt has been to present these approaches with concrete applications and types of questions they can help answers for addressing global health issues, while keeping the mathematical formulations intertwined with population dynamics, if any, expressed in discrete terms to render them accessible to the wider readership in global health. Suitable uses of these approaches will undoubtedly contribute to comparable measures, fuller understanding, and nuanced interpretation of population health problems facing global one-health on the planet of populations of human and nonhuman species interacting everyday everywhere. Such understanding is essential for the design, implementation, and evaluation of policies, programs, and interventions that are often introduced by governments, nongovernmental organizations, and international institutions and various actors working on/around health issues, in view of addressing global health issues. For instance, when the population dynamics approaches are applied to the study of health issues – diseases, disability, or death (e.g., illnesses), the focus is on the people who contract a disease or become disabled or died (micro-approaches) as well as on the aggregate properties of diseases, disability states, and deaths themselves. Comparable indicators used in population dynamics are used to study, compare, and contrast population processes at the global, regional, national, and local levels. Mortality and fertility analyses have internationally agreed measures, such as life expectancies and total fertility, indicators that are assembled by international agencies and used in/for all countries. Cross-national migration analysis with standards in the computation of comparable measures of migration activity permits comparable cross-national measures of internal and international migration activities. There are several reasons for presenting such comparable indicators. First, measures computed in the same way between and within different countries on the planet take on added significance in an international context and in global health. Secondly, theory can be advanced by examining population dynamics and global health measured in the same way in different national contexts and over time. Thirdly, it is only through comparison that usual versus unusual features of population processes and health

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issues within and between countries can come to light. Finally, increased rigor in cross-national measurement of components of population change (i.e., fertility, mortality, and migration) and how they impact global health may help stimulate better research, and inform effective policy and action to address, in all countries and territories, global health issues.

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Global Migration and Population Health

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Dynamics of Modern Global Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Evolution of Migration and its Effects on Migration Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History and Development of Migrant Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health of Migrants in Relation to the Phases of Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Predeparture Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Movement Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Arrival or Reception Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Return Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Migration and Health: The Wider Application of Nationally Derived Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health and Migration: The Basic Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Health Effects of Migration: Association Versus Actual Cause . . . . . . . . . . . . . . . . . . . . . . . The Interface of National and Global Migrant Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Issues in Migrant Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Issues in Specific Migrant Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Nature and Scope of Migration Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

388 390 394 396 399 399 400 401 402 403 403 404 404 407 407 410 412 413 415 417

Abstract

Migration represents one of the basic components of an integrated, globalized world. It supports the global economic system by providing a flexible, mobile labor force and transfer of income through remittances. Migration supports and sustains family and cultural associations between nations and continents and increasingly provides important demographic support to aging populations in areas of low birth rates. In addition to these positive attributes, global migration B. D. Gushulak (*) Migration Health Consultants, Qualicum Beach, BC, Canada © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_21

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provides a window onto global disparities and inequity. Refugees and displaced populations reflect the scope and consequences of conflict, violence, disasters, and emergencies. All of those activities and processes are influenced and subject to the determinants of health in the migrant population themselves. Historically, the health status and outcomes of migrant and mobile populations had been a long-standing area of interest, investigation, and monitoring for relatively few nations. During the past half century, however, the topic has assumed wide international importance. This chapter describes those changes in the context of global population health. Keywords

Migration · Migrant workers · Refugees · Health disparities · Global health determinants

Introduction Since the development of our early hominid ancestors in Africa, some three million years ago migration has been part of the human experience. Migration is probably one of the earliest collective human activities, predating settlement, urbanization, agriculture, language, and religion. Extending the human footprint into new areas and territory has always been accompanied by health effects and consequences. Movement to new places that were unoccupied by other humans could be associated with ecological, geographic, and environmental health implications for the new arrivals. The journey itself could be dangerous, associated with risks or deprivation. Mobile populations could be exposed to geographically isolated or vector borne diseases that were not present at their previous place of origin. When the migratory movement involved entry into areas where other social communities and populations were already resident, more complex layers of health interactions and consequences could result. The newcomers could be either welcomed or sometimes be considered in the context of representing threats to the host population. The basic drivers of migration are frequently considered in the simple terms of push and pull factors. People leave their homes because they are forced by events and circumstances beyond their control; or voluntarily in the desire for an improved life and wellbeing for themselves and those around them (Crawford and Campbell 2012). Early in human existence, people moved for new or improved agricultural opportunities, better situations for their livestock, or less challenging physical environments. When populations were small and resources abundant, these historical movements appear to have been primarily passive. However, as human civilization expanded and became more complex, resources and territory acquired political and nationalistic characteristics. Force and conflict became tools of expansion and the less powerful were often forced from their lands, transported, assimilated, enslaved, or eliminated as the more powerful extended their dominions.

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Aspects similar to those basic historical processes, both physical and social continue to be observed in modern migratory population flows. People still move in attempts to better their lives. However, modern migratory journeys practically all entail travel through or to territories occupied and settled by others. While the basic process of migration remains simple and uniform, the framework in which that movement takes place has become both more fluid and complex. As migration has evolved, the environments and global factors (social, political, economic, cultural, biological, and climatic) and context in which the migratory journey takes place have also and changed over time. All of those factors affect and influence health determinants, health indicators, and outcomes at individual, community, and population level. From a historical perspective, much of the focus and concern related to the health of what today would be called migrants was set in a negative context. Disease outbreaks and epidemics were associated with newly arriving populations; the fear this created was associated with the creation of some of the earliest organized public health activities. Traces of these negative sociological associations can be seen even today in some responses to global migratory movements. Considerable interest and attention is still directed on the investigation and study of individual diseases and conditions in migrant populations as opposed to the determinants of health and wellbeing in a broader, more modern, global context. Another historical aspect reflected in the field of modern migration health is that the threads of concern regarding the potential health risks of migration frequently present themselves at national level. The majority of health information related to or dealing with migrant populations today is collected and reported at national level due to the fact that citizenship, nationality, border controls, statistics, and health information collection are areas of national responsibility. The European Union, however, does provide some differences in approach and is an increasingly important source of regional migration health information. In general, the understanding of modern migrant health in a global context is and will be better supported by an appreciation and understanding of the interface of two basic elements; the simple process of movement and the circumstances around those movements. That simple framework still provides the context for modern global migration health. This chapter takes a global and population-focused look at the processes and nature of migration. Basic and common processes, forces, and situations are used to provide relevant population health centered insight on the nature, effects, and outcomes related to health and migration. This is important, because many of the administrative, political, jurisdictional, and annotative aspects of migration have been and are subject to diversity and variability depending on location and time. While specific situations and observations may have local or national relevance and importance at that level, they may only have limited global applicability. A more globally focused, population-centered understanding of migrant health is required to support current international endeavors. At the global level, the world is moving towards wider and more integrated approaches to addressing the important issues of migration through collaborative, international undertakings such as the

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Compacts on Migration and Refugees. The health aspects of the populations involved are topical and important components of those processes requiring a global and population health perspective.

The Dynamics of Modern Global Migration As described in greater detail later in this chapter, one of the challenges associated with an overview of the health aspects of global migration is the variability in definition and terminology applied to the populations themselves. At the global level, the United Nations defines a migrant as: " Definition “Migrant” “any person who is moving or has moved across an

international border or within a State away from his/her habitual place of residence, regardless of: the person’s legal status; whether the movement is voluntary or involuntary; what the causes for the movement are; or what the length of the stay is” (United Nations 2020). The definition is broad and encompassing due to a need to be inclusive. The consequence, however, is that is somewhat imprecise. The scope of that international definition represents the general intent and spirit of this chapter. The term specifically excludes other globally mobile populations such as international tourists and visitors, who greatly outnumber migrants and who have their own impact on global health. Current estimates of migrant populations place the number of global migrants in excess of 270 million individuals, a number that has increased by some 50 million (23%) over the preceding ten years (UNDESA 2019a). The proportion of migrants in relation to the world’s total population is also increasing. Migrants now comprise approximately 3.5% of global population compared to 2.8% in 2000. If the 272 million international migrants were residents of a single country, that nation would be the fourth largest nation (by population) in the world today (UNDESA 2019b) (Fig. 1). Often referred to as a single entity, the global migrant population is a diverse and nonhomogenous collection of groups, cohorts, and subpopulations. The appreciation and understanding of the diversity of migrants is a fundamental pillar of the field of global migrant health. The largest population of global migrants are represented by migrant workers. This cohort of global migrants make up approximately 65% of the global migrant population (ILO 2018). Perhaps less frequently considered in terms of global health than other migrant groups, these migrant workers numbering around 175 million people globally influence several global population health indicators including those of occupational health, the demographics of the global health and medical workforce, and the economic determinants of health flowing from and related to the global remittances resulting from their employment. The above described UN definition of migrant, also includes those displaced from their normal place of residence but remaining within their country of

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Fig. 1 Number of international migrants 1990–2019. (Source data UNDESA 2019a)

birth. These migrants represent the second largest global migrant cohort, the internally displaced. This subpopulation of migrants, currently numbering nearly 46 million individuals (IDMC 2020), represent those displaced from their homes as a consequence of conflict or violence. Refugees, representing those individuals under the mandate of the United Nations High Commissioner for Refugee and the United Nations Relief and Works Agency, comprise the third largest subpopulation of international migrants. Currently global refugee numbers approach 26 million people (UNHCR 2020a). Related to the situations and events that create displaced and refugee populations are the populations of those seeking asylum and safe haven. Commonly referred to as asylum seekers or refugee claimants, these populations currently number approximately 4.2 million individuals globally. They represent individuals and communities who are in the process of making claims for protection, asylum, or refuges status as well as those who have made such claims and are awaiting results. In addition to the populations of asylum seekers, there are an almost equal number of individuals who have no homeland or country of origin. Global estimates of those who are “stateless,” defined as having the legal nationality of no country, place that migrant cohort also in the range of 4 million individuals (ISI 2019). Globally, the displaced, refugees, asylum seekers, and stateless populations represent vulnerable populations at risk. Health issues in these migrant populations frequently present as components of complex or chronic humanitarian emergencies. Their health and wellbeing is an important aspect of global health activities. The remaining numbers of international migrants represent traditional immigrant populations, international students, and those awaiting naturalization or citizenship residents of foreign birth who have not changed their status. The health of these

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migrant groups, while smaller than some of the other populations defined previously, is often an area of interest and investigation in countries where they reside. In locations where immigration has been a long-standing occurrence, their descendants may also have health outcomes and indicators related to that process and represent an additional population of interest in the field of migrant and ethnic health. While this organized summary of global migrant demography might suggest that these cohorts and subpopulations are clearly defined and delineated, that is not the case. Many national differences exist in the nomenclature, definition, and determination of status for foreign born individuals and the children born to those without citizenship. Data sources, repositories, and statistics related to migrants and migrant health differ between countries and organizations collecting and reporting the information. In some of these information systems, country of birth may be a surrogate for “migrant” while in others nationality is used as the determinant. An additional set of problems is presented by the fact that individual migrants themselves can move between population data sources over time, depending on location and situation. A migrant worker may file a refugee claim, an immigrant or an asylum seeker granted protection may later acquire citizenship or naturalization status and move from “migrant” to “resident” categories in nation data sets and statistics. The differences and variability in data collection and use add a level of complexity to the comparison of migrant health and medical information at international and global level. Population health-relevant migrant demography must be considered in that context and the nature and structure of data sets carefully compared when national migrant health information is considered in a global or international perspective. The impact of diversity in global migrant health is not limited to the definitions and descriptions of the populations involved. While the term global migration suggests a somewhat uniform process, the reality of modern migration is much different. The locations from which migrants originate, the regions and countries some of them travel through, and their ultimate destinations and future homes are very unequally distributed across the globe. Those differences mean that the health impacts and outcomes associated with migration are not equally shared across the planet and that the health needs of the migrant populations themselves vary between global locations. At the close of 2019, 82 million international migrants (approximately 30% of the global total) were located in Europe, some 59 million (@ 22% of global international migrants) were in Northern America, while Northern Africa and Western Asia held a further 49 million (18% of the global migrant population). Within those regions, there are significant differences between countries in terms of migrant origin, transit, and destination. In 2019, a third of all global international migrants originated from ten countries (Table 1). Similar large variations exist between the numbers and nature of migrants hosted by individual countries. These demographic realities have huge influences on global migrant health as both the health impacts of migration and the health, medical demands and needs of migrant populations are unequally shared between nations.

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Table 1 Country of origin of global migrant populations 2019 Country India Mexico China Russian Federation Syrian Arab Republic Bangladesh Pakistan Ukraine Philippines Afghanistan

Number of international migrants (2019) 17,500,000 11,800,000 10,700,000 10,500,000 8,200,000 7,800,000 6,300,000 5,900,000 5,400,000 5,100,000

Source Data Migration Data Portal 2020 Table 2 Countries hosting migrant populations 2019 Country United States Germany Saudi Arabia Russian Federation United Kingdom United Arab Emirates Australia Canada France Italy

Number of international migrants (2019) 51,000,000 13,000,000 13,000,000 12,000,000 10,000,000 9,000,000 8,000,000 8,000,000 8,000,000 6,000,000

Source data UNDESA 2019a

Half of the global international migrant population can be found to reside in only 10 countries. Nearly one in five international migrants (19%) were located in the USA in 2019. In terms of population health, the dynamics of global migration are very important. An example is provided by the two major countries of origin in 2019. The nearly 19 million migrants from India are distributed globally with large populations residing in the Middle East, Asia, North America, and Europe. In a totally different pattern, migrants from Mexico, the second largest source of international migrants, primarily reside in one nation, the United States (Table 2). In terms of global public health, considerable attention is directed towards the intercontinental movement of people. Once again, global migrant demographic dynamics show large regional variation. In North America, 98% of international migrants originate from other global regions. Similar observations are noted in Oceania, where nearly 90% from outside the region. These proportions are different in Northern Africa and Western Asia where more migration is intracontinental and only approximately 60% of migrants where born in a different region.

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However, it is important to note that, in global terms, many migrants are found in the geographic regions of their birth. In sub-Saharan Africa, for example, nearly 90% of international migrants have originated in that region. Similar situations are observed in East and South East Asia where 83% of migrants there are from that region; and Latin America and the Caribbean where 73% are from the same region. In Europe, more than 65% of migrants originate in Europe region. Similar situations are observed in Central and South Asia where 63% of migrants are from the same region. These migrant origin and distribution patterns have more than demographic importance. The differences in locations patterns of migrants between origin and destination countries have significant implications for global health in terms of migration-related impacts. The nature and proportion size of migrant populations in destination countries can be associated with volume dependent impacts on demand for some health services, particularly those that are migrant specific. Additionally, as will be explained further in this chapter, intercontinental migration is more likely to be associated with travel across biological and epidemiological disparities for some diseases that are geographically or environmentally limited. In those situations, the movement of migrants between those disparate epidemiological boundaries can have health implications. Those situations can influence the prevalence of some conditions in migrant populations and are associated with some aspects of migration medical assessment and screening. One of the most important aspects of attention to migration-associated aspects of global population heath is the understanding that while the process of migration is more and more frequently considered a global phenomenon, the impact and distribution of the health outcomes remains globally variable and disparate. The types, structures, and nature of data sets applied to migrant populations likewise differ between nations, making the comparison of migrant populations between countries let alone the health characteristics of these populations, sometimes difficult to impossible to measure. These national differences extend to regional levels where even in an integrated European Union, the comparison of reliable data in Europe has been observed to be difficult (Kupiszewska et al. 2010), and are even more pronounced at global levels where the differences in data availability and comparability are greater. Global population health-based approaches to aspects of migrant health need to be robust enough to account for national and region differences and be flexible enough in structure to effectively dealt with those disparities. Health needs of migrant populations vary across many variables and practices and activities and interventions required or appropriate in one location may not be applicable in another. At the global level, this requires a relatively high-level, macro approach in terms of migration health policy and program development.

The Evolution of Migration and its Effects on Migration Health Early migratory movements were predominantly intracontinental. This pattern of migration reflected national and regional approaches to managing either newly acquired or newly lost territory in the geo-political context of the time. Nations

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governing new territories acquired through conflict or treaty frequently attempted to improve and sustain their control through the migration of populations friendly to the new governing system. Additionally, the previous occupants of the territory could be subject to restrictions or constraints designed to force or encourage the departure. Historical examples can be been seen in the demographic shifts in Europe with the wane of the Ottoman Empire. Other intracontinental migratory movements included both the positive inducement or negative restriction of residents on the basis of religious or political grounds. Examples include the movement of religious minorities in Europe such as those resulting from Catherine the Great’s decree of 1763 encouraging immigration to some while restricting residents to others. Later intracontinental movements were created by industrialization when the evolution of agrarian economies to more mechanized environments supported the recruitment of workers to areas of mining, manufacturing, and the metropolitan environments associated with those activities. This intracontinental migration was primarily intended to be uni-directional, with the new arrivals becoming part of the permanent population, but recurring conflict and shifting military outcomes could result in some resettled populations being displaced sometimes generations after arrival. These migratory movements were undertaken primarily by land and involved populations originating primarily in the same region. Those historical intracontinental movements could be associated with health issues, often related to poverty, marginalization and access to services, some of which remain present today. The development of modern, intercontinental migration, however, was associated with the establishment of, several principles that continue to frame current aspects of migration health. Many of these can be traced to the periods of European colonial expansion. Vast, newly acquired territories fell under initially colonial and later independent control of expanding mercantile, political, and military powers. Depending on situation and national colonial policy at the time, the resident, indigenous, local population could be coerced, displaced or deminished through violence, deprivation and disease. Over time the acquired territory became populated by the arrival of new settlers from the colonial homeland or regional area. History commonly describes these arrivals as relatively passive movements of those seeking an improved life or opportunity in new lands, but it is important to remember that a significant component of international migration at that time was anything but voluntary. The transport of large numbers of enslaved populations to colonial dependencies followed the European expansions of the fifteenth century (Micheletti et al. 2020). Additionally, penal transportation and deportation served the dual purpose of supporting colonization and dealing as well as dealing with crime at home. Finally, some colonial powers with large territorial dependencies supported the movement indentured or induced workers between colonies. Historical intercontinental migration was a process primarily involving maritime travel. As a consequence, those disembarking vessels found themselves subject to the medical requirements for all new arrivals at seaports. The health formalities at ports of entry were the product of quarantine activities intended to prevent or

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mitigate the importation of diseases of epidemic potential. Beginning in the fourteenth century in Europe, they accompanied the expansion of European colonial development and became integral parts of the arrival process at ports in migrant receiving nations. Those undertakings represent the first organized approaches to migrant health. At time migration was primarily considered as a uni-directional process. This context supported an approach to migration health through a relatively simple framework of demographic and population-based monitoring and study. The health characteristics of immigrant and migrant populations, usually defined as those being born outside of the national boundaries of their new residence, were observed and contrasted with those of the host or receiving population. These historical relationships were created at times and during environments where interests in migrant health had become issues in those nations receiving large numbers of intercontinental migrants and were often focused on communicable diseases. The result was the traditional approach to migrant health, a matter of concern to major immigrant receiving nations and commonly concerned with infectious diseases. That pattern changed during the last half of the twentieth century. Since that time global migration dynamics have been subject to a series of events and influences that have changed both the nature and the context of the traditional immigration/emigration paradigm. Those changes have been associated with a corresponding evolution in the scope and nature of the field of migrant health.

History and Development of Migrant Health A considerable amount of the available information and attention given to the health of migrant populations today is a direct consequence of the history of migration. What would today be considered the field of migration health originated from the attempts to manage infectious disease epidemics arriving via maritime vessels. Attempts to deal with plague resulting from the arrival of vessels, crew, passengers, and cargo resulted in the development of quarantine practices in fourteenth-century Europe. Observation and experience had shown that outbreaks of disease followed the arrival of ships from distant ports where the maladies were present (Tognotti 2013). Quarantine measures followed the expansion of European colonial settlement and illness or diseases in newly arriving crew and passengers in North America could result in isolation or refusal of landing as early as 1647 (Peabody 1909). These practices were expanded and included specific focus on migrants during the great waves of migration to North and South America, Oceania, and other regions. By the early twentieth century, many major immigration receiving nations in those regions required the medical examination and evaluation of newly arriving migrants. As the practices flowed from quarantine procedures, most of the attention directed at the health of migrants was concerned with communicable diseases of concern at the time such as smallpox, plague, Yellow Fever, and cholera.

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Developments in medical science in the nineteenth century including the development of the germ theory of disease expanded the number of diseases and conditions that migrants were evaluated for. By the end of the nineteenth century, these grew to include trachoma, typhoid fever, sexually transmitted infections (particularly syphilis), and tuberculosis. Arriving migrants were examined by port of arrival health staff and depending upon their status they could be refused landing and returned to their port of boarding, isolated, or quarantined. While the most attention to migrant health in the early twentieth century was focused on communicable diseases, social and political views in nations of resettlement began to draw attention to other disorders and conditions in immigrants (Baynton 2016). Immigrant selection at the time began to include assessments for illnesses and conditions that were deemed unwanted in new arrivals. Depending on the nation of arrival, alcoholism, chronic mental health conditions, psychiatric conditions, seizure disorders, deafness or blindness, and developmental impairment could affect or prevent immigration. Several of those restrictions were based on the premises of the eugenics movement which began to focus on immigration; others were related to the anticipated likelihood of employment and self-support. The development and understanding of genetics later in the twentieth century resulted in the demise of eugenics leaving the primary focus on migrant health once again centered on dealing with infectious diseases in immigrants. Following the end of the Second World War, a combination of events and technological advancements produced profound changes in the patterns and volume of global migration. Decolonialization resulted not only in the creation of new nations but was associated with profound demographic effects as populations redistributed themselves between newly independent territories and colonies and prior colonial homelands (Miege 1993). The development and expansion of air travel using jet engines which increased both the speed of travel and reduced its cost began in the 1950s and expanded explosively in the next decade. The geopolitical structure and polarization of the world that followed the Second World War was associated with chronic ideological and periodic military conflicts that become major influences on creation and movement of refugee populations. Later in the last century the demise of that long-standing interface beginning with the end of the USSR produced profound changes in travel and migration routes as well as creating large population redistributions. All of those events produced a corresponding evolution in global migration health. Initially reflecting the history of the topic, infectious diseases remained an important aspect of migrant health. The growth in migrant populations originating in tropical and subtropical regions of the world meant that migrants could arrive at their new home with conditions that had previously rare or unusual. Parallel advances in virology allowed for the recognition of and understanding of the natural history and epidemiology of infectious like hepatitis B and later HIV. By the 1980s the majority of global migration health activity remained focused on managing communicable diseases in immigrant and refugees. These approaches

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were disease-based as oppose to health-based and primarily targeted at regular, organized migration. By the last decade of the twentieth century, the focus began to expand (IOM, WHO 1990). Nations not previously considered “countries of immigration” began to receive larger numbers of new arrivals and started to recognize and manage the associated health issues. The evolving nature and diversity of migration meant that traditional immigrants were no longer the majority of migrant populations. Large refugee movements exemplified by the population flows following the end of the conflict in South East Asia required coordinated, multinational responses including attention to medical and health needs of those involved. Irregular and unorganized migration flows created populations who, unlike immigrants arriving in an organized, regular process, may have limited access to health services. As the twenty-first century progressed, the greater number and diversity of migrant populations, coupled with increasing destination locations and a growing interest in migrant health instead of limited attention to specific diseases, has changed both the scope and nature of migration health. The role of migration in terms of global development, the role of migration in global economic system, and impact that migration has on population dynamics in nations of low domestic birth rates are all issues of major and growing international importance. In those locations such as Australia, Canada, Western Europe, and the United States, international migration is becoming one of the major drivers of national population growth (European Commission 2020). Improving and sustaining migrant health will be necessary to support future national population health in those locations. As a consequence, migration health policies, programs, and practices are increasingly multinational or global in scope. Additionally, they tend to be more widely focused on individual and population health as opposed to specific diseases. National migration health policies and practices continue as determined by the needs of individual countries, but more and more those activities are coordinated within the context of regional or international frameworks and standards. That coordination works towards better standardization of terminology and migrant-specific health information records, hopefully leading to improved comparability of migrant-relative health information across the planet. As international and global interest in the health and wellbeing of migrants increased towards the end of the twentieth century, more appropriate and population health-relevant methods of examining the health of migrants were proposed (Gushulak and MacPherson 2004). These approaches are founded on a systematic consideration of migration as a series of related processes that could be consistently and uniformly used for all migrants, independent of their administrative or legal status, local terminology, time or direction of migration, and geographic location. In a manner analogous to the life course perspective on health, examining health using the phases of the migratory process as a framework allows for a comprehensive, global, comparative, and population health compatible evaluation of migration health (Zimmerman et al. 2011).

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Health of Migrants in Relation to the Phases of Migration The Predeparture Phase Not related to the administrative or legal status of the migrant and notwithstanding the forces and influence that cause or trigger the migratory journey, all migrants have a place of origin. The state of their health before they begin the process of migration is determined through the interaction of geographic, environmental, biological, social, cultural, and economic factors at that location. Some of those health determinants will extend through and influence the migrant’s health through the entire migratory journey and other will affect the health of the migrant through their entire life.

Biologic Factors at Migrant Origins The human genetic makeup can affect health determinants and outcomes at the individual and population level (Claussnitzer et al. 2020). Over time some human genetic traits have become unequally distributed across the planet. Depending on history, geographic isolation, travel patterns, and cultural factors that influence marriage and family dynamics, variability in the prevalence of genetic health determinants exits between human populations. Classic examples with implications for migrant populations include conditions like Sickle cell disease (Serjeant 2013), Tay Sachs disease, and differences in ABO blood groups, which have been long recognized. Newer genetic analysis is revealing ever more genetic determinants of health that include specific gene effects on specific disease outcomes such as the effect of BRCA genes on some malignancies as well as the broader impact of genetic makeup on population health outcomes for systemic diseases (Palaniappan et al. 2018). Geographic and Environmental Factors at Migrant Origins Location and environment can exert significant influences on the health of populations. Climatic factors can affect the biology of insect and other disease vectors and micronutrient deficiencies affect health outcomes large numbers of people. Physical environmental factors may also be associated with locationspecific exposures to hazards such as exposure to toxic agents such as lead (Burki 2020). Examples of the former include a variety of infectious diseases such as malaria, schistosomiasis, Chagas’ disease, and strongyloidiasis, while micronutrient-associated disorders include the outcomes of iodine, iron, and vitamin deficiencies (Tulchinsky 2010). In this context, it is important to note that prevalence differences between migrant origins and destinations frequently provide the basis for the routine medical screening of migrants practiced by some destination countries (Agbata et al. 2018). Social and Cultural Factors at Migrant Origins Health status and outcomes are strongly influenced by the social and cultural environment in which populations live and function. They affect the way people

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appreciate, access, use, and relate to all the levels (prevention, promotion, and service delivery) of the health care system. Social and cultural factors are also important aspects in the development of behaviors that can affect health risk such as diet, tobacco, and alcohol use and sexual behavior (Arsenijevic and Groot 2018). During migration, individuals and populations of migrants may subsequently travel through and/or reside in locations where the social and cultural attributes differ in regard to health, medical practices, and health risk behaviors. Depending on the destination, several health determinants and outcomes in resettled migrant populations can be related to social and cultural factors (Suphanchaimat et al. 2015). This can be particularly important in the context of the use of traditional or complementary medicine and the access to and influence of traditional healers and providers (Shewamene et al. 2020).

Economic Factors at Migrant Origins The levels and extend of economic development and poverty during the predeparture phase of migration can be crucially important influences on migrant health. These extend from the societal level where development and national wealth define and determine the scope and capacities of the health system in general. Health promotion and prevention, the availability of both primary and greater levels of health care delivery, as well as public health interventions such as vaccination and screening programs are all related to national and local levels of income and development. At the individual level, the consequences of poverty and economic stress provide additional barriers to accessing and utilizing medical and health services and significantly determine health outcomes. Almost universally poverty is observed as having a deleterious affect on health (Marmot 2002). The interaction of all of these factors combine to influence and define the health status of migrant populations before the process of migration itself begins. Some of the factors such as the genetic aspects are fixed from birth, while others are influenced by the time of exposure and hence the age of the migrant at the time the journey begins. The most relevant population health-associated consequence of the predeparture phase is that it is responsible for health determinants and outcomes in migrant populations. Those determinants may be differ from those of other nonmigrant populations with who the migrants may work with or reside with during the other phases of migration. Awareness and understanding of the scope and nature of the health aspects of the predeparture phase is necessary to design and support migrant-relevant health policies and programs in both transit and destination locations (Table 3).

The Movement Phase In common with many aspects of migration, the actual journey from origin to destination is a nonuniform process that differs between many migrant populations. Depending on situation, health during the migratory journey is dependent on local physical and environmental conditions and circumstances. Those in turn are influenced by the duration and route of the journey all of which can be associated with health risks. Migrants travelling through a process of organized, regular migration such as immigrants, some migrant workers, and international students experience direct,

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Table 3 Aspects of the predeparture phase that can affect the future population health of migrants Factor Biological

Geographic and environmental Social and cultural

Economic

Potential outcome Inherited genetic disease trait Genetic response to therapies Challenges related to tissue typing for minority populations at destination Prevalence of diseases/conditions that differ from those of transit or destination locations Indicators for targeted screening and or treatments Social determinants of health at origin that differ from those of transit or destination Concepts of health and disease that differ from host populations Different approaches to health care delivery options Limited predeparture access to health prevention, promotion and public health services compared to those at destination Different or unavailable screening, diagnostic and or treatment options Diseases presenting at later stages Needs for catch-up or additional immunization

Adapted from Gushulak and MacPherson 2011

comfortable journeys similar to those of routine travellers. Refugees and displaced populations forced from their places of residence on the other hand are often unable to access regular routes of travel. Their journeys may be imposed on them though violence and intimidation or be the result of rapid unplanned departures. Similar challenges are faced by irregular migrants attempting to make the journey without advance authorization. In those situations, the movement phase may be associated with deprivation, lack of sustenance, and limited or absent access to health care. The nature of the forced or irregular journeys is also fraught with dangerous methods of transport, exposure to the elements, violence, and coercion. The young, unaccompanied women and girls, the elderly, and those with preexisting medical issues are particularly vulnerable during this phase of the journey. For migrants who are being trafficked or smuggled, physical and sexual violence is a frequent threat. In addition to the variabilities in direction that migrants’ journeys take, the duration of the travel is another variable that differs between migrant populations. Particularly for refugees and the displaced, the time involved in leaving the migrants’ origin and reaching the final host destination make take months or even years. The combination of local conditions in transit or holding environments and the time spent there are major determinants for health outcomes in these populations.

The Arrival or Reception Phase In terms of a population health approach, it is useful to consider the reception or arrival aspect of the migrants’ life course at their ultimate destination as two components: the immediate arrival period and the integration or longitudinal period.

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The initial period of the migrant’s arrival at their new home is associated with several factors and processes that affect the determinants of future health. Common to all populations, accommodation, employment, level of income, and support systems are crucial components of the social determinants of health for migrants. Similar factors relate to the acquisition of education and learning for children. In addition, migrants are subject to specific influences that can affect health outcomes at individual and population level. Access to health care and ancillary health services may be affected or limited by regulatory or administrative requirements. Additionally, there may be linguistic and/or cultural barriers to accessing and using health services some of which may differ in concept or context from those familiar to the newly arriving migrants. The longer-term component of the arrival phase presents longitudinal aspects of health specific to migrant populations that can extend for years and in some cases generations. Elements of the migrants’ journey may have created health issues that persist for long periods of time as seen in the effects of trauma and torture experienced by some refugee, forcibly displaced and trafficked populations. Biological and genetic aspects present in some migrant populations will affect health outcomes for generations influencing the incidence of some diseases, response to therapy for others, and availability of organs or tissues for transplantation. In locations where long-term migration has resulted in the establishment of migrant communities and populations of size, cultural environments, practices, and biologic determinants in those communities may be significant enough warrant specific population-based attention. In some nations with large migrant populations, these activities overlap with what is known as the study of the ethnic aspects of health (Institute of Medicine (US) 2003).

The Return Phase As noted earlier, traditional patterns of migration were considered to be primarily uni-directional with populations leaving their origin and travelling permanently to new homes where they remained. These one-way flows of global populations were sustained by the economic drivers of immigration and costs and exigencies associated with long sea voyages which made return journeys difficult for newly arrived migrants. In the context of modern migration that pattern has changed for millions of migrants. Advances in transportation technology, particularly high speed, affordable air travel coupled with the processes of globalization, technological and communications integration now allow for easily available return journeys for many migrants. Additionally, millions of migrant workers follow a pattern of cyclic departure and return. Return travel is a frequent component of the live of migrant workers, millions of whom travel internationally and intercontinentally for employment and return to their place of origin periodically or at the end of their employment. Return travel is also observed in other migrant populations, where migrants, established

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at their new destinations, return to their homelands or origin to visit friends and family. That population component of the greater migrant population represents an important subpopulation of the Travel Health Sector, where travel to visit friends and relatives (VFR Travel) is a significant area of study (Barnett et al. 2010). These patterns of repetitive migration have important influences on health determinants for migrants and their families. From a population health perspective, the return phase of the migration cycle is important as it involves the repetitive movement between locations and situations of disparate health determinants and risks.

Global Migration and Health: The Wider Application of Nationally Derived Knowledge Health and Migration: The Basic Relationships The final common pathway involved in aspects of migrant health is disparity. The impetus behind the study and investigation of migrant health is provided by the differences in health outcomes and determinants for some populations of migrants and other populations. Attention is more frequently paid to situations where the health differences in migrant populations are less positive than other communities or populations. It must be noted however that not all migrant health outcomes or indicators are negative. There are several situations where migrant populations are observed to have determinants and health outcomes that exceed those of nonmigration populations. In some situations, those positive findings can diminish over time resulting in poorer health outcomes after migration. These circumstances are known as the Healthy Migrant Effect (Moullan and Jusot 2014) and are important areas of study and investigation in strategies and programs designed to support global migrant health. Migration assumes an important role in nature of global health because the movement of large populations across and between regions and locations of disparity acts as a bridge between inequities in health. Global and regional differences in the prevalence of important infections such as malaria or tuberculosis, the impact of psychosocial illness such as PTSD, or the effects of trauma and torture in refugees and existing global gaps in primary health prevention activities are exemplified in the health indicators and outcomes present in populations of migrants. Global migrants provide a window onto existing health disparities. At the same time longitudinal studies can serve as monitoring indicators to assess the impact of global health interventions designed to reduce those inequities. In this context, migration health can be seen to be an important component of the broader approaches and global health initiatives to improve health. Most international focus and action is centered on reducing the inequities and disparities that are associated with poorer health outcomes for many of the world’s inhabitants.

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The Health Effects of Migration: Association Versus Actual Cause Differences in the incidence and prevalence of health indicators and outcomes between migrant and nonmigrant populations reflect two basic etiologies. The first and most common are conditions and indicators that simply echo existing global health and disease disparities. Examples are provided by diseases that are geographically limited such as malaria, or those that result from disparities in social determinants of health such as tuberculosis. The incidence and prevalence of those infections varies considerably between global populations in different locations and the process of migration simply transports those preexisting differences between the migrant’s origin and destination. This relationship is important to understand as it is not limited to migrants per sec but occurs in all who journey between locations of disparate disease prevalence. All travellers, including those who journey for business, tourism, or other reasons, can mirror differences in disease prevalence between origin and destination. The second major cause of differences in health between migrant and nonmigrant populations is those resulting directly from the process of migration itself. They are less common than the former and are also unequally distributed between migrant groups. However, their recognition and management can be very important in nations through which migrants transit, or ultimately reside. The health impacts directly related to migration may be observed in all phases of the process. They are more frequently noted in the most vulnerable such as refugee, displaced and forced migrant populations, but they can also be observed in some populations of migrant workers. The violence, conflict, and intimidation that may precipitate some migrant movements can create physical and psychosocial health consequences that extend throughout the migrant’s life (Bogic et al. 2015). Other migration related consequences may result from exposure to injury, accident, deprivation, and violence during or after the journey. In some refugee and displaced populations where the transit period form origin to ultimate destination may extend for years, the risks are increased. Finally, issues of reception and integration at the destination such as access to medical services and care, limits on housing, employment, education, family reunification, and travel can all have downstream health outcomes that are related to the process of migration. Appreciating the differences in these two basics sets of forces that define the health of migrant populations is important in the context of global population health. That understanding is crucial in regard to decisions related to where to best intervene to improve migrant health. Reducing or eliminating those that are the result of existing inequities and disparities across the planet will be accomplished by coordinated international action, much of which is already underway or planned.

The Interface of National and Global Migrant Health As noted earlier, the majority of migration health outcomes are studied and evaluated through the comparison of health indicators in migrant populations against the

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same indicators in a nonmigrant population. In these situations, the reference population is usually that of the host population at the migrants’ destination location or country (McKay et al. 2003). Differences in the incidence or prevalence of a disease or illness, disparities in the access to or use of health or medical services, and variations between outcomes such as lifespan or cause of death between migrant and nonmigrant populations have been the basis of many of the approaches to health of migrant populations. Reflecting historical aspects of international migration interest in the health of migrants throughout most of the twentieth century was primarily located at the national level. Exploring and examining the differences between migrants and host populations within the nations receiving immigrants was sufficient for the time. As the nature of migrant health has become more globally focused, it has become more common to use a broader range of comparison populations to better define the determinants of the health of migrants. Much of the global experience and information related to migrant health has been obtained in this manner and with the growth and importance of migration increasing that those data sources are expanding as well. However, in the context of global population health, the results of national studies and investigations are relatively narrow. Extending the knowledge and experience derived from national migrant health activities to regional and global levels is significantly hampered and impeded by several factors. Depending on the national history of migration and current health program structures, some nations limit the focus on their attention on the health status of migrants at the time of their arrival. When provided, migrant-specific health interventions at the health program level, such as screening or immunization, are frequently associated with these arrival phase approaches. Other nations, particularly those where migration has been a long-standing component of population growth, include aspects of migrant status in their monitoring of national health indicators over time. This can result in information that follows the evolution of those characteristics both within migrant populations and with comparison with the host population longitudinally. Knowledge from longitudinal studies tends to be used to structure and support more policy-oriented health activities, such as the development and provision of migrant inclusive health services and interventions intended to mitigate the disparities revealed between migrant and nonmigrant populations. Global development and the capacities and availabilities of health care have evolved dramatically over the past few decades. This development can create caveats in terms of the comparison of migrant health data over time. Health determinants present at many origin locations for major global migrant populations can be substantially different than they were only three decades ago. This means that for nations with long standing immigration programs, current new arrivals from particular origins may exhibit different health indicators than cohorts from the same place in the past. Additionally, migrants from the same origin may experience different levels of access to and use of health services and other social determinants of health following arrival at different destinations. These factors make the trans-national comparison of migrant health indicators and outcomes challenging.

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To be more globally relevant, longitudinal studies of migrant health need to consider health indicators and outcomes in migrants in comparison not only with the host population at one destination, but also against the outcomes of cohorts who remained at the place of origin and did not migrate as well as with those who migrated to different locations. Together, this modern approach to global migration health will better define specific global migration health determinants and provide mechanisms for the standardized comparison of data collected at national level. One of the major challenges in approaching migrant health from a global perspective remains the pervasive use of nonstandardized terminology between nations. The determination of citizenship and nationality resides at the level of individual nations. Newly arriving migrants, foreign nationals, and those of undefined nationality or statehood may be classified and entered into national health data systems using terminology that differs between nations (WHO European Office 2018). Depending on location, the terms refugee, migrant, immigrant, and asylum seeker may be applied differently across the migration spectrum. Country or region of birth may not be systematically recorded and migrants who acquire citizenship or naturalization may then be considered part of the host population in some data systems. Additionally, depending on location and national practices, children born to newly arrived migrants may be considered as nationals in the host nation even though their parents may not yet have acquired the same status. A great deal of international focus and action is centered on reducing the inequities and disparities that are associated with poorer health outcomes for many of the world’s inhabitants. Programs and policies designed to diminish or erase global disparities are an integral part of the United Nations 2030 Agenda for Sustainable Development, adopted in 2015 (United Nations 2015). In addition, broad international action is underway to support the strengthening health systems (HSS) at global level and Universal Health Coverage (UHC) is an integral part of international development and global health agenda (United Nations 2016). Together those integrated, global endeavors will act to decrease many of the preexisting health and disease disparities that occur between migrant origins and destinations. As the disparities decrease across the planet, the differences in health indicators and outcomes that result from them in migrant populations will likewise decrease. Addressing the health outcomes that result from migration-specific factors requires focused action at national and civil society levels (IOM 2017). Reducing violence, providing services to vulnerable migrant and mobile populations, and facilitating access to services and integration into host populations will be essential to reduce the disparities in migrant health outcomes in that regard. The importance of the health of migrant populations is recognized in all of the major initiatives related to supporting global migration, particularly the Global Compact for Safe, Orderly and Regular Migration adopted in 2018 (United Nations 2018) and in the Compact on Refugees which is under development (UNHCR 2020b).

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Health Issues in Migrant Populations As noted earlier, the absence of standardized terminology coupled with disease monitoring and surveillance systems that may not reflect migrant history or place of birth makes the systematic trans-national or global comparison of migrant health indicators and outcomes challenging. Additionally, the heterogeneity in the methods and trajectory of the journey migrants take from origin to destination complicates the comparison of health characteristics between populations that may superficially appear homogeneous. Extrapolating observations between countries or migrant populations requires detailed attention to the demographic make-up and specific migration history of those whose finding are reported. However, insight and knowledge from some national and regional studies do allow for the understanding of general trends and some common patterns of health in migrant populations. Reflecting the diversity in global disease prevalence, migrants commonly exhibit the incidence and prevalence of health indicators at their origin. If those rates are different than those at their new destination, investigation will note population-based differences between migrants and the host population. In the consideration of the examples presented, it is important to understand that there will be variability within migrant populations themselves, in relation to disease prevalence levels. Older migrants who will have had longer periods of risk exposure will frequently have higher rates than migrants who left their place of origin as children. Additionally, in the context of global health, rates of prevalence and incidence of health conditions are frequently considered and reported at national level, yet there is often great diversity in those rates between subpopulations within nations (Pini et al. 2019). Social determinants of health vary, and downstream health indicators are unequally distributed within nations and within migrants from those nations.

Infectious Diseases Information concerning infectious diseases is migrant populations probably represents one of the largest areas of study in the field of migrant health. This reflects the origin of many migrant health activities in the practice of quarantine, which was focused on communicable diseases and the fact that the monitoring and surveillance of infectious diseases is a regulatory requirement in many countries. In terms of population health, it is helpful to consider infectious diseases in migrants in regard to two frames of reference: disparities in infections occurring during the phases of migration and the duration of the infection.

Infections and Migration Phases Generally migrant populations reflect the epidemiology and nature of infectious diseases common at their place of origin. Those departing from locations where certain infections are more common or widespread can be expected to be at greater likelihood of exposure. Additional risks may be encountered during the movement

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or transit phase of the process. Displaced populations, refugees, and irregular migrants can have long journeys during which they may transit areas where exposure or risks are increased. Similar location-specific risks are experienced by some migrant workers who may travel to work in locations where geographic, occupational, or social conditions affect exposure to situations associated with the acquisition of infections. Exposure to infectious disease risks also occurs during the arrival and resettlement part of the migratory journey. Social and environmental determinants of health at the destination can affect the exposure to and acquisition of infections. Finally, those migrants who return to their places of origin from their new homes often to visit friends and relatives may be exposed or re-exposed to risks of infection that are different than those present at their current place of residence.

Migrants and Acute Infections or Epidemics In view of the global impact of COVID-19 infection in 2020, some perspective on the relation of migration global public health is warranted. In terms of global population health and international public health, acute and short-term infections are of greater importance for nonmigrant travelers than for migrants. As noted earlier, while migrant populations do represent a globally important population, nonmigrant travelers represent a much larger number of people that exceed all global migrants almost fourfold in term of pre-COVID-19 travel patterns. As such in global terms, at any one time there are probably more acute infections in travelers than in migrants. The implications resulting from that proportional relationship are important for global public health and disease control policies and programs. Migrants are often considered groups of interest during widespread epidemic or pandemic events but empirically, activities directed at the control or mitigation of acute infections should consider the risks associated with all international travel, not simply migration. Some migrant populations may be exposed to greater situational risks during some outbreaks of acute infections, depending on location and situation such as outbreaks involving migrant workers, but these have limited global implications. However, outbreaks of infections in migrant populations can create concern or interest local and national level. This often occurs when migrants are arriving from an origin that has not been a regular source location for the destination or if the infection involved is uncommon. In these situations, knowledge, clinical experience, or diagnostic capacities limited delaying recognition and treatment. Tropical diseases such as malaria and dengue as well as infections that have been controlled or almost eliminated in receiving countries such as measles or polio may present issues and concern for those dealing with arriving migrants. Additional aspects of migration health that are related to the management and control of acute infectious diseases can be associated with the vaccination status of migrant populations. Many migrant children may arrive with incomplete or interrupted immunization schedules placing them and those around them at some risk. Again, these situations are local and have limited global implications.

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In terms of organized migration, including, immigrants, migrant workers, and regular refugee resettlement operations, medical evaluation including screening and treatment for acute infections either prior to departure or on arrival is a common component of the process. Similar activities are often included as components of the registration or reception process for irregular or unorganized movements. Depending on location, situation, and status of the migrant, the vaccination needs of the newly arrived can be addressed in nations of migrant transit or resettlement. Despite concern and some public or media anxiety regarding the health risks associated with arriving migrant populations, transmission of acute infections to the host population rarely occurs. Depending on accommodation, availability of health care, and support after arrival, some infections may occur in the migrants themselves but extension to the host population is exceedingly uncommon. Evaluation of the impact of the large flow of migrants to Europe in 2014 and 2015, for example, revealed marginal impact in terms of imported infections in receiving nations (Semenza et al. 2016). Migrants and Chronic Infections More importantly in terms of migration health at the population level are the epidemiological and clinical consequences of infectious diseases of long duration or those that are associated with long periods of latency. As described earlier, migration is becoming an increasingly important component of national population dynamics in many resettlement countries. As this continues, the proportion of the national population represented by those born outside of country of residence increases. Proportions vary according to the history of migration in each nation but as birth rates decrease in the industrialized world, greater proportions of population growth are provided by migrants (Pison 2019). In countries with long histories of migrant arrivals, the proportion of the population of foreign origin can increase over time. While the percentage of the global population represented by migrants is in the range of 3.5%, nearly 50 countries had migrant populations that exceeded 20% of the national population (UNDESA 2019c). Migrants who arrive at their new home with long standing or chronic infections will continue to harbor those infections if they are not detected or treated. Over time as the migrant component of the population increases, migrants may come to represent significant or in some cases the dominant population at risk for those chronic infections in the country of destination. This is particularly true for infections that are prevalent at low rates in the host populations either because of public health interventions or geographic isolation. Well-documented and long-standing examples of these relationships between chronic infections and migration are provide by diseases such as tuberculosis (Pareek et al. 2016). In many industrialized nations where domestic tuberculosis prevalence is low, migrants represent the populations with the greatest amount of disease. In Australia, Canada, Western Europe, and the United States, for example two thirds or more of national tuberculosis cases are recorded in migrant population cohorts. Similar relationships exist for other chronic infections where global disparities have produced marked differences in prevalence between regions such as HBV,

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HCV, and HIV. Migrants moving from high prevalence origins to low prevalence destinations can represent persistent populations at greater risk of infections of long duration. Parallel situations occur for some bacterial and parasitic infections where complications or illness may develop long after infection. Disparities in Group A Strep infections and the availability of treatment for that infection have resulted in higher rates of rheumatic cardiac disease in some migrant populations (RHD Action 2018). Persistent parasitic infection such as strongyloidiasis in migrants from endemic areas may recur long after migration and can present complications for treatments that affect the individuals’ immune status, such as chemotherapy or the administration of steroid medication (Stauffer et al. 2020). Chagas’ disease, normally geographically isolated to certain regions, can be persistent and can become an infection of importance for blood transfusions in countries hosting migrant populations from affected areas (Schmunis 2007).

Noncommunicable Diseases The patterns and presentations of noncommunicable diseases in migrant populations are primarily the consequence of the social and physical determinants of health experience by the migrants during their journey. Those originating from conditions of poverty, lack of access to health care, and poor nutrition will start the migrations process with illnesses and diseases that result from those determinants. For the marginalized and vulnerable, particularly refugees, the displaced and irregular migrants, the journey itself can worsen existing conditions through lack of care or treatment. The violence and conflict associated with the movement of refugees and the displaced creates mental and psychosocial illnesses in some of these populations. For migrant populations who experience long periods of transit or who may be prevented from moving on or incarcerated health conditions frequently deteriorate or persist without treatment. At the end of the journey following arrival at their ultimate destination, access and availably of care and programs targeted to the specific needs of migrants may be limited depending on location and the population involved. Together those factors can delay the recognition, diagnosis, and treatment of illness and disease. The diversity of migrant origins coupled with differences in exposures to and duration of social health determinants and the use of health services by various migrant populations means that broad trends in specific noncommunicable are difficult to elucidate. Studies and investigations document and describe many differences in health outcomes and health indicators between migrant populations and host country cohorts. While useful and important to those working at those specific locations, their applicability to broader, more global situations can be limited due to individual characteristics in play. Observations in certain populations, for example, resettled refugees, in specific resettlement nations may not be comparable to other migrant cohorts such as migrant workers or spontaneously arriving asylum seekers either in the same country or in

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other in other locations. In the majority of the situations, health care providers and health policy developers dealing with migrants need to consider the specific issues related to the phases of migration and the demographics of the individual populations involved in their area. This allows the development of tailored effective health promotional, preventive, and interventional activities for the migrant communities at hand. Focusing the social determinants of health and ensuring adequate access to the full spectrum of health services is more important at the global level than the comparison of disease or condition-specific outcomes in different populations at different locations. There are, however, some general conditions and concerns presented by some specific populations that can be more widely applied. Exposure to violence, trauma, and torture is more frequently encountered by refugee and displaced migrants. The routine evaluation for the psychosocial consequences of these events in these populations can be indicated. There are differences in the epidemiology of some malignancies (Small et al. 2017) related to disparate social determinants of health, the detection of which can be increased through the use of targeted testing, or investigation which can be generally indicated. Additionally, some migrant populations can originate from locations where specific health risks are more prevalent, examples being exposure to lead or micronutrient deficiencies. Yet those conditions represent a minority of the spectrum of noncommunicable diseases. In this regard, it is more important that migrant-sensitive health services are developed on more inclusive, health determinant-based approaches rather than disease specific initiatives that may not be widely useful across diverse migrant communities. Health services designed to be culturally and linguistically supportive, often including migrants themselves as members of the health care team have been shown to improve outcomes and patient compliance in migrant populations. Migrant health approaches of this type have been shown to improve the understanding and uptake of preventive services such as screening for disease, which may be new to those arriving from regions of less developed health services. Illnesses and diseases identified by migrant-oriented health services are then dealt with through the regular national medical services sector, although some degrees of support usually linguistic or cultural may be required by migrant patients. The majority of study and investigation into the health of migrants compares findings in that population to the host population. Because of the historical relationships between migrants and communicable diseases such as tuberculosis where prevalence was greater in migrant populations, it is commonly believed that health indicators are generally worse in those populations. In fact, in terms of noninfectious diseases, many migrants arrive in states of health that are better than those of similar cohorts of the host population, a factor known as the healthy migrant effect. Examples are presented by health determinants such as weight and body mass index, dietary habits, maternal child heath, and some risk-taking behaviors such as substance use and abuse or the acquisition of sexually transmitted infections (Brännström et al. 2017). Over time, longitudinal studies have shown that some of these positive health indicators may actually deteriorate after the migrants’ arrival.

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Sustaining the attributes associated with the healthy migrant effect is an important area of study and research in many nations with large migrant populations.

Health Issues in Specific Migrant Populations Migrant Workers The largest global migrant population is made of migrant workers representing nearly 65% of the migrants on the planet. In addition to the influences affecting health related to the phases of migration common to all migrants, this large migrant cohort can be exposed to a variety of occupational and work-status related risks. While large numbers of migrant workers are involved in organized and regular occupations where some basic levels of safety and medical services are included, many other migrant workers are found in the unofficial or unregulated employment sector. In the latter situation, attention to occupational health and safety may be weak to nonexistent, depending on the workplace. Additionally, in several locations, migrant workers are involved in activities that have greater occupational health risks, the so-called dirty, dangerous, and demeaning jobs. Rates of occupational illness and injury are frequently elevated in migrant workers compared to nonmigrant cohorts. Migrant workers may not have the same access to compensation or insurance as nonmigrant workers and those who acquire chronic disease or disability during their employment can pose significant hardships on their families and community following their return to their origin. Other important social health determinants are associated with migrant labor. These include the location and nature of accommodation or provided. For example, poor housing and over-crowding can facilitate the spread of communicable diseases such as tuberculosis and the location of some industries involving migrant labor may result in the exposure to endemic diseases not prevalent at the migrants place of origin. The isolation and family separation experienced by many migrant workers can be associated with increased risk-taking behaviors such as substance abuse and exposure to sexually transmitted infections. Additionally, vulnerable migrant workers may be subject to physical violence, sexual and economic exploitation. From a global population health perspective, it is important to note that in addition to the deleterious impacts and outcomes associated with migrant workers, there are as well important positive consequences. The earnings remitted to the families and countries at the workers origins are an important and growing component of the global economy. In 2018 international remittances by migrant workers approached $ 700 billion USD (IOM 2020). From a population health perspective it is important to note that the benefits of those remittances include the improved determinants of health for the families of those recieiving them. Additionally, in the context of the global health, it is equally important to acknowledge that migrants working in the health sector make up a large and increasing component of the health labor force in many countries. In the industrialized nations, migrant health care workers are essential to the provision and delivery of services. At the same time these movements are related to the global shortage in the health workforce experienced in some regions (Aluttis et al. 2014).

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Refugees and Displaced Populations While representing less than a quarter of the global migrant population refugees, asylum seekers and the displaced experience some of the greatest health risks of all migrants. In addition to the health impacts and determinants experienced by all migrants, these communities are more frequently subject to violence, conflict, deprivation, and danger. Those forces are magnified in situations of rapid displacement such as experienced in the Middle East in 2014–2016 where large numbers of people quickly left the region, many by dangerous or life-threatening means. These groups often suffer the greatest mortality associated with the movement phase of migration. Additionally, their exposure to trauma and torture places them at elevate risks of long-term psychosocial illness such as PSTD. In addition to the health risks and consequences associated with the journey, those applying for asylum after arrival at a destination can experience specific health risks and effects related to the refugee determination system itself. Depending on location and situation, access to health and medical services may be limited for those in the asylum process. While emergency or urgent services may be provided, health promotion, prevention, and care for chronic conditions may not be available and access to national health insurance schemes may not be available to those who do not yet have status. Again, depending on the location and national requirements, those in the process of having their claims assessed may be subject to work restrictions or even detention which can produce downstream consequences in terms of the social determinants of health. Irregular and Undocumented Migrants From a population health perspective, irregular and undocumented migrants present numerous challenges. Their very nature ensures that understanding regarding the size and demography of these populations are estimates. As their lack of status can be associated with administrative or legal consequences, they may avoid interaction with others or institutions where they reside, including health and medical services and providers (Martinez et al. 2015). This results in greater risk of illnesses and medical needs coupled with lack of solid information on the nature and scope of their problems. When they exist, health and medical services for these communities are frequently provided by humanitarian services and detailed information may not be collected or collated making population-based assessment on their health challenging. They remain migrant populations with greater but less defined needs and that lack of definition extends to understanding of the long-term health impacts of these cohorts.

The Nature and Scope of Migration Health Information There is no unified or systematic global convergence place for the science and study of the health of migrant populations. The history and evolution of migration have created health issues and situations that have been areas of interest across a wide spectrum of the bio-medical sector.

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At global level, the International Organization for Migration (IOM), which originated in 1951 as an intergovernmental organization and which in 2019 became part of the United Nations system, has a migration health unit within its organizational structure. Several aspects of health and migration are supported, analyzed, and reported by IOM. IOM also maintains the Global Migration Data Portal which itself is home to migration health information. Also located within the UN is the Office of the High Commissioner for Refugees (UNHCR) that is globally responsible for refugees, displaced populations, asylum seekers, and stateless populations. Health relevant information about those populations is frequently considered and reported by UNHCR. The International Labour Organization (ILO) is a UN agency whose origin extends back to the League of Nations after the First World War. Its work and publications are often relevant in terms of the health and wellbeing of migrant workers. The United Nations Department of Economic and Social Affairs (UNDESA) is penultimate source of global migration statistics which are used by many other organizations, agencies, and researchers. Another component of the UN system, the World Health Organization has global responsibilities for promoting the health of migrants and refugees and working to achieve universal health coverage for all including migration populations. Within the WHO organizational structure, some of its regional offices, such as the Regional Office for Europe, have specific interest in migration health and are major sources of migrant health information. Outside of the UN system, the Organization for Economic Cooperation and Development (OECD) collects and reports migration-relevant information as does the World Bank. At the policy level, the Migration Policy Institute reports on some health relevant topics. Historical relationships to quarantine and port health activities resulted in a large amount of attention in the field being devoted to communicable diseases. That association continues and is reflected in the wide interest and investigation by the infectious disease community into the interface between migration and epidemiology and management of infectious diseases at national, regional, and international level. The European Center for Disease Control, for example, is a major source of migrant health information at global level. The same is true in the United States where the Centers for Disease Control and Prevention contains a global migration unit. Interests in those institutions extend to field of emerging and re-emerging diseases and international disease control where publications describing the role of migration in those processes are common. Nations where immigration has been a long-standing component of population growth, such as Australia, Canada, the UK, and the USA and others, frequently monitor and report on various aspects of health and demography related to migration. The growing recognition that Europe has become a region of immigration has been associated with increased attention at nation level there directed at migrant health. Health organizations in many European nations including France, Germany, Italy, The Netherlands, the Scandinavian nations, and the UK monitor and report several aspects of health and migrant populations. This information may be produced by national statistical, public health or health policy agencies. Organizations dealing with social determinants of health, particularly those in countries or regions

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Table 4 Sources of migration health-relevant information (representational and noninclusive) Sources of globally relevant migration health information Area of Organization interest Location/Website IOM Global https://www.iom.int/ Migration Data Portal Global https://migrationdataportal.org/?i¼stock_abs_& t¼2019 UNHCR Global https://www.unhcr.org/ ILO Global https://www.ilo.org/global/lang%2D%2Den/index. htm UNDESA Global https://www.un.org/development/desa/pd/themes/ international-migration WHO (Geneva HQ) Global https://www.who.int/health-topics/refugee-andmigrant-health#tab¼tab_1 WHO (Europe) Regional https://www.euro.who.int/en/health-topics/healthdeterminants/migration-and-health OECD Global https://www.oecd.org/migration/ World Bank Global https://www.worldbank.org/ Migration Policy Institute https://www.migrationpolicy.org/ Global Migration and Global https://www.glomhi.org/about.html Health Initiative ECDC Regional https://www.ecdc.europa.eu/en CDC National https://www.cdc.gov/ncezid/dgmq/index.html

of significant migration or refugee flows, often report or publish migrant-health relevant information. Finally, at more clinical levels, societies and organizations involved with infectious diseases, tropical medicine and travel medicine, cultural and ethnic health may consider migrant health as a specific area of interest. The result of all of this attention and interest in the subject area is the availability of large amounts of information and data on aspects of migrant health. Reflecting where and why it is gathered, however, means that it often lacks global perspective. As noted elsewhere in this chapter, the diversity of migrant origins and destinations coupled with the differences within and between migrant populations themselves makes the global population-based comparison of findings and outcomes challenging. Initiatives based on cooperative, international collaboration using standardized terms and methodology and involving multiple locations are now more prevalent. They will support the development of broad migrant health information and insights of greater global perspective (Table 4).

Conclusion Migration represents one of the important components that enhance and support global interdependence across the planet. As noted in this chapter, if migrants alone were considered residents of a single nation, it would be the fourth largest nation in

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the world. Global migration has huge economic and global development impact related to both, the work performed by migrant labor and the remittances returned to their places of origin. As such it is a key factor in collaborative undertakings to build a better world through reduced disparities. In a related manner, migration is becoming a critical element in the dynamics of population demography in nations of aging populations and low birth rates. Several industrialized nations and economies are or will be dependent on migration to support and sustain their workforce as well as economic and social environments. Given the importance of migrants in these processes monitoring, sustaining and improving the health of migrant populations can be expected to become increasingly important areas of interest and activity at national, regional, and international level. At the same time migration provides both a mirror and a window through which existing disparities and inequities across and between global regions can be recognized and observed. The health of migrant populations reflects both adverse and beneficial health indicator and outcome differences between migrant and host or transit populations. These outcomes can be used as global indicators for locations where action is required to reduce levels of poor health. At the same time, monitoring the prevalence of health outcomes in migrant populations can be used as a tool to assess the impact of efforts to improve health over time. Global programs to reduce the prevalence of tuberculosis or malaria, for example, should be associated with diminishing rates of those diseases in migrant populations originating from regions of increased endemicity. Additionally, refugees, the displaced and other vulnerable migrant populations, provide views of the medical, health, and social impacts and consequences of conflict, disaster, and violence. These migrant cohorts carry those consequences and sequelae of those events through transit and host destinations. They represent some of the migrant communities at greatest risk and in greatest need and continue to remind the rest of the world of the human cost of those situations. For primarily historical reasons, considerable attention in the area of migrant health remains centered on infectious and communicable diseases. In the majority of situations, differences in the prevalence of diseases of this type are the result of preexisting global disparities in the geographic and social determinants of health and migrants simply reflect the fact that many illnesses are unequally distributed across the planet. Investigation into situations where infections are more prevalent in migrants continues to show that while rates of certain infections may remain elevated, risks of transmission to host or nonmigrant populations are marginal. There are real risks of international disease transmission associated with international travel in some situations, such as those observed in the 2019–2020 SARSCoV-2 pandemic (Peeri et al. 2020). These events, however, are not related to migration per se but to the volume and dynamics of international travel in general. Migrants do represent important populations in some locations, in regard to some chronic infections or those with long latency periods. In resettlement locations where those infections have been diminished or significantly reduced such as tuberculosis, targeted screening or interventions may be needed as components of integrated control activities. It must not be overlooked, however, that primary prevention

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through the elimination of the precipitating disparities such as the global differences in tuberculosis incidence would eliminate the subsequent risks in migrants originating from those locations. As described in this chapter, aspects of health other than those related to specific diseases are receiving more attention in the sphere of migrant health. Populationbased outcomes in relation to economic and social determinants of health are assuming greater global study. In this regard it is apparent that many health issues present in migrant populations result from limited or reduced access or use of health services. Some of those limits are structural, in the case of lack of access to health insurance due to immigration or citizenship status. Others are the result of poverty or social cultural barriers to care. Whatever their origin most of these would be dealt with through the domestic health care system if access and availability were ensured (Onarheim et al. 2018). Improving access through facilitated culturally and linguistically appropriate services would reduce or eliminate many of the adverse health outcomes experienced by migrant populations. At the global level, the betterment of migrant health requires the understanding and integration of migration into ongoing and planned collaborative international policies and programs intended to improve global health and reduce inequity and disparity (Matlin et al. 2018). This includes efforts to mitigate or prevent conflict, mange environmental or humanitarian emergencies, and improve the income and conditions for migrant workers (McKinsey Global Institute 2016). The health of migrant populations is primarily an indicator of global health disparities. When those disparities decrease adverse health outcomes in migrant populations will follow suit.

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United Nations (2018) Global compact on migration. Press Release. https://www.un.org/en/conf/ migration/assets/pdf/GCM-Press-Release-12112018.pdf United Nations (2020) Global issues, migration. https://www.un.org/en/sections/issues-depth/ migration/index.html#:~:text¼The%20UN%20Migration%20Agency%20(IOM,the%20causes %20for%20the%20movement United Nations, Department of Economic and Social Affairs, Population Division (2019a) International migrant stock 2019 (United Nations database, POP/DB/MIG/Stock/Rev.2019). www. unmigration.org United Nations, Department of Economic and Social Affairs, Population Division (2019b) World population prospects 2019: highlights (ST/ESA/SER.A/423). https://www.un.org/development/ desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/wpp2019_high lights.pdf United Nations, Department of Economic and Social Affairs, Population Division (2019c) International migration 2019: report (ST/ESA/SER.A/438). https://www.un.org/en/development/ desa/population/migration/publications/migrationreport/docs/InternationalMigration2019_ Report.pdf WHO. Regional Office for Europe (2018) Report on the health of refugees and migrants in the WHO European Region. https://apps.who.int/iris/bitstream/handle/10665/311347/ 9789289053846-eng.pdf?sequence¼1&isAllowed¼y Zimmerman C, Kiss L, Hossain M (2011) Migration and health: a framework for 21st century policy-making. PLoS Med 8(5):e1001034. https://doi.org/10.1371/journal.pmed.1001034

Part IV Global Burden of Disease

Global Burden of CVD Prevalence, Pattern, and Trends

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K. Srinath Reddy and Manu Raj Mathur

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Burden of CVD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ischemic Heart Disease (IHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiovascular Risk Factor Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diet and Low Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . High Low-Density Lipid (LDL) Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Economic Burden of Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Sources on Global Burden of Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interventions to Reduce CVD Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fiscal and Intersectoral Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Health Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health System Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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K. S. Reddy (*) Public Health Foundation of India, New Delhi, India e-mail: ksrinath.reddy@phfi.org; ksr@phfi.org M. R. Mathur Public Health Foundation of India, Gurgaon, India e-mail: manu.mathur@phfi.org © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_24

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Abstract

Cardiovascular Diseases (CVDs) are a global threat to health and sustainable development. CVDs contribute to a major part of the overall disease burden with ischemic heart disease and stroke as the primary contributors of global mortality. Although, incident cancers have replaced CVDs as the most prevalent disease condition in high-income countries, CVDs are still the foremost cause of mortality and morbidity in low- and middle-income countries. Social determinants of health and behavioral risk factors such as tobacco, age, unhealthy diet, physical inactivity, high cholesterol, obesity, and alcohol use are the factors behind this continuously growing epidemic. Economically, CVDs also causes an indirect and/or direct burden on the individual as well as the community. The global health policy agenda has finally started recognizing CVDs and reducing CVD mortality is one of the key indicators of the United Nation’s Sustainable Development Goals. Mostly preventable with the elimination of its risk factors, developing a stronger evidence and implementing interventions (fiscal and intersectoral, health system, community-based and public health interventions) hold the key to lower the CVD burden and improve cardiovascular health globally. Keywords

Cardiovascular disease · Non-communicable diseases · Risk factors · Mortality · Sustainable Development Goal

Introduction Cardiovascular diseases (CVDs) are diseases of the heart and blood vessels, which include mainly “Ischemic Heart Disease (IHD), hypertensive heart disease, rheumatic heart disease and cerebrovascular disease or stroke” (World Health Organization 2015). Regarded as the primary cause of mortality globally (Prabhakaran et al. 2016) contributing to 32% deaths. The global burden of CVDs are currently estimated to be nearly 8 times than its mortality. IHD is the leading cause of early death and disability in high income countries in 2016 and is predicted to hold its position by 2040 (Fig. 1) (Institute for Health Metrics and Evaluation (IHME) 2018). A distinct second leading cause of death above the age of 60 years is stroke. On similar lines, the prevalence rate for Hypertensive heart disease in 2017 was also estimated to be 223 per 100 k. In the wake of its increasing burden the third Sustainable Development Goal (SDG) has also recognized its importance by embarking a one-third reduction in premature mortality due to Non-Communicable Diseases (NCDs) (United Nations 2018). The World Health Organization, estimates 17.9 million CVD deaths annually of the total NCDs deaths (41 million/annually), substantially more than the estimated nine million cancer deaths globally (World Health Organization 2018). These figures, however, represent the tip of the cardiovascular iceberg, a larger proportion of individuals have the asymptomatic disease and other undetected risk factors.

Fig. 1 The leading causes of early death and disability worldwide

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Global Burden of CVD At age 24, your risk for CVD is just 20%. By age 45, your chances more than double to 50%. 90% percent of individuals over the age of 80 have some form of CVD. (American Heart Association 2017)

Nearly 70 years after the Framingham Heart Study, considerable progress has been made in reducing mortality from CVDs in high income countries. The Prospective Urban and Rural Epidemiologic (PURE) (Rangarajan et al. 2019) study published in the Lancet highlights that cancer is now the foremost cause of death in High-Income Countries (HIC) while CVDs persevere in Low-Income Countries (LIC) and Middle-Income Countries (MIC). The ratio of Ratio of CVD to Cancer Deaths has been estimated as “0.4(HIC); 1.3 (MIC); 3.0 (LIC).” To elaborate, the mortality of CVDs in 2017 for low middle- income countries was estimated to be 28% which is much higher than the global estimate of 18% in the year 1990. Highincome countries like United States and United Kingdom also have a mortality of 31.5% and 29%, respectively. To elucidate further, countries with low Sociodemographic Index (SDI) have a mortality of (18%); middle SDI (36%), and high SDI (32%) (Fig. 2). The World Health Organization (World Health Organization 2019b) puts forth the fact “four out of five CVD deaths are due to IHD and stroke, and one third of these deaths occur prematurely.”

Ischemic Heart Disease (IHD) Mankind’s greatest epidemic: Ischemic Heart Disease has reached enormous proportions striking more and more at younger subjects. It will result in coming years in the greatest epidemic mankind has faced unless we are able to reverse the trend by concentrated research into its cause and prevention. (WHO 1969)

Fig. 2 Cardiovascular diseases, both sexes, all ages, 2017, percent of total deaths

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Table 1 Statistics: ischemic heart disease

Indicator Prevalence rate per 100,000 Incidence rate per 100,000 DALYs rate per 100,000

1990 1340 130 2215

2005 1478 143 2177

2017 1655 139 2229

Table 2 Statistics: stroke

Indicator Prevalence rate per 100,000 Incidence rate per 100,000 DALYs rate per 100,000

1990 988 126 1833

2005 1062 137 1756

2017 1364 156 1728

Ischemic Heart Disease (IHD) is now the leading cause of death worldwide; and “has become a true pandemic that respects no borders” (World Health Organization 2019b). Globally, approximately 16% men and 15.8% women die worldwide from IHD. According to the Global Burden of Disease Study, the LMICs contributed 4% of the 13% global deaths from IHD in 1990. The dynamics of the IHD epidemic has also changed in terms of “pattern, magnitude, and timing” (The global burden 2010). The burden of mortality for IHD remains high across Europe 26% and the rest of the world at 16% (Table 1).

Stroke Remarkably, stroke remains the second leading cause of death worldwide, with 11% of deaths attributed to this cause in 2017. Fewer men (10%) than women (12%) died from stroke in the year 2017. Women and men had similar age-specific incidences at ages up to 55 years, but the rates were greater in men at 55–75 years, flattening out at ages older than 75 years (Table 2) (Global Burden of Disease (GBD) 2017).

Cardiovascular Risk Factor Burden The number of people with multiple cardiovascular risk factors is increasing alarmingly. Cardiovascular health burden like general health is also affected by social determinants of health which are influenced by the context, structural and transitional determinants. Behavioral risk factors such as tobacco, unhealthy diet, physical inactivity, high cholesterol, obesity and alcohol use also have a substantial contribution to the continuously growing CVD epidemic (Fig. 3). Evaluation suggest 40–50% of the premature mortality caused by NCDs are preventable by managing its risk (World Health Organization 2010a). The morbidity and mortality from CVDs mainly occurring in adulthood and/or old age results from the exposure to risk factors that begin early in life. The economic changes associated with sedentary lifestyle has also substantially increased the prevalence of risk factors for CVDs.

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Fig. 3 Leading risk factors causing early death and disability

Age CVDs are one of the leading causes of premature death across the globe. Evidence suggests that CVD risk factors begin in childhood and is directly associated with the same CVDs outcomes as that of the adults. Estimates suggest risk factor such as obesity has a marked increase in its numbers in high income countries; Diabetes, previously rare in childhood is also climbing the ladder in countries such as North America, Japan, and Thailand. The incidence of CVDs has also radically increased in young adults (15–49 Years) at 263 per 100,000 population in 2017 from 241 in 1990. In the year 2017, 66% of global deaths are also attributed to dietary risk factors for the age group 15–49 years. Similarly, in the same age group 4% mortality is attributed low physical activity. Although, data on incident cases of CVDs in the age group of 15–49 years is limited, and estimates are often associated with broad confidence intervals (Andersson and Vasan 2018). To summarize, the complications of cardiovascular disease (CVD) are usually seen in later years of life. However, the predecessor for diseases such as IHD, cerebral artery disease and peripheral artery disease begin early in life and progresses gradually through adulthood.

Hypertension The risk of cardiovascular disease doubles for every 10-point increase in diastolic blood pressure or every 20-point increase in systolic blood pressure. (World Health Organization 2010b)

Globally, hypertension has the dubious distinction of being the primary predictor of CVD mortality since 1990 regardless of Socioeconomic Status. Globally, 24% of adult men (18 years of age) and 21% of adult women have hypertension (defined as 140/90 mm Hg) (CDRF Collaboration 2017). Current estimate evaluation suggests that the hypertension burden in HIC have significantly reduced. Conversely, MICs and LICs have experienced an increase in population BP levels (Table 3). High systolic blood pressure and smoking has also been established as the primary risk factors causing early death and disability for all ages (Fig. 3) (Institute for Health Metrics and Evaluation (IHME) 2018).

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Table 3 Statistics: cardiovascular deaths attributed to high systolic pressure (risk factor)

70 60 50 40 30 20 10 0

429 Indicator Global (%) High SDI (%) Middle SDI (%) Low SDI (%) 60

52

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2017 55 48 56 52

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GBD Super Regions

Fig. 4 Cardiovascular deaths attributed to diet (risk factor)

Diet and Low Physical Activity Nutrition is one of the most prominent preventable risk factors of CVD, with approximately 53% of CVD deaths attributable to this risk factor in 2017 a slight reduction from 57% in 1990, in part as a result of its effects on other major CVD risk factors. The GBD super regions also estimate a similar pattern as the global countries (Fig. 4). In terms of single dietary risks, a diet low in whole grains accounted for approximately 16% deaths, followed by a diet high in sodium (15%), a diet low in fruits (11%), and a diet low in omega-3 fatty acids (8%). Low physical activity has also stuck globally on the ninth rank for stroke mortality since 1990, and has remain constant throughout the varying SDI.

High Low-Density Lipid (LDL) Cholesterol Hypercholesterolemia, particularly high LDL, became globally a major contributor to deaths in age group (15–49 years) between 1990 and 2017. To elaborate the percentage of deaths attributed in low SDI (15–49 years) increased to 31% from 25% in 1990. Following a similar trend for ages 50–69 years at 29% for the year 2017.

Tobacco Tobacco smoking is the fifth leading cause of stroke in 2017. Approximately 35–40% of smoking-related deaths have also been acknowledged to CVDs. Nonsmokers who are often exposed to tobacco smoke also have an increased the risk of CVDs morbidity and mortality by 25–30% (Centers for Disease Control and

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Percentage

25 20

18

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Global

Global High SDI High SDI High SDI Middle Middle Middle Low SDI Low SDI Low SDI SDI SDI SDI

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GBD Super Regions

Fig. 5 Cardiovascular deaths attributed to diabetes (risk factor)

Prevention 2010). Another invention that is increasing in popularity are e-cigarettes. Recent epidemiological studies have also estimated the prevalence of current use of e-cigarettes as 3.8% in United States (USA) and 1.8% in the European Union (Benowitz and Fraiman 2017). However, the evidence on the effect of e-cigarettes on cardiovascular outcomes is still in its nascent stages.

Alcohol Alcohol, as a CVD risk factor, has epidemiological evidence from observational studies and metanalysis showing a nonsignificant protective effect on cardiovascular outcomes. The global rank for stroke fatality percentage related to alcohol drinking has thus risen from the ninth rank in 1990 to seventh in 2017. No change in rankings of this risk factor was observed in men during this period. Still being a debatable risk factor, more data is required to explore particular subgroups that might be impacted by alcohol consumption.

Diabetes Diabetes is a crucial risk factor for coronary heart disease and stroke, and is on same rank fourth since 1990 (Fig. 5). A higher proportion of obesity is also observed in HICs than LMICs, which can contribute to the occurrence of first stroke at younger ages in countries of lower-income level. Currently, USA, China, India, Japan, and Indonesia are the top five countries with the largest numbers of people aged 20 and above with diabetes.

Economic Burden of Cardiovascular Disease Out of pocket expenditure is often seen as the primary source of purchasing cardiac health care services in many developing and developed countries which can then cause indirect and direct effect on the global economy. CVDs significantly contribute

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Fig. 6 Cardiovascular disease death rate Vs GDP per capita, 2017

to the increasing cost burden globally, from US$863 billion in 2010 to US$1044 billion in 2030 (World Heart Federation 2019). Drugs prescribed for LDL reduction generated 13.9$ in the year 2003 in United States. To elaborate, in a recent study Gheorghe et al. (CDRF Collaboration 2017) (2018) “the costs per episode for hypertension and generic CVD were generally homogeneous across studies, ranging between $500 and $1500. In contrast, for coronary heart disease (CHD) and stroke, cost estimates were higher and more heterogeneous, with several estimates in excess of $5000 per episode.” These inconsistencies have “tremendous implications for diminished earnings potential, labour productivity and stress on our health care system” (American Heart Association 2017). The study also highlighted the data sources, studies included was generally poor and more robust data especially from sub-Saharan Africa, Central America and Eastern Europe (Fig. 6).

Data Sources on Global Burden of Cardiovascular Disease Only 8% of published cardiovascular research is from developing countries, although lowand middle-income countries shoulder 80% of the disease burden. (World Health Organization 2010b)

Despite the political commitment to improve CVD outcomes by 2030, the existing evidence on the CVD burden in LMICs does not appear to be robust with regard to research data and methods. The two most prominent studies to date are MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) (World Health Organisation 2019a), involving teams from 38 populations in 21 countries from the mid-1980s to the mid-1990s, and the GBD (Global Burden of Disease) (CDRF Collaboration 2017) study, which has now complied together data using many sources covering much of the world. Statistically, the Number of published clinical trials on humans in any language in the National Library of Medicine‘s PubMed in the year 2004 is a mere 57,507 for Coronary Heart Disease. The top three countries with the highest number of publications on cardiovascular

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disease indexed in Medline (1991–2001) are USA (12502), Japan (3769), and UK (2667) (World Health Organization 2010b). Most of the HIC and MIC have the Guidelines for management of CVD and Drug therapy/counselling to prevent heart attacks and strokes (Chigom 1988). However, there is currently a lacuna on standardized guidelines from LMICs.

Interventions to Reduce CVD Burden It is evident that CVDs are one of the major cause of mortality and morbidity worldwide. Apart from contributing significantly to the health burden, CVDs have a substantial impact on the other pillars of sustainable development too. CVDs share some common risk factors and determinants with other NCDs. Broader fiscal and public health interventions addressing these risk factors and determinants will not only aid in reducing the burden of CVDs but for the entire spectrum of NCDs. Some of these interventions are outlined below including fiscal and intersectoral interventions, public health interventions, community-based interventions, and health system interventions.

Fiscal and Intersectoral Interventions • Legislative measures to control the sale and distribution tobacco products (e.g.: Taxes, Regulations on Advertising) Tobacco taxation and advertising has been proven to be the single most effective way to encourage tobacco users to quit it. An increasing number of countries are now embracing taxes raised on tobacco for antismoking activities or other specific activities. World Health Organization recommends 75% of retail prices as excise tax on tobacco products (World Health Organization 2014). Many countries apply different types of taxes and/or tax rates on different types of tobacco products. In India for example, the introduction of the Goods and Services Tax (GST) in 2017, have led to all tobacco products — cigarettes, bidis and smokeless tobacco attract the highest tax rate of 28%; however, it is well below the WHO recommendation. Recent studies have nevertheless estimated a decrease in consumption of all tobacco products post GST (John et al. 2019). Another example of a successful tobacco and/or alcohol tax is the “Sin Tax” implemented in Philippines, the tax has collected around 22 billion Philippine Peso as revenue in its first year (Paul 2015). However, subject matter experts continuously accentuate that the current tax is not sufficient and more stringent policies and tax measures need to be implemented. • School-Based Programs Various single interventions among school children particularly targeting reduction in tobacco use and promoting hygiene have been tested in different countries (Monse et al. 2013), but most of them do not cover the comprehensive and sustainable interventions of promoting health in school settings. There are

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many stakeholders working in multiple approaches independently for promoting behavior change such as tobacco control, reduction in sugar consumption, and encourage physical activity. Considering the personnel, resource, and material constraints within which the LMICs health system functions, decisions about choosing one program over another are often shadowed by theoretical, implementation capacity (practicability), and financial concerns. Upstreaming comprehensive school-based health interventions can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt longterm, healthy dietary behaviors and physical activity across their life course.

Public Health Interventions • Dietary Intervention: Elimination of trans fat, promotion of healthy foods (including support for subsidies), promotion of decreased salt consumption, and reductions in content in processed foods. The relationship between diet and coronary heart disease has been explored in many studies. The World Health Organization (WHO) in 2018, proposed a guide to exclude the “industrially-produced trans-fatty acids from the global food supply chain” (WHO 2018). An increased Sugar Sweetened Beverages (SSBs) consumption is also associated with higher intake of discretionary food in adults (An 2016) and adolescents (Mathias et al. 2013; Ranjit et al. 2010). The consumption of Sugar Sweetened Beverages can also be associated with television viewing and screen time (Monse et al. 2013; WHO 2018). Likewise, advertisements and programs promoting the use healthy food habits can be a game changer. The World Health Organization in 2017 also endorsed reducing intake of added sugars in foods and drinks. It recommended reducing intake of added sugars to less than 10% of total energy intake for adults (about 12 teaspoons per day). A leading example in reducing the consumption of Sugar Sweetened Beverages (SSBs) is the campaign “First Came Obesity, Then Diabetes” (Powell et al. 2017; Sisson et al. 2012; Raynor et al. 2013; Sonneville et al. 2012; BarrAnderson et al. 2009; Giammattei et al. 2003; EPHA 2017) in Mexico City from November 2012 to February 2013. In January 2014, the government of Mexico added a 1 peso per liter excise tax on any nonalcoholic beverage with added sugar to the country’s Special Tax on Production and Services. Many countries have followed suit with their own version of “Sugar Tax” which has shown to contribute to significant public health gains.

Community-Based Interventions • Training of Community Health Workers (CHW): for screening for CVD using both simple paper-based non-lab risk scores, encouraging adherence to therapies and mobile technologies. CHW play a pivotal role at the grassroot level in

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management of CVDs. Endorsed by WHO; successful community-based interventions have been carried out in Indonesia between 2003 and 2006 (Centre for Disease Control Research and Development NHRD Ministry of Health Republic of Indonesia in Collaboration with World Health Organization 2006), to reduce risk factors for NCDs. Training CHW workers in simple and complex scoring tools can also give beneficial outcomes and robust surveillance data also on CVDs. • Diabetes self-management: Self-management is a relatively new concept, evolved with the introduction of mobile technology and Internet. Alterable with health literacy of a particular individual, supporting patients with instructing programs and apps can reduce the burden on the health system.

Health System Interventions • Opportunistic screening for hypertension and overall CVD risk scoring: Opportunistic screening can be upscaled in LMICs at the primary health care level to introduce an early intervention. • Tobacco cessation counselling at the level of primary care: Focusing on a wholesome education, tobacco counselling should be continuously repeated with each visit of the patient through several weeks and months. Special emphasis should be given to patients who have been successful in quitting. • Management of Ischemic heart disease, PAD, ischemic stroke should be undertaken at Primary Care Level through generically priced individual and fixed-dose combination therapy for high CVD risk and secondary prevention through aspirin, beta-blockers, ACE-Inhibitors/ARBs, and statins. • Continuous availability of essential medications at Primary Health Centers for diabetes, hypertension, diabetes, and lipids.

Conclusion In order to reduce the burden of mortality and morbidity from CVDs, there is a need to focus on developing robust and resilient health systems with focus on primary healthcare, concentrated action on social determinants of health, and integrated multi-sectoral interventions. The CVD epidemic across the globe is accelerated by the economic and cultural globalization. Developing a stronger evidence base of the knowledge of risk factors and their determinants as well as implementing proven effective strategies (both at individual as well as societal level) for CVD risk reduction hold the key to lower CVD burden and improve cardiovascular health globally. By taking this path, the world can move towards attaining the Sustainable Development Goal of a 30% reduction in premature mortality attributable to NCDs by 2030.

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Powell LM, Wada R, Khan T, Emery SL (2017) Food and beverage television advertising exposure and youth consumption, body mass index and adiposity outcomes. Can J Econ Can d’économique 50(2):345–364 Prabhakaran D, Jeemon P, Roy A (2016) Cardiovascular diseases in India: current epidemiology and future directions. Circulation 133(16):1605–1620 Rangarajan S, Md J, Lamelas P, Teo K, Attaei MA, Boström B et al (2019) Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study. Lancet Glob Heal 7:e748–e760 Ranjit N, Evans MH, Byrd-Williams C, Evans AE, Hoelscher DM (2010) Dietary and activity correlates of sugar-sweetened beverage consumption among adolescents. Pediatrics 126(4): e754 Raynor HA, Steeves EA, Bassett DR, Thompson DL, Gorin AA, Bond DS (2013) Reducing TV watching during adult obesity treatment: two pilot randomized controlled trials. Behav Ther 44(4):674–685 Sisson SB, Shay CM, Broyles ST, Leyva M (2012) Television-viewing time and dietary quality among U.S. Children and Adults. Am J Prev Med 43(2):196–200 Sofia JIS, Li X-M, Zhao Q, Zhao Q, Ma Y-T, Yang Y-N, et al (2014) Background, development and organization of MONICA # 1 background to the WHO MONICA project. BMJ Open 8:1–40. Accessed on: 2020 Dec 6. Available from: http://www.depkes.go.id/download.php?file= download/pusdatin/infodatin/infodatin-jantung.pdf Sonneville KR, Rifas-Shiman SL, Kleinman KP, Gortmaker SL, Gillman MW, Taveras EM (2012) Associations of obesogenic behaviors in mothers and obese children participating in a randomized trial. Obesity (Silver Spring) 20(7):1449–1454 The global burden of coronary heart disease – Medicographia. 2010 United Nations (2018) Transforming our world: the 2030 agenda for sustainable development. In: A new era in Global Health. United Nations, New York U.S. Department of Health and Human Services (2010) How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. Accessed on: 2020 Dec 6. Available from: https://www.ncbi.nlm. nih.gov/books/NBK53017/ WHO (1969) World Health Organization warns heart diseases are becoming mankind’s greatest epidemic. Bull Int Soc Cardiol (1):1.Apud WHO plan to eliminate industrially-produced trans-fatty acids from global food supply. 2018 World Health Organization. Prevention of Cardiovascular Disease: pocket guidelines for assessment and management of cardiovascular risk. World Health Organization. 2007 [Accessed on: 2020 Dec 6]. Available from: https://www.who.int/cardiovascular_diseases/guidelines/Full% 20text.pdf. World Health Organization (2010a) Global status report on noncommunicable diseases. Chapter 1: Burden: mortality, morbidity and risk factors. WHO. World Health Organization; 2010a [Accessed on: 2020 Dec 6]. Available from http://www.who.int/nmh/publications/ncd_ report2010/en/ World Health Organization. The Atlas of Heart Disease and Stroke. WHO. World Health Organization; 2010b [Accessed on: 2020 Dec 6]. Available from https://www.who.int/cardiovascular_ diseases/resources/atlas/en/ World Health Organization (2014) Tobacco – taxation World Health Organization and Department of Noncommunicable Diseases and Environmental Health (2015) ‘Cardiovascular Diseases fact sheet’, World Health Organization. Department of Noncommunicable Diseases and Environmental Health [Accessed on: 2020 Dec 6]. Available from http://origin.searo.who.int/entity/noncommunicable_diseases/advocacy/fact-sheet-oncvd-2015.pdf

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World Health Organization (2018) Noncommunicable diseases. World Health Fact Sheet, Geneva [Accessed on: 2020 Mar 12]. Available from https://www.who.int/newsroom/fact-sheets/detail/ noncommunicable-diseases World Health Organization (2020a) Cardiovascular diseases. Accessed on: 2020 Mar 19. Available from: https://www.who.int/healthtopics/cardiovascular-diseases/#tab=tab_1 World Health Organization (2020b) [Accessed on: 2020 Dec 6]. Available from: https://www.euro. who.int/en/health-topics/disease-prevention/tobacco/publications/key-policy-documents/whoframework-convention-on-tobacco-control-whofctc/key-areas-of-tobacco-control-policy/ taxation World Health Organization (2019a) Multinational Monitoring of trends and determinants in Cardiovascular disease. MONICA Publications World Health Organization (2019b) Cardiovascular disease World Heart Federation (2019) The cost of CVD. Champion Advocates Programme

Global Burden of COPD Prevalence, Patterns, and Trends

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John R. Hurst and Trishul Siddharthan

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition, Diagnosis, and Heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment of Disease Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Natural History of COPD and Risk Factors for Lung Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Early-Life Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exposure in Adulthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exacerbations of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approaches to Prevention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Burden and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COPD and Multi-morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory condition characterized by small airway and parenchymal lung disease resulting in expiratory airflow obstruction. While COPD has been well studied in highincome country (HIC) settings, epidemiologic and clinical studies focused on low- and middle-income country (LMIC) settings have been completed only more recently, where the majority of morbidity and mortality occurs. In addition to well-established risk factors in HIC (tobacco smoke exposure and genetic predisposition), populations in LMICs are exposed to additional risk factors which predispose individuals to develop COPD across the lifespan, including J. R. Hurst (*) UCL Respiratory, University College London, London, UK e-mail: [email protected] T. Siddharthan Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_25

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biomass exposure and nutritional deficiencies. Additionally, LMICs face challenges in the diagnosis and treatment of COPD including limited availability of equipment and access to therapies. In this chapter, we review the definition and diagnosis of COPD, the natural history, and risk factors and consider approaches to COPD management in LMICs. We additionally highlight areas of future COPD research relevant to LMICs. Keywords

Chronic obstructive pulmonary disease · COPD · Emphysema

Introduction The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Strategy document defines chronic obstructive pulmonary disease (COPD) as a “common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases” (Pauwels et al. 2012). According to the Global Burden of Disease Study, the global prevalence of COPD in 2016 was 251 million, with COPD accounting for 5% of all deaths in the previous year (3.17 million in total), with more than 90% of those deaths occurring in low- and middle-income countries (LMICs) (WHO 2011; Mathers and Loncar 2006). The global burden of disease is expected to increase over the next decade, and COPD is predicted to be the third leading cause of death globally by 2030 (Mathews et al. 2011). The greatest increase in morbidity and mortality is expected to occur in LMICs. LMIC settings have unique risk factors that predispose individuals to chronic respiratory diseases, including COPD. While studies have sought to assess the prevention and treatment of COPD in LMICs, most evidence related to COPD management has been generated among populations in high-income settings. There is a growing evidence that COPD in LMICs has a distinct natural history with differential responses to treatment. Furthermore, LMIC health systems, which have historically been oriented to infectious diseases, are poorly aligned to manage chronic non-communicable diseases (NCDs) like COPD. As populations in these settings age, the increased burden of disease is expected to overwhelm already overburdened health systems.

Definition, Diagnosis, and Heterogeneity COPD is a clinically heterogeneous syndrome characterized by expiratory airflow obstruction due to pathology of the small airs and parenchyma (emphysema) in the lungs. The diagnosis of COPD requires the demonstration of post-bronchodilator airflow obstruction using spirometry and is defined by impairment in the ratio of the volume expired in 1 s (FEV1) to vital capacity (VC).

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Two approaches have been used to define airflow obstruction based on the ratio of FEV1 to VC. The simpler definition of airflow obstruction is when the FEV1/FVC ratio is less than a fixed cutoff of 0.70. However, because this ratio declines with healthy aging and due to differences in lung function across populations, it may be advantageous to define obstruction when the ratio is less than the lower limits of normal for that population (Kumar et al. 2010). Such normal ranges may not exist for all populations, and these vary by age, sex, height, and race. The lack of standard reference values in LMICs has complicated global estimates of the burden of COPD. More recently, continuous predication equations derived from populations in LMICs have been proposed. In 2012, the Global Lung Function Initiative compiled data across 72 centers in 33 countries to develop a multiethnic reference across settings, though this was limited by a lack of data from large regions in LMICs (notably subSaharan Africa). Additionally, there is evidence of clinically significant chronic respiratory disease among patients with normal lung function, who do not have obstruction on spirometry. Among current or former smokers with preserved pulmonary function, 50% exhibit respiratory symptoms similar to COPD, and former smokers with preserved lung function have higher rates of exacerbation (infection)like events compared to lifelong nonsmokers (Woodruff et al. 2016). A major limitation to the management of COPD in LMICs remains the requirement of diagnostic testing equipment and specialized training on use and interpretation. Current diagnostic guidelines for COPD require spirometry. In lower-income country settings, spirometry is not affordable for the majority of the population and often located in urban centers, while the majority of disease is located in rural settings. Due to the limited availability of spirometry in LMIC settings, the WHO pragmatically recommends considering clinical symptoms and signs, while increased forced expiratory time and low peak flow can be used to support the diagnosis. Simple case-finding approaches in LMIC are currently being tested which may improve diagnostic capabilities where spirometry is limited. COPD, as diagnosed above, requires the demonstration of airflow obstruction. The major site of this is in the small airways (defined as those less than 2 mm in diameter). The obstruction occurs due to airway wall remodeling, airway mucus, bronchoconstriction, and loss of alveolar attachments. There is also a reduction in the number of small airways. Environmental exposures such as tobacco smoke can also affect the alveolar compartment, resulting in emphysema defined as abnormal, permanent enlargement of the air spaces distal to the terminal bronchiole which is a structural, pathological, and/or radiological diagnosis (American Thoracic Society 1962). When the larger airways are affected, with mucus gland hypertrophy and hypersecretion, the end result is the clinical diagnosis of chronic bronchitis (classically defined as cough productive of sputum on most days of 3 or more months in 2 or more consecutive years). The small airways are considered the major site of pathology in COPD. Although COPD is considered a chronic respiratory disease, it results in systemic changes including immune dysregulation and increased levels of inflammation which can result in disease beyond the lung itself (Barnes and Celli 2009). COPD is an inflammatory disease, with accumulation of inflammatory cells in the small

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airways. Among those with more severe airflow obstruction, this is associated with the presence of germinal follicles, suggesting the presence of an abnormal adaptive immune response (Hogg et al. 2004). The inflammatory response in the lung to noxious airborne stimuli in COPD is qualitatively and/or quantitatively different from normal and persistent after removal of the initiating insult. Increased circulating levels of interleukin (IL)-6, IL1-β, and TNF-α among those with COPD are thought to contribute to muscle wasting and cachexia, osteoporosis, ischemic heart disease, metabolic syndrome, and normocytic anemia. Whether COPD represents a systemic disease or potentiates existing co-morbid conditions remains debatable, though there is increasing research related to multi-morbidity, described further below. COPD is defined by airflow obstruction, though the clinical presentation of COPD is very heterogeneous. Understanding this heterogeneity, identifying groups of people with a particular pattern of disease and thus a particular natural history or treatment response is important and referred to as “phenotyping.” COPD has traditionally been subclassified into two phenotypes. The classic description of the emphysema-predominant phenotype was the “pink puffer,” marked by shortness of breath, minimal cough, emphysema, and cachexia. Those with a chronic bronchitis phenotype, marked by chronic productive cough, obesity, and cyanosis were referred to as “blue bloaters.” A more contemporary overview of phenotypes includes those with airway hyper-responsiveness (asthma) and includes various overlap syndromes (Fig. 1). Few studies have characterized the clinical presentation of COPD in LMICs. There is evidence that COPD in LMICs presents as a more asthmatic and chronic bronchitic phenotype, rather than the emphysematous changes noted in high-income populations (Moran-Mendoza et al. 2008). Furthermore, there is less

Fig. 1 COPD phenotypes

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severe hypoxia among those with COPD when adjusted for lung function (FEV1) (Moran-Mendoza et al. 2008). When there is a specific underlying pathogenic mechanism to a phenotype, it may be referred to as an “endotype.” The classic endotype in COPD is alpha-1 antitrypsin deficiency which was first identified by Laurell and Eriksson (1963). Alpha-1 antitrypsin deficiency (A1ATD) results from a mutation in the SERPINA1 gene with dysregulation of neutrophil elastase, a protease enzyme, that results in destruction of lung tissue and emphysema. Among those with A1ATD, exposure to environmental exposures such as cigarette smoke accelerates lung injury. While A1ATD is most common among Caucasian populations in high-income settings, analysis of allele frequencies and prevalence from global epidemiologic cohort studies demonstrate a contribution of A1ATD in sub-Saharan Africa and other LMIC settings (de Serres et al. 2010). The treatment of severe A1ATD may include replacement of A1AT protein, although the cost-effectiveness of this is debated, and screening in those with early-onset, familial, or severe COPD is standard practice among populations in high-income settings. Despite this, few studies have examined A1ATD in LMICs, and there are currently no recommended guidelines for testing and treating A1ATD in LMIC. Although COPD is characterized and diagnosed by the presence of airflow limitation measured by spirometry, the clinical definition of COPD as outlined by GOLD requires the presence of symptoms (Pauwels et al. 2012). This is problematic in that many of the symptoms related to COPD including shortness of breath, cough, and wheeze may be associated with other conditions, which prevents the use of symptoms for the diagnosis of COPD. Furthermore, identification of individuals early in the course of COPD, prior to the development of limiting symptoms, would allow for risk reduction strategies including smoking cessation and immunization. In the absence of spirometry, the common symptoms of COPD including cough and sputum may be mistaken and mistreated. The diagnosis of COPD should be considered in people with symptoms and/or recurrent lower respiratory tract infection and in the context of an appropriate exposure history.

Summary: Challenges in the Definition and Diagnosis in Low- and MiddleIncome Settings

1. Availability of spirometry, extending to the equipment (and maintenance and calibration of equipment and training in correct use and interpretation). Spirometry requires a maximal forced expiration, and poor patient performance risks over-diagnosis of pathology. 2. Not everyone with airflow obstruction has COPD. Other respiratory diagnoses can be associated with fixed airflow obstruction, including chronic asthma and bronchiectasis, the latter a potential consequence of previous TB. Classically, asthma is associated with a response in spirometry following administration of bronchodilator, which is why the definition (continued)

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of COPD requires post-bronchodilator testing. Some people with long-term asthma can develop fixed airflow obstruction which meets the spirometric definition of COPD. Exposure-related lung diseases can be present with normal spirometry. Smoking, for example, can be associated with emphysema in the absence of significant airflow obstruction and therefore present with “normal” spirometry. Coexistent obstructive and restrictive lung diseases can also result in “normal” spirometry. Only a minority of people with a significant exposure (usually considered to be 20 pack-years of cigarette smoke exposure or more, but more difficult to quantify for other exposures) develop COPD. Significant loss of lung function has to occur before the development of symptoms, and the development of breathlessness, for example, varies by the degree of physical activity. Some LMIC settings have no “word” for COPD and thus it is challenging to address a condition that has no name.

Assessment of Disease Severity Traditionally, the severity of COPD was graded by the severity of airflow obstruction, and this is still important for prognosis as FEV1 tracks with important outcomes such as mortality. The GOLD scheme (Pauwels et al. 2012) is as below: Stage 1 Stage 2 Stage 3 Stage 4

Mild Moderate Severe Very severe

FEV1/VC 75%) comprised of immigrants and African Americans, are spatially and racially segregated, bear the industrial externalities (i.e., pollution, solid waste, etc.) of the region, and all have high crime and homicide rates. In 2007–2009, Richmond fits all these measures and more. Richmond, California was one of the unhealthiest cities in California, with the shortest life expectancy and few supportive social determinants of health. The Contra Costa Times reported in 2010 that the zip code in central Richmond (94603) had a life expectancy of 71.2 years (the California state average is 78.4 years) while a few miles away in another zip code over the Richmond Hills life expectancy was over 87 years (Bohan and Kleffman 2010). Richmond was also the ninth most violent city in the USA in 2009, in terms of gun homicides per person. The Mayor at the time was contemplating requesting the National Guard occupy the city to reduce violence. Industrial pollution from a petrochemical refinery owned by Chevron Corporation in Richmond, the largest in the Western USA, was polluting the air and contributing the highest childhood asthma hospitalization rates in California. Dilapidated social housing, where a majority of the African American population resided, was found to contain toxic mold and lead, and the federal Housing and Urban Development (HUD) agency was on the verge of taking control of these unhealthy structures. In 2010, nearly 20% of Richmond residents were unemployed, 38% of children were living in poverty, and 57% of households paid more than 30% of their income for housing (US Census 2010). In 2010, nearly half of homes in a single Richmond zip code were in foreclosure or at risk for foreclosure and the city was ranked among the most violent American cities. Health outcomes in Richmond reflect these social inequalities. According to the Contra Costa County Health Service agency in 2010, 22% of African American children were hospitalized for asthma compared with less than 9% of White children; 32% of adults age 20–44 were obese, compared with 21% of similar Californians; and over 28% of residents report their health as fair or poor, compared with only 16% of similar Californians (CCHS 2010). In part a response to these social and health issues, residents organized and demanded that government and the private sector address inequalities and improve well-being. The city responded in 2007 by drafting a community health and wellness element, or chapter, in its general plan, which generated objectives and policies to promote health through 2030. This was the first time in California that a local government had integrated health equity into its general plan and land use planning processes. Building on this work, the City, academic and civil society partners launched a HiAP strategy in 2012, as a way to implement and expand the objectives launched in the general plan. The HiAP strategy was drafted through an 18-month public process that included tens of residents and community workshops. As we highlight below, two key themes or drivers of health inequities emerged during this

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process that gave rise to a unique HiAP strategy. The first was the importance of structural racism, or how a set of historical and contemporary decisions in multiple sectors, from housing to land use, to employment, to police, and to education, was responsible to poor health and living conditions in Richmond. Residents demanded that the HiAP prioritize addressing structural racism. Second and related to structural racism, the HiAP strategy process identified that multiple adverse exposures, from pollution to poverty, to unsafe and unaffordable housing, and to violence and food insecurity combined to impact people’s well-being. We defined these adverse exposures as “toxic stressors,” and a goal of the HiAP strategy became reducing and eliminating the multiple toxic stressors in Richmond that were contributing to poor health through targeted and concerted actions by the city and civil society partners. The city adopted the HiAP strategy into law in 2014, passing an ordinance that put into law the objectives and processes of the HiAP strategy. By 2019, the HiAP had been implemented and undergone two external evaluations for its influence on public policy, community development, inter-sectoral partnerships, and population health improvements. We highlight how the HiAP was conceived and implemented, and report on some of its impacts. We utilize 25 interviews with leaders from local government agencies and community-based organizations conducted between 2014 and 2019. Each interview included semi-structured questions about health inequities in Richmond, how each organization was addressing these issues, and whether or not they knew about and worked on the HiAP strategy. We also reconstruct events using minutes of tens of public meetings, internal staff emails, confidential project grant reports, and public documents about the HiAP process (such as meeting reports and presentations found at: Richmondhealth.org). Using these data, we reveal the conceptual frames, practical strategies, and evaluation evidence that contribute to making health equity planning work. We also present objective data from seven waves of a community survey (biannually from 2007–2019) to track changes in health equity indicators in Richmond and explore whether or not the HiAP law is influencing community health equity.

Urban Health Equity in All Policies Health equity, as defined by the US Government’s Healthy People 2020 report, entails efforts to address avoidable social inequalities by equalizing the conditions for health for all groups, especially for those who have experienced socioeconomic disadvantage or historical injustices. Health inequities are increasing in cities and neighborhoods around the world and present one of the greatest equity challenges for urban planners today. Where you live and how that place is governed can determine when and if you get sick, receive medical treatment, and die prematurely (Galea and Vlahov 2005). City living can be beneficial for human health, since urban areas generally offer greater economic and educational opportunities, medical services, political and gender rights, affordable housing, and cultural, political, and religious expression (Dye 2008). This holds true in both rich and poor cities of the global North and South.

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Yet, not everyone in cities can take advantage of these socially produced resources and the poor and socially marginalized often experience health inequities, or differences in access to health-promoting resources that are unnecessary, avoidable, and unfair (Braveman and Gruskin 2003). As the UN-Habitat and World Health Organization (WHO) stated in their 2010 report, Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings: Health inequities are the result of the circumstances in which people grow, live, work and age, and the health systems they can access, which in turn are shaped by broader political, social and economic forces. They are not distributed randomly, but rather show a consistent pattern across the population, often by socioeconomic status or geographical location. No city – large or small, rich or poor, east or west, north or south – has been shown to be immune to the problem of health inequity. (WHO and UN-Habitat 2010)

One example of the persistence of health inequities is in the San Francisco Bay Area (the geographic focus of this article) where an African American child born in West Oakland will die, on average, 15 years earlier than a White child living just a few miles away in the Oakland Hills (ACPHD 2013). In the Bay Area, life expectancy for everyone increased between 1960 and 2006, yet the difference in life expectancy between Whites and African Americans has persisted and is increasing. This is what public health researchers call a health inequity; an avoidable difference that is unfair and unjust. What explains these disturbing and persistent patterns of death and disease? The WHO, among others, has pointed to the social determinants of health, or more directly that social injustice is killing people on a grand scale (WHO 2010). Similarly, the New York City Department of Health and Mental Hygiene noted a decade ago that the concentration of health disparities in poor, predominantly African American and Latino neighborhoods, are not likely due to disparities in access to health care, risky individual lifestyles, or genetic differences, but that, They are due primarily to differences in the social, economic, and physical conditions in which people live and the health behavior patterns that arise in these settings. ‘Health disparities’ are more than ‘health-care disparities’. . . one lesson from the health data is that disparities exist for almost every condition. This observation suggests that, regardless of the specific issue, poor health shares common root causes. It is important to remember, then, that strategies aimed at particular issues need to be complemented by attention to those root causes of poor health: poverty, discrimination, poor housing, and other social inequities. Fundamentally, eliminating health disparities is about social justice, which is the underlying philosophy of public health. (Karpati 2004)

Planning for Health Equity in All Policies In part a response to persistent health inequities, Richmond residents have organized for environmental and social justice. Since the 1980s, African American residents organized into groups such as West County Toxics Coalition and Communities for a Better Environment (CBE) to reduce pollution from the Chevron refinery and hold

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the company accountable for its contribution to adverse health impacts (Malloy 2012). By 2006, when the city initiated the planning process to update its general plan, community groups had formed the Richmond equitable development initiative (REDI). REDI included environmental justice groups and organizations working to promote affordable housing, employment opportunities, improved access to health services, and violence reduction. (The members of REDI include: Alliance of Californians for Community Empowerment (ACCE); Contra Costa Faith Works; Contra Costa Interfaith Supporting Community Organization (CCISCO); East Bay Alliance for a Sustainable Economy (EBASE); Greater Richmond Interfaith Program (GRIP); Urban Habitat; Asian-Pacific Environmental Network (APEN); Laotian Organizing Project (LOP); and Communities for a Better Environment (CBE). See: http://urbanhabitat.org/richmond) According to former executive director of Urban Habitat, Juliet Ellis (2012, Personal communications), REDI used research, policy advocacy, and organizing strategies to ensure that the growth and development decisions in Richmond benefited the city’s low-income communities and communities of color. During some of the first public meetings for the general plan update, REDI members attended and demanded that the plan include environmental justice and health issues. A technical advisory committee (TAG) was formed to advise the health element research and drafting processes. (The TAG also included representatives from the Contra Costa Health Services Department (CCHS); the Environmental Health Investigation Branch (EHIB) of the California Department of Health Services; and the Department of Public Health, City and County of San Francisco. Members included: Richard Jackson, MD, MPH, Adjunct Professor, School of Public Health, University of California, Berkeley; Richard Kreutzer, MD, Branch Chief, Environmental Health Investigations Branch, California Department of Health Services; Wendel Brunner, MD, Public Health Director, Contra Costa Public Health; Poki Stewart Namkung, MD, MPH, Public Health Officer, Santa Cruz County Health Services Agency and President of the National Association of County and City HealthOfficials (NACCHO); Dennis M. Barry, Director, Contra Costa County Community Development; Richard Mitchell, Planning Director, City of Richmond; Victor Rubin, PolicyLink; Sharon Fuller, Ma’at Academy; Sheryl Lane, Urban Habitat; Barbara Becnel, North Richmond Neighborhood House; Delphine Smith, Communities for a Better Environment.) The REDI coalition was also funded by TCE to participate in the health element process and to organize Richmond residents to engage in and shape the content of the plan. The first tasks of the TAG were to describe the connections between land use planning, city management, and public health, generate a set of goals for the health element, and describe these in a baseline conditions report. One of the initial TAG reports for the health element defined the planning process as (COR 2007, 5): The Health Element will address health disparities and promote healthy living, and use the General Plan as a vehicle for promoting sound public health and land use policy. The Element will outline a framework and methodology for evaluating and understanding existing community health and wellness conditions, develop goals, policies and

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implementing actions to address key community issues and opportunities, and create a tool for tracking progress over time. The Element will involve key stakeholders and the Richmond community in the process and focus on key community needs and opportunities.

Recognizing and addressing health disparities was the first goal of the element and, according to Sheryl Lane of Urban Habitat and a leader of REDI, this was an important orientation of the work and one that differentiated it from other health and “built environment” efforts. Other explicit goals for the health element were to draft implementing policies, not just land use or urban designs, to address community health and to develop a tracking and monitoring strategy.

From Planning Drafts to Pilot Implementation By 2008, the first draft of a Community Health and Wellness Element (HWE) was publicly released and articulated 11 aspects of healthy planning raised by community members and researched by the TAG as: 1) improved access to parks, recreation, and open space; 2) expanded access to healthy food and nutrition choices; 3) improved access to medical services; 4) safe and convenient public transit and active circulation options; 5) a range of quality and affordable housing; 6) expanded economic opportunity; 7) complete neighborhoods; 8) improved safety in neighborhoods and public spaces; 9) improved environmental quality; 10) green and sustainable development practices; and 11) leadership in building healthy communities. Each priority area included specific policies and actions intended to make the goal a reality. At the same time the draft HWE was being reviewed, community groups mobilized to define indicators of equity in Richmond. Two nonprofit organizations, the Pacific Institute and West County Toxics Coalition, launched a year-long effort to define what they thought were the indictors of a healthy and just Richmond. They gathered oral histories along with publicly available data into a report entitled Measuring What Matters: Neighborhood Research for Economic and Environmental Health and Justice (Pacific Institute 2009). The report reflected a broad set of community assets and challenges, from lead paint in homes and freight transportation pollution to liquor stores and former prisoners returning to the community. A new regional health equity coalition, the West County Indicators Project, was created to track progress on the group’s indicators and advocate for implementation of the HWE. The community indicators’ work helped inspire a second phase for the health and wellness element focused on developing pilot interventions that could help prepare planners for ongoing healthy planning practice. In 2009, the Richmond City Planning Department took the lead on what was called the pilot implementation phase (since the general plan itself had not been formally adopted), or phase II of the community health and wellness element. The work plan of phase II established a neighborhood strategies work group (NSWG) that selected two areas in Richmond with the poorest health, social, and economic conditions, called the Iron Triangle and

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Belding Woods, for focused interventions. Two primary schools in each neighborhood acted as the sites where residents came together to create action plans.

Richmond Healthy Equity Partnership (REHP) As the pilot implementation phase of the HWE was concluding in late 2010, the California endowment was launching a new, place-based initiative focused on 14 communities in California called building healthy communities (BHC), and Richmond was selected as one of the sites. The BHC initiative presented an opportunity for the City of Richmond to coordinate a range of disparate neighborhood-based equity efforts and further integrate equity into the everyday practices of city government (Lindsay, 2011, Personal communications). The RHEP designed a 2-year process for coordinating work under three umbrella projects, including drafting a Health in All Policies (HiAP) strategy and ordinance for the city, developing a full service community schools (FSCS) strategy for Richmond schools and drafting an annual health equity report card by the local health department (Fig. 1).

Drafting the Health in All Policies Strategy In Richmond, we organized our HiAP strategy into training, collaborative strategy drafting, and indicator development. We began by organizing trainings in health equity for all city staff, starting with senior managers of every city department, from the police chief to the director of housing. The idea was to begin to integrate a health

Fig. 1 Richmond health equity partnership, model of change

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equity approach for all city departments from the highest levels of leadership. In 2012, the Mayor and Richmond City Council were unanimous in directing city staff to draft the HiAP ordinance and accompanying implementation and monitoring strategy. The health equity trainings were organized using a structural racism framework. By structural racism we meant that seemingly neutral policies and practices can function in racist ways by disempowering communities of color and perpetuating unequal historic conditions. Powell notes that a structural racism lens helps to analyze the following: . . .how housing, education, employment, transportation, health care, and other systems interact to produce racialized outcomes. Such a model allows us to move beyond a narrow merit-based, individualized understanding of society to show how all groups are interconnected and how structures shape life chances. At the level of cultural understanding, the structural model shows how the structures we create, inhabit, and maintain in turn recreate us by shaping identity and imparting social meaning. Chief among the processes in a structural model that connect institutions to identity formation is the relationship between racial identity and geography. . .the racialization of space. (Powell 2007, 793)

This emphasis came from residents and city staff who insisted that racism be the focus of health equity planning processes. According to one resident participant: This city has experienced all the forces of racism over the years; denying blacks home ownership or union jobs at the port, forcing Vietnamese refugees to live near pollution, not serving our Latino immigrants in the schools. Yet, we get newly paved highways, shopping malls and supermarkets none of us can afford. Many of the things the city controls have influenced why we have more liquor stores than libraries, more pollution than parks and more homelessness than hospital beds.

The HiAP process recognized that this reality was not the fault of Richmond residents nor could the city and the regional health care system “treat their way out of this,” as another HiAP participant noted. A driving idea behind linking racism to health in Richmond’s HiAP strategy was that no one community or neighborhood was experiencing a single challenge at a time, but rather multiple, overlapping challenges for health that often accumulated over time. According to the UC Berkeley research and action team that was coleading the HiAP drafting, this meant that many of Richmond’s poor residents and communities of color were experiencing toxic stress.

Embodiment and Toxic Stress Taken together, our four principles encourage planners concerned with health equity to focus on embodiment, or how multiple inequities interact and accumulate over time, with place acting as the linchpin holding these arrangements together. As Krieger (2005, 353) notes:

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Embodiment reminds us that a person is not one day African American, another day born low birth weight, another day raised in a home bearing remnants of lead paint, another day subjected to racial discrimination at work (and in a job that does not provide health insurance), and still another day living in a racially segregated neighborhood without a supermarket but with many fast food restaurants. The body does not neatly partition these experiences – all of which may serve to increase risk of uncontrolled hypertension, and some of which may likewise lead to comorbidity, for example, diabetes, thereby further worsening health status. Embodiment research suggests that our bodies do not partition experiences with inequality and these experiences act cumulatively as stressors on the immune and neurologic systems that lead to a range of diseases and premature death (Fig. 2) (Geronimus and Thompson 2004; NSC 2009; Shonkoff et al. 2012). While stress can be life saving for most – think of the fight or flight mechanism – constant adversity is toxic, meaning that the prolonged activation of the stress response systems can disrupt the development of the brain architecture and other biologic systems (Sawyer et al. 2012). Under “normal” stressful situations the human body has a range of physical and chemical responses, but primarily epinephrine (adrenaline) and cortisol are released to bring the endocrine and immune systems back to homeostasis. The

Fig. 2 Relational equity measures for Richmond’s Health in All Policies strategy

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body’s ability to maintain stability under stress has been called allostasis (McEwen 2007). In toxic stress situations, stressors are constant and the “allostatic load” continues to increase and the chemical release of “fight or flight” hormones do not properly regulate or shutoff. Increased allostatic load wears away at the immune system as it overworks to manage the hormonal releases and attempt to return to homeostasis. Under toxic stress circumstances, the oversecretion of cortisol and adrenaline trigger other biologic responses like poor glucose regulation and constant feelings of hunger that can contribute to chronic diseases such as overweight and obesity, diabetes, hypertension, cardiovascular disease, stroke, asthma, and other immune-related illnesses (Shonkoff et al. 2012). Some known toxic stressors include chronic poverty, racial, gender, and other forms of discrimination and marginalization, physical or emotional abuse, exposure to violence, and housing instability – and these stressors start influencing health in utero and have cumulative impacts over a lifetime (Velasquez-Manoff 2012). For example, reports of discrimination by African Americans and Asian Americans have been linked with visceral fat accumulation, which increases the risk of metabolic syndrome (and thus the risk of heart disease and diabetes) (Gee et al. 2012; Smedley 2012). (While race is an unscientific, societally constructed taxonomy that is based on an ideology that views some human population groups as inherently superior to others on the basis of external physical characteristics or geographic origin, the concept of race is still socially meaningful. A preponderance of research suggests that racial and ethnic variations in health status result primarily from variations among races in exposure or vulnerability to behavioral, psychosocial material, and environmental risk factors and resources. Racism encompasses prejudice, negative attitudes and beliefs about other groups, and discrimination, which is the differential treatment of people based on their race or ethnicity. The weathering hypothesis suggests that racism, not race, affects health status by, among other hazards, diminishing social status, increasing exposure to risk factors and resources, and directly affect health through increasing stress and the biologic response.) The toxic stress framework and four relational principles emerged as the guiding approach to the Health in All Policies planning in Richmond (Fig. 3). Using the toxic stress idea and framework (Figs. 2 and 3), the planning process emphasized that every city department could and should have a role in eliminating or reducing the multiple exposures in Richmond. According to one city leader, the structural racism and cumulative exposure approach were not only novel but spoke to their experience as a life-long Richmond resident, noting: The idea that health was not just something you get at your doctor’s office was new for us and that housing, finance, engineering and other departments were also ‘health departments’ was also new. We valued that institutionalized racism wasn’t swept under the rug and the connections made clear about how even when individuals might not be racist, institutions and decisions – whether from legacies or being inattentive to racial impacts – have not really changed. This was important for moving the conversation from race and health to hidden discriminatory outcomes from city policies and practices.

Fig. 3 Multiple toxic stressors identified in Richmond’s Health in All Policies strategy

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Accompanying the trainings with city staff was a drafting committee that researched HiAP and health equity models around the world and began drafting a strategy document and ordinance. Staff from the city manager’s office and other departments brought early outlines of the HiAP strategy to community meetings, introduced the toxic stressors framework, and had participants reflect on different stressors regularly experienced in their neighborhoods and/or lives. Residents and members of community-based organizations participated in additional public meetings to help set health equity priorities, review proposed actions, and suggest measures or indicators to track progress. Twelve measures of equity using existing publicly available data were selected to capture resident’s priorities and give the HiAP a clear set of measurable indicators for moving toward greater health equity (Fig. 2, left side), and a similar set of indicators were selected as inequities that the group wanted to reduce or avoid (Fig. 2, right side). In Fig. 2, the two polygons represent our relational approach to measurement: each axis indicates the existing conditions in Richmond (shaded grey area) in comparison to the county and state; the dashed line reflects a 2-year goal for gauging progress. Within each of the six action categories in the HiAP strategy, one or more of the equity measures were analyzed by race and ethnicity in Richmond. The HiAP strategy was accompanied by an ordinance that would give legal and additional institutional authority behind the goals and actions. Overview: Intervention areas for action and implementation of HiAP strategy: 1. 2. 3. 4. 5. 6.

Governance and Leadership Economic Development and Education Residential and Built Environments Full Service and Safe Communities Environmental Health and Justice Quality and Accessible Health Care.

Governance was defined as the day-to-day management decisions within the City of Richmond, including but not limited to how inclusive it is to different viewpoints and participants, and reflects the distribution, exercise, and consequences of power. Economic status, particularly wealth and relative levels of inequality, are key drivers of health inequities, and education helps support critical thinking, access to information about science and health, and can be a pathway for a rewarding career and stable income. Where we live and whether it is affordable, safe, has culturally relevant services, and other amenities or hazards can predict a population’s chances of getting sick, degree of suffering, and even premature mortality. Environmental injustices are key drivers of health inequities and include the burdens of excess pollution and lack of environmental “goods,” such as access to healthy foods, parks, and transport, that burden the poor, people of color, and

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Fig. 4 Richmond’s HiAP intervention areas and an example of an action plan

other marginalized populations. Quality and accessible health care means that all people must have their preventive and treatment needs met, regardless of employment or immigration status, in a country where health care is a market commodity not a human right. For each action area, specific plans, policies, or programs were identified (either existing or proposed for the future) and specific measures to track progress were attached to each action. A health equity statement was included that made explicit the goal or challenge being addressed with the action and the responsible city department and the desired direction of change (i.e., more of something or to reduce or eliminate) was also made explicit (Fig. 4).

Implementing HiAP for Urban Health Equity The HIAP ordinance, adopted unanimously by the Richmond City Council, put a set of goals and strategies into place for the achieving health equity. Once the HiAP law was adopted, the drafting committee turned into an implementation and partnership committee. A series of new and proposed policies and programs were launched to work toward health equity and address the toxic stressors identified in the planning process.

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Intervention Area #1: Governance and Leadership The leadership for implementing HiAP was within the city manager’s office, which is the municipal department responsible for budgeting and decision-making. The drafting group of the HiAP strategy explicitly decided to not have the HiAP responsibility reside in the planning department since it was viewed as weak and somewhat captured by private sector development interests. A new interdepartmental HiAP implementation team was created with representatives from each city department. The interdepartmental HiAP team met monthly to review strategies and share progress. The interdepartmental team also continued to lead trainings about HiAP to city staff and to the community, since HiAP remains an elusive concept and practice. The aim, according to the deputy city manager, was as follows: We worked to get all city staff to see themselves in the HiAP. We emphasized from the top to all leadership all the way down to the staff on the streets, that they were ‘community clinicians.’ What this meant was that we were all, as city employees, responsible for the health of our residents. We held trainings and workshops to continually communicate this for the first two years of the HiAP ordinance.

A key task of governance and leadership was to also address structural racism within city government. A team called the Governance Alliance for Race and Equity (GARE) was established to train city staff in implicit bias, microaggressions, and institutional racism. Emerging out of the work of this group after 18 months was a racial equity law, called Resolution 93–18, which mandated that every city department and council decision include a review of the impacts of the decision on racial and ethnic groups and that all public meetings and documents would be translated in the three most commonly used non-English languages in the city (http://carichmond2.civicplus.com/ArchiveCenter/ViewFile/Item/9157). The resolution was one of a set of steps the city took to develop a racial equity plan that would accompany the HiAP ordinance. Ongoing measurement and monitoring were also a critical aspect of governance. The city worked with the Contra Costa County Health Department to draft the Richmond Health Equity Report in 2016 (https://cchealth.org/health-data/pdf/ Richmond-Health-Equity-Report-Card-Full.pdf). The report provided baseline data that would be used to track progress toward health equity goals and other social determinants of health. The city and community groups developed a toolkit for community engagement, which specified new, more open processes for public meetings, city–community engagement around policy issues, and the responsibilities of the city during public meetings, such as providing childcare, food, and other community supports. Finally, in its continuing effort to ensure transparency and that as much citycollected data as possible is available to everyone, the City of Richmond launched the transparent Richmond open data platform (TRP) in 2019.This platform (https://

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www.transparentrichmond.org) includes data on all six HiAP intervention areas, plus additional information on the city’s budget and expenditures, as well as descriptive statistics about the city and its demographics. According to Jim Becker, director of the Richmond Community Foundation, a philanthropic organization in Richmond with the mission “to mobilize the power of connection to build healthy, thriving communities,” the new data portal will support this organization to: think about and evaluate our current community improvement strategies, look at a particular dataset and explore with our partners how to impact those numbers in a direction that promotes equity, and include these data in our reports to inform our future policy work.

Another community activist leader, Jamileh Ebrahimi, from the RYSE Center, a nonprofit in Richmond, focused on “creating safe spaces grounded in social justice for young people to love, learn, educate, heal, and transform lives and communities,” stated: The data [within Transparent Richmond] does not have to just showcase needs, but should also help to uplift things that are positive. Too often public data in health and government just documents bad, negative things. We see this as a platform for community data that tells the real stories of Richmond from the community’s perspective.

Intervention Area #2: Economic Development and Education The HiAP ordinance emphasizes economics development and educational opportunities should support health and wellness. As part of these efforts, the city increased their investments into four programs that together aim to improve economic and educational opportunities. The Richmond promise program was created to pay the college tuition for eligible Richmond graduating high school students, and since the program began in 2016 it has given out over $4.5 M USD in scholarships to over 936 Richmond students for higher education. Another program, called Richmond BUILD, offers free construction skills and an apprenticeship program in the solar installations. These “green jobs” are offered to youth from social/public housing, those that have been homeless and those that are returning from the criminal justice system/jail. Most that 1,000 Richmond youth have participated in this program over 10 years and over 80% of graduates are placed in high-paying union jobs. Two related programs, called Youth WORKS and Richmond WORKS, provide career and job preparation services for youth and supports adult jobseekers with interview skills, small business loans, and employment placement services. A new city law was passed in 2019, called the local employment ordinance, which mandates that for all government-funded construction projects in the city at least 25% of the employees must be Richmond residents. A new business incubator space, called CoBiz, was launched in Richmond with the support of city where startup businesses, innovators, nonprofits, musicians, and freelance artists can access cutting-edge technologies and use collaborative spaces. The idea is to create a cluster

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of economic innovation that supports the needs of Richmond while also taking advantage of the technology expertise and resources in the San Francisco Bay Area, according to CoBiz CEO Wesley Alexander. A major source of funding for the economic innovation and equity initiatives in Richmond is the settlement from a lawsuit against Chevron Corporation, which claimed its local refinery was in violation of its pollution control permits. The company and the city negotiated a community benefit agreement in 2014 that mandated Chevron modernize its pollution control equipment and pay $90 M USD to the city over a 10-year period to fund an environmental and community investment fund (ECIA) (http://www.ci.richmond.ca.us/2906/Chevron-CommunityInvestment). The ECIA is supporting a host of community-based greenhouse gas (GHG) reduction programs, direct community grants, and a photovoltaic solar farm. More specifically, in 2019 the ECIA allocated: • • • •

$2 M to public transit programs $1 M to the city’s climate action plan $2 M to urban forestry, city tree planting, and greening $6 M to install free rooftop solar and perform energy retrofits for low-income households • $3.7 M to the Richmond Promise college scholarship program • $2 M to job training programs, including YouthBUILD, RichmondBUILD, and the Literacy for Every Adult Program (LEAP) • $1 M on free Internet access.

Intervention Area #3: Full Service and Safe Communities Throughout the drafting of the HiAP, violence reduction was regularly the top priority for residents. Pressured by local activists and learning from national experiments in violence reduction, Richmond decided that continuing to criminalize poverty and incarcerating young men of color was not a solution (Boggan, 2013, Personal communications). To address some of the causes of community violence and to promote safety, the City of Richmond created an office of neighborhood safety (ONS) in 2007. The idea behind the ONS is to leverage city, county, and regional resources, in a way that nonprofits cannot, to enhance services for the city’s most disconnected and vulnerable youth and young adults with the aim of reducing violence (ONS 2012). To achieve this goal, ONS worked to coordinate inter-departmental and cross-jurisdictional activities, built new partnerships with nonprofit service providers, and recruited neighborhood change agents (NCA) to conduct street-level outreach to at-risk individuals and enroll young people in the peacemaker fellowship program. The ONS also coordinated the Richmond community wellness collaborative, which brings together street and school-based outreach and case management, including the Contra Costa County reentry network, all of which facilitate life-supporting opportunities for young people and their families.

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Recent data demonstrate the success of the peacemaker program (Fig. 5), including the prevention of over 16 gun homicides, mediating 37 street conflicts that could have led to a homicide, an 85% reduction in shootings with an injury since the program began, and 65% decrease in gun homicides. Also importantly, of the 127 young people that have participated in the fellowship, 97% are alive, and 83% have not been injured by a firearm.

Fig. 5 City fo Richmond, CA: Office of Neighborhood Safety Gun Violence Reduction Accomplishments, 2019

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Intervention Area #4: Residential and Built Environments Housing, safety, affordability, and quality, as well as broader neighborhood environments, continue to play a major role in health and well-being in Richmond, California, and many cities around the world. Richmond has struggled to ensure all residents are in safe and secure housing, but has made some progress. A Fair Rent and Just Cause for Eviction Law was passed in 2016 and a rent control program was established in 2017 to ensure all residents can afford to remain in their homes. In 2019, there were over 543 units of affordable housing built and another 977 units permitted. Since the HiAP ordinance, the city has partnered with community groups to improve and build new parks. A new park called the Richmond Greenway, replaced an abandoned railway line. In an innovative community effort, residents reclaimed a local park called Elm Playlot that had been overtaken by drug dealers. They formed an organization called Pogo Park and launched a participatory planning process to reenvision the park. Along with the city and local architecture firms, they codesigned a new space and built a “pop-up” or temporary park and then observed how residents utilized the space. The group then redesigned their original plan to reflect the uses they observed. The result is a new and improved Elm Playlot where residents now work to maintain the park and lead programming, such as childcare, food distribution, exercise, and cooking classes. Due to poverty, immigration status, and other issues, Richmond opened a center of human trafficking in the San Francisco Bay Area. In order to confront this social justice issue, the city partnered with social service providers to build and staff the West Contra Costa Family Justice Center, which opened in 2015, where victims of human trafficking, domestic violence, sexual assault, and elder abuse can receive care, support, and services. The center colocates the trauma and health care, legal protective services, housing, and child protective services in a welcoming and non– law enforcement setting (Gwinn and Strack 2006).The Family Justice Center coordinates supports for victims of interpersonal violence and their children, working to address anxiety, depression, social isolation, and substance use/abuse.

Interventional Area #5: Environmental Health and Justice Environmental issues, including air pollution, climate change, food security, and energy poverty – or the amount of money low-income households spend on utilities – are some of the leading environmental injustice issues in Richmond. A series of actions, supported by the ECIA resources mentioned above, have moved the city toward greater environmental justice. The HiAP process set in motion the drafting of the city’s first ever climate action plan (CAP), which aimed to reduce local pollution and mitigate greenhouse gas emissions, reduce the energy footprint of the city, and develop an adaptation strategy that protected the city’s most vulnerable residents. Richmond has over 32 miles of

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shoreline along the San Francisco Bay, and projected sea level rise is expected to adversely impact hundreds of acres of developed land. The CAP strategies focused on stronger regulations of emissions from the Chevron Refinery, one of the regions’ largest GHG emitters. The CAP also recommended a ban on coal exports through the city’s port terminal, aiming to discourage the use of coal and eliminate the dust impacts from train cars filled with toxic coal. A pedestrian and bicycle plan and street tree planting and vehicle-calming plan were also integrated into the CAP. As part of this plan, 1,718 new rooftop photovoltaic solar energy systems were installed on low-income households at no cost. The city also launched a “citizen science” community air monitoring program in partnership with environmental groups, to continuously monitor the ambient air along the “fence line” of the refinery and sensitive receptors such as schools in Richmond. The City also coordinated a “park prescription day” where health care providers and the parks department coordinate activities and emphasize the health benefits of accessing nature and physical activity.

Intervention Area #6: Quality Health Care and Services The HiAP ordinance also recognized that many Richmond residents were delaying or avoiding medical care due to lack of insurance, fear of deportations, or lack of resources. Further exacerbating the challenge of seeking medical care, one Richmond hospital called Doctor’s Medical Center closed in 2015. One response by the city was to work with the State of California to increase enrollment in the state’s free medical care program, called Covered California. A new community clinic, which can absorb some of the lost out-patient and emergency department patients from the closed hospital, was initiated by a partnership between the city and an experienced community clinic operator, LifeLong Medical Center. The new clinic, LifeLong William Jenkins Health Center, opened in 2019 and the new health center expands pediatric services currently offered at the site and will feature primary care, obstetrics, dental services, and urgent care for families. Importantly, the clinic mandates that all its staff members are trained in the science of childhood adversity and trauma-informed practices, including knowledge of and responses to adverse childhood experiences (ACE) and toxic stress, including how to screen and refer patients (Felitti et al. 1998).

Impacts of HiAP Implementation on Urban Population Health We used a biannual community survey administered to all Richmond residents since 2007 to highlight some of the impacts of Richmond’s HiAP on population perceptions of neighborhoods, safety, health, and the built environment. A few key indicators suggest that perceptions of community and well-being are improving. The Richmond community survey (RCS) results suggest that residents self-rating their neighborhood, Richmond, quality of life, place to raise children, and overall image as good or excellent have all significantly improved from 2007 to 2019 (Table 1). Since

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Table 1 Richmond, California, Community Survey: Percentage of Respondents Responding Good or Excellent Community characteristic How I rate my neighborhood Richmond as a place to live My overall quality of life Richmond as a place to raise children Richmond’s overall image Self-rated health Quality of development Richmond as place to work Recreational opportunities Ease of bicycle travel Citizen involvement in decision-making Experiences with discrimination or racism Gun homicides

Year 2007 50% 20% 17% 9% 4% 2009 36% 33% 22% 23% 35% 23% 42% (2013) 47

Year 2019 65% 47% 38% 24% 13% 2019 65% 71% 36% 39% 44% 37% 24% 15

Percent change +30% +135% +123% +166% +225% +81% +115% +64% +70% +26% +61%
43%
68%

Source: https://www.ci.richmond.ca.us/1871/Community-Surveys

2009, there were other questions added to the survey, and those also reflect key indicators of population health. For example, between 2009 and 2019, residents’ positive self-rated health has improved by over 80%, as well as overall quality of development, Richmond as a place to live, recreational opportunities, and ease of bicycle travel. Citizen involvement in decision-making has improved by over 60% and experiences with discrimination in the last 6 months have decreased and gun homicides have decreased by 68%. There are other, more qualitative examples of how the HiAP has helped shift the narrative of health equity and the actions of city government toward greater health equity. For example, the the mayor and city council proposed using the power of eminent domain to support families under threat of losing their homes to foreclosure and to redevelop abandoned neighborhoods (Said 2013). The Richmond police chief rejected a proposal to expand the West County Detention Facility in Richmond. According to Adam Kruggel, executive director of Contra Costa Interfaith Supporting Community Organization (CCISCO), a group organizing for violence reduction and city programs to support people not prisons, the decision by the City of Richmond was “a great example of elected officials really, truly listening to the voice of the community and responding” (Brown 2012). A San Francisco Bay Area newspaper described the changes in Richmond as a “renaissance” (Geluardi 2011): A new spirit in city government has helped transform industry, the quality of life in the city, and Richmond’s grim reputation. The city has undergone a facelift, citizens are attending community meetings and events in unprecedented numbers, and new businesses – many of them green – are bringing economic opportunities back to town. While other cities are desperately contending with debilitating budget deficits and struggling to maintain public

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safety and other basic services, Richmond has produced balanced budgets and enjoys a full complement of police officers. The combined efforts of city departments and community members have resulted in meaningful reductions in violent crime. And the city has completed numerous civic and neighborhood revitalization projects that have given Richmond a new air of vitality and community health.

Health in All Policies, Urban Health and Health Equity The case from Richmond, California, suggests that implementing HiAP focused on health equity demands having an explicit vision of the multiple drivers of health inequities in a specific place, and taking a relational approach to analysis and practice. Richmond planners encountered numerous challenges, many that are not unique to their city, and how they addressed the challenges can offer more general insights for making health equity planning work in cities everywhere. A first challenge was that the early health and equity planning agenda was not defined by local government but rather by organized residents, as community organizations demanded environmental justice, equitable development, and violence reduction. A key response was that the city-led HiAP drafting and implementation process partnered with community-based organizations and invited them to cocreate the HiAP. A second challenge was implementation and learning by doing. In many examples, the city and civil society partners started a small-scale project and learned through practice if it was having a positive impact on vulnerable communities. This can often be a challenge where municipal agencies are given strict budgets and mandates that are not flexible. Third, the “learning by doing” approach mentioned above built new partnerships that allowed each governmental body to continue to justify the work internally and to the public while also fostering coalitions that applied for and secured financial resources in the form of grants to continue the work. Under tight fiscal constraints, early health equity planning was partially justified and avoided some political opposition by securing financing external to the city’s budget. A fourth challenge was building an evidence base to support the work, particularly when data about health and place are not easily available at the neighborhood scale. The health equity planners developed ongoing processes to identify quantitative indicators and included community organization’s narratives to measure progress. The creation of the transparent Richmond data web site and the fact that all HiAP information is available at richmondhealth.org built public awareness and ensured progress toward key indicators could be tracked over time.

Conclusion Realizing urban health equity in Richmond is an ongoing process that will require continued institutional attention, public engagement, and accountability. The urban HiAP strategy is helping to reshape city governance toward greater population health equity. We hope the experimentation, learning by doing and explicit focus on equity

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in Richmond can inspire others that health equity planning can and must work. It seems that preliminary data suggest that the population is benefiting, but additional research is necessary to track outcomes. Sustained efforts are also needed to further shift the culture of city management and municipality’s work to make health equity and undoing structural racism a central and explicit component of urban development and city life.

References Alameda County Public Health Department (ACPHD) (2013) How place, racism, and poverty matter for health in Alameda county. https://acphd.org/data-reports/reports-by-topic/social-andhealth-equity/. Accessed 13 Oct 2020 Bohan S, Kleffman S (2010) Shortened lives: where you live matters. Contra Costa Times. http:// www.contracostatimes.com/life-expectancy. Accessed 12 Nov 2012 Braveman P, Gruskin S (2003) Defining equity in health. J Epidemiol Community Health 57 (4):254–258 Brown J (2012) Contra Costa tables controversial jail expansion. Richmond confidential. http:// richmondconfidential.org/2012/09/07/contra-costa-tables-controversial-jail-expansion/. Accessed 21 Oct 2012 California (CA) (2013) Health and safety code section 131000–131020. http://www.leginfo.ca.gov/ cgi-bin/displaycode?section¼hsc&group¼130001-131000&file¼131000-131020. Accessed 27 Jan 2014 City of Richmond (COR) (2007) Richmond general plan update: issues & opportunities paper #8: community health and wellness. City of Richmond Planning Department, Richmond Contra Costa Health Services (CCHS) (2010) Community health indicators for Contra Costa County. http://cchealth.org/health-data/hospital-council/2010/pdf/2010_community_health_ indicators_report_complete.pdf. Accessed 11 June 2012 Dye C (2008) Health and urban living. Science 319(5864):766–769. https://doi.org/10.1126/ science.1150198 Felitti VJ et al (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med 14(4):245–258. https://doi.org/10.1016/S0749-3797(98)00017-8 Galea S, Vlahov D (2005) Urban health: evidence, challenges, and directions. Annu Rev Public Health 26(1):341–365 Gee G, Walsemann K, Brondolo E (2012) A life course perspective on how racism may be related to health inequities. Am J Public Health 102(5):967–974 Geluardi J (2011) The man behind Richmond’s renaissance. East Bay Express. http://www. eastbayexpress.com/oakland/the-man-behind-richmonds-renaissance/Content?oid¼2647128. Accessed 1 Aug 2013 Geronimus AT, Thompson J (2004) To denigrate, ignore, or disrupt: racial inequality in health and the impact of a policy-induced breakdown of African American communities. Du Bois Rev 1 (2):247–279 Gwinn C, Strack G (2006) Hope for hurting families: creating family justice centers across America. Volcano Press, Volcano Karpati A (2004) Testimony before New York State Assembly Committee on Health and the Black, Puerto Rican and Hispanic Legislative Caucus, April 22. http://www.nyc.gov/html/doh/html/ public/testi/testi20040422.html. Accessed 20 Sept 2005 Krieger N (2005) Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health 59(5):350–355 McEwen B (2007) Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 87(3):873–904

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National Scientific Council (NSC) on the Developing Child (2009) The developing child, excessive stress disrupts the architecture of the developing brain: working paper # 3.” http://developingchild. harvard.edu/resources/reports_and_working_papers/working_papers/wp3/. Accessed 3 Dec 2013 Office of Neighborhood Safety (ONS) (2012) 2012 annual report: changing the odds. http://www. ci.richmond.ca.us/DocumentCenter/View/26434. Accessed 11 Dec 2013 Pacific Institute (2009) Measuring what matters: neighborhood research for economic and environmental health and justice in Richmond, North Richmond, and San Pablo. http://www.pacinst. org/wp-content/uploads/2013/02/final7.pdf. Accessed 10 June 2011 Powell J (2007) Structural racism: building upon the insights of John Calmore. N C Law Rev 86:791–816 Said C (2013) Richmond Pushes Forward with Eminent Domain Plan. San Francisco Chronicle. http://www.sfgate.com/realestate/article/Richmond-pushes-forward-with-eminent-domainplan-5073950.php. Accessed 19 Dec 2013 Sawyer P et al (2012) Discrimination and the stress response: psychological and physiological consequences of anticipating prejudice in interethnic interactions. Am J Public Health 102 (5):1020–1026 Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care (2012) The Lifelong effects of early childhood adversity and toxic stress. Pediatrics 129(1):e232–e238 Smedley B (2012) The lived experience of race and its health consequences. Am J Public Health 102(5):933–935 U.S. Census Bureau (2010) American community survey. http://www.census.gov/acs/www/data_ documentation/summary_file/. Accessed 10 Oct/Nov 2013 Velasquez-Manoff M (2012) An epidemic of absence: a new way of understanding allergies and autoimmune diseases. Scribner, New York WHO and UN-HABITAT (2010) Hidden cities: unmasking and overcoming health inequities in urban settings. World Health Organization, The WHO Centre for Health Development, Kobe, and United Nations Human Settlements Programme, Kobe World Health Organization (WHO) (2010). The Social determinants of health. https://www.who.int/ health-topics/social-determinants-of-health#tab¼tab_1. Accessed 29 June 2020

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Global Trade and Investment Regime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Birth of a Global Trading System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Establishing the World Trade Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expansion of Bilateral and Regional Trade and Investment Deals . . . . . . . . . . . . . . . . . . . . . . . . The International Investment Regime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Governing Trade and Investment for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Noncommunicable Disease Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Political Economy of Trade and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Who Are the Actors? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Are the Ideas? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Are the Institutions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reforming Trade and Investment for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trade-Proofing Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health-Proofing Trade Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2010 2011 2011 2012 2012 2013 2015 2015 2016 2018 2021 2024 2024 2024 2025 2026 2026 2028 2029 2032

Abstract

The commitments that states make within international trade and investment agreements have both direct and indirect effects on the health of the population. For example, these treaties can influence food environments and dietary health, regulatory policy space for alcohol control measures, as well as costs of medicines and access to healthcare. This chapter provides an introduction to the A. Schram (*) · B. Townsend School of Regulation and Global Governance, Australian National University, Canberra, Australia e-mail: [email protected]; [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_84

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international trade and investment regime and how it intersects with important issues in global health including access to medicines and health services, noncommunicable diseases, and the broader social determinants of health, including the environment. It will introduce readers to the key elements of trade and investment agreements, the impacts they can have, and the risks and opportunities for improving health and health equity. This chapter will also provide a political economy analysis of trade and investment agreements to reveal vested interests in the system and the dynamics of negotiations. Finally, it will review advances that have been made around the protection of public health as a result of significant efforts from health and trade advocacy groups and introduce ideas for further reform to support a global health agenda. Keywords

Trade and investment · Medicines · Health services · Noncommunicable diseases · Social determinants of health

Introduction Globalization has been one of the defining features of the late twentieth and early twenty-first centuries, and among its defining debates is whether or not it has been good or bad for human health. The literature has been polarizing, with both sides presenting evidence for its positive (Bergh and Nilsson 2010; Mukherjee and Krieckhaus 2012; Sapkota 2011) and negative (Cornia et al. 2008; Labonté et al. 2015; Tausch 2012) effects. Yet, the only truth that has emerged from the abundance of human and financial capital invested in studying globalization is that its outcomes are far from ubiquitous, producing winners and losers around the globe (Gaston and Khalid 2010; Teney et al. 2014). Rising levels of inequality, associated with the period of intensifying global integration, have produced a growing number of discontents, fuelling a backlash against globalization in the form of rising protectionism, nationalism, and intolerance (Pastor and Veronesi 2018). However, reversing social and health inequalities is unlikely to be achieved by undoing globalization; rather it will be achieved by rewriting the national and international rules of redistribution that guide global economic integration. One critical set of rules in this space is international trade and investment agreements. Although the connection between trade and investment policy and public health has been recognized for some time now (World Health Organization et al. 2002), academic interest in the topic has picked up in recent years (Labonté 2019). From an economic perspective, the connections between trade and health focus on the idea that wealth creates health, and as a result, pathways tend to focus on whether openness to trade has contributed to a reduction in poverty. Such assessments are usually aggregated at a country level, ignoring within country disparities. From a health perspective, the most examined issue has been the impact of

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intellectual property right extensions on access to medicines. However, as of late the commercial determinants of health perspective have increasingly dominated the field, with the majority of new evidence appearing around diet, and more limited investigations of tobacco and alcohol. Assessment of the impacts on health systems has been very limited (Chanda 2011), as has investigation from the broader social determinants of health lens (McNamara 2015). This chapter will begin by introducing readers to the global trade and investment regime, including key international institutions, rules, and procedures, and discuss contemporary shifts and trends in the regime. It will then turn to the pathways between trade and health, focusing specifically on access to medicines, health services, noncommunicable diseases, and the broader social determinants of health. This section will draw on a number of prominent dispute cases related to health to help draw attention to existing tensions and how the various outcomes support or undermine policy and other drivers of health. The subsequent section will focus on the political dynamics of trade, including the ideas, interests, and institutions that drive negotiating agendas, and the implications for enhancing attention to public health. Finally, the chapter reviews existing and proposed reforms to enhance alignment of trade and investment policy with global health policy goals.

The Global Trade and Investment Regime The Birth of a Global Trading System In the 1930s, a series of tariff hikes (e.g., border taxes), competitive currency devaluations, and discriminatory trading blocs were faulted as destabilizing the international political and economic order and creating the conditions for World War II. In the early forties, as the war drew to a close, leaders of the United States, the United Kingdom, and other allied countries began negotiations to establish rules for the postwar international economy. Based on their beliefs of what created the conditions for war, they presumed that free trade and economic integration would be the path to international peace and prosperity. These negotiations concluded in July 1944 in Bretton Woods, New Hampshire, and marked the establishment of the International Monetary Fund and the World Bank. An international agreement on trade proved more challenging to facilitate. It was not until 1947 that 23 nations agreed to the first postwar round of tariff reductions to be implemented by the General Agreement on Tariffs and Trade (GATT). The GATT also codified the rules of the trading system until an International Trade Organization could be created. A charter for an International Trade Organization was drafted and signed by 53 countries; however, opposition from the United States prevented the organization from coming to fruition. Consequently, the GATT, an interim agreement, would come to govern international trade relations for almost 50 years until an international trade body was ultimately developed.

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Establishing the World Trade Organization In January 1995, the World Trade Organization (WTO) was officially established with 123 member countries. The agreement founding the WTO suggested it would be one of “. . .raising standards of living, ensuring full employment and a large and steadily growing volume of real income and effective demand, and expanding the production of and trade in goods and services, while allowing for the optimal use of the world’s resources in accordance with the objective of sustainable development. . . (World Trade Organization 2016a).” The intention of creating the WTO was to develop a binding set of rules on governments for the conduct of international commerce that would help business while protecting legitimate social and environmental objectives of states. The WTO was also intended to serve as a forum for settling disputes regarding these rules and the negotiation of new trade and investment agreements (World Trade Organization 2016d). Two fundamental principles of the WTO are trade without discrimination and progressive liberalization of trade through additional negotiations. Nondiscriminatory trade is enforced through the right to most-favored nation (MFN) and national treatment. MFN prevents discriminatory treatment among one country and its trading partners, that is, the most favorable conditions provided to one trading partner must be provided to all trading partners. There are select exceptions to this obligation such as the formation of a free trade bloc and special access for developing countries. National treatment prevents discrimination between domestic and foreign producers, such that imported goods and services should be treated no less favorably than domestic goods and services. These rights are enshrined within the WTO agreements (World Trade Organization 2016c). The WTO also provides a dispute settlement system whereby members can seek compliance with the terms of the WTO agreements. Disputes arise when one WTO member adopts a policy or takes an action that another member considers to violate its WTO commitments. The Dispute Settlement Body (DSB) consists of all WTO members and establishes a dispute panel, which hears the case and makes recommendations to the DSB. The ruling can only be rejected by consensus. An Appellate Body mechanism exists to hear appeals. The goal of the dispute process is to have the respondent country bring its policies into line with its WTO obligations. If it fails to do so, the member must enter into negotiations on acceptable compensation, such as tariff reductions in the interest of the complaining member (World Trade Organization 2016b). If compensation cannot be agreed on, the member bringing the complaint may be permitted to retaliate by removing trade concessions in relation to the goods or services of the recalcitrant member. The WTO only provides for state-state dispute settlement (SSDS), whereby procedures can only be initiated by states against states.

Expansion of Bilateral and Regional Trade and Investment Deals In 1999, when WTO member nations met for the next time in Seattle, Washington, to discuss the agenda for the next round of WTO negotiations they were also met by

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30,000 to 40,000 protestors. What ensued has been labelled the “Battle in Seattle” (Summers 2001). The primary objection among civil society protestors was the perceived failure of the WTO to protect labor, environmental, and human rights. While there was considerable turmoil outside the venue, the situation inside was equally fraught. US President Clinton responding to protestors suggested they would create a working group on trade and labor, which incensed developing nations who saw this as an opportunity for disguised protectionism, a way for developed nations to use labor standards to discriminate against developing country exports (Summers 2001). While some attribute the breakdown in negotiation as largely a battle over labor rights between developed and developing countries (Summers 2001), others point out the larger public dissatisfaction with the encroachment of the WTO on domestic policy issues and national sovereignty, coupled with frustrations in the South at the continued lack of access to Northern markets for their manufactured and agricultural exports due to weak concessions in the original agreements (Gill 2000). Consequently, progressive trade liberalization stalled within the multilateral forum of the WTO and began forum-shifting to bilateral and regional negotiations. Bilateral agreements are negotiated among two countries, while regional agreements tend to be larger blocs with shared regional or geographic features. Collectively they can be referred to as Preferential Trade Agreements (PTAs), as they develop preferential rules among select countries, which stand in opposition to the multilateral platform of the WTO which seeks equal treatment among all members. As of 17 January 2020, there were 303 PTAs in force (World Trade Organization 2019). This proliferation of trade agreements outside the WTO has been referred to as a “spaghetti bowl,” with concerns raised around possible inconsistencies and trade diversion (Menon 2009). Recent examples include the Trans-Pacific Partnership Agreement (originally among 12 nations) and the Regional Comprehensive Economic Partnership (currently being negotiated among 15 nations).

The International Investment Regime Although the WTO has elements of investment within its agreements, it is principally an institution supporting global trade. The Organisation for Economic Cooperation and Development (OECD) attempted to develop a Multilateral Agreement on Investment (MAI) in 1995; however numerous sources of opposition blocked the signing of the MAI, and the idea of a multilateral agreement was abandoned (Bernasconi-Osterwalder et al. 2012). Instead, a network of international investment agreements (IIAs) has continued building, beginning with a Bilateral Investment Treaty between Germany and Pakistan in 1959 and rising to an astounding 2,336 BITs in force as of early 2020 and a further 314 treaties with investment provisions contained within (United Nations Conference on Trade and Development n.d.) The international investment treaty system was originally predicated on the need to promote and protect foreign direct investment (FDI) into developing nations. For investors from developed states, the system would ensure fair and effective procedures in the event that a dispute arose. Primarily, concerns were around the expropriation of foreign investments by governments in socialist and newly

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developing states. While for developing states, it would help drive inward FDI, which had been argued would create an influx of capital, knowledge, and technology transfer, as well as new employment opportunities, and increased competition and efficiency in the host state (Mabey and McNally 1999). The content of an investment treaty can be divided into three key components. The first are the definitions of who qualifies as an “investor” and what constitutes an “investment.” This is important as it is the first step in determining who will have access to the rights and dispute settlement procedures provided by the treaty. The second component is the actual rights provided to the investor by the country hosting the investment. The set of rights, among many others, include the right to compensation in the case of direct or indirect expropriation and the right to fair and equitable treatment – these have proved to be the most important for public health. Expropriation is a fairly standard right across agreements and covers both direct expropriation, the seizure by a government of private foreign physical property, and indirect expropriation, a government measure that does not include a physical taking but permanently destroys the value of the foreign investment or the ability of the investor to manage, use, or control it in a meaningful way. Fair and equitable treatment, on the other hand, has been incorporated in highly variable ways across treaties. At a minimum it appears to protect against denial of justice, breach of due process, manifest arbitrariness, discrimination on manifestly wrongful grounds (e.g., gender, race, or religious beliefs), and abusive treatment of investors, although some tribunals have made much more extensive rulings in terms of the obligations on the state. Between 1997 and 2011 cases where an arbitral decision was made based on an evaluation of the merits of the case, that is, where a tribunal ruled on an alleged breach of a substantive right, tribunals found a breach of fair and equitable treatment in approximately half of all cases and a breach of indirect expropriation in approximately one-quarter of all cases. The third component of investment treaties and the area that has created the most controversy is investor-state dispute settlement (ISDS), that is, when the treaty gives foreign investors a process to sue the host state in which they have invested if government actions are perceived to violate one of the aforementioned rights and negatively impact the value of an investment. ISDS has been extremely controversial as foreign investors have used the system to challenge a wide array of public policy measures, including measures on taxation, chemical and mining bans, environmental restrictions, transportation and disposal of hazardous waste, health insurance, tobacco, the price and delivery of water, and regulations to improve the economic situation of minority populations (Bernasconi-Osterwalder et al. 2012). Growing public backlash, conflicts of interest and a lack of safeguards in the system have ignited a global effort to reform the investment arbitration system under the auspices of the United Nations Conference on Trade and Investment Law (Roberts 2018). While reforms started with a narrower focus on matters of procedure and arbitration, the agenda has been expanding, and states are increasingly advocating for more substantive rule reform (Roberts and St. John 2019). Table 1 provides an overview of the most common chapters in trade and investment agreements relevant to health, a brief overview of what the content of each chapter seeks to achieve, and whether the chapter is found in the WTO only, in PTAs

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only, or in both. The next section will begin unpacking the specific relationships between trade and investment agreements and public health.

Governing Trade and Investment for Health As introduced at the beginning of this chapter, there are multiple avenues by which trade and investment agreements alter the determinants of health outcomes. This section will provide an overview of some of the key areas impacted including access to medicines, health services, noncommunicable disease risk factors, and the social determinants of health.

Access to Medicines Trade and investment agreements can create barriers to access to quality generic medicines through a number of different pathways (Gleeson et al. 2019). First, intellectual property (IP) rules which extend pharmaceutical monopolies can delay the entry of cheaper generic competitors, meaning governments and/or citizens pay higher prices for longer. Rules for IP protection for pharmaceuticals became globalized though the WTO’s Trade-Related Agreement on Intellectual Property Rights (TRIPS) implemented in 1995. Since then, a number of high-income countries, particularly the United States and European Union member states, have pushed for higher levels of IP protection that go beyond the TRIPS agreement through bilateral and regional trade agreements. A study of the impact of elevated IP rules in Jordan following WTO accession and the US-Jordan trade agreement, for example, estimated delays to the market entry of generic medicines as costing more than 18 million dollars for the retail market in 1 year alone (Abbott et al. 2012). Similarly, a study of the potential impact of 5-year patent term extensions in Thailand found that the additional cost to government after 5 years would be 822.1 million dollars (US), extending to over six billion dollars after 20 years (Kessomboon et al. 2010). Second, the provision of investor protections and ISDS noted earlier can lead to disputes or the threat of dispute by a foreign firm against a government. This may affect access to medicines if a government reverses or delays a related policy decision, such as decisions regarding the length of a pharmaceutical monopoly (Gleeson et al. 2019). The case of Eli Lily v Canada (see Box 1) illustrates how ISDS can be used by pharmaceutical firms to claim compensation against governments and initiate arbitration claims regarding their domestic policies. Third, rules on customs administration, such as rules on IP enforcement at the border, can threaten the movement of legitimate generic medicines between countries. This issue came to attention globally in 2009 when several shipments of legitimate generic medicines from India, which were destined for a number of developing countries, were seized in-transit by Dutch Customs authorities on suspicion of infringing IP. The medicines did not infringe IP in the host or recipient countries, and some shipments were destroyed, delaying access for those developing countries (Mara 2009).

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Trade agreements can also have a potential positive impact for access to medicines. Rules on tariff liberalization can potentially improve access to medicines if it results in lower prices of good quality imported pharmaceuticals. Similarly, rules on government procurement such as open tendering may lead to governments and/or hospitals paying lower prices for medicines, depending on the procurement process (Gleeson et al. 2019). However, tariff liberalization and open procurement can also weaken the viability of local generic industries through increased competition, which can make health systems dependent on overseas imports potentially reducing capacity to meet local needs (United Nations Conference on Trade and Development 2011). It also worth noting that flexibilities in the TRIPS agreement can assist countries to improve access to medicines. In Thailand, for example, when the government made use of flexibilities to issue government use licenses for the generic supply of seven patented drugs, it was able to provide more medicines to patients in need and was estimated to have saved $370 million dollars over 5 years (Mohara et al. 2012).

Box 1 Eli Lily vs. Canada

In 2013, the multinational pharmaceutical company Eli Lilly initiated an ISDS claim against the Canadian government after Canada’s courts invalidated patents on two of Eli Lilly’s medicines on grounds that they had not delivered the promised health benefits (italaw n.d.). Eli Lilly claimed that Canada had violated terms of the North American Free Trade Agreement (NAFTA), in particular indirect expropriation and a violation of minimum standards of treatment, and sought over 480 million dollars in compensation. Eli Lilly also challenged Canada’s domestic IP law, particularly the criterion for determining the utility of a patent. While the tribunal eventually found in favor of Canada, it still had to pay 25% of its legal costs, and the decision has been described as only a partial victory because the arbitration tribunal “failed to close the door to the possibility that invalidation of intellectual property rights under domestic law could constitute a violation of international investment law in the future (Baker and Geddes 2017).” Furthermore, the Canadian Supreme Court subsequently weakened the utility requirement in question in Canada’s patent law, reducing the proof of usefulness to defend a patent in Canada. Scholars allege that similar policy reversals have occurred in Colombia (which withdrew a compulsory licensing proposal) and Ukraine (which deregistered a generic hepatitis C medicine) after threats of dispute settlement claims by pharmaceutical companies Baker and Geddes 2017).

Health Services Trade agreements can also have positive or negative impacts on public health as the result of the liberalization of health services. International rules for trade in services were formalized through the WTO’s General Agreement on Trade in Services

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(GATS) which entered into force in 1995. Through GATS governments made a number of commitments to facilitate services liberalization; however, these rules only apply to health services if governments specifically listed this subsector, known as the “positive list” approach to services liberalization (excluding related services under other subsectors such as health insurance, discussed below). For those countries who have included commitments for health services liberalization in GATS, some have specified limitations by negotiating their inclusion on a “negative list” of exceptions. Trade in health services has increased globally through a number of pathways (Smith et al. 2009). First, there has been an increase in the cross-border supply of health services between countries, known as e-health (Mode 1). Facilitated by new online and communications technologies, e-health allows the remote provision of services for patients or recipients in another country, such as information websites, diagnostics, teleconsultations, and medical claims processing (Smith et al. 2009). Greater crossborder supply of e-health services can potentially increase access to e-health services for remote areas and those areas with human resource pressures and can promote cheaper access to technologies and services and greater dissemination of knowledge (Blouin et al. 2005). Risks to health, however, include lack of access due to poor infrastructure, potential resource diversion to curative services and tests, inequities in access, and less local capacity to deal with health issues (Blouin et al. 2005). Health tourism has also increased through a greater number of patients travelling from one country to another to use a health service (Mode 2). This mode also includes governments’ liberalization commitments to allow students to travel abroad for medical and nursing education. The potential positive impacts of health tourism include greater access to foreign exchange and opportunities to upgrade health infrastructure for exporting countries and reduced pressure on constrained health services and access to cheaper treatment for importing countries (Blouin et al. 2005). Risks, however, include inequities in access for local and international patients’ incountry, diversion of resources from the public to the private system, and loss of foreign exchange for importing countries (Blouin et al. 2005). Third, health services liberalization provisions for foreign direct investment have facilitated the transfer of funds from one country to another for private or joint ventures in the establishment of new clinics and other health services (Mode 3) (Smith et al. 2009). Greater foreign investment can enable more resources for health services, employment in recipient countries, knowledge transfer, and standards transfer, while risks can include diverting funds from the public sector to attract private resources, inequities in access to private or semi-private services, and internal brain drain (Blouin et al. 2005). The temporary movement of health personnel from one country to another has also been facilitated by health services liberalization (Mode 4). Potential health benefits of the temporary movement of health personnel include meeting health personnel shortages, knowledge exchange and transfer, and greater remittances back to the sending country. Risks however include brain drain of personnel from the sending country, including loss of training and public investment (Blouin et al. 2005).

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It is important to note that liberalization of other services sectors in trade and investment agreements can also have an impact on health. Health insurance, for example, is liberalized through the insurance subsector rather than health services. Policymakers have been caught off guard for unintentionally opening their health insurance sectors to liberalization. Scholars, for example, argue that Canada opened its health insurance sector to liberalization without realizing when it included insurance in its 1994 GATS commitments (while excluding health services from liberalization commitments) (Sanger and Sinclair 2004). The potential impacts of liberalizing health insurance services include greater privatization and increased costs of health insurance, with equity implications, and significant challenges for governments if they decide to reorient back to publicly provided systems in the future. Box 2 outlines the ISDS case of Achmea vs. Slovakia which demonstrates the constraints governments can experience when committing to services liberalization. Box 2 Achmea vs. Slovakia

In 2004, the government of Slovakia implemented a number of reforms to its health system, including opening up insurance to private health providers. Subsequently, the Netherlands company Achmea established a subsidiary in Slovakia to provide private health insurance. In 2006 Slovakia partially reversed its decision and ruled to prevent private health insurers from distributing profits to their shareholders (Ankersmit 2018). Achmea initiated an ISDS claim against Slovakia through a Netherlands-Slovakia bilateral investment treaty (BIT) claiming compensation, which was heard by an arbitration panel in Germany. The arbitral panel ruled in favor of Achmea, determining that Slovakia had breached its commitments under the BIT, and subsequently ordered Slovakia to pay Achmea EU 22.1 million dollars (Ankersmit 2018). The case demonstrated the constraining effect of services liberalization commitments, in particular when coupled with investor rights, and led to wider EU debates over the appropriateness of ISDS mechanisms in trade agreements. Indeed, following Slovakia’s appeal, in 2018 the Court of Justice of the European Union determined that the ISDS mechanism in the Slovakia-Netherlands BIT “prevents investment treaty disputes from being decided within the judicial system of the EU and, thereby, is incompatible with EU law (InfoCuria 2018).” Following subsequent legal challenges to the use of ISDS in other EU BITs, in early 2019, member states of the European Union issued a Declaration stipulating that EU law takes precedence over intra-EU law and committed to terminate all intra-EU BITs (European Commission 2019).

Noncommunicable Disease Risk Factors International trade and investment has created multiple challenges for rising noncommunicable disease rates. First, liberalization of goods and services through lower

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tariffs (i.e., border taxes) and the elimination of restrictions on foreign direct investment (FDI) have generally increased both the volume of imports and foreign investment into local production, manufacturing, distribution, and marketing, respectively (Commission on Social Determinants of Health 2008). Rising imports and FDI have been shown to preferentially target health harmful commodities such as tobacco, alcohol, and ultra-processed foods and beverages (which come with higher profit margins, longer shelf lives, and greater capacity for branding) over more health promoting commodities like fruits and vegetables (Stuckler et al. 2012). Second, trade and investment agreements have historically negatively affected access to medicines, as discussed above, which proves an additional challenge as the products associated with greater trade and investment tend to be drivers of noncommunicable diseases (e.g., cardiovascular diseases, diabetes, cancers), thus promoting disease while making treatment less affordable. Finally, additional international obligations on the domestic policymaking environment introduced through regulatory harmonization initiatives and enforced through dispute settlement have the potential to slow or interfere with efforts to regulate increased sales of harmful commodities associated with trade and investment liberalization. Policies regulating commodities such as tobacco and sugar have been challenged in both state-state and investment-state dispute settlement (see Box 3 and Box 4). However, policies have also been challenged in more discreet forums, such as committees within the WTO. A recent analysis revealed challenges to the introduction of mandatory front-of-pack interpretive nutrition labelling in Thailand, Chile, Indonesia, Peru, and Ecuador as a means of addressing diet-related NCDs through the Technical Barriers to Trade Committee (Pritchett and Summers 1993). Other WTO member countries, likely acting on behalf of domestic industries, requested greater justification for the measures and scientific evidence for their effectiveness and suggested that the measures are more trade restrictive than necessary and that less trade-restrictive measures, such as education campaigns, could be implemented instead. Similar practices have been documented in reference to alcohol labelling (Blouin et al. 2009). Box 3 Philip Morris vs. Australia

In 2010 the Australian government announced its plan to introduce tobacco plain packaging as a public health measure. The legislation mandates all aspects of cigarette packaging including the specified position, font, size, and color of the brand name and prohibits the use of any trademarks (Australian Government Department of Health 2014). Less than 1 year after this announcement, Philip Morris Asia purchased Philip Morris Australia in order to gain access to the investor-state dispute settlement (ISDS) procedures within the bilateral trade agreement signed between Hong Kong and Australia in 1993. Just 4 months after this acquisition, in June 2011, Philip Morris Australia notified the government of Australia of its intention (continued)

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Box 3 (continued)

to sue over its plain packaging legislation in international arbitration (Chapman 2015). The focus of the challenge to this legislation was the ban on the use of trademarks (protected under intellectual property rights), arguing it interferes with consumer capacity to differentiate brands, thus violating basic expectations of the tobacco company and damaging the value of its investment (Lo 2012). On December 18, 2015, the arbitrators dismissed the case on jurisdiction. They unanimously decided they had no authority to rule, due in part to the acquisition of Philip Morris Australia at a time when the investor had full knowledge of a possible impending dispute and were thus preemptively seeking access to investment procedures. While this was praised among the media as a victory for public health, Marc Firestone, Senior Vice President and General Counsel for Philip Morris International was quick to note that, “There is nothing in today’s outcome that addresses, let alone validates, plain packaging in Australia or anywhere else (Hurst 2015).” The decision that many nations were waiting for to get the green light for tobacco plain packaging became a permanent amber light. However, the culmination of the successful defense of Australia’s plain packaging measures in the Australian High Court and in WTO state-state proceedings, as well as Uruguay’s successful defense of its tobacco control measures against Philip Morris International in another ISDS case, will reduce the likelihood of future trade and investment arbitration over tobacco control measures. It should be recognized however that while the Australian case hung in the balance, other states were less likely to introduce plain packaging (New 2014). For example, the New Zealand government officially stated it was waiting for a decision in the case before proceeding with its own legislation (Johnston 2015). Moreover, even though it did not lose the case, Australia was still required to pay 12 million in damages (Ranald 2019). However, since then a number of countries across the globe have implemented tobacco plain packaging, with more countries passing enabling laws for such legislation to proceed or announcing plans to introduce plain packaging (World Health Organization 2018).

Box 4 United States vs. Mexico

In January 2014, the government of Mexico introduced an excise tax on any nonalcoholic beverage with added sugar. Producers pay an additional 1 peso per liter, which represents about a 10% increase in price for the consumer (World Health Organization 2017). The tax has been shown to be effective in (continued)

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Box 4 (continued)

reducing the purchase of sugary beverages, in diverting purchases to bottled water (Colchero et al. 2017), and in raising funds for public health investments (The Nutritional Health Alliance 2016). Subsequently, the sugary drink tax spreads globally in many different forms (Wan et al. 2017). But the battle over sugary drinks in Mexico started well before 2014. Upon signing the North American Free Trade Agreement (NAFTA), which entered into force in January 1994, Mexico believed it would be able to significantly increase its sugar exports to the United States (US). However, disputed interpretations of side letters to the agreement between the two countries led the United States to block much of this new market potential. Mexico’s sugar industry took a further hit, as exports of sugar from the United States to Mexico, specifically the financially competitive high fructose corn syrup, began increasingly rapidly. Mexico’s attempts to resolve this dispute through NAFTA mechanisms were again blocked by the United States. At that point Mexico began imposing additional duties on high fructose corn syrup from the United States, between 1997 and 2002, until they were eventually deemed noncompliant by the WTO. In 2002, Mexico then adopted a 20% tax on soft drinks and other beverages that use any sweetener other than cane sugar, which initiated another dispute settlement case at the WTO. The United States argued that the tax violated Mexico’s obligation not to treat directly competitive or substitutable domestic products more favorably than imported products, in this case favoring Mexican produced cane sugar which did not have a tax, relative to applying a 20% tax on high fructose corn syrup produced in the United States. The WTO found in favor of the United States, and Mexico revoked the tax in 2007 (Davey and Sapir 2009). This is a rather clear example of using a health policy as disguised protectionism to resolve an existing trade disagreement. It would be another 7 years before Mexico would establish its trade-compliant version of a sugary drink tax.

Social Determinants of Health Trade and investment agreements can have impacts on the social determinants of health (SDH) – “the conditions in which people live and work that affect their opportunities to lead healthy lives (Commission on Social Determinants of Health 2008).” Four identified pathways by which trade agreements can affect the SDH include material deprivation, acute psychosocial stress, unhealthy lifestyles (explained in the above NCD section), and high level of stratification and lack of social cohesion (Corrigall et al. 2008).

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Trade and investment agreements can create positive flows for health though improvements in material living conditions and greater access to health improving goods and services. Indeed, greater country wealth is associated with higher life expectancy (Pritchett and Summers 1993). However, the economic benefits of increased trade are not distributed equally and can lead to inequalities, in particular if there is a lack of complementary economic and social policies to redistribute the benefits of trade. When the benefits of trade are inequitable, levels of inequality within a country increase, which is associated with less healthy populations (Blouin et al. 2009). Furthermore, economic insecurity is associated with increases in acute levels of psychosocial stress which can increase preventative morbidity and mortality. Growing inequality in life expectancy in the United States, for example, is indicative of the effect of economic insecurity on psychosocial stress, as indicated by increasing deaths from alcohol, drug addiction, and suicide (Centers for Disease Control and Prevention 2019; Chetty et al. 2016). While the rationale for negotiating trade agreements with developing countries includes enhanced employment opportunities for lower paid workers, research has shown that liberalization can compound wage inequality within countries between skilled and unskilled workers (Blouin et al. 2009). Agricultural producers in developing countries, for example, are seen to be negatively affected by liberalization when cheaper imports, or rules on IP for seeds, threaten their livelihoods (McNamara 2017). While women’s employment has increased in low and middle countries, poor working conditions from deregulation and competition has negatively and disproportionality affected their health (and that of migrant workers). In high-income countries, impacts include job losses and depressed wages through increased competition, which negatively affects psychosocial health (Corrigall et al. 2008). Food security is another determinant of health which can be affected by trade liberalization. Liberalized food markets are related to greater food insecurity in low-income countries due to global food price instability, reduced subsidies, and cash crop schemes for commercial export (Labonte et al. 2007). Reduced tariffs, however, can promote greater access to healthy food (McNamara 2017). Trade agreements can also have positive or negative effects for the environment (see Box 5 for recent environmental disputes). Increases in production and exports can contribute to increases in air pollution, fossil fuel production, and thus climate change (Barlow et al. 2017). In contrast, increasing trade in environment-promoting technologies, such as renewable energy technologies and services, can have positive affects for environment and thus health. Environmental protections remain a contentious issue in trade agreements, with ISDS particularly criticized as facilitating investor arbitration claims with several government measures concerning food safety, water and land use, pollution control, and hazardous waste being challenged through this system (see Box 6 for the case of Veolia vs. Egypt) (Van Harten 2013).

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Box 5 Climate Change Cases

One of the most disappointing cases for environmental protection is recent years is that of Bilcon v Canada. The case was brought against Canada after the province of Nova Scotia rejected a project to develop and operate a quarry on the grounds that there would be a significant and adverse environmental effect on the community core values. The finding for Bilcon came as a surprise to many as it was reminiscent of some of the earliest disputes when arbitral tribunals provided very little deference for government action to protect the environment (Schacherer 2018). Canada was ordered to pay Bilcon $7 million, considerably less than the $443 million they were originally seeking (Withers 2019). There have also been several recent cases of threats of ISDS arbitration against governments by foreign companies over environment related policy decisions. In 2015, TransCanada filed a fifteen-billion dollar claim with the US government over its decision to reject the construction of the Keystone pipeline (which cited climate action grounds). TransCanada suspended its claim when the newly elected US government under President Trump approved a resubmitted application (Sachs et al. 2019). In 2019, US-based mining company Westmoreland initiated a claim of $357 US million in damages against the Government of Canada over a decision by the Alberta provincial government to close and phase out coal-fired power plants by 2030 (Sachs et al. 2019), which has recently commenced. At the time of writing, German energy company Uniper is also threatening ISDS arbitration against the Netherlands after it passed legislation in December 2019 to shut down its coal-fired power plants by 2030.

Box 6 Veolia vs. Egypt

In 2012 French waste company Veolia initiated an ISDS claim against Egypt claiming damages after the country increased its minimum wage from EU 41 per month to EU 72 per month. Veolia had signed a contract with Egypt’s Governorate of Alexandria in 2000 to supply waste management services for a period of 15 years. Veolia claimed that Egypt’s subsequent increase in the minimum wage negatively affected the company’s investment and violated the terms of an Egypt-France Bilateral Investment Treaty (Australian Fair Trade and Investment Network 2018). In 2018, the arbitral tribunal found in favor of Egypt, signalling an important win for the public interest. However, the details of the case, including the costs for Egypt’s defense and how much Veolia was ordered to pay, remain confidential.

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Political Economy of Trade and Health In order to understand the barriers and opportunities for advancing greater attention to health in trade and investment agreements, we need to understand the political dynamics at play surrounding trade policy agendas including the interactions between interests, ideas, and institutions (Hall 1997). In the following we discuss each in turn, reflecting on trade and investment negotiations and barriers and enablers for agenda-setting for health.

Who Are the Actors? Trade agreements are negotiated between states at different levels, including the multilateral (e.g., WTO), regional (e.g., the Comprehensive and Progressive Agreement for Trans-Pacific Partnership), or bilateral between two countries. States can have very different interests and different economic, geopolitical, and security rationales for joining trade and investment agreement negotiations. Power asymmetries between states can often mean that governments agree to rules that are not favorable to health. For example, scholars have been particularly critical of the pressures imposed by the United States in its bilateral and regional agreements with other countries (Sell 2007). Several low-, middle-, and high-income countries have entered into bilateral agreements with the United States, ultimately agreeing to higher levels of IP for pharmaceuticals, leading to concerns for the potential impact on access to generic medicines. Low-income countries can also experience capacity challenges in trade agreement negotiations which can be lengthy over several years, expensive, and cover a significant number of issues, often without any prospective public health impact assessment. While trade agreements do not include business or civil society representation, these actors are certainly involved in agenda-setting as they seek to influence governments’ offensive and defensive interests in trade and investment agreement negotiations. Analyses of industry and civil society submissions to government demonstrate that a majority of industry actors’ advocate for market-oriented objectives to facilitate private enterprise, market competition, export growth, and trade liberalization (Sell 2007). In contrast, a majority of civil society and public health organizations lobby governments to protect the public interest, including measures to ensure trade agreements do not restrict state sovereignty and the right to protect and promote public health (Townsend et al. 2020).

What Are the Ideas? In order to understand why it is that some interests are advanced over others in trade and investment agreement negotiations, it is important to investigate the role of ideas and ideologies in shaping how governments and policy actors think about the

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purpose of trade and investment agreements. Internationally, neoliberalism remains the dominant ideology in trade policymaking (Lencucha and Thow 2019; Schram 2018). While the term has many interpretations, neoliberalism refers to “the new political, economic and social arrangements within society that emphasize market relations [and] re-tasking the role of the state,” extending a discourse of “competitive markets into all areas of life (Springer et al. 2016).” Through this pro-market lens, governments envisage a limited role for the state in the promotion of market interests, configure citizens primarily as “consumers,” and regard most public regulation as excessive or intrusive on producers’ economic rights (Townsend et al. 2020). Aside from economic factors like employment and GDP, the social determinants of health are largely excluded from this dominant framing, creating barriers to public health efforts to shift government thinking toward more holistic social and health framing. Indeed, counter framing to elevate public health and protection of the public interest by public health advocates remains largely on the periphery of trade and investment negotiations (see reflections on some public health successes in the following section).

What Are the Institutions? Within trade policymaking, institutions defined as “the formal and informal rules, norms, precedents, and organizational factors that structure political behavior” (Hall 1997) are informed by the dominant neoliberal paradigm outlined above. The processes for government consultation with non-state actors often facilitate power asymmetries in access and influence between industry and civil society. Indeed, industry actors and governments often share neoliberal ideas for the promotion of export growth and market liberalization. Shared language and framing can enable greater influence for industry actors over government priorities. Multinational corporations, for example, played a key role in lobbying governments to adopt the WTO TRIPS agreement (Sell 2007). Analysis of industry and public health actors’ strategies to influence governments in trade negotiations suggests that this shared discourse confers authority to industry actors and makes them less reliant on other forms of authority (Townsend et al. 2019). Interviews with policy actors in international and domestic trade policymaking processes also show public health actors’ widespread criticism of a lack of meaningful engagement and input into governments’ trade interests (Battams and Townsend 2019). Overall, industry actors have reported more satisfaction with the formal and informal processes available to advance their interests (Battams and Townsend 2019). These include processes “inside” the trade policy system, such as attending official consultations (formal) or lobbying government on the sidelines of negotiating rounds (informal), as well as processes outside the trade domain such as parliamentary inquiries (formal) or shaping public opinion through media (informal) (Friel et al. 2019). Processes differ by country. In the United States, for example, domestic industry committees enable 600 corporate stakeholders, and a small number of approved

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nongovernment organizations, to view sections of negotiating text confidentially (Ranald 2015). Institutional barriers can also appear between government portfolios. Some health officials in Malaysia and Australia, for example, have reported a power imbalance with trade officials, resulting in a perceived lack of consultation and reliance on unofficial leaked text to assess the potential impacts for health in trade agreement negotiations (Battams and Townsend 2019). Finally, institutional norms in trade and investment negotiations prioritize secrecy and a lack of transparency, creating barriers for public health experts and advocates to analyze the potential impacts of proposed treaty negotiations for health. Final texts of bilateral and regional agreements are not released publicly until after they are signed, and few governments implement robust health impact assessments of the treaty text. How these institutions might be restructured differently is the focus of the next section.

Reforming Trade and Investment for Public Health Trade and investment liberalization and public health can be mutually beneficial endeavors under the right set of circumstances. At present the system has operated on the principle that liberalization (i.e., the process of progressively opening domestic markets to international competition, entrenching rules in enforceable international forums, and generally paving the way for privatization) is universally good for economic growth and that the benefits will automatically flow to the people and for our purposes improve material circumstances and health. This idea is usually captured by the idiom the “rising tide lifts all boats.” However, faced with mounting evidence that benefits have not been as distributive as once proposed, the system is in turmoil. Interestingly, there are multiple competing narratives on who has and has not benefited from globalization, including its key processes like trade and investment. The environment is increasingly recognized as one of the “losers” of globalization and economic integration, as finite natural resources and ecosystem health have not been ascribed as having any “value” under the current model. In the view of the authors, while the model of economic growth developed in Bretton Woods all those decades ago may have been an acceptable response to the postwar challenges of the time, today we face pressing challenges of rising social inequities and climate catastrophe which will create cascades of conflict, food shortages, and large-scale human migration (Jones 2017; Samberg 2017). There are several ways that we can alter the trade and investment system such that it supports a new era of sustainable development era without abandoning an important forum for international cooperation.

Trade-Proofing Health Policy Before turning to ways to reform trade and investment policy, there are considerations that could be made in the health policy process to adhere to principles of trade

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and investment without sacrificing policy effectiveness. This may be an important part of an approach in moving toward policy coherence by showing a willingness to work with economic sectors in a collaborative way. The first suggestion involves having reasonable evidence for the selected policy approach, which simply reflects good practice. International efforts to aggregate evidence and make policy recommendations under the banner of respected institutions like the World Health Organization, such as the Framework Convention on Tobacco Control, have proved useful in defending tobacco control measures in trade and investment disputes (Gruszczynski and Melillo 2018). Guiding documents such as this demonstrates a robust evidence base and an emerging international approach to product regulation. This is useful for all countries, but developing countries in particular, that do not necessarily have sufficient resources to defend costly litigation or to conduct firsthand research. While debate exists around whether such documents would necessarily need to be a treaty or could simply be a guideline or standards, an international document of this nature has been suggested as having merit in the diet and alcohol space (Swinburn et al. 2019; Yeung and Lam 2019). It may also prove useful to implement a package of policies rather than any single policy. This approach was cited in support of tobacco plain packaging during the trade disputes to demonstrate a commitment to achieving a policy goal. Similarly, by implementing trans-fat labelling measures in New York prior to implementing a trans-fat ban, they were able to demonstrate evidence that the labelling and awareness campaigns had produced insufficient results and thus had such measures been challenged in a trade forum; it would have been much easier to demonstrate that less restrictive trade measures were not available to achieve the intended policy outcome. However, in both examples above, it is important to remember that the precautionary principle is a part of trade policy and a protected right for states. If the evidentiary burden is not yet sufficient but there is significant reason to believe a considerable health risk exists, or where action is needed and labelling or awareness campaigns are an insufficient response to a timely concern, then there are still ways to defend these policies in trade and investment disputes. Finally, there have been examples where a health policy has coincided with disguised protectionism. For example, banning flavor additives to cigarettes that increase their desirability is an example of good health policy. So, when the United States banned clove-flavored cigarettes in 2009, it was concerning that this policy was the focus of a trade dispute with Indonesia, the primary exporter of cloveflavored tobacco. However, the exclusion of menthol-flavored cigarettes from the ban, a product primarily produced within the United States, revealed a legitimate case of domestic protectionism. Banning clove-flavored cigarettes was a positive step for population health, but banning both clove- and menthol-flavored cigarettes would have been an even better policy. This demonstrates the possibility for trade policy to align with health policy in a way that not only doesn’t undermine health policy but could actually strengthen it. The principle of national treatment here, not treating domestic products (menthol flavoring) differently from foreign products (clove-flavoring), aligned trade and health policy in mutually beneficial ways.

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Health-Proofing Trade Policy There are two different approaches to reforming trade and investment policy to support health policy goals. The first involves defensive measures, wherein the aim is to ensure that trade agreements do not undermine health policy. One of the most prominent defensive tactics for protecting health policy space in trade agreements, first employed in the WTO General Agreement on Tariffs and Trade, is a provision known as the general exception. This provision permits members to adopt measures that violate GATT if it is “necessary to protect human health, animal or plant life or health” (Article XX[b]) and provided they do not constitute a means of arbitrary or unjustifiable discrimination between countries or a disguised restriction on trade. This same provision is included in the General Agreement on Services, thus protecting health policy in both goods and services trade, and has been copied into most PTAs. In practice, only 1 of 44 attempts to invoke this general exception has been successful. In the 33 cases where the exception was deemed to be relevant, the majority (N ¼ 18) failed to establish that measures were “necessary to” protect health (Public Citizen 2015). The United Nations Conference on Trade and Development (UNCTAD) in their Investment Policy Framework for Sustainable Development has suggested that instead of providing that the measure must be “necessary to” achieve the policy objective, the text could require that the measure be “designed to” achieve the policy objective, thus lowering the burden of proof for states (United Nations Conference on Trade and Development 2015). Interestingly, the Peru-Australia Free Trade Agreement, signed in 2018 and entering into force in 2020, has included a provision with this wording in the Investment chapter, stating that “No claim may be brought under this Section [ISDS] in relation to a measure that is designed and implemented to protect or promote public health.” It will be important to track what impact, if any, this shift in wording has on dispute panel decisions. In fact, many of the progressive shifts in health protection have come on the investment side of trade and investment policy. This is likely in response to largescale public disapproval of ISDS and the backlash from Phillip Morris suing Australia through investment arbitration over tobacco plain packaging measures. For example, the Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) signed in 2018 included a “carve-out” of tobacco measures from ISDS in the CPTPP. This type of exception allows members to exclude any tobacco control measure from an investment dispute. Ultimately this is a narrow protection that applies only to tobacco and only under this one agreement (leaving all previous agreements between members in play). Malaysia (a member of the CPTPP) initially proposed a more comprehensive carve-out of tobacco control measures from the TPP agreement; however this did not make it into the final text and is much less ambitious than the exception included in the Peru-Australia Free Trade Agreement. As an alternative to pursuing broader exceptions from dispute settlement as a way to achieve greater regulatory autonomy, UNCTAD has suggested measures to empower states to decide on the application of general public policy exceptions. That is, if a state invokes a public policy exception during a dispute settlement

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procedure, the matter could be referred to members of the agreement for a binding determination of whether or not the measure falls within the scope of the exception. This option may be perceived as achieving a better balance between trade and heath objectives, as opposed to blanket carve-outs, and would help re-establish domestic sovereignty and accountability over policy decisions. Additionally, the public health community has targeted the removal of select provisions from negotiations where there is strong evidence to suggest negative health impacts. This has often been the case for intellectual property rights, where chapter content has frequently been leaked during negotiations and where a clear causal pathway can be drawn from patent extensions to increases in medicine prices. For example, while the original TPP included a number of extensive IP provisions, many were suspended in the CPTPP following the US withdrawal, including the requirement to provide patents for new uses, methods, and processes of using existing products and the provisions providing for patent term adjustments and data/market protection (Gleeson et al. 2019). The second approach to reforming trade and investment policy is through offensive measures, where the aim is to try and have trade and investment actively promote progress toward health policy goals. Increasingly we see countries including chapters on social determinants of health, primarily environment/sustainable development and labor. Research indicates that the impact of labor standards has been hindered by a lack of legal add political prioritization (Harrison et al. 2019; Marx et al. 2016). While there has been more optimism around the capacity to upgrade environmental standards in developing country partners (Bastiaens and Postnikov 2017), others have noted unintended social consequences, including public backlash against the perception of developed countries drafting environmental law for developing countries (Jinnah 2011). We’ve also seen this in proposals around the UNCITRAL reforms noted earlier. Some countries try to rebalance the purpose of these agreements. For example, in its submission to the reforms, South Africa noted that “Promoting and attracting investment should not be an end in itself, but a step toward realizing the broader objectives of the SDGs and human rights obligations, such as reducing poverty and hunger, empowerment of Indigenous peoples, promoting decent work, and reversing environmental degradation and climate change.” Whether this is incorporated into preamble, generally quite unenforceable in a legal context, or implemented in a more concrete and enforceable way remains to be seen.

Conclusion The current chapter covered four areas of content regarding international trade and investment and global public health. The first section provided an introduction to the trade and investment system, including the nature of its origin, its institutional development, its guiding rules, and a brief overview of key content. This background information was intended to provide the necessary context to enable readers to engage with the key issues for health discussed in the second section. The major

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health issues covered included access to medicines, health services, noncommunicable disease risk factors, and the social determinants of health, providing a fairly inclusive survey of the health issues that have received attention in this space to date, including prominent dispute settlement cases. The third section employed a political economy perspective by reviewing the ideas, interests, and institutions that drive the trade policy agenda. This is a fundamental component for understanding the barriers and enablers to creating trade and investment agreements that are more supportive of global health policy goals. Finally, the fourth section covered recent and proposed reforms to the trade and investment system that would enable greater policy coherence between the two domains. Together these four sections deliver a comprehensive introduction to the trade and investment policy space for a global health audience unfamiliar with work in this area. There are two important trends to consider from a global health perspective. This first is to note that in general we are seeing greater attention being paid to public health issues within trade and investment policy. This has been reflected in the reforms cropping up targeted at health, particularly in the investment policy arena which is itself undergoing a period of substantial reform to address mounting opposition. Furthermore, if we compare the health policy space to environmental policy, we have had a much stronger track record in terms of having health regulations respected in investor-state dispute settlement. For example, the most recent cases challenging what is very clearly health policy (e.g., tobacco control measures) have all supported the right to regulate for public health and failed to find for the tobacco companies, or in the case of the WTO, the countries bringing forth the challenge to the measures. Challenges to environmental measures on the other hand have had very mixed results. While we may not have achieved everything we would like and many protections still have limited enforceability, the progress made by public health actors should not be undervalued. The second trend is broader but has implications for global health. This is the move away from multilateral trade deals toward more bilateral and regional deals. On the one hand, smaller deals may allow for innovation in ways that multiparty deals do not. Provisions like the one in the Peru-Australia Free Trade agreement that carved out public policy from ISDS proved politically unfeasible in the Trans-Pacific Partnership but represent what is likely the strongest protection for public policy in the investment system to date. Taking an optimistic view, this innovation, once shown to be possible in an agreement, may diffuse among other parties and potentially reach a point where it is socialized into the policy discourse and thus becomes more viable in larger agreements. The flipside, however, is that the shift to multiple regional and bilateral deals can create a complex network of possibly conflicting rules, the so-called “spaghetti bowl” phenomenon, that becomes increasingly difficult to untangle. Similarly, it may deliver less certainty about whether new domestic policy is compliant with trade rules, as multiple sets of varying international obligations are naturally more difficult to comply with that one set of multilateral rules. This may make risk-averse governments more cautious about introducing new policy for fear of possible dispute. This also makes it more difficult to upskill health policymakers in the trade and investment space. Additionally, when positive

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innovation does happen in individual agreements, the capacity for system-wide transformation is limited. For example, the tobacco carve-out in the TPP did not retroactively affect existing agreements between countries. Since five regional agreements and 24 bilateral agreements already existed among the 12 original negotiating TPP countries and the rules were written such that tobacco companies could still draw on existing treaties to seek arbitration, the already limited impact of this narrow carve-out was significantly diminished. Moving forward, there are three streams of opportunities for global health actors to engage in trade and investment policy. This is not a comprehensive list but rather some sample areas for action. The first is to address the dearth of research regarding trade and investment agreements and health services. While from a social determinant of health perspective, one which the current authors generally employ, the greatest capacity for improving population health comes from structural change outside the traditional health sector, there is a glaring gap in the literature in this regard. It could be argued that work in the access to medicines space has helped socialize public health actors being a part of the trade conversation, even if only in a limited way. More investigation into the impacts on health services could provide another channel in and another avenue through which to build influence in the larger conversation. It would be valuable for those that study the healthcare sector already to more systematically consider the impact of trade and investment liberalization, both positive and negative, on the different modes of service delivery. It is an area where there are challenges and opportunities in almost equal measure and a natural space for global health actors to provide additional input. Second, public health should explore more offensive actions in the trade and investment policy space. By and large efforts have focused on the idea of carving out public health or protecting our policy space. However, it would be beneficial to think of new ways that trade and investment policy could be designed such that is actually supported health goals rather than simply doesn’t undermine them. What types of rules and measures could be introduced to promote nutritious food systems? What type of intellectual property regime would support the transfer of life-saving health technologies at affordable pricing? How could we operationalize and introduce criteria around public health into investment decisions? What would be needed for government to support comprehensive, independent evaluations of health and health equity impacts before treaties are signed? This switch from a defensive to offensive position will require greater innovation among global health actors, implementable ideas, and a keen understanding of the political economy around agenda-setting in order to bring such changes to fruition. Finally, there is a growing recognition among global health scholars that the greatest threat to human health at present is the ever-escalating climate crisis. The shift to discourses of “human and planetary health” or “healthy and sustainable development” or “health and climate” among the work of health scholars and advocates can be felt. Those working in the trade and investment space should be maximizing our efforts by addressing health and environmental objectives collectively. Single public health issues, such as seeking tobacco carve-outs or even language that just protects public health policy, will be insufficient for the challenges

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we face. Decisions which undermine environmental protection during dispute settlement should be seen as decisions which undermine public health, and the same outrage and attention that developed in response to the Philip Morris v Australia case (see Box 3) should be generated for these case (e.g., Bilcon v Canada, Box 5). While there is undeniably merit to small “wins” that build momentum, it is becoming increasingly apparent that our time to make real change is limited. We started by introducing the inception of an international trading system that responded to the needs and challenges of the 1940s postwar global society. What we need now is a new system for trade and investment that is redistributive and regenerative by design and that responds to the needs and challenges of the current times.

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Health Promoting Schools Applying Health in All Policies in Schools

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health and Well-Being of Children and Adolescent in a Transformative Society . . . . . . . . . . . . The Purpose of Schooling and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clues Toward Healthier Schools for Sustainable Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Promoting Schools (HPS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health in All Policies (HiAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applying HiAP in Health Promoting Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Promoting School Approach and HiAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why Does It Work or Does Not Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Are the Prerequisites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HiAP Framework for Schools in SDGs Era . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges and Realities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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“It takes a village to raise a child.” African Proverb D. Houéto Healthier Population Division, Department of Programme Management, WHO African Regional Office, Brazzaville, Democratic Republic of the Congo e-mail: [email protected]; [email protected] S. Good (*) Healthier Population Division, Department of Programme Management, WHO African Regional Office, Brazzaville, Democratic Republic of the Congo Health Promotion and Social Determinants of Health, Department of Healthier Population and Non communicable Diseases, WHO South-East Asia Regional Office, New Delhi, India e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_85

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Abstract

A health promoting school (HPS) establishes and documents school policies and programs that promote health and well-being; provides a safe, secure, clean, sustainable, conducive, and healthy physical environment for learning; builds a secure school social environment that fosters positive relationships among and between students, staff, parents, and the wider community; strengthens community links through connections and partnerships among families, the community, schools, organizations and other stakeholders; includes action competencies for healthy living in the formal and informal curricula for development of students’ knowledge and life skills; and facilitates access to health-care and health promotion services. Schools represent a privileged setting for Health in All Policies (HiAP) implementation, recognizing its contributions to the SDG’s achievement. The international community, aware of the interest of HPS and HiAP in achieving the SDGs, initiated number of processes for its recognition and adoption by countries. This chapter highlighted examples of HPS implementation and its benefits to intersectoral action for sustainable development. There are some implementation gaps that need to be addressed to take full advantage of health promoting schools in most countries especially in low-resource settings. Keywords

Health promoting school · Health in al policies · Social deteminants of health · Sustainable health education · Health literacy · Healthy settings · Life-skills · Community enagement · Child-center-education

Introduction Health promoting schools (HPS) is one of the healthy settings derived from the Ottawa Charter stating that “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love” (WHO 1986). This was emphasized through the Jakarta Declaration (WHO 1997) stipulating that “comprehensive approaches to health development are the most effective . . . particular settings offer practical opportunities for the implementation of comprehensive strategies. These include megacities, islands, cities, municipalities, local communities, markets, schools, the workplace, and health care facilities.” According to WHO (1997), there are three conditions to achieve the status of a healthy setting: creation of a healthy working and living environment; integration of health promotion into the daily activities of the setting; and creation of conditions for reaching out into the community. These conditions are based on three key elements of the settings approaches which are an ecological model of health; a systems perspective; and a whole system organization development and change focus. This systemic setting approach aims to address not only the health issues but also its determinants. Health promoting school approach, goes beyond school health

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services and programs that target particular health conditions such as growth rate, oral health, nutrition and diets, prevention of diseases through immunizations, or addressing risk factors such as sexual and reproductive health education, drugs and substance abuse, etc. School as a healthy setting is concerned with development of personal competences; policies, reshaping environments, and building partnerships; bringing about sustainable change by means of participation; developing empowerment; and ownership of change for everyone in the setting and those who are influenced by or having impacts on the health and its determinants. In the Global Conference on Health Promotion 2013, WHO and Member States adopted the “Health in All Policies” approach, to address upstream determinants of health and consider intersectoral actions from the whole-of-government. WHO defined Health in All Policies (HiAP) as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. As a concept, it reflects the principles of: legitimacy, accountability, transparency and access to information, participation, sustainability, and collaboration across sectors and levels of government.” (WHO 2014) This chapter aims at showing that a genuine implementation of a setting approach in schools and efforts to address children’s health is achieving Health in All Policies while moving forward to achieve sustainable development goals for health and education.

Health and Well-Being of Children and Adolescent in a Transformative Society Health threats and risks for children and adolescent are many and varied within and between countries. Significant numbers of children and young people are suffering from climate change, air pollution, degradation of physical environment, deprivation from social and economic spaces, and increasingly exposed to risk factors of communicable and noncommunicable diseases such as food-, water-, or vectorborne diseases, childhood obesity or malnutrition, depression, mental illness, and injuries. Tackling child and adolescent health through school health programs become increasingly challenging because of multiple determinants of health. Quality and effectiveness of school health program are also depended on existing determinants: (a) physical environmental conditions of schools (availability and accessibility of safe water supply, safe space for children, teachers and staffs to plays, walk, and engage with other children or interact with other members of school communities); (b) social environment (respectful environment, recreational space to learn and play, inclusiveness, cohesion, discrimination, rights and gender-based violence, bullies, and policies related to educational systems and school functions); (c) commercial determinants (consumerism, advertisement and marketing of unhealthy products such as tobacco, alcohol, high-fat, salt, sugary products, etc. that are affecting and interfering school health promotion programs); and (d) biological and cognitive determinants of health of students, particularly in complex education

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Fig. 1 Multiple determinants of school health conditions

system that push the limits of children capacities to drive for intellectual excellence and may often neglected the needs of children to learn, play, and interact with others to build characters (see Fig. 1). In many countries, schools may be the only place where children feel safe to interact with other children of their ages, socialize, and learn new things, while countries in political conflicts, children sanction to leave their homes, nor having schools for months or year. Children health required nurturing for inseparable physical, mental, and social well-being. Child development depends on a whole society and school is one of the settings that concentrate its functions toward child cognitive and intellectual development, yet in need of supports from all the sectors, families, communities, and all the policies to generate healthier childhood to every children. Children need to feel safe and secure at home, in school, and public places where they do not need to fear, worry, and have anxiety from being discriminated, excluded, or prevent from fulfilling their highest potentials. Determinants of children’s health inclusive of parenting, caretaking, home-based, and school-based teaching and learning, while the whole society require to provide supportive environment for every child to flourish, and safeguard to things that are harmful to their health and well-being as it is said by this African Proverb, “It takes a village to raise a child.”

The Purpose of Schooling and Education Historically, formal modern education system was founded on industrialized modern society where mass production of products drove men/women and people in society to thrive for becoming capitalists or socialists, deviated from rural agrarian to

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urbanize industrial lifestyles. Modern societies valuing time, money, capital, specialized expertise, productivities have great impacts on the ways young generation are raised, socialized, and educated. Education became a gateway to employment, economic growth, prosperities, power, and prestige that everyone must achieve. School becomes primary sources of knowledge, education defines as the process of giving and receiving systematic instructions, indoctrinating; students with cognitive skills, theories, and practices to become literate and experts on the given subjects. At the turn of the millennium, “Education for all” became a global movement led by UNESCO – United Nation Educational, Scientific and Cultural Organization – aiming to meet the “learning needs” for all children, youth, and adult by 2015. The Dakar Framework for Education for All (UNESCO 2000) adopted at World Education Forum in Senegal was adopted with aspiration to ensure that all children would receive primary education by 2015. The goal has been progressively achievable by more and more countries. In 2015, WHO organized a Global School Health Initiatives: Achieving health and education outcomes which results in renewal of school health initiatives preparing toward sustainable development goals and documentation of lessons with multiple partners particularly the FRESH (Focusing Resources on Effective School Health) network. In the same year, UNESCO and international agencies launched the Incheon Declaration: Education 2030 for sustainable development, setting the SDG Education targets to ensure inclusive, equitable quality education, and lifelong learning opportunities for all can be achieved through frameworks for actions with multiple partners to support implementation, coordination, and monitoring of the targets. Education, similar to health, is an important key to sustainable development. The Declaration urged countries to develop contextualized plans and strategies, taking into account different national realities, capacities, and levels of development and respecting national policies and priorities (UNESCO 2016). In this new era of sustainable development, health and education are recognized as fundamental rights for all the population and important process of human development and for peace and prosperities of a nation and the planet. In this transformative society, new ways of education, learning, and receiving information emerge out of vast open space for learning through information technology. Educational reform and transdisciplinary learning are called for in order to create quality human resources need for the future. Health promoting school is one of critical approach to transform competitive education to collaborative learning, co-designing appropriate curriculum, and learning process to empower students and teachers in order to sustain healthy behavior and continue a lifelong learning for school staffs, parents, and communities for lifelong learning for healthier life. Traditional health education and school health services would need to be transformed toward health literacy and holistic approach to health and well-being, not limited to specific health services. Applying health literacy in health promoting schools will support the aspiration of Incheon Declaration, empowering students and everyone associate with schools to become lifelong learning, knowing and learning “how to” learn, discover, retrieve information, and knowing what actions to take appropriately for better health

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conditions. To meet sustainable development goals for health and education along with other goals, new kind of schools could be considered through experiences on successful health promoting schools in several countries. If implemented effectively, schools should be able to cultivate characters, build resilience individuals, contribute to economic livelihood of individuals, families, communities, countries, and the world, transforming individuals and community to have health, social, and environmental consciousness. Long-term outcomes of schooling and educations would instill future citizens and leaders to make healthier choices for the society and responsive to global political, economic, social, cultural, and planetary issues.

Clues Toward Healthier Schools for Sustainable Development Existing approaches such as child-centered education, rights-based approach, comprehensive school health programs, and health promoting schools illustrate potential for intersectoral action to improve health and well-being of children and adolescents. Child-centered approach: Several schools adopted child-centered approach in education, yet implementation are varied. Child-centered approach requires putting children’s needs as priorities. One of revolutionary methods is known as “Montessori” education that employed revolutionary classroom, to foster natural development of children, where children learn different multiple skills together in children of mixed age group. Montessori educational practice (The International Montessori Index 1999) assists children develop creativity, problem-solving, critical thinking, time management skills, care of the environment, and others. The method could prepare children to contribute to society and to become fulfilled persons. The basis of Montessori practice in the classroom is mixed age group (1–3, 3–6, 6–12, or 12–15 ages in one class), individual choice of research and work, and uninterrupted concentration. Group lessons or lectures by an adult are seldom found in a Montessori classroom, and learning abounds, children students have a lot of choice on what to work on, they enjoy their work, and remember what they learn. This means that children are co-designing curriculums that will be meaningful for their life. In many countries child-centered approach is designed by adult based on adults’ knowledge and perception of children’s needs assuming that children do not have ability to make decision. Child-centered approach means putting children’s needs as priorities: including physical growth (food and basic physical needs), activities to build body strength, mental and intellectual abilities, cognitive skills and behavior that build characters of children to become resilience to life’s adversities, social skills that build sharing and caring societies. Participatory educational system where children can co-designed curriculums and classroom environment, where parents and communities can participate in sharing local wisdoms bring healthier development for children and adolescents physically, mentally, and socially. Health promoting schools in Thailand, for example, have integrated approach for physical, mental, and social health interventions where students, teachers, parents,

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elders, local government, and local artisans can contribute to children’s physical, social, and mental health. Local governments play crucial roles in providing enabling environment for health promoting schools and work in collaboration with education, health, agricultural sectors, transportation, and policymakers to synergize the supports for healthier schools. Thailand’s integrated education system allows schools to have alternative courses where local knowledge and wisdoms that promoting health be taught or practice in schools, such as school gardening that promote healthy food production, participatory learning on natural sciences, mathematics, nutrition, and local knowledge of nutritious food as well as herbs to heal minor ailment. South African school health policy (Ministry of Health/Ministry of Basic Education South Africa 2013): The integrated school health program (ISHP) in South Africa aims to ensure that children’s rights are upheld and that provision is made to enable all children to reach their full potential. This is especially important in the formative school years, during which providing special attention to children’s optimal health will improve not only their survival, growth, and health but also their learning outcomes and development. The school health policy recognizes that its implementation requires strong intersectoral collaboration on the part of different sectors. The components of the ISHP include: • A commitment to close collaboration between all role-players, with the Departments of Health, Basic Education and Social Development taking joint responsibility for ensuring that the ISHP reaches all learners in all schools • Provision of services to learners in all educational phases • Provision of a more comprehensive package of services, which addresses not only barriers to learning, but also other conditions which contribute to morbidity and mortality among learners during both childhood and adulthood • More emphasis being placed on provision of health services (as opposed to screening and referral) in schools, with a commitment to expanding the range of services provided over time. Mechanisms for ensuring that learners who are assessed as requiring additional services receive these services need to be in place • A more systematic approach to implementation • Implemented within the Care and Support for Teaching and Learning Framework to cohere all care and support initiatives implemented in and through schools including school health services.

Health Promoting Schools (HPS) According to WHO (1998), a health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning, and working. A health promoting school fosters health and learning with all the measures at its disposal; engages health and education officials, teachers, teachers’ unions, students, parents, health providers, and community leaders in efforts to make the school a healthy place; strives to provide a healthy environment, school health education, and

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Fig. 2 Key features of HPS (WHO 2017c)

school health services along with school/community projects and outreach, health promotion programs for staff, nutrition and food safety programs, opportunities for physical education and recreation, and programs for counseling, social support and mental health promotion; implements policies and practices that respect an individual’s well-being and dignity, provide multiple opportunities for success, and acknowledge good efforts and intentions as well as personal achievements; and strives to improve the health of school personnel, families, and community members as well as pupils; and works with community leaders to help them understand how the community contributes to, or undermines health and education (see Fig. 2). For WHO (1998), the focus of Health promoting schools is on: caring for oneself and others; making healthy decisions and taking control over life’s circumstances; creating conditions that are conducive to health (through policies, services, physical/ social conditions); building capacities for peace, shelter, education, food, income, a stable ecosystem, equity, social justice, and sustainable development; preventing leading causes of death, disease, and disability: helminthes, tobacco use, HIV/AIDS/ STDs, sedentary lifestyle, drugs and alcohol, violence and injuries, and unhealthy nutrition; and influencing health-related behaviors, e.g., knowledge, beliefs, skills, attitudes, values, and support. Practically, HPS approach is based on principles like promoting the health and well-being of students; upholding social justice and equity concepts; involving student participation and empowerment; providing a safe and supportive environment; linking health and education issues and systems; addressing the health and well-being issues of staff; collaborating with the local community; integrating into the school’s ongoing activities; setting realistic goals; and engaging parents and families in health promotion. In sum, the essential elements for an HPS according to IUHPE (2008, 2010) are having school policies in place which promote health and well-being; attention to the

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school’s physical environment; attention to the school’s social environment; the development of health skills and action competences for healthy living; links with the community; and links with school health-care and promotion services. As a result, International School Health Network (2018) published a “New Paradigm for School” (FRESH 2018) for which the school-based and school-linked health promotion of the 21st century must be and will be significantly different than the traditional, issue-focused, and quickly find/develop the best (including consideration of costs, risks) program of the past three decades. The need to evidence-based and experience-tested programs will not disappear, but they will need to be nurtured within a dramatically new approach that includes these elements or dimensions that are common to all sectors/approaches working with schools: • Starting with the contextualization of approaches and programs into several generalized types of country and regional situations and truly understanding the local situation and needs • Greater, regular attention to better data, monitoring and analysis, more and betterinformed multisector choices and focusing of resources on priority issues or conditions relevant to country/state program planning, including attention from donors and external partners to ensuring that funded projects are tied to feasible long-term programs and country/stakeholder ownership and an ongoing cooperative process to manage emerging issues • Positioning these choices regarding priority issues within the needs of the whole child and ensuring that all children have equitable access and opportunities for educational success. Specifically addressing social and economic determinants and alleviating disadvantages are part of this consideration • Choosing evidence-based and experience-tested interventions (specific policies, programs, services, practices) that are suited to the local context and capacities and then combining several into multiple intervention programs addressing broad education and health and social issues and conditions • Combining these selected multi-intervention programs into a multicomponent approach (MCA) such as School Health and Nutrition/health promoting schools/ Essential Package and ensuring that this adapted MCA is aligned with other MCA’s being used by other sectors, ministries, and agencies that promote safe schools, child-friendly/inclusive schools, and others • Building and maintaining the core components or infrastructure to be used by of all multicomponent approaches, including overarching policy, health/life skills instruction/education, health and other services, social support from parents/ community, and healthy physical environment/practical resources • Addressing the quality of implementation of programs and approaches and ensuring from the outset that they can be maintained, scaled up, have planned successions, and transitions, thereby increasing the likelihood that they will be sustained • Building organizational and system capacity as well as professional knowledge and competencies. These capacities include defined start up and ongoing financial and human resources as well as operational capacities such as coordinated policy/

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leadership, assigning intersectoral and intrasector coordinators at all levels, establishing informal and formal mechanisms for cooperation, ongoing knowledge development and exchange, long-term workforce development strategies in several sectors, regular monitoring and reporting linked with systematic improvement, joint strategic issue management processes and explicit planning for sustainability of programs and approaches • Integration of health and social programs within the core mandates, constraints, and concerns of education systems so that the mutual, ongoing commitments of financial and human resources are explicitly negotiated and regularly reviewed, so that educational priorities such as school attendance/ participation and at-risk students are achieved as well as healthy or social priorities that the work lives and beliefs/concerns of educators are better understood and addressed • Shifting toward an ecological approach and systems-focused actions that address the structures, processes, and practices of complex, open, adaptive, and bureaucratic systems through the better use of systems science and organizational development tools and strategies. An effective HPS program can be one of the most cost effective investments a nation can make to simultaneously improve education and health. Because of comprehensive nature of health promoting school that practice inclusiveness, paying attention to equity, and involvement of multiple stakeholders, implementation of HPS can demonstrate multi-sectoral collaboration leading to implementation of health and well-being in all policies for benefits of children. Education, health and development can simultaneously enhance social and economic growth (Valimaa et al. 2008) Education is recognized by WHO (2008) as one of the main determinants of health. The process of setting up HPS in African countries characterized by high illiteracy rate should begin through encourage compulsory education for all. This is a very manageable situation, especially since the majority of these countries have included in their constitutions this obligation to schooling every child up to the age of 15/16 years. Having compulsory education with wholistic approach to cultivate and nurture children and adolescent to have stronger life-skills and health literacy would help them become higher qualified persons and better future decision makers for better health and well-being for themselves, their families, communities, and future society. In order to achieve health promoting school, a reform of the education system need to take this perspective into account while improve quality of teachers and recognize their important roles to ignite dormant potentials of every child to be come greater human capital of the society. . In third grade of Junior High School (JHS), corresponding to the age of 15/ 16 years, schoolchildren are labeled with regard to their potential either to continue on the way to school or to go on an apprenticeship. While the most successful continues on the Senior High School (SHS), the others are recovered at the level of local government (LG) for an apprenticeship according to their

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already identified potentials. Local government plays important role in supporting educational institutions and schools to build local capacities and skills needed for the cities and communities . The chamber of commerce would be able to suggest the kind of skills need for local economic and labour markets where by senior high school students can become apprentices to learn and earn income at the same time. Local government and the chamber of commerce can also collaborate to find economic activities that support healthier communities sustainable livelihood. They can promote homegrown organic products and other unique local products that could be commercialized while making a better health, and improving social and economic well-being for society. It is a win-win intersectoral actions appling health in all policies approach. Students from health promoting schools should have a good level of health literacy that help them make decision to make healthier choices available for society. For examples, those students going to masonry can learn to build improve housing with health and well-being of people in mind and adopt building standard for human health while respecting local ecological sustianability. Similarly, students interested in fishing can become apprentice in fishing industry with support from local government and the chamber of commerce. Health literacy will increase awareness for all parties involved to practice ethical operation for farming, fishing, and all food industries. Fishing technic and practices could be improve toward sustainability of fish species, water treatement, and ecological system that support human health and livihood for long time to comes. This means that health in all policies (HiAP) approach is useful for wholistic approach for all sectors to come together to create knowledgable and health literate communities, industries, and societies that can start from health promoting schools. Those students living in agricultureal based society will learn the procedures of healthy production and the marketing of various products contributing to the improvement of the populations’ health. In the same way, those in carpentry will learn the sustainable way of using wood for the manufacture of furniture giving comfort and health to the population, thus contributing to the of the population. “Health in All Policies.” is useful concept for multisectoral actions for better schooling and promoting health and well-being. The others on the other hand, continuing on the SHS and the university will become the elites with assets allowing them to take care of the good management of the country, good governance, and the minimum of corruption leading therefore to the nation development, health, and well-being for all. The education system and the curriculums are designed with that purpose as it is the case in Finland (Välimaa et al. 2008). In other words, those of the students who must continue on their way to university are those endowed with a certain facility for advanced studies and are the elites of tomorrow. They will be able to solve impossible problems (Raami 2019). Based on the curriculum leading them, they learned the importance of working for the well-being of those around them and their environment, on which their lives depend also (Kioupi and Voulvoulis 2019).

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For Glasser (2019), these are people who are trained in this kind of educational system to: • Do more with less: increase human productive capacities by employing new, “advanced” technologies, reimagine existing approach to technology and design, rethink existing approach to production and consumption by creating circular resource flows and eliminating waste, or utilize more environmentally sensitive and accessible traditional and open-source, appropriate technologies • Do better with less: decrease human numbers, expectations, or both by slowing, and ultimately reversing, the rate of human population growth; decrease overall per capita consumption equitably; reduce profligate consumption; increase equity and vital consumption by the needy; end exploitation of humans and nature; and support the regeneration of biological and cultural diversity by acknowledging planetary and social carrying capacity limits • Elevate the common good: reinvent how we define and measure quality of life, educate, plan, govern, allocate scarce resources, and reproduce culture so that human and planetary well-being are the ultimate metrics, and the behaviors we most seek are incentivized and reinforced through well-thought-out and sophisticated “choice architectures.” This is yet another way of implementing Health in All Policies.

Health in All Policies (HiAP) Foundation of Health in All Policies approach was rooted in the World Health Organization rich heritage of ideas, actions, and evidence that have emerged since the Lalonde Report with the multiple determinants of health (1974), the Alma Ata Declaration on Primary Health Care (WHO 1978), and the Ottawa Charter for Health Promotion (WHO 1986). According to WHO (2014), HiAP is founded on health-related human rights and obligations of governments. HiAP contributes to strengthening the accountability framework of policymakers for health impacts at all levels of decision-makings. It emphasizes the consequences of public policies on health systems, determinants of health, and well-being. It also contributes to sustainable development. Governments are facing with a range of priorities, competitive markets for country prosperities, and economically driven decisions. Health, education, and equity may not automatically gain precedence over other policy’s objectives. However, human development is critical part of economic development, and investment in health and education is equally important to the national prosperities. Protection and promotion of people health mean an economic gain because by doing so countries will take measures to prevent economic catastrophe due to health-care cost and expenditures. Early prevention in school health programs and promote healthy lifestyles for everyone in schools and related to schools (parents, teachers, school staffs, communities) means major reduction of expenditure on health care. This means governments can save a large sum of budget

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on building more expensive health-care facilities for long-term chronic illness related to noncommunicable diseases, if health promotion and health literacy for the people being effectively implemented. School health programs and services should be expanded to preventive care and instilling health literacy to all using health promoting school approach. Founded in the Universal Declaration of Human Rights, the UN Millennium Declaration, the UN Sustainable Development Goals, and Principles of Good Governance, Health in All Policies reflects the principles of the rights and obligations conferred by national and international law; accountability of governments toward their people; transparency of policymaking and access to information; participation of wider society in the development and implementation of government policies and programs; sustainability in order that policies aimed at meeting the needs of present generations do not compromise the needs of future generations; collaboration across sectors and levels of government in support of policies that promote health, equity, and sustainability. Concert efforts from all sectors must be made to capitalize on opportunities for co-benefits across sectors and for society. Health and health equity are values in their own right and are also important prerequisites for achieving many other societal goals. Many of the determinants of health and health inequities in populations have social, environmental, and economic origins that extend beyond the direct influence of the health sector and health policies. Thus, public policies in all sectors and at different levels of governance can have a significant impact on population health and health equity.

Applying HiAP in Health Promoting Schools WHO promotes health promoting schools as a strategic means to prevent important health risks among youth and to engage the education sector in efforts to change the educational, social, economic, and political conditions that affect health. Health in All Policies is a collaborative effort of all sectors of governments to support the future of their countries through children’s education. Educational institutions, schools and university included, are places where children, adolescents, and youth spend almost all of their waking hours to learn, play, and interact with others. Through health promoting school (HPS) approach, collaboration between several sectors can be designed appropriate to the local needs, with communities and stakeholders, dealing with health and inequities that affecting health conditions of children, adolescents, parents, teachers, school staffs, communities associated with schools, etc. Educational institutions contributed to all sectors of society as they are producers of human resources, innovation, ideas, etc. However, it seems very few sectors invest in existing education. Why do we spend more in trainings after schools, at workplaces, and for future business ventures, without making education that is relevant to everyday life and future of society? Education should be considered as everyone’s business, and it is a win-win solution for many future issues in the world. Health education and health promotion in schools require more than health services

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and health information, but life skill and health literacy that critically address determinants of children health will last for lifelong learning for health and wellbeing. Schools, universities, and all type of education systems should be considered as unique opportunities to build future generation that make the world a better place for peace, security, and prosperity. Each and every child, as well as each and every teachers and school staffs could become role models for healthier society that respect people health, equity, and protection of the environment for the planet. Their skills will be valuable and need to be constantly updated. Integrated transformative education is needed to bring expertise from various disciplines to invest in new ways of research, learning know-how, and collaborative learning. School infrastructure and systems required supports from all government agencies and policies that drive public and private schooling and educational systems that promote health and well-being as equal part of learning what important subjects. With this approach, schools and educational system can be part of solutions, or problem-solving institutes, which can be found in advance health promoting schools that teachers and students joined hand with communities and health service providers conduct health impact assessment for their communities and be the frontline for public health prevention. Implementation of HiAP in school settings means, every sector within the government, and where it is possible, private partners, communities, and families, should contribute to the educational systems and processes that support learning, health, and social well-being. This means all sectors should see the values of education as equal partners to economics and political institutions, as driving force for transformative societies. Every ministry should be able to see the benefits of investment in early education, formative years of education, vocational trainings, and informal education as part of their human resource development that is not limited to in-service trainings. If a country needs best future engineers, doctors, climatologists, historians, or researchers, each sector should invest in school-age children to build the right kind of human resources they need for the future (see Fig. 3). This also means school curriculum should be codesigned by a multidisciplinary team. Teachers should be well trained and paid because of their roles in building the future societies. Experiences from some countries, e.g., Finland, showed that teachers should be at a minimum of Bachelor’s level before 2 years training in pedagogy for them to be able to teach children from kindergarten to the primary school. Transdisciplinary, or multidisciplinary, approach is key in teacher trainings because their roles are all converged to addressing the complex determinants of child and adolescent health (see Fig. 4). By doing so, health promoting school is a way of aligning Health in All Policies approach in school health program (see Fig. 5). This approach roughly corresponds to the Finnish model of the education system which WHO used as an example for HiAP in school system (WHO 2015). Finland applied HiAP in its Health Care Act 2011 that incorporate health into all of their decision-making process. The Government has reformed the Health Care Act to mandate health promotion services and require municipalities to involve all sectors

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Fig. 3 Application of Health in All Policies in school health program

in their plans. Finnish Ministry of Social Affairs and Health and Municipalities jointly implement the Health Care Act where all children and their families are provided free health-care counseling and examinations in schools and communities because the Finnish Government recognize that factors that influence child and adolescent health lie outside health sectors. National Institute of Health and Welfare provides technical support to municipalities to track progress, shares best practices, and obtains trainings to implement health in all policies approach. The Finnish Government also recognized the needs for educational system reform to correspond to the 21st century transformative society. New education system focuses on physical and mental health of students with better communication skills and teamwork. The new approach also referred as “playful” learning that focuses on creation of a happy, safe, and inspiring environment, so that students can be more active and creative, while striving for knowledge. Teachers are trained to apply new system in the most effective way. In most countries of the world, an old-fashioned education system is aimed to create a reliable, predictable, and obedient citizen, while new

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Fig. 4 Application of Health in All Policies in school health program addressing complex determinants of child and adolescent health

education system in Finland is focused on developing critical thinking and creative solutions where the country can build future leaders for solving global issues. The HiAP approach is not only applicable to high-income countries like Finland, Singapore, and other European countries but also middle- and low-income countries such as Thailand, Uruguay, Brazil, Bhutan, Maldives, Seychelles, Pakistan, etc. For example, school health program in Pakistan embedded in the National Education Policy 2009 (Ministry of Education/Government of Pakistan 2009) demonstrated collaborative efforts and synergy between health and other sectors to integrated approach recognized in school health program. The policy stated that “School Health Education and School Safety shall be infused within the curricula and learning materials with focus on improving school environment, enriching health education content, instituting regular mechanism for health screening and health services of students and nutritional support to needy children in coordination with Departments of Health, Environment and Population at the Federal, Provincial and District levels” (Policy Action No 10, pp. 45–46). “Emerging trends and concepts such as School Health, Prevention Education against HIV/AIDS and other infectious diseases, Life Skills Based Education, Environmental Education, Population and Development Education, Human Rights Education, School Safety and Disaster and Risk Management, Peace Education and inter-faith harmony, detection and prevention of child abuse, etc. shall be infused in the curricula and awareness and training materials shall be developed for students and teachers in this context, keeping in view cultural values and sensitivities” (Policy Action No 9, p. 45). Holistic school health program in Pakistan also demands that collaborative work between education and health, as well as all UN agencies supporting different components of school health program to harmonize their efforts and delivering as

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Fig. 5 Health promoting school: aligning Health in All Policies approach in school health program

one agency along with the leadership of the government. This approach resonates with application of health in all policies in health promoting school.

Health Promoting School Approach and HiAP What Works In general, health in all policies approach works well where there are clear goals toward health, equity, and sustainability; intersectoral collaboration; co-benefits from multiple partners; engage with multiple or key stakeholders; and create structural or procedural changes that foster collaborative efforts (Rudolph et al. 2013). Health promoting school approach success also lie in similar elements, particularly on having policy development and long-term objective setting, long-term planning,

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that become a framework for partnership, creating new skills for teacher education and professional development; monitoring progress; and working with relevant sectors (WHO 2017a). While implementing HPS, all children and youth will receive high-quality child care and educational opportunities that foster and promote their ability to develop, be healthy, and achieve to their highest potential. Success of school health programs in low-resource countries relied on vertical health programs and funds such as deworming program; school lunches; immunization; health screening weight and height measurement; eyesight and hearing; water and sanitation facilities (provision of water pumps, toilets, etc.); and hygiene (WASH) and water quality monitoring. Health screening; hygiene, sanitation and environment education; AIDS prevention education; reproductive health education; life skills education; education on prevention of substance abuse; population education; and food for education – school feeding programs – are among popular programs in schools. Prevention of NCD risk factors such as promotion of physical activities, healthy diets, control of sugary beverage, oral health, and prevention of tobacco use are often found in highresource, high-income countries (WHO 2017b). Co-benefits for health and education are demonstrated in increasing attendance rate, reducing absentees, and improving academic scores, while children have better physical health outcomes, boosting immunization, decrease stunting, improve oral health, increase physical activities, vegetable and fruit intakes, etc. However, health, this vertical program approach, do not bring sustainable program for schools. Some of the programs brought high physical health impacts for children, but not sufficiently demonstrate educational and psychosocial impacts for health and well-being. Success also depends on teachers’ competencies and skills. Health promoting schools require training of teachers for the new ways of working toward integrated approach for school health programs and advocate for multisectoral partnerships. Leadership from government and UN agencies to harmonize the efforts to improve child and adolescent health need to be considered for better usage of resources and create high results and high impacts program. Coordination among UN agencies, between health and other program would bring greater results such as school health program in Bhutan where WHO provided technical support and UNICEF provided financial supports for the same outcomes creating sustainable health and educational achievements.

Why Does It Work or Does Not Work The expectation that collaboration can occur without a supporting infrastructure is one of the most frequent reasons why it fails. Kania and Kramer (2011)

HPS works for several reasons, among which are (WHO 2017b) ownership by government; existing national policies and prioritizing school health programs; involvement of all relevant ministries (ministries of health, education, agriculture,

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finance) and local government; financial and/or technical support by donor agencies; participation of children and communities including parents and guardians; allocating appropriate funding; ownership by school principals and/or teachers; scheduling interventions as official school activities; allocating focal teachers and providing teacher training; including school health in the curriculum of teacher training institutions; and setting culturally appropriate menus for school lunches including using locally available food. In other words, here are some critical aspects for successful HPS programs at country level (Ministry of Education/Government of Pakistan 2010): • Legislation and policy reforms for provision of health and nutritional support to all children in schools • Formulation and enforcement of equitable standards of school facilities for all schools • Resource mobilization for school health program (SHP) • Coordination mechanisms between health and education sectors • Institutional capacity development, i.e., technical and administrative support to the relevant organizations and institutions at national, provincial, and district level • Advocacy and research in favor of increased attention to education and health of school children • Sustainability mechanisms, to ensure that projects launched are consequently integrated into the regular system As for the barriers in successful implementation, WHO (2017b) mentioned lack of policies, guidelines, scale-up plans, and policy implementation; insufficient lobbying and advocacy for school health and nutrition (SHN) activities; lack of political and legal support for implementation on SHN activities; insufficient amount of and timeliness of budget allocation; lack of coordination among related ministries and stakeholders (e.g., UN bodies, NGOs, and academic institutions); lack of technical capacity on human resources and training; lack of quality and quantity of resources for implementation, monitoring, and evaluation, as well as insufficient data and evidence for promoting SHN activities; and cultural barriers to implementation, especially reproductive health programs.

What Are the Prerequisites According to FRESH (Focusing Resources on Effective School Health) network (2018), in order to have successful school health program, the following prerequisites must be considered: • Country ownership and leadership: Efforts should be made to enhance country ownership and leadership of national programs. This will require the political commitment and financial support of governments, transitional funding from donors, strengthened management and capacities within the education, and

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other sectors as well as community engagement as well as support from the private sector. Clear roles and responsibilities for each level of governance and links with other ministries/departments should be defined so that implementation can be scalable and sustainable. Broad-based national and international coordination and collaboration: Considering the resources required to tackle the multiple problems in lowresource countries, the role of civil society and private sector, nongovernmental development organizations, and international cooperation in assisting lowresource countries is important. Strong collaboration between all these stakeholders should be at the core of the any global, regional or national planning. Effective coordination mechanisms at the global, regional, and national levels are crucial to the success of such collaboration. Empowerment of people and communities: The involvement of populations affected by or at risk of a wide variety of problems that are exacerbated by fewer economic resources in countries/regions and lower economic status of the populations is important for the success of the comprehensive approaches as well as individual policies, programs services, and other interventions. Communities should therefore be empowered, guided, and involved in activities to promote their own health, education, social, and economic development as well as to prevent or control specific problems. Activities, which are simple and enjoyable, supported by lean management processes and user-friendly facilities help to ensure that the program is implemented at scale and can be sustained. If interventions are too complex, they will not be sustained long-term without external support. Evidence-based and experience-tested approaches, programs and incremental, and implementation/sustainability planning: Decisions to scale up or scale down interventions, particularly, will be based on evidence generated through mapping, monitoring, evaluation, and research. Furthermore, all strategies to promote health, education, and development should be based upon scientific evidence derived from applied research as well as the real-world experience of local citizens, communities, and practitioners as developed through surveys and consultations, local data gathering and analysis, and empowering local or national decision-making. These plans should consider cost-effectiveness, affordability, public health and community development principles, and cultural considerations. Encouraging schools and other agencies to begin with small improvements that can be achieved using resources already available can start the incremental process. Equity and gender-based interventions: Access to health services is more difficult for women in low-resource countries, especially in rural areas where problems are often highly endemic. Many approaches, programs, and interventions should intentionally address or advance gender issues and other inequities.

HiAP Framework for Schools in SDGs Era With SDGs, schools represent a genuine setting to implement HiAP, for they provide an efficient and effective way to reach large numbers of people (Ben Abdelaziz et al.

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2018). For instance, over 90% of children of primary school age and over 80% of children of lower secondary school age were enrolled in school globally in 2015 (UNICEF 2018). As reported by Langford et al. (2014), evidence exists that HPS have positive effects on a range of students’ health outcomes. Also, according to Cooper et al. (2012), children acquire basic knowledge and experiences that influence their lifestyles in adulthood. For WHO (2017c), promoting healthy behavior of schoolchildren contributes to enhancing the lives of other family members and the community. Through different SDG objectives, e.g., 2: (2.2), 3: (3.7), 4: (4.7), 5: (5.6), 6: (6.2), and 16: (16.2), schools with HPS approach can contribute strongly to HiAP implementation as shown on Fig. 6. To strengthen this process, it will be important to support the establishment of enabling conditions for the health promoting schools development in countries, by closing the implementation gap as reported by Ben Abdelaziz et al. (2018), namely, lack of focal point for HPS at national level; limited funding resources; lack of institutionalized capacity building for teachers; challenges of working across sectors; unreliable monitoring mechanisms and evaluation of impact on health and education; lack of common performance indicators to support progress assessment; and unclear accountability mechanism. From the African region for instance, the need will be to clearly reorganize the majority of the educational systems in countries in order to adopt and implement the HPS approach that could be for a great contribution for achieving SDGs with HiAP implementation through schools.

Fig. 6 Health promoting schools in the context of the SDGs

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This was the perspective in which UNESCO (2016) together with UNICEF, the World Bank, UNFPA, UNDP, UN Women, and UNHCR organized the World Education Forum 2015 in Incheon, Republic of Korea, from 19 to 22 May 2015, hosted by the Republic of Korea. Over 1,600 participants from 160 countries, including over 120 ministers, heads and members of delegations, heads of agencies and officials of multilateral and bilateral organizations, and representatives of civil society; the teaching profession, youth, and the private sector adopted the Incheon Declaration for Education 2030, which sets out a new vision for education for the next 15 years and stressed the important role of education as a main driver of development and realization of the SDGs: “Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all” (UNESCO 2016).

Challenges and Realities Five years after the Incheon Declaration, the road to achieve this commitment is still a long way to go for in many countries, especially the African region where the realities are different. According to Ben Abdelaziz et al. (2018), HPS still has many challenges, namely, inadequacy of school health services and programs focusing on specific health outcomes; proportion of children are forced to, or being left out of schools and thus no school health program reaching out to them; absent of moral and ethical leaders in schools; teachers with social responsibility; and ineffective governance structure within government, public, or private institutions that influence how schools were built, made, and operate. In reality, effective implementation of health promotion approach is about understanding of health promotion paradigm, design intervention process, research, and monitoring the impacts. Putting health services in schools is preventive measures toward control of particular diseases and health conditions; a small proportion toward health promotion was narrowly defined in health education. However, health promotion in schools, and all settings, means co-creation and co-benefits, complex interventions, and intersectoral action to achieve not only health outcomes but also social well-being and quality of life; evidences appeared from contextualized realities of the settings rather than expert-driven process for health outcomes. Applying health in all policies approach to health promoting schools will bring greater outcomes and impacts for better health and well-being of children and adolescents, as well as their parents and teachers and communities if implement effectively.

Conclusion At the Global Conference on Health Promotion 2013 in Helsinki, Finland, the former President of Finland stated in her plenary session discourse that the best way of achieving the goal of a better health for a nation is to adopt a good educational agenda for all. Education that is well organized allows to gain both health and education and development, she said, with the Finnish example. This is clearly

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from experience, and the entire world actually knows what the Finnish example is in the field of education, health, and development. The good news is that the international community is aware of that relationship between education and health, especially in the SDGs era and through some initiatives among which the Incheon Declaration; the UNESCO Chair for Global Health and Education is putting enormous effort to convince all stakeholders to invest in education. The UNESCO Chair by aiming at strengthening the relationship between universities, policymakers, practitioners, and civil society (south, north, west, east) and putting emphasis on, for instance, the universities’ core business that should be their contribution to knowledge base (research), knowledge dissemination, and capacity building with a strong connection with the UN agencies and existing networks is definitely making history for a better off society where everyone can live an optimal life. With that perspective, health promoting schools is an important approach contributing effectively to the implementation of HiAP which is indispensable for SDG’s achievement in 2030. And yet it is possible for the global community to achieve the SDGs with HPS if its global standards can be embraced in every educational system with strong support from countries.

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World Health Organization (WHO) (2017a) Health promoting schools: experiences from the Western Pacific Region. World Health Organization Regional Office for the Western Pacific. Licence: CC BY-NC-SA 3.0 IGO World Health Organization (WHO) (2017b) Global school health initiatives: achieving health and education outcomes. Report of a meeting, Bangkok, Thailand, 23–25 November 2015. World Health Organization (WHO/NMH/PND/17.7), Geneva. Licence: CC BY-NC-SA 3.0 IGO World Health Organization (WHO) (2017c) Health promoting schools: An effective approach to early action on non-communicable disease risk factors. Health Promotion Unit, WHO, Prevention of Non-communicable Diseases, Geneva, WHO/NMH/PND/17.3

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Adelheid W. Onyango, Laetitia Nikiema, and Ruth W. Kimokoti

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Health Promoting Role of Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutritional Status Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Malnutrition in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Undernutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stunting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Underweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diet-Related Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Perspectives of the Double Burden of Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Under-5 Year Olds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . School Age Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Essential Nutrition Actions in Community Health Promotion: A Life Course Approach . . . . Preconception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pregnant and Lactating Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The First 1000 Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preschool Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adults and Older People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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A. W. Onyango (*) · L. Nikiema Regional Office for Africa, World Health Organization, Brazzaville, Republic of the Congo e-mail: [email protected]; [email protected] R. W. Kimokoti Simmons University, Boston, MA, USA e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_86

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Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engaging with Planetary Health and the Social Determinants of Health . . . . . . . . . . . . . . . . . . Emerging Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Nutrition is a key determinant of health and wellbeing for individuals and populations. Currently, malnutrition in various forms affects every country globally, with resultant adverse health, social, and economic consequences. In 2019, an estimated 144 million children under-5 years old were stunted, 47 million were wasted, and 38 million were overweight. In 2016, 75 million girls and 117 million boys aged 5–19 years worldwide were moderately or severely underweight, while 213 million were overweight and 124 million were obese. In the same year, approximately 1.9 billion adults were overweight (over 600 million of these being obese, whereas 462 million were underweight). Worldwide, two billion people have micronutrient deficiencies. Further, the double burden of malnutrition, characterized by the coexistence of undernutrition and overweight or obesity, often with diet-related noncommunicable diseases, is prevalent. It affects especially low- and middleincome countries and can exist within individuals, households and populations, and across the life course. A successful response to the double burden of malnutrition requires a life course approach, providing interventions from conception to old age. Conventionally, interventions for undernutrition and overweight/obesity have been implemented separately. Given that the conditions are interrelated, double-duty interventions addressing multiple types of malnutrition concurrently or benefit multiple individuals need to be implemented. Moreover, since the causes of malnutrition are embedded in many sectors, interventions should also be multisectoral. This chapter gives an overview of the double burden of malnutrition (stunting, wasting, underweight, overweight/obesity) globally and discusses examples of double-duty and multisectoral interventions that are being implemented. Keywords

Nutrition · Malnutrition · Diet · Burden of disease · Noncommunicable diseases · Essential nutrition actions

Introduction The Health Promoting Role of Nutrition Nutrition is a key determinant of health and wellbeing for individuals and populations. The food we eat plays a central role in building the body, protecting it from disease, and repairing damaged cells and tissues to ensure survival and

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wellbeing. Nutrition plays a central role in the establishment of a robust physiological constitution and a sturdy architecture of the brain and central nervous system. Beginning at conception, nutrients serve as building blocks for tissues and organs; and they regulate cell division, the functional differentiation of tissues, growth, and overall development of the organism. In addition to these constructional functions, nutrients also play a role in protecting the body from disease by building the immunity and resilience needed to resist and recover from infections. Food is the primary source of nutrients which come in the form of macronutrients (carbohydrates, fats, proteins) and micronutrients (vitamins and minerals). For it to satisfy the body’s needs, food must be adequate in quantity and quality, and the body must be able to break it down, absorb, metabolize, assimilate, and utilize its various components. The body’s immediate energy needs are supplied by glucose (from carbohydrates), and any excess is converted into fatty acids for storage, adding to those obtained through the direct breakdown of fats. Proteins are broken down into amino acids whose primary function is the synthesis of cells and muscle tissue. In fasting states or starvation, the body after depleting stored fat catabolizes protein and converts amino acids into glucose to supply its energy needs. Micronutrients are the generic term for the vitamins and minerals needed by the human body to maintain normal cellular and molecular functions (West et al. 2012). Historically, the term malnutrition was used to describe protein-energy deficiency, referred to variously as protein-calorie malnutrition and protein-energy malnutrition. From this viewpoint, malnutrition (“bad nutrition”) is the result of not having enough to eat (hunger), not eating the right quality of foods, or not being able to utilize the food consumed due to some underlying health problem. Alternatively, underlying health conditions may cause the body to lose nutrients, as happens during fever when body tissues are catabolized. The vicious cycle between nutritional deficiency and infection is backed by an expansive body of literature (Tomkins and Watson 1989), and the research seeking to deepen understanding and possibly break the cycle continues (Rodriguez-Morales et al. 2016; Walson and Berkley 2018). Beginning from the 1990s, overweight/obesity associated with excess energy intake relative to expenditure has also come to be rightly understood as a form of malnutrition with serious health consequences. When energy intake exceeds expenditure, the body stores up the surplus as fat, and with time this imbalance leads to overweight and obesity. That together with intake of excessive amounts of so-called unhealthy foods (usually highly processed, low in nutrient density and/or high in sugars, saturated fats, trans-fat, and salt) increases the risk of diet-related noncommunicable diseases (NCDs), such as type 2 diabetes, cardiovascular diseases, and some cancers.

Nutritional Status Assessment How nutritional status is assessed depends on whether the objective is to measure overall growth and size, the level of nutrients in body tissues or fluids, or deficiency

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or excess of certain nutrients as may be manifest in clinical signs and symptoms. Clinical features associated with malnutrition may be observed in the eyes (e.g., lesions or night blindness due to vitamin A deficiency), skin (e.g., dermatosis in kwashiorkor, or pellagra – pigmented rash – due to niacin deficiency), tongue (e.g., redness due to vitamin B12 deficiency), gums (e.g., swollen and bleeding gums in vitamin C deficiency), and hands (pallor due to anemia). Biochemical markers of nutrients or their metabolites may be assessed in samples of blood, urine, saliva, hair, etc. When the objective is to measure body dimensions or size (relative to age for growing children), anthropometry is the method of choice. As the name suggests, anthropometry involves measuring various dimensions of the body: weight, height, circumferences (head, waist, arm), and skinfolds. Anthropometric measures may be used in their raw form (e.g., adult height), as dimensional indices (e.g., waist to hip ratio), or in combination with age, relative to a reference (e.g., height-for-age). At the time of this writing, age- and sex-specific attained growth is assessed based primarily on the WHO Child Growth Standards for children under-5 years (https:// www.who.int/childgrowth/en/), and for those aged 5–19 years, the WHO growth reference for school-aged children and adolescents (https://www.who.int/growthref/ en/). In community-based programs and some peripheral health facilities, mid-upper arm circumference is used to screen for moderate and severe wasting based on fixed cut-offs for all children aged 6–59 months. Adult size is classified based primarily on body mass index (BMI) with fixed cutoffs defining underweight, normal weight, overweight, and different degrees of obesity. Waist circumference and waist to hip ratio are used to assess abdominal fat accumulation in individuals and populations, but globally agreed-upon cut-offs do not exist currently. Population-level nutrition monitoring relies heavily on anthropometry because weight and height are more easily measured in large representative samples than the biochemical and clinical indicators of malnutrition (WHO 1995). Anthropometry facilitates cross-sectional comparisons among countries and the monitoring of national and global trends in undernutrition and overweight/obesity: and this, socalled double burden of malnutrition, is at the core of the discussion in this chapter. (Some prefer the term triple burden of malnutrition to keep micronutrient deficiencies visible as part of the malnutrition challenge.) Given its focus on health promotion in community programs, this chapter will not deal in depth with nutritional conditions such as specific micronutrient deficiencies (e.g., pellagra, beriberi, scurvy) that require clinical management. Nevertheless, actions to reduce micronutrient deficiencies – which affect some two billion people worldwide (Bailey et al. 2015) – are integral to public health programs that address undernutrition. Thus, for example, dietary diversification, food fortification or biofortification, micronutrient supplementation, salt iodization are important public health interventions that aim to reduce micronutrient malnutrition in individuals and populations at risk. The chapter also does not address the dietetic management of individuals with chronic disease conditions.

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Malnutrition in Global Health Malnutrition as a public health problem encompasses undernutrition and overweight/obesity in view of their relationship with communicable and noncommunicable diseases (NCDs). While it might appear that undernutrition is associated with infections and overweight/obesity with NCDs, the relationships are more complex, in that undernutrition at the beginning of the lifecycle could increase the risk of obesity and the metabolic precursors of associated NCDs later in life. Whatever form it takes, malnutrition is costly because it endangers survival, contributes to failure to thrive in growing children, compromises the body’s resistance to infections, and predisposes it to debilitating chronic diseases. Many of the public health challenges confronting low-, middle-, and high-income countries today are to some degree associated with malnutrition (Global Burden of Disease (GDB) 2013 Risk Factors Collaborators 2015). At the individual level, malnutrition increases the short-term risk of morbidity and is associated with high levels of child mortality in low- and middle-income countries. In the medium to long term, malnutrition has cumulative negative impacts on the physical growth and cognitive development of children and adolescents, with increased risk of obesity and other metabolic complications in adulthood. At the societal level, the consequences of malnutrition significantly undermine national development (Black et al. 2008).

Undernutrition Undernutrition is the blanket term used to describe deficiencies that typically limit growth, generally because of inadequate food intake (energy and/or nutrients) and the experience of infections. It includes the often-overlapping conditions known as stunting (linear growth retardation), underweight (low attained weight relative to age), and wasting (low body mass relative to height). Undernutrition includes micronutrient deficiencies (sometimes referred to as hidden hunger), but these can occur also in overweight and obese individuals. Undernutrition compromises the body’s immunity, making children, for example, more susceptible to episodes of severe diarrhea and other infectious diseases. An analysis of data from 10 longitudinal studies involving more than 55,000 child years of follow-up estimated that undernutrition associated with intrauterine growth retardation, suboptimal breastfeeding practices, stunted growth after birth, wasting, vitamin A and zinc deficiency was responsible for 3.1 million under-five deaths (about 45% of global mortality) in 2011 (Black et al. 2013).

Stunting Under-fives, school age children and adolescents are classified as stunted if their attained height-for-age falls below
2 standard deviations of respective WHO

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growth reference medians. No cut-offs have been defined formally to classify stunting among adults, but height below 145 cm appears in published literature as the descriptor for stunting (Özaltin et al. 2010). Stunting was originally identified with antecedent protein-energy malnutrition, but because of its association with inadequate food intake and repeated or mildmoderate chronic infections, it is referred to also as chronic malnutrition. The nutrient-dependent dimension of growth failure was described in a hypothesis according to which inadequate intake of so-called type II nutrients (protein, zinc, magnesium, phosphorus, and potassium) triggers arrested growth (stunting) as a means of conserving their tissue concentrations (Golden 1995). However, nutrients are but one among multiple factors that drive stunting through a complex web of interrelations (Black et al. 2013; Harper et al. 2018). A biological model of human growth proposed in the late 1980s defines three phases of linear growth (infancy, childhood and puberty), each of them influenced by different sets of hormones (Karlberg 1989). According to this model, the nutritiondriven fetal growth phase begins to cede to the growth hormone-stimulated childhood phase from the latter half of infancy. The second phase lasts through childhood to the pubertal growth spurt which is sex hormone-dependent. Studies in undernourished populations have shown that delayed maturation (i.e., prolongation of the prepubertal growth period) affords some catch-up growth for stunted children, especially girls (Prentice et al. 2013). Interventions to prolong what appears to be a window of opportunity for catch-up growth in later childhood have not been reported. The proximal causes of stunted growth and development in early childhood are found within the household and family. Maternal nutrition and health, adequate infant and young child feeding, and the prevention of infections all influence growth and development in the critical first 1000 days of life (from conception to age 2 years). Those proximal causes in turn have interlinked determinants in contextual factors rooted in the political economy; health and healthcare; agriculture and food systems; socio-cultural norms and practices; water, sanitation, and environment; and in education. It has been noted that undernutrition in the first 1000 days carries life-long negative consequences (Victora et al. 2008) on health and human capital. Nutritional rehabilitation research in the 1990s demonstrated linkages between growth and development, contributing to the understanding that both growth and development are affected by deprivations in the physical and social environments in which children are raised. The present-day early childhood development paradigm recognizes that the achievement of a child’s full potential for growth and development requires an adequate supply of nutrients, prevention of infections, and opportunities for social interaction, play, and stimulation (Ngure et al. 2014; Stewart et al. 2013). Growth retardation has been identified as the main determinant of cognitive, motor, and socio-emotional developmental deficits (Grantham-McGregor et al. 2007). Several longitudinal studies in the early years of life have shown clearly that growth retardation in the first 2–3 years predicts impaired cognitive development in later childhood and adolescence, and

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lower academic achievement (Daniels and Adair 2004). Other longitudinal studies have reported that children who were stunted at age 2 years experienced high levels of depression, anxiety, and reduced self-esteem in adolescence compared to nonstunted peers (Walker et al. 2007). Overall, short stature at birth and at 2 years of age is associated with short stature in adulthood, low educational achievement with reduced human capital and economic productivity, increased risk of cardiovascular disease in adulthood, and, for women, a higher risk of undernutrition in their offspring.

Wasting By its classic definition, wasting is “. . .a deficit in tissue and fat mass compared with the amount expected in a child of the same height or length, resulting either from failure to gain weight or from actual weight loss” (WHO Working Group 1986). The immediate causes of wasting could be recent severe reduction in food intake or loss of body stores through infection. Depending on severity, wasted children are two to nine times more likely to die than children of normal weight-for-height (Black et al. 2008). Infections – especially the diarrheal, acute respiratory, and febrile types such as malaria – contribute directly to wasting through the loss of the body’s nutritional stores. Chronic infections such as HIV/AIDS and tuberculosis also contribute to wasting. Broadly speaking, infection fosters malnutrition through loss of appetite, malabsorption, and altered metabolism. In its turn, malnutrition engenders lowered immunity and epithelial barrier damage, thus increasing susceptibility to infection (Rodriguez-Morales et al. 2016). Repeated cycles of wasting culminate in linear growth retardation (Schoenbuchner et al. 2019). A recent analysis of multiple country data sets found that children 6–59 months who are both stunted and wasted had an exponentially higher risk of mortality than those who are wasted only or stunted only (Myatt et al. 2018) and had less satisfactory treatment outcomes than those who were wasted only (Odei Obeng-Amoako et al. 2020).

Underweight Underweight in young children is assessed in relation to expected weight-for-age relative to a defined population reference. The WHO Working Group on the use and interpretation of anthropometric indicators of nutritional status focused attention on stunting and wasting as the distinguishing features of, respectively, linear growth retardation and loss of muscle or fat mass. However, because weight is easier to measure than length or height, weight-for-age gained wide usage in community- and facility-based growth monitoring and nutrition programs. Until the advent of the WHO Child Growth Standards, the “road to health” chart was a primary tool in growth monitoring and promotion programs in the developing regions of the world. The risk posed by the exclusive use of weight-for-age in nutrition programs was that

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short children with normal weight-for-height might receive food supplements that would accelerate overweight in target populations. Underweight was the proxy indicator of hunger in the countdown to the Millennium Development Goals of 2015. However, as the double burden of malnutrition came into focus, stunting and wasting (rather than underweight) were, in 2012, selected for inclusion among the six global nutrition indicators adopted by the World Health Assembly to monitor progress until 2025 (extended to 2030 as part of the Sustainable Development Goals). However, underweight remains operationally attractive for nutrition programs, and some researchers have argued that defined weight-for-age thresholds could be used to screen for under-fives who are both wasted and stunted with high levels of both sensitivity and specificity (Myatt et al. 2018).

Overweight and Obesity The accumulation of excess stored energy manifests itself as overweight or obesity depending on the severity. Among growing children and adolescents, overweight and obesity are classified based on age- and sex-specific cut-off points of the WHO weight-for-height and body mass index (BMI)-for-age standards. In adults of both sexes, overweight is defined as BMI 25.0–29.9 and obesity from BMI 30.0 upwards, with increasing severity in the risk of comorbidities. It is to be noted that BMI is a crude index that does not distinguish between fat versus lean mass or the distribution of fat relative to variations in body proportions. The differences in metabolic risk associated with the distribution of fat and of lean versus fat mass as a percentage of body weight will be discussed in more detail in the next section. Diet-related overweight/obesity is determined by the balance between energy intake and expenditure. Therefore, prevention focuses on promoting healthy dietary intake and physical activity. In addition to excess body weight, diets that are energydense and nutrient-poor (popularly referred to as unhealthy diets) also contribute to diet-related NCDs. For example, consumption of sugars contributes to increased weight and increases risk of insulin resistance and type II diabetes. Unhealthy diets are typically low in fiber, high in sugars, salt, fats, and industrial trans-fats, all of which are associated with increased risk of NCDs (see next section). The need to prevent obesity right from childhood lies not only in the avoidance of poor adult health but also of many concurrent health problems. The list of these includes type 2 diabetes, hypertension, early puberty, menstrual irregularities and polycystic ovary syndrome, steatohepatitis, sleep apnea, asthma, benign intracranial hypertension, musculoskeletal disorders, and psychological problems (Reilly et al. 2003). Many reviews have established that childhood overweight/obesity was associated also with psychological comorbidities such as depression, emotional and behavioral disorders, negative mood states, and low self-esteem. Uncertainty remains about whether psychiatric disorders and psychological problems are a cause or a consequence of childhood obesity or whether common factors influence both obesity and psychiatric disturbances in susceptible children

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and adolescents. Notwithstanding, overweight children and adolescents are more likely to experience obesity stigma, teasing and bullying from their peers (Rankin et al. 2016).

Diet-Related Noncommunicable Diseases Apart from the concurrent association between overweight/obesity and NCDs, clear links have been shown to exist between malnutrition in early life, including intrauterine growth restriction (IUGR), and the risk of cardiovascular disease in adulthood (Leeson et al. 2001). Nutritional deficiency in the first 1000 days predisposes to deficits in lean body mass compared to fat mass in the long-term (Rogers 2003), increased central adiposity (Schroeder et al. 1999), and increased risk of insulin resistance, type 2 diabetes, and other features of the metabolic syndrome in adulthood (Victora et al. 2008.) Birthweight has been shown to predict obesity and NCD risk in later life. For example, low birthweight was associated with reduced muscle mass versus body fat (Yajnik et al. 2002), while birthweight between 2500 and 3999 g was associated with higher lean body mass (Yang and Huffman 2013). This relationship was demonstrated also in an analysis of the Consortium for Health Research in Transition Societies (COHORTS) study, with data from Brazil, Guatemala, India, Philippines, and South Africa (Kuzawa et al. 2012). These findings are consistent with the thrifty phenotype and developmental origins of adult disease hypothesis according to which undernutrition during pregnancy leads to structural and functional changes in the developing fetus that predispose to chronic conditions including high blood pressure, coronary heart disease, stroke (Hales and Barker 1992; de Boo and Harding 2006).

Global Perspectives of the Double Burden of Malnutrition The WHO Expert Committee on Physical Status noted that average population body mass index rises with the increasing consumption of high-fat diets and reduced physical activity in populations transitioning from poverty to affluence (WHO 1995). Today it is recognized that malnutrition in multiple forms affects every country in the world. A systematic analysis conducted as part of the Global Burden of Disease Study 2013 revealed that six out of the top 11 risk factors driving the global burden of disease and mortality were related to diet (GBD 2013 Risk Factors Collaborators 2015). Nutritional deficiencies remain more prevalent in low-income and lower-middle-income countries, while overweight/obesity is the predominant malnutrition form in upper-middle-income and high-income countries. This does not mean, however, that there is a dichotomy in the nutritional challenges faced by lowincome versus high-income countries (Popkin et al. 2020). The double burden of malnutrition is characterized by the coexistence of undernutrition (wasting, underweight, stunting, and/or micronutrient deficiencies) and

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overweight or obesity, often with diet-related noncommunicable diseases. It can exist within individuals, households, and populations, and across the life course, and affects especially low- and lower-middle income countries (Popkin et al. 2020). These are countries experiencing the nutrition transition, a phenomenon characterized by an increasing burden of overweight/obesity in predominantly undernourished populations. An analysis of worldwide trends (1975–2016) in body size among children, adolescents, and adults found that children’s and adolescents’ body mass index had plateaued in many high-income countries while it increased in low- and middle-income ones. The double burden of malnutrition within a country generally reflects socioeconomic inequalities and inequitable access by households to nutritious food, water, sanitation, health care, and other basic amenities. At household level, it may be due to inequitable intrahousehold food distribution based on age, gender, disability, and other discriminatory factors or to age-related physiologic and lifestyle determinants of risk. Within individuals, as discussed in an earlier section, undernutrition experienced between gestation and the age of 2 years sets the stage for increased risk of overweight/obesity at later ages and metabolic risks such as raised blood pressure, glucose intolerance, and hyperlipidaemia. These factors in turn increase the risk of noncommunicable diseases including hypertension, type 2 diabetes, and heart disease.

Under-5 Year Olds In the 2020 edition of the joint malnutrition estimates (UNICEF/WHO/World Bank Group 2020), it was estimated that 144 million under-5 year old children were stunted in 2019, while 47 million were wasted and 38 million were overweight. Asia was home to more than half of the stunted under-fives (54% of the global total), more than two-thirds of those wasted (69% of the global burden), and 45% of the overweight. Africa accounted for 40% of the global burden of stunting, 27% of wasting, and 24% of overweight. In sum, the two world regions accounted for more than 90% of the global prevalence of undernutrition and more than two-thirds (69%) of the global burden of overweight. Disparities exist among countries and subregions of the world as they do in subnational divisions within countries. Regarding trends, whereas the proportion of stunted under-fives dropped by nearly one-third between 2000 and 2019, the absolute number of stunted children remains high, at more than one in five globally and about one in three in sub-Saharan Africa. Although Asia still has the highest absolute burden of undernutrition (due to population size), the region made remarkable progress by reducing stunting prevalence from 37.8% to 21.8% between 2000 and 2019. Comparative progress in Africa was a more modest reduction from 37.9% to 29.1%, while for Latin America and the Caribbean the proportion dropped from 16.8% to 9.0% in the same period (UNICEF/ WHO/World Bank Group 2020). Overall, the risk of stunting is five times higher in low-income and lower-middle-income countries compared to upper-middle-income

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countries and ten times higher than in high-income countries (https://www.who.int/ gho/publications/world_health_statistics/2019/en/).

School Age Children and Adolescents A recent analysis of data from 57 low- and middle-income countries in all 6 WHO Regions found that 10.2% of children aged 12–15 years were stunted. The highest prevalence was in South East Asia (19.8%), followed by the Eastern Mediterranean (16.4%), and the lowest prevalence was in Europe (5.5%). The global prevalence of thinness was 5.5%, ranging from 2.5% in the Americas to 15.0% in Southeast Asia. The prevalence of undernutrition was higher among boys (12.3% stunting and 6.7% thinness) than girls (8.2% stunting and 4.5% thinness). There was marked heterogeneity among countries, and an examination of macrocontextual factors found that undernutrition rates were higher in countries with recent internal conflict, lack of democracy, and food insecurity (Caleyachetty et al. 2018). A study involving six sub-Saharan African (SSA) countries (eight study sites) reported an 18.1% pooled prevalence of stunting and 14.3% underweight (equivalent to thinness in the Caleyachetty et al. 2018 analysis), and that girls were less likely to be undernourished than were boys (Darling et al. 2020). This is consistent with several single-country studies in SSA and a seven-country study of school-attending adolescents which found that boys were twice more likely than girls to be underweight (Manyanga et al. 2014). Age-stratified analyses of worldwide trends in BMI, underweight, overweight, and obesity presented by the NCD Risk Factor Collaboration (NCD-RisC) Group showed a distinct increase in mean age-standardized BMI and skewing to the right of the distribution in both male and female adolescents between 1975 and 2016. According to their estimates, girls in 1975 had higher age-standardized mean BMI than boys in most countries in sub-Saharan Africa, south Asia, the Middle East, and North Africa, while the reverse was true in many European countries, Latin America and the Caribbean. In 2016, higher BMI among girls than boys remained evident in many sub-Saharan African and South Asian countries, while, by contrast, the BMI gap between the sexes in the Middle East and North Africa shrank or was reversed as boys gained more weight than girls. This may be the main driver of the global agestandardized prevalence of obesity increasing from 0.9% in 1975 to 7.8% in 2016 in boys compared to 0.7% in 1975 to 5.6% in 2016 in girls, with an estimated 74 million boys and 50 million girls being obese (NCD-RisC 2017). In the 57-country analysis by Caleyachetty and co-workers (2018), overweight/ obesity was most prevalent in the Western Pacific, affecting 33.7% of adolescents compared to 11.1% in Southeast Asia. Stratified analyses by sex found highest rates in the Western Pacific for both boys (31.8%) and girls (34.9%) and lowest rates for boys in Africa (10.1%) and girls in Southeast Asia (9.8%). The earlier-cited African studies which found that adolescent boys were more likely to be stunted or underweight also reported consistently that girls were more likely to be overweight/obese than boys.

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Adults According to the 2020 report on State of Food and Nutrition Security in the World, the number of undernourished people has been increasing since 2016, and by 2019, an estimated 690 million people in the world were not meeting their basic energy needs (FAO et al. 2020). Paradoxically, obesity among adults is increasing in all regions of the world. Global age-standardized mean body mass index (BMI) increased from 21.7 in 1975 to 24.2 in 2014 in men and from 22.1 in 1975 to 24.4 in 2014 in women (NCD-RisC 2016). Excess body weight is an important risk factor for mortality and morbidity from cardiovascular diseases, diabetes, cancers, and musculoskeletal disorders, causing nearly three million deaths annually in the world (GBD 2013 Risk Factors Collaborators 2015). Urbanization has long been reported as a major factor in the overall increase in obesity worldwide (WHO 2016). This understanding was supported by positive correlations in most countries between increasing BMI and the proportions of populations living in cities (NCD-RisC 2016). However, a recent analysis based on 2009 population studies with height and weight measurements of more than 112 million adults showed that, contrary to this theory, the increase in average BMI from 1985 to 2017 was mainly due to increasing BMI in rural populations. Rural women and men gained, on average, 2.09 and 2.10 kg/m2, respectively, compared to urban women and men who gained 1.35 and 1.59 kg/m2, respectively. Rural populations accounted for between 60% and 90% of observed increases in national average BMI in sub-Saharan Africa, east, south and southeast Asia, and Oceania. These trends have led to a reduction, and in some countries a reversal, of the urban-rural BMI gap in low- and middle-income countries, especially for women (NCD RisC 2019). The globalization of food systems comes with intensified food marketing initiatives by national and transnational corporations. Economic growth in low- and middle-income countries leads to the “urbanization of rural life.” As the food chain in many low- and middle-income countries has shifted progressively into the control of agribusinesses, food retailers, and manufacturers (Popkin et al. 2020), rural communities have been targeted in the push by national and transnational corporations to expand markets for cheap ultra-processed foods and beverages.

Essential Nutrition Actions in Community Health Promotion: A Life Course Approach A successful response to the double burden of malnutrition requires a life course approach, providing interventions (or essential nutrition actions) from conception to old age (WHO 2019). Essential nutrition actions have generally been classified as nutrition-specific and nutrition-sensitive since the 2010s. Nutrition-specific are interventions aimed at disease prevention and management, early child development, dietary diversification and nutritional supplementation, as well as nutrition in emergencies (Black et al. 2013). The nutrition-sensitive ones are delivered through nutrition-sensitive development in agriculture; maternal education and women’s

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empowerment; improved hygiene, sanitation, and water quality; and social protection programs to increase purchasing power and access to services and amenities (Ruel et al. 2013). Conventionally, nutrition interventions have been implemented as if undernutrition and overweight/obesity were separate issues, thus, for instance, food supplements for undernutrition in young children have resulted in obesity and DR-NCDs later in life. Given that undernutrition and overweight/obesity have interrelated drivers (Wells et al. 2020), experts are recommending double-duty interventions, which address multiple types of malnutrition concurrently (Hawkes et al. 2020) or benefit multiple individuals. The best examples of the latter are interventions targeting women before conception, during pregnancy and postpartum, which benefit both mothers and their babies. Moreover, since the causes of malnutrition are embedded in many sectors, interventions for its prevention and management should be multisectoral, comprising actions that ensure access to safe and nutritious foods, healthcare, wealth, water and sanitation, education and social protection (Black et al. 2013; Ruel et al. 2013). Since UNICEF published the conceptual framework on the causes of malnutrition in 1990, many variants have been developed to reflect the complexity and interrelated nature of the causes of malnutrition in its various forms. Among these is the WHO framework on the context, causes and consequences of stunted growth and development (https://www.who.int/nutrition/healthygrowthproj/en/index1.html; Fig. 1), originally developed when stunting was emerging as pivotal to understanding the double burden of malnutrition as well as the link between childhood stunting and economic development (Stewart et al. 2013). In this adaptation, stunted growth and development are coupled at the center of the framework, recognizing that they share common causes and that the period between conception and the age of 2 years is highly sensitive for both. Moreover, the association between undernutrition in early life and obesity/diet-related diseases in adulthood justifies investment in measures to address the causes of stunted growth and development with a view to preventing the double burden of malnutrition over the life course. Strategies that promote and protect healthy growth benefit children’s physical, mental, socio-emotional, and intellectual growth and development and potentially mitigate the NCD risk factors that originate in early life. The framework consists of three concentric circles representing national/community and household contexts that surround the child in whom the short-medium and long-term consequences of stunting are expressed. The innermost circle is the child during the sensitive period of growth when malnutrition compromises growth and brain development with short- and long-term health, developmental, and economic consequences. Children who survive the malnutrition-infection cycle grow into adults with increased risk of NCDs, low educational achievement, and reduced capacity for productive work and earning power. This circle captures the lifelong course of malnutrition. The second circle summarizes the multifactorial causes of stunting that are embedded in the household. The home provides the physical, social, psychosocial, and economic conditions that affect the nutrition and wellbeing of both mother and

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Fig. 1 Stunted growth and development: context, causes, and consequences

child. The focus on the mother’s health and nutrition in this sensitive period underlines the intergenerational nature of nutrition as a determinant of health. In her own right and as the baby’s primary caregiver, the mother needs care and psychosocial support from other household members. If these are absent, the child is at risk of receiving inadequate feeding and care. Each household is a microeconomy where decisions are made on resource allocation to prioritized needs. Household resources and the prioritization of needs will determine how much food is available, its safety, nutritional quality and how it is distributed among household members, as well as sanitation and hygiene practices that condition exposure to illness. The outer circle surrounding the household layer embodies the multisectoral infrastructure at subnational and national levels where policies are formulated and the provision of services to households governed. While the health sector is

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responsible for providing most of what are described as nutrition-specific services, other sectors are needed to provide critical nutrition-sensitive interventions (education; agriculture and food systems; water, sanitation, and environment; political economy; society and culture, etc.). The following section outlines proposed interventions through the life course, highlighting the forms of malnutrition they seek to address and the sectors that can contribute to their delivery. Some interventions are relevant for multiple age groups or throughout the life course.

Preconception This period applies to women of reproductive age, which includes adolescents and adult women, typically 15–49 years of age. A woman’s nutritional status before conception is important for her own as well as her offspring’s nutritional status and wellbeing. Menstrual blood losses impose the need for increased intake of iron, folate, and vitamin B12 to counter the risk of anemia. Folate plays a critical role in neural tube development in the early stages of fetal life and is therefore a high priority vitamin for prepregnant women. Given that many women, and especially adolescents, realize they are pregnant weeks after conception, folate is combined with iron in many supplementation programs targeting women of childbearing age irrespective of pregnancy status. Increased demands for energy and nutrients to support heightened growth and maturation increase the risk of undernutrition, including micronutrient deficiencies, among adolescents especially in economically disadvantaged populations. On the other hand, endocrinal changes and behavioral drivers of unhealthy food consumption and reduced physical activity can engender overweight/obesity. Since the normal cause of pregnancy entails weight gain for the mother, a woman who enters pregnancy with excess weight is more likely to have a high birthweight baby, with consequences that will be outlined in the next section. Worldwide estimates indicate that ten million girls under the age of 18 years get married each year and soon carry their first pregnancy, hence the growing interest in adolescent health as an entry point for improving the health of women and children (Bhutta et al. 2013). According to the 2019 UNICEF report on State of the World’s Children (SOWC) (https://data.unicef.org/resources/state-of-the-worlds-children2019/), a global average of 5% girls aged 15 years and 21% aged 18 years were married, but the prevalence was higher in South Asia (8% at age 15 years and 30% at age 18 years) and in sub-Saharan Africa (12% at age 15 years and 37% at age 18 years). Increased completion of secondary level schooling by girls greatly contributes to the reduction of child marriages and of teenage pregnancies, yet only 20.4% adult women in South Asia and 13.8% in sub-Saharan Africa were reported to have completed secondary schooling. The 2015 SOWC (https://data. unicef.org/resources/state-worlds-children-2015/) reported on adolescent childbearing and estimated that a global average of 50% girls aged 15–19 years had given birth, with the highest rate being in sub-Saharan Africa (124%). It is currently

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estimated that adolescent fertility accounts for 11% of all births globally, with 95% of these occurring in LMICs (https://www.who.int/news-room/fact-sheets/detail/ adolescent-pregnancy). These child-mothers would likely have dropped out of school, have low birthweight babies, be less likely to receive the psychosocial support needed for breastfeeding, and be ill equipped to nurture their infants. Interventions targeting adolescent girls should therefore seek above all to delay marriage and childbearing, especially in populations where early marriage is a social norm. This would allow for the completion of the girls’ own physiological growth and development, psychological maturation, acquisition of life skills, and for those enrolled in formal schooling to complete their education and training (World Bank 2007). Through the combined efforts of the education, social protection, and health sectors, the provision of school meals in low-income communities can serve as an incentive to keep girls in school and prevent undernutrition as well as obesity and diet-related NCDs through promoting healthy diets and physical activity. Weekly iron and folate supplementation can be integrated in the school health programs, helping to prevent iron-deficiency anemia and build up folate stores as girls reach puberty. For nonschool going teenage girls, interventions can be delivered through social welfare and youth programs.

Pregnant and Lactating Women Pregnancy is a period of increased nutritional needs to support the growth and development of the fetus and to prepare the mother for lactation. Maternal undernutrition and suboptimal gestational weight gain increase the risk of poor fetal growth and development resulting in small for gestational age babies, and for stunted mothers, increased risk of obstetric complications requiring caesarean section (Wells et al. 2020). A pregnant woman whose nutritional intake is suboptimal mobilizes her bodily stores to meet the needs of the growing fetus at the expense of her own basic requirements. At the opposite extreme, obesity and high gestational weight gain also are associated with complications, including hypertension, increased risk of caesarean section, and delivering a high birthweight or obese baby. Pregnant women have increased need for iron and other blood-forming raw materials because of their expanded blood volume, as well as requirements of the fetus and placenta. In addition to adequate energy intake, therefore, mothers need diets that are rich in protein and micronutrients such as iron, folate, and vitamins (B, C, etc.) that are essential for red blood cell production. Risk factors for anemia include malaria, which causes excessive breakdown of red blood cells, and infestation with hookworms and schistosomiasis which causes blood loss. Maternal nutrition counseling as part of antenatal care should be tailored to address the risks identified for individuals or groups of mothers. Where available, balanced energy and protein supplementation should be provided for undernourished women to prevent their own nutritional deprivation and intra-uterine growth restriction for their offspring (Imdad and Bhutta 2012), as well as to reduce the risk of stillbirth (Kramer and Kakuma 2003). For women who are overweight or obese at

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the start of a pregnancy, nutrition counseling focuses on measures to avoid excessive weight-gain, and breastfeeding is the natural means of shedding some of the weight accumulated during pregnancy (Onyango et al. 2011). Evidence-based strategies recommended to combat anemia in pregnancy include supplementation with iron and folic acid tablets and counseling on consumption of micronutrient-rich foods; malaria prevention through intermittent prophylaxis and use of insecticide-treated bed nets; deworming where hookworm and schistosomiasis infestation prevalence is high; and optimal birth spacing. (A more detailed description of interventions is presented in the next section.)

The First 1000 Days The first 1000 days have been described as a window of opportunity to lay a firm foundation for lifetime nutritional wellbeing. Maternal nutrition and health are the cornerstone of that foundation. Thus, what was described for pregnant and lactating women overlaps with what refers to the baby in this period. The baby needs energy, fluids, proteins, fatty acids, and micronutrients to support growth, development, and functional differentiation of the central nervous system, lean tissue, and bones. In addition to energy for basic vital functions, nutrients supply the raw material and micronutrients for regulating growth and development. The brain is programmed for rapid development from the third trimester through to age 3 years when 80% of the adult’s brain volume should be formed (Cusick and Georgieff 2016). Among the nutrients needed for the developing brain and central nervous system are proteins for cell proliferation and synaptogenesis; iron for myelination and dopamine synthesis; zinc to regulate DNA and RNA synthesis and the release of neurotransmitters; and iodine which is involved in synaptogenesis and thyroid hormone synthesis. The needs are supplied in utero from the mother through the placenta, and after birth, ideally by breastmilk only during the first half of infancy. From the age of 6 months, breastmilk alone cannot fulfill the increased nutrient requirements of the growing baby, hence the recommendation that they receive safe and nutritious foods to complement breastfeeding until the age of 2 years and beyond. Apart from receiving energy and nutrients for growth, babies’ sensory development is influenced by the organoleptic characteristics of the foods they eat. The eating experience contributes to the development of their taste, sight, smell, and touch, as well as their dental health, fine motor skills, and coordination. Food preferences are established along with the social habits of shared meals, and babies learn to associate certain tastes with love and comfort. It is therefore important that caregivers use responsive feeding to cultivate babies’ enjoyment of healthy foods in this formative period. When nutritional needs are met and infections are prevented or treated effectively, infants and toddlers grow in length and gain weight (on average they gain over 37 cm in length and more than triple their birth weight by the age of 2 years (https://www. who.int/childgrowth/standards/en/). With appropriate nurturing and stimulation, they achieve developmental milestones and thrive. Analysis of child growth patterns

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in 54 developing countries demonstrated that linear growth deficits increase dramatically in the first 2 years and then average height-for-age seems to stabilize to age 5 years (Victora et al. 2010), and other evidence suggests that linear growth deficits accrued in the first 1000 days are largely irreversible (Leroy et al. 2014). The threefold recommendation about breastfeeding (initiated within 1 h of birth, exclusive for the first 6 months and continued up to the age of 2 years and beyond, with adequate quantities of safe and nutritious complementary foods) carries numerous benefits for mothers and babies alike, as summarized by the Lancet Breastfeeding Series Group (Victora et al. 2016). For infants, the benefits range from survival and prevention of acute infections in the short term to reduced risk of obesity and diabetes and a higher intelligence quotient in the long term. Initiating breastfeeding in the first hour after birth has many benefits, not least among which is ensuring that the newborn receives colostrum, rich in nutrients and antibodies that boost its immunity. Kangaroo mother care (KMC) is an intervention that includes continuous skin-to-skin contact between mothers and newborns. It prevents neonatal deaths among low birthweight and premature babies by regulating the baby’s temperature, accelerating weight gain, and reducing the risk of infections. But KMC is beneficial also for term healthy newborns. An evaluation based on randomized controlled trials revealed that KMC was associated with significant improvements in breastfeeding practices including early initiation, exclusive breastfeeding, and prolonged breastfeeding (Moore et al. 2016). Epidemiological evidence shows that breastfeeding within the first 24 h after birth reduces the risk of neonatal mortality (Khan et al. 2015). For the mother, early initiation facilitates the establishment of lactation, which reduces risk of breast engorgement and mastitis. Early initiation also may contribute to lowering the risk of postpartum hemorrhage and thereby maternal mortality. Breastfeeding establishes in the mother-child dyad deep and lasting bonds with unquantifiable psychological benefits. Exclusive breastfeeding reduces in young infants the incidence of diarrheal diseases and acute respiratory infections, including pneumonia. Suboptimal breastfeeding, especially nonexclusive breastfeeding in the first 6 months of life, is estimated to result in 1.4 million deaths and account for 10% of the disease burden in children younger than 5 years (Black et al. 2008). In addition to the benefits of reduced infant mortality and undernutrition associated with optimal breastfeeding, there is increasing recognition of its benefits for preventing overweight/obesity later in the life course. A review found that the risk of being overweight was 20% higher among infants who are exclusively bottle-fed compared to those exclusively breastfed during the first 6 months of life, suggesting that exclusive breastfeeding in this period is central to the mechanism by which breastfeeding protects against later obesity (Singhal and Lanigan 2007). Ending inappropriate marketing of foods for infants and young children (World Health Assembly resolution 69.9, https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_ R9-en.pdf?ua¼1) is a key intervention for the prevention of both undernutrition and overweight. It is relevant for low-income households for whom the products are costly and who lack the safe water and sanitation facilities required for their hygienic

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preparation and feeding. On the other hand, many products that are marketed for infants and young children aged 6–36 months have high contents of sugar, for example, and are thus implicated in the increasing burden of overweight in children (Colby et al. 2010). Maternal benefits of breastfeeding (exclusive in the first 6 months and its continuation thereafter) include the prolongation of lactational amenorrhea which conserves maternal iron stores and contributes to birth spacing in the absence of contraceptive use. In the long-term, breastfeeding is associated with reduced risk of breast and uterine cancers in women (Victora et al. 2016). The recommended double-duty interventions in this period are primarily nutrition-specific and delivered through the health sector, especially where coverage of antenatal and postnatal care services is high. The Baby-Friendly Hospital Initiative (BFHI) has been a vehicle for the delivery of these interventions since it was launched in 1981. In the first 25 years of its implementation, the BHFI was almost synonymous with the certification of maternity facilities that fulfilled Ten Steps to Successful Breastfeeding (WHO 1989). A review conducted by WHO and UNICEF identified gaps in the effectiveness and sustainability of this approach and led to the revision of the guidance on the BFHI operationalization (WHO/ UNICEF 2018). The new orientation lays emphasis on scaling up to universal coverage and ensuring sustainability through integration of the Ten Steps in person-centered, high quality maternal and newborn care. While the entry point remains maternity services, the new guidance recognizes that other interventions are needed to ensure adequate support for breastfeeding, including in antenatal care, postpartum care, communities and workplaces, as well as adequate maternity protection and legislation to protect and support the recommended durations of exclusive and continued breastfeeding. In sum, it is critical that the BFHI program is coordinated with all other aspects of breastfeeding protection, promotion, and support which depend on carefully designed and effectively implemented health, social protection, trade, labor, and legal policies. Community strategies incorporating home visits to support women, the use of peer counselors or community volunteers have been successfully tested in improving breastfeeding practices (Shakya et al. 2017). Growth monitoring and promotion as part of primary health care in the community or facilities provides opportunities for early detection of growth faltering or of excessive weight gain for timely remedial action to prevent or treat malnutrition (nutrition counseling, nutrient supplementation, treatment of acute malnutrition, etc.). A review of strategies to promote adequate complementary feeding has shown that well-designed interventions linked with growth monitoring and promotion can have beneficial effects on feeding practices (Martin et al. 2020). In food secure situations, nutrition education strategies alone on good complementary feeding practices have been shown to be effective in improving young child growth (Penny et al. 2005). In food insecure populations, however, the Brazilian experience demonstrated that to achieve measurable and sustained impact, education and behavior change communication should be part of comprehensive packages to improve access to food and health services (Box 1).

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Box 1 Case Study: Brazil Family Health Strategy

Brazil’s Family Health Strategy (FHS) or Programa Saúde da Família (PSF) was established in 1994 in order to expand health care access to the poorest Brazilians and provide integrated primary care using multidisciplinary Family health care teams. The program was built on several decades of experience in rural underserved areas with community health workers, referred to as Community Health Agents (CHAs) in Brazil. Initially, the CHAs provided maternal and child health (MCH) services (such as immunizations and family planning) and health promotion advice on infectious diseases and undernutrition in isolated rural areas where services were limited. However, now they are an integral part of family health care teams and the cornerstone of the public health care system. They were legally recognized as professionals in 2002. Each team comprises a doctor, a nurse, an assistant nurse, and CHAs. Some teams include a dentist, an assistant dentist, a dental hygienist, and a social worker as well. Each CHA is responsible for about 150 families. Brazil has undergone epidemiological and nutritional transitions since the 1970s and is currently experiencing high levels of NCDs. Therefore, the CHAs’ health promotion and preventive activities have extended to NCDs. They support primary prevention and management of cardiovascular disease risk factors as well as secondary prevention for high-risk individuals. They offer advice on diet and related lifestyle factors such as smoking, weight management, and physical activity (Perry et al. 2017; Macinko and Harris 2015). Brazil’s FHS employs a holistic approach. Health care teams link health care users with social programs and also connect them to water and sanitation services, law enforcement, and schools (Macinko and Harris 2015). The Bolsa Familia program (BFP) is a conditional cash transfer program for poor families. Beneficiaries must comply with specific education and health-related conditions. Children must be kept in school, get annual vaccinations and check-ups, and also participate in growth monitoring programs. Pregnant and lactating women must attend antenatal and postnatal clinics, as well as health and nutritional educational activities. It is recommended that healthrelated conditions should preferably be met using FHS facilities (Macinko and Harris 2015; Rasella et al. 2013). Among FHS successes are marked increases in access to MCH interventions as well as marked declines in child stunting and mortality, maternal mortality, increased breast-feeding, health disparities, and inequity in health care utilization. Between 1990 and 2015, under-5 mortality decline by twothirds; between 1990 and 2002, infant mortality rate decreased from 49.7 to 28.9 per 1000 live births. The programmatic impact was largest in under-5 mortality, the poorest municipalities, and the more rural regions in the country with worse baseline health indicators (Perry et al. 2017). Evaluation shows that FHS access and its healthy lifestyle initiatives have been associated with (continued)

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Box 1 (continued)

reduced mortality from cardiovascular disease, the leading cause of mortality in Brazil, as well as reduced rates of complications from diabetes and fewer hospitalizations of NCDs (Macinko and Harris 2015). BFP was found to have contributed significantly to improved health care use, especially of the conditionality-related preventive services, which contributed to reduced child mortality, in particular of poverty-related deaths associated with undernutrition and diarrhea (Rasella et al. 2013). An important lesson learnt from the FHS is that community-based primary care can work if done properly. The program appears to be very cost-effective: it costs $50 per person each year (Macinko and Harris 2015).

Preschool Years The need for nurturing care in a safe, secure, and loving environment, with the right nutrition and stimulation from caregivers, continues beyond the first 1000 days, to ensure that children survive, thrive, and are adequately prepared for formal learning (WHO et al. 2018). Where nurturing care is deficient, children’s intellectual potential and future educational achievement are put at risk. Micronutrient supplementation is recommended in areas where local foods are deficient in key micronutrients such as vitamin A, iron, and zinc which enhance energy utilization for optimal growth and bodily resistance to infection. Under-fives are a high-risk group for foodborne illnesses and related mortality, underlining the need for attention to food safety measures as part of nurturing care. For children who were small for gestational age at birth or were stunted by age 2 years, excessive weight accumulation in this period has been shown to increase metabolic risk as a precursor to diet-related NCDs (Victora et al. 2008). The risks associated with rapid weight gain in this age period may not be limited to undernourished children as suggested by studies on the timing of the adiposity rebound (Rolland-Cachera et al. 2006). In normally growing children, BMI curvature shows that fatness increases rapidly between birth and 6 months, drops from the second half of infancy, continues the downward trend during the second year, and remains mostly stable through age 5 years before the upswing that marks the adiposity rebound (WHO Child Growth Standards, BMI-for-age, https://www.who.int/ childgrowth/standards/bmi_for_age/en/). Children who experience the adiposity rebound about age 3 years are more likely to be obese in early adulthood than those whose rebound takes place after age 5 years (Rolland-Cachera et al. 2006). The consumption at this age of energy-dense diets – typically from highly processed foods with high sugar content – carries multiple risks: one is the rapid weight gain that portends overweight in succeeding years, and the other is the acquisition of unhealthy food preferences that persist through school age and adulthood. Cultivating healthy diet preferences and active lifestyles in a nurturing home environment is

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important for the positive socialization of children in habits that will help prevent all forms of malnutrition. Direct nutrition interventions in this period include the provision of food that is safe and adequate in quantity and quality, micronutrient supplementation, deworming, and the treatment of wasting. These measures help to reduce the burden of both undernutrition (including micronutrient deficiencies) and overweight. The malnutrition-infection cycle can be broken by the prevention and treatment of diarrhea, pneumonia, malaria, and other childhood infections which reduces malnutrition, and this in turn increases resistance to infections. This virtuous cycle is an important factor in the reduction of under-five mortality. In countries where the early child development programs are organized formally, preschool settings run curricula geared towards intellectual preparation for schooling. But they also may be the channels for social protection services such as offering food supplementation to children from low income households. The choice of foods should aim to provide nutritionally adequate diets and to nurture healthy food preferences. Community programs in Water, Sanitation and Hygiene (WASH) though not specifically targeting under-fives do nevertheless have a direct influence on their health and nutritional status. WASH interventions including handwashing with soap, improving the quality of drinking water, and building latrines have been shown to be effective in reducing the risk of diarrhea (Cairncross et al. 2010), and a World Bank review based on analysis of data from Demographic and Health Surveys showed that a 20% reduction in open defecation was associated with an increase in a standard deviation of child height (Spears 2013). In sum, the sectors that play key roles in reducing all forms of malnutrition in this age period are health, food security, education, WASH, and social and child protection. Box 2 Case Study: Integrated Nutrition Programme in the Western Cape Province of South Africa

In the Western Cape Province of South Africa, the Integrated Nutrition Program (INP) (https://www.westerncape.gov.za/service/integrated-nutritionprogramme) is part of the primary health care system and aims to achieve food security and promote optimum nutrition through an intersectorial approach. The program was launched in 1995, the integrated strategy meant to replace the previous fragmented and mostly food-based approaches in addressing the multisectoral and complex causes of malnutrition. The focus is on individuals with NCDs, pregnant and lactating women, and young children with emphasis on promotion of breastfeeding. The program emphasizes capacity building among its users and implementers. The goals are: • Prevent an increase in mortality due to diseases of lifestyle • Promote the health of women and in particular pregnant and lactating women (continued)

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Box 2 (continued)

• Reduce the prevalence of malnutrition in children • Ensure optimal growth of infants and young children • Improve capacity at all levels in order to solve the problems of malnutrition and hunger • Improve intersectoral collaboration and community ownership of the program and resources Among INP’s collaborators are the Departments of Agriculture and Public Works, Universities, Child Health Units and Human Nutrition Departments, NGOs, Food and Agriculture Organization, and UNICEF. Health facilitybased nutrition interventions include growth monitoring and promotion for young children. The Primary School Nutrition Programme (PSNP) is a key component: its main activities are the feeding program, nutrition education, and health education. The PSNP is used as a spring-board for the development of community-based nutrition projects. It includes the development of a comprehensive program with linkages to the community, other school health services, and other nonhealth sectors. Seventeen of these projects encompassing food-based income generation projects plus nutrition and health education projects were piloted among disadvantaged populations and informed development of country-wide poverty alleviation projects. Evaluation of the program showed mixed results for undernutrition with better outcomes among school-aged children than under-fives. Overweight/ obesity-related outcomes are yet to be evaluated (Shung-King et al. 2019).

School Age There is an overlap in preschool and school age children’s needs for optimal growth and development considering that “early child development” goes up to age 8 years (WHO et al. 2018). The needs described for the preschool years (adequate nutrition, intellectual stimulation, prevention and treatment of infections and nurturing care) remain relevant for the school age child. Good nutrition maximizes intellectual potential and school performance (Grantham-McGregor et al. 2007) and helps prevent all forms of malnutrition and diet-related NCDs. As discussed in earlier sections, a delayed onset of puberty prolongs the growth hormone-driven childhood growth phase, thus extending the window of opportunity for catch-up growth for individuals who experienced stunting in childhood (Karlberg 1989; Prentice et al. 2013). The secular trend towards earlier onset of puberty in association with the growing burden of overweight/obesity among children suggests that measures to prevent overweight in children and adolescents could indirectly contribute to some catch-up in linear growth. In the natural process of intellectual development, before age 12 years the brain is only capable of straight processing of facts. Abstract thinking begins between 12 and 14 years of age with full maturity achieved only by around age 18 years (Dosenbach

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et al. 2010). Young children, therefore, lack the capacity to make critical judgments and counteract the influence of commercial advertising and the pressure of peers on their consumption choices (of food, beverages, and other goods). Industry players exploit the fact that lifelong addictions and brand loyalties are established at this age (https://www.who.int/news-room/detail/29-05-2020-stop-tobacco-industry-exploita tion-of-children-and-young-people) and therefore employ a wide range of tactics to reach children and adolescents, be it by individually targeted advertising through digital media or event sponsorships and bursary schemes. Healthy diets in this period are important for the dual function of maintaining healthy growth (i.e., preventing all forms of malnutrition) and cultivating healthy habits in food consumption and physical activity. School feeding programs thus provide a platform for addressing food insecurity and undernutrition as well as the prevention of overweight/obesity, reducing other chronic disease risk factors and improving fitness. Additionally, they offer the opportunity to generate healthy life skills and learn healthy dietary habits. In Uttar Pradesh, India, school feeding has helped control anemia in adolescents (Vir et al. 2008). The Institute of Medicine (IOM) proposed for the USA that schools be made the national focal point for obesity prevention by means such as providing quality physical education, ensuring strong nutritional standards for all foods and beverages sold in or provided by the schools, and incorporating food literacy and skills development in the curriculum (IOM, Food and Nutrition Board 2012). In view of the growing burden of childhood obesity worldwide, the World Health Assembly endorsed a set of recommendations on controlling the marketing of food and nonalcoholic beverages to children (WHO 2010) as part of measures to prevent overweight and obesity. The recommendations lay special emphasis on limiting the consumption of foods high in saturated fats, trans-fatty acids, free sugars, and salt as factors that increase the risk of obesity, cardiovascular diseases, diabetes, and raised blood pressure. Successful interventions require close collaboration between health and other sectors. For example, while the health sector may instigate legislation to control the marketing of foods and nonalcoholic beverages, the enactment and enforcement of the relevant policies requires the collaboration of law makers and the sector responsible for commerce and trade. Programs targeting children and adolescents in educational institutions need a strong partnership between health and education, as well as parents and community members. Home-grown school feeding programs bring together agriculture and education sectors, giving local farmers opportunities for income generation as they produce fresh foods for local schools, as has been done in Senegal, Malawi, Mozambique, Ethiopia, and Niger through Purchase from Africans for Africa (http://www.fao.org/3/a-i7448e.pdf) with support of the Food and Agriculture Organization and the World Food Programme. Such programs can be coupled with school gardens in the curriculum to build agricultural skills among the students and supplement the food supplies for their own school meals. Dietary diversification to address micronutrient deficiencies can be adopted as an objective of such initiatives.

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The principles of the nutrition-friendly school include integrating the scientific basis of healthy diet and active living into the school curriculum, and then reinforcing the scientific knowledge by serving healthy meals in the school. The modeling of healthy behaviors by teachers and other staff also reinforces learning. In addition, students should have access to safe drinking water, sanitation facilities, as well as time and facilities for physical activity. Through what they learn in school, students should be encouraged to become change agents in their own communities for better nutrition and food safety. Schools should cultivate an inclusive culture for overweight/obese children who often suffer from low self-esteem, depression, social isolation and may be victims of bullying. For children and adolescents not in school attendance, joint programs with social welfare and sectors responsible for youth and community development are the candidate partners for initiatives to improve their nutrition.

Adults and Older People Growth in height stops at variable ages between the late teens and early twenties, following which one’s adult height remains stable until age-related loss in bone density and degenerative processes lead to the spinal compression that results in noticeable loss of height after age 60 years. Weight on the other hand can change, and in fact adults are prone to gain weight under the influence of hormonal changes and unbalanced food consumption versus physical activity. The primary nutritional needs in adulthood consist in maintaining energy balance and supplying the nutrients needed for bone and soft tissue maintenance and enhanced humoral immunity. The process of aging is accompanied by a progressive loss of muscle mass in a dynamic of decreased protein synthesis with little change in degradation, accumulation of fat within and around muscle cells, and decreasing bone density. These changes contribute to the slow-down in metabolism and reduction in muscle strength and capacity for physical exertion that are characteristic of the aging process. Accumulation of visceral fat is associated with insulin resistance and increased risk of type 2 diabetes. Older persons may be undernourished when food intake is adversely affected by relative disability associated with decreasing sensory acuity (smell, taste, touch, and vision) and weakening or loss of teeth. In contexts of food insecurity, older persons may not receive enough to eat the more physically and mentally dependent they are. They have increased need for calcium and vitamin D to reduce osteoporosis and the risk of fractures as well as immune boosting micronutrients (vitamin A, C, D, B12, zinc, etc.) and dietary fiber in view of decreased intestinal motility and proneness to indigestion. The dual challenge of reduced food intake and ability to break down and absorb nutrients from food means that older persons need nutrient supplements to satisfy their requirements. In general, there are few public health interventions targeting adults and older people except social protection and cash transfer programs for vulnerable populations, usually associated with emergencies. Iran has a community health

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program that includes services for the prevention and management of NCDs and does, therefore, pay specific attention to health issues affecting adults as well as children and women (Iran case study). As social welfare systems evolve and more older persons live in aged care facilities, it becomes easier to define standardized intervention packages for comprehensive care and management of the nutritional problems associated with aging. Box 3 Case Study: Iran Community-Based Program

Iran’s public health care system provides 90% of the country’s health services. Community health workers, known as behvarzs, are a key component of the system and focus on the health needs of rural populations specifically maternal and child health (MCH) in terms of infant mortality, maternal mortality, and childhood illnesses such as diarrhea. One male and one or more female behvarz(s) work from “Health Houses” (Khaneh Behdasht), each of which serves approximately 1500 people and covers the main village plus four satellite villages. The “Health Houses” were a product of health care reforms implemented in Iran in the 1980s and are central to Iran’s primary health care services. Behvarzs conduct home visits and make referrals to health centers. Specific behvarzs’ responsibilities include vaccination, growth monitoring, breastfeeding promotion, nutrition support for infants and children, as well as Integrated Management of Childhood Illness (IMCI). Ante-natal and postnatal care are provided along with family planning services, treatment of minor illnesses, and first aid. Behvarzs’ also provide care for the elderly, oral health care, and care of young people at school. Male behvarzs’ are responsible for environmental and occupational health. Beyond general promotive/preventive services and basic care, behvarzs’ responsibilities presently include NCD detection and management principally diabetes and hypertension. Hyperglycemia and high blood pressure are the leading metabolic risk factors for death in Iran. As part of the National Programme for Prevention and Control of Diabetes protocol, behvarzs are trained to identify high-risk groups including those aged 30 years or older who are pregnant, have a family history of diabetes, or are overweight. High-risk individuals are referred to physicians who visit the Khaneh Behdasht. The workers then follow up patients with diabetes monthly to check for treatment compliance, arrange for new drug supply, examine them for symptoms of hyperglycemia (e.g., diabetic wounds and ulcers), and to refer patients with complications (such as ulceration, painful limbs, and blurred vision) to doctors at the rural health centers. Additionally, behvarzs hold training sessions on healthy diet and lifestyle for, among others, high-risk individuals (Perry et al. 2017; Farzadfar et al. 2012). The behvarz program has contributed significantly to narrowing the gap of infant mortality rate (IMR), among other health indicators, between rural and (continued)

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Box 3 (continued)

urban areas. Between 1976 and 2000, IMR declined from 60.4 to 27.7 per 1000 live births in urban Iran; it decreased from 123.7 to 30.2 per 1000 live births in rural Iran. The system is credited with improving diabetes outcomes in rural Iran. A recent study found that treatment lowered mean FPG by an estimated 1.34 mmol/L (0.58–2.10) in rural areas and 0.21 mmol/L (
0.15 to 0.56) in urban areas. Behvarz-worker density was associated with lower FPG concentration. Each additional behvarz worker per 1000 adults was associated with a 0.09 mmol/L (0.01–0.18) lower district-level average FPG (P ¼ 0.02). The effectiveness of Behvarz workers in the management of hypertension is modest since the program for hypertension prevention and control is smaller in scope and functions of Behvarz are not well defined (Farzadfar et al. 2012).

Cross-Cutting Interventions for All Age Groups The foregoing section has outlined essential nutrition actions corresponding to different stages of the life course. It is clear, however, that nutritional needs follow a continuum from conception to old age, and that deficiencies at any one stage have immediate to long-term consequences over the life course. Similarly, coordinated multisectoral action is essential to fully address the multifaceted causes of malnutrition. Governments in low- and middle-income countries need to invest in raising standards of living for the large segments of their populations that are food insecure and have no access clean water or improved sanitation. This will help prevent infections and reduce undernutrition among poor rural communities and urban slum populations. The socioeconomic disparities that drive the double burden of malnutrition are captured in an analysis presented by Perez-Escamilla and co-authors (2018). They note that the intergenerational transmission of malnutrition risks is heightened in the presence of social, economic and gender inequities. For example, in an analysis of DHS data from 52 countries, the lowest wealth quintiles in Asia and Africa had under-five stunting rates of 40–50% compared to the highest quintiles with rates of 10–20%. On the other hand, the rates of overweight although being highest in the richest quintiles (5–7%) were not much lower in the poorest quintile (3–5%). The importance of inequities in connection with the double burden of malnutrition is highlighted also in the 2020 report on the State of Food and Nutrition Security, which notes that in every region of the world, healthy diets are unaffordable to many people, especially the poor (FAO et al. 2020). Commercialized food production, processing, and distribution defines a large part of the global food system as smallholder farming contributes progressively less to the household food basket in most countries of the world. This carries implications for smallholder farmers’ livelihoods, the resilience of ecosystems, biodiversity, and environmental conservation, all of which feedback into nutrition, health, and wellbeing. The

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commercialization of food production does offer opportunities for the regulation of food safety and quality. For example, fortification of processed foods with iodine, iron, and vitamin A has contributed to the reduction, respectively, of iodine deficiency disorders, anemia, and night blindness. In addition to raising the standards of living for rural communities and the urban poor, complementary policies are needed to regulate the marketing of the wide range of unhealthy foods and beverages that variously target infants, children, adolescents, and adults. These products may carry claims (of enhancing health, strength, intelligence, longevity, etc.) associated with one additive while not declaring the presence of other nonhealthy ingredients (e.g., highlighting that margarine is cholesterol-free but not declaring that it contains trans-fat). Such practices should be controlled by defining and enforcing appropriate food labeling standards, and where necessary, taxation of products that contain defined levels of disease-promoting ingredients. Health literacy is an important complement to governments’ efforts to regulate the food environment. Consumers need to know what their needs are and what foods meet those needs with minimal “side effects.” That requires population sensitization and education on how to read food labels and judge what is safe and healthy or otherwise. Governments can facilitate access to and affordability of fresh foods and vegetables (e.g., through facilitated access to urban markets by rural farmers), but their desirability depends on consumer awareness and cultivated taste. Overall, prevention and management of the double burden of malnutrition rests on two pillars: healthy diet and adequate physical activity. These are relevant through the life course and are the concern of governments, households, and individuals.

Conclusion Summary The food we eat plays a central role in building the body, protecting it from disease, and repairing damaged cells and tissues to ensure survival and wellbeing. Nutrition is a key determinant of health throughout the life course, and malnutrition in early life can have lifelong repercussions. The definition of malnutrition evolved from its historical equation with protein-energy and micronutrient deficiencies to present-day understanding of overweight/obesity and diet-related NCDs as components of the double burden of malnutrition. The characterization of nutritional status based on anthropometry permits global monitoring of malnutrition trends and comparisons of countries’ and regions’ progress towards global developmental targets. A review of trends in world regions and all age groups reveals that malnutrition in multiple forms affects every country in the world. Nutritional deficiencies remain more prevalent in low-income and lower-middle-income countries, while overweight/obesity is the predominant malnutrition form in upper-middle-income and high-income countries. Undernutrition monitoring among under-fives shows that high levels of wasting persist in regions and countries affected by natural disasters,

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climate events, and conflict. Asia has the highest concentration of the undernourished in numbers due to its population size. The African region has seen the slowest decline in child undernutrition and in fact the number of stunted children in increasing in sub-Saharan Africa. The double burden of malnutrition is especially prevalent in countries experiencing the nutrition transition, a phenomenon characterized by an increasing burden of overweight/obesity in predominantly undernourished populations. Overweight/obesity has increased in all age groups since the 1990s with a variegated picture of differences among regions and by sex. Inequity is an important factor in who suffers from malnutrition globally, within countries and within households. Obesity is a growing problem for rural populations and the urban poor, many of whom cannot afford a healthy diet. Since the risk factors for the double burden of malnutrition are relevant at all stages of the life course, its prevention requires a comprehensive package of policies. A set of ten priority interventions delivered through health services, social safety nets, educational settings, as well as agriculture, food systems, and food environments have been proposed as double-duty actions. These include WHO recommendations on antenatal care; breastfeeding; complementary feeding; growth monitoring and promotion; micronutrient-fortified foods and supplements; redesigned cash and food transfers, subsidies, and vouchers; redesigned school feeding programs; nutrition-sensitive agricultural programs; new agricultural and food system policies to support healthy diets; and policies to improve food environments. Regulatory interventions to control the marketing of unhealthy foods should be complemented with policies promoting the availability, affordability, and demand for healthy foods. Food standards and marketing policies should aim to improve population access to nutrient-rich foods while minimizing the marketing and consumption of foods that drive obesity and diet-related NCDs. Comprehensive multisectoral programs that raise standards of living and access to health, education, WASH, and other services are more effective than vertical programs or those that aim to improve knowledge without empowering households to apply the acquired knowledge. Programs in Brazil, Rwanda, and South Africa have demonstrated how multisectoral collaboration can bring about change for the better.

Box 4 Case Study: Rwanda “Building Back Better”

The Rwandan Ministry of Health instituted health reforms following the genocide in 1995, which included decentralization of the health system and establishing community health workers (CHWs) to provide services at the lowest level of the health system – the village. The aim was to increase uptake of essential maternal and child clinical services through education of pregnant women, promotion of healthy behaviors, and follow-up and linkages to health services. There are three CHWs for each village of about 100–150 households: a male and female pair (binômes) of CHWs and one Animatrice de santé (continued)

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Box 4 (continued)

maternelle (ASM). Binômes primarily provide basic care and integrated community case management (ICCM) of childhood diseases, whereas the ASM is in charge of maternal and newborn health. Additionally, both cadres are responsible for family planning, promotion of healthy behaviors and primary prevention of NCDs including consuming a healthy diet, avoiding tobacco and excessive alcohol as well as exercising regularly (Perry et al. 2017; Egan et al. 2017). The community health system comprises the following integrated programs: the Community-based Nutrition Program (CBNP), Integrated Community Case Management (ICCM) program, the Community Maternal Newborn Health program, the Community-Based Provision of Family Planning program, and the Non-Communicable Diseases and HIV/AIDS program. Most are national in scope and intersectorial. For instance, the CBNP collaborates with the Ministry of Agriculture and other programs engage the Ministry of Education to improve nutrition and provide health education, respectively. Some similarly partner with nongovernmental organizations, for example, in implementing family (kitchen) gardens aimed at diversifying diets to address malnutrition. Several community groups likewise support the CHW program. Community hygiene clubs assist in issues such as clean water, sanitation in addition to promoting behavior change and healthy lifestyles. Umugoroba w’Ababyeyi (parents’ evening forum) are groups where parents discuss challenging subjects including health. CHWs mobilize community members and deliver health education during these forums. Achievements of the CHW program include, among others, reductions in childhood stunting and mortality also maternal mortality (Perry et al. 2017; Egan et al. 2017). Between 1995 and 2016, notable achievements include an increase in facility-based deliveries (from 45% to 69%), the introduction of maternal and child death audits at all health facilities, and an increase in vaccination coverage (from 80% to 90%). This is reflected in marked reduction in maternal and child mortality. The impact of the community program on diet-related noncommunicable diseases (DR-NCDs) has not yet been evaluated. In the country’s current Health Sector Strategic Plan, the government aims to enhance the capacity of CHWs in relation to strengthening programs for NCD control and increasing community education and awareness of dietary practices. The strategy’s goal is to reduce mortality due to NCDs in the under 40 years age group by 80% in 2024 (Republic of Rwanda 2018).

Box 5 Case Study: KwaZulu Natal, South Africa – “Operation Sukuma Sake”

“Operation Sukuma Sakhe” (which means “Let’s Stand Together and Build”) in KwaZulu-Natal province of South Africa is an initiative to eradicate (continued)

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Box 5 (continued)

poverty, food security, health (primarily HIV/AIDS and TB), and other social ills pertaining to gender inequality, substance abuse, and crime. It was launched in 2011 being adopted from the “War on Poverty” Campaign by President Mbeki in 2008. Partnerships exist between the government, local leaders, civil society, religious and vulnerable groups, the business sector, development partners, and the communities. Core service interventions are food security, grant access, skills development and job creation, education, health, utilities, housing, and specific programs to address social problems and promote good health. Improved food security, increased rates of exclusive breastfeeding, reduced stunting, and reduced rates of malnutrition-related fatality are major accomplishments of the program (OSS KZ-N).

Engaging with Planetary Health and the Social Determinants of Health Global, continental, and regional trade agreements are a key driver of economic development, but they do not guarantee equity among nations, nor do they systematically make provisions for State Parties to protect the health of their citizens. For example, it is not unheard of that countries trying to regulate the marketing of breastmilk substitutes or foods and nonalcoholic beverages to children are threatened with prospects of international legal challenges. In other instances, multinational corporations and agribusiness operators can mass-produce and offer nutrient-poor, highly processed foods at more affordable prices than fresh, minimally processed products supplied by local small-scale farmers, for example. Governments may not be able to offer subsidies that protect the livelihoods of smallholders, and where the large corporations contribute significantly to the economy through employment and tax contributions, imposing sanctions related food standards of marketing controls may be considered too costly by the government. As long as development is measured in monetary terms, public investment will tend to favor economic growth over equity, social cohesion, environmental conservation, nutritional wellbeing, and health.

Emerging Issues The coronavirus disease 2019 (COVID-19) pandemic has revealed a new facet of the vulnerability associated with the double burden of malnutrition. Clinical data analyzed so far have shown consistently that COVID-19 patients who are obese and have diabetes, hypertension, and cardiovascular disease are prone to severe illness and face increased risk of fatal outcomes. This heightens the urgent need to promote healthy diets that boost immunity and prevent obesity and associated NCDs.

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Similarly, the pandemic has underlined the vulnerability of communities living without access to running water and decent sanitation. These nutrition-sensitive WASH interventions should be part of the package for governments seeking to “build back better” after the pandemic. What is at its core a health emergency has had profound effects on agriculture, education, trade, and commerce and raised many questions about the future of food systems. In underscoring the interrelatedness between human and animal health and the environment, the pandemic offers an opportunity to reflect on how to reconstruct a food system that would provide access to affordable, healthy, and safe foods in a sustainable production and distribution framework. In addition to the stakeholders known to date as responsible for delivering nutrition-specific and nutrition-sensitive actions, new solutions require the collaboration of sectors dealing with, inter alia, climate change, forestry and natural resources, wildlife conservation and urban development, as well as indigenous communities.

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One Health and Emerging Zoonotic Diseases

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Framework, Integration, and Challenges Bruce A. Wilcox and Jennifer A. Steele

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zoonoses and Their Global Health Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causes and Drivers of Emerging Zoonoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ecology of the Human, Animal, and Environment Interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Social-Ecological Systems Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operationalizing and Validating One Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

One Health is a rapidly developing area of integrative research and intervention focused on zoonotic diseases in the context of the human, animal, and environment interface. Its central tenet is the inseparability of the health of humans, animals, and ecosystems. Spawned by the recognition of the need for greater collaboration between veterinary and human medicine, One Health also requires consideration of the social and ecological dimensions of health challenges in order to create an integrative framework beyond biomedicine, including natural and social sciences, as well as local and traditional knowledge and perspectives. One Health offers an opportunity to reconcile disciplinary silos in the health sciences, and its transdisciplinary imperative offers solutions to the limits of conventional thinking in biomedicine and public health. This chapter examines how different sectors address and define zoonoses and points to the need to develop a global prioritization scheme for surveillance, reporting, and assessment of endemic, epidemic, and pandemic zoonoses according to their relative health burdens. With its more holistic, social-ecological systems framing One Health B. A. Wilcox (*) · J. A. Steele Global Health Group International, Kasetsart University, Bangkok, Thailand e-mail: [email protected]; [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_88

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holds substantial promise toward reversing current trends in disease emergence. This chapter starts by distinguishing zoonoses and their emergence from other infectious diseases, as well as understanding how and why new zoonoses emerge to cause epidemics and even pandemics, previously controlled diseases reemerge, and “old” diseases persist. Finally, the chapter describes how One Health is operationalized as transdisciplinary implementation research, aimed at understanding and preventing disease emergence in the human-environment systems context, and the challenges as well as new opportunities for global health this presents. Keywords

One Health · Zoonotic disease · Infectious disease · Transdisciplinary · Pandemic · Epidemic

Introduction One Health and the associated challenges of emerging zoonotic diseases have become an area of substantial interest worldwide among governments, UN agencies, NGOs, and donors spanning the environment and development sectors, as well as human and animal medicine and public health. With the COVID-19 pandemic emerging zoonotic diseases arguably have become a preeminent global health issue, and along with this challenge that of implementing One Health interventions. One Health and its principle focus on emerging zoonotic diseases coincide with the meaning and scope of global health, particularly the emphasis on collaborative action with these specific characteristics (Beaglehole and Bonita 2010): (i) crossinstitutional; (ii) transnational; (iii) evidence based for policy drawing on a full range of disciplines; (iv) improvement of health and of health equity on this basis; (v) the full range of health promotion strategies directed at the underlying social, economic, environmental, and political determinants of health; and (vi) strengthening primary health care as the basis of all health systems aligned with Alma Ata Declaration’s health for all. One Health seeks to broaden research and intervention domains beyond the clinic and laboratory to local communities, particularly in agricultural landscape and natural ecosystem settings. Also, “health” rather than “medicine” recognizes zoonoses as not only a problem of understanding disease in a medical context, e.g., etiology, pathology, and treatment, but how diseases emerge and spread, how epidemics can be prevented, and when they occur (or where in the case of endemic zoonoses), they can be controlled, eliminated, or eradicated. Thus, hygiene, sanitation, and epidemiology, including social and environmental factors, all part of conventional public health practice, come into play. The need for the convergence of human and veterinary medicine with public health around the growing problem of new zoonotic diseases caused by novel agents, as well as reemerging and persistent endemic zoonotic diseases, including so-called

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neglected tropical diseases, is clearly compelling. Thus, interest in One Health has grown rapidly since its origination. It is increasingly is being cited as an important part of the solution to pandemic prevention and mitigation of the consequential health risks, as well as of local outbreaks and epidemics. Yet, this critical global health challenge is argued to require new thinking, knowledge, skills, and responses beyond those of conventional medicine, epidemiology, and public health (human and veterinary). In addition to the bridging of these disciplines, this arises from the environmental dimension. In particular, how changes in the environment—whether natural or anthropogenic—affect interactions between pathogens, vectors, and hosts in multiple and complex ways, making the emergence or decline of endemic, epidemic, and zoonotic diseases difficult to predict. This requires operationalizing One Health approaches employing integrative methods that enable transcending of disciplinary and sectoral barriers, full participation of stakeholders, and especially local communities who are most at risk and affected by outbreaks, and represent “first responders” (World Health Organization 2019). A significant gap also remains between these health fields and environmental sciences, in particular, ecology. Operationalizing One Health has proven difficult and, until recently, a translational framework according to its stated purpose of addressing zoonoses at “the human, animal, and environment interface,” has been lacking. While “interface” is generally understood to refer to where humans, domestic animals, and wildlife intersect, as well as to what happens and how, an associated framework has only recently begun to take shape. This is developing on the basis of similar problems in environmental management drawing on the so-called ecosystem approach and adaptive management, as employed in the environmental and natural resources fields (e.g., forestry, wildlife, fisheries, and watershed management). This area has evolved into a science of human–environmental systems with the aim of improving understanding and intervention outcomes. This includes understanding the patterns and cycles of societal and institutional changes in response to those of the environmental, including the natural or “ecological” subsystem components, being “managed” (Wilcox et al. 2019a). The goal of One Health and other efforts seeking to develop as an applied science and practice of managing zoonotic disease risk, including preventing local outbreaks, epidemics, and pandemics, is to integrate what are academically and professionally disparate fields toward a holistic science of human, animal, and ecosystem health. The challenge can perhaps best be described as similar to that addressed in the formative era of medical science when physiology and pathology emerged. Understanding how these human–environmental systems function “normally” in a healthy state—in which components and processes are regulated within certain boundaries—as distinct from when they are not, i.e., are pathological, is applicable. Understanding One Health and emerging zoonoses requires broadened perspectives on health and the integration of knowledge, methods, and skills spanning many disciplines and professions. This starts with understanding what distinguishes zoonoses and their emergence from other infectious diseases, including their global

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health burden. Also, understanding how and why new zoonoses emerge to cause epidemics and even pandemics, previously controlled diseases reemerge and “old” diseases persist, is essential. Finally, operationalizing One Health as a transdisciplinary approach aimed at understanding and preventing disease emergence in a human-environment systems context, challenges as well as presents new opportunities for global health. The following describes this history and background, how they apply to current understanding of the causes, thus prevention and control strategies of emerging and reemerging zoonoses. The chapter then describes integrative problem-framing employing evidence-based medicine and public health addressing emerging zoonoses. The fundamentals and core principles required are discussed, including the challenge of tying zoonoses prevention and control to current understanding of the role of ecosystem processes, biodiversity, and sustainability, along with their interrelationships. Mitigating zoonosis risk, the overarching goal of One Health interventions, is shown to require application of transdisciplinary research methods as the most critical of the fundamentals in terms of knowledge, tools, and skills. Recent developments in the operationalization of transdisciplinary research employing implementation science methods including logic models is briefly described. This includes development of the integrative research underway to address the challenge of emerging zoonoses, which aligns with global health as a field and mission.

Historical Background Interest in zoonoses increased dramatically with the emergence of exotic pathogens originating from wildlife including HIV, Ebola, SARS, highly pathogenic avian influenza subtype H5N1, and most recently, SARS-CoV-2 responsible for the COVID-19 pandemic. Although specific zoonoses such as malaria and rabies are familiar in name to everyone the concept of zoonoses, and especially that of the zoonotic disease emergence, is just as unfamiliar to most in the medical and health sciences as it is complex. Thus, as will be discussed in the next section, the simple definition of zoonoses as diseases transmitted between humans and animals, either direction, is not without ambiguities. The underlying characteristic common to most infectious diseases, including “old” human-to-human transmitted diseases such as measles and chicken pox, is their origination from animals (Wolfe et al. 2007). Yet the study of how human diseases emerge is relatively new, as is recognition of the need to better understand the role of the environment and ecosystem factors as a basis for validation of the One Health approach (Rabinowitz et al. 2013). This refocusing in the field of infectious diseases, which predominantly employs laboratory methods to understand molecular and cellular biological processes, to also consider these dynamics in the context of social and ecological processes has sown the seeds of a paradigm shift. This involves the recognition, at least tacitly, of how the emergence problem, thus research scope and interventions, require understanding phenomena well beyond medicine and

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public health. The identification of “factors of emergence” (Institute of Medicine 1992, 2003) as not only within the domain of biology, medicine, and epidemiology, but also the social sciences, environmental sciences, and ecology, represented a major break with tradition. It was suggested these factors acted as “forces” that operate on different elements of the process of emergence, shaping it. It further was recognized these could be distinguished by whether their primary role involved acquisition by humans and other animals or primarily affect the microbe’s spread through a population. Yet, the pathways by which “new” infectious agents/diseases emerge involve the complex interaction of microbes, their human and animal hosts, and the environment. This recognition of infectious disease emergence as a problem of understanding these three interdependent elements in the context of their shared environment, and as involving complex interactions, anticipated both the challenge and way of framing One Health research and interventions. Around the time of the close of the Institute of Medicine (IOM) project that had been spearheaded by the eminent microbiologist Joshua Lederberg, memorialized in one of the closing volumes, the concept of One Health emerged in the veterinary medicine community (Gibbs 2014). Veterinary medicine’s history is intertwined with that of zoonotic disease research dating to the early nineteenth century in Europe, of which the significance to human medicine awaited Koch’s and others’ identification of “germs” as disease agents later in the century. The term “zoonosis” and idea of “one medicine” was advanced around the same time by Rudolf Virchow, a renowned pioneering physician, scientist, and public health activist whose impact on modern medicine including social medicine was enormous (Schultz 2008). The conception of One Health, often described as inspired by one medicine, was a response to the emerging infectious disease crisis and recognition that the most serious threats involve agents transmitted from animals to humans. Not only was there this concern with regard to human disease and associated epidemics and pandemics, but more familiar to veterinary researchers were epizootics, the equivalent of epidemics in domestic and wild animals. Not only could these amplify and/ or transmit in the reverse directly impacting human population health, they could have enormous economic consequences for the livelihoods of farmers and pastoralists. Prior to this a number of research and intervention approaches seeking to combine human and animal medicine, often with environmental, wildlife conservation, and ecological perspectives, had been advocated by veterinary and medical researchers and practitioners (Gibbs 2014). This includes a variety of related and overlapping “communities of practice,” for example, “conservation medicine,” “medical ecology,” “ecohealth,” and “ecosystem health.” Like One Health, each of these self-identified as interdisciplinary, and most of them transdisciplinary. Yet, One Health’s concisely articulated zoonotic diseases research and intervention focus at “the human, animal, and environment interface” has allowed it to gain more traction among health scientists and practitioners. Moreover, among policymakers and donors the moniker “One Health” has become particularly appealing. This seems due to both its concisely defined focus, and perhaps, how it more simply connotes

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the idea of a single system, the total health of which depends on these three interacting components. In practice, however, understanding and explaining how such systems work, i.e., how the health of humans, animals, and their environment (or “ecosystem” which One Health researchers often describe is meant by “environment”), in relation to the phenomenon of zoonotic diseases, is complicated. It even goes beyond the biomedical and ecological sciences to include social and sustainability sciences, applying “complex systems science” (Wilcox et al. 2019a). The continual expansion of human populations since prehistoric times, and particularly since settled agriculture with domesticated animals exposing humans to their pathogens as well as those spilling over from wild animal populations, has incrementally added to the pathogen load through successive invasions by different agents over time. Episodic disease emergence events that had devastating consequences are documented to have occurred throughout modern as well as ancient history, such as the “Spanish flu” early last century and the bubonic plague of the 14th Century. As with the recent events, these accompanied periods of episodic bursts of geographic connectivity or globalization. In his classic book Plagues and Peoples historian William H. McNeill identified seven such prior emerging infectious disease eras in human history, as well as predicted the current era, largely framed as social-ecological phenomena (Table 1) (McNeill 1998). Today’s geographic connectivity, in terms of the possibilities for pathogen spread as well as economic and health system interdependencies and potential vulnerabilities, exists on an unprecedented scale. Emerging zoonotic pandemics can eclipse all other causes of morbidity and mortality. Indirect global health impacts due to the cascading follow-on societal impacts may unfold for many years following subsidence of the direct impacts. New thinking and, accordingly, new prevention and control approaches are required as Earth enters the Anthropocene: a new age in terms of globalization and geologic history as humans become the dominant force shaping its physicochemical and biotic character. This unavoidably demands what in sustainability science is called “adaptive governance,” viewing humans and environment as an integrated system (Folke et al. 2005). One Health can be understood as the extension of this to zoonotic diseases—“adaptive governance of zoonotic diseases.” That is, its elaboration on the basis of the interdependence of the health of humans and animals, including domestic livestock and wildlife, and of their urban, agricultural, and natural ecosystems. The idea of viewing human, animal, and ecosystem health as integrally tied together as a functional system has a long history in environmental science and conservation. This momentum has been building over decades around a paradigm that integrates human and animal medicine, and public health, along with environmental science. More recently, the above idea of humans and environment as an integrated system emerged as the dominant theme of a school of thought and practice in ecology, including advances in “systems ecology” drawing on complex systems science (Gunderson and Holling 2002).

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Table 1 Chronology of human–pathogen social ecology 100,000–40,000 BP human and parasites in balance • Humans were confined to a relatively narrow ecological niche 40,000–20,000 BP human global expansion • Humans expanded to all regions • Increased population size 20,000–10,000 BP agriculture settlements • Agricultural practices such as irrigation assisted the spread and maintenance of water borne diseases like schistosomiasis AD 3000 BC–500 urban settlements • For the first time the population sizes of settlements grew large enough (>100,000) to support disease requiring constant “crop” of susceptible people • Period that the urban–rural pattern of infectious disease dynamics emerged 500–1200 confluence of “civilized” disease pools for Eurasia • The major civilizations of Europe and Asia arose • The major cities were connected by trade routes allowing pathogens to spread 1500–1700 transoceanic exchanges • The “invasions” of European explorers and their pathogens led to the “waves” of epidemics and the destruction of societies of native people of America, Pacific Islands, and Australia 1700–1960s ecological impact of medical science and organization • Methods of hygiene and quarantine were developed early in this period, later vector control (via management of breeding habitat), pesticides, antimicrobial, antimalarial, and antihelminth medicines and vaccines were developed and employed with great success 1970s–transition to the Anthropocene • By the 1970s and 1980s, global environmental change added dramatically to the changing ecology of microbes, and “accelerated globalization of human disease ecologies” (Barrett et al. 1998) Based on McNeill 1998

Its applicability to the problem of emerging zoonoses began to be recognized about the same time One Health was introduced. This posed and continues to pose challenges to research, intervention, and policy, and especially the articulation of the scientific and evidence basis for principles and testable postulates. Primary among these are operationalization of transdisciplinary research as an approach to dealing with complex systems problems; that is, problems whose solutions require holistic thinking applied in real-world contexts (Hirsch Hadorn 2008). Transdisciplinarity in particular is contrary to the siloed, disciplinary, and reductionist thinking and practices that dominate academia, though its aim is to complement disciplinary and interdisciplinary research. Biomedical academic training and practice in clinical, laboratory, and even farm settings in the case of veterinary medicine, tends to engrain linear, reductionist thinking. This even holds for epidemiological studies and trials which purposely are designed to “control” for realworld complexity. This reflects the dominant reductionist approaches of biomedical research and its focus on understanding the disease process (pathogenesis) in the individual, complemented by “Koch’s postulates” (germ theory) marking the

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beginning of modern medicine. Similarly, epidemiological research predominantly focuses mechanistically on disease causation by cataloging the proximate risk factor behaviors and exposures. With the success of germ theory, the cornerstone of the reductionist biomedical model and its interpretation of infectious disease etiology, biomedical science’s growing dominance eclipsed broader perspectives and approaches to zoonotic disease control. This was reinforced by the discovery of the role of mosquitoes and other arthropods in disease transmission; thus, the potential for eliminating disease via vector control formed much of the basis of the astounding successes in control and elimination of infectious diseases throughout much of the twentieth century. However, this success led to a shift away from emphasizing field research and ecological understanding of disease transmission systems to top-down prevention/ control/elimination programs that were not locally self-sustaining. This shift along with complacency at the policy level, dwindling financial and political support, overreliance on insecticides, drug treatment, and the promise of vaccines yet developed coincided with the massive social and ecological transformation occurring globally (Gubler 1998; Wilcox and Gubler 2005). As powerful as the reductionist-deterministic approach has been, and remains in medicine and public health, evidence-based medicine and public health point to the limitations of “positivist” or “normal science” and the tendency for research and intervention projects to tacitly (non-critically) choose the conventional paradigm by default. Correspondingly, in relation to the problem of emerging infectious diseases, leading researchers—coincidental in timing but unrelated to the origination of One Health—called for a paradigm shift in infectious disease research toward a more ecologically informed view of the dynamic relationships among and between microbes, hosts, and their environments (Institute of Medicine 2006). Thus, One Health potentially is contributing to such a new paradigm as it views understanding, prevention, and control of emerging zoonoses as more than a biomedical and public health problem, but also an environmental and ecological one. Thus, it requires integrating theory, concepts, and practices from the biomedical and behavioral sciences, and epidemiology, with those from the ecological and social sciences And, in turn, under a broadened framework including analytical and practical methods that account for human, animal, and environment interfaces as “complex adaptive systems” (CAS), as described later in the chapter.

Zoonoses and Their Global Health Burden Around 1.400 species of human pathogens are known to exist, about 100 having been discovered since 1980. These include viruses, bacteria, fungi, protozoa, and helminths, with viruses being dominant among the newly emerging pathogens. Around 80% are “zoonoses,” broadly defined as diseases transmissible between animals (domestic and wildlife) and humans (Woolhouse and Gaunt 2007). The remainder are either “anthroponoses,” human-to-human transmitted pathogens, or

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“sapronoses,” species that have environmental reservoirs. Most sapronoses are bacteria, fungi, or protozoa, few of which are highly transmissible to humans, an important exception being Vibrio cholera, which is both sapronotic and zoonotic. Nearly all anthroponoses originated from a nonhuman vertebrate reservoir, although the original hosts of some have not been definitively determined (Wolfe et al. 2007). Anthroponoses range from diseases where humans are largely incidental hosts to those where animals are incidental hosts, called “reverse zoonoses” (e.g., Schistosoma haematobium, rubella virus, and Mycobacterium tuberculosis). Infectious disease categorization by transmission mode is fraught with such exceptions. Differences in international agencies’ “official” definition of zoonoses further adds to confusion. Box: Infectious Diseases by Category of Transmission

Zoonoses: Diseases transmissible between animals and humans Anthroponoses: Diseases transmissible between humans Sapronoses: Diseases transmissible to humans from environmental reservoirs The World Health Organization (WHO) limits zoonoses to “diseases or infections which are naturally transmitted between vertebrate animals and humans.” This excludes diseases caused by pathogens with invertebrate reservoirs, i.e., vector borne diseases, and those that involve vertebrate animals only as intermediate hosts with humans as the sole definitive host (helminths). These ambiguities around definitions of zoonoses reflect and reinforce different conceptions of them, thus research and intervention approaches. Particularly vexing are the distinct perspectives and agendas held by the agencies, researchers, and practitioners of human medicine and public health, in contrast to those in the animal health fields. One Health’s “human, animal, environment interface” and imperative to transcend disciplinary siloes, holds promise toward reconciling these differences. While interpenetration of veterinary and human medicine with environmental science can be seen as daunting, viewing zoonoses from an ecological perspective has the potential to resolve many of these issues. The different responsibilities and scopes of international agencies, in particular those prioritizing control of human disease versus animal, or livestock versus wildlife, will not dissolve. Indeed, such differences in scope and focus are necessary for depth in terms of detailed knowledge. But this has led to knowledge and data gaps, and less than rational prioritization in terms of vulnerability and at-risk populations. The most significant of these is the gap between human health and livestock health systems and agencies. The result is a huge deficit of attention and resources applied to the combined problem of human and animal infections in nearly a third of the world’s population, who happen to be smallholder “livestock keepers.” How zoonoses are defined and categorized affects how their global burden is determined, thus how they are prioritized. Expanding on the broad definition of zoonotic diseases above, three types of zoonotic transmission can be described:

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animal to human, human to animal, and zoonoses capable of transmitting in either direction (Pappas 2011). This accounts for the considerable direct and indirect health impacts of animal to animal transmitted disease. Moreover, as will be described later, it acknowledges the full spectrum of transmission modes in the coevolution of pathogens, hosts, and vectors from entirely natural transmission cycles to entirely human. Inclusive of all three types of transmission it recognizes the enormous impact of zoonotic pathogens on livestock among the most vulnerable human populations, as discussed further below. It also recognizes the growing problem of humans infecting wildlife that can disrupt natural or semi-natural ecosystems by impacting the population size or even totally eliminating species whose ecological role is critical to the functional integrity of an ecosystem. Zoonoses also frequently are described according to the ecosystem type in which the pathogen or parasite circulates. Synanthropic zoonoses cycle in urban (domestic) ecosystems, with domestic and synanthropic animals as the source of infection (e.g., urban rabies, cat scratch disease, and zoonotic ringworm). So-called “exoanthropic” zoonoses occur in sylvatic cycles in semi-natural or natural habitats (e.g., arboviruses including natural or introduced domestic variants of dengue and chikungunya viruses, wildlife rabies, Lyme disease, and tularemia). Some zoonoses circulate in both urban and natural ecosystems (e.g., yellow fever and Chagas disease). Zoonoses also are categorized according to their epidemiological characteristics, whether they are endemic, epidemic, emerging, or “old” zoonoses that originated as zoonoses but now spread almost entirely by human-to-human transmission. Emerging infectious diseases, that is, new diseases or geographically spreading diseases, are commonly distinguished from reemerging infectious diseases, previously existing diseases that were considered controlled but are now resurging epidemiologically (which often includes their geographic expansion). As with any classification, grouping human diseases in epidemiologic categories according to the source of infection has pitfalls. Some arthropod-borne diseases (urban yellow fever, dengue, epidemic typhus, tickborne relapsing fever, epidemic relapsing fever, and malaria) might be regarded as anthroponoses rather than zoonoses because the donor of the infectious blood for the vector is an infected human and not a vertebrate animal. However, the human infection is caused by an (invertebrate) animal in which the agent replicates, and the term zoonoses is thus preferred. HIV is of simian origin with sylvatic cycling among wild primates and accidental infection of humans who hunted or ate them; the human disease (AIDS) can thus be regarded as having been a zoonosis during the early phase of its emergence. Its pandemic emergence occured only after it gained sufficient ongoing human-tohuman transmission functionality allowing it to spread in the human population as a typical Anthroponosis. Finally, many zoonoses are diseases of livestock, which may be transmitted from and maintained in wild animals, in addition to causing disease in humans. This is of considerable importance to global health as livestock morbidity and mortality is highest among “livestock keepers,” including farmers and pastoralists. The livelihoods of an estimated 2.5 billion people depend upon livestock, including for their nutritional and caloric needs, which determine their health status. Thus, their

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resistance to the same or other infectious diseases, including the same zoonoses affecting their livestock, can be impaired. Livestock and human health in this case are tightly interdependent, and a very strong relationship exists between poverty, dependence on livestock, and zoonotic disease. Collectively, and in some cases individually, zoonoses have high impacts on humans, animals, and ecosystems in terms of human and animal morbidity and mortality, livelihoods, and the capacity to manage ecosystems sustainably (Table 2). Yet, accurate assessment of the extent of these impacts presents significant challenges. Estimating the true global burden of disease for zoonoses is hindered by the fact that zoonoses are widely unreported in poor countries and may be underreported relative to non-zoonotic diseases. Zoonoses known to have considerable burdens (e.g., rabies, echinococcosis, cysticercosis, leptospirosis, and brucellosis) are not reported in many countries. The global data are organized by diseases, not pathogens or transmission pathways. Thus, diarrheal diseases, with the highest impacts in poor countries, are combined in one category preventing identification of the zoonotic agent. Global hotspots have been identified where high densities of poor livestock keepers and high incidence of zoonoses converge. These represent about 1 billion people, the vast majority of which depend on livestock for up to half of their household income and much of their protein intake (Grace 2019). These hotspots are in the same regions experiencing the so-called livestock revolution—rapid growth in population, income, urbanization, and changing diets—expected to continue for decades to come. Specific reporting challenges to overcome include the World Health Organization (2020) and the World Organization for Animal Health (2020) reporting systems covering only about 10% of important zoonoses, lack of identification of the infection sources of important zoonoses (including tuberculosis, schistosomiasis, and gastrointestinal diseases), misdiagnosis of diseases, gross underestimation of the importance of endemic zoonoses, and lack of information on actual burden on the poor. In short, zoonotic diseases (and other diseases) are found to be massively underreported in developing countries, which is a major impediment to understanding prevalence and impacts of disease and developing appropriate control strategies. Endemic zoonoses are continually present to a greater or lesser degree in certain populations. Examples are cysticercosis, brucellosis, bovine tuberculosis, leptospirosis, and food-borne zoonoses. They are common in poor populations and are responsible for around a billion illnesses and millions of deaths every year (Table 2). However, endemic zoonoses have been neglected by international donors, standard setting, and research communities. Epidemic zoonoses typically cause outbreaks intermittently. Examples are anthrax, rabies, Rift Valley fever, and leishmaniasis. Endemic zoonoses may occur as outbreaks in naive populations or when triggered by events such as climate change, flooding, waning immunity, or concomitant hunger and disease. They typically have high temporal and spatial variability. Their overall impact in terms of morbidity, mortality, and production loss is much less than endemic zoonoses, but because they can “shock” systems they are often of high priority to farmers and decision-makers. They can also cause important

Disease/agent/taxon Enteric/gastro intestinal

Malaria

Cysticercosis

Dengue

HIV/AIDS*

Hepatitis E

Chagas (Human American trypanosomiasis)

1

2

3

4

5

6

7

Table 2 Significant zoonotic diseases

Vector-borne (mosquitoes) Direct (body fluids) Direct contact (feco-oral) Vector-borne (kissing bugs)

Vector-borne (mosquitoes) Indirect

Mode of transmission Direct and indirect

6–7 million

14 million

38 million

50 million

219 million 50 million

Morbidity 2 billion

14,000

300,000

690,000

20,000

50,000

Mortality 1.5 million 435,000

Forests, agriculture

Urban

Peri-urban, urban

Urban

Urban, agriculture

Peri-urban, urban

Ecosystem (urban, agriculture, and forest) Urban, agriculture

Wild and domestic ruminants

Wild pigs

Humans

Wild and domesticated pigs and cattle Old-world primates

Humans and macaques

Reservoir species Poultry, livestock, wild animals

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Leishmaniasis

Leptospirosis

Tuberculosis (zoonotic)

Brucellosis

Hanta virus Rabies Japanese encephalitis

9

10

11

12

13 14 15

Direct and indirect contact Indirect contact Direct Vector-borne (mosquitoes)

Indirect

Vector-borne (tsetse fly) Indirect contact

Indirect contact

175,000 70,000 40,000

500,000

554,500

1.7million

2million

3.5million

1750 70,000 11,000

25,000

100,000

123,000

47,000

3000

Agriculture Urban and forests Peri-urban, urban

Urban, agriculture

Peri-urban

Agriculture

Forests, peri-urban

Agriculture

Rodents Dogs, horses, bats, raccoons Pigs, ardeid birds

Dogs, cattle, pigs, deer, rodents, fish Horses, cattle, pigs, deer, wild mammals (badger) Pigs, sheep/goats

Cats, dogs, cattle, sheep/goats, deer, rodents Dogs, rodents

The diseases shown are a compilation from the following sources, and the chapter author’s judgement in combining evaluation criteria based on the differing perspectives of the sources: Grace et al. (2012); Wolfe et al. (2007); Goodwin et al. (2012); World Organization for Animal Health (2020); and World Health Organization (2020). *HIV/AIDS is the only “significant zoonotic disease” currently limited to human to human transmission

Q fever

8

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economic losses, often related to institutions’ reactions to the disease rather than the disease itself. Some diseases which now occur in endemic foci have in the past resulted in major outbreaks or epidemics. Emerging zoonoses newly appear in a population or have existed previously but are now rapidly increasing in incidence or geographical range. They are relatively rare, around 300 events in the last 70 years (Jones et al. 2008), and most are of minimal impact. The distinction between and relative impact of emerging diseases and endemic diseases is not straightforward. Diseases novel in one place may be endemic in other places, and burdens are not necessarily linked to the site of emergence So the mapped point of emergence may not correlate with impact. Also, donors and decision-makers are often more concerned about emerging diseases though the impacts on poor farmers are orders of magnitude less than those of endemic zoonoses. Old zoonoses are diseases originally zoonotic but are now spread mainly or entirely by human-to-human transmission (some with remaining zoonotic reservoirs). These include HIV/AIDS, influenza, malaria, measles, and dengue. These diseases have jumped species in multiple places and their burden is not linked to site of emergence. Their current order of magnitude is similar to that of the endemic zoonoses. Box: Different Epidemiologic Types of Zoonoses

Endemic zoonosis: A zoonotic disease constantly present in a population without immigration of infected individuals, i.e., repeated reintroduction of the disease agent Epidemic zoonosis: A zoonotic disease that occurs as sporadic outbreaks unpredictably in space, time, and severity Emerging zoonosis: A zoonotic disease newly appearing in a population or previously appearing but rapidly increasing in incidence or geographical range Old zoonosis: A zoonotic disease originally zoonotic but subsequently spread mainly or entirely by human-to-human transmission (some with remaining zoonotic reservoirs) Pandemic zoonosis: An emerging zoonotic disease whose geographic range extends to a wide area with unpredictable, and occasionally extreme, severity

The most significant reported zoonoses are responsible for an estimated 2.7 million human deaths and around 2.5 billion cases of human illness a year (Grace et al. 2012). Most of the top-ranked zoonoses have high impact on livestock, all have a wildlife interface, and all are amenable to agriculture-based interventions. Many significant zoonoses have important wildlife reservoirs across many regions, including gastrointestinal zoonoses, leptospirosis, rabies, leishmaniasis, toxoplasmosis, echinococcosis, Q fever, trypanosomiasis, and anthrax. Wildlife may play an important role in some epidemiological circumstances. For example, tuberculosis

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associated with a number of wildlife species in conservation areas in Tanzania and South Africa, and brucellosis associated with buffaloes, and hepatitis E and cysticercosis with wild pigs. Where a wildlife interface exists, zoonoses control is much more complex. Other zoonoses with an important wildlife interface include Chagas disease, chikungunya, Ebola, hantavirus disease, avian influenza, psittacosis, and Rift Valley fever. The importance of wildlife reservoirs in zoonotic disease emergence is exemplified by influenza viruses. The cause of seasonal epidemic zoonoses and pandemic zoonoses, influenza viruses episodically rival other zoonoses with the highest rates of morbidity and mortality. In fact, their episodic character is a consequence of ongoing influenza virus transmission between wild and domestic animals and humans. This interspecies exchange and thus viral genome reassortment opportunities allow influenza A viruses (Fig. 1), the most epidemiologically significant category of influenza, to always keep ahead of the collective immunity of human populations, i.e., herd immunity, whether through vaccination or exposure. The relative size of the silhouetted figures in Fig. 1 belies the extent of natural host reservoir consisting of an enormous number and geographic range of aquatic birds and their extraordinarily unique ecology. This involves migratory, feeding, and defecation habits and species’ geographic ranges spanning all continents and most of the Northern and Southern Hemispheres, including seasonally frozen shallow water bodies in the arctic tundra to rice paddies in the tropics. This system provides ideal conditions for viral persistence and continual evolutionary diversification and adaption and, thus, human domestication of some of the most common and geographically ubiquitous species of new influenza virus variants. This represents an incalculably large and genetically diverse reservoir of influenza viruses that circulate as commensals, i.e., asymptomatically as part of the microbiome of aquatic birds worldwide. Fig. 1 “Wheel of influenza” Aquatic birds are the natural reservoir for all subtypes of influenza A viruses. Dashed lines indicate transmission continually occurs between the taxa indicated but the specific route(s) are not known. Transmission of influenza A viruses is known between pigs and humans (solid line), with the former acting as a bridge host. This is facilitated by adaptation of influenza A viruses to swine upper respiratory cells with similar binding properties to those of humans. (Source: Yoon et al. 2014)

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Pandemic zoonoses can be considered a category of emerging zoonoses, the severity of which, episodically at least, is comparable to annual morbidity and mortality rates of most of the zoonoses listed in Table 2. However, as in the case of HIV/AIDS, whether during the initial pandemic phase and/or subsequently as an endemic anthroponosis, influenzas contribute substantially to the global health burden of emerging zoonoses. As with the case of some historic pandemics, such as the 1918 pandemic Spanish Flu, the impact of influenzas measured in mortality, as well as politically and economically, can be inestimable. Zoonotic disease pandemic severity at times far exceeds expectations based on assumptions (i.e., standard Gaussian probability distribution rather than a “Fat Tail” distribution actually observed historically) upon which risk assessment and predictive models typically are based. Influenza A viruses are the most commonly known transmissible zoonoses, responsible not only for seasonal flu but having been the cause of most of the zoonotic pandemics in the past 100 years. These include the Spanish Flu, Asian Flu in 1957, Hong Kong Flu in 1968, highly pathogenic avian influenza subtype H5N1 in 2003, and Swine Flu in 2009, in addition to the H5N1 pandemic. The Spanish Flu was the most severe pandemic of the twentieth century, causing an estimated 50–100 million deaths. The H5N1 pandemic resulted in a similar number of poultry deaths, though it caused a limited number of human cases and fatalities. It continues to circulate as an endemic zoonosis in about 30 countries, regularly causing outbreaks in a variety of domestic and wild birds, and occasionally other animals. More concerning is the possibility of it acquiring through genetic reassortment the capability of sustained human-to-human transmission. The 2009 Swine Flu pandemic resulted in under a million deaths and is considered relatively mild (Centers for Disease Control 2020). The SARS and COVID-19 events broke the historic pattern of pandemics being caused by highly transmissible respiratory diseases originating from an avian host. This may represent the beginning of a new phase in the current Anthropocene era in which zoonoses increasingly emerge as a result of environmental, social, and behavioral changes in urban ecosystems.

Causes and Drivers of Emerging Zoonoses The historical framing of emerging infectious diseases shown in Table 1 centers on the idea of episodic social and ecological imbalances affecting the relationship between humans and their microbial symbionts (McNeill 1998). With the advent of the current era of global disease emergence the relationship of these imbalances with ecological and evolutionary instabilities was found crucial to understanding the causes and drivers of emergence (Lederberg 2000). This challenged the conventionally reductionist biomedical framing of infectious disease etiology and epidemiology. It prompted the establishment of “emerging infectious diseases” (EID) as a new field of research and a reconceptualization of the human–microbe relationship. This began with an inaugural expert panel and report (Institute of Medicine 1992) that first recognized “emerging infections” as a new category of global health threat.

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While it dealt only with human diseases in the USA, this seminal report introduced the idea of disease agent categorization by “causes of emergence,” a departure from the convention of categorization by type of agent (i.e., viral, bacterial, protozoal, helminth, or fungal). A series of expert panel studies followed under the auspices of the Institute of Medicine (IOM), culminating in a proposed overarching interdisciplinary causal framework and a model to guide future research (Institute of Medicine 2003). By this time, the IOM project had broadened its scope to “emerging infectious diseases” globally, including “emerging zoonoses,” and recognized the distinction between animal and human disease research community perspectives. The IOM project focus remained human disease, though of zoonotic origin, defining emerging infectious diseases as “either a newly recognized, clinically distinct infectious disease, or a known infectious disease whose reported incidence is increasing in a given place or among a specific population.” A capstone IOM panel report (Institute of Medicine 2003) reframed and updated their 1992 assessment, recategorizing EID according to four broad categories: genetic and biological factors; physical environmental factors; ecological factors; and social, political, and economic factors. Thirteen “individual factors” originally were described as belonging to one or more of these broad categories (Table 3), to which an additional factor can now justifiably be added, “Commodification of the health system.” The financial investment and potential gains offered by therapeutic drugs and vaccines—with a retail customer base in the billions such as for vaccines against SARS-CoV-2—are enormous and include many medical researchers and global health philanthropists as beneficiaries. This has introduced comparably large biases and potential conflicts of interest further disincentivizing investment in research and interventions employing integrated, holistic, emerging zoonoses risk prevention strategies. Another emergence factor for which developments subsequent to the 2003 IOM report require modification is “lack of political will and cooperation,” originally “lack of political will.” Besides the continuation of a political environment representing an insufficient commitment on the part of advantaged towards disadvantaged regions, within and between countries, changed political circumstances have substantially negatively impacted international cooperation. This is most apparent in the breakdown of what for many decades had been a remarkably effective outbreak intervention capability coordinated by the World Health Organization with the technical support of US Centers for Disease Control (CDC). As described below, the lack of international cooperation in the case of COVID-19 stands in sharp contrast to that of the rapid mobilization of outbreak investigation teams that prevented the 2002–2004 SARS pandemic from becoming far more severe than it could have been. The penultimate factor in Table 3, intentional or accidental pathogen release, was given the more limited name “intent to harm” in the 2003 IOM report. Since that assessment, biological weapons research and development and the number of laboratories maintaining and/or genetically manipulating highly pathogenic microbes has grown dramatically. This includes the advent of “gain of function” research. Controversial for its potential risk, this involves genetically engineering

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Table 3 Factors in emergence Emergence factor Microbial adaptation and change

Human susceptibility to infection

Climate and weather

Changing ecosystems

Economic development and land use

Human demographics and behavior

Technology and industry

International travel and commerce Breakdown of public health measures

Poverty and inequality

War and famine

Lack of political will and cooperation

Associated conditions undergoing dramatic changes in recent decades Extremely rapid rates of replication, generation of novel genetic variation via mutation, and the capacity for interspecific genetic exchange provides microbes with tremendous evolutionary potential for adaptation against drug therapies and vaccines Human and animal immune systems normally are extremely adept in providing barriers to infection. Immunity varies substantially among and within individuals over time depending on innate characteristics, nutrition, and psychosocial circumstances Meteorological conditions, including seasonality play an important role in determining the growth and reproduction of reservoir hosts, vectors, and pathogens/parasites, thus strongly influence infectious disease dynamics Microbes, together with their hosts and/or vectors are coevolving complexes embedded within ecosystems that not only naturally undergo continual change, but vastly more so due to human action, locally to globally Changes in land use, e.g., urbanization, agricultural intensification, and deforestation that alter habitat, thus host reservoir and/or vector populations and disease transmission dynamics Changing age structure, density, and movement of human populations, along with that of individual’s risk behavior, chronic disease incidence, particularly in relation to urbanization, profoundly affect infectious disease transmission Medical technology including blood transfusions, organ and tissue transplants, animal husbandry and food production, including the use of antimicrobials, and antimicrobial resistant pathogen strains Air, sea, and ground transport disseminate hosts (including infected humans), vectors, and pathogens widely despite biosecurity measures Failure of public health infrastructure to keep up with growing population and health challenges, including chronic and infectious diseases, drug therapy coverage requirements, development of new vaccines, and nosocomial infections Trans- and intranational disparities in income and wealth, and social inequality contribute to greater disease risk for those whose health access already is compromised, as well as emerging disease risk for the population in general Violent conflict and famine are linked to each other and to the spread of infectious diseases. Geographic displacement, including migration due to conflict, commonly are associated with malnutrition, poor hygiene, lack of sanitation, and adequate housing A lack of commitment to political action by more affluent regions toward disadvantaged regions and international cooperation impedes the formulation and implementation of sustainable (continued)

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Table 3 (continued) Emergence factor

Intentional or accidental pathogen release

Commodification of the health system

Associated conditions undergoing dramatic changes in recent decades prevention and control strategies, as well as the rapid mobilization of outbreak investigation teams to limit epidemics and pandemics Known pathogens, “unknown” pathogens purposely or incidentally “created” in laboratories, and purposely weaponized biological agents increasingly present a significant global health threat. This threat is increasing substantially along with that of domestic and international conflicts, and due to the expansion of research activity involving genetic manipulation of pathogens with “intent to harm” or “innocent” research purposes Reduced financial risk and high reward potential of drugs and vaccines, whose beneficiaries include medical researchers and institutions, biases against investment in emerging disease risk prevention research and intervention, generally not commercializable

Factors contributing to environmental change in which infectious diseases can emerge and become established in society. Modified and updated from Institute of Medicine (2003)

and/or artificially selecting microbes with the intent of creating new variants of increased transmissibility and/or virulence. The coinciding of factors within the four categories, i.e., converging in space and time, is described as “the convergence model” of disease emergence. This is represented as the area of overlap in a Venn diagram of overlapping squares (rather than circles) referred to as a “black box” (IOM 2003), suggesting the mechanisms are unknown. This reflects an absence of knowledge of the mechanistic details of causality and the complexity of EID problem, common themes expressed throughout the IOM Panel reports. An important step toward filling this knowledge gap, including addressing the issue of “complexity,” subsequently was addressed by framing the emergence process from a global environmental change perspective. Building on the observation that different emerging vector-borne diseases tend to be associated with major land use change categories (Gubler 1998), a framework borrowing this categorization from earth sciences was developed. This included the hierarchical, cross-scale (macro to micro time and space scale) characterization of “social-ecological systems” developed on the basis of advances in systems ecology applied to complexity (Wilcox and Gubler 2005). The resulting schema (Fig. 2), described as an emerging infectious disease research “blue print”, has been found helpful for research and intervention policy and project design. This schema employs the generally adopted view of human-environment interactions in which the impact of human population and technology is taken as the driving force, or the ultimate cause of global and regional change (Wilcox and Gubler 2005). Here, the combination of population growth, technological capacity, and resource consumption act as system drivers. These and “mitigating” factors are in turn influenced by “human behavior,” referring to patterns of actions and the rationales giving rise to them. These forces and their effects on ecosystems represent

Landscape level

Natural community level

• • • • •

Fig. 2 (continued)

Population level

Urbanization

Agricultural intensification (including food production) Water diversion and irrigation Vector and reservoir expansion Concentration/mixing, wild/domestic species Bushmeat trade Agrochemical accumulation

Species’ ecology-evolutionary dynamics

• • • • •

Disease emergence

• •

•

Forest habitat alteration Biotic collapse and hyperabundance of actual and potential vector &reservoir species Decline of natural pathogen regulation capacity Human settlement, encroachment, increasing humanwildlife contact

Natural ecosystem

Feral reservoir species Human encroachment

Emergence processes of host-parasite biology • Host switching (host novelty) • Breaching of pathogen persistence thresholds • Transmission amplification and genetic exchange (pathogen novelty)

Host-pathogen dynamics

Human-natural environment continuum

Opportunistic habitat expansion/ecological release (domestication/transport)

Human ecosystem

Vector/reservoir Wildlife

Increasing city or peri-urban settlement population size Suburban and peri-urban encroachment into wildlands Settlement coalescence Rapid long distance transport Habitat expansion/creation for domestic or peridomestic hosts & vectors

Regional environmental change

Population growth, technology and consumption

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the “ecological factors” in social-ecological systems, while human behavior, including institutional, represents the “social factors.” Collectively, these dynamics occur on the scale of molecules and cells to regional ecosystems, that is, human-natural systems. This represents genome level changes in parasites, pathogens, and hosts, population level changes, and diminished biodiversity at the “natural community level,” thus reduction in the ecosystem’s natural capacity to regulate these dynamics within “normal” bounds. Changes in “public health infrastructure,” as shown in the figure, largely amount to divestment in locally, ecologically-based strategies as described previously. For example, public health programs that had successfully controlled dengue and other old diseases were, in effect, disease management at the “landscape level,” through improved hygiene and sanitation in urban ecosystems. This shift to increased reliance on “quick-fix” solutions based on drugs, vaccines, and pesticides unwittingly coincided with the historically unprecedented accelerating rate and scale of regional environmental change. This left countries and international agencies alike unprepared as the current EID crisis began to unfold. It can be seen that zoonotic disease emergence involves a multitude of causal factors that operate across spatial and temporal scales. The most distal being the macrolevel factors that operate on a large spatial scale (>1000’s of km2) and slow temporal scale (10’s to 100’s of years), thus are “slow variables.” Landscapes are ecologically defined as “~km2 mosaics” of land cover types, themselves consisting of heterogeneous arrays of “ecotopes” (smallest mappable units), each supporting a unique array of aerially visible features and habitat types. The latter are defined by the species’ assemblages adapted to them, representing distinct “ecological communities.” Community-level, population-level, and finally, individual organisms’ (hosts’ and pathogens’) dynamics acting as “fast variables” are, successively, more proximal causal factors associated with what specifically is referred to as the “emergence process.” The latter include infection, immune response, and potentially, pathogenicity. The entities at each level are “embedded” in and dynamically constrained by the larger entity, characteristic of complex adaptive systems, as described in more detail below. Thus, zoonotic disease emergence is ultimately driven by forces operating on a macroscale that cascade through ä Fig. 2 Causal schema of the global change, cross-scale process that drives zoonoses emergence The pattern of change characteristically involves three types of land use change: urbanization, agricultural intensification, and deforestation (or degradation of natural ecosystems in general). The associated alteration of landscape, i.e., the changes in mosaic pattern as seen from the air, produces compositional changes at the ecological community level (assemblages of species and their relative abundances). This shifting and mixing of species across the natural (sylvatic) to human (domestic) ecosystem continuum includes that of opportunistic wildlife such as some rodents and bloodsucking arthropods (mosquitoes, ticks, midges, and others), and feral species such as domestic pigs, goats, rats, mice, dogs, and cats. The altered ecological and evolutionary dynamics encompass population changes in hosts and parasites (and pathogens), including densities of the former that exceed the threshold required, given the latter’s R0 (described in the text and Box below) for onward transmission. (Sources: Wilcox and Colwell (2005); Wilcox and Gubler (2005))

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mesoscale forces to those operating on the microscale. At this scale, the critical forces are those that link infection in reservoir hosts, disease agents, and vectors to the determinants of recipient hosts’ exposure and susceptibility. Shortly following the establishment of emerging infectious diseases as a new field, two of the most severe pandemics to occur since the HIV/AIDS pandemic were SARS and H5N1 in 2002 and 2003, respectively. This provided the first opportunity to apply new thinking and tools to begin to elucidate the details of the pandemic emergence process, shedding light on the above-mentioned black box. A detailed synthesis was thus made possible, drawing on these, and other important emerging zoonoses. This allowed the deconstruction of the emergence process into stages as follows (Childs et al. 2007). First, two transition stages found common to, and required for all disease emergence events, i.e., local outbreaks, include: (1) human contact with the infectious agent and (2) cross-species transmission of the agent. Second, two transition stages, unavailable to many zoonotic pathogens, thus rare, and not required for emergence but prerequisite for the pandemic emergence of a pathogen include: (3) sustained human-to-human transmission and (4) genetic adaptation to the human host (see Box: Zoonosis emergence process). Box: Zoonosis Emergence Process

The process of zoonotic disease emergence involves four transition stages. The first two represent reiterative events: (1) interaction (contact) between infectious propagules originating from the wildlife population (donor host) and individuals of a susceptible host (recipient host), and (2) cross-species transmission (spillover) that involves the infectious cycle within the recipient host. These first two transitions may require a mediating host (bridge host) such as an arthropod vector or an intermediary vertebrate host (e.g., civet cat in the case of the SARS Cov 1) to which pathogen adaptation often will occur. Contact and spillover are necessary to result in an epidemic zoonosis but not sufficient to produce a pandemic zoonosis. This requires two other transitions on the emergence pathway: (3) sustained intra-host transmission of the zoonotic pathogen, and (4) adaptation to humans (e.g., SARS coronavirus). Whether disease emergence results in a local outbreak, a regional epidemic, or a pandemic depends on the nature of the pathogen and the influence of modifying factors. There are at least three points along the emergence pathway where failure is the rule, and success thought to be extremely rare. These are (i) failure to initiate cross-species infection following exposures, (ii) failure to generate additional infections within the recipient host population, and (iii) epidemic fade out when human-to-human transmission falls below 1 (R0 < 1). Population density and/or social connectivity are among the most important modifying factors in the initial transition to sustained intra-host transmission, and largely explain the current trend of increasing emerging zoonoses and challenge to preventing pandemic zoonoses.

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Step 2 of the first transition stage requires a pathogen’s acquisition of human infection and human-to-human transmission functionality, allowing a species barrier to be breached, referred to as “spillover.” Spillover actually is exceedingly unlikely as the potential disease agent must overcome a hierarchical series of barriers to cause spillover infections (Plowright et al. 2017). This involves an ongoing, repetitive exposure process that drives the crossing of the species barrier in four phases: (1) initial exposure of the potential hosts; (2) subsequent cross-species infection (e.g., determined by degree of host specificity); (3) onward transmission of the novel pathogen within the focal population, where R0 > 1; and (4) spread of disease between host populations. Each of these phases presents multiple barriers to a pathogen that separate a reservoir and recipient host, thus occurs only when each successive barrier aligns in space and time. This rarity and the highly dynamic spatiotemporal nature of zoonotic spillover events represent a major limitation to their epidemiological investigation (Plowright et al. 2017). Spillover events that involve highly transmissible pathogens (R0 > 1) are extremely challenging to investigate. Once detected, human cases typically are far removed from the spillover event in terms of locality, time, and circumstances. This is the case for Ebola virus, and SARS-CoV-1 and SARS-CoV-2, reponsible for SARS and Covid-19. In the case of pathogens with R0 < 0, such as Nipah, MERS, and H5N1, the opposite is true. While H5N1’s “gain of function” via genetic adaptation allowed it to breach the species barrier separating domestic poultry and wild waterfowl, adaptation for efficient human-to-human transmission has not occurred, except artificially in a biosecurity laboratory.

Box: Definitions of Key Zoonotic Disease Emergence Concepts

Host: An organism that harbors a parasite or pathogen. A person or other living organism that is susceptible to or harbors an infectious agent under natural conditions Reservoir: A host that acts as a reservoir of infection, a carrier population that harbors pathogenic organisms without injury to itself and serves as a source from which other individuals can be infected Spillover (host switching): An event when a pathogen that jumps from one host species to infect another species, which may or may not lead to disease emergence Basic or intrinsic, rate of infection, R0: The number of infective hosts (secondary infections) that results from a single infective host (primary infection) assuming a population consists entirely of susceptible individuals Transmission threshold or critical population size, Pc: The minimum host population size (i.e., density of susceptible individuals), given a pathogen’s basic reproductive rate, R0, that allows the pathogen population to maintain itself (continued)

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Herd immunity: The resistance of a host population to the continued transmission of an infectious agent, or invasion by an infectious agent (ongoing disease transmission in the host), due to a population’s proportion of individuals immune to a pathogen being above the critical population size, Pc. Host competence: The degree to which a host can be infected and maintain a high viremia/parasitemia/bacteriemia that allows for transmission to vectors or the next host

Gain of function in this regard requires that genomic change(s) (modification of genes, or insertion or deletion of genes) occurred in a microbe’s lineage resulting in the expression of a new trait that allows the microbe to, in effect, colonize (or more readily colonize) a particular host population. In the case, for example, of an influenza or coronavirus, this involves change(s) in key proteins, due to changes in nucleotide bases that code for proteins, that allow a virus particle to more readily attached to and insert its genetic material into a host cell, take over the hosts cells’ genetic machinery, replicate, and cause the release of new virus particles from the cell en masse. It may also include changes that improve a microbes’ capacity to disperse, remain viable, and/or and be transported, or in the case of some bacteria, improve motility to transport itself to infect a new host individual. Gain of function can occur either through natural selection or artificial selection in a natural or domestic environment, which in the latter case is how for thousands of years humans domesticated wild species and “improved” the resulting cultivated varieties of plants and animals. Domestic environments where zoonotic pathogen gain of function takes place include farms or other livestock breeding and maintenance facilities, wet markets where wild and domestic animals and products are traded, and research laboratories. These domestic environments provide the most ideal circumstances for the mixing and recombination of genotypes, thus making the occurrence of a novel genetic variant vastly more probable than in nature. Such new variants that happen to include a gain of function trait also have a much greater likelihood of incidental infection and onward transmission in a new host species. Also, the probability this will be a human or domestic animal population is far higher than in a natural setting simply due to the opportunities for repeated close contact between individuals, including of different species, and the relatively high population sizes and densities. As described in detail by Childs et al. (2007), the outbreak and subsequent pandemic of severe acute respiratory syndrome (SARS) beginning in 2002 in Guangdong Province in Southern China, was the most severe and readily transmittable zoonosis to emerge in the twenty-first century. The infectious agent was found to be a previously unknown member of the Coronavirus genus, given the name SARS-CoV (subsequently also referred to as SARS-CoV-1), for which the natural reservoir hosts were determined to be bats of the genus Rhinolophus, commonly found roosting in caves in Southern China as well as elsewhere in Asia. Genome sequence analysis determined that palm civets captured for the food market

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acted as a bridge host infecting animal traders and handlers who transported or stored multiple wildlife species in cages typically piled and transported together. The animal and human cases’ SARS-CoV genetic sequences were found to be almost identical, at 99.8% sequence identity. Yet, a sequence segment deletion event occurred during adaptation in the new human host quite early. Also, evidence suggests transmission had occurred via all possible routes, animal to human, human to human, animal to animal, and human to animal, with a number of the species found to susceptible, asymptomatic. The high human case fatality rate and rapid global spread led to an urgent response coordinated by World Health Organization. Rapid identification of index cases in Guangdong Province, contact tracing, and quarantine allowed the pandemic to be curtailed early despite having spread to 30 different countries in less than 5 months, resulting in about 8000 cases and fewer than 800 fatalities. A single human individual who infected other travelers in a Hong Kong hotel during international transit was mainly responsible for the spread of SARS worldwide. Such so-called “super spreaders” contribute to secondary infections far out of proportion to the average number of secondary infections generated by one infected individual (R0). The R0 was relatively moderate for SARS-CoV-1, estimated at 2.2–3.7, compared to that of influenza viruses with R0 values in the range of 5–25. In areas during disease outbreaks with moderate to large numbers of cases super spreader events play a pivotal role, as was reported for the COVID19 pandemic. Although the ancestry of the causative agent of COVID-19, SARS-CoV-2, is the same as SARS-CoV-1, its emergence pathway has not been determined. However, the relatively large genetic distance as shown by its sequence identity between it and its presumed ancestral “wild type” virus found in Rhinolophus bats suggests it either had been circulating in another animal host or humans long before it was first detected in Wuhan, China. Alternatively, other factors may have contributed to insertions and deletions of sequence segments at a far higher rate than is known to typically occur naturally. Unlike with SARS, political circumstances prevented a rapid response coordinated by an international team for the COVID-19 pandemic. Neither “index cases” nor “early clusters” have been identified. Thus, gene sequence data allowing the origin, pathway, and cause(s) of the outbreak remain to be conclusively determined. However, the main causes of the severity of the pandemic are understood. Besides the lack of a coordinated rapid response at the time of the outbreak, at least three epidemiological and biological factors played an important role. An apparently higher R0 and proportion of asymptomatic infections, resulting in “silent transmission,” and a suite of novel and variable symptoms reflecting a more complex and unfamiliar pathology. Related to this is the role of comorbidities, particularly chronic diseases. Also, it appears unlikely SARS-CoV-2 could have caused nearly as apparently severe a pandemic were it not for the historically high incidence of chronic disease comorbidities. Thus, the COVID-19 pandemic is the first in which chronic disease incidence has been a significant causal factor. This uniqueness extends to SARS-CoV-2’s genetic divergence from its known closest wild relative, and having acquired genes not found in the wild type virus’s genome, associated

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with functions enhancing its transmissibility and virulence. Finally, failure to curtail circulation early provided the opportunity for the virus to diversify genetically, posing a significant challenge to vaccine development and efficacy. Deconstruction of the emergence process has been particularly revealing in the case of the 2003–2004 H5N1 pandemic. Although the virus did not breach the animal-to-human species barrier, it offers numerous insights into not only biological but also social and institutional emergence factors, and the macroscale to microscale linkages. While the H5N1 virus did not gain sustained human-tohuman transmission capability, it has nonetheless resulted in several hundred human fatalities, and is the most economically damaging and geographically extensive pandemic after HIV/AIDS in the four-decade period leading up to COVID-19. H5N1’s emergence exemplifies how experts and government authorities either ignored or otherwise were oblivious to the changes taking place regionally. The initial outbreak in Hong Kong, where H5N1 was first isolated, optimistically but mistakenly was thought to have been successfully eliminated by massive poultry culling in 1998. That the capstone IOM report lauded this containment as having eliminated the H5N1 threat attests to the limitations of expert knowledge is dealing with complex adaptive systems (CAS). Thus, the H5N1 pandemic could be described as a “black swan” or, as it is described in the context of the coevolving nature of social-ecological systems, an “ecological surprise” (Saksena et al. 2015): “a cognitive disagreement between ecosystem behavior and a priori expectations.” H5N1 also can be seen as an exemplary case of a One Health problem, employing the social-ecological systems framework (Wilcox et al.2019a). It demonstrates how zoonotic disease emergence is intertwined with a multitude of issues related to the intersection of environment, development, and public health—where transboundary factors/ play a role in virus transmission—thus, definitively a global health challenge. H5N1 is now part of a new social-ecological system regime represented as a regional agroecosystem distinct from that previously, structurally and functionally, including a number of less desirable social, economic, political, environmental, conservation, and public health features. Prominently, this includes a less diversified poultry production sector now dominated by large agribusinesses, and increased dependence on agrichemicals, drugs, and vaccines. Retrospective analysis (Saksena et al. 2015) indicates specifically how experts and government authorities either ignored or otherwise were oblivious to the change (in the large, slow variables) taking place regionally. A key challenge is improving understanding of how macroscale and microscale emergence processes are linked. In the case of influenza viruses in general, whose natural hosts are water birds, this is illustrated in Fig. 3. On the macroscale, growth of industrial-scale poultry operations in China was occuring while poultry production together with a peri-urban landscape transformation was taking place in geographically contiguous Vietnam. These changes were pushed by global forces, driven by the economic opportunity presented by the growing export market. The operations in China, which included breeding facilities with up to a million birds, constituted a crucible of genetic innovation (a small, fast variable). Among the untold new microbial variants

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Fig. 3 Linking microscale to macroscale emergence processes This schema illustrates with avian influenza as a case example, the sequence of donor to recipient host species transmission events involving ecological and evolutionary changes. These create opportunities for cross-species transmission, with the potential for a pathogen to breach the species barrier. The changes are driven by mesoscale and macroscale social and ecological factors associated with agricultural intensification. In A, the three sets of overlapping circles (i–iii) represent three historic phases in agricultural development. The sizes of the circles represent human, associated livestock, and wildlife populations. Their degree of overlap represents the potential exposure between species. Open arrows represent external forces of ecological or evolutionary change. The solid arrows represent cross-species transmission of the virus from a wild donor reservoir (e.g., wild waterfowl) or a domestic donor host (e.g., free-grazing ducks). The sets of circles illustrate the following: The first set (i) represents the period of human history (most of Southeast Asia until relatively recently) when humans and their livestock populations were small and isolated in pockets surrounded by nature. The second set (ii) represents the transitional phase to modern industrial agriculture during in which agricultural landscapes are approaching the areal extent of natural landscapes, and their human and livestock population sizes begin to exceed those of wild animals. The third set (iii) represents the present phase of extensive and intensive agricultural landscapes, continually encroaching upon the remnant and increasingly degraded fragments of natural landscapes. In B, the sequence (i–vii) represents events leading to exposure and infection of H5N1, and the potential for sustained human–human transmission: (i) spillover of low pathogenic avian influenza (LPAI) variants from wild to domesticated avian species; (ii) reassortment of different strains among species resulting in increased pathogenicity; (iii) onward transmission of the highly pathogenic virus strain in wet markets and continued transmission among poultry, including (iv) spill-back to wild avian species and (v) dispersal via human transport between wet markets and of duck flocks transported for free grazing on rice paddies, with sporadic human infections (most

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generated, H5N1 variants sporadically and unpredictably spilled south over the China–Vietnam border via local trade networks and migrating ducks (another small, fast variable). Peri-urban areas of Vietnam with higher chicken density and duck and geese flock size diversities than rural and urban areas were found to be hotspots of emergence risk. These were mappable landscape zones where intensive and extensive forms of poultry production overlap. The geographic expansion of this mode of intensification spanned Vietnam from north with the south and into Cambodia, Laos, and Thailand via the Mekong corridor—the main path followed by the virus as it spread through mainland Southeast Asia, then onward, globally, carried by migratory waterfowl. This might have been of limited consequence, as it was geographically speaking, with the contained 1998 Hong Kong outbreak where this agroecosystem’s insularity helped prevent H5N1’s escape to the south and ultimately globally. But it was the ongoing transformation, which is retrospectively observable via satellite and on the ground. This represented “an accident waiting to happen,” which did as evidenced by the explosive epidemic waves of 2003–2004 initiated in Vietnam with H5N1 spreading to 60 countries. Finally, climate change has often been invoked as a possible driver of zoonotic disease emergence. Weather and seasonality influence infectious disease transmission, particularly vector-borne diseases, and changing climate is expected to influence, and has affected, disease incidence. However, changing weather patterns may either ameliorate or exacerbate disease transmission depending on the particular disease. Moreover, historical analysis has shown other factors besides climate have been more important. Reliably projecting the effects of climate change on disease incidence is fraught with difficulties due to both a lack of research data and the complexity inherent in vector-borne disease transmission systems. Again, this points to the need for a framework that can integrate climate change, ecosystems, economies, and societies with disease dynamics (Parham et al. 2015). This complexity extends to how exposure and susceptibility to infectious disease is affected by “modern” chronic diseases as described by the “epidemiologic transition” (Harper and Armelagos 2010). These “double-burden” development-driven health risks are strikingly apparent in developing regions such as sub-Saharan Africa, with increasing incidence of obesity, diabetes, cardiovascular diseases, and other noncommunicable diseases. This, along with social inequality and political marginalization, has been shown to increase vulnerability to zoonoses (Wilcox et al. 2019b).

ä Fig. 3 (continued) undetected); (vi) clusters of infected humans nearly always due direct exposure to infected birds; and, (vii) hypothetical epidemic spread, assuming the virus gains sufficient human-to-human transmission capability (R0 > 0) (i.e., spillover to humans occurs), and local outbreaks are not contained. (Source: Kapan et al.2007)

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Ecology of the Human, Animal, and Environment Interface One Health’s central proposition, that the “human, animal, and environment interface” is critical to understanding and managing zoonoses risk, represents perhaps its most significant challenge. This includes conceptual framing in light of relevant sciences, and ultimately its operationalization as a basis for validation. Ecological concepts and principles are most relevant. While ecological thinking has a relatively long history of application in the health sciences, given One Health’s relatively recent appearance much remains to be done in this regard. Emerging infectious disease researchers and expert panels repeatedly point to the importance of the environment and of understanding the human-environment interaction. Yet, not until One Health had there been a call for understanding disease emergence explicitly in the context of human-animal-environment systems, and had this become institutionalized or broadly agreed-upon by a wide range of agencies and sectors. The terms environment, ecology, and ecosystem health repeatedly are mentioned, while operationalizing their application to emerging zoonotic disease prevention and control has only recently begun, along with the appearance of researchers crosstrained in ecology and infectious diseases. Application of ecological concepts in the health sciences has demonstrated how linkages between the numerous factors in the environment influence an individual’s life course including vulnerability to disease. These include those between settings that a person may or may not be directly exposed to, but that are nonetheless important as they impact a person’s immediate environment. The biomedical and behavioral sciences’ application of ecological perspectives in the form of social ecology to public health interventions (Institute of Medicine 2001) acknowledges the critically important role of people’s interactions with their physical and sociocultural surroundings. These models borrowed from biological ecology the multilevel conception of nature, which in biological ecology is expressed in the form of “levels of organization hierarchy”— cells, organisms, ecological communities, landscapes and ecosystems, and ultimately the ecosphere (Odum and Barrett 2005). The “ecosystem” concept has its roots in holism and systems theory as distinct from ecology’s largely reductionist foundations. “Ecosystemology” is a distinct area particularly relevant to understanding and managing “human landscapes” (Naveh and Lieberman 1994); that is, landscape level ecological phenomena including zoonotic disease management as described below. The ecosystem concept in biology extends to human-built or “hybrid” human-natural systems such as cities and cultivated landscapes, including “urban ecosystems” and “agricultural ecosystems” (sometimes called “agroecosystems”), as well as natural ecosystems (Odum and Barrett 2005). How understanding zoonoses and their emergence is as much an ecological as it is a clinical research or epidemiological problem becomes especially apparent in light of how they are a manifestation of host-parasite relationships. The overwhelmingly dominant perspective of medicine and public health when it comes to microbes is that of “germs,” infectious agents, etc., to be avoided, eliminated, and eradicated, if possible. In fact, not only has it proven possible to eradicate only a negligible

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number disease causing microbes, the dividing line between what are harmful and beneficial microbes is often not clear. Humanity’s relationship with microbes extends to the evolutionary origins of human and all higher organisms’ cells as they are the product of symbiotic co-evolution of primordial single-celled organisms. The causative agents for many newly emergent diseases are often discovered virtually simultaneously with (or in some cases before) their associated disease syndromes. This was the rationale for the capstone IOM report and it’s title, Emerging Microbial Threats, stressing differentiation of the agent and the disease (Institute of Medicine 2003). Infection implies that an agent, such as a virus, has entered a host’s tissues and is multiplying within that host—not necessarily causing pathogenesis, i.e., the disease commonly associated with that agent. Thus, also the chastening title of the IOM report War No More Against Microbes (Institute of Medicine 2006). This includes the warning of how medical interventions have contributed to disease emergence. As stated in the report, pathogens coexist within host-microbial communities, which places infectious disease within an ecological context. Host-parasite relationships are ubiquitous in nature, as the “unseen” part of any ecological community, as is the case with predator-prey relationships and interspecific competition which collectively regulate distribution and abundance of species. This in turn determines the species composition and ultimately the structure and functioning of ecosystems (Horwitz and Wilcox 2005). Parasites, likewise “pathogens,” cannot be understood except in the context of host relationships, ecological communities of which they are an inseparable part, and their ecosystem context. In this sense, contrary to the reductionist disease perspective, holistically speaking, parasites are considered by disease ecologists essential to the health of ecosystems. This complexity extends to how, and whether, a host-parasite relationship entails disease. The classical, textbook definition of a parasites is an organism (or nonorganism in the case of viruses and prions) directly dependent on another, host organism, for their growth and survival. Yet, the degree of parasite dependence, virulence, or both, varies in time and space, as do the costs and benefits to hosts. Thus, host-parasite relationships are not necessarily “parasitic” per se, but represent varying degrees of parasitism, commensalism, and mutualism. For example, typically, over time, highly virulent parasites become less virulent as they evolve toward a mutualistic relationship with the host. Yet, a commensal or mutualist can switch from benign to injurious, that is, become a pathogen. This has important consequences in the context of traditional veterinary and medical focus on diagnosis, treatment, and disease prevention. As has long been known by infectious disease researchers and now widely known among the lay public due the COVID-19 pandemic, being infected is not necessarily the same as having a disease. It is not uncommon for post-epidemic serological studies to find most serologically positive individuals were asymptomatic or had mild symptoms. Thus, classifying every infected person as a “case” and administering treatment including medications with potential side effects can be highly problematic. With regard to prevention, conventional “top-down” approaches employing chemical control can have ecological and evolutionary “side effects” as follows

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(Horwitz and Wilcox 2005): (i) Development of parasite genotypic resistance to antiparasitics, just as disease vectors and agricultural pests develop resistance to pesticides. (ii) Host population overexposure to an antibiotic reduces selection for development of immunological, genotypic responses over a longer, evolutionary timescale. (iii) At the ecological community level, nontarget species, that is, the competitors, predators, or parasites, comprising the system that normally regulates the distribution and abundance of the parasite and/or its vector, often are collateral damage. Or, (iv) they may develop resistance and become pests. (v) At the ecosystem level, these and other effects of chemicals, compounded by other disturbances, may undermine biodiversity and related functionality, thus the wide range of societal benefits normally derived. Among emerging zoonoses, vector-borne diseases have a long history of application of ecological approaches, including a start on applying ecosystem thinking, which offers an opportunity that can be built upon toward developing the One Health approach (Ellis and Wilcox 2009). As shown in Table 2, vector-borne diseases represent a substantial amount of the global health burden of zoonoses, particularly dengue and malaria, both considered reemerging diseases. Dengue is perhaps the most striking example of a reemerging zoonosis. From 1950–1959, less than 1000 cases were reported annually worldwide compared to today’s estimate of approaching half a billion cases. At least 20 other vector-borne diseases have also emerged during this time, having increased in incidence and/or expanding their geographical range (Gubler 1998). Vector-borne disease transmission cycles typically involve a set of important pathogen(s), arthropod vector(s), and vertebrate host(s) that occur within a variety of particular environments (Fig. 4). The hosts of dengue virus include humans and nonhuman primates. Dengue primarily has been a disease of urban areas, but

Fig. 4 General ecological model of vector-borne disease transmission cycles Vector-borne disease epidemiological foci span sylvatic to domestic ecosystems and a vast diversity of pathogens, hosts, and vectors. Details of their biology, e.g., pathogen’s host range, transmissivity, pathogenicity, and host/vector competency (ability to transmit a pathogen), are unknown except for very few species, such as those responsible for malaria and dengue haemorrhagic fever in certain well-studied localities. However, these diseases can generally be described within three broad categories of environments and transmission cycles: natural (e.g., forests), modified (e.g., rural and agricultural), and human (urban). Even zoonotic diseases that do not involve vectors exhibit this sylvatic to domestic ecosystem “migration” pattern of transmission cycles. The emergence of Ebola and HIV’s presumed original form, simian immunodeficiency virus (SIV), is a result of hunting, butchering, or illegal procurement of forest wildlife (Wolfe et al. 2007). Adapted from Ellis and Wilcox 2009.

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increasingly is also found in peri-urban and rural areas, and apparently is increasingly being transmitted between these and urban areas. As is the case for vectorborne diseases in general, dengue is especially ecologically sensitive since environmental conditions can have dramatic effects on the vectors, pathogens, and potential hosts involved in the transmission cycle. As is the case for all insects with an aquatic life stage, the population abundances of species of Aedes mosquitoes, the principle dengue vectors, are controlled mainly at the landscape-level, through the interaction of abiotic and biotic factors in both terrestrial and aquatic habitats. In addition, interactions between “trophic levels” (i.e., the horizontal relations of organisms from the top to the bottom of the “food pyramid”) indirectly mediate these complex relationships. This manifests, for example, in the consistent pattern of change observed in mosquito species composition and diversity across landscape continua from urban, agricultural, to natural. Thus, the association between environment and disease epidemiology is a consequence of vectors and nonhuman reservoir hosts, as is the case for all species, having specific habitat requirements. As habitats change, whether due to natural or human processes involving a range of possible causal mechanisms and factors, so too does disease epidemiology. The landscape-level focus has long been argued to be a key to understanding zoonotic and vector-borne disease dynamics, with the field of “landscape epidemiology” defined nearly a century ago (Malkhazova et al. 2019). Accordingly, infection risk is controlled by three sets of factors: (1) host-pathogen biology and transmission cycle; (2) landscape-scale ecosystem processes, including climate; and, (3) human social and behavioral factors. The latter two generally are not considered while the integration of all three, particularly how they interact dynamically across scales (spatially and temporally), remains relatively poorly understood and considered (Lambin et al. 2010). Failure to account for these cross-scale dynamics, and how disease emergence may be mitigated through their understanding, represents from a social-ecological system perspective a “disease management pathology” (Wilcox and Colwell 2005). Landscape “features,” as they are referred to in landscape ecology, include “ecotones” as hybrid or “edge” habitats of intensified biological activity—including mixing of hosts and parasites typically not in contact—commonly associated with emerging zoonoses. Some ecotones occur on a relatively small scale, typically as a result of clearing of forest (or other types of natural habitat) for cropland. The resulting “habitat fragmentation” multiplies the number of remnant habitat fragments and along with it the amount of “edge” habitat (area of ecotone). The same effect, i.e., fragmented habitat and increased ecotonal area, occurs where areas with habitat regrowth is patchy. In either case, the diversity and the composition of the ecological communities supported, i.e., the assemblage of types of species including hosts, vectors, and parasites, is distinct from the original landscape of continuous habitat. This tends to reduce the diversity of species within each patch, and in some cases across the whole landscape, as is found along ecosystem continua from most to least natural, e.g., natural forest to urban. This led to the proposition that reduced biodiversity results in increased zoonosis disease emergence risk. The “dilution hypothesis” offers an explanation for one of the mechanisms inolved. It posits that

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communities with higher host species diversity, which inevitably include “incompetent” hosts, dilute a parasite/pathogen’s transmission prospects—although the implication for public health depends on local social and ecological circumstances (Salkeld et al. 2015). Yet biodiversity, or “biological diversity” as it also called, as defined by the UN Convention on Biological Diversity affects not only transmission of zoonoses but health more generally, thus zoonoses emergence risk indirectly. As defined by the UN convention, biodiversity is ‘the variability among living organisms from all sources, including, “inter alia,” terrestrial, marine, and other aquatic ecosystems, and the ecological complexes of which they are part: this includes diversity within species, between species, and of ecosystems.’ Most compelling in relation to One Health is the nexus of health, biodiversity, and local (including traditional) knowledge in the context of rural population vulnerability. Approximately 80% of the world’s poor are rural, thus depend directly on biodiversity. Rural lands mostly consist of modified and cultivated ecosystems (cropland, pasture, and plantation) that support largely subsistence farmers and pasturalists, and to a lesser but increasing degree more intensive, industrial scale commercial agricultural operations.

Box: Definitions of Key Disease Ecology Terms

Ecosystem: Any unit that includes a community of living organisms along with the nonliving environment interacting as a system so that the in a given area the flow of energy clearly leads to a biotic structure and cycling of materials between the living and non-living components Landscape: A mosaic types of land cover and land use, or local ecosystems; a regional-level biological organization between the local ecosystem and the biome Ecological community: An assemblage of species inhabiting a specific area at the same time Population: A group of inter-breeding organisms of the same species in a particular locality Ecotone: A boundary or transition zone between two adjacent ecosystems where biological activity is concentrated, including pathogen transmission events such as infection of an “accidental host” that can lead to disease emergence Dilution hypothesis: The proposition that infection prevalence per host species declines as host species diversity increases Biodiversity–pathogen regulation: The capacity of intact ecosystems and ecological communities, i.e., whose biodiversity is maintained, to provide “natural” control of disease emergence

Traditional agricultural ecosystems or semi-traditional agriculture ecosystems (partially intensified) support much of the world’s biodiversity. This not only includes native plants, fish, and wildlife in remnant patches of natural habitat, but

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also the “genetic resources” represented by local crop plant varieties and livestock breeds, along with the myriad animal pollinators and vast fungal and microbial diversity in soils that are essential for sustaining rural livelihoods, thus health. This variety and variability, including the greater genetic heterogeneity found in nature or traditional farming systems than intensive agriculture, inhibits pathogen spread. The biodiversity supported by semi-natural or disturbed, even semi-degraded traditional rural ecosystems given their areal exent, likely is comparable to that of the remaining natural ecosystems (e.g., found in the world’s national parks and other protected areas), and is essential to regional ecosystem integrity. These lands represent buffer zones between urban areas and natural ecosystems. In addition, they provide a constant flow of abiotic (e.g., clean water and nutient laden sediments) as well as biotic resources, in the form of propagules to recolonize or otherwise support the maintenance of organisms beneficial (e.g., crop pollinators) to agroecosystems. Rural societies’ dependence on biodiversity, particularly locally, for their livelihoods and health is not only appreciated by but it typically is culturally codified in traditional rural societies. Yet economic development policies and other factors out of their control encourage destructive and unsustainable land use practices, as well as contribute to the erosion of knowledge and norms of the past. A significant challenge remains in aligning biodiversity, combining zoonotic disease emergence risk mitigation and conservation interventions, with participatory methods drawing on traditional knowledge. For example, this requires accounting for how knowledge is informed by a society’s worldview including spirituality, values, normative rules, and cultural practices. Thus, a broader set of issues and gaps emerge when biodiversity is considered in the context of rural, developing country environments and livelihoods, from an intervention perspective in light of complexity and social science. The challenge for One Health is to address “biodiversity and health” employing a broader conception of biodiversity, as well as of health, beyond the reductionist disease focus to a more holistic perspective consistent with global health. As with biodiversity research in general, that on the relationship of biodiversity to zoonoses emergence risk has focused almost exclusively on the species level, not accounting for ecological complexity. Anthropogenic impacts on landscape and ecosystem-level dynamics, independent of species diversity measures commonly employed, can result in an ecosystem’s diminished “resilience” (Perrings et al. 1995)—thus, that of a socialecological system’s resilience, which as described in detail as below includes the capacity to mitigate zoonotic disease risk.

The Social-Ecological Systems Framework One Health’s central idea of “the human, animal, and environment interface” implies a describable spatial context, whether a geographic or geopolitical region, and/or a place, that loosely can be referred to as an ecosystem. Such a “target” or “study” ecosystem’s boundaries can be approximately delineated corresponding to an ecologically functional whole, e.g., a watershed or river basin. Or, it could be a

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contiguous habitat area supporting a particular set of ecological processes and interacting species spanning a complex of protected areas or even national boundaries (e.g., Serengeti ecosystem, Greater Yellowstone Ecosystem, Amazon Basin, or Central Mekong River Basin). As an elaboration of the ecosystem concept, a “socialecological system” is a system of humans and nature coupled together with the human and natural components interacting via numerous feedback mechanisms to form a single, dynamic whole (Berkes et al. 2003). It similarly can be viewed as a “bio-geo-physical unit,” with the additional consideration of spatial and functional boundaries as delimited by the associated institutions and problem context. One Health is widely described as a systems approach, specifically an ecosystem approach. The social-ecological systems framework (SESR), including its unique conception of resilience, is an elaboration on the ecosystem approach (Wilcox et al. 2019a). SESR is an analytical framework consisting of theories, models, and heuristic devices with transdisciplinary, participatory research and adaptation, or “adaptive management,” as its core “methods.” The idea of “resilience” as conceived in this school of thought is understood as the basis for adaptive capacity, and thus a measure of vulnerability. The field of climate change adaptation (research, practice, and policy) has largely adopted concepts of adaptation and vulnerability. The concepts of biodiversity, traditional knowledge, and their interrelationship, increasingly are being addressed employing SESR. Moreover, the applicability of the SESR to health and disease in general also has been described and advocated, including its integration with health promotion principles and intervention. Development of the body of theory constituting SESR began mainly in response to failed forest and crop pest control efforts, and the collapse of “scientifically managed” fisheries—suggested later as applicable to sustainable vector-borne disease control—where an adaptive approach based on collaborative learning was found more promising than rigid, top-down interventions. As complex adaptive systems (CAS) problems, these were found to require more creative forms of collaboration between scientists and society, involving a broader range of disciplines, skills, and participation. SESR has proved useful in bridging social and biophysical sciences, providing an integrative approach in natural resources management and sustainability science (Gunderson and Holling 2002). The key elements of SESR evolved largely from a paradigm shift in the ecological sciences from a mechanistic to a CAS view of ecosystems (Levin 2005). The former views ecosystems as linear, deterministic, and equilibrium systems understandable applying the mechanistic models of classical physics. The latter views ecosystems as self-organizing and far-from-equilibrium systems. This shift formed the basis for new theoretical, as well as practical, insights into how human-natural systems “learn” including: models of knowledge-system integration; visioning and scenario building; leadership, agents and actors; social networks; and institutional change, that underlie adaptive capacity largely centered on SESR’s concept of resilience (Folke 2006). A social-ecological system can be envisioned as shown in Fig. 5, in which the ecological and social sub-systems are reciprocally linked by interacting components

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SOCIAL-ECOLOGICAL SYSTEM

SOCIAL SUB-SYSTEM Institutions

Infrastructure

Social processes

Communities

Industries

ECOLOGICAL SUB-SYSTEM Disturbance

Climate

Natural processes

Abiotic elements

Biodiversity

Fig. 5 Graphical representation of a social-ecological system The large rectangle represents an entire social-ecological system including its component social and ecological sub-systems. The two large arrows aimed in opposite directions connecting the two subsystem boxes represent interactions between them. For example, the arrow from the social subsystem targeting the ecological sub-system represents human influences on nature. These are the outcome of processes influenced and/or driven by citizens, commercial interests, institutions (rules, regulations, and customs), and the human-built infrastructure. They impact the ecological subsystem in numerous and often invisible ways mediated through ecosystem processes and functions, as a result of myriad abiotic and biotic interactions. The arrow targeting the social sub-system represents the outcome of all these factors. (Adapted from Wilcox et al. (2019a))

as indicated by the two large arrows. The arrow in the figure pointing from the social sub-system to the ecological sub-system represents the influence of human activities on natural systems. This includes maladaptive policy and management responses to the unintended “side effects” of top-down interventions (e.g., antimicrobial and pesticide resistance), aimed at the control of ecosystem elements (e.g., vectors or parasites), completing one feedback cycle. Proving beneficial in the short term, as widely documented this often results in a social-ecological system “pathology” (Gunderson and Holling 2002). This pathology involves a loss of resilience and sustainability with unintended consequences, which can include a return of the problem an agency originally sought to solve. In this view, human-environment complexes, as CAS, exhibit “non-linear dynamics” and “emergent properties” (including disease emergence); thus, they are “predictably unpredictable,” despite human intentions. Intervention programs are part of the social component (sub-system) of these systems, and thus a factor in system dynamics that further adds to their complexity and potential unpredictability. As a result of these qualities and undergoing continuous change, they are “moving targets” from a management standpoint.

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Box: Definitions of Key Terms Associated with the Social-Ecological Systems Framework

Emergent property: A property of complex adaptive systems that arises out of the interactions of its multiple parts and that is irreducible to a system’s constituent parts Coupled human-natural systems: A perspective and problem-solving approach in which humans are seen as an integral part of (not separate from) nature (including natural ecosystems from a global perspective) Adaptive cycle: A pattern of change that alternates between long periods of aggregation and transformation of resources and shorter periods that create opportunities for innovation, employed as a heuristic for understanding complex adaptive systems Adaptive management: An inductive approach that relies on comparative case studies, and social and ecological theories and observations, the aim of which is to identify uncertainties and test hypotheses about them by employing interventions (management) as tools to change the system Resilience: An ecosystem or a social-ecological system’s capacity to absorb disturbance and reorganize while undergoing change and retain essentially the same function, structure, identity, and feedbacks Surprise: A cognitive disagreement between system behavior and a priori expectations, an inherent property (and emergent property) of coupled humannatural systems as complex adaptive systems The “adaptive cycle” serves as a heuristic metaphor for understanding the dynamics of how coupled human-natural systems learn, thus adapt to continuously changing internal and external conditions (Gunderson and Holling 2002; Berkes et al. 2003; Folke 2006). Its application to specific problems is complemented by models of knowledge-system integration, counting the critical roles of visioning and scenario building, leadership, etc., as mentioned above, all of which underlie adaptive capacity. The adaptive cycle metaphor is central to understanding and heuristically navigating social-ecological systems as CAS, as it explicates resilience and vice versa and is helpful in understanding a systems vulnerability, including to zoonotic disease threats. Humans—acting as controllers of the natural system—can be thought of as both part of the system and the problem. The latter typically results from how intervention strategies aimed at controlling natural variables (e.g., vector population abundance) tend to interupt natural rhythms and cycles that otherwise reinforce system resilience. As shown in Fig. 6, adaptive cycles exhibit four distinct stages: (i) growth or exploitation (r), (ii) conservation (K ), (iii) collapse or release (Ω), and (iv) reorganization (α). These represent two major phases (or transitions). The fore loop from r to K is the slow, incremental phase of growth and increased connectivity. The back loop from Ω to α is the rapid reorganization leading to the system’s renewal, or

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Fig. 6 Adaptive cycle and cross-scale linkages among adaptive cycles in a social-ecological system (A) Adaptive cycle, as described in the text. (B) Panarchy, conceived as smaller, faster cycles hierahically embedded in larger, slower ones. (C) Three-dimensional representation of the adaptive cycle, its variables descrived as follows. Potential represents resources in the form of stored capital available to effect change, which may include knowledge and financial, social, and natural capital. Connectedness refers to the flexibility or rigidity of controlling variables or processes in response to external variation. Resilience is as defined in the Box above.

possibly a social-ecological system’s collapse to a new stability domain. Also referred to as a regime shift, this generally means a tipping point or threshold had been reached. These collapses can be triggered by politics, invasions, market shifts, or global climate change external to a system whose resilience at a particular scale has contracted due to states and dynamics at scales above and below. The adaptive cycle metaphor, including regime shift, can be applied to relatively abrupt, irreversible agroecosystem transitions impacting livelihoods and human well-being. The applicability to One Health is apparent, for example, in the dramatic agroecosystem transformation underway in the Greater Mekong Subregion with zoonotic disease emergence consequences (Wilcox et al. 2019a). This mainly involves the widespread industrial intensification of agricultural production and food supply chain, with considerable but as yet not systematically investigated emerging zoonotic disease risks. This transformation, involving changing land use and land cover, increased chemical inputs including pesticides and antimicrobials, represents attempts to control a range of key variables including increased food and reduced pests and pathogens. Here the r, or Exploitation, phase is driven by the quest for increased economic output through agricultural intensification. The initial positive results from increased investment and improvement (administrative, operational,

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organizational, technical, etc.) breeds confidence, producing increasing reliance, for example, on chemicals, even when effectiveness wanes, for example when pesticide and antimicrobial resistance begin to develop. . The response typically is to intensify chemical use, which drives dependence on chemicals and increasing resistance.This is the K, or Conservation, phase during which the system becomes entrenched both in its thinking and mode of operation—reflecting a loss of flexibility, over-connectedness, and resulting fragility (loss of resilience). This entails the erosion of natural regulatory processes of an ecological sub-system that mitigate disease emergence risk. The Ω, or Release, phase, a crisis stage, is when the system clearly becomes unprofitable, as events such as major disease outbreaks become increasingly costly for the controlling institutions. This phase is prompted by “revolutionaries” within or outside of them pushing for change, and the system enters the creative destruction phase. Assuming the system’s resilience remains sufficient, that is, sufficient adaptive capacity remains, and the system has not collapsed to a different state, irrevocably, the opportunity for system reconfiguration may exist. Thus, the system enters, α, the reorganization phase, in which the experience from the past may be applied and lead to more a desirable outcome in the next cycle. Or, the undesirable trajectory may be repeated. A regional agroecosystem will consist of many ecosystem subtypes spanning small-scale traditional and smallholder systems to intensive large-scale corporate, industrialized systems. It can be envisioned how each has its own adaptive cycle whose dynamics operate on different time and space scales, including smaller, faster cycles being embedded in larger, slower ones, “panarchy” (Fig. 6b). The larger, slower cycles can constrain smaller, faster cycles, which the latter can disrupt and even cause a regime shift in which the social-ecological system is fundamentally altered. As shown in the three-dimensional graph of the adaptive cycle in Fig. 6c, resilience represents a third dimension that expands and shrinks through the cycle as slow variables change. It shrinks as the cycle moves toward K, and the system becomes more fragile. Then it expands abruptly when a cycle shifts into a “back loop” to reorganize for the initiation of a new cycle. In Fig. 6a, “X” represents a regime shift whereby the system “collapses” to a new, functionally and structurally distinct system. The back loop, Ω crisis stage phase, is a period in which novelty and experimentation is needed, and possible, given a decline in connectedness (e.g., as institutional rigidity or inflexibility diminishes) and resilience increases. This constitutes an opportunity for “revolt,” a cross-scale phenomenon precipitated by fast, small scale variables. These may be pathogens or vectors, for example, in a ecological sub-system, or heretical individuals or groups in a social sub-system, released from control by a slow, structural variable as status quo’s domination becomes diluted over time. A resilient system may successfully navigate itself through each of the phases and into new regime that satisfies societal goals. In general, however, successful navigation (an indication of resilience) suggests the capacity to recognize barriers, critical thresholds, and principles associated with this front loop that can trap a

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system—resulting in a pathology. Specific system features, allowing escape from these traps, can determine the efficacy of an adaptive management regime. A major challenge for operationalizing One Health is to overcome the common default conceptual frames, for example, that of mathematical epidemiology with its elegant mathematical models of transmission dynamics. Its SIR model, relating the number of susceptible (S), infected (I), and recovered (R) individuals, and associated interventions, often has proven powerfully effective. Yet, social and ecological drivers of disease emergence today are far different from when smallpox and rinderpest were eradicated, polio eliminated, and numerous infections that had previously plagued humans and livestock been controlled. The present global emerging zoonotic disease crisis demonstrates how the reductionist biomedical frame is inadequate by itself for understanding and managing problems of host– pathogen–environment complexes. The uptake by zoonotic disease researchers and practitioners of unfamiliar concepts, particularly holistic problem framing and transdisciplinarity, represents a significant challenge. Conventional human and animal medical training—and practice in clinical, laboratory, and even farm settings—tends to engrain a linear, reductionist ways of thinking and reinforce disciplinary boundaries. This even holds for fieldwork, including epidemiological studies and trials, which typically are designed to “control” for real-world complexity. Yet, recent testing and development of operational procedures for systems analysis and transdisciplinary research applied to One Health are beginning to show promise (Rüegg et al. 2019). SESR currently is the most well developed framework allowing transdisciplinary integration of multiple knowledge domains, including of “local science” as well as “global science,” employing an evidence-based approach applicable to One Health. For example, this has been demonstrated for drylands, the biome with the majority of the world’s land area and population of rural poor who are particularly vulnerable to zoonotic diseases. Research shows how dryland ecosystems potentially can maintain relatively high levels of resilience, thus mitigate emergence risk drawing on SESR (Wilcox et al.2019b). Despite drylands’ extreme climatic unpredictability among other distinct features—resource scarcity, remoteness from markets, and distance from centers of governance—SESR has been shown to offer a promising re-envisioned “drylands development paradigm.” Similar SESR-based “development” schemes tailored to social and ecological characteristics specific to other major bioclimatic zones, biome types, or ecosystems require similar articulation.An additional requirement, for drylands as well, are operational criteria including explicit guidelines and/or protocols for conducting transdisciplinary interventions, as described below.

Operationalizing and Validating One Health Demonstration and improvement of the efficacy of One Health remains its most significant challenge. Explicitly considering One Health as a transdisciplinary, ecosystem-based approach provides a basis for synthesis of existing theory and practical

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experience, yielding a set of criteria and an associated protocol (Richter et al. 2015; Wilcox et al. 2019a). These criteria specify the comprehensiveness of knowledge integration, participation, and systems thinking employed in an intervention, from the least to the most comprehensive. The stepwise process shown in Fig. 7 is designed to overcome impediments, such as tacit acceptance of a particular disciplinary frame by default, as the first step. This includes negotiating a process of appreciating different perceptions of the problem, and identifying the pertinent knowledge. The stepwise procedure numbered 1–16 is rationally derived from theory and principles as described in Richter et al. (2015), elaborated as follows: Steps 1 and 2 describe the initial recognition of a problem and the formation of an interdisciplinary team composed of members considered appropriate to span the disciplinary expertise relevant to the problem. Step 3 analyzes the affected community and stakeholders as a prerequisite for integration of knowledge and normative social values. Step 4 is development of a common transdisciplinary metalanguage across disciplines and knowledges of the affected community and stakeholders, as well as of a shared vision. Steps 5–6 involve the framing of the complex situation as a synthesis of multiple perspectives, disciplinary analyses, and system descriptions. Step 7 analyzes the problem within its systemic context. Step 8 involves the reformation of the interdisciplinary team according to which disciplines are essential to understand the problem. The addition of disciplinary perspectives in Step 8 may in turn require revision of the description of the social–ecological system (Step 6). Steps 9–11 describe the scientific research process from the development of an idea to the analysis and interpretation of obtained data and results. Steps 11–16 follow the “Shewhart cycle” for learning and improvement, while recognizing that more research, additional research questions, or additional areas of knowledge/expertise including that representing ‘local science’ may become necessary (Steps 8–10). As already noted, Steps 11–16 outcomes eventually should result in a return to Step 1, and reconsideration of the problem focus. The initiation of the transdisciplinary process as part of an intervention results in the “intervenors” themselves becoming a component of the social-ecological system, driving the tasks and related activities in Fig. 7 among themselves and the other stakeholders. Once the initial cycle is complete (Steps 1–16) the knowledge and perspectives collectively gained compel a reassessment of actions and thinking including that of the conception of the problem itself. The two-way flow between Organizational capabilities and Intervention management is the main iterative dynamic constituting “adaptive management.” Overall, transdisciplinarity and systems thinking are central to achieving adaptive management’s the main goal of mitigating emerging zoonoses risks. This includes the problem of the unpredictability (“surprise”) with the view that management policies can be treated as “experiments” from which managers can learn. As such, adaptive management is an inductive approach that relies on comparative case studies, social and ecological theories, and observations. Specifically, adaptive management involves the design of interventions aimed at understanding the linkages shown in Fig. 6; e.g., how human action effects

16. Monitoring effects

13. Designing interventions

10. Conducting research

7. Contextualization of the problem

15. Implementing interventions

12. Analysis of intervention options and feasibility

9. Description of research questions and their treatment

14. Identification of indicator framework for monitoring

Intervention management

6. Description of the ecological & social systems and their interconnections

11. Analysis and interpretation of data & results

Implementation research

8. Reformation of the transdisciplinary team according to the problem

Transdisciplinarity

5. Identification of proper boundaries and scales of socio-ecological system

System analysis

Fig. 7 General schema and sequence of tasks comprising a transdisciplinary adaptive management protocol. The bi-directional arrow denotes information flowing cyclicly back and forth from the first to the last steps, as described in the text. (Adapted from Richter et al. 2015)

4.Development of a common vision & language

3.Analysis of the affected communities & stakeholders

2.Formation of an interdisciplinary team

1.Problem orientation

Organizational capabilities

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changes in nature, and in turn, nature affects humans, reiteratively. The aim is to identify uncertainties and test hypotheses about these dynamics by employing interventions (management) as tools to change the system. Matching the human and natural dynamics across temporal and spatial scales, thus ensuring greater resilience, is learned in the process. This includes the capacity to deal with change and surprise, and avoid a social-ecological system’s collapse to a less desirable state, while providing flexibility and opportunity (Gunderson and Holling 2002). “Problem orientation” (Step 1) refers to the different perspectives on a problem (based on different world views in some cases) held by stakeholders including but not limited to university researchers from different disciplines. The process of sharing perspectives and appreciating the different ways of looking at, thus understanding and framing a problem—particularly when the participants are able to transcend their held conceptual/theoretical frames drawing on systems thinking— drives knowledge integration. This, in turn, feeds back on problem orientation as a collective phenomenon (Step 16 feeding back on Step 1), potentially leading to modification of the problem frame. This supports adaptative capacity overall, i.e., the flexibility to respond and reorient thinking about the problem and its resolution based on monitoring the effects of the intervention. As with any global health issue, zoonotic disease research and interventions typically involve multiple entities with a vested interest in a project. These include the initiators of the project concept and the agencies and communities representing targeted at-risk population(s) as the primary “stakeholders.” Secondarily, other interested, involved, or otherwise influential groups, including those affected collaterally, positively, or negatively, by the intended outcome of an invention typically are acknowledged as stakeholders. An intervention’s operational efficiency depends on identifying stakeholders’ interests, appreciating their distinct “personalities,” anticipating potential misunderstandings, and reflecting on how best to positively influence other stakeholders. The System analysis phase (Steps 5–7) deals with the manner and extent to which different parts of a “whole” interact, as agreed upon and reevaluated by the stakeholders, and also iteratively linked to problem orientation. This may involve developing schemata, mental maps, computer simulations, or actual geographic maps of the system’s boundaries, social and ecological components, and their interconnections. This transdisciplinary ecosystem approach corresponds to similar intervention schema suggested for health systems, recognized as CAS, as a form of “implementation research.” Arapidly growing field of methodological research in the health sciences, implementation research aims to “understand why and how interventions achieve, or not achieve their expected outcomes” (Peters et al. 2013). It includes analysis of the social, cultural, economic, political, legal, and physical environment, as well as the institutional setting, in addition to stakeholder’s positions and their interactions. “Logic models” typically are an integral part of implementation research, constructed on the basis of theories of change and the rationale for an intervention program.

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Often expressed graphically much like the process in Fig. 7, expressing the steps taken by a program, in detail, the purpose of logic models, ideally, is to account for how the intervention activities lead to desired changes. Yet, as transdisciplinary research programs are complex systems, thus subject to uncertainty and unpredictability, a logic model can fall far short of being a valid representation of what actually happens in the real world. “Emergence,” as a characteristic feature represented by CAS’ inherent uncertainty and unpredictability, challenges the linear nature of logic models. However, this can expose patterns which can be used to predict outcomes for similar interventions in the future (Rogers 2008), as found with the adaptive cycle and its use as a heuristic tool to help guide interventions.

Box: Definitions of Key One Health Operational Elements

Transdisciplinary research: A form of integrative research that addresses a “real-world,” or so-called “wicked problems” that involve a complex adaptive system and seek to combine knowledge from all stakeholders representing scientific and local communities, private, and public sector organizations Implementation research: A form of methodological research carried out in a real-world, complex adaptive system context, ideally employing a logic model, aimed at understanding why and how an intervention succeeds or fails to achieve expected outcomes Logic model: An intervention plan depicted diagrammatically that makes the planners’ assumptions explicit in terms of the problem addressed, resource and activity “inputs,” “outputs,” and “outcomes,” on the basis of an overall theory of change Theory of Change: An explanation of the process(es) of change that describes the causal linkages between the intervention inputs and outputs or outcomes given a particular context Fidelity: The degree to which an intervention is implemented as it was originally designed and faithful to the logic model, measured by indicator variables representing components of the intervention Scorecard: A measurement system used to gauge and evaluate an intervention’s performance, including fidelity, in terms of its management efficiency, and aid in identifying institutional or other impediments to the provision of expected inputs, and achievement of expected outputs and outcomes

Effective organizational management depends on cycles of planning, implementation, monitoring, and evaluation, leadership that promotes collaboration, and the generation of new knowledge and innovation from within the system. Efficient management approaches additionally recognize and incorporate direct and indirect cross-dependencies within the realm of the management objectives that can be either supportive or detrimental to the mission. Scorecards can be used as a means of evaluating, managing, and benchmarking, simultaneously addressing the need to

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measure “fidelity” of an intervention as an element of implementation research (Peters et al. 2013). Combing the transdisciplinary process with logic modeling remains a key challenge for One Health. This can be understood in the context of logic model’s “inputs,” which include building an interdisciplinary team as an iterative process with problem orientation. This represents an “if, then” decision in which an initial team begins the process of problem orientation including arriving at a common definition of the problem. Once acheived, this, then, allows identification of the additional disciplinary knowledge required, and additional team members are added accordingly. Once the Organizational capabilities and System analysis (Steps 1–6) are initially completespecific intervention activities designed on the basis of the participatory modeling are conducted. This Transdisciplinarity phase requires engagement approaches, drawing on appropriate theories of change with ongoing monitoring of the prior phase’s performance along with adjustments, equivalent to the experimentation aspect of adaptive management. Thus, different components based on different applicable theories of change which incorporate both the natural and social aspects are imbedded in a logic model. For example, depending on the intervention, this may include theories of how education, behavioral change, institutional behavior, and efforts to facilitate individuals, households, government agencies, etc., lead to most effective disease prevention and control. Fidelity involves measurement of the extent to which intervention activities designed accordingly actually adhere to the applicable theory. This requires ongoing monitoring, and adjustment when practicable; an approach that could be described as second-order adaptive management. In general, adaptive management, though having proven effective in addressing problems in environment and natural resources management, only recently has begun to be combined with implementation research methods and applied to zoonotic disease risk management.

Conclusion One Health holds substantial promise for improving the understanding of zoonotic diseases and reducing the global burden of endemic and epidemic zoonoses, as well as preventing the emergence of new zoonoses. This includes pandemic zoonoses, which generally contribute less to the global health burden than endemic zoonoses because of their episodic nature and the relative rarity in severity of the associated diseases. Nonetheless, the extremity of their impact even in the modern era, as with the COVID-19 pandemic, can be devastating, due as much to the indirect social, economic, and political consequences as to the direct burden of disease. One Health purports to tie together the significant disciplinary knowledge, methods, and practical expertise, developed for over a century in zoonotic disease prevention and control, with that of the environmental and ecological sciences applying complex systems thinking. This responds to the call for a new paradigm by the leading biomedical scientists prompted by the appearance of a new era of

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emerging infectious diseases. This includes the conclusion that understanding and preventing emerging infectious diseases represents more than a biomedical and public health problem as conventionally perceived, but an environmental, social, and ecological one as well. This points to the need to integrate theory, concepts, and practices from the biomedical sciences and epidemiology with those from the ecological and social sciences. One Health’s proposed transdisciplinary ecosystem-based approach and focus on the “human, animal, and environment interface,” as complex adaptive systems, uniquely offers a basis for fundamentally new ways of thinking and practice. This will require wider acceptance of a broadened, integrative framework adapted from what has proven, to date, most effective in managing environmental risk—the social-ecological systems framework with its unique concept of resilience. However, wider acceptance of this, or another framework that can accommodate emerging zoonotic diseases as a complex adaptive system problem, presents numerous challenges. This includes the ambiguities around definitions of zoonoses that reflect and reinforce different conceptions of them, and thus, research and intervention approaches. Particularly vexing are the distinct perspectives and agendas held by agencies, researchers, and practitioners in human medicine and public health in contrast to those in the animal health fields. How zoonoses are defined and categorized affects how their global burden is determined. How they are prioritized will benefit from a wider appreciation of zoonotic diseases defined as infectious diseases transmitted from animal to human, human to animal, and those transmitting in either direction. This includes acknowledging of the full spectrum of transmission modes as part of a dynamic, coevolutionary phenomenon in which pathogens, hosts, and vector complexes range from entirely natural transmission cycles to entirely human. Acknowledging these as complex adaptive systems is critical to account for the considerable direct and indirect human health impacts of animal to animal transmitted diseases. One Health’s explicit human, animal, and environment interface focus—a placebased, coupled human-natural systems view—is imperative to transcend disciplinary siloes and holds promise toward bridging other gaps. While interpenetration of veterinary and human medicine with environmental science can be seen as daunting, viewing zoonoses from an ecological perspective has the potential to resolve many of these issues. This includes addressing the gap between human health and livestock health systems and agencies. Remedying the deficit of attention and resources applied to the combined problem of human and animal infections has the potential to dramatically improve health of approximately a third of the world’s population who happen to be smallholder livestock keepers. An ecological perspective also recognizes the growing problem of humans infecting wildlife, and how this potentially can disrupt natural or semi-natural ecosystems by impacting the population sizes of, or even eliminating species whose ecological roles are critical to their functional integrity. In spite of this considerable promise, One Health’s wider adoption will require its validation, and assuming its potential efficacy is demonstrated, it will require continual improvement. This will necessitate explicit criteria and standards,

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including metrics, against which intervention outcomes can be measured. Initial progress made toward operationalizing the transdisciplinary ecosystem approach including measurement criteria and a suggested stepwise procedure, developed on the basis of the same principles as the social-ecological systems framework, will require further development. The growing field of implementation research including logic models represents a critical opportunity in this regard, although this also is not without challenges. Perhaps the most significant obstacle to One Health is how its transdisciplinary imperative challenges disciplinary boundaries upon which modern academic institutions and research training are based. In contrast to conventional research’s aim of finding the “right solution” to a problem within a specific disciplinary frame, or even combining theory and concepts from several disciplines, as in interdisciplinary research, transdisciplinary research involves transcending disciplines and academic knowledge altogether. Thus, a transdisciplinary program’s success depends on the sharing and appreciating different ways of looking at, understanding, and managing a problem. Complex adaptive system problems are moving targets, their mitigation requires adaptive capacity, the flexibility to respond, and reorient thinking about the specific threat. This may include resolution of some aspects given current, known circumstances, but requires continually anticipating and preparing for the unpredictable.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparative Effectiveness Research: A Key Component of EBM . . . . . . . . . . . . . . . . . . . . . . . . . . . The Intersection of Evidence-Based Medicine and Comparative Effectiveness Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CER and Continued Medical Education of Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CER and Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implementation of CER in Low to Middle Resource Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indonesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bhutan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The need to focus global healthcare financing on innovative and sustainable health systems that efficiently use existing effective therapies and interventions are major drivers stimulating evidence-based medicine (EBM). Lack of adequate access and high cost of essential medicines and technologies in many countries increases morbidity and mortality as well as costs of healthcare that forces people and families into poverty due to disability and out-of-pocket expenses. In this chapter, we introduce the concept of evidence-based global health and a key methodology used for its conduct – Comparative Effectiveness Evaluation. Enabling the development of effective EBM systems globally paves the way R. Balkrishnan (*) School of Medicine, University of Virginia, Charlottesville, VA, USA e-mail: [email protected] A. Rekulapelli University of Virginia, Charlottesville, VA, USA © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_89

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for tangible local and regional definitions of equity in healthcare, because EBM fosters the sharing of critical assets, resources, skills, and capabilities for the development of multisectorial frameworks to improve health equity, outcomes, and metrics globally. Keywords

Evidence-based medicine · Comparative effectiveness research · Health technology assessment

Introduction Evidence-based medicine (EBM) can be defined as: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 1996). EBM is an integral part of CER and epitomizes the synthesis of clinical outcomes research and its application in clinical practice. EBM places a heavy emphasis on physicians keeping up with new advances in clinical research and utilizing this research to optimize patient care. Nonetheless, with the rapid nature of medical advancement, it becomes difficult for physicians to keep step with the latest research, especially given that physicians must evaluate and apply research in a deliberate manner. A more effective approach to EBM is for a physician to utilize questions regarding patient outcomes and problems to guide research, enabling the physician to address both the problem of the patient and future patients with the same problem, while also developing the physician’s knowledge base. When looking at EBM implementation, it certainly has its merits in various specialized fields, but EBM plays an important role in primary healthcare given the wide diversity in patient backgrounds and ailments. Overview: Five-step Approach for EBM Integration in Primary Healthcare (Masic et al. 2008).

Step 1 is to define the problem presented to the physician by the patient, utilizing the problem to develop a clinical question. Step 2 is to use the clinical question to guide a search for information using medical journals, other electronic databases, and even the help of fellow practitioners. Step 3 is to critically evaluate the information in the context of the physician’s patients. Step 4 is to apply the information to each patient, making sure to note the unique circumstances of each patient and the information’s applicability to the physician’s patient population. Step 5 is to evaluate the efficacy of EBM application, investigating if the physician’s patients responded in a similar way to patients in the studies referenced.

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EBM has a wide-ranging capability to improve medical care globally. Particularly, the establishment of evidence-based guidelines for medical practice that can be implemented in a variety of healthcare scenarios is an important facet of evidencebased medicine. For example, hospitals under the Center for Medicare and Medicaid Services in the United States altered the protocol for admission and care for individuals with community-based pneumonia, a disease that is common across the world. The approach was centered around the change from intravenous to oral antibiotics with the goal of decreasing patients’ length of stay in the hospital. Through the incorporation of an advanced practice nurse to supervise the approach, patients with pneumonia CMS hospitals experienced a decrease in length of stay while having no change in the readmission rate. However, it is also important to recognize that guidelines are not sufficient without the full investment of local stakeholders, namely, physicians and other healthcare professionals (Timmermans and Mauck 2005). Furthermore, in 2016, the World Health Organization (WHO) established a set of recommendations to prevent surgical-site infections, utilizing evidence-based medicine. Surgical-site infections transcend the economic boundaries between high and low- and middle-income countries (LMICs), but often place the largest economic burden on health-care systems in LMICs. Recognizing this burden, the WHO determined 16 evidence-based global recommendations to prevent surgical-site infection. For example, Recommendation 1 suggests that patients who are undergoing surgery with general anesthesia and an endotracheal intubation should receive 80% forced inspired oxygen perioperatively. The meta-analysis of 11 randomized controlled trials (RCTs) found that the use of perioperative oxygen significantly reduces the incidence of surgical-site infections in patients under general anesthesia and an endotracheal intubation. While the ability to obtain bottled oxygen can be difficult for health-care facilities in LMICs, the WHO has strongly encouraged policymakers to make securing bottled oxygen for perioperative use a priority, given its ability to markedly reduce surgical-site infections. Additionally, Recommendation 16 outlined the importance of the discontinuation of surgical antibiotic prophylaxis after a 24-h period postsurgery. Through the meta-analysis of 69 RCTs, the WHO determined that there was no benefit gained from an extended administration of surgical antibiotic prophylaxis. Moreover, the WHO found that such an extended administration of antibiotics can increase the potential for antibiotic resistance to develop. Through evidence-based recommendations by the WHO and other health organizations, EBM can play a crucial role in optimizing healthcare in both a medical and economic context in LMICs across the globe (Allegranzi et al. 2016). Historically, clinical research has provided objective scientific information to healthcare providers about a specific disease condition in terms of its diagnosis, symptoms, manifestations, progression, management, and treatment. This in turn provides the consumers and caregivers a variety of alternatives to evaluate and choose the most appropriate treatment for a specific condition. However, amidst a lack of clear evidence of comparative effectiveness between disease-specific or system specific strategies, the process of making choices that maximize value to the individual while balancing the needs of society for healthcare equity becomes challenging or impossible. This challenge becomes especially apparent when

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considering the diversity in healthcare delivery methods and health-related outcomes across the globe (“National Healthcare Expenditures Data” 2019; “OECD Health Data 2020” 2020; “How Changes in Medical Technology Affect Healthcare Costs” 2007; Mnuchin et al. 2020; Sarata 2020; “Initial National Priorities for Comparative Effectiveness Research” 2009).

Comparative Effectiveness Research: A Key Component of EBM Comparative effectiveness research (CER) informs patients, providers, and caregivers about the most effective treatment option available in a given circumstance by assessing wide-ranging health related outcomes by comparing different interventions such as medications, procedures, medical devices, technologies, behavior change strategies, and healthcare delivery systems (Stafford et al. 2009; Johnson and Chung 2014; Wang et al. 2017; Sox and Greenfield 2009). CER is defined as: “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve healthcare at both the individual and population levels” (“Initial National Priorities for Comparative Effectiveness Research” 2009). This definition indicates that CER must involve direct comparisons between established treatment(s) and valid comparator treatment(s) to show the real marginal benefits of proposed treatment(s). Also, to generalize CER results to an entire healthcare system, the research subjects included in CER studies should be adequately representative of the patient seen typically in different clinical care settings, as appropriate for the circumstance under study (Mushlin and Ghomrawi 2010). The variability of implementation of treatment options is partly responsible for differing costs and outcomes. Particularly within low and middle income countries, increased out-of-pocket health expenditures compounded with limited access to treatment options adversely affects health outcomes (Murphy et al. 2019; Francies et al. 2020; Hannon et al. 2016). The need to reduce the ever-mounting healthcare expenditures along with an efficient usage of the existing therapies is one of the major drivers stimulating rigorous CER across the globe. CER establishes rigorous criteria for the mode of implementation of different options, thus creating a uniform and consistent basis for comparing outcomes. CER conducted in highly resourced nations provides a framework for low- and mid-resource countries to establish and manage an efficient and sustainable comparative effectiveness (CE) program (Clement et al. 2009).

The Intersection of Evidence-Based Medicine and Comparative Effectiveness Research EBM has played an immense role in building the foundation of Comparative Effectiveness Research (CER), which is a closely related approach to EBM (Djulbegovic and Guyatt 2017). In particular, EBM has contributed to the

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development of CER in a global context, particularly in LMICs. For example, there are a growing number of individuals who are hesitant to receive a vaccine and digital reminders have shown some promise in increasing vaccine adherence. A systematic review by Frascella et al. (2020) investigated the comparative effectiveness of email reminders versus paper reminders and no reminders. Through CER, it was determined that email reminders confer a significant increase in immunization rates across the globe, compared to no reminders at all. Furthermore, the ease of mass email distribution has the potential to confer an advantage for emails when compared to traditional paper forms of reminder distribution (Frascella et al. 2020). Beyond the need for greater vaccination coverage, malaria is another health impediment LMICs face. A comparative effectiveness study performed by Wangdi et al. (2018) discerned that, despite the perceived greater effectiveness of prophylactic drugs, insecticide treated nets were the only protective measure that caused a significant decrease in malaria infection when compared to prophylactic drugs, indoor residual spraying, and untreated nets. Utilizing comparative effectiveness research as evidence for the optimization of preventative measures is crucial for LMICs, especially in countries where advanced diagnostic care is few and far between. The intersection of EBM and CER can provide immense benefits to advancing global preventative care and beyond, providing a platform for the discussion and implementation of healthcare interventions tested in real-world scenarios (Balkrishnan et al. 2013). While EBM has extensive benefits on paper, there has been some discord in the implementation of EBM in clinical practice. Due to the aforementioned diversity in patient population, there is a gap between what can be determined from the literature compared to the variety of clinical decisions that need to be made. For example, an anecdotal account by a pediatrician discussed how the use of amoxicillin, perceived to be the gold standard for treating streptococcus infections, failed to prevent reinfections. When the pediatrician switched to cephalosporins, the reinfection rate decreased, yet the American Academy of Pediatrics had yet to alter the recommendations for addressing streptococcus infections. Furthermore, EBM research sometimes proposes treatments that are too expensive for the large majority of patients, forcing physicians to find alternatives not always documented in the literature (Hay et al. 2008). As a whole, however, EBM has a strong ability to be a valuable tool for physicians across the world to optimize care for their patients. If EBM can continue to diversify the clinical situations which it evaluates and develop stronger lines of communication between physicians and researchers, it has the potential to improve health outcomes globally.

Example: CER and Its Application in Drug Development

The process of drug development has been evolving rapidly in recent years. In addition to approval of a drug by regulatory authorities, pharmaceutical companies are witnessing a trend whereby private and public payers are subjecting drugs to health technology assessments (HTAs) to better define their utilization and usefulness in different populations. While HTAs are (continued)

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already commonly implemented in high-income countries, they have been successfully utilized in LMICs such as Vietnam and the Philippines as a way to optimize drug and medical device coverage (Tantivess et al. 2017a). CER can serve as a tool to perform value-based appraisal of HTA and for determining reimbursability. CER employs a “real world” comparison of an upcoming drug or technology with an existing one as a basis to evaluate multiple outcomes of interest for individuals and society. The application of CER thus could be thought to lend holistic appeal to the process of manufacturing pharmaceuticals. One approach to accelerate knowledge acquisition about the exact costeffective applications of drugs would be to encourage pharmaceutical and medical device developers to modify the standard existing R&D (Research & Development) pathways by designing postmarket observational research methods aimed at demonstrating real-world value, addressing multiple investor demands, and formulating a transparent and standardized CER evaluation protocol. The long-term goal of CER should be to steer R&D towards innovation and production of value based products that meet the needs of both the patients and investors (Doyle 2011).

CER and Continued Medical Education of Physicians CER provides a useful aid to physicians to frame and practice evidence-based recommendations specific to unique circumstances faced by patients (Conway and Clancy 2010). For example, CER has been utilized to determine overall survival of breast cancer patients when provided radiotherapy or a combination of radiotherapy and hormonal therapy, producing real-world derived data that can subsequently be implemented by physicians (Ali et al. 2019). Amidst numerous pharmaceuticals and medical technologies, CER assists physicians to recommend options after considering cost effectiveness and safety through the results of CER. Useful outcomes of CER studies can be user friendly, web based decision-making tools that enable the physician to share with the patient the process of entering personalized key parameters found to be useful determinants of efficacy and cost effectiveness. One study showed that physicians arrived at the consensus that CER is an especially useful tool for subpopulations that show variations in treatment response (“MedPAC Presents Study on CER and Physician Perspectives” 2009). Another study found that over 70% of primary care physicians believed that CER could improve the quality of patient care (Manning and Bullard 2015). Once a CER study is conducted, the next equally important step towards widespread utilization of the findings is prompt and targeted physician and healthcare practitioner education about the study’s findings. Part of promoting CER hinges on instilling a culture whereby there is open-mindedness about potential outcomes of CER. For instance, the findings from AHRQ Comparative Effectiveness Review 229, which addressed the use of opioid treatments for chronic pain, indicated that opioids showed no noticeable difference in patients’ pain management when compared to nonopioids

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(Chou et al. 2020). Furthermore, the Clinical Antipsychotic Trials Intervention Effectiveness (CATIE) trial failed to demonstrate effectiveness of certain antipsychotic medications (Grohol 2018).

CER and Medical Devices Comparative effectiveness research (CER) increases beneficial population health outcomes with simultaneous reduction of healthcare costs. In the context of medical technologies such as cardiac stents and prosthetics, there is a growing interest in CER to judge the effectiveness of ubiquitous medical devices (Teng et al. 2018; Qian et al. 2018; Bulsei et al. 2019; Fawsitt et al. 2019). Additionally, CER has started to play a role in reducing cost of disease diagnostic techniques in LMICs (Cambiano et al. 2019; Duchesne et al. 2020). In order to conduct studies comparing the effectiveness of different medical devices and diagnostic methods, it is necessary to classify and build upon appropriate measures that can be tracked and evaluated on the basis of the end results obtained from those studies. Maintaining transparency about reporting adverse events (AE) and off label usage are the two serious concerns that pharmaceutical companies and medical device companies have to face as the focus of regulatory bodies continues to shift towards standards of quality and outcomes. Because medical devices often require complex interventions to be functional (such as orthopedic procedures for joint prostheses or thoracic surgery for certain cardiac devices), the careful reporting of adverse events occurring at different stages of this complex process must be rigorously accounted for in effectiveness research studies. As an example for orthopedic prostheses, AEs that occur in hip and knee replacement procedures amount to about 3.4 and 4.1% of devices implanted, respectively (Wolf et al. 2012; Berg et al. 2018). AEs that occur with Class III medical devices are classified under three categories: AEs during implantation, AEs after implantation, and medical device failure after implantation. One survey studying the complications during medical device implantation by orthopedic surgeons found evidence that the orthopedic surgeons experienced 29% equipment errors during implantation surgery (Wong et al. 2009). The malfunction of implantable defibrillators resulting in failure and fracture during attempts at resuscitation exemplify other aspects of device failure that belong in a thorough analysis of their effectiveness in comparison to supportive management with physical therapy and medicines (Kallinen et al. 2008; Maisel 2008). Even though device failures in CER are relatively uncommon, when these occur after approval has been issued, it causes enormous burden on the regulatory authorities to restrict approval of such devices or to end the further distribution of ineffective or faulty devices, if these are already in the market (Maisel 2005). For example, the total reverse shoulder prostheses was initially developed and approved for glenohumeral arthritis with an irreparable rotator cuff or irreparable rotator tear and glenohumeral instability. However, physicians now use these prostheses for the treatment of osteoarthritis of the shoulder (Frankle et al. 2006; Wright et al. 2020). While clinical and outcomes data have increased in prevalence regarding the

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potential risks and benefits of the widespread off label use of these prostheses, it is still imperative to organize objective outcomes information to assist patients and doctors in making treatment decisions. Patient registries that record outcomes data about medical device usage in real-world clinical settings can be a useful source for obtaining valuable safety information for both the physicians and the patients.

Implementation of CER in Low to Middle Resource Countries Overview: WHO Model List of Essential Medicines

The WHO Model List of Essential Medicines has been a gold standard reference list for over 40 years for nations looking to develop essential medicine lists for their health guidelines. Pharmaceutical costs can account for upwards of 50% of health spending in developing countries, making it crucial for health agencies in low- and middle-income countries to comparatively evaluate medicines and treatment methods in the context of cost and efficacy. With the rapidly changing nature of disease treatment and prevention, the Model List of Essential Medicines offers a flexible list of medicines that can be tailored on a country-by-country basis through the implementation of the Model List and the subsequent large-scale evaluation of medication costeffectiveness. Furthermore, for countries looking to develop universal health coverage, the Model List of Essential Medicines can help nations construct medication reimbursement schemes around commonly used medicines. Overall, the Model List of Essential Medicines provides countries with a valuable framework for the creation of nation-specific medication lists and the comparative evaluation of medications within such lists for cost effectiveness (“Essential Medicines”).

This section presents an overview on ongoing efforts and challenges in low to middle income countries, surrounding the successful implementation of CER programs including CER definition, appropriate use of CER, scope of CER, and financing CER. These issues are especially pertinent when considering the diversity of current healthcare systems across the world. CER is assessment of clinical effectiveness and is different from cost effectiveness and cost-benefit analysis. This difference should be explained to the researchers and various another stakeholders funding and participating in the CER program. It should also be clarified if CER will include assessment of only drugs, medical devices, and procedures or if the scope of the same should be broadened to include healthcare delivery, integrative health practices, and chronic disease management interventions. The use of CER evaluations by the public health system can vary. CER provides information to physicians and patients to help them make better decisions. Hence, it is possible that CER evaluations might be considered similar

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to patient reported outcomes research. It is important to clearly define the scope and depth of the CER program. The nature of CER research in terms of setting priorities and the person appointed to do so can sometimes challenge the authority and power of the various key stakeholders involved. The role of identifying priority topics and research questions for CER evaluations should not be affected if the stakeholders are nongovernmental or are manufacturer of pharmaceuticals, drugs, and devices. Another challenging aspect is to make sure that the populations for whom a particular therapy is not generalizable are not being discriminated against. It is advisable to involve nonprofit corporations for the sake of protecting the interests of the people as well as to ensure fair CER evaluations. Even though the presence of diverse practice patterns, especially among private practitioners, can hinder the uniform use of the CER based guidelines, these might be appropriate to local settings based on the physical and cultural characteristics of the population. Some questions might be better answered by healthcare personnel working in the healthcare facilities while some questions are better answered by stakeholders making the important healthcare policy decisions. In low resource countries with limited funds, it is challenging to provide funding in a sustainable manner. Also, once the CER guidelines are in place, the challenge lies in deciding whether CER should drive the physician decision making or should incentives be provided to physicians to follow CER based guidelines (“Methods Guide for Effectiveness and Comparative Effectiveness Reviews”).

Overview: Recommendations for Launching a Sustainable CER Program at the National Level (National Academy of Medicine, USA)26

(i) Selection of CER topics should be made with regards to emerging disease conditions, practical interventions, and public need. (ii) A successful CER program requires significant participation from everyone including stakeholders, people, physicians, healthcare personnel, and patients. The process of outlining and designing research questions should involve public participation. (iii) The potential CER topics should be selected on the basis of protocols with strong evidence of literature, robust methodology, and practical interventions. The protocols should be designed by researchers who are experts in their fields and who have updated knowledge of treatment guidelines. (iv) An updated portfolio of the ongoing CER study should be maintained by researchers to provide evidence of continuous quality improvement to the prioritizing body. (v) An advisory panel overlooking the application and utility of the CER program should be established. Studies should be designed to include (continued)

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(vi)

(vii)

(viii)

(ix) (x)

and advantage racial and ethnic minorities and underrepresented patients like elders and children. Support and participation from patients, healthcare personnel, and physicians is essential at every step of CER namely, developing, planning, prioritizing, peer reviewing, and publishing. CER studies involving observational data and data from clinical trials should be guided by accurate and valid methodology, informed by prior research and be likely to be prospective or longitudinal in nature. The studies should also evaluate short term and long-term advantages and disadvantages. The focus of the CER studies should be directed towards patient outcomes measures like morbidity, mortality, and quality of life. There is a need for establishment of centralized data networks for consolidating data to assure its efficient usage. The studies performed using such data can thus drive real-world clinical decisions that can aid in better decision making for the public, patients, clinicians, or policy makers. Provision of financial and technical support can improve the capacity of the CER workforce to successfully conduct CER research. The CER program should be characterized by effective utilization of CER findings, speedy distribution of information based on new and old CER findings among healthcare personnel, and adoption of CER recommendations to drive current practice guidelines (VanLare et al. 2010).

India Indian officials in the Ministry of Health and Family Welfare have worked closely with the iDSI (International Decision Support Initiative), formerly known as NICE International, since 2013. This partnership characterized by exchange of guidelines, development methods, case studies, and discussions can foster establishment, adaption, and standardization of both the existent and new clinical guidelines. In particular, iDSI and the Ministry of Health and Family Welfare have collaborated with the common goal of establishing of universal health coverage in India through institutionalization of HTA and evidence-based medicine. iDSI has worked to support HTAIn, India’s first national HTA agency, in order to optimize decision-making in a diverse patient population. HTAIn has already shown promise, optimizing the use of an intraocular lens to address cataracts. This program was conducted under India’s main national health insurance program, PMJAY, or Pradhan Mantri Jan Arogya Yojana (“India”). Furthermore, HTAIn has been at the forefront of the establishment of a National Health System Cost Database, which informs providers of the costs of inpatient and outpatient services utilizing data retrieved from six states (“India”; “National Health System Cost Database for India”).

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On a state level, iDSI has developed a partnership with the state of Kerala to develop STGs (standard treatment guidelines) and utilized to provide more costeffective and higher quality care. In particular, the STG associated with hypertension focuses on improved detection and control of hypertension, while integrating hypertension data with Kerala’s state medical record system, Aadhar. During a two-day training initiative, 46 doctors and 57 nurses from six districts in Kerala were informed regarding detection and control of hypertension. Through the implementation of STGs, the prevention of up to 966 cardiac events along with $1.23 million in savings is estimated by iDSI for Kerala (Mehndiratta and Cluzeau 2017a, b). These evidence-informed quality standards have similarly extended to addressing maternal deaths in Kerala. As NICE International, iDSI was able to implement a pilot program in April 2013 that strove to improve and standardize obstetric care. iDSI identified postpartum hemorrhage and hypertension as the largest causes of maternal death in Kerala and established five quality standards for each cause. Improved management of the third and fourth stages of labor, use of sterile delivery kits and oxytocin during labor, the accurate measurement of maternal blood loss, and better record keeping were the main changes implemented by iDSI in order to accord with the quality standards. From 2011 to 2013, the maternal mortality rate in Kerala was 61 deaths per 100,000, but after the quality standards were implemented, the rate has dropped to 46 deaths per 100,000 between 2014 and 2016 (Vlad et al. 2016). Hopefully, in the years to come, with the aid of iDSI, the Indian states can set an example for the neighboring nations by working synergistically towards a wellregulated healthcare system in the nation.

China HTA was initially introduced to China in the 1980s, and particularly gained traction among universities in the 1990s, culminating in a national HTA conference in 1999 that focused on reproductive medicine technologies and gamma knife surgery. At the turn of the century, policy making became of greater emphasis in HTA research in China, along with both keystone and novel technologies such as magnetic resonance imaging and the Da Vinci surgical apparatus, respectively. However, it was in 2017 where HTA became fully implemented into the Chinese pharmaceutical industry, through the National Reimbursement Drug List, or NRDL. In 2017, the Ministry of Human Resources and Social Security (MOHRSS) brought an evidence-based approach to the NRDL, using HTA as a key component in the determination of drugs that would be covered by the national health insurance policy. With the guidance of HTA, MOHRSS discerned which drugs should be included, which drugs should not be included, and which drugs should be included but had a higher than desired cost. Subsequently, MOHRSS negotiated with manufacturers of highcost drugs, requiring producers to outline clinical and economic benefits of their drugs. Through this process, MOHRSS was able to reduce the prices of 36 drugs in the NRDL by an average of 44%, increasing accessibility while mitigating costs for Chinese citizens (Chen et al. 2018).

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iDSI has also been involved in the development of comparative effectiveness research through HTA in China. In 2018, iDSI sponsored the establishment of the National Center for Medicine and Health Technology Assessment (NCMHTA), which will play a crucial role in maintaining and updating the Essential Medicines List (EML) using HTA (“China”). Furthermore, the Chinese government has also developed the China Health Outcomes Research Alliance to lead patient outcomecentered research that is culturally sensitive to the needs of 1.4 billion Chinese citizens and utilize social media to collect data on common diseases and disorders in China (Richards 2018). Overall, China has shown a commitment to developing HTA and outcome-centered research to develop a streamlined path towards universal health coverage rooted in patient benefit.

Indonesia The Package of Essential Noncommunicable disease (PEN) intervention program has been implemented by the World Health Organization (WHO) to provide costeffective screening and treatment of common noncommunicable diseases like asthma, hypertension, and diabetes in LMICs (“Tools for Implementing WHO PEN (Package of Essential Noncommunicable Disease Interventions”). Noncommunicable diseases are the cause of 73% of all deaths in Indonesia, which has implemented PEN in the past decade to address this growing epidemic (“Indonesia”). In 2016, WHO, iDSI and Indonesia’s Ministry of Health collaborated on a study to determine the cost-effectiveness of diabetes and hypertension screening and treatment under the PEN program and use the data to inform policy decisions and further develop the potential for HTA in Indonesia. The study found that the PEN program was more cost-effective than no screening and treatment plan, but also developed a policy plan that was more cost-effective than the PEN plan while also limiting loss of health benefits. Rather than localizing screening and treatment to two different facilities, the study found that both screening high-risk individuals and providing subsequent treatment at primary healthcare facilities enables the Indonesian government to expand diabetes and hypertension screening coverage from 28% under the PEN program to 63% of the population (Rattanavipapong et al. 2016). Beyond developing cost-effective diabetes and hypertension screening, iDSI has also collaborated with the Ministry of Health’s HTA Committee to optimize the Jaminan Kesehatan Nasional (JKN), Indonesia’s national health insurance scheme, which covers over 200 million Indonesian citizens. iDSI has identified a potential 31.9 million dollars in savings for the JKN, particularly making in-roads in 2018 to remove two cancer drugs from the JKN, cetuximab and bevacizumab, which are commonly utilized for the treatment of metastatic colorectal cancer (“Indonesia”). Through various HTA studies, the elimination of bevacizumab was found to have a minimal adverse effect on the Indonesian population, while saving the JKN 151 million Indonesian rupiah, or upwards of $10,000 per patient (Endarti et al. 2018). Cetuximab similarly incurs a high cost for the JKN. Compared to the total 0.6 trillion Indonesian rupiah budget impact for standard metastatic colorectal cancer treatment,

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the addition of cetuximab drastically increases the budget impact to 1.3 trillion Indonesian rupiah. Similar to bevacizumab, the addition of cetuximab to a metastatic colorectal cancer regimen offers minimal benefit to the patient, making it a costineffective approach. Furthermore, 55% of cetuximab prescriptions were found to have been prescribed inappropriately, failing to follow the Indonesia National Drug Formulary, incurring a cost of approximately 25 billion Indonesian rupiah per year for the JKN (Megraini et al. 2018). Overall, through HTA and cost-effectiveness analysis, the partnership between iDSI and the Indonesian government has already proven to provide millions in savings for the JKN, while optimizing care for a diverse Indonesian citizenry.

Bhutan iDSI has started to develop a robust HTA system in Bhutan, recently spearheading the implementation of a nationwide vaccination effort against pneumococcal disease (“Bhutan”). Pneumococcal diseases, including meningitis, bacteremia, pneumonia, and acute otitis media, have high incidence rates in Bhutan and other Asian countries, leading Bhutan’s national health agency to spend a considerable portion of its budget on the treatment of these diseases. A study was undertaken by iDSI and the Bhutan Ministry of Health to investigate the cost-effectiveness of two pneumococcal vaccines, PCV10 and PCV13. Compared to no treatment, it was found that the introduction of PCV10 and PCV13 would increase the national spending by 591 and 578 thousand dollars over five years, while averting 3,177 and 2,214 pneumococcal episodes, respectively. It was then determined that both vaccines were cost-effective at the projected price points, but PCV13 was the most cost-effective, given the lower cost and greater number of potential cases averted (Dorji et al. 2018). Subsequently, the Bhutan cabinet moved to introduce the PCV13 vaccine into the national immunization protocol in 2018. Given this success, the Bhutan Ministry of Health has now started to utilize HTA in order to evaluate the inclusion of the rotavirus vaccine, further strengthening the integration of HTA and cost-effectiveness analysis into the country’s healthcare system (“Bhutan”).

Ghana Ghana was the first sub-Saharan African nation to institute a tax-funded nationwide health scheme, establishing the National Health Insurance Scheme (NHIS) in 2003. However, due to the high prevalence of hypertension in Ghana, 60% of the NHIS budget for medications is allocated towards anti-hypertensive drugs (“Ghana”). iDSI and the Ghana Ministry of Health collaborated on a subsequent case study in 2017 that found thiazide-like diuretics and calcium-channel blockers to be the most costeffective anti-hypertensive drugs. Using this information, iDSI looked to further reduce the cost of the aforementioned drugs, determining that price negotiation could elicit a 10% decrease in medication spending, or $5.6 million dollars.

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Furthermore, it was found that under 25% of these savings could then go towards providing diuretics to all untreated hypertensive individuals in Ghana, vastly improving health outcomes nationwide. Acknowledging these benefits, iDSI, and the Ghana Ministry of Health subsequently revised the nation’s Standard Treatment Guidelines for hypertension (“Making the Case for HTA in Ghana”). Moving forward, the institutionalization of HTA and cost-effectiveness analysis is poised to play an instrumental role in Ghana’s goal of universal health coverage by 2030 (“Ghana”).

Conclusion Globally, every country’s healthcare system is in need or in the process of some type of reform. Escalating costs of healthcare have put immense pressure on payers, especially government healthcare systems to make investments in the most costeffective technologies. However, we will not know what medical technologies work effectively in a particular country unless we have longitudinal real-world outcome databases that allow us to examine these issues. The diversified healthcare systems across the globe require investment in CER to fill the void of providing to the public; credible, up-to-date and scientifically based comparative effectiveness information about drugs and other health interventions. In turn, usage of CER creates opportunities for provision of more efficient, high-quality healthcare and encourages development of innovative products that offer measurable value to patients. There is wide-ranging evidence to suggest that CER will be a stimulus for the academic, medical and public health communities in low to middle resource countries to develop a research agenda that is responsive to the needs of the clinical community, providing healthcare professionals with information for clinical decision making (Anderson et al. 2012; Conway and Clancy 2010; Saokaew et al. 2016; Preusse et al. 2020). Harmonization of administrative medical claims data and patient registries is an important first step in this direction, and so is the development of longitudinal registries and nationally representative population-based surveys covering health, nutrition, and medical care delivery. These efforts require significant human resources and technology investments, and therefore, of particular importance is getting stakeholders involved right from the government to healthcare providers uniformly across countries. One of the key factors which will drive the success of global comparative effectiveness evaluations is the investment in health informatics and preventive medicine across the board in every country, and especially in low to middle income countries, partnerships with international centers devoted to global health research will foster the development of longitudinal database capabilities to track the quality and effectiveness of extant medical care. The National Health Insurance Research Database in Taiwan is a good example of an effort to harmonize healthcare data collected under a unified payer system. This database includes healthcare data from Taiwan’s 23 million citizens and is being used to make effective evidence-based medical care policy in this country. Changing the global climate so that healthcare

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decision makers favor data from CER will create disincentives for the development of “me-too” medical technologies and render CER a catalyst for effective innovation. The first step in developing such capabilities globally is recognizing that health informatics is a cost-effective investment to improve quality of healthcare and maximizing the use of health informatics capabilities to track longitudinal medical technology driven outcomes in populations. The development of effective global comparative effectiveness systems requires a commitment from all the players in the country’s healthcare system to the concept of objective data driven healthcare effectiveness evaluation and policy making globally. The investment in technology resources needs to be complemented with a parallel investment in human resources devoted to this task. The time is right to form groups of “worker bees” globally who will devote the time, energy, and attract investments of governments (for developed countries) and philanthropists (for underdeveloped countries) in healthcare data harmonization efforts across the globe. To enable the development of effective CER systems globally, an understanding for the concept of equity in healthcare and global effectiveness of healthcare is essential. In addition, there needs to be willingness to share critical assets, resources, skills, and capabilities to facilitate the evaluation of the burden of a particular disease/condition in a region and development of collaborative frameworks to improve health outcomes and metrics globally. Finally, it is important to develop sustainable implementation science which will enable appropriate monitoring and evaluation of effective healthcare technologies and strategies to serve generations of future populations whose healthcare outcomes will continuously benefit from these investments in healthcare systems.

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Cambiano V, Johnson CC, Hatzold K et al (2019) The impact and cost-effectiveness of communitybased HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis. J Int AIDS Soc 22(Suppl 1):e25243. https://doi.org/10.1002/jia2.25243 Chen Y, He Y, Chi X et al (2018) Development of health technology assessment in China: new challenges. Biosci Trends 12:102–108. https://doi.org/10.5582/bst.2018.01038 Chou R, Hartung D, Turner J et al (2020) Opioid treatments for chronic pain [internet]. Agency for Healthcare Research and Quality (US), Rockville; 2020 Apr. (Comparative Effectiveness Review, No. 229.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK556253/ Clement FM, Harris A, Li JJ et al (2009) Using effectiveness and cost-effectiveness to make drug coverage decisions: a comparison of Britain, Australia, and Canada. JAMA 302:1437–1443. https://doi.org/10.1001/jama.2009.1409 Conway PH, Clancy C (2010) Charting a path from comparative effectiveness funding to improved patient-centered healthcare. JAMA 303:985–986. https://doi.org/10.1001/jama.2010.259 Djulbegovic B, Guyatt GH (2017) Progress in evidence-based medicine: a quarter century on. Lancet 390:415–423. https://doi.org/10.1016/S0140-6736(16)31592-6 Dorji K, Phuntsho S, Pempa et al (2018) Towards the introduction of pneumococcal conjugate vaccines in Bhutan: a cost-utility analysis to determine the optimal policy option. Vaccine 36:1757–1765. https://doi.org/10.1016/j.vaccine.2018.02.048 Doyle J (2011) The effect of comparative effectiveness research on drug development innovation: a 360° value appraisal. CER 27. https://doi.org/10.2147/CER.S15478 Duchesne L, Hejblum G, Njouom R et al (2020) Model-based cost-effectiveness estimates of testing strategies for diagnosing hepatitis C virus infection in Central and Western Africa. PLoS One 15:e0238035. https://doi.org/10.1371/journal.pone.0238035 Endarti D, Kristin E, Pinzon R, Pratiwi WR, Nugrahaningsih DAA, Setiawan D, et al (2018) Policy brief: should high cost bevacizumab be used for metastatic colorectal cancer (mCRC) treatment in JKN in Indonesia? Available from: http://www.globalhitap.net/wp-content/uploads/2019/01/ PB_Bevacizumab-2019.01.14_final.pdf Fawsitt CG, Thom HHZ, Hunt LP et al (2019) Choice of prosthetic implant combinations in total hip replacement: cost-effectiveness analysis using UK and Swedish hip joint registries data. Value Health 22:303–312. https://doi.org/10.1016/j.jval.2018.08.013 Francies FZ, Hull R, Khanyile R, Dlamini Z (2020) Breast cancer in low-middle income countries: abnormality in splicing and lack of targeted treatment options. Am J Cancer Res 10:1568–1591 Frankle M, Levy JC, Pupello D et al (2006) The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am 88(Suppl 1 Pt 2):178–190. https://doi. org/10.2106/JBJS.F.00123 Frascella B, Oradini-Alacreu A, Balzarini F et al (2020) Effectiveness of email-based reminders to increase vaccine uptake: a systematic review. Vaccine 38:433–443. https://doi.org/10.1016/j. vaccine.2019.10.089 Grohol JM (2018) Psychiatrists, MDs ignore CATIE, keep prescribing atypicals. World of Psychology. 2018. Jul 8. Available from: https://psychcentral.com/blog/psychiatrists-mds-ignorecatie-keep-prescribing-atypicals/. Accessed on 15 Sept 2020 Hannon B, Zimmermann C, Knaul FM et al (2016) Provision of palliative care in low- and middleincome countries: overcoming obstacles for effective treatment delivery. J Clin Oncol 34:62–68. https://doi.org/10.1200/JCO.2015.62.1615 Hay MC, Weisner TS, Subramanian S et al (2008) Harnessing experience: exploring the gap between evidence-based medicine and clinical practice. J Eval Clin Pract 14:707–713. https:// doi.org/10.1111/j.1365-2753.2008.01009.x Johnson SP, Chung KC (2014) Comparative effectiveness research in hand surgery. Hand Clin 30:319–327, vi. https://doi.org/10.1016/j.hcl.2014.04.001 Kallinen LM, Hauser RG, Lee KW et al (2008) Failure of impedance monitoring to prevent adverse clinical events caused by fracture of a recalled high-voltage implantable cardioverterdefibrillator lead. Heart Rhythm 5:775–779. https://doi.org/10.1016/j.hrthm.2008.02.039

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Sox HC, Greenfield S (2009) Comparative effectiveness research: a report from the Institute of Medicine. Ann Intern Med 151:203–205. https://doi.org/10.7326/0003-4819-151-3200908040-00125 Stafford RS, Wagner TH, Lavori PW (2009) New, but not improved? Incorporating comparativeeffectiveness information into FDA labeling. N Engl J Med 361:1230–1233. https://doi.org/10. 1056/NEJMp0906490 Tantivess S, Chalkidou K, Tritasavit N, Teerawattananon Y (2017a) Health technology assessment capacity development in low- and middle-income countries: experiences from the international units of HITAP and NICE. F1000Res 6:2119. https://doi.org/10.12688/f1000research.13180.1 Tantivess S, Chalkidou K, Tritasavit N, Teerawattananon Y (2017b) Health technology assessment capacity development in low- and middle-income countries: experiences from the international units of HITAP and NICE. F1000Res 6:2119. https://doi.org/10.12688/f1000research.13180.1 Teng M, Zhao YJ, Khoo AL et al (2018) Cost-effectiveness analysis of biodegradable polymer versus durable polymer drug-eluting stents incorporating real-world evidence. Cardiovasc Ther 36:e12442. https://doi.org/10.1111/1755-5922.12442 Timmermans S, Mauck A (2005) The promises and pitfalls of evidence-based medicine. Health Aff 24:18–28. https://doi.org/10.1377/hlthaff.24.1.18 VanLare JM, Conway PH, Sox HC (2010) Five next steps for a new national program for comparative-effectiveness research. N Engl J Med 362:970–973. https://doi.org/10.1056/ NEJMp1000096 Vlad I, Paily VP, Sadanandan R et al (2016) Improving quality for maternal care - a case study from Kerala, India. F1000Res 5:166. https://doi.org/10.12688/f1000research.7893.1 Wang Z, Whiteside SPH, Sim L et al (2017) Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis. JAMA Pediatr 171:1049–1056. https://doi.org/10.1001/jamapediatrics. 2017.3036 Wangdi K, Furuya-Kanamori L, Clark J et al (2018) Comparative effectiveness of malaria prevention measures: a systematic review and network meta-analysis. Parasites Vectors 11:210. https:// doi.org/10.1186/s13071-018-2783-y Wolf BR, Lu X, Li Y et al (2012) Adverse outcomes in hip arthroplasty: long-term trends. J Bone Joint Surg Am 94:e103. https://doi.org/10.2106/JBJS.K.00011 Wong DA, Herndon JH, Canale ST et al (2009) Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am 91:547–557. https://doi.org/10.2106/JBJS.G.01439 Wright MA, Keener JD, Chamberlain AM (2020) Comparison of clinical outcomes after anatomic total shoulder arthroplasty and reverse shoulder arthroplasty in patients 70 years and older with glenohumeral osteoarthritis and an intact rotator cuff. J Am Acad Orthop Surg 28:e222–e229. https://doi.org/10.5435/JAAOS-D-19-00166

Part XI Global Environmental Health

Environment, Biodiversity, and Planetary Health: Links Between Natural Systems and Human Health

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Suneetha M. Subramanian and Unnikrishnan Payyappallimana

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy Developments in the Context of Biodiversity and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthy Planet and Healthy People: Implementation of Integrated Approaches . . . . . . . . . . . . . Agrobiodiversity, Food, and Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Traditional Medicine, Health, and Livelihoods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . One Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Landscapes, Health, and Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Degradation of the environment and loss of biodiversity are negatively affecting human health and well-being. It has been estimated that environmental factors account for about one quarter of the global burden of diseases. Over the years, several conceptual framings that link human health to nature have evolved including Biodiversity and Health, Planetary Health, Ecohealth, One Health, Health in socio-ecological systems – all of which take a systems approach to addressing human well-being with the natural environment. Policy forums including the World Health Organization and the Convention on Biological Diversity have undertaken a joint program of work and independent guidance to their member states to advocate for synergizing policy approaches on environment and health. This chapter through literature review and illustrative examples highlights these various efforts and the necessity and feasibility of implementing such integrated approaches at multiple levels of implementation.

S. M. Subramanian (*) · U. Payyappallimana UNU-IIGH, United Nations University, Tokyo, Japan e-mail: [email protected]; [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_90

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Keywords

Health and Biodiversity · Environment and Health · Planetary Health · Socioecological systems · Community health

Introduction Environmental factors account for about one quarter of the global burden of diseases (WHO 2016). Much has been written about the environmental and social determinants and drivers of health. The World Health Organization (WHO) has been consistently highlighting the interconnectedness between environmental management and health security over several decades (WHO 2012, 2016). In 2012, along with the three Rio conventions (UNFCCC, UNCBD, UNCCD), the WHO published a report titled “Our Planet, Our Health, Our Future” (WHO 2012 ibid). Linking health priorities to changes in biodiversity, climate, and desertification, the report specifically suggested the need for more integrated indicators of health and natural systems in the sustainable development goals (SDG). The report also focused on the importance of traditional knowledge to ensure health and well-being. A more recent report by the WHO (2016) cited above looks at specific diseases and their links with environmental factors through a detailed yet linear approach. The 72nd World Health Assembly agenda document (A72/15) on Health, Environment and Climate Change has comprehensively highlighted a vision in relation to the 2030 SDGs. It aims “to provide a vision and way forward on how the world and its health community need to respond to environmental health risks and challenges until 2030, and to ensure safe, enabling and equitable environments for health by transforming our way of living, working, producing, consuming and governing.” The document discussed major challenges such as air and water pollution, inadequate sanitation and hygiene, vector-borne diseases, chemical exposures, food and nutritional safety and security, climate change events, and non-dominant (within the health sector) dimensions such as biodiversity loss and ecosystem instabilities; loss of livelihoods and equity; lack of infrastructure, resources, and institutional capacities for health protection; knowledge-gaps; and lack of policy coherence in tackling the complexity. The increasing complexity and intersectorality in tackling health have resulted in diverse perspectives at the nexus of environment and health such as Biodiversity and Health, Planetary Health, One Health, Ecohealth, Health in socioecological systems among others (see Table 1 for a snapshot of elements that characterize these different perspectives). Over the last two decades, there has been considerable literature highlighting the links between biodiversity and health, including calls for a stronger interface between science, policy, and society. The Convention on Biological Diversity (CBD) is perhaps the most influential policy forum that highlights the intricate links between environment, biodiversity, health, and well-being and urges countries and stakeholders to take integrated actions. Over several decisions and cross-cutting

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Table 1 Elements relating to different perspectives linking human health, biodiversity, and environment Perspective Biodiversity and Health

Definition/scope “Biodiversity underpins ecosystem functioning and the provision of goods and services that are essential to human health and well-being”

Planetary Health

“The achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems— political, economic, and social—that shape the future of humanity and the Earth’s natural systems that define the safe environmental limits within which humanity can flourish. Put simply, planetary health is the health of human civilisation and the state of the natural systems on which it depends”

One Health

“One Health’ is an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes”a “The areas of work in which a One Health approach is particularly relevant include food safety, the control of

Approach “Human beings are an integral, inseparable part of the natural world, and that our health depends ultimately on the health of its species and on the natural functioning of its ecosystems”(Chivian And Bernstein 2008) “Situates human health within human systems. The threats that our species faces are not abstract physical risks, such as disease, climate change, ocean acidification, or chemical pollution. The risks we face lie within ourselves and the societies we have created” “Planetary health concerns the natural systems within which our species exists—for example, the health and diversity of the biosphere. Human beings live within a safe operating space of planetary existence” (Horton and Lo 2015) Scope includes agriculture, food safety and security, nutrition, livestock farming and veterinary sciences, anti-microbial resistance, newly emerging and reemerging infectious diseases (EID), zoonotics, pollutants, environmental health, conservation medicine, entomology, water systems, global trade,

Reference Connecting Global Priorities – Biodiversity and Human Health- A State of Knowledge Review” – Jointly published by WHO and CBD (2015)

Whitmee, S. et al. “Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health.” The Lancet 386.10007 (2015): 1973–2028

https://www.who.int/ features/qa/one-health/ en/

(continued)

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Table 1 (continued) Perspective

Ecohealth

Health in socialecological systems (HSES)

a

Definition/scope

Approach

zoonoses (diseases that can spread between animals and humans, such as flu, rabies and Rift Valley Fever), and combatting antibiotic resistance (when bacteria change after being exposed to antibiotics and become more difficult to treat)” It is a “holistic, transdisciplinary, and cross-sectoral approach, emphasizing the intimate interconnections between ecosystem health, human health, and social justice”

climate change, biodiversity and ecosystems, land degradation, integrative medicine, public health, and wildlife conservation

This includes a combination of One health, ecosystem health, systems biology, and SES approaches

Founded upon and guided by the principles of the ecosystem approach. In particular, it aims to consider how biological, physical, social, and economic environments mediate human health outcomes in research, policy, and practice “HSES moves beyond “One Health” and “Ecohealth” expecting to identify emerging properties and determinants of health that may arise from a systemic view ranging across scales from molecules to the ecological and sociocultural context, as well from the comparison with different disease endemicities and health systems structures”

Reference

CBD/SBSTTA/21/9 – Guidance on Integrating Biodiversity Considerations Into One Health Approaches (SCBD, 2017)

Zinsstag J, Schelling E, Waltner-Toews D and Tanner M, (2011), From “one medicine” to “One Health” and systemic approaches to health and well-being, Preventive Veterinary Medicine 101: 148–156

https://www.who.int/features/qa/one-health/en/

areas of work (highlighted further below), the CBD has been constantly highlighting the importance of biodiversity and ecosystem functions to ensure human health. The close links between biodiversity and health were well elaborated in two seminal publications in the last decade – Chivian and Bernstein (2008) fully explored how biodiversity loss endangers human health, by systematically documenting the different ways biodiversity links to health across multiple sectors. Secondly, the Millennium Ecosystem Assessment (2005) published a volume on

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ecosystems and human well-being/health that highlighted three dimensions: (1) direct negative health impacts due to ecosystem changes (viz., increased disasters, pollutants, water shortage, etc.); (2) ecosystem-mediated health impacts (viz., infectious disease risk, reduced food and nutrition, natural medicines, and cultural services); and (3) indirect health impacts (viz., livelihood loss, population displacement, conflicts, etc.). The report also critically reflected on questions of priority actions at global, regional, and local level and policy implications. In 2015, the WHO and CBD published a comprehensive state-of-the-art knowledge review as a compendium on the nexus between biodiversity and health (CBD and WHO 2015). The publication covered an array of relevant topics including broad science-policy perspectives to more specific areas such as water and air quality; sustainable production and consumption; agrobiodiversity and nutrition; physical, mental, and spiritual health including landscapes and healing; infectious diseases; lifestyle and NCDs and microbial diversity; climate change and disasters; and traditional medicine and natural products, among others. Following the publication of this report, a joint program of work was set up between the WHO and the CBD to advance knowledge, policy advocacy, and implementation in related areas. In the meantime, various decisions within the CBD by member countries provided clear guidance on mainstreaming biodiversity into the health sector (highlighted further below). Conceptually, new integrated perspectives, such as Planetary health, One Health, Eco-social health, etc., have evolved that look at links between natural systems and health in a comprehensive and integrated manner. These are multidisciplinary and multisectoral processes and can help us to better analyze and evaluate the interactions between different variables to better develop more coordinated, coherent, and integrated science-policy-practice interfaces. In 2015, the Rockefeller Foundation-Lancet Commission on planetary health published a seminal report titled “Safeguarding human health in the Anthropocene epoch.” The report highlights the inseparable link between human life and natural systems and the challenges relating to high degradation of natural systems and the attendant challenges of governance and organization of knowledge. Apart from these there is a swiftly growing body of academic literature on One Health, eco-social health, and other innovative approaches. These may be considered as novel intersectoral perspectives on environmental determinants and health. These initiatives have been driven by the emergence of new infectious diseases; rapid increases of noncommunicable diseases (NCD); rising morbidity due to ecosystem and climatic changes; increased awareness of challenges of chemical use in human and livestock farming like antibiotics, fertilizers, and pesticides in agro-ecological systems; and so on (WHO 2012). An ecological public health model has been proposed by the Planetary Health commission that integrates the “material, biological, social, and cultural aspects of public health and accepts the complexity and non-linearity of the dynamics of natural systems.” The model stresses not only how ecosystems underpin human health but also makes the case for widening the responsibility for health across disciplines and sectors beyond the traditional confines of the health sector.

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The 12th Conference of the Parties of the Convention on Biodiversity in decision XII/21 (https://www.cbd.int/decision/cop/?id¼13384), recognized the value of the “One Health” approach to address the cross-cutting issue of biodiversity and human health, as an integrated perspective consistent with the ecosystem approach (decision V/6) that encompasses the complex relationships between humans, microorganisms, animals, plants, agriculture, wildlife, and the environment. “It is an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes.” As an interdisciplinary and cross-sectoral approach, it seeks to examine holistically interconnections among human and environmental or ecosystem health. Further, One Health is a highly intersectoral strategy involving multiple stakeholders such as epidemiologists, veterinarians, ecologists, urban planners, structural and environmental engineers, geologists, hydrologists, climatologists, geospatial scientists, botanists, parasitologists, microbiologists, and local communities, among others. The ecological dimensions of health (Eco-health) and One Health are closely linked. Determinants such as ecosystem change, land use changes, and climate change are yet to get sufficient attention. Major ecosystem changes through forest conversion for plantations and resultant biodiversity erosion, intensification of livestock farming resulting in high human and domestic animal densities, growing intensification of trade, contamination of food chain with antibiotics and pesticides, increasing zoonotics and newly emerging and re-emerging infectious diseases, forest fires and transboundary haze pollution, and increasing urbanization are significant environmental drivers affecting health. Whereas the negative and proximate drivers of “ill-health” often get good traction in an overly medicalized world, there are significant positive contributions of environment and ecosystems toward good health and well-being that need better attention. These drivers include access to food, cultural and medicinal resources, therapeutic (healing) landscapes, and ecological benefits such as clean air, safe water, and safeguards from natural disasters, among others (MA 2005; SCBD and WHO 2015).

Policy Developments in the Context of Biodiversity and Health Strengthening linkages explicitly between biodiversity conservation and health goals have gained increasing emphasis since the Conference of the Parties-10 of the CBD (Decision X/20). COP-12 of the CBD calls for specific action on biodiversity and health urging related sectors and agencies to work in a more coherent matter (Decision XII/21). The different dimensions related to biodiversity and health objectives are captured across various goals and targets of the Aichi Targets of the New Strategic Plan of the CBD (Targets 4, 5, 7, 12, 13, 14 and 18) and further strengthened by subsequent decisions of the Subsidiary Body on Scientific, Technical and Technological Advice (SBSTTA). Associated indicators relevant to biodiversity and health include trends in benefits that humans derive from selected

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ecosystem services, trends in health and well-being of communities that depend directly on local ecosystem goods and services, and trends in the nutritional contribution of biodiversity and food composition. This contributes also to implementing in spirit Articles 8(j) and 10 (c)) of the CBD on protecting traditional knowledge and community practices, the Nagoya Protocol on ABS, and the objectives of the UN Declaration of the Rights of Indigenous Peoples. This also marks a shift toward embracing a more bio-cultural perspective toward identifying appropriate interventions. Biocultural diversity emerges conceptually from an anthropological consideration of the manner in which human societies adapt to the varied biological circumstances in which they live. Biocultural diversity is concerned with the relationships among traditional knowledge, biological diversity, and cultural diversity (Johns and Sthapit 2004). For instance, world over, various traditional health practices consider this holistic perspective of co-existence with natural ecosystems toward achieving and maintaining good health and wellbeing. Ayurveda, the Indian traditional medical system, has a comprehensive conceptual approach to Svasthya (well-being). Svasthya in Sanskrit language literally means “to be established in oneself” and stems from the deep and subtle premises of the interrelatedness of outer (loka) and inner worlds (purusha). The approach is understood in the context of ecosystems, geography, culture, seasons, dietary diversity, and individual constitution, among diverse other factors (Payyappallimana 2013). Other major processes that have an interest in such a linked approach include the Intergovernmental Platform on Biodiversity and Ecosystem Services (IPBES) which is soon undertaking a full thematic assessment on the nexus between biodiversity, water, food and health, and the SDGs. As mentioned at the outset of this paper, the 72nd World Health Assembly, a Resolution was adopted that focused on “a world in which sustainable development has eliminated the almost one quarter of the disease burden caused by unhealthy environments, through health protection and promotion, good public health standards, preventive action in relevant sectors and healthy life choices, and which manages environmental risks to health” (WHO 2019a). The Sharm el Sheikh Declaration of the 14th Conference of Parties of the CBD commits member countries to “Mainstream biodiversity and health linkages into policies, plans and strategies in line with the objectives of the 2030 Agenda for Sustainable Development and regional and national development agendas” (CBD 2018).

Healthy Planet and Healthy People: Implementation of Integrated Approaches The nexus between biodiversity and health is highly multisectoral. While there are several areas where a combination of sectors may be deployed, in this section, we focus on a few areas and highlight some impactful initiatives that are enabling coachievement of health, biodiversity, and some of the SDGs and which, importantly, can potentially be replicated elsewhere. These four short case studies also highlight strategies for multi-stakeholder partnerships and new forms of international

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cooperation and financing. At the same time, they also address certain important issues of equity and inclusivity of marginalized and vulnerable groups toward access to resources and healthcare as well as rights to their knowledge and health practices.

Agrobiodiversity, Food, and Nutrition Recent analyses of the global burden of disease showed a shift toward NCDs (ischemic heart disease, stroke, and depression), which are a mix of lifestyle-related and age-related (GBD 2016). Furthermore, diseases caused due to various forms of pollution are projected to stay persistent. Of the various risk factors, malnourished diets, insufficient physical activity, and pollution control have been identified as important aspects to be addressed in both health policy and actions. It was also found that sub-optimal diets are a major cause of disease and mortality (GBD 2019). Globally, dietary risks were responsible for 11 million deaths among adults, primarily led by cardiovascular diseases followed by cancers and type 2 diabetes. There is therefore an increased emphasis in many countries and at the WHO on ensuring healthy diets and nutrition as an important strategic public health intervention (see, for instance, the UN Decade on Nutrition 2015–2025 and decisions of the UN Standing Committee on Nutrition (https://www.unscn.org/en/ resource-center)). Guidance on safeguarding agrobiodiversity to ensure nutritional security is being advocated strongly by the WHO and institutions at the forefront of battling malnutrition. It is no surprise that agro-biodiversity and nutritional security go together. This is one of the most important sectors in the nexus between biodiversity and health. In developed and rapidly developing regions of the world, rapid lifestyles changes and an aging population have resulted in increase in non-communicable chronic diseases, while, in less developed regions, continuing poverty, inequity, and environmental degradation have contributed to continuing malnutrition, and infectious diseases, among other related ill-health outcomes. Undernutrition – especially protein energy malnutrition and deficiencies of vitamin A, iodine, and iron – continues to be a major issue in most developing countries. Conversely in transition economies increasing unhealthy diet patterns, high saturated fat, high salt intake, high calorie, and low fiber diets are becoming common leading to different sets of health issues. NCD kills 41 million people each year, equivalent to 71% of all deaths globally. Four groups of diseases account for over 80% of all premature NCD deaths: cardiovascular diseases (17.9 million), cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million) (GBD 2016). Tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets all increase the risk of dying from an NCD. A healthy diet helps protect against malnutrition in all its forms. The Biodiversity for Nutrition (BfN) (http://www.b4fn.org/) initiative coordinated by Bioversity International and funded by the Global Environmental facility (GEF), a multicountry project, has been spearheading the facilitation of policy developments to promote agro-diverse farming and diets, especially for children (through school gardens and lunch interventions) and women (through home gardens,

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facilitating women producer collectives). This initiative led by Brazil, Kenya, Sri Lanka, and Turkey is coordinated by Bioversity International with implementation support from the United Nations Environment Programme and the Food and Agriculture Organization of the United Nations. National partners come from relevant ministries, the scientific community, non-government organizations, civil society, and local communities.

Traditional Medicine, Health, and Livelihoods The relevance of biodiversity to modern healthcare is understood better due to the high visibility of innovative compounds and novel drugs that have been developed based on plants and other natural resources. At the same time, the significance of ecosystem specific plants and other resources and related indigenous and local traditional knowledge toward the health and nutritional security of people in insufficiently connected and marginalized regions of the world is also profound. The paradox is that the regions which have poor access to formal public healthcare infrastructure or personnel often are abundant in bio-cultural resources that can have major impact on community health and well-being (Payyappallimana and Subramanian 2012). A recent WHO report that reviewed the status of traditional medicine in 179 member states indicates that there is an increasing demand and policy attention of traditional and complementary medicine globally (WHO 2019b). Estimates suggest that globally between 50,000 and 70,000 species of medicinal plants are used in traditional and modern medicinal systems and around 6000 plants are actively in trade in the global markets (Leaman 2006). This highlights the importance of more integrated approaches to assessment of status of biodiversity, health, and well-being and of ensuring conservation and sustainable use of such resources at various scales. To improve healthcare access for communities, there is a renewed interest to strengthen the potential of traditional knowledge and health practitioners and augment medicinal and nutritional resources to fulfill this role. Identifying local health priorities and supplementing them with ecosystem and community-specific traditional medical knowledge and resources through primary health programs is critical both to ensure conservation of biodiversity and health security at the local level. This is especially important in the context where progressively high out-of-pocket spending for health, increasing privatization, overmedicalization of healthcare, and curative focus are becoming important challenges of health systems. While there are several models at the local level on diverse nodes of interventions, concerted policy attention and integrated frameworks/approaches for bringing together multiple institutions and stakeholders are still missing (Payyappallimana and Subramanian 2012 ibid). Strengthening the capacities and credibility of traditional health practitioners, often the first and sometimes, the only point of healthcare intervention in remote and marginalized communities has become an immediate necessity. Organizations such as the Foundation for Revitalization of Local Health Traditions (FRLHT) and the

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Medicinal Plant Conservation Network in India have been involved in country-wide, large-scale conservation initiatives for endangered medicinal plants through publicprivate partnerships. Systematic national assessments carried out under this initiative show that around 300 important medicinal plants fall into various categories of threat in the country. They have also been engaged in mobilizing community health practitioners to identify local health priorities and safe, effective, and evidencebased solutions for more than two decades and engaging them in participatory conservation, primary health, and livelihoods program. This has created a countrywide healers’ and indigenous and local knowledge holders’ network in India. A main objective is also to enable the development and promotion of appropriate integrative methodologies for assuring evidence on quality, safety, and efficacy of health practices based on standards within and across health systems and various disciplines. Furthermore, development of local documentation of knowledge linked to Peoples’ Biodiversity Registers and further linking them to intangible property rights are happening in a dynamic fashion within the ambit of international and national legal systems. Global platforms also facilitate bringing together communities of practice. For example, the Biodiversity and Community Health (BaCH) Initiative hosted by the United Nations University brings together the expertise of several stakeholder agencies with an interest in community health to leverage on and synergize multiple efforts mentioned earlier. This global partnership has led to innovative capacity building initiatives such as peer learning exchange programs between communities from different developing countries across continents and with plans to replicate such efforts through stronger South-South cooperation.

One Health The world’s livestock sector is going through a major expansion. The intensification of livestock farming has resulted in several challenges (FAO 2009) including (1) increasing pressure on the ecosystem and natural resources; (2) risk of spread of animal diseases due to globalization of food systems; and (3) negative social implications of the structural changes in the sector. Since then two other major challenges have been added to this list: (4) climate change effects of livestock and more recently (5) the multiresistant strains of microbes due to indiscriminate antibiotic use. Studies suggest that there will be an increase of 67% antibiotic use in veterinary care by 2030 (Van Boeckel et al. 2015). The study says that there will be 99% increase in antibiotic consumption in BRICS countries (Brazil, India, China, South Africa) during the same period due to intensification of production. Around 66% of the global increase of antimicrobial consumption is expected from an increase in demand for animals for food production, whereas 34% will be owing to adoption of intensive farming systems, indicating this could lead to issues like resistance and poses serious threats to preservation of effectiveness of antibiotics (See http://www. cddep.org/blog/posts/global_livestock_antibiotic_use_expected_increase_67_2030).

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Microbial resistance and antibiotic reduction are a central and cross-cutting theme today in both human and animal health. This has resulted in the promotion of perspectives such as agro-ecology that strives for a balance between various aspects of the agricultural system and promotes the ecological intensification in (smallholder) farming. Numerous organizations worldwide are now promoting this view including organizations like the FAO which is rethinking this as a foundational principle for food security and nutrition in the future. The Healthy Cows Healthy Food program is a partnership of four country partners – the Netherlands, Ethiopia, Uganda, and India. Focusing on the critical theme of antibiotic reduction, the program in a holistic manner proposes to address various dimensions such as change practices toward ecologically friendly farming; rational breeding programs; improved animal health management and enhancing quality of milk; and strengthening usage of ethno-veterinary practices and thereby reducing the use of antibiotics. Demonstrably, the Natural Livestock Farming (NLF) (http://www.b4fn.org/) network coordinated from the Netherlands has embarked on a multicountry partnership in the field of One Health using Ethno-veterinary care of livestock as an entry point to reduce antibiotic use and resistance while looking at other dimensions such as local breeds, integration of traditional medicine, animal management, and so on. There are several such examples of one health approach. While the rise in NCDs has begun to trigger greater uptake and new recommendations in this area, much more is needed. To get there we not only have to address the common drivers already described but also consider governance and institutional challenges in conservation and sustainable use.

Landscapes, Health, and Healing There is increasing evidence suggesting natural/therapeutic/sacred landscapes can contribute to our mental and spiritual health. Initiatives such as the IUCN commission on Cultural and Spiritual Values of Protected Areas (https://www.iucn.org/ theme/protected-areas/wcpa/what-we-do/cultural-and-spiritual-values-protectedareas) and community-based case studies from countries like Guatemala are welldocumented examples of local and global efforts in this area. Augmenting and managing green spaces was identified as a tactical public health intervention strategy (Rojas-Rueda et al. 2019) with beneficial effects to mental health. The Human Urban Microbiome Initiative has also been promoting the expansion of green space interactions in urban areas as a strategy to enrich and thereby strengthen the human microbiome (Mills et al. 2019). For example, the environment ministry of Singapore has a policy to establish parks in almost every neighborhood to enable exercise and facilitate social and mental well-being. This is built on theories of biophilic planning that exposure to natural environments improves brain cognition and reduces stress. The government of Singapore has therefore initiated “Horticultural Therapy” to tackle elderly care, mental well-being of its citizens. The impacts are being studied in collaboration with academia, and capacity building resources for practitioners is being developed as

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initial results are already demonstrating good outcomes for stress reduction along with other ecological benefits (Yap 2018). The initiatives mentioned above are indicative of several local efforts to deliver good health at low cost by utilizing available resources of natural ecosystems, locally relevant strategies, knowledge, and innovative technologies. They illustrate the potential to design activities that cut across multiple dimensions of human wellbeing from health and food security to ensuring access to natural resources and sustainable livelihoods. It is possible that with sufficient support and awareness, similar efforts can be adapted in different regions.

Conclusion This chapter provided an overview of the impact of socio-ecological systems on human health and well-being, which brings us back to the WHO definition of health referring to “a complete state of physical and mental well-being,” reinforcing the need for more holistic approaches. We highlighted some reflections on the interconnections between nature and human wellbeing that goes beyond mere medicalized care or pharmaceuticals. Despite a lot of understanding about these wider determinants, the health policy community is yet to embrace these concepts in health system planning and implementation. Further although the SDGs, as a convening framework seeks to integrate between multiple priorities, links between health and biodiversity are not adequately and explicitly reflected in the health-related goals or indicators. Thus, actions to achieve the broader mandate of good health and well-being requires us to connect sectoral implementation plans and strategically consider how to make best use of available resources – natural, human, and financial. This requires us to understand interdependencies of natural ecosystems and health and to adopt a systems approach to jointly address issues and thereby allow us to leverage on the strengths and synergize efforts to achieve concurrent benefits. Such approaches and practices are not entirely new and as highlighted here, there is growing evidence that several initiatives have moved beyond pilot phases and are being adopted by different stakeholder groups. To further strengthen these initiatives, there is a need to strategically focus on appropriate efforts in the realms of research, awareness raising, capacity building, science-policy interfacing, advocacy, and further upscaling successful pilot models. In this context, facilitating inter-agency cooperation has become an urgent requirement. As the management of natural resources typically falls outside the traditional role of health ministries and departments, it is important that the environmental sector and the conservation community takes an active role in pursuing this agenda by bringing together health, development, and other relevant sectors. This needs concerted action in the following areas including integrated assessment and research methods, intersectoral coordination and science policy linkages, education and capacity building, upscaling of pilot models, expanding partnerships, and peer-

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learning exchanges. Finally, it is fairly clear that policy implementation is successful when it resonates to local contexts, requiring investment and support of existing efforts and resources for bottom-up initiatives. Health is both a resource for, as well as an outcome of, sustainable development. The goals of sustainable development cannot be achieved when there is a high prevalence of debilitating illness and poverty, and the health of a population cannot be maintained without a responsive health system and a healthy environment. Environmental degradation, mismanagement of natural resources, and unhealthy consumption patterns and lifestyles impact health. Ill-health, in turn, hampers poverty alleviation and economic development. (http:// www.who.int/wssd/en/. World Summit on Sustainable Development)

References Chivian E, Bernstein A (eds) (2008) Sustaining life. How human health depend son biodiversity. Oxford University Press, New York FAO (2009) The state of food and agriculture – livestock in the balance. FAO, Rome GBD 2015 Risk Factors Collaborators (2016) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1659–1724 GBD 2017 Diet Collaborators (2019) Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 393(10184):1958– 1972 Horton R, Lo S (2015) Planetary health: a new science for exceptional action. Lancet 386 (10007):1921–1922 Johns T, Sthapit BR (2004) Biocultural diversity in the sustainability of developing-country food systems. Food Nutr Bull 25(2):143–155 Leaman DJ (2006) Sustainable wild collection of medicinal and aromatic plants. In: Bogers RJ, Craker LE, Lange D (eds) Medicinal and aromatic plants. Springer, Dordrecht, pp 97–107 Millennium Ecosystem Assessment (2005) In: Corvalan C, Hales S, McMichael AJ (eds) Ecosystems and human wellbeing: health synthesis. Island Press, Washington, DC Mills JG, Brookes JD, Gellie NJC, Liddicoat C, Lowe AJ, Sydnor HR, Thomas T, Weinstein P, Weyrich LS, Breed MF (2019) Relating urban biodiversity to human health with the ‘Holobiont’ concept. Front Microbiol 10:550. https://doi.org/10.3389/fmicb.2019.00550 Payyappallimana U (2013) Health and wellbeing in Indian local health traditions. In: Morandi A, Nambi ANN (eds) An integrated view of health and well-being: bridging Indian and western knowledge. Springer-Netherlands, Dordrecht, pp 99–112 Payyappallimana U, Subramanian S (2012) Biodiversity, traditional knowledge and community health-strengthening linkages. UNU-IAS, Yokohama Rojas-Rueda D, Nieuwenhuijsen MJ, Gascon M, Perez-Leon D, Mud P (2019) Green spaces and mortality: a systematic review and meta-analysis of cohort studies. Lancet Planet Health 3:469–477 SCBD (2017) Guidance on integrating biodiversity considerations into one health approaches, CBD-SBSTTA, 21st meeting, Montreal, Canada, 11–14 December 2017, CBD/SBSTTA/21/9, 13 December 2017 SCBD (2018) Sharm El-Sheikh declaration investing in biodiversity for people and planet SCBD–WHO (2015) Connecting global priorities: biodiversity and human health, a state of knowledge review. https://www.cbd.int/health/SOK-biodiversity-en.pdf Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, Teillant A, Laxminarayan R (2015) Proc Natl Acad Sci 112(18):5649–5654

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Whitmee S, Haines A, Beyrer C et al (2015) Safeguarding human health in the Anthropocene epoch: report of the Rockefeller Foundation–Lancet Commission on planetary health. Lancet 386(10007):1973–2028 WHO (2012) Our Planet, our health, our future – human health and the Rio Conventions: biological diversity, climate change and desertification. World Health Organization, Geneva WHO (2016) Preventing disease through healthy environments- a global assessment of the burden of disease from environmental risks. World Health Organization, Geneva WHO (2019a) Health, environment and climate change Draft WHO global strategy on health, environment and climate change: the transformation needed to improve lives and well-being sustainably through healthy environments, A72/15. World Health Organization, Geneva WHO (2019b) WHO global report on traditional and complementary medicine 2019. World Health Organization, Geneva Yap W (2018) Singapore’s experience in addressing human health and biodiversity linkages, regional workshop to address inter-linkages between human health and biodiversity in the ASEAN region 5–7 November 2018, Manila, Philippines Zinsstag J, Schelling E, Waltner-Toews D, Tanner M (2011) From “one medicine” to “one health” and systemic approaches to health and well-being. Prev Vet Med 101:148–156

Climate Change and Global Health Building Health Resilience

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Impacts of Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extreme Temperatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extreme Weather Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water-Related Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Policy Measures and Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paris Agreement (2016) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SDG 13 (2015) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sendai Framework for Disaster Risk Reduction (2015) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Global Policy Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Anthropogenic climate change threatens to diminish global health gains achieved over the past century. This chapter describes the myriad of ways environmental, economic and societal determinants of health are impacted if greenhouse gas emissions continue unabated. It highlights that since collective resources such as water, air and food are impacted, the negative health consequences of climate change are felt universally. This indicates that the climate crisis is a health crisis. A global policy review of the Paris Agreement, Sustainable Development Goals and the Sendai Framework indicate, however, that there remains limited development and integration of climate-resilient health systems in the climate action discourse. Given the unprecedented and potentially irreversible impacts to all life L. Taing (*) · K. Mahadeo United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, ON, Canada e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_91

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on the planet, urgent actions and investments are needed from the world’s leaders to build global health resilience, by developing climate-resilient health systems that critically safeguard both population and planetary health. Keywords

Climate change · Health determinants · Health resilience · Planetary health · Sustainable development

Introduction Anthropogenic climate change threatens to diminish global health and societal gains accumulated over the past century (Watts et al. 2015). The human population is healthier than it has ever been before, as global life expectancy rises, and rates of poverty and child mortality decline (Horton and Lo 2015). However, these public health achievements have occurred at the planet’s expense: rapid economic and population growth have resulted in an unprecedented increase in carbon dioxide emissions, ocean acidification, deforestation, and energy, water, and fertilizer use (IPCC 2014a; Whitmee et al. 2015). Of particular concern are the record concentrations of carbon dioxide and other greenhouse gas (GHG) emissions in the planet’s atmosphere, which trap energy and accelerate climate change (Parker et al. 2010; Harris 2014). The Intergovernmental Panel on Climate Change (IPCC 2018) defines climate change as variability in Earth’s average weather and meteorology over an extended period of time. Earth’s climate is determined by the balance of incoming and outgoing radiation, which is facilitated by atmospheric GHGs. Variations in atmospheric conditions such as average temperature, precipitation, and wind patterns result in climatic changes. Although the Earth’s climate changes naturally over time, human activities since the industrial era have accelerated this process. Consequently, atmospheric GHGs have reached the highest levels experienced in 800,000 years, resulting in rising global temperatures and sea levels, changing weather patterns, and more extreme natural disasters (IPCC 2014b; UN 2020). If anthropogenic climate change is not appropriately addressed, an estimated 40% of the global population will be living in areas under severe water stress by 2050, and approximately five million more deaths will be attributable to climate change (Whitmee et al. 2015). Moreover, the International Labour Organization (ILO 2019) forecasts that the equivalent productivity of 80 million full-time jobs will be lost by 2030 due to heat-related stress. Reduced labor productivity will decrease human capital accumulation, and impact national gross domestic products (GDPs) and social welfare in the short-term, with lasting impacts on the global economy in the long-term. It is important to note that the negative impacts of climate change will disproportionately affect the economies and public health of low-income countries, which largely are not responsible for anthropogenic climate change. Latin America, Africa, and Southeast Asia are anticipated to suffer the largest per capita income

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reductions from decreased agricultural yields and disrupted economies, while Africa and the Middle East will disproportionately experience higher heat-related mortality rates (SIEPR 2019). In addition, recent studies suggest that 99% of economic loss due to climate change in low-income countries is uninsured, and the capacity of disease vectors are expected to increase (Watts et al. 2018b). The combination of the severe health-related and economic consequences of climate change can cripple low-income households for generations, while increasing the pressure on already under-resourced health facilities. This chapter describes the profound direct and indirect impacts of anthropogenic climate change on human health in terms of physical, societal, and mental health and well-being. It discusses the illnesses linked to extreme temperatures, extreme weather events (including floods, droughts and food and water insecurity) and water-related diseases. Several social and mental health concerns are also examined, with emphasis on the impact to vulnerable populations. Furthermore, the chapter discusses current global policy initiatives which address the threats and impacts of climate change. The chapter concludes by highlighting key gaps in these initiatives from a global health perspective, such as the urgent need to invest in climate-resilient health systems to safeguard both population and planetary health.

Health Impacts of Climate Change Extreme Temperatures The year 2019 experienced record-breaking global temperatures. According to the World Meteorological Organization (WMO 2020), 2019 – which had a global mean temperature that was 1.1 °C warmer than pre-industrial times – was the second warmest year on record. Alarmingly, what may seem like an abnormal heat spell was part of a global warming trend: the WMO (WMO 2020) reported that the past 5 years (2015–2019) and the past decade (2010–2019) were the warmest on record, and that each successive decade since 1980 has been warmer than the preceding one. Extreme heat tremendously impacts global health in numerous ways. The direct impacts to human health caused by dramatic changes in temperature include shortterm dizziness, muscle cramps, dehydration, fever, heat rashes, heat exhaustion and (potentially fatal) heatstroke. Long-term exposure to high temperatures can cause acute cardiovascular, respiratory, and cerebrovascular responses, increasing overall rates of mortality (Heal and Park 2016). The number of hot days is positively correlated with mortality rate (Smith et al. 2015). Warmer temperatures also favor the production and release of airborne allergens such as fungal spores and plant pollen, leading to an increase in cases of allergies. Mortality rates due to temperature stress are significantly higher in low-income countries and populations, as these populations are generally less able to undertake adaptive measures in the face of increasing temperatures, leading to more devastating public health effects (Heal and Park 2016). However, high-income populations are not immune from the large-scale health risks – especially those residing in

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high-density built urban environments. An urban heat island effect can occur in urban environments where high concentrations of heat-retaining surfaces such as asphalt and tar rods sustain higher daily temperatures. Additionally, heat waves worsen urban air pollution, which can further exacerbate cardiovascular and respiratory diseases (WMO 2020). Health risks of extreme temperatures also increase with physical activity levels (Smith et al. 2015). The ILO (ILO 2019) has estimated a 2.2% loss of total working hours worldwide by 2030 due to heat stress, with the agricultural and construction sectors expected to account for 70% of global working hours lost, and Africa’s workforce being disproportionately affected.

Extreme Weather Events Higher ambient temperatures will intensify patterns of evaporation and precipitation, leading to increased frequency and more intense extreme weather events globally (Patz and Khaliq 2002). An extreme weather event is an above average climate outcome for a given location and time of year (e.g., drought of heavy rainfall) over a persistent length of time (e.g., a season) (IPCC 2018). Put differently, extreme events have weather patterns that go above or below previously observed values (Wu et al. 2016). Increases in floods, droughts, and other extreme weather events are expected to have devastating effects on human health (Smith et al. 2015). There are expected to be 2.3 billion flood exposure events and 1.4 billion drought exposure events within the next century. The next sections describe the causes and health impacts of this increase in floods and droughts (Watts et al. 2015).

Floods The majority of climate change scenarios predict increased precipitation globally, which forewarns flood risk. Floods are the most frequently occurring natural disaster, and have increased in frequency due to climate change (Smith et al. 2015). Increased flooding is caused by atmospheric changes and glacial melting due to global warming. Earth’s atmosphere retains more moisture as global temperatures increase, which increase the volume and intensity of storms. There is also high confidence that increases in heat waves and glacial and permafrost melting will lead to increased flooding in relevant regions (Dokken et al. 2012). Flooding directly affects health through drowning injuries, hypothermia, and trauma (Smith et al. 2015). The indirect effects of floods include increases in dermatitis and infectious diseases (such as cholera and leptospirosis) caused by the exposure to contaminated water, vector-borne disease due to seasonal and geographic distribution shifts, and respiratory diseases through overcrowding and overgrowth of mold in flooded homes (WHO 2015). Additionally, levels of diarrheal diseases, scabies, conjunctivitis, and trachoma may increase as sewerage systems overflow and safe water, sanitation, and hygiene (WASH) facilities become inaccessible (Wu et al. 2016; Andrade et al. 2018). Release of dangerous chemicals from storage sites and waste disposal sites into flood waters also pose

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immediate risk of illness to those who encounter contaminated water (Patz and Khaliq 2002). At present, 15% of all deaths related to natural disasters are due to floods (Watts et al. 2018a). This number likely under-represents flood-related health impacts because natural disasters are not attributed as causes of death in medical or legal records (UNISDR 2017). A flood-related death, for instance, is commonly registered as a drowning victim. The lack of attribution masks the severity of flood events and what populations might be especially vulnerable. It is expected that more people in Asia, Africa, and Central and South America will be vulnerable to flooding because of increased precipitation patterns (Smith et al. 2015). Populations residing in low-lying coastal communities are especially vulnerable, as well as individuals living in rural areas with limited access to healthcare services (Smith et al. 2015).

Droughts Globally, there is a high likelihood that the tropics and high-latitude areas will get wetter, and mid-latitude areas will get drier if anthropogenic climate change persists (Mankin et al. 2019). Below-normal precipitation in areas or regions indicates drought conditions, with climate change contributing to drought in several ways. Warmer temperatures can enhance evaporation from soil, making periods with low precipitation drier than they would be in cooler conditions. Droughts persist through a positive feedback loop, where higher temperatures interact with barren terrain, to decrease rainfall, which can further suppress rainfall in an already dry area. Drought is viewed as an indirect health impact due to limited direct attributions (Lee et al. 2020). Prolonged drought is one of the most dangerous environmental determinants of premature mortality, with a recent Lancet publication highlighting linkages to unsafe WASH resources, reduced crop yields, and food insecurity (Watts et al. 2019). Dehydration and malnutrition increasingly occur during periods of drought due to water scarcity and food security (Patz and Khaliq 2002; Dokken et al. 2012). Increased stress due to drought has also been associated with increased human susceptibility to infectious diseases (Wu et al. 2016), including meningitis (Dokken et al. 2012). Increases in droughts can furthermore increase or decrease the prevalence of mosquito-borne infectious diseases such as malaria, depending on local conditions. Droughts (in combination with heat waves) are also correlated with increased wildfire risks. The direct effects of wildfire on human health include burns and smoke inhalation, while the release of particulate matter and other toxic substances can cause and aggravate existing respiratory illnesses (Patz and Khaliq 2002; Dokken et al. 2012; Smith et al. 2015). Drought and high winds may also produce windborne dust and mobilize other materials such as pollen and spores, transporting pollution and allergens to new regions (Smith et al. 2015). Increased frequency of annual drought is expected in South America, Africa, and Southeast Asia (Watts et al. 2018a), requiring extensive measures to diminish the significant public health impacts (Box 1). This is especially concerning for areas that already face severe water scarcity and food insecurity, as climate change will translate to millions more vulnerable people struggling to survive due to drought-induced famines.

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Box 1: Case Study – Extreme Drought in Brazil

From 2012 to 2015, the Northeast of Brazil experienced unprecedented drought conditions. Northeast Brazil is home to a population of approximately 53 million, and it is the most densely populated dry land region on Earth. Both urban and rural populations – especially farming communities – were deeply impacted by the abnormally long period of nominal rainfall. These conditions, in combination with the dense population distribution, resulted in states of emergency being declared in over half of the region’s districts. The decrease in agricultural output, along with reductions in freshwater availability and quality impacted water and food security. Many populations residing in urban areas experienced shortages in drinking water and energy supply, while rural populations reliant on agricultural production suffered from reduced yields and an economic loss of approximately 6 billion USD. Projections for this area indicate that this drying trend will endure, with anticipated dramatic temperature increases being accompanied by further reductions in precipitation. The positive impacts of established policy measures in response to previous droughts in the area are expected to be significantly diminished by the impact of climate change, warranting more extreme adaptive measures (Marengo et al. 2017).

Water-Related Diseases Water is a key component in a number of climate change health impacts. In addition to dehydration due to heat stress or drought, and flood-related drowning, infectious and vector-borne diseases, and poisoning due to the consumption of water contaminated with marine toxins are potential outcome of climate change, especially in marine or coastal zones (Patz and Khaliq 2002). For example, warm water and nitrogenous waste favor blooms of dinoflagellates in marine conditions, resulting in red times which can cause paralytic, diarrheic, and amnesiac shellfish poisoning. Cholera outbreaks are also correlated with monsoon seasons, sea-surface temperatures, and rainfalls, as well as increases in zooplankton populations. Water-related diseases are expected to become more prevalent globally if climate change continues to affect water security (Box 2). Furthermore, changes in climactic variables also impact the survival, reproduction, and distribution of disease pathogens and hosts, many of which are associated with water. Temperature increases can shorten the incubation period of pathogens such as viruses, bacterium, parasite germ, and fungi, and extended heatwaves algal blooms or vector capacity of small water bodies. Warmer temperatures in addition to increased humidity will especially change vector habitat patterns. A vector is a living animal or plant in which a pathogen resides, which can transmit it to other living organisms. Vectors such as mosquitos associated with water-related diseases have shifted seasonally or expanded geographically as temperatures rise (Wu et al. 2016), increasing the scope of susceptibility to these diseases, which were previously region-specific.

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Box 2: Case Study – Increased Prevalence of Dengue in Nepal (WHO 2020, Pandey and Costello 2019)

Dengue is a mosquito-borne viral disease that induces flu-like symptoms, potentially resulting in mortality (WHO 2020a). Dengue was first recorded in Nepal in 2004, and cases of have rapidly increased each year since then. A study done by Pandey and Costello (2019) found that in 2018, 3425 cases of dengue were reported in Nepal, but extended precipitation and flooding associated with a prolonged monsoon season in 2019 increased the duration of ideal temperatures for mosquito breeding, resulting in over 10,000 cases of dengue. It is estimated that temperatures in Nepal will increase by up to 2 °C by 2030, and up to 6.4 °C by 2090, further prompting the spread of dengue (Pandey and Costello, 2019). Mosquito-borne diseases such as Zika virus and yellow fever may follow a similar increasing trend as climate change increases opportunities for vector breeding (Pandey and Costello 2019).

Social Determinants of Health In growing recognition of climate change’s myriad effects on human systems, there has been increasing impetus to unpack social determinants such as the economic and social conditions that can influence health statuses. For example, in addition to extreme heat’s physical impacts to human health, the ILO (ILO 2019) has highlighted that heat stress will be a barrier to the achievement of the United Nations’ Sustainable Development Goals (SDGs) relating to poverty, health, decent work and economic growth due to significant global productivity losses. Africa’s labor force is expected to be disproportionately affected by heat-related productivity loss, as 18% of the global working population is expected to reside on the continent by 2030 and half of this population will work in the agriculture sector (ILO 2019). Furthermore, limited agricultural yield will result in restricted incomes, as food prices rise due to decreased supply and increased demand, affecting nutrition in lower socioeconomic areas (Smith et al. 2015; ILO 2019). This indicates the potential conflict between health protection and economic productivity in the near future, with increased risks for disenfranchisement and mental well-being concerns among laborer obliged to work in physiologically unsafe conditions at the risk of losing income and employment (Smith et al. 2015; WHO 2015). In addition to economic repercussions, geography is a significant determinant that links health to one’s environment. As noted earlier, urban residents are vulnerable to heat island conditions and higher levels of air pollution (WMO 2020). Floods in cities – especially with open sewers or overwhelmed sewage systems – increase the risk of water-related disease pathogens such as leptospirosis and cholera. Populations in rural and remote areas largely dependent on functioning natural environments and productive agricultural economies are vulnerable to extreme climate change events. This is because floods and droughts lead to ecosystem

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degradation, which can cause crop failure, malnutrition, and starvation, as well as an increase in the likelihood for population displacement and resource conflict (Smith et al. 2015; Serdeczny et al. 2017). Overall, fatality rates and economic losses for extreme weather events as a proportion of GDP are significantly higher in low- and middle-income countries (LMICs). From 1970 to 2008, 95% of deaths from natural disasters were in developing nations (IPCC 2012). As LMICs are anticipated to have greater economic and population growth in the coming decades, populations in affected countries will be exposed to higher concentrations of contaminants in water, air, and sediment, which is especially problematic among those whose unique immune, endocrine, and neurological systems make them especially susceptible to environmental pollutants (Suk et al. 2016). When considering age, older individuals face a higher risk in the face of storms, floods, and heatwaves, as they are less mobile and are more likely to suffer from health conditions that limit the body’s ability to responds to stressors such as heat and air pollution (Smith et al. 2015). Child health is the most affected by the accumulative impacts of climate change, as children are especially at risk for undernutrition and diarrheal diseases. Furthermore, the impacts of undernutrition in children are more devastating, and are associated with a range of adverse health effects, such as life-long stunting, wasting, and even death when experienced by extremely young children (Watts et al. 2018a).

Mental Health Measuring climate change’s impact on mental health and well-being is challenging largely because mental health is influenced by a diverse range of factors that are highly subjective across different social and economic circumstances. Despite these challenges, experts recognize that climate change can affect mental health in the short- and long-term by causing anxiety-related responses such as post-traumatic stress, chronic psychological distress, and depression disorders (Watts et al. 2015). Mental illness also can be observed during, immediately after, or years after the impacts of climate change are felt. For slow developing events such as prolonged droughts, for instance, impacts include elevated levels of depression and increased incidence of suicide (Smith et al. 2015; Watts et al. 2015). Vulnerable populations are especially at risk – specifically Indigenous groups and low socio-economic populations living in low-resource settings. Anecdotal evidence indicates that following floods and drought events, farmers who have lost their land and livelihoods struggle with mental health as well as urban dwellers who lost their homes (Lee et al. 2020). Figure 1 summarizes the environmental outcomes and public health impacts of global climate change. It highlights that climate change influences the environmental, economic, and societal determinants of health and well-being in a myriad of ways. Since collective resources such as water, air, and food are impacted, the negative consequences of climate change are felt universally. In light of this, a

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Climate change drivers Greenhouse gases (GHGs) due to: (1) Natural causes (2) Human activities

Global Climate Change

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Environmental outcomes

Public Health Impacts

Extreme temperatures

Immediate biological stress (e.g. dizziness, heat exhaustion, drowning injuries)

Extreme weather events (e.g. floods, droughts & wildfires)

Long-term biological stress (e.g. acute cardiovascular, respiratory, and cerebrovascular responses)

Air quality decline Increased waterrelated disease risks (e.g. seasonal & geographic vector shifts)

Increases in water-related and infectious diseases (cholera, dengue) Diminished mental health (anxiety, depression) Population displacement and resource conflict Reduced food security

Fig. 1 Climate change environmental and public health impacts

number of pioneering global policy responses have been established to curb and ameliorate the threats of anthropogenic climate change. The next sections detail three key global initiatives: the Paris Agreement, SDG 13 (climate action) and the Sendai Framework.

Global Policy Measures and Gaps Paris Agreement (2016) Box 3: The Paris Agreement (UNFCCC 2015)

The Paris Agreement’s explicit goals are to strengthen global climate action by: (1) holding the net increase in global average temperature to below 2 °C above pre-industrial levels and limiting temperature increases to 1.5 °C above pre-industrial levels; (2) increasing government ability to adapt to changing conditions, foster climate resilience, and develop low GHG industries in ways that do not threaten food production; and (3) aligning economies with climateresilient development principles (UNFCCC 2015). Each signatory has agreed to set national goals and establish plans with short-term peak GHG emission goals, followed by a dramatic decline in emissions, with the long-term aim of transforming national economies and building climate-resilient societies.

The Paris Agreement is an accord within the United Nations Framework Convention on Climate Change (UNFCCC) treaty, which was signed by 188 nations in November 2016 to proactively address the threat of climate change through

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mitigative, adaptive, and financial measures (Box 3). With regards to health, the Paris Agreement acknowledges in principle the public health co-benefits of decreasing global emissions and preserving carbon sinks, such as the decrease in loss and damage due to extreme weather events, and preserved biodiversity on land and in the oceans. It explicitly ties climate action to a healthier environment and population – from cleaner air and water, to reduced risks of extreme heatwaves and greater food security. However, the agreement does not include corollary targets or indicators to reduce the health impacts of climate change. Regardless of the political commitments made in the Paris Agreement and scientific warnings, GHG emissions have reached a record high in 2018 (UNEP 2019). The global dependency on carbon remains virtually unchanged since 1990 (Watts et al. 2019), and economies continue to invest more in fossil fuels than climate action (UN 2020). The UN (UN 2020) has recently warned that the targets outlined in the Paris Agreement are far from being met. Considering this limited progress, the authors of the 2019 Lancet Countdown report – an independent and interdisciplinary body of health experts and climate scientists monitoring the health effects of climate change, the Paris Agreement’s implementation, and the implications of (in)action – concluded that global warming will undo what enacted climate action measures have achieved, because governments are struggling to cope or are unwilling to respond (Watts et al. 2019).

SDG 13 (2015) The 2015 Sustainable Development Goals are the UN’s blueprint to achieve a more equitable and sustainable future for all by the year 2030. While the 17 goals address a range of global and interconnected challenges, SDG 13 stresses taking urgent climate action to combat climate change and its negative impacts. While SDG 13 has five targets and eight indicators, only one explicitly measures health-related impacts as part of a target to strengthen resilience and adaptive capacity to climaterelated hazards and natural disasters. Indicator 13.1.1 tracks the number of deaths, missing persons, and affected persons attributed to climate-related hazards and natural disasters. There is no indicator addressing resilience in health institutions. In its recent assessment, the UN (UN 2020) reported that global progress is not consistent with achieving SDG 13’s targets. Consequently, climate change continues to exacerbate the severity and frequency of natural disasters that have disrupted the lives of more than 39 million people in 2018 (UN 2020). This narrow focus on people affected overlooks how health resilience can be built in both individuals and institutions. The latter ostensibly is addressed in SDG 13’s alignment with the Sendai Framework.

Sendai Framework for Disaster Risk Reduction (2015) The Sendai Framework was the first global framework in the UN’s post-2015 agenda that made explicit references to health, development, and climate change to bridge

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gaps and build policy coherence between the Paris Agreement and the SDGs (Murray et al. 2017). The Sendai Framework addresses SDG 13’s health limitations. It does this by adopting a broader framing of health resilience in terms of developing individual and institutional capacities, the latter of which should be addressed through reduced damage to critical national health infrastructure and limited disruption of basic services (target d) (UNISDR 2015). To date, only 85 countries have aligned their national disaster risk reduction strategies to the Sendai Framework (UN 2020). This indicates limited uptake of this landmark policy framework. Even with increased uptake, it is questionable whether governments will effectively integrate health resilience planning and development in planning. While health resilience is explicitly promoted as a key principle of the Sendai Framework, the concept itself is not clearly conceived to guide government planning and implementation. For example, building health resilience can include assessments of national and city-level climate change impacts and vulnerabilities; development of health adaptation plans; monitoring and communications of climate and health data; adaptation delivery and implementation to support health emergency detection, preparedness, and responses; and financial resources to support health adaptation activities (Watts et al. 2019). The limited conceptualization in the Sendai Framework is likely due to its greater focus on reducing disaster risks, as well as resilience being an emerging interdisciplinary concept in global health discourse that has yet to be unpacked and explicitly defined (Haldane et al. 2017; Fridell et al. 2019).

Key Global Policy Gaps The world is currently off track to achieving global climate action goals outlined in the Paris Agreement, SDGs, and the Sendai Framework. The UN has warned that if the climate crisis continues unabated, the catastrophic effects of climate change will be far greater than the implications of the current Covid-19 pandemic (UN 2020). While each of these global initiatives recognizes health as being an important aspect of climate change adaptation, there remains limited integration of climate-resilient health systems in global climate action discourse. For example, the main climate change indicator monitored at a global scale continues to be GHG emissions (Horton and Lo 2015). Global impact indicators only focus on climatological and environmental factors (specifically, mean temperature, atmospheric composition, and direct impacts of land, oceans, and ice) (WMO 2020). This narrow focus on the climatological and environmental impact overlooks the need to account for the capacity of human systems to monitor and address the various climate change threats which affect the social and environmental determinants of health as well. To accelerate the integration and development of climate-resilient health systems in climate action initiatives, governments need to adopt systemic approaches such as health resilience (WHO 2015; Wulff et al. 2015) and planetary health (Horton and Lo 2015; Whitmee et al. 2015) that tackle the direct, ecosystem-mediated, and

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indirect or displaced health effects, while developing the social systems and protecting ecosystems on which we depend. Both health resilience and planetary health are incipient interdisciplinary concepts that have grown in traction in the realization that complex crises such as anthropogenic climate change are population health crises.

Conclusion As the 2030 SDG deadline approaches, the WHO encouraged world leaders to invest resources in health systems that safeguard lives, livelihoods and economies (WHO 2020b). Given the public health impacts of global warming and pollution, the WHO stated that ensuring health security should not be the sole responsibility of health authorities and highlighted that public health is ultimately a political choice. Leading experts and advocates from a diverse range of disciplines have similarly warned that anthropogenic climate change will continually undermine the determinants of good health and well-being, as well as exacerbate socioeconomic inequality, if it remains unchecked. These impacts highlight that the climate crisis is a health crisis. Given the unprecedented and potentially irreversible impacts to all life on the planet, urgent actions and investments are needed from the world’s leaders to build health resilience, by developing climate-resilient health systems that critically safeguard both population and planetary health.

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Watts N, Amann M, Arnell N et al (2019) The 2019 report of the lancet countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet 394:1836–1878 Whitmee S, Haines A, Beyrer C et al (2015) Safeguarding human health in the Anthropocene epoch: report of the rockefeller foundation–lancet commission on planetary health. Lancet 386:1973–2028. https://doi.org/10.1016/S0140-6736(15)60901-1 WHO (2015) Operational framework for building climate resilient health systems. Geneva, Switzerland WHO (2020a) WHO | what is dengue? WHO WHO (2020b) Urgent health challenges for the next decade WMO (2020) WMO statement on the state of the global climate in 2019. World Meteorological Organization, Geneva Wu X, Lu Y, Zhou S et al (2016) Impact of climate change on human infectious diseases: empirical evidence and human adaptation. Environ Int 86:14–20 Wulff K, Donato D, Lurie N (2015) What is health resilience and how can we build it? *. Annu Rev Public Health 36:361–374. https://doi.org/10.1146/annurev-publhealth-031914-122829

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Concept, Assessments, and Implications for Global Health David Rojas-Rueda

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Environmental Burden of Disease Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other EBoD Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparative Risk Assessment Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examples of BoD, EBoD, and CRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The Environmental Burden of Disease (EBoD) is a tool to integrate health metrics and evidence into the public health decision-making process. EBoD helps to integrate morbidity and mortality in the same unit, estimating base on the life expectancy and the natural history of the disease, those years that certain populations will live with a disability related to specific health diagnosis and those years of life lost due to premature death related to an environmental risk factor. EBoD is a tool that can help health professionals and stakeholders understand the impact of different environmental exposures on diseases and causes of death in a population. EBoD can also help to compare how different health and nonhealth interventions can impact public health. The aim of this chapter is to provide an overview of the EBoD concept and how it is commonly being conducted.

D. Rojas-Rueda (*) Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_92

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Keywords

Burden of disease · Disability-adjusted life years · Morbidity · Mortality · Health impact assessment

Introduction The Environmental Burden of Disease (EBoD) is a tool to integrate health metrics and evidence into the public health decision-making process. EBoD helps to integrate morbidity and mortality in the same unit, estimating base on the life expectancy and the natural history of the disease, those years that certain populations will live with a disability related to specific health diagnosis and those years of life lost due to premature death related to an environmental risk factor. EBoD is a tool that can help health professionals and stakeholders understand the impact of different environmental exposures on diseases and causes of death in a population. EBoD can also help to compare how different health and nonhealth interventions can impact public health. The EBoD is a framework for integrating, analyzing, and communicating information that is available on a population’s health, along with some understanding of how that population’s health is changing so that the information is more relevant for health policy and planning purposes (Barendregt et al. 1996; Arnesen and Kapiriri 2004; Lopez et al. 2006; Forouzanfar et al. 2017; Stanaway et al. 2018).

Environmental Burden of Disease Approach The burden of disease (BoD) is a concept developed in the 1990s by the World Bank and the World Health Organization (WHO) to describe death and loss of health due to diseases, injuries, and risk factors for all regions of the world (Lopez et al. 2006). The burden of a particular disease is estimated by adding together the number of years of life a person loses as a consequence of dying early because of the disease based on their life expectancy (called Years of Life Lost (YLL)), and the number of years of life a person lives with disability caused by the disease, based on the natural history of the disease and life expectancy (called Years of Life lived with Disability (YLD)). Adding the years of life lost and years of life lived with disability provides an estimate of disease burden, called the disability-adjusted life year (DALY). One DALY represents the loss of 1 year of life lived in full health and is the primary health unit used by the burden of disease approach. Besides the DALY, several other measures have been devised, including the quality-adjusted life year (QALY), the health-adjusted life expectancies (HALE), and the healthy life year (HeaLY). The EBoD follows the same approach as the BoD focusing on environmental risk factors. The DALY is the most common measure used by the burden of disease approach and combines in one measure the time lived with disability and the time lost due to premature mortality (Devleesschauwer et al. 2014). The following formulas describe how DALYs can be estimated (Fig. 1 summarizes the DALY components):

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N= number of deaths in a given age category

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L= remaining years to standard life expectancy at age of death (in years)

I= number of incident cases

Years of Life Lost (YLL)

DW = disability weight

L= average duration of disability (years)

Years Lived with Disability (YLD)

DALY Fig. 1 Disability-adjusted life years components

DALY ¼ YLL þ YLD where: YLL ¼ years of life lost due to premature mortality and YLD ¼ years lived with disability. The YLL corresponds to the number of deaths multiplied by the standard life expectancy (from the geographical location) at the age at which death occurs. The basic formula for calculating the YLL for a given cause, age, or sex is: YLL ¼ N  L where: N ¼ number of deaths and L ¼ standard life expectancy at the age of death (in years). To estimate YLD, the number of disability or disease cases is multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). The formula for YLD is: YLD ¼ I  DW  L where: YLD ¼ years lived with disability, I ¼ number of incident cases, DW ¼ disability weight, and L ¼ average duration of disability (years). Number of deaths: The total number of deaths are the reported and registered number of fatalities on the specific cause of death, in a specific population in each time (WHO 2014). This value can be found in the death certificate, health, and populational statistics of the region and country. The number of deaths can be reported in an aggregation of estimates of deaths by cause, age, and sex by geographical location. For the estimating of YLL, a specific number of deaths for the geographical location under study should be chosen. Standard life expectancy: Life expectancy refers to the number of years a person can expect to live. By definition, life expectancy is based on an estimate of the average age that members of a population group will be when they die. The life expectancy can be obtained from national and regional vital registrations, census,

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and surveys. Global life expectancy at birth in 2016 was 72.0 years (74.2 years for females and 69.8 years for males), ranging from 61.2 years in the African Region to 77.5 years in the European Region (WHO 2018). Women live longer than men all around the world. The gap in life expectancy between the sexes was 4.4 years in 2016. There are two main options when choosing the life expectancy in the BoD approach, (a) can use the latest available life expectancy of the country or region where the BoD is estimated, and (b) also can use the highest life expectancy reported around the world, for example, Japan has a life expectancy of 85.3 years in 2017. The main decision between choosing one option is based on the assessor judgment based on a representative approach vs. an equity approach. The representative approach (option a) will choose the life expectancy of the county or regions where a BoD is performed; an equity approach (option b) will assume that all the humans have the same potential to survive as the maximum reported in the best-case scenario, in other words, if Japanese people have a life expectancy of 85.3, any human being can have the same life expectancy under a proper healthy lifestyle. Number of incident cases: Incidence is the number of newly diagnosed cases of a disease in a specific population and time (CDC 2012). The BoD estimations should use similar time frames for the number of deaths and incident cases in the population to estimate DALYs. Incident cases can be found in the official records and health statistics of a region or county (CDC 2012). Disability weight: A disability weight is a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (equivalent to death) (WHO 2013). Disability weights, which represent the magnitude of health loss associated with specific health outcomes, are used to calculate years lived with disability (YLD) for these outcomes in a given population (Ock et al. 2019). For example, a disability weight for mild diarrhea could be 0.074 compared to severe diarrhea 0.24. But more severe health outcomes could have more impact on disability such as treated spinal cord lesion at the neck with a disability weight of 0.58 or an untreated spinal cord lesion at the neck with a disability weight of 0.073. The most recent list of disability weight is provided by the global burden of disease (GBD) study in 2013 (Salomon et al. 2015). Average duration of disability: The average duration of disability is the disease duration until remission, cure, or death. This is also called the natural history of the disease, where the process of the disease that without management or treatment could result in disease remission or death, and with management or treatment would result in the disease cure or control. The disease duration is based on the disease incidence approach and can be found on scientific publications for the specific diagnosis. Traditionally, the burden of disease has been estimated by an incidence-based method. However, since the first GBD study in 2010, the prevalence-based approach has become more widespread (Forouzanfar et al. 2015; Murray et al. 2015). The prevalence-based approach estimates all healthrelated losses over the course of a year, whereas the incidence-based approach captures the burden of disease in new diagnostic cases. Since the incidence-based YLD is calculated as the sum of future health loss related to disease incidence in the reference year, it will not reflect the prevalence of all YLDs, nor does it

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accurately capture the time between which a disease occurs and the age at which health loss begins.

Other EBoD Health Indicators Healthy Life Year (HeaLY) combines the healthy life lost due to death with that lost due to morbidity. The healthy life lost requires knowing the incidence rate, case fatality ratio, the age of disease onset, the age of death, and the life expectancy at these ages. The HeaLY includes three components for disability: case disability ratio (CDR, analogous to the case fatality ratio), the extent of disability, and duration of the disability. The CDR and duration of disability can be determined objectively, but the assessment of the extent of disability, which ranges from 0 (no disability) to 1 (equivalent to death), may have a substantial subjective element (Hyder et al. 2012). An essential difference between the HeaLY and DALY is that the starting point for the HeaLY is the onset of disease; the loss of healthy life is based on the natural history of the disease (as modified by interventions). The YLD component of the DALY is similar, but the YLL is based on mortality in the current year. In a steady-state, there is no difference, but when there is a changing incidence, the DALY approach can significantly underestimate the health impacts. HALE (health-adjusted life expectancy) is a health measure that summarizes the expected number of years to be lived in what might be termed the equivalent of full health. HALE provides one of the best summary measures for the overall level of health. Health expectancy indices combine the mortality experience of a population with the disability experience. In some cases, HALE is calculated using the prevalence of disability at each age in order to divide the years of life expected at each age according to a life table cohort into years with and without a disability. Mortality is captured by using a life table method, while the disability component is expressed by additions of the prevalence of various disabilities within the life table. This indicator allows an assessment of the proportion of life spent in disabled states. HALE does not relate to specific diseases but rather to the average extent of disability among that proportion in each age group that is disabled (Hyder et al. 2012). Quality-adjusted life years (QALYs) is a statistical health indicator that reflects health quantity and quality. It was developed in the late 1960s by economists and is mainly used for cost-effectiveness analyses of improvements in social welfare and clinical interventions. The QALY method can estimate the number of years lived and the quality of life during those years that can be attributed to an intervention. When combined with the cost of providing intervention, QALYs are used to develop costutility ratios required to generate a year of “perfect health,” a perception of life without pain or disease. The health-related quality of life (or utility values) in QALYs is not linked to specific diseases but rather is based on individuals’ opinions about their own health state (patient weights) or on the judgments of others (e.g., a representative sample of the population, study researchers, or health professionals) about a particular health state (community weights where perfect health value ¼ 1 and death ¼ 0). The community weights integrate biomedical and psycho-social

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aspects of the burden of disease and consider five quality of life dimensions: (a) mobility, (b) pain or discomfort, (c) self-care, (d) anxiety-depression, and (e) usual activities (Lajoie 2015). These burdens of disease units are especially useful for policy comparison that affects different causes of mortality, different disease diagnoses, and environmental risk factors. The burden of disease gives the stakeholders a unit of comparison that summarizes mortality and morbidity, comparing different diagnosis, helping to understand more comprehensively the magnitude and direction of a specific intervention, plan, program, or policy. The main disadvantage of these measures (DALYs, YLL, and YLD) is the difficulty to be interpreted for nonhealth practitioners, who are, in most cases, the final audience of a public health intervention.

Comparative Risk Assessment Approach The comparative risk assessment (CRA) approach compares the changes of an intervention, policy, program, or plan on health determinants and their impact on the BoD (mortality and/or morbidity) compared with a baseline scenario or business as usual (Fig. 2) (Rojas-Rueda et al. 2011, 2012; Viana et al. 2015). The aim of the comparative risk assessment approach is to provide quantitative estimates of the expected health impacts (e.g., changes in premature deaths, cases of the disease, disability-adjusted life years (DALYs), etc.) and the distribution thereof among the population (Rojas-Rueda et al. 2012). The steps of a CRA are: • Hazard identification. The intervention, policy, or program context and the relevant exposure (or a multitude of exposures) need to be identified (e.g., type of pollutant), and the baseline exposure level distribution of the population under study needs to be quantified. • Exposure assessment. The exposure level at baseline is compared with the aimed at the exposure level of the counterfactual scenario, and the resulting difference in exposure level is quantified. • Exposure-response assessment. An exposure-response function (ERF) that quantifies the strength of association between the exposure and the health outcome needs to be available from the literature or available guidance. The ERF needs to be of the best available evidence. In an ideal case, the ERF was estimated particularly for the population under study, reflecting most accurately the level of risk the population is exposed to. However, in many cases, an ERF for the population under study is not available; therefore, the ERF should preferably be a pooled, generalized estimate of the overall effect coming from a meta-analysis (or large longitudinal study). • Risk characterization. The risk estimate obtained from the ERF that most epidemiological studies report in terms of relative risk (RR), which is the ratio of incidence observed at two different exposure levels, quantifies the strength of association between the exposure and health outcome. The risk estimate is scaled

Attributable cases to air pollution in the city

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to the difference in exposure level resulting from the comparison of the baseline exposure level with the counterfactual exposure level. In addition to these steps, when a policy plan or program is assessed, it is essential to consider the following points: • Scenario(s) definition. A counterfactual scenario (or a set of scenarios) is defined, which describes the possible exposure level that is aimed at with the proposed intervention, policy, or program. Various criteria may determine the choice of counterfactual exposure distribution. Ideally, counterfactuals should represent intervention, policy, or program actions that are realistic and can be implemented (e.g., motorized traffic reductions to reduce air pollution levels in cities) rather than counterfactuals that are not achievable (e.g., zero air pollution). Murray and Lopez (1999) looked into different counterfactual scenarios categories and identified exposure distributions corresponding to theoretical minimum risk (i.e., exposure distribution with lowest population risk), plausible minimum risk (i.e., imaginable exposure distribution), possible minimum risk (i.e., exposure distribution observed in some populations), and cost-effective minimum risk (i.e., considers costs of exposure reduction). • Health outcome definition. The health outcome (or multiple health outcomes) of interest needs to be defined that was shown by previous epidemiological studies to be associated with the exposure. A causal relationship between the exposure and the health outcome of interest is a prerequisite. • Health data identification. The total burden (TB) of the health outcome of interest needs to be available for the population under study. Incidence rates are preferred over prevalence proportions because only new cases expected over a given time (i.e., incident cases) are preventable under the assumption that exposure levels will change.

Examples of BoD, EBoD, and CRA The Global Burden of Disease project (GBD) is the most extensive, and the most known example of BoD. The GBD is published each year and includes a global perspective on multiple causes and diagnoses, providing YLL and prevalence YLD (Vos et al. 2015). The GBD provides multiple resources to communicate their results and DALYs, YLL, and YLD can be consulted by country or region in their website https://vizhub.healthdata.org/gbd-compare/. The GBD provides different results based on age, sex, year health outcome, and risk factor, offering a great resource to consult the BoD of a specific geographical location, point in time, and health outcome, a comparison among years, locations, age, sex, and outcome. The GBD includes some environmental exposure in their estimations, such as outdoor and household air pollution, lead, radon, unsafe sanitation, and handwashing, in addition to some occupational risk factors (considered by the GBD as environmental exposures), such as occupational carcinogens, noise, and ergonomic, among others

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(Forouzanfar et al. 2016; Stanaway et al. 2018). The World Health Organization (WHO) also provides a Global Burden of Disease, and their estimates are produced on average every 5 years (WHO 2019). The GBD from the WHO also provides DALYS, YLL, and prevalence YLD, globally, by region, and country. Similarly to the GBD project, WHO also estimates the EBoD, which include water and sanitation, indoor and outdoor air pollution, and vector-borne diseases, among others (WHO 2007). Scientific publications on EBoD that capture a more significant number of risk factors are also available. Recent studies have estimated the EBoD in specific age groups and geographical locations, such as in Europe (Hänninen et al. 2014; RojasRueda et al. 2019). This EBoD, focuses on estimating the health burden (Cases of disease, DALYs, YLL, and YLD), related to specific environmental risk factors (e.g., air pollution, lead, and secondhand smoke) and specific health outcomes (e.g., asthma, otitis media) (Rojas-Rueda et al. 2019). In this case, the EBoD instead of comparing health outcomes compares the health burden of different risk factors among countries (Fig. 3). The aim of comparison between countries will be to identify the geographical locations that are suffering more of a specific environmental risk factor and disease. This comparison also helps to identify countries where specific environmental exposure is low and could highlight areas where policies 0

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Dampness 6%

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Fig. 4 Environmental burden of childhood disease in Europe 28 in disability-adjusted life years (DALYs). (Modified from (Rojas-Rueda et al. 2019))

have been useful. On the other hand, comparison of environmental exposures across all the European Union of 28 countries, as shown in Fig. 4, could help to highlight the risk factors that are importantly affecting and could require more urgent policy interventions to improve public health. In comparison to EBoD, the comparative risk assessment approach does not focus only on quantifying health outcomes and risk factors (Rojas-Rueda et al. 2012; Soriano et al. 2018; Stanaway et al. 2018). The CRA adds the dimension of an intervention to these assessments, comparing different policy scenarios and their impact on health determinants (risk factors) and outcomes. For example, Mueller et al. (2017a, b) attributed almost 660 premature deaths and almost 10,000 DALYs to breaching WHO (PM2.5) air quality guidelines in Barcelona, Spain, recognizing that motorized traffic is the most important contributor to local air pollution levels. In another study, Khreis et al. (2019) looked into the air pollution childhood asthma burden in 18 European countries with over 64 million children and estimated that if minimum pollution levels recorded for NO2, PM2.5, and BC could be complied with, then over 135,000, 190,000, and 89,000 incident cases of asthma could be prevented, respectively. A recent study assessed the Barcelona Superblock Model, an innovative land use intervention with the aims to reclaim space for people, reduce motorized transport, promote active transport, increase urban greening, and mitigate effects of climate change, and found that with full implementation of the model, current city-wide annual mean NO2 concentrations of 47.2 μg/m3 could be reduced to 35.7 μg/m3, which in return would result in 291 preventable deaths and an increase of average life expectancy by 129 days (Mueller et al. 2019). In addition, CRA could be structured in the context of policy and governance, providing a

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Fig. 5 Environmental burden of disease and comparative risk assessment of transport-related risk factors and governance in developing countries (NGO: nongovernmental organizations; PT: public transport; and AT: active transport)

general overview of the impacts on environmental risk factors in the local policy framework (Gascon et al. 2016). Figure 5 includes a description of a CRA of transport-related environmental risk factors in the context of governance in the developing countries. This framework is relevant to highlight the need for a good governance structure to integrate the recommendations related to policy scenarios in transport-related risk factors.

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Conclusion The burden of disease approach and the comparative risk assessment are essential and valuable tools to measure multiple health outcomes, risk factors, and policy interventions. Global health practitioners and authorities guide their policies based on several health metrics, and currently, DALY, YLL, and YLD are among the most common health metrics used to assess population health and compare health and nonhealth sector policies. Examples such as the Global Burden of Disease, environmental BoD, or comparative risk assessment should be considered as best practices to assess and evaluate global health policies and interventions.

References Arnesen T, Kapiriri L (2004) Can the value choices in DALYs influence global priority-setting? Health Policy 70(2):137–149. https://doi.org/10.1016/j.healthpol.2003.08.004 Barendregt JJ, Bonneux L, Van Der Maas PJ (1996) DALYs: the age-weights on balance. Bull World Health Organ 74(4):439–443 CDC (2012) Morbidity frequency measures, principles of epidemiology. Available at: https://www. cdc.gov/csels/dsepd/ss1978/lesson3/section2.html. Accessed 27 May 2020 Devleesschauwer B, et al (2014) Calculating disability-adjusted life years to quantify burden of disease. Ó Swiss School of Public Health. https://doi.org/10.1007/s00038-014-0552-z Forouzanfar MH et al (2015) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386(10010):2287–2323. https://doi.org/10.1016/S0140-6736(15)00128-2 Forouzanfar MH et al (2016) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1659–1724. https://doi.org/10.1016/S0140-6736(16)31679-8 Forouzanfar MH et al (2017) Global burden of hypertension and systolic blood pressure of at least 110 to 115mmHg, 1990–2015. JAMA 317(2):165–182. https://doi.org/10.1001/jama.2016. 19043 Gascon M et al (2016) Urban policies and health in developing countries: the case of Maputo (Mozambique) and Cochabamba (Bolivia). Public Health Open J 1(2):24–31. https://doi.org/10. 17140/PHOJ-1-106 Hänninen O et al (2014) Environmental burden of disease in Europe: assessing nine risk factors in six countries. Environ Health Perspect 122(5):439–446. https://doi.org/10.1289/ehp.1206154 Hyder AA, Puvanachandra P, Morrow RH (2012) Measuring the health of populations: explaining composite indicators. J Public Health Res 1:222–228 Khreis H, et al (2019) Outdoor air pollution and the burden of childhood asthma across Europe. Eur Respir J. https://doi.org/10.1183/13993003.02194-2018 Lajoie J (2015) Understanding the measurement of global burden of disease. National Collaborating Centre for Infectious Diseases. Available at https://nccid.ca/publications/understanding-themeasurement-of-global-burden-of-disease/. Accessed 26 May 2020 Lopez AD, et al (2006) Global burden of disease and risk factors editors and Pacific the caribbean. Available at http://apps.who.int/iris/bitstream/10665/41864/1/0965546608_eng.pdf Mueller N, Rojas-Rueda D, Basagaña X, Cirach M, Cole-Hunter T, Dadvand P et al (2017a) Health impacts related to urban and transport planning: a burden of disease assessment. Environ Int 107:243–257. https://doi.org/10.1016/j.envint.2017.07.020

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Mueller N, Rojas-Rueda D, Basagaña X, Cirach M, Cole-Hunter T, Dadvand P et al (2017b) Urban and transport planning related exposures and mortality: a health impact assessment for cities. Environ Health Perspect 125(1):89–96. https://doi.org/10.1289/EHP220 Mueller N, et al (2019) Changing the urban design of cities for health: the superblock model. Environ Int. 105132. https://doi.org/10.1016/j.envint.2019.105132 Murray C, Lopez A (1999) On the comparable quantification of health risks: lessons form the global burden of disease study. Epidemiology 10:594–605 Murray CJLL et al (2015) Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet 386(10009):2145–2191. https://doi.org/10.1016/S0140-6736(15)61340-X Ock M, et al (2019) Disability weights measurement for 289 causes of disease considering disease severity in Korea. J Korean Med Sci 34(Suppl 1). https://doi.org/10.3346/jkms.2019.34.e60 Rojas-Rueda D et al (2011) The health risks and benefits of cycling in urban environments compared with car use: health impact assessment study. Br Med J 343:d4521 Rojas-Rueda D et al (2012) Replacing car trips by increasing bike and public transport in the greater Barcelona metropolitan area: a health impact assessment study. Environ Int 49:100–109. https:// doi.org/10.1016/j.envint.2012.08.009 Rojas-Rueda D et al (2019) Environmental burden of childhood disease in Europe. Int J Environ Res Public Health 16(6):1084. https://doi.org/10.3390/ijerph16061084 Salomon JA et al (2015) Disability weights for the global burden of disease 2013 study. Lancet Global Health 3(11):e712–e723. https://doi.org/10.1016/S2214-109X(15)00069-8 Soriano JB et al (2018) The burden of disease in Spain: results from the global burden of disease 2016. Med Clin 151(5):171–190. https://doi.org/10.1016/j.medcli.2018.05.011 Stanaway JD et al (2018) Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392(10159):1923–1994. https://doi.org/10.1016/S0140-6736(18)32225-6 Viana M et al (2015) Environmental and health benefits from designating the Marmara Sea and the Turkish straits as an emission control area (ECA). Environ Sci Technol 49(6):3304–3313. https://doi.org/10.1021/es5049946 Vos T et al (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386(9995):743–800. https://doi.org/10.1016/S0140-6736(15)60692-4 WHO (2007) Country profiles of environmental burden of disease. WHO, Geneva WHO (2013) Disability weights, discounting and age weighting of DALYs, Health statistics and information systems. Available at https://www.who.int/healthinfo/global_burden_disease/daly_ disability_weight/en/. Accessed 27 May 2020 WHO (2014) Department of Health Statistics and Information Systems, estimates for 2000–2012. Available at http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html WHO (2018) Life expectancy. WHO, Geneva WHO (2019) Disease burden and mortality estimates. World Health Organization, Geneva

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water-Related Disease Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current WASH Sector Research and Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health and Well-being: From Biological Health to Holistic Well-being . . . . . . . . . . . . . . . . . . WASH Across a Continuum of Care: From Prevention to Recovery and Care . . . . . . . . . . . WASH at Scale: From Household to Institutional and Citywide Scales . . . . . . . . . . . . . . . . . . Future Policy and Program Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broadened Conceptual Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Realizing Equitable WASH Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter provides an overview of key health frameworks that have shaped the water, sanitation, and hygiene (WASH) sector since 1958, presents current trends in WASH practice and research, and suggests future policy and research directions. WASH is a fundamental component of global health programming, as its absence results in severe health consequences ranging from biological harm to adverse mental health. While the former has been the focus of WASH research and programming since its nascency, the latter has started gaining traction recently. In addition to transitioning to a more holistic approach, WASH professionals are developing programs across the care continuum, incorporating an equity lens, and scaling services at systemic levels. WASH-associated disease frameworks need to reflect physical, mental, and social well-being outcomes to account for broadened perspectives. Current literature and practice indicate that L. Taing (*) · N. Dang United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, ON, Canada e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_94

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while WASH programming has become more inclusive in the Sustainable Development Goals (SDGs) era, there is still scope for reaching a diverse range of populations that continue to be overlooked. Greater integration of WASH and health programming is essential to accelerate achievement of the SDGs and leave no one behind. Keywords

WASH · Sustainable Development Goal (SDG) · Health and well-being · Water · Sanitation · Hygiene

Introduction In 2020, the world witnessed an unprecedented global shutdown due to a highly infectious respiratory disease. Infecting millions globally, the Covid-19 pandemic has had tremendous implications on global health, economics, and politics. While governments and experts across the world have adopted different policies and approaches to flatten the curve, all of them have continuously highlighted one simple yet effective means to contain Covid-19’s spread: frequent handwashing with water and soap. Unfortunately, accessibility to safe running water and soap to wash one’s hands is not universal. While household WASH services have improved since the beginning of the century, delivery has been slow as the population has exponentially grown, leading many to question whether the Sustainable Development Goals (SDGs) will be achieved by 2030. As of 2017, as much as 40% of the world does not have access to basic handwashing facilities, more than half of the global population does not have access to safely managed sanitation, and around a third still lack safely managed water (WHO/UNICEF 2019a). Delivery of sanitation services increased by 23% from 2000 while safe water coverage improved by 10% in the past two decades, indicating a stagnant growth (WHO/UNICEF 2019a). The shortage of basic services is largely experienced in low-resource areas. In least developed countries, roughly a third of the population has access to safely managed water, basic sanitation, and hygiene (WHO/UNICEF 2019a). As the global response to Covid-19 underscores, access to safely managed water, sanitation, and hygiene (WASH) is vital to public health and the economy. Inadequate WASH translates to serious consequences: in a pre-Covid-19 study, an estimated 1.6 million deaths and 105 million disability-adjusted life years (DALYs) are lost because of poor WASH (Prüss-Ustün et al. 2019). These deaths – caused by diarrheal disease (52%), acute respiratory infections (23%), and malnutrition (2%), as well as vector-borne diseases such as malaria (22%) and schistosomiasis (1%) – are largely considered preventable (Prüss-Ustün et al. 2019). Poor WASH is also the source of 15% of annual patient healthcare-associated infections in developing countries (Allegranzi et al. 2011) and has been found to adversely influence patients’ healthcare-seeking behavior and lower patient satisfaction with medical care

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(Bouzid et al. 2018). If access to WASH is universal, then millions of lives and DALYs, as well as billions of dollars, could be saved: investing in WASH could reduce an estimated US$260 billion in annual global economic losses and produce an estimated return of five dollars for every US dollar spent (WHO 2018b). These statistics highlight WASH’s critical role in controlling risks for a range of preventable diseases and supporting the global economy, as well as the significance of achieving Sustainable Development Goal (SDG) 6 (clean water and sanitation) to realize SDG 3 (good health and well-being), 1 (no poverty), and 8 (decent work and economic growth). This chapter focuses on the critical role WASH plays in global health programming and realizing SDG 3. Firstly, two key health frameworks that have guided WASH program design to prevent disease transmission from 1958 and 1972 are discussed. Thereafter, reflection on the relevance of these health frameworks in light of current sector research and guidance is provided, and directions and a new disease framework for future policy and programming to further enhance integration across the global health and WASH sectors are proposed. Considering the overarching 2030 agenda to “leave no one behind,” realization of SDG 3 and 6 requires continued synergetic collaboration between health and WASH professionals.

Water-Related Disease Frameworks This section describes two key water-related disease transmission frameworks that have influenced WASH programming for over half a century: the Wagner and Lanoix’s F-diagram and the Bradley classification tool. The aim of the former is to prevent water-related disease transmission by introducing sanitation, safe water supplies, and handwashing measures as barriers that contain pathogen spread and contamination (Fig. 1). This seminal disease transmission model from 1958, which

Fig. 1 Wagner and Lanoix’s F-diagram (OpenWASH 2016)

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alliteratively shows how fluids, fingers, flies, fields (or floors), and food can transmit pathogens from feces to a new host, focuses on preventing fecal-oral disease transmission. Most programs based on the F-diagram aimed to break exposure pathways through the provision of household water and sanitation infrastructure and individual hygiene education to improve WASH and health outcomes. While useful to describe one possible exposure pathway of WASH-associated disease transmission, some critics have noted that it overlooks transmission as a result of unsafely managed WASH services. For example, an adapted model from WHO (2018c) highlights how different stages of a broken sanitation system can expose people to additional risks via environmental hazards (Fig. 2). The adapted WHO model additionally includes animals as possible disease vectors. Various studies have indicated that feces from domesticated animals are a significant source of disease transmission, with increased risks of environmental enteric dysfunction, trachoma, and soil-transmitted helminths (Zambrano et al. 2014; Penakalapati et al. 2017). Another shortcoming of the F-diagram is that it does not adequately capture disease origins beyond fecal matter. Given that maintaining hand hygiene is a fundamental barrier against pathogen transmission for emerging epizootic respiratory infections such as the H1N1 and the current COVID-19 pandemics, future research and interventions will likely further identify WASH-related disease pathways besides the more established fecal-oral route. The Bradley classification (Table 1) of water-related diseases is another classic framework that has influenced WASH programming since 1972. It characterizes spread of biological agents via waterborne, water-washed/water-access, waterbased, and water-related vector-borne transmission (White et al. 2002). Thompson

Fig. 2 A modified F-diagram depicting the transmission of excreta-related pathogens (WHO 2018c)

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Table 1 Bradley classification of infective water-related diseases (White et al. 2002) Category I. Waterborne (a) Classical (b) Nonclassical II. Water-washed (a) Superficial (b) Intestinal III. Water-based (a) Water-multiplied percutaneous (b) Ingested IV. Water-related insect vectors (a) Water-birding (b) Water-breeding

Example Typhoid Infectious hepatitis Trachoma, scabies Shigella dysentery Bilharziasis Guinea worm Gambian sleeping sickness Onchocerciasis

and Cairncross (2002) stated that the Bradley classification highlighted two significant correlations between domestic water supplies and disease transmission: Overview

• Environmental correlations: These were drawn between water-related disease and their environmental transmission routes. Intervention designers subsequently focused more on environmental factors to effectively reduce water-related morbidities rather than taxonomic or clinical disease characteristics commonly used in medicine. • Water access and hygiene correlation: Bradley drew attention to the importance of increasing access to sufficient quantities of water (as opposed to improving water quality) to improve health outcomes of multiple hygiene behaviors associated with known fecal-oral disease transmission routes.

Bartram and Hunter (2015) suggested updates to the Bradley classification to reflect improved understanding of: (i) various causal agents; (ii) reduced water quality between source and use; (iii) animal and human fecal pollution risks; and (iv) chemical hazards. They further expanded upon the classic typology by adding new classes of water-related health hazards, including aerosol-transmitted diseases, bacteria transmitted through engineered water systems, and physical injury and violence associated with water collection. Both Bradley’s original and Bartram and Hunter’s revised classifications of water-related disease transmission routes focus on water’s central role in exposing vulnerable populations to various microbial, chemical, or vector-borne diseases. Put differently, water as a medium itself is targeted, which has the potential to overlook the influence of sanitation and hygiene, the other elements of WASH, as root causes of disease. Additionally, while these classifications helped frame interventions around environmental causal agents, a key limitation is that the majority of

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water-borne diseases can be transmitted by multiple means (Eisenberg et al. 2013; Robertson et al. 2013). For example, fecal-oral diseases such as cholera and shigella dysentery can arguably be classified as both water-borne and water-washed; vectors such as guinea worm could fall under water-borne or vector-borne categories. Identifying only one water-related causal agent had the potential to result in major programming gaps. These two classifications, moreover, do not account for potential mental and emotional repercussions of poor WASH services as per WHO’s health definition (WHO 2006). Summarized in the next sections are research findings and best practices that attest to the need for a broadened health and well-being framing and intervention scale to reach more people with integrated health and WASH programming.

Current WASH Sector Research and Guidance Recent research and lessons learnt from WASH programming has indicated limitations of both the F-diagram and Bradley Classification, thereby necessitating expansions of these seminal frameworks. Since the beginning of the century, the WASH sector has increasingly expanded its programming to: • Reflect WASH’s diverse range of supporting functions in disease interventions • Adapt servicing paradigms beyond a household setting This section covers how the sector is broadening its conceptualization of disease by shifting from a biological health to holistic well-being focus and from a preventative emphasis to coverage across the continuum of care. It closes with a discussion of how the WASH sector is transitioning from a household focus to institutional and citywide scales.

Health and Well-being: From Biological Health to Holistic Well-being The WHO (2006) defines health “not merely [as] the absence of disease” but as “a state of complete physical, mental, and social well-being.” Despite this holistic framing, WASH and health interventions have largely regarded disease in terms of biological health consequences as a result of infectious pathogens and contaminants linked to poor WASH resources. Recent research, however, has begun unpacking physical, mental, and social well-being aspects of WASH interventions. Notably, many of the consequences related to inadequate WASH beyond traditional health outcomes are disproportionately experienced by women and girls. Both the WASH and health sectors are conducting formative research to effectively address physical, mental, and social well-being associated with limited WASH services. For instance, Sommer et al.’s (2015) four types of gender-based violence (GBV) associated with WASH access – sexual (rape, assault, and molestation), psychological (harassment and bullying), physical (injury or death from fights)

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and sociocultural violence (e.g., ostracism, discrimination and marginalization) – reflect an understanding of physical, mental, and social aspects of health and wellbeing. GBV affecting women and girls accessing off-premises facilities, in particular, has received attention in both the development and humanitarian sectors, as fetching water or using toilets could result in both GBV-related physical and mental health trauma. Water carriage research has indicated that not all physical WASHrelated injuries are the consequences of GBVor fighting, as anatomical (specifically, musculoskeletal) consequences could result from limited coverage and off-premises water access (Geere et al. 2018; Geere and Hunter 2020). Nevertheless, women and girls are disproportionately affected as they are the main water collectors in a majority of Sub-Saharan areas where the number of people having to travel more than 30 minutes to fetch safe water doubled in the past two decades (WHO/ UNICEF 2019a). This could lead to even greater reduction in opportunities and well-being for girls and women in these regions as a result of limited safe water services. Several sanitation studies also describe negative impact of limited sanitation services on women’s and girls’ mental well-being, as limited coverage subjects them to increased risk of unwanted attention, including verbal, physical and sexual assaults (Sclar et al. 2018). Overall, privacy and safety are the most common themes, with both being either violated perceptively or physically, leading to anxiety and/or fear, and embarrassment, shame, and/or loss of dignity (Sclar et al. 2018). Sclar et al. (2018) hence recommended addressing structural (facility design and maintenance), environmental (location), and social privacy (with regards to norms, gender inequalities, and violence) considerations in WASH programming to reduce anxiety and stress experienced by affected women and girls. Formative research on anxiety and stress also features prominently from people who live with HIV and who cope with menstrual health and hygiene (MHH) management. Among people living with HIV, inadequate WASH has been found to contribute to anxiety and stress associated with disease management, particularly chronic diarrhea, which is twice more prevalent than HIV-negative people (Lule et al. 2005). Hodes et al. (2018) found that adolescents living with HIV thus adjusted their treatment regimens and mobility according to WASH access due to the need for water to take medication, and sanitation and hygiene facilities for side effects. With regards to MHH, adequate management means that people who menstruate can use clean materials to collect menstrual blood, which can be changed in privacy, as often as needed, for the duration of one’s period, with soap and water, and they can safely dispose of used menstrual materials (UNICEF 2019). Safe menstrual hygiene practices and disposal of used products are often hampered by lack of access to menstrual management materials and adequate and private WASH services, as well as stigma and lack of knowledge, leading to physical and mental health consequences for women (Elledge et al. 2018), including urogenital infections, STDs, and GBV linked to transactional sex in exchange for money to purchase menstrual products (Kuhlmann et al. 2017). All of this research highlights the significance of framing health holistically to comprehensively understand and

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address the diverse range of potential health and well-being impacts of how WASH services are designed and delivered.

WASH Across a Continuum of Care: From Prevention to Recovery and Care Following the logic of the F-diagram and Bradley classification, the health sector has largely framed WASH programs as preventative measures, with an especial focus on reducing diarrheal risk. Alarmingly, diarrheal diseases remain the second and sixth leading cause of death in low- and middle-income countries (LMICs) (WHO 2018a) despite the widespread availability of oral rehydration solutions (ORS). Children are disproportionally affected as their underdeveloped immune systems put them at greater risk of diarrheal infections and consequent complications: 36% of underfive diarrheal deaths in LMICs are attributed to poor WASH, which amounts to 5% of all deaths in this vulnerable subpopulation (Prüss-Ustün et al. 2019). Jung (2017) found that interventions targeting water, sanitation, or hygiene elements in silo may avert up to 27% of diarrhea episodes and saving more than 300,000 child lives. Moreover, when integrating WASH programs with other child health interventions, the effect estimates increase to 51% of diarrhea risk reduction, with a further reduction of 250,000 deaths among children (Jung 2017). A range of siloed and integrated WASH interventions have thus been employed to successfully reduce diarrheal risk. Based on a WHO report ( 2014) and a systematic review of 84,000 participants mainly in LMICs, interventions to improve water at point-of-use have shown significant effects in reducing diarrheal incidents. Specifically, disinfecting products may cut diarrhea risk by 25%; filtration systems by half; and solar disinfection by a third, with greater effects observed where water is safely stored (Clasen et al. 2015). Point-of-use interventions might be a temporary solution to address diarrhea in LMICs until piped water can be provided universally (Clasen et al. 2015), but studies have shown that more than 20% of diarrheal incidents were decreased by converting from unimproved to piped water (WHO 2014). Similar effect estimates are reported by a systematic review of 135 studies – sanitation programs lower diarrheal risk by 25%, but risk is lowered by 45% when sanitation coverage reaches 75% in a community (Wolf et al. 2018). This evidence indicates that WASH interventions integrated into child health programs could reap more benefits than when implemented in sector silos. In the SDG era, WASH increasingly has been viewed as an essential component in health treatment, care, and recovery for a range of diseases as well. In HIV programming, Yates et al. (2015) stated that water supply, treatment, and hygiene interventions cost-efficiently reduce health morbidities (e.g., delay viral progression and control diarrhea severity) among people living with HIV in multipronged programs. WASH is also essential across the health spectrum for Neglected Tropical Diseases (NTDs), as limited access to a continuous supply of safe water and sanitation limits patients’ ability to recover. The WHO (2015a, b) describes the relationship between unsafe WASH and the 1 billion people suffering from NTDs

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across 149 countries as a cycle of poverty and disease: suboptimal WASH conditions due to poverty contaminate the communal environment, exposing local residents to infections and resulting in financial and stigma-based burdens, especially among the most vulnerable. To better integrate WASH and health sector NTD responses, WHO (2015b) has proposed four strategic objectives focused on improving awareness of WASH-NTD linkages to incubate collaboration; monitor intervention progress and gaps by standardizing disaggregated data collection; embed practical operational research into guidelines; and synergistically engage stakeholders at all levels. These strategies are not only applicable in addressing NTDs through WASH but can also be adapted in other intersectoral WASH-health interventions. Recent WASH research has been exploring its additional roles in treatment and care, confirming WASH as a key facilitator in maximizing health outcomes at any point in the continuum of care.

WASH at Scale: From Household to Institutional and Citywide Scales Traditionally, WASH programs focused on household infrastructure and individual behaviors. The assumption underpinning these interventions was that the lack of physical availability of infrastructure in households resulted in poor WASH behaviors. In recognition, however, that providing hardware has not always translated to improved WASH outcomes due to a narrow focus of WASH settings and target populations’ behaviors, WASH interventions are expanding this purview in recognition that people are not islands. Recent programming expands this purview to account for WASH needs in institutional settings and at a citywide scale. This section discusses current research and guidance with regards to WASH in institutional settings (specifically, healthcare facilities, and schools) and at a city-wide scale.

Institutional Settings WASH in institutional settings have received greater attention as it is recognized that overall desired effect (i.e., a reduction in risks of WASH-related diseases) of interventions cannot be maximized if interventions narrowly focus on household interventions. Adequate WASH services in healthcare facilities are especially crucial to providing effective treatment and care for patients who are already burdened with disease and enabling a safe environment for their families and healthcare providers. Nevertheless, 900 million people lack safe water services at their hospitals; 1.5 billion people have unsafe or no toilets at their healthcare facilities; and 16% of healthcare facilities globally do not have soap or water (WHO/UNICEF 2019b). Moreover, WASH in healthcare facilities has an additional implication on human health beyond patient care: approximately 15% of facility waste is hazardous and often not treated safely before being released into the environment (WHO/UNICEF 2019b). WHO hence has provided guidance on infection and prevention control, sanitation management, cleaning, disinfection, and waste treatment measures to limit pathogen transmission (WHO 2019; WHO/UNICEF 2019b). The guidelines also provide

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advice on prioritizing distribution of resources under emergency scenarios when resources might be drastically shifted, creating unintentional gaps in services that might persist beyond outbreaks. Recent research has shown that WASH interventions in schools can potentially reduce school absenteeism by 20–60% by decreasing risk of infection among schoolchildren (Sclar et al. 2017; McMichael 2019). Unfortunately, almost 670 million children go to school without water to wash their hands, and one third of schools do not have functional on-site sanitation facilities (WHO/UNICEF 2018). Despite increased attention and emerging evidence, international guidance on WASH services in schools is scantly available, leaving countries and individual schools responsible for providing WASH facilities based on their own discretion. Country-specific guidance for WASH in schools often is developed and monitored by national education authorities in collaboration with international organizations and often is a part of broader health campaigns. One such campaign is the “Fit for School” program developed in 2008 by the Philippine Department of Education and GIZ to improve schoolchildren’s oral and intestinal health through hygiene practices. Implementers worked closely with a range of stakeholders to comprehensively address children’s health needs in part due to limited resources (Fit for School). Findings from other WASH in school interventions flagged that targeting singular elements of WASH tend not to have a significant impact on students’ health outcomes and school attendance (McMichael 2019), which further builds the case for designing integrated health and WASH in school programs.

City-Wide Services In addition to institutional programming, the WASH sector has shifted from its rural focus as more of the world’s population moved to cities. WASH needs in cities and small towns are distinct from rural settings in that services are constrained by population density (especially in informal settlements), limited social capital, inequitable coverage, silo management, and technology limitations, as well as an inability to meet demand for waterborne services and improve nonsewered services (Hawkins et al. 2013; Marks et al. 2020). Moreover, there is a greater variety of stakeholders involved, meaning greater complexity and potential for politicization in policy processes and implementation responsibilities. Regardless of these constraints, the WASH sector has ambitiously evolved its serving models from providing per capita household infrastructure to universal water and sanitation services that are designed to be safely managed at a city-level (World Bank 2017; Schrecongost et al. 2020; Gambrill et al. 2020), thus advocating for embedding such systems-level thinking in municipal policies. Most of these models remain conceptual rather than based on the successful integration of a variety of perspectives to ensure long-term sustainability and implementation viability with regards to political and financial contexts. Nonetheless, these systems models highlight that achieving universal coverage requires concerted efforts by authorities at all levels and from different sectors to induce changes systemically and to support equitable and sustainable WASH at scale.

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Future Policy and Program Directions In light of considerable diversification in recent WASH research interests, updated frameworks to guide future research and policies based on currently best evidence are imperative to avoid unequitable investments in a particular vulnerable groups or sectoral areas. Frameworks built on existing versions employ time-tested knowledge and should be practical to be contextualized by program officers and be embedded seamlessly into ongoing research. Research guided by adapted frameworks may fill gaps that have been hitherto overlooked, informing regulatory changes that reflect equity.

Broadened Conceptual Frameworks The research and practical lessons outlined in this chapter indicate that the conceptual frameworks that have underpinned WASH programming for over half a century need to be expanded beyond its fecal-oral and biological health focus. Frameworks firstly need to reflect disease origins beyond human fecal matter, such as diseases that originate from animal sources. Considering how zoonoses can severely threaten human health, proponents of a One Health framing have advocated for broadening WASH conceptual frameworks such as the F-diagram to better depict the relationship among humans, animals, and shared environments (NNN and WHO 2018). Secondly, physical, social, and mental well-being impacts have increasingly been explored in WASH programming, especially when a gender lens is applied. There’s especial need to continually unpack the various mental and social well-being impacts associated with WASH or the lack thereof. This broadened purview suggests that frameworks such as the Bradley and associated typologies should look beyond biological and physical well-being factors by including aspects of mental and social well-being as well. In particular, mental and social ill-health linked to WASH access – especially among vulnerable groups – is gaining more traction in the field. Psychosocial consequences as a result of stigmatization and ostracization of individuals who menstruate or gender-based violence trauma have urged many global researchers to realize that the impact of inadequate WASH on mental health is an important factor that needs to be monitored and addressed. Additionally, with regards to disease classification, it is important to re-frame the scope of the tool as WASH-associated, rather than water-focused. To address these classification limitations, a further adaptation of Bradley’s water-related diseases classification based on the disease agent (rather than the environmental causal agent) and covering the range of physical, mental, and social well-being outcomes for WASH-associated diseases is presented based on a synthesis of literature discussed in this publication (Table 2). By using this WASH wellbeing adaptation, the WASH and health sectors might find it more straight-forward to identify which group their outcomes of interest belong to, which mechanisms are responsible for those conditions, potentially determine research gaps and find it easier to develop appropriate interventions.

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Table 2 WASH-associated disease and well-being classification, adapted from Bradley (White et al. 2002) and Bartram and Hunter (2015) Proposed WASH disease category Physical well-being Infectious: Disease transmission from ingestion, inhalation, or contact with water contaminated with infective pathogens (e.g., bacteria, viruses, protozoa, amoeba, arthropods, and helminths) originating from natural and engineered water systems

Bradley classification

Bartram & Hunter classification

Waterborne – Infectious

Waterborne – Infectious

Water-access – Superficial Water-access – Intestinal Water-access – Respiration Water-based - ingested

Waterwashed (waterhygiene)

Water-based – Multiple percutaneous N/A

Water-based – Contact Engineered water systemsassociated – Ingested, inhaled, contact

N/A Waterborne – Toxic chemicals Engineered water systemsassociated – Ingested, inhaled, contact Water-based – Contact

Chemical: Disease from ingestion, inhalation, or contact with chemicals or minerals in water

Waterborne

Vector-borne: Disease caused by insects (i.e. mosquitoes, sandflies, triatomine bugs, blackflies, ticks, tsetse flies, mites, snails, and lice breeding in or near water bodies) that transmit infective pathogens

Water-based – Multiple percutaneous Water-based – Ingested Vector-borne – Bite

Vector-borne – Breeding

Disease examples Cholera, typhoid, hepatitis, cryptosporidiosis, giardiasis, etc. (fecal-oral diseases from consuming or contacting unsafe water) Trachoma, scabies Shigella dysentery Pneumonia Gastrointestinal disorders, liver damage due to cyanobacterial toxins from algae Leptospirosis, Naegleria fowleri Legionella, Mycobacterium Avium Complex, Pseudomonas

Reproductive tract and urogenital infections Poisoning: arsenic, fluoride (high exposure), lead Radon

Bilharziasis (schistosomiasis) Dracunculiasis (Guinea worm) Malaria, Gambian dengue, sleeping Filariasis, sickness yellow Onchocerciasis fever (continued)

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Table 2 (continued) Proposed WASH disease category Physiological: Adverse bodily functions as a result of limited WASH services and/or access

Bradley classification N/A

Bartram & Hunter classification Water-access – Hydration Water-access – injury and violence associated with off-premises services N/A

Mental and social well-being Psychological or N/A societal: Adverse function associated with limited WASH services and/or access

Disease examples Dehydration, malnutrition Musculoskeletal disorders due to injuries or genderbased violence

Drowning Stress, anxiety, or trauma due to MHH-associated stigma, gender-based violence, etc.

Realizing Equitable WASH Services Current literature and practice indicate that while WASH programming has become more inclusive in the SDG era, there is still scope to reach a diverse range of populations that continue to be overlooked. The UN has flagged the need to pay especial attention to groups that historically have been discriminated against due to socio-economic, structural (e.g., gender, age, disability, migratory or indigenous status, ethnicity, or other minority status), or geographic factors (UN SDG 2019). One left behind group that has generated more attention are women and girls. While gender is more and more being mainstreamed in WASH programming, gender matters are largely treated as binary within the sector, which is evident by a lack of policies and interventions for gender-nonconforming people (Sclar et al. 2018). Research on WASH for the LGBTQIA+ community (Lesbian, Gay, Bisexual, Transgender, Queer, Intersexed, Agender, Asexual, and Ally community) has been seriously limited, almost exclusively focusing on transgender populations and with a greater proportion being done in developed countries (Benjamin and Hueso 2017). Aside from nonconforming gender, there is a significant lack of evidence of WASH health impacts on people with disabilities (Sclar et al. 2018). In a crosssectional survey where 2.5% of 99,252 participants sampled have disabilities, Mactaggart et al. (2018) found that people with disabilities struggled individually with poorer quality access within their households. Banks et al. (2019) similarly found they struggled with increased pain and time allocation, as well as reduced privacy, dignity, and autonomy, when compared to people without disabilities. With regards to MHH, studies that investigated barriers and interventions for people with disabilities were observational, done in high-income countries, and focused on

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intellectual impairments (Wilbur et al. 2019). As with the limited evidence base for nonbinary populations, more rigorous studies for people with disabilities – especially in LMIC – are needed. In the coming decade, further formative research on the needs of vulnerable populations at risk of being left behind will increasingly feature on WASH agendas to address servicing inequity. Design of effective WASH interventions requires such deep insights into a range of determinants specific to these groups to ensure that facilities and services are meeting their health and well-being requirements. These insights can also inform the development of standardized indicators to monitor health and WASH outcomes for vulnerable populations and enable countries to remain accountable and on track for achieving SDG 3 and 6.

Conclusion This chapter provided an overview of the current status and future direction of WASH programming in relation to global health objectives. Foundational frameworks of WASH-related ill-health have acted as the backbone for programming and research in the WASH sector. Through implementation, these frameworks have been improved to better represent conditions on-the-ground and different disease-specific and population-specific needs and will likely be further developed by the integration of the One Health approach and systems thinking in WASH programming. The key to accelerated progress is integration. Despite available evidence for the positive impact of WASH interventions on a variety of well-being conditions, countries have yet witnessed a substantial improvement in WASH-associated outcomes, failing to integrate or align WASH programs with health programs and policies. As many WASH programs have been trialed in different areas and become ready to scale up, synergistic effects of intra- and inter-sector interventions are expected to be explored and established in the future to accelerate progress across multiple SDGs and bring the world closer to achieving universal WASH for everyone by 2030. Implementation, actual usage, and cost analysis of WASH services are recommended as the priorities for future research, as well as standardized definitions of outcome measures and practical guidance on the incorporation of WASH interventions with the social welfare, education, health, and private sectors to facilitate universal enjoyment of safe WASH and ultimately, well-being.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accounting for Chemicals and Hazardous Substances and Their Global Disease Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Air Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heavy Metals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pesticides, Other Synthetic Chemicals and Their Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Persistent Organic Chemical Pollutants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Stockholm Convention on POPs and the Dirty POPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter addresses the global impacts of heterogenous chemicals and toxic substances on human health and the environment. Chemicals and hazardous substances are ubiquitous in every nook and cranny of society across the globe. The challenges facing the scientific community in documenting the number and variety of chemicals, and hazardous products that are manufactured, available on the market, and in use as well as the disease burden associated with them are discussed. The chapter addresses the chemicals, hazardous substances of global public health concern, including air pollution, inorganic substances especially heavy metals, and synthetic organic compounds such as the Persistent Organic Pollutants (POPs) and pesticides. Gaseous elements, acids and bases are also covered. Major sources of releases into the environment and routes of exposure and the consequences for exposed population’s health and well-being are addressed. The estimated Global Burden of Disease (GBD), Disability Adjusted F. O. Adeola (*) Department of Anthropology and Sociology, The University of New Orleans, New Orleans, LA, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_96

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Life Years (DALYs), and economic loss associated with selected chemical substances are discussed along with the health symptoms and the acute and chronic effects of specific chemicals. How to bridge the gap between the rapid release of manufactured chemical substances for use and the slow pace of scientific research to uncover their adverse health effects on human population and wildlife, remains a serious challenge to scientists as discussed in this chapter. Keywords

Chemicals · Hazardous substances · Air pollution · Pesticides · Nano-particles · Persistent Organic Pollutants (POPs) · Global burden of disease

Introduction Poison is in everything, and no substance is without poison. The dosage makes it either a poison or a remedy. (Paracelsus)

Chemicals and toxic substances are ubiquitous in societies across the globe. They are encountered in every facet of daily lives in the air, soil, water, work places and in households, making them mostly unavoidable. According to the World Health Organization (WHO), all living and non-living matters are made up of chemicals and every manufactured product involves the use of chemicals (WHO 2019a, b). While many chemical elements exist naturally (e.g., various earth metals – such as arsenic, cadmium, lead, mercury, organic matters, etc.), the majority of hazardous substances and toxic chemical compounds are manufactured for commercial purposes. There is a growing concern about the rapid production of toxic chemicals and hazardous products and their releases to the environment, consequently posing serious threats to public health across the globe. This chapter focuses on global impacts of chemicals and toxic substances on human health and the biophysical environment. The nature, sources, characteristics, exposure pathways, health effects and global burden of diseases for selected hazardous chemicals are discussed. Emphasis is placed on a group of chemicals and chemical products considered to be of major public health concern, among which are heavy metals, air pollution, organochlorine products, pesticides, and other Persistent Organic Pollutants (POPs). Goldman (2002) distinguishes between chemicals and toxic substances, indicating that chemicals are substances manufactured, processed, and commercialized, other than those marketed as pesticides, herbicides, pharmaceuticals, or food additives. Chemicals encompass a wide range of substances – including acids, alkalis, gases, metals, organic and inorganic compounds (see Table 1). Pesticides are toxic substances or mixture of substances that are produced and marketed for their toxicity and ability to kill unwanted pests and plants, especially in agriculture. These include biocides [or bactericides], fungicides for eliminating molds and fungi, herbicides [weed killers used in agriculture, lawns and gardens], nematicides [for killing nematodes in banana and pineapple farms], rodenticides used for killing rodents

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Table 1 Hazardous chemicals, toxic substances, and health effects upon exposure Chemicals/ Substance Acids: Hydrochloric acid Hydrofluoric acid Nitric acid Sulfuric acid Aldehydes: Acetaldehyde Metaldehyde Benzaldehyde Ketones Alkalis: Sodium Hydroxide Potassium Hydroxide Potassium Carbonate Gases: Ammonia Chlorine Formaldehyde Hydrogen cyanide Hydrogen sulfide Nickel carbonyl

Established health effects or symptoms Respiratory risk, hazard to eyes and skin Destruction of tissue; highly irritant to mucous membranes Respiratory risk; hazard to skin and eyes Same as above Irritant on mucous membranes Same as above Same as above Irritant on eyes and respiratory system. Dermatitis Caustic (burn, corrosive, destroy) skin, flesh, eyes, and the entire respiratory tract Caustic to skin, flesh, eyes, & respiratory tract Same as above

Irritant to eyes, nose, throat & skin Highly irritant; can induce permanent reduction in lung function Respiratory irritant, skin irritant and allergen; suspected carcinogen Extremely poisonous; affects enzymes and thus limits oxygen availability

Nausea, irritation of respiratory system and eyes; possible nervous system disorders Irritation of respiratory tract, headache, chest pains, weakness, cyanosis,; possible carcinogen Nitrogen Irritation of upper respiratory tract; chronic bronchitis from long-term dioxide exposure Nitrous oxide Possible cause of abortions in operating theater personnel Sulphur dioxide Irritation to eyes, nose, and throat Inorganic chemicals: Carbon disulfide Toxic to central nervous system and may cause respiratory failure Heavy metals: Arsenic Poisonous in higher concentration; it is a known carcinogen associated with bladder, kidney, liver, skin and lung cancers; abnormal hearth functions, liver and kidney problems, nerve and skin disorders Asbestos Mesothelioma, cancer of various sites – colon, lung, kidney, oral cavity, esophagus, stomach, larynx and pharynx Beryllium Acute chemical pneumonitis, tracheobronchitis, dermatitis, and chronic granulomatous pulmonary disease; acute beryllium disease consists of (continued)

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Table 1 (continued) Chemicals/ Substance

Established health effects or symptoms

respiratory tract irritation and dermatitis; sometimes with conjunctivitis; lung cancer Cadmium Nausea, vomiting, diarrhea, muscular cramp, kidney failure following ingestion, lung irritation, chest pain, bone deformity, ouch-ouch (itai-itai) disease, carcinogenic Lead Fatigue, insomnia, headache, loss of appetite, constipation, neurotoxicity, intelligence quotient deficits, learning disorder, attention deficits, and hyperactivity especially among children Mercury Nervous system problems – including tremor, psychological withdrawal, and irritability Methylmercury Minamata disease, cerebellar ataxia, paralysis, convulsions, hearing impairment, loss of consciousness, speech impediments, high blood pressure (BP), congenital disorders, death Zinc Metal fume fever from inhalation of fumes with symptoms similar to influenza Other toxic substances: Toluene Irritant which may cause asthma and prolonged exposure may cause diisocyanate dermatitis Phenols Dermatitis Nanomaterials Under investigation Sources: Adapted from Rowland and Cooper 1983: 169–177; Epstein et al. 1982: 415–427

and other undesirable small animals, and termiticides [for killing termites] (Bohme 2015; Goldman 2002: 403; UNEP 2019). Chemicals can also be classified by industry’s market segments. Five categories include: (1) basic inorganic and organic chemicals – which constitute the foundation feedstocks for a wide range of downstream chemicals; (2) specialty chemicals – including per-and polyfluorinated chemicals, flame retardants, and nanomaterials; (3) agricultural chemicals including fertilizers and pesticides; (4) pharmaceuticals – both prescription drugs (medicines) and non-prescription over the counter medicines; and (5) consumer products – ranging from household appliances, plastics and cleaning products, electronics, to cosmetics. Through natural, occupational, accidental and careless releases into the environment and poor waste management, exposure to these substances are associated with numerous adverse health consequences including acute poisonings, chronic morbidity and deaths in human population across the globe. In developing countries and among migrant farm workers in the Global North, misuse of toxic materials and accidental poisonings frequently occur due to illiteracy among rural and migrant agricultural laborers and laxed chemical and environmental regulations, especially in low-income countries in the Global South. Deaths, suicides, injuries, and chronic health problems have been linked to exposures to pesticides and other agrochemicals (Bohme 2015; Goldman 2002; Nicolopoulou-Stamati et al. 2016; Mew et al. 2017). According to the United Nations (UN) and WHO, approximately 25 million people

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suffer pesticides poisoning and at least 200 thousand people die every year (UNEP 2019; WHO 2019a). Around 75% of pesticides-related morbidity and mortality are from occupational exposures among farmers and farm laborers in developing countries. Due to high rates of illiteracy, many people use pesticides without properly understanding the warnings or wearing appropriate protective gear (Adeola 2012; Cunningham and Cunningham 2012). Nevertheless, many chemicals, pesticides, pharmaceuticals and food additives are manufactured and marketed as substances that are beneficial to humans. In fact, when used correctly, many chemicals can significantly contribute to improved quality of life, health and well-being of population as well as overall economic development. According to Paracelsus, the dose of a substance makes it either a poison or a remedy. As stated in the UN Global Chemical Outlook II report, from pharmaceuticals and agrochemical products to the manufacturing of automobiles, computers and other electronics, papers and textiles, several manufactured chemicals have significantly contributed to improved human health and quality of life, food security, economic productivity, and longevity. Indeed, during the nineteenth and twentieth centuries, many scientists subscribed to the idea that the science of pesticides and petrochemicals offered the solution to creating the abundance and prosperity that would eradicate hunger and cure diseases globally (Bohme 2015). As noted in the World Health Organization (WHO) report, even though many chemicals are harmless or even useful for curing illnesses and many other beneficial uses, there are many other hazardous chemicals and toxic substances that pose major threats to human health and well-being (WHO 2016). Improper releases, pollution and poor management of these products have caused a great deal of harm to humans, wildlife, and the environment. Toxic chemicals can kill, cause irreparable damage to human health including chronic disability, morbidity, endocrine disruptions, reproductive dysfunctions, and destruction of the biota. Notably, modern chemistry has accelerated the production and releases of toxic chemical compounds that pose major health hazards to humans and other species. Indeed, modern society is awash with assortment of dangerous chemicals and toxic substances ranging from hydrocarbons, toxic heavy metals, flame retardants, organochlorines, plastics, Persistent Organic Pollutants (POPs) including polychlorinated biphenyls (PCBs), to dioxins and furans (Ross 2017; Johansen 2003). Table 1 presents a list of hazardous and toxic chemicals by category and their confirmed health effects on populations across the globe. No one is immune to exposures to these environmental-health stressors. From acids and bases, aldehydes, gases, inorganic metals, to novel nanoparticles, the burden of disease and disability associated with these chemicals are quite substantial. Of particular concern globally are arsenic, asbestos, cadmium, lead, and mercury contamination and poisonings (WHO 2007, 2018; USATSDR 2007a, b; CDC 2014). Their adverse health effects are dreadful. These chemicals are present in every continent and biome on the planet. About 20 years ago, Thornton (2000) described the global accumulation of toxic pollutants as the most pressing environmental health problems of our time. Toxic chemical pollution and the health impacts are among the most pressing problems over the past three decades. An important attribute of the current Anthropocene epoch has been

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the widespread or universal contamination of the biosphere by toxic chemicals. This epoch is characterized by anthropocentric domination and massive disruption of Earth system processes critical to the planet’s self-regulating homeostasis (see Crutzen 2002; Steffen et al. 2007). Extensive global chemical pollution has been a hallmark of the epoch. Among the settings in which people often come in contact with or become exposed to harmful chemicals and toxic substances are farms and gardens, lawns, homes, hospitals, schools, laboratories, clinics and hospitals, work places (especially mines and industrial plants), outdoors, playgrounds, and polluted bodies of water, which suggest that there is no safe place. Furthermore, among the direct exposure pathways are through food and water consumption, soils, breathing or inhalation (smoking), and dermal contacts. Depending upon toxicity level, magnitude or dosage and duration of exposure, and level of tolerance of individuals, age and sex, the health sequelae may manifest as acute poisoning, death, and chronic health conditions that may take several years to detect and that may linger over several years of living with chronic health problems or disability with diminished quality of life. This chapter is divided into four major segments. The first segment is the introduction followed by segment 2 which addresses the tasks and challenges faced by scientists when it comes to accounting for the actual number and varieties of chemicals and hazardous substances manufactured, released into global commerce, and in active use as well as their associated latent or adverse health effects including the Global Burden of Disease (GBD). The top ten chemicals and hazardous substances of global health concern and the estimated GBD are presented in this section. Subsequently, section “Pesticides, Other Synthetic Chemicals and Their Health Effects” focuses on pesticides and related hazardous organochlorine products and their adverse health effects on humans and other organisms in the biosphere. International efforts such as the Stockholm Convention to regulate and ban the production and use of the most toxic substances that constitute human health and environmental stressors are addressed. The last section offers summary and concluding remarks.

Accounting for Chemicals and Hazardous Substances and Their Global Disease Burden There are many challenges facing the scientific community when it comes to addressing the global impacts of chemicals and toxic substances on human health. Specifically, the following critical questions have been raised: (1) How many chemicals and chemical products are produced and used in the world today? (2) What proportion of the current disease burden is associated with exposures to chemicals and toxic substances? These questions will be addressed in this study. For the former, Goldman (2002) quoted Paracelsus, the sixteenth century German-Swiss alchemist, botanist, physician, and toxicologist who is credited for introducing the

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concept of disease to medicine, expressing what a daunting task it was to attempt to provide a wholistic account of chemicals used in society about 500 years ago. Paracelsus noted: What, then, shall we say about the receipts of Alchemy, and about the diversity of its vessels and instruments? These are furnaces, glasses, jars, waters, oils, limes, sulphurs, salts, saltpetres, alums, vitriols, chrysocollae, copper-greens, atraments, auri-pigments, fel vitri, ceruse, read earth, thucia, wax, lutum sapientiae, pounded glass, verdigris, soot, crocus of Mars, soap, crystal, arsenic, antimony, minium, elixir, lazarium, gold-leaf, salt-nitre, sal ammoniac, calamine stone, magnesia, bolus armenus, and many other things. Moreover, concerning preparations, putrefactions, digestions, probations, solutions, cementings, filtrations, reverberations, calcinations, graduations, rectifications, amalgamations, purgations, etc., with these alchemical books are crammed. (Paracelsus 1531, cf. Goldman 2002: 408)

The inventory of chemicals during the fifteenth century pale in comparison to the explosion of chemicals manufactured and released into the global commerce from the nineteenth century through the twenty-first century. The number of chemicals registered by the American Chemical Society (ACS)‘s global Chemical Abstracts Service now exceed 142 million and approximately 100,000 chemicals are commercialized (Herman 2016; ACS 2015). As Ross (2017: 12) observes, the production and application of industrial chemicals has grown exponentially – more than 15-fold over the past 75 years, and there is increasing concern about chemicals impact on human health both in the developed countries in the Global North and low-income countries in the Global South. Chemists have produced millions of chemical substances and tens of thousands of these are in the market, and tens of thousands are manufactured in more than one million pounds every year (Schettler 2006). Today, more than 100,000 toxic substances are in commercial use and about 2300 new chemicals are developed and submitted for registration annually. But unfortunately, there is a lag between the industrial capacity to manufacture new chemicals or hazardous substances and scientific research tests concerning the potential or actual adverse health consequences in human population. Global capitalism has been vigorous at developing different ways to exploit chemistry for profit; but as noted by Johansen (2003: 1), this system has been less sagacious at anticipating, detecting, and addressing chemistry’s latent (or unintended) consequences. In modern society and culture, novelty, convenience, and profit tend to come first, and health and environmental questions are not asked until later. New chemicals are often released into the market ahead of scientific research findings about their potential or actual adverse health consequences. Thus, establishing and understanding their human health effects are increasingly becoming a challenge (Li and Suh 2019). The Lancet Commission on Pollution and Health’s article by Landrigan et al. (2018: 1) states that chemical pollution has now become a great and growing international problem. The authors further note that the effects of chemical pollution on human health are poorly defined and its contribution to the global burden of disease (GBD) is almost certainly underestimated. More than 140,000 new chemicals and pesticides have been synthesized since 1950. Of these materials, the 5000 that are produced in greatest volume have become widely dispersed in the

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environment and are responsible for nearly universal exposure. Fewer than half of these high-production volume chemicals have undergone any testing for safety or toxicity, and rigorous pre-market evaluation of new chemicals has become mandatory only in the past decade and in only a few high-income countries in the Global North. Consequently, chemicals and pesticides whose effects on human health and the environment have never been assessed have repeatedly been connected directly to the episodes of diseases, disability, morbidity, mortality, and environmental contamination. Among the historical examples are exposures to lead, asbestos, Dichloro-Diphenyl-Trichloroethane (DDT), mercury, and PCBs with devastating health consequences. There are some new species of trouble in the chemical world with the introduction of newer synthetic chemicals in the past three decades which have undergone little or no pre-market assessment. These include developmental neurotoxins, endocrine disruptors, novel insecticides, herbicides, pharmaceutical wastes, medical wastes, and nanomaterials. Over one thousand products with nanomaterial components are being sold in the market. The adverse environmental health effects of these new chemicals are under scientific investigation. There is increasing concern over the impact of nanomaterials on human health and the biota. As noted by Herman (2016) in a white paper for the ACS, scientific research studies have confirmed that in the environment, man-made nanomaterials can be transferred from one organism to another, and can increase in concentration (or biomagnification) as they travel up the trophic levels. Furthermore, nanomaterials have been found to have adverse effect on fish reproduction and disrupt cell membrane functioning, and there is increasing concern that long-term exposure to low levels of nanoparticles can have cascading effects on aquatic life. To address the question concerning the proportion of current disease burden that is correlated with environmental exposures to chemicals and toxic substances, this study draws upon recent empirical evidence in the reports by the WHO, UNEP, US Center for Disease Control and Prevention (CDC) and peer-reviewed articles in the extant literature. According to recent data from the CDC biomonitoring program, almost all Americans now have detectable levels of a wide variety of xenobiotics in their bodies, including many that are endocrine disruptors, neurotoxic, and carcinogens. Among these are POPs such as polychlorinated biphenyls (PCBs), dichlorodiphenyl-trichloroethane (DDT), and non-persistent toxic chemicals such as plastic components and plasticizers bisphenol A and phthalates. Sly et al. (2016: 4) indicate that there is a strong evidence that exposures to many xenobiotics correlate with increased risk of chronic noncommunicable health problems including cancer, cardiovascular disease, diabetes, hypertension, and obesity (also see Norman et al. 2013; Grandjean and Bellanger 2017). It has now been established that the burden of disease (BOD) from chemicals across the globe is quite high. Noncommunicable diseases (NCDs) such as cardiovascular disease, cancers, chronic respiratory problems, diabetes, and mental health dysfunctions along with endocrine disruption, allergic, renal, and autoimmune disorders have gained considerable attention in recent years as the products of human exposure to toxic chemicals and hazardous substances in the environment (Frumkin

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and Haines 2019). For instance, in 2018, the WHO estimated the disease burden considered preventable through proper management and reduction of chemicals in the environment at about 1.6 million lives and approximately 45 million disabilityadjusted life years (DALYs) in 2016. This translates to 2.7% of total global deaths and 1.7% of total burden of disease globally for that year (WHO 2019a, b). The economic implications of NCDs are huge, with a projected cost to the global economy of 47 trillion US dollars over the next 20 years (Frumkin and Haines 2019: 262). The common frequently used metric in the measurement of the Global Burden of Disease (GBD) is the DALY, which combines duration and quality of life into one common metric that can be applied across diseases and organs (Grandjean and Bellanger 2017: 2). In a comprehensive review of three methodological approaches to estimating DALYs, Grandjean and Bellanger (2017) suggest that environmental chemical exposures contribute costs that may exceed 10% of the gross world product (i.e., gross-domestic products of all nations). In its 2017 publication, the Lancet Commission on Pollution and Health employed 2015 data to compute the combined effect of pollution of air, water, and soil by chemicals as directly responsible for 268 DALYs and nine million premature deaths annually – which is 3 times the total annual deaths caused by HIV/AIDS, tuberculosis, and malaria – with the greatest burden found in low-income and middle-income countries (see Shaffer et al. 2019; Landrigan et al. 2018). The WHO has identified the top ten chemicals and hazardous substances of global public health concern. These include: air pollution, arsenic, asbestos, benzine, cadmium, dioxin, fluoride, lead, mercury, and pesticides – especially the persistent organic pollutants (POPs). PCBs and Dibenzo-furans are added to the original list as displayed in Fig. 1. The specific diseases or health risks and symptoms associated with some of these substances are discussed subsequently. The public health threats posed by air pollution, arsenic, asbestos, cadmium, lead, mercury, pesticides and selected POPs are discussed in the following sections.

Air Pollution Air pollution occurs through the releases of toxic or hazardous substances and energy into the atmosphere naturally and through anthropogenic activities such as the operation of automobile and machinery involving fossil fuel combustion, burning and incineration of wastes, forest fires, industrial emissions, agricultural aerial chemical applications and associated air drifts, chemical releases and tropospheric ozone pollution, indoor pollution, and other activities that involve the use of fossil fuel. Both indoor and outdoor air pollutants are harmful to human health and the ecosystem. Polluted air with high concentration of particulate matter threatens human health and well-being and the integrity of the environment. Major air pollutants include fine particulate matters (PM), ozone, nitrogen oxides, oxides of carbon, sulfur, hydrocarbons, and metals; many of these are combined through intricate atmospheric chemistry (Frumkin and Haines 2019: 266). Air pollution travels globally without regards to national or geopolitical boundaries. Airborne

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Air Pollution Arsenic

Pesticides

Asbestos

Mercury

Chemicals of Public Health Concern

Lead

Benzene

Fluoride

Cadmium

DibenzoFurams

PCBs Dibenzop-Dioxins

Fig. 1 Chemicals of major public health concern

pollutants move across national borders, oceans, and continents because there are no physical barriers that can block the global currents of airborne pollutants. The current COVID-19 pandemic is a testimony to this assertion. The Lancet Commissions document a wide range of air pollution induced diseases affecting several organ systems of humans. The strongest causal connections are found between airborne fine particulate matter pollution (PM) and cardiovascular and pulmonary diseases (Landrigan et al. 2018). Polluted air is correlated with higher risk of stroke, heart disease, lung cancer, acute and chronic respiratory diseases, and premature deaths. For instance, asthma and bronchitis have been established as the products of exposure to indoor air pollution (Baird and Cann 2008). Prolonged exposure to air pollution, especially outdoor PM, is linked to myocardial infraction, hypertension (or high Blood Pressure), congestive heart failure, arrhythmias, cardiovascular mortality, chronic obstructive pulmonary disease, and lung cancer (see Chan et al. 2015; Gold and Samet 2013; Landrigan et al. 2018; Link and Dockery 2010). Also as stated by Frumkin and Haines (2019: 266), the excess mortality from ambient PM exposure is attributable to primarily non-communicable diseases (NCDs) – including ischemic

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heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, and lung cancer with a small fraction of deaths due to lower respiratory infection. Furthermore, air pollution is a major cause of acid rain, deforestation., global warming and climate change. Landrigan et al. (2018: 9) summarize the key findings of the GBD study which estimates that pollution-precipitated diseases were responsible for nine million premature deaths in 2015 which represent 16% of total deaths. The GBD study further estimates that disease caused by all types of pollution account for 268 million DALYs – i.e., 254 years of life lost and 14 million years lived with disability. The WHO also estimates that, in 2012, unhealthy environments account for 12.6 million deaths globally – which represent 23% of total global deaths and 26% of children under 5 years of age. Focusing mainly on pulmonary disease, lung cancer, and cardiovascular effects in GBD calculations, ambient air pollution was reported as 74.7 million DALY lost due to particulate matter and ozone with a crude economic estimate of 1.1 trillion US dollars annual costs (Grandjean and Bellanger 2017; European Commission for Environmental Policy 2018). Thus, air pollution takes a heavy toll on human quality of life and the health of the planet as a whole.

Heavy Metals There are numerous naturally occurring toxic heavy metals that are hazardous to human health. Among these are arsenic, asbestos, cadmium, lead, and mercury. The properties of these metals and specific health risks they pose to humans and other species in the environment are discussed in the following sections.

Arsenic Arsenic poisoning or toxicity is a global health problem affecting millions of people. Arsenic is ranked number one every year among the top 20 most hazardous substances commonly found in waste-streams in the United States (USATSDR 2007a, b). It is one of the most toxic naturally occurring metalloids found in nature – it is present in soils, rocks, water, and plants. Given the fact that arsenic is a naturally occurring element in the earth’s crust, some level of exposure to this metal is inevitable. Civilizations have found a wide variety of uses for this metal. For instance, ancient Greek, Roman, Arabic, Peruvian, and Egyptian used the compounds of arsenic therapeutically, as poisons, and for other purposes. In contemporary society, arsenic compounds are employed in the production of insecticides, herbicides, fungicides and rodenticides, desiccants and defoliants used to facilitate the mechanical harvesting of cotton, and wood treatments. Arsenic is also used in the glass industry and other metal smelting operations. These industrial processes represent the sources of arsenic releases into the environment. Of course, arsenic is also released into the environment through the systemic process of weathering of the rocks and surface run-offs. As noted by Wang and Rossman (1996: 221) and Berman (1980), arsenic may be released from soil or rocks into hot spring waters. Thus, this metal is commonly found in drinking water, seawater, seaweeds, and food such as

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vegetables, grains, cereals, fruits, and seafood. Many high-income industrialized and low-income developing countries have their drinking water supplies contaminated with arsenic (Ratnaike 2003). Clear scientific evidence has established the toxicity of arsenic. In higher concentration, this metal is poisonous. According to the US Agency for Toxic Substances and Disease Registry (ATSDR 2007a, b), inorganic arsenic has been identified as a human poison since ancient times. A large oral dose (above 60,000 ppb) in water can result in death. Several arsenic compounds are similar to white sugar and this innocuous characteristic and the fact that it is tasteless and odorless, makes it a potential murder weapon (Ratnaike 2003; Baird and Cann 2008). Acute arsenic poisoning is associated with nausea, vomiting, abdominal pain, and severe diarrhea while chronic arsenic toxicity results in multisystem health problems. Other adverse effects associated with swallowing or ingesting inorganic arsenic include decreased production of red and white blood cells, which may cause fatigue, abnormal rhythm, damage to blood-vessels, which may result in bruising and impaired nerve function, causing “pins and needles” sensation in hands and feet. Arsenic is a known carcinogen associated with various types of cancer including bladder, kidney, liver, lungs, and skin cancer respectively (WHO 2018). Exposure to higher concentrations of arsenic (>400 micrograms/day) may cause death while exposure to lower levels (100–400 micrograms/day) may induce morbidity conditions such as abnormal heart functions, liver and kidney dysfunctions, gastro-intestinal tract, nerves and skin disorders (Wang and Rossman 1996; USATSDR 1998). Furthermore, non-allergic contact dermatitis and conjunctivitis have been found among workers exposed to arsenic dusts. Other serious health problems associated with arsenic poisoning include birth defects, mental and physical impairments especially in children, loss of memory, and suppression of immune systems (Berman 1980; Crawford 1997). In 2015, over one million illnesses were estimated to be caused by four foodborne metals including arsenic, cadmium, lead, and mercury. The majority of deaths (96%) were caused by arsenic (Gibb et al. 2019: 191).

Asbestos Similar to arsenic, asbestos is a naturally occurring heavy metal that is hazardous to human health, especially in fibrous state. Asbestos fibers have been used in a wide variety of products such as heat-resistant fabrics, insulation of electrical wiring, hot pipes and furnaces, building materials, and friction products (Adeola 2011: 32). Increased regulation at the domestic level has successfully and significantly cut down its production, supply and demand. For instance, the federal government in the USA has taken a number of steps to protect its citizens from exposure to asbestos, including a mandate to remove asbestos from all public-school buildings in the country and a total ban by the EPA of production and new uses of asbestos as of July 12, 1989. Many high-income industrialized countries in the Global North have also introduced stringent regulations against the production and use of asbestos. Nevertheless, production and consumption of asbestos continue around the globe. In 2016, 1.4 million tons production of asbestos minerals were reported and asbestos cement products are expected to continue to be the leading global market

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for asbestos (USGS 2018; UNEP 2019). Among the top producers were Russia, China, Kazakhstan and Brazil. Zimbabwe is also recognized as a potential producer. The majority of low-income countries in the Global South continue to demand and use asbestos products. In addition to the disease of asbestosis, asbestos is a confirmed carcinogen associated with cancers of multiple sites including lungs, larynx, pharynx, oral cavity, esophagus, leukemia, mesothelioma, stomach, and colon. The WHO estimated that asbestos exposure claims 107,000 deaths annually across the globe (Prüss-Ustün et al. 2011). About 1,523,000 DALYs were reported for lung cancer, mesothelioma, and asbestosis in a year with 41,000 deaths and 370,000 DALYs due to asbestos-caused lung cancer, and 7000 deaths and 3000 DALYs caused by asbestosis and the remaining 59,000 deaths and 775,000 DALYs were associated with malignant mesothelioma (Prüss-Ustün et al. 2011: 8).

Cadmium Cadmium is another naturally occurring heavy metal found in the earth’s crust and which is considered extremely harmful to human health. Most soils, rocks, and mineral (phosphate) fertilizers contain some cadmium. It is rarely found in its pure form because it reacts with other elements. Cadmium is a by-product of the processing of sulfide ores of zinc, lead, and copper. As mentioned by Baird and Cann (2008), most cadmium is produced as a by-product of zinc smelting because the two metals typically occur together. It is often regarded as a metal of the twentieth century because unlike other heavy metals such as lead and mercury which have been used since times immemorial, cadmium has been refined and used only relatively recently in human history (IARC 1993). It is found in the air, water, sediments, plants, and food. The principal uses of cadmium include electroplating, as electrode in rechargeable nickel-cadmium (Ni-Cd) batteries, pigments, coatings and plating, and as a stabilizer in plastics among others. There are many sources of human exposure to cadmium that often lead to adverse health effects. According to WHO (2019b), cadmium can be released to the environment through systemic natural processes as well as through anthropogenic activities. Geologic natural activities such as volcanic eruptions are known to spew cadmium into the environment; similarly, it is released into the environment by weathering of the rocks, soil erosion, and river transport. Anthropogenic activities such as tobacco smoking, food supply, mining, smelting and refining of non-ferrous metals, fossil fuel combustion, incineration of municipal waste, production of phosphate fertilizers, and recycling of cadmium-plated scrap and electronic waste, are the major sources of environmental contamination and exposure to cadmium. Once released, cadmium can be transported and deposited to areas far from the original sources of emission through a long-range atmospheric dispersion, which explains the ubiquity of cadmium in the biosphere. It bioaccumulates in many organisms, especially mollusks and crustaceans. Lower concentrations of cadmium are found in vegetables, cereals, and starchy roots such as potatoes, yams, wheat, rice, and other grains. Thus, human exposure occurs primarily from the consumption of cadmium-contaminated food, as well as active or second-hand inhalation of

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tobacco smoke, or ingestion by chewing tobacco, and inhalation by workers in industrial facilities engaged in processing cadmium compounds. Among the health effects of cadmium exposure, as displayed in Table 1, are nausea, vomiting, diarrhea, and muscle cramps for acute exposure, while people with chronic exposure suffer from osteomyelitis, bone mineralization, chest pain, kidney stones, and cancer of various sites. In Japan, consumption of cadmium-contaminated rice caused itai-itai (ouch-ouch) disease characterized by severe kidney damage, osteomyelitis (osteomalacia), and osteoporosis which mainly affected women who had given birth to many children (see IARC 1993; Kasuya et al. 1992; Adeola 2011).

Lead Lead is one of the metals of antiquity that has been used by all known human civilizations. It is recognized as an ancient poison; its toxicity has been known since at least the second century BCE, when the Greek physician Discorides concluded that “lead makes the mind give way” (Discorides, cf. Landrigan 2018; Berman 1980). Ancient Greek and Romans used lead for a wide variety of purposes. Some scholars have speculated that lead toxicity might have contributed to the fall of the Roman Empire (see Berman 1980; Drotman 1985). It is a highly toxic metal that poses major health risks to exposed populations. It is a naturally occurring element in the earth’s crust; this metal does not display any characteristic taste or smell and will not burn or dissolve in water. However, lead can bind with other chemicals to form lead salts or compounds. Some man-made lead compounds can burn, e.g., organic lead compounds in gasoline. As Landrigan (2018) recently points out, until the modern era, lead poisoning was a rare disease confined mostly to populations exposed through their occupations. However, this changed in the late nineteenth and early twentieth centuries starting with the opening of lead mines in Australia, the western USA, and Zambia; and subsequently, global production of lead increased to unprecedented levels. Lead was used in a growing range of consumer products and spread far and wide beyond industrial plants. Large-scale environmental contamination and massive human population exposure occurred. Annually, more than nine million metric tons of lead wastes are generated in the United States. The EPA has found lead in at least 1026 (about 76%) of the 1335 waste sites currently placed on the National Priority List (NPL). This finding reflects the fact that lead is widely dispersed in the environment. It is currently ranked second on the USATSDR substance priority list. The use of lead in industry has grown exponentially over time. In contemporary society, lead has been used for several purposes including the manufacture of batteries, glass, ammunition, a wide variety of metal products (e.g., sheet lead, solder, pipes, brass and bronze products), medical equipment, paints, ceramics, scientific equipment, and military equipment. In the past, lead compounds such as tetraethyl lead and tetramethyl lead have been used as gasoline additives to increase octane rating in the United States. The use of these chemicals was discontinued in the 1980s, and lead was banned for use in gasoline effective January 1, 1996. As indicated by Ericson et al. (2016: 688), the principal global use of lead now is in manufacturing of plates and components for lead-acid storage, lighting, and ignition (SLI) batteries, which accounts for 85% of global lead

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consumption. The lead used for manufacturing batteries is obtained from two main sources: (1) primary lead mining and smelting (newly mined from lead containing ore) and (2) secondary lead smelting from recycled used batteries and other sources. Today, global production of lead has remained stabilized with China being the largest producer of lead from mines (at 52% of global production) and the USA accounting for 10% of global lead production (UNEP 2019). There are many sources of exposure to lead and lead products including residential proximity to hazardous waste sites, living in older homes with lead paint or homes with lead-glazed ceramics, exposure to electronic wastes (e-wastes), consumption of foods contaminated by lead, drinking water from lead pipe, supplying municipal water from a contaminated river such as Flint River as recently occurred in Flint, Michigan, USA, lead-glazed pottery, and using health-care products and toys that contain lead. People can also become exposed to lead in soil directly or through ingestion, inhalation, and skin contact with contaminated soil particles. Substances such as folk remedies, certain health foods, cosmetics, and ‘moonshine whiskey’ are among other sources of lead exposure that are difficult to monitor or control. Occupational exposure is common among people employed in mines, soldering shops, plumbing and pipe fitting, lead smelting and refining industries, brass/bronze foundries, battery manufacturing plants, and lead compound manufacturing facilities. Construction workers and employees of municipal waste incinerators are also prone to lead exposure (Drotman 1985). At risk of lead exposure are also people working at e-waste recycling facilities or living in proximity to e-waste dumping sites, or scavenging on such sites. With mounting epidemiological evidence based on studies carried out in the past three decades, many public health authorities in the UA. have concluded that there is no acceptable level of lead exposure (USCDC 1991). Exposure to lead poses a wide variety of health hazards. Even in small dose, neurotoxicity, IQ deficits, learning disorder, attention span disorder and hyperactivity, especially among children are possible health effects of lead exposure (Rice and Silbergeld 1996; USATSDR 1997; Drotman 1985). At high concentrations (i.e., >15 μg/dL), lead may cause significant damage to the brain and kidneys in adults and children as well. Other health problems include cancer, hearing loss, and chronic neurobehavioral dysfunctions. It has been associated with miscarriage among pregnant women. Lead poisoning may also result in anemia, increased blood pressure, hypertension, and associated cardiovascular disease (USATSDR 1997; Epstein et al. 1982; Drotman 1985; Chapman 1998). Although, there is no subgroup either by race or socioeconomic status, immune to lead toxicity, however, minority groups such as African Americans, Mexican Americans, Puerto-Rican Americans, and American Indians and their children are at higher risk of lead exposure and associated health dysfunctions. According to the USATSDR, approximately 17% of children in the USA are at risk of lead poisoning; for minority groups, about 46% of African American children were estimated to be at risk of lead toxicity (Adeola 2011). In the United States, African Americans are disproportionately at risk of occupational and residential exposure to lead and other xenobiotics as a result of a combination of factors including poverty, racism,

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historical housing and occupational discrimination, and the patterns of hazardous facilities placement in low-income powerless neighborhoods (Adeola 1994). Similar patterns of social vulnerability of minority groups obtain in other societies across the globe. According to empirical data collected by the Institute for Health Metrics and Evaluation (IHME) in the context of the Global Burden of Disease Study, in 2017 lead exposure was responsible for more than one million deaths and the loss of around 24.4 million DALYs, with the highest burden in poor or low-income and middle-income countries (UNEP 2019). The GBD study estimates that lead exposure accounts for 2.5% of the global burden of ischemic heart disease. Lead is also estimated to account for 12.4% of the global burden of idiopathic intellectual disability [i.e., mental retardation due to lead-related IQ deficits] (Landrigan et al. 2018: 17; Prüss-Ustün et al. 2011). The GBD further indicates that 465,000 cardiovascular deaths, 240,000 heart disease deaths, 155,000 cerebrovascular disease deaths, 155,000 stroke disease deaths, 47,000 hypertensive heart disease deaths, and 28,000 chronic kidney disease deaths were all attributable to lead exposure across the globe in 2015. Thus, lead contamination and poisoning take a heavy toll on humans across the globe.

Mercury Mercury is another naturally occurring toxic heavy metal that is found in the air, water, and soil. From the earth’s crust, it is released into the environment from systemic events such as volcanic activity, forest fires, weathering of the rocks, soil erosion, and through anthropogenic activities such as coal fired power stations, industrial processes, residential coal burning, waste incinerators, and mining for mercury, gold, other metals such as copper, zinc, and silver, as well as from refining activities (WHO 2007, 2017). Due to its unique chemical characteristic – a silvery liquid at room temperature and its physical properties, including low viscosity, high density, excellent electrical conductance, and reflective surface, industries and scientists have recognized versatile utility of mercury. It is used in a variety of applications, including artisanal and small-scale gold mining, vinyl chloride monomer production, measuring and control instruments, chlor-alkali production, dental amalgams, as a preservative of vaccines, as a component of some medical devices, and batteries (UNEP 2019b). This metal exists in various forms: elemental (or metallic); inorganic (e.g., mercuric chloride) to which people are often exposed in their occupational settings (e.g., in artisanal and small-scale gold mining and dentistry), from contact with certain products (e.g., dental amalgams, some skin lightening creams and cosmetics, broken fluorescent bulbs, broken thermometer, and other waste products); organic (e.g., methylmercury and ethylmercury), to which human population may be exposed through their food or diet, especially seafood (WHO 2007, 2017). Elemental mercury is a liquid that vaporizes readily; it can stay in the atmosphere for up to 1 year and can be transported globally. Ultimately it settles in the sediment of lakes, rivers, bayous, estuaries, or bays where it becomes transformed into methylmercury by microorganisms, absorbed by phytoplankton, ingested by zooplankton and fish,

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and bioaccumulates in predatory species in the food chain. Once deposited in the aquatic or marine environment, elemental mercury becomes methylated by bacteria and becomes incorporated in the food chain where it undergoes biomagnification and bioaccumulation. For many communities that depend on seafood as their primary diet, consumption of contaminated fish [e.g., tuna, swordfish, mackerel, grouper], shell fish, and marine mammals represents an important source of mercury exposure (Basu et al. 2018). Food crops such as rice grown in soils heavily contaminated with mercury, represent another potential source of community exposure (Rothenberg et al. 2014; Li et al. 2010). Currently, it is estimated that all populations in the world are likely exposed to some amount of mercury (UNEP/ WHO 2008; Basu et al. 2018). In all forms, mercury is a pollutant of global concern because of its negative effects on human health across the globe. The state of knowledge concerning mercury toxicity and the human health effects has been extensively reviewed (see Basu et al. 2018; WHO 2007, 2008; USATSDR 1999; Oliveira et al. 2018). The brain and central nervous system are the main target tissues for the effects of mercury in adult population as well as in neonates, infants, and children. According to the WHO (2008: 3), elemental and methylmercury are toxic to the central and peripheral nervous system. For instance, the inhalation of mercury vapor can cause negative effects on the nervous, digestive and immune systems, lungs and kidneys and may be fatal. Neurological and behavioral disorders may manifest after ingestion, inhalation, and skin contact with different mercury compounds. Among the symptoms of mercury toxicity are tremors, insomnia, memory loss, neuromuscular effects, headaches, and cognitive and motor dysfunction. Based upon the cases of mercury contamination episodes in Minamata Bay, Japan and Iraq, methyl mercury poisoning was associated with marked distal sensory disturbances, constriction of visual fields, ataxia, dysarthria, auditory disturbances, and tremors (Adeola 2012: 67–68). Children and pregnant women are especially vulnerable and can be exposed directly by consuming contaminated fish and rice. As stated by the WHO (2007), bioaccumulated methylmercury in fish and rice consumed by pregnant women may cause neurodevelopmental problems in the developing fetus. Among the neurodevelopmental symptoms are mental retardation, seizures, vision and hearing loss, delayed or arrested development, language disorders, memory loss, and acrodynia. Despite the fact that methylmercury is a confirmed neurotoxicant with detailed dose-response data and exposure information, it has not been included in the GBD report (GBDORFCs 2020). However, recent dose-response data have been used to estimate the annual costs of methylmercury-induced diseases for the EU and US at 15.6 billion dollars. Currently, global costs are difficult to estimate (Grandjean and Bellanger 2017: 5). Steckling and associates estimated that out of 14–19 million workers employed as Artisanal Small-Scale gold miners (ASGM) globally, between 25% and 33% of them suffer from chronic metallic mercury vapor intoxication, leading to 1.22–2.39 DALYs (Steckling et al. 2017). In addition to the health effects of all the toxic metals discussed heretofore, there are numerous non-metallic synthetic substances that have been found to be harmful to human health and the environment. The next section focuses on pesticides,

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organochlorine products, and other synthetic persistent organic polluting chemicals and their deleterious effects on the health of humans and wildlife.

Pesticides, Other Synthetic Chemicals and Their Health Effects By design, pesticides are substance or mixture of substances formulated for exterminating, preventing, repelling, or reducing undesirable and harmful organisms that pose major threats to crops, livestocks, and public health. They are used in agriculture and the built environment to control insect pests, fungi, rodents, weeds, or diseases, mites, mollusks, nematodes, and vector-borne diseases such as malaria, dengue fever, yellow fever, schistomiasis, and many others that pose severe economic and public health threats to millions of people. As previously mentioned, under the umbrella of pesticides are avicides (for controlling birds), bactericides, insecticides, fungicides, herbicides, nematicides, rodenticides, termiticides, all named according to what they are intended to control or kill, and plant growth regulators and defoliants (Nicolopoulou-Stamati et al. 2016; Bernardes et al. 2015; Fishel 2013; Unsworth 2010; Yadav and Devi 2017). They are mostly used in agriculture but these substances are also utilized for other purposes, such as the improvement and maintenance of residential lawns and gardens, household pest control, and other non-agricultural urban green spaces such as public parks, sport fields including golf courses. The use of chemicals to control or eliminate menacing pests has a long history, dating back to antiquity. For instance, the Mesopotamians used sulfur compounds to control insects and mites about 4500 years ago. In the fifteenth century, toxic chemicals such as arsenic, mercury, and lead were applied to different crops to control pests. Pyrethrum, a compound derived from the dried flowers of Chrysanthemum cinerariaefolium, has been used as an insecticide for over 2000 years. In the 1600s, a mixture of arsenic and honey was used for controlling ants. In 1867, an impure form of copper, arsenic was used to control the outbreak of Colorado beetle in the United States. Inorganic substances such as sodium chlorate and sulfuric acid or organic chemicals have been widely applied as pest control until the 1940s (Fishel 2013; Unsworth 2010; Kaur et al. 2019). Organics such as nitrophenols, chlorophenols, creosote, naphthalene, and petroleum oils were used to control fungus and insects, while ammonium sulfate and sodium arsenate were employed as herbicides. The major problems with many of these earlier products have to do with their high rates of application, lack of selectivity, and phytotoxicity (Unsworth 2010). DDT was first synthesized in 1874 and was widely used for many years. Pesticides application increased dramatically during the World War II as the 1940s saw a significant growth in the production and use of synthetic pesticides such as aldrin, DDT, dieldrin, endrin, parathion, and 2,4-D aimed at pest control in agriculture and disease control for public health. During the war, DDT was the insecticide of choice to protect US soldiers and civilians from insect-borne diseases such as malaria, typhus, and other vector-borne diseases (WHO 2010a, b). In fact, DDT was praised as the insecticide to eradicate all insect problems in the world. Paul Mueller, a

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Exhibit 1a US soldier demonstrates the use of DDT spray on human

chemist working for the Swiss chemical company, Geigy, discovered the toxic and persistent properties of the chemical compound of DDT, making it extremely useful as a pesticide. It was quite effective in combating Anopheles malaria-causing mosquitoes, typhoid, yellow fever, and body louse (Robson 2019). Muller received the 1948 Nobel Prize in Physiology or Medicine for his 1939 discovery of insecticidal qualities and use of DDT in combating vector-borne diseases such as malaria and yellow fever that were responsible for millions of deaths annually in the world. In the post-World War II period, DDT was widely adopted both in the developed and developing countries and used extensively in agriculture and urban areas as illustrated in Exhibits 1a and 1b. It became the most widely used pesticides in history. The era of Green Revolution particularly witnessed the exponential growth in the production and use of a wide array of synthetic organic pesticides along with DDT. The emergence of monoculture and industrial farming relied heavily on continuous application of pesticides and other agrochemicals to achieve higher crop yields to meet the food and fiber demands of the growing world population. Notably, synthetic pesticides remain as one of the core requirements of Green Revolution technologies, that by enabling monoculture and intensification of rice and wheat, have exponentially increased farm productivity and revenues. Based on their chemical composition, synthetic organic pesticides are classified into four categories, including: (1) organochlorines (such as aldrin, dieldrin, endosulfan, DDT, and chlordane), (2) organophosphates (such as diaznon, parathion, malathion, and glyphosphate), (3) carbamates (such as carbofuran, propoxur and aminocarb), and (4) pyrethroids (e.g., cypermethrine and permetrine). In the book Silent Spring, published in 1962, Rachel Carson sounded the alarm concerning the adverse health effects of indiscriminate application of pesticides on humans and wildlife. This influential book contributed to raising public awareness about the health and environmental risks associated with DDT and other pesticides in the United States. The use of DDT in the US was banned by the government in 1972. Other developed countries in the Global North also placed a ban on it. However, both in the USA and other industrialized nations in the Global North, production and sales to the Global South nations continue. DDT has been listed under the Stockholm

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Exhibit 1b Photo of how people were sprayed with pesticide DDT to control polio in 1940. (Source/Credit: Public Domain/Mediadrumworld.com (Accessed 9/25/2020))

Convention with the objective to protect human health and the environment from POPs. Parties to the Convention are allowed to produce and use DDT for disease vector control in keeping with the recommendations of the WHO and when locally safe, effective and affordable alternatives are not available (van den Berg et al. 2017). Echoing Rachel Carson’s contention, Kaur et al. (2019) note that pesticides are purposefully designed to kill and since mode of action is not specific to one organism or species, they often kill or harm unintended (innocent) organisms including humans. Both accidentally and intentionally, pesticides poisoning has become a major health issue, especially in the Global South. Consequently, about three million cases of pesticides poisoning and about 220,000 deaths are reported annually. Today, there are more than 20,000 commercial chemical pesticide products available on the global market and an estimated 5.2 billion pounds are used annually in the world. In fact, the global pesticides market size was nearly 84.5 billion US dollars in 2019 with a computed compound annual growth rate of 4.2% since 2015 and is projected to grow at a compound growth rate of 11% to nearly 130.7 billion US dollars by 2023 (Business Research Company 2020). The spread of intensive farming systems based on monoculture along the lines of the Green Revolution, industrialization of agriculture and corporate takeover of agribusiness around the globe are among the key drivers of global pesticides demand. Some of the heaviest use of pesticides takes place in low-income to middleincome countries in the Global South where use and exposure data are limited or non-existent. Pesticides, when used properly, are considered as labor-saving

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technology which can eliminate pest populations and at the same time improve crop yields, quality, and reduce crop loss as well as increase farm revenue. Their dispersion and misuse have generally unleashed a cocktail of toxic chemicals into the global environment contaminating food, drinking water, air, and poisoning humans and populations of wildlife. Furthermore, the introduction of highly toxic pesticides such as the organochlorine and organophosphorus pesticides such as parathion, endrine, aldrin into poor rural households that are ill-equipped to use or handle them safely has produced latent outcomes, with deaths and disabilities associated with unintended occupational poisoning being reported (Konradsen 2007). Karunarathne et al. (2020: 229) estimate the total global burden of pesticide suicides from 1960 (the start of the Green Revolution) to 2018 as 14.3 million. They indicated that this large number is probably an underestimate given the fact that cultural barriers, difficulty in registration or issuance of death certificates and legal obstacles make obtaining accurate pesticides-related suicide deaths count impossible in many developing countries. With regards to DDT, as Robson (2019) notes, in addition to its acute toxicity and persistence properties, its bioaccumulation, lipophilic, and grasshopper tendencies as well as endocrine effects were later discovered to be of major threats to human health and the environment, which appear to far exceed its initial benefits. In the systematic review conducted by Prüss-Ustün et al. (2011: 15), it was noted that a voluminous body of scientific evidence now support the observation that pesticides exposures are the major cause of various diseases including cancers, birth defects, neurotoxicity, kidney and liver damage, sterility, and endocrine disruption. Other adverse health effects associated with pesticides exposures are dermatological, gastrointestinal, respiratory, and reproductive dysfunctions (Nicolopoulou-Stamati et al. 2016; Bhome 2015).

The Persistent Organic Chemical Pollutants The Persistent Organic Pollutants (POPs) are synthetic organic chemicals of utmost public health concern across the globe. They are among the most toxic compounds ever produced by modern chemistry. POPs are polyhalogenated hydrocarbons that contain chlorine, bromine, or fluorine. They include pesticides, industrial chemicals, chemicals used in consumer products, as well as by-products of certain manufacturing and combustion processes (WHO 2010a, b; USEPA 2020). Figure 2 displays the basic categories of POPs – both the intentionally and latently produced toxic chemicals. The characteristics of POPs identified by scientists as posing grave danger and concern for human and other species’ health in the biosphere are: • Extreme toxicity with long half-lives and consequently they persist in the environment for years or decades; • Bioaccumulation and bio-magnification tendency in the environment, as they penetrate the food chain – i.e., they become concentrated at higher levels as

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Fig. 2 Persistent Organic Pollutants (POPs) classification

they go up the food chain as they move from one organism to another, thereby polluting all living things including humans; • They exhibit the “grasshopper’s effect” with long-range atmospheric transboundary migration and deposition, travelling globally in air and moisture currents and in living organisms; and • POPs are hydrophobic and lipophilic (i.e., fat loving) as they have a tendency to remain in adipose tissue; they enter lipids of organisms more easily than the inside of aqueous medium of cells and are stored in fatty tissue (Ashraf 2017; WHO 2010a, b; Adeola 2011). Thus, POPs have been detected in human blood, body fat and breast milk in several studies around the globe (WHO 2010a, b; Lind et al. 2019).

The Stockholm Convention on POPs and the Dirty POPs To address the global concern about POPs, the UNEP convened the Stockholm Convention on POPs in May 2001, to decrease or eradicate the discharge of 12 most problematic POPs chemicals designated as the “dirty dozen.” At the Convention, 92 countries agreed to reduce or eliminate the production, use, or release of the dirty dozen. Among the 12 are 10 intentionally manufactured pollutants including: aldrin, endrine, chlordane, DDT, dieldrin, heptachlor, mirex, toxaphene, hexachlorobenzene (HCB), and PCBs; and two unintentionally produced pollutants – polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzo-furans (PCDFs) (see WHO 2010a, b; Ashraf 2017; Johansen 2003). In May 2009, nine additional chemicals were added to the list of POPs and the Convention’s agreement entered into force on August 26, 2010. Total elimination of these chemicals has been made difficult because of lack of accurate and complete information about where they are present and how to replace them with safer and effective alternatives. Furthermore, despite the fact that the designated POPs have been banned, some of

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these chemicals are still present in polluted sites or being traded and used in some developing countries. India continues the production, use, and export of DDT; from 2012 to 2014, India stands out as the main producer and user of DDT. Mozambique, South Africa, and a number of Sub-Sahara African countries also use DDT to control malaria (Van den Berg et al. 2017). Several other classes of chemicals displaying similar characteristics as POPs – referred to as persistent toxic substances (PTS) or persistent, bio-accumulative and toxic (PBT) substances, remain in frequent use globally. POPs are released into the atmosphere from different industrial sources (e.g., power stations, incinerators), household furnaces, volatilization from water surfaces and soils, landfill transport, and agriculture. They are distributed across the globe through the air and ocean currents, travelling long distances via air-water exchange and cycles involving rain, snow and dry particles. They are transported in food and they are also transported by polluted organisms. POPs are found in remote places far away from industrial sites or from agricultural areas where they were originally released, migrating north and south to areas such as the North and South Poles, exposing remote populations of humans and nonhuman species, especially those that depend on aquatic diet to these chemicals (WHO 2010a, b). Among the sources of exposure to POPs are food consumption such as fish, meat and dairy products, inhalation, and skin absorption. Since POPs are ubiquitous, human exposure begins even before conception. As stated by WHO (2010a, b: 5), concerns for children’s health include the possibility of effects on sperm and ova before children are conceived, and effects resulting from pregnancy when maternal fat stores are mobilized, leading to exposure of embryo and then to the fetus through the placenta. Postnatal exposure occurs via breast milk. Exposure to high level of POPs has caused serious adverse health effects including deaths, diseases, and birth defects among humans and animals. Table 2 presents 27 of most commonly traded and used POPs commonly found in the environment due to human activities and the scientifically established health effects of each compound across the globe. Some of these are well-known pesticides widely used in agriculture and some are industrial chemicals and by-products of combustion as previously stated. The “Dirty Dozen” banned internationally are shown with (+) notation and those commonly found in hazardous or polluted waste sites are in asterisks. Exposure to high levels of POPs may cause health problems including death, disease, disability, birth defects, and cancer among humans (WHO 2010a, b; Ruzzin 2012). Depending on the levels and duration of exposure, the specific health effects of these chemicals can include dizziness, nausea, malaise, cancer of various sites, allergies, hypersensitivity, damage to the central and peripheral nervous systems, disruption of the immune system, mutations, birth defects, endocrine disruption, kidney and liver dysfunction, and metabolic diseases (such as obesity and Type 2 diabetes) (Ruzzin 2012; WHO 2010a, b). Other adverse health effects of POPs are: stunted growth among children, permanent impairment of brain function, endometriosis, learning disabilities and other neurodevelopmental problems, reproductive dysfunctions such as lower sperm count and quality, and male genital anomalies (Thornton 2000).

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Table 2 Synthetic persistent organic chemical compounds commonly found in the environment and their health effects Toxic chemical Aldrin*(+) Benzene* Carbon tetrachloride Chlordane*(+) Chloroform Chloroethylene (vinyl chloride)* Chlorotoluene Dichlorobenzene Dichloro-DiphenylTrichloroethane (DDT)*(+) Dichloroethylene Dieldrin*(+) Endrin*(+) Furfural Heptachlor*(+) Hexachlorobenzene (HCB)*(+)

Mirex*(+) Organophosphorous compounds

Phosgene 2,4,5-T

Polychlorinated Biphenyls (PCBs)*(+) Polychlorinated Dibenzo-ParaDioxins (PCDD) *(+) Polychlorinated Dibenzo Furans (PCDFs)*(+) Styrene Tetrachloroethylene*

Established adverse health effects/symptoms Dizziness, nausea, malaise, liver and biliary cancers Mutations, cancers, birth defects, still-births Cancers, birth defects, stillbirths, neurotoxicity, hepatoxicity, and kidney diseases Cancers (Tests remain inconclusive) Cancers, birth defects, embryo toxicity, and hepatoxicity Mutations, cancers, nervous disorders, liver disease, and lungs disorders Mutations, cancers Mutations, nervous disorders, liver disease, and kidney disease

Cancer of liver, immune system suppression, organs dysfunction Mutations, cancers, birth defects, stillbirths, nervous disorders, and liver and kidney disorders Liver and biliary cancers Cancers Mutations, nervous disorders Mutations, cancers, stillbirths, birth defects, and liver disease Mutations, cancers, birth defects, fetal and embryo toxicity, nervous disorders, liver disease, photosensitive skin lesions, and hyperpigmentation Acute toxicity, possible cancers Lowering of blood cholinesterase (vital to nerve cells), pains and defective circulation in extremities; paralysis of limb muscles Serious respiratory system damage Highly toxic and readily absorbed by inhalation and ingestion. Weakness, diarrhea, loss of appetite, cardiac arrest, death. Teratogenic and carcinogenic Mutations, cancers, birth defects, fetal and embryo toxicity, neurological disorders, and liver disease Peripheral neuropathy, fatigue, depression, hepatitis, liver disease, abnormal enzyme levels, hepatoxicity, chloracne, embryo toxicity, and gastric lesions Peripheral neuropathy, fatigue, depression, hepatitis, liver disease, abnormal enzyme levels, hepatoxicity, chloracne, embryo toxicity, and gastric lesions Irritant to skin and mucous membranes Cancers, nervous disorders, liver disease, and kidney dysfunctions (continued)

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Table 2 (continued) Toxic chemical Toluene+) Toxaphene*(+) Trichloroethylene* Xylene*

Established adverse health effects/symptoms Mutations, birth defects, stillbirths, and nervous disorders Cancers, chromosome aberrations, liver and kidney dysfunctions Mutations, cancers, nervous disorders, and liver disease Birth defects, stillbirths, and nervous disorders

Sources: Adapted from Epstein et al. (1982), Hazardous Waste in America, pp. 415–427 and http:// irptc.unep.ch/pops/indxhtms/asses0-html. Note: Asterisks designate those compounds commonly present in hazardous wastes and (+) designates POPs’ Dirty Dozen

Summary and Conclusion The global chemical industry is among the leading industries capturing significant market shares in all nations across the world. The industry’s total contribution to global GDP in 2017 was 5.7 trillion US dollars, and it provided an estimated 120 million jobs (ICCA 2019). Chemical products ranging from fertilizers, pharmaceuticals, pesticides, fibers, to consumer products including plastics, PVCs, detergents, batteries, etc., continue to find applications and are in demand in virtually all segments of the global economy. While some of these chemical products are considered safe and beneficial to human health and well-being, the vast majority are toxic or hazardous by design with unrecognized and unintended negative health consequences for humans and the biota long after they have been released and used in the environment. Today, chemicals and hazardous substances are ubiquitous in every segments of societies including remote indigenous communities across the globe. Populations are exposed to toxins in the air, food, water, soil particles, and dermal absorption through contacts and in various occupations. The synergistic effects of exposures to multiple chemical substances are also of major concern. The litany of the health effects of xenobiotics is quite extensive as discussed in this chapter including asthma, cancer of various sites, chloracne, embryo toxicity, endocrine disruption, death, dermatitis, intelligence quotient deficits, kidney and liver dysfunctions, metabolic diseases, miscarriages among pregnant women, mutagenicity and teratogenicity, osteomyelitis, and much more. Calculating the actual Global Burden of Diseases and Disability Adjusted Life Years for all chemicals released heretofore into the global environments remains a Herculean task for scientists. The global chemical industry and capitalism continue the practice of externalizing these costs of production while engaging in greenwashing, appropriating the concept of sustainability. Despite international efforts at controlling or banning some dangerous chemicals and hazardous substances, the reluctance or failure of the chemical industry to adopt a precautionary principle – that when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effects are not fully established (Maxwell 2014: 64). That is, it is better safe than sorry; the global

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chemical industry has the onus to prove that chemical products are safe for human health and the environment beyond reasonable doubt prior to introduction into global commerce. The reverse of this principle has been the practice of global chemical industry and this needs to change. The prominent questions raised in this study concern accounting for the volume and variety of chemicals and hazardous products manufactured, commercialized, and in use in the world today and the proportion of the current disease burden correlated with exposures to these chemicals in the environment. These questions have been addressed in this chapter. With over 142 million chemicals manufactured and approximately 100,000 in global commerce, only 1% of them have been tested for safety prior to release. Expressing skepticism about the inventory of chemical substances, Erickson (2017: 23) states that no one, not even the US EPA knows how many chemicals are actually in use today. The agency has more than 85,000 chemicals listed on its inventory of substances that fall under the Toxic Substances Control Act (TSCA). However, the US EPA is currently unable to determine which of those chemicals are in the global commerce and how they are being used. A number of studies have addressed the GBD and DALYs for most toxic heavy metals, organochlorine products such as pesticides and POPs, and air pollution (see Landrigan et al. 2018; Grandjean and Bellanger 2017; Gibb et al. 2019; Gibb and O’Leary 2014). The long-term economic and social psychological dimensions of the burden of adverse effects of exposure to heterogenous toxic chemical products around the globe are yet to be fully investigated. Future studies to bridge the gaps in these areas are strongly encouraged.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Importance for Global and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Global Burden of Work-Related Disease and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Work-Related Diseases and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention of Occupational Diseases and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hierarchy of Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employer Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Government Responsibility for Occupational Health and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . Workers’ Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Health and Globalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Health and Social Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Health and the Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalization and the Organization of Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalization and the Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Health and Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Occupational Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Work Ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disaster Response and Emergency Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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T. L. Guidotti Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada I. D. Ivanov (*) Division of Healthier Populations, World Health Organization, Geneva, Switzerland e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_98

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Abstract

“Occupational health” refers to prevention of diseases and injuries as well as management of work and workplace factors that determine the capacity to perform job functions and have the potential for enhancing health. Occupational health is maintained by implementing primary prevention, controlling hazards, and avoiding exposure to hazards. The “hierarchy of controls” is a robust classification of the efficacy of technical measures to control occupational hazards. Furthermore, surveillance at the enterprise level plays a role in ensuring that primary prevention is effective and that secondary prevention measures are in place for workers in whom primary prevention fails. The global burden of disease from occupation-related injuries and illnesses is difficult to quantify but high and under-appreciated. Surveillance at the country level tracks trends in occupational injury and disease reporting and is an essential guide to planning and evaluation. However, structural problems virtually guarantee that nonfatal injuries and especially diseases are underreported. Occupational health is pivotal in sustainable development and addresses virtually all Sustainable Development Goals. Special problems and opportunities include outreach to small- and medium-scale enterprises, disaster response and emergency management, work ability support, worksite health promotion, performance management of contractors and vendors, and consideration of the special needs of migrant, expatriate, travelling, and informal workers. The relationship between work and health is reciprocal: good (meaning safe, healthy, and decent) work protects and enhances the health of workers and protects the health, wellbeing, and support of their families and the community. Keywords

Occupational health · Occupational hazards · Occupational safety · Workplace injury and illness · Sustainable Development Goals · Global burden of disease

Introduction What is “occupational health”? Broadly speaking, occupational health refers to the protection of people at work with respect to physical safety from injury, and prevention and limitation of occupational risk factors that cause illness or diminish a person’s ability to function in their lives. Occupational health is a component of public health. It is a multidisciplinary activity aiming at: • The primary prevention of occupational diseases and injuries by reducing and removing exposure to occupational risks • The early detection and management of occupational diseases and injuries • The enhancement of the physical, mental, and social well-being of workers and support for the development and maintenance of their working capacity as well as professional and social development at work

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In this way, occupational health enables workers to conduct socially and economically productive lives and to contribute positively to sustainable development. Box 1 Definition of Occupational Health

In 1950, the Joint ILO/WHO Committee on Occupational Health stated that “Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities.” In summary: the adaptation of work to the person, and of each person to his or her job. (Source: Executive Board, 7. (1951). Joint ILO/WHO Expert Committee on Occupational Health: Report on the first session. World Health Organization. https://apps.who.int/iris/handle/ 10665/86728)

Occupational health goes beyond the management of hazards (i.e., things or conditions that can harm workers) and risks (i.e., the probability that these hazards will cause injury or disease) to emphasize the contribution of good workplace management to the worker’s physical, mental, and social well-being; personal or general health in and outside the workplace; personal development; and the wellbeing of the worker’s family and immediate community (Ponsonby 2017; Guidotti 2011). Occupational health relies on primary prevention (i.e., prevention of exposure to the hazard in the first instance to prevent the occurrence of injury or disease). In other areas of global health, secondary prevention (i.e., early detection and intervention) may play a larger role, for example, in cancer prevention. However, secondary prevention in occupational health means that the injury or disease has already started and has progressed to a level that is detectable by conventional medical technology. That is why surveillance for disease in the individual worker is of only secondary importance in occupational health. For example, monitoring blood lead levels in workers exposed to lead has been routine in occupational health for decades (blood lead levels are useful principally to ensure that control measures are actually working and to pick up individual cases in which prevention failed), but by the time an overexposure is identified, some degree of nerve injury has already occurred. For that reason, measures that prevent exposure to lead are of greatest importance. On the other hand, surveillance of the working population to monitor trends is critical to ensure that primary prevention measures are working. Accidental workplace injuries can be caused by obvious, alarming events. However, certain occupational diseases, such as cancer caused by asbestos, may appear as many as 40 years after the exposure. Employers, workers, and people in general worry most about and act upon imminent dangers. They do not respond with the

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same sense of urgency to long-term, slowly developing risks, which are characteristic of occupational diseases. Therefore, prevention of disease and prevention of injury at the workplace must coincide. By linking safety with health protection, health and disease issues are not forgotten and issues that fall between the two, such as chronic musculoskeletal disorders, are not overlooked. Health and disease prevention issues are usually more difficult to identify and correct than safety problems. Considering both safety and health protection in the workplace acknowledges the reality that injury and disability often result in secondary physical and mental health problems and that health conditions sometimes predispose to injury.

Importance for Global and Public Health Occupational health is the practice of public health in the workplace and, like public health, it gives priority to the prevention of disease in the first instance by control of hazards in the workplace (primary prevention), screening and early detection of health problems when they do arise (secondary prevention), prevention of disability resulting from these problems, and the return to work of people with other health conditions (tertiary prevention). Compared to other areas of public health, occupational health places greatest emphasis on primary prevention. Occupational health uses secondary prevention mainly as means to ensure that primary prevention is working and to ensure that it does not fail individual workers. When injuries and illnesses do occur, occupational health is engaged deeply in prevention of disability through rehabilitation services, early treatment, retraining, prevention of second injuries and complications, compensation for permanent impairment, and facilitation of the return to work of people with health conditions by adapting workplaces to their needs. Occupational health overlaps with community-oriented public health in many ways and often draws upon the same expertise, laboratory analyses, and environmental control technologies. Many occupational health problems can become community public health problems when chemical exposures carry beyond the walls or fence of the workplace or are brought home on workers’ clothes, or when an infectious disease (such as tuberculosis, COVID-19) is brought in to the workplace from the community. Employers and owners of enterprises and farms have the responsibility to control occupational risk arising from their activities. However, in the case of diseases with community transmission, employers and business owners have the responsibility to ensure that the workplace does not become a site for amplification of the outbreak. This requires a good collaboration between the occupational health experts working for employers and the public health experts working for the community. The workplace is a special setting with many health risks and situations specific to each entity’s technological processes and work organization. Therefore, addressing health at the workplace requires specialized knowledge of the specific occupational risks and their prevention, and community public health shares these principles.

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Box 2 Overview: Occupational Health Affects Global Health in Many Ways and at Many Levels and So Matters for

• Individual workers as a matter of health protection, income security, and prevention of disability • Workers’ families and dependents as a matter of financial security, continued integrity of the family (which comes under strain when the primary earner is lost or disabled), and prevention from falling into poverty • The enterprise because workers are critical to production and injuries and illnesses could impose costs and lost opportunity • The community as a public health issue • The economy because disability and death compromise productivity and job security • The country because workers are the most economically productive segment of the population and it is their effort that builds out infrastructure, achieves economic development, and brings innovation to reality • The world because our societies and economies are interconnected and materials, goods, and workers themselves cross national boundaries • The environment because workplace processes can be sources of environmental pollution and a clean workplace is good for the neighboring environment • Sustainability because a healthy and safe workforce is a prerequisite for sustainable economic development

The Global Burden of Work-Related Disease and Injuries Occupational injuries are usually straightforward to identify; they arise out of activities performed at the workplace or in relation to off-site work tasks such as commuting directly to and from the worksite. In contrast, occupational diseases usually develop over time and their relationships to the work environment or work tasks are more difficult to evaluate. An “occupational disease” is not a clinical diagnosis; it is the legal recognition that work has caused a specific disease, giving the victim the right to financial compensation and other benefits. Occupational diseases are not defined by a test or clinical examination. Relatively few occupational diseases are seen exclusively in a working population or after exposure to a particular work-related risk factor, and there may be other causes of the disease in the community. The defining feature of an occupational disease that it is more common or characteristic of workers in a particular occupation. Many occupational diseases are individually uncommon but all together impose a significant burden, especially in certain sectors such as agriculture. New occupational diseases are often recognized by advancements in research, and additional risk factors are introduced into the workplace with new technology and materials. WHO’s 11-th revision of the

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International Classification of Diseases now includes a special section on risk factors and causes of disease, which recognizes occupational risks as causes of disease. A physician who diagnoses an occupational disease needs to ask the patient about his or her current job and work history, including risk exposure, and either refer the patient to an occupational medicine clinic for confirmation and follow-up or report directly to the national insurance scheme for occupational diseases and injuries. However, the causal relationship in the specific work environment, including the current or previous jobs of the claimant, must be demonstrated to conclude that a disease is occupation-related. Most countries have national lists of occupational diseases of which there is confirmed exposure to causative risk factors at work and are therefore recognized and compensated as occupational diseases. The International Labour Organization has developed an international list of occupational diseases to be used by countries in developing their national lists. However, actual practice in countries is very diverse, affecting the capacities of the employment injury benefit schemes to provide compensation, the availability of expertise in occupational medicine, and the predominant work processes and economic sectors. The WHO study “Preventing disease through a healthier and safer workplace” (Wolf et al. 2018) provides estimates of the burden of disease and injuries attributable to different health risks in the environment, including occupational health risks. The study found that, using 2015 as the benchmark year, an estimated 1.2 million deaths from diseases and injuries worldwide were directly attributable to occupation. These deaths comprise 2.1% of all deaths in the general population. Of the recorded deaths and disabling conditions, 70% were due to noncommunicable diseases, 22% to injuries, and 8% to infectious disease. When converted to disability-adjusted life years (DALYs), the attribution to occupation was similar at 2.7% but the distribution changed dramatically. The leading causes of disabling conditions through life were noncommunicable diseases at 70%, followed by injuries, mental and behavioral conditions, and communicable diseases. This means that poor occupational health rarely kills but contributes to significant burden of suffering and reduced working capacity. The burden of death and disability was disproportionally high in low- and middle-income countries and male gender. There was much regional variation in the burden, with Africa experiencing a greater burden from infectious disease and the western Pacific from noncommunicable diseases, with high-income countries typically showing less of a burden for each and smaller rates of death and disability from injury.

Work-Related Diseases and Injuries Many infectious health outcomes, such as respiratory infections, malaria, infectious hepatitis, and HIV/AIDS, have a strong risk component related to occupation because of exposure at work (e.g., Chagas’ disease), proximity and transmission in the workplace (e.g., tuberculosis), working conditions (e.g., dengue), or the location of the work performed (e.g., malaria). The workplace, including transportation, represents a major pathway of exposure and transmission opportunity for many

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communicable diseases and therefore, once potential risk is recognized, an important opportunity to interrupt transmission. Some infectious diseases have animal reservoirs. Exposure to such animals has been the presumed pathway into human populations for several viruses, most obviously MERS (Middle-East Respiratory Syndrome, camels). Working with such animals places a worker at risk for contracting the disease and (depending on the pathogen) spreading it to the community. In other diseases (such as Q-fever), the community may be at risk from direct exposure to the infected animals. Among infectious diseases, tuberculosis affects about a third of the world’s population (but mostly in latent infection). Tuberculosis is linked to specific important occupational risk factors, such as exposure to silica dust (which makes the lung more susceptible to tuberculosis) and providing patient care to patients with active tuberculosis. Tuberculosis is both more prevalent and more progressive when combined with suppression of immunity by HIV/AIDS and is more difficult to treat in communities with a high prevalence of multidrug resistance, in people who live in crowded communities, and in people who smoke. Since these risk factors occur together in many communities that are dependent on the mining industry, particularly in southern Africa, this complex of interrelated health issues requires an integrated approach to resolve (ILO 2010). Cancer can be caused by a number of occupational carcinogens in the work environment. Occupational risks are accountable for about 2.1% of deaths worldwide, or 2–8% of all cancer deaths. Work-related cancer also contributes a disproportionate number of DALYs because the average age of workers dying from cancer is less than for other causes, resulting in more years lost (Wolf et al. 2018). The single most widespread and significant chemical or material known to cause cancer (i.e., carcinogen) is asbestos, including chrysotile. Asbestos causes lung cancer and several other cancers, including mesothelioma, an otherwise rare cancer of the lining of the chest and lung. A variety of other carcinogens are found in workplaces, including diesel exhaust gases, some pesticides and herbicides, some organic solvents (such as benzene and trichloroethylene) and formaldehyde, products of combustion (including the family of ringed organic chemicals known as polycyclic aromatic hydrocarbons or PAHs, and a similar set of chemicals produced together with PAHs in diesel exhaust called “nitroarenes”), some hair dyes, some dyestuffs, and chemicals encountered in the rubber industry. Some physical agents, such as ionizing and ultraviolet radiation, are also important carcinogens, the former causing cancer in many tissues, and the latter causing skin cancer primarily. WHO’s International Agency for Research on Cancer (IARC) is the global authority on identifying causes of cancer. IARC reviews the evidence about occupational risks causing cancer and carries out epidemiological studies on occupational cancer. Mental, behavioral, and neurological conditions are highly prevalent (15% of the population over age 60) and, while usually not fatal by themselves, are associated with and reflected in rates for suicide, cirrhosis of the liver (alcohol abuse), drug use, and comorbidity from mortality from other causes. This class of disorder also contributes to disproportionally high disability. Although only 4.1% of deaths

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recorded worldwide indicate a cause in this category, it contributes to 10% of the global disease burden overall. Depression is the most common disorder and often occurs together with substance abuse because the worker or affected person tries to feel better by “self-medicating” with alcohol or a drug. The great majority of causal factors arising in the workplace are related to social and work organization problems, including job strain from overwork, lack of control over the work being performed, unjust or arbitrary workplace management, work insecurity, imbalance between work and personal life, and bullying from managers and coworkers. There are also specific behavioral disorders, such as posttraumatic stress syndrome, which particularly affects public safety personnel. Neurological disorders are more directly and obviously related to impairment of the nervous system in the body. There are many specific occupational diseases that cause nerve or brain damage or temporary dysfunction, including solvents, heavy metals such as lead, head trauma, and pesticide overexposure. Many of these conditions appear first as behavioral disorders, and others may resemble stroke or neurodegenerative conditions such as Alzheimer’s disease. This category of disease is undercounted because these conditions are common in the general population. Epilepsy can be made worse or seizures can be triggered by workplace conditions such as flashing lights or by sleep deprivation and shift changes due to unfavorable work organization. Sensory problems are clearly associated with conditions and exposures in working populations, with 25% of hearing loss attributed to occupational noise exposure. Eye problems are highly variable with industry and may include cataracts from sun or UV exposure or ionizing radiation and retinal damage due to lasers and intense UV exposure. Cardiovascular disease is responsible for high levels of mortality and disability in all countries, with two main outcomes: ischemic coronary artery disease leading to myocardial infarction (a heart attack, when enough oxygen is not delivered to the heart due to inadequate supply to the heart muscle or abnormal heart rhythm, or both) and stroke. These are common cardiovascular conditions, and the contribution of occupational risk factors is difficult to disentangle from other common risk factors. The main occupational hazards appear to be work organization and chronic psychosocial stressors, traffic-related air pollution, carbon monoxide, and secondhand cigarette smoke. Diseases of temperature extremes is a category that often manifests itself as cardiovascular disease but occurs when the body reaches physiological limits to adapting to temperature extremes. The temperature of the human body is very tightly regulated within a narrow range. The body is much more effective in heating itself up than cooling itself down. At temperatures above the limits of normal body temperature (conventionally set at 37 °C), the human body cannot transfer heat to the environment, and so temperature rises, eventually to levels that cause serious tissue injury, brain damage, and death. Mortality from these conditions is a grave risk for the future because rapid climate change now makes it inevitable that within a few years some parts of the world will exceed this temperature frequently and for long periods. Outdoor workers, public safety personnel (such as firefighters), construction workers, and people who work indoors but in hot environments are at greatest risk.

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Chronic obstructive pulmonary (airways) disease is a category of lung diseases that are characterized by an impediment to flow of air when the lung empties (expiration or exhalation). The results are that the lung functions poorly to exchange air and the airways are often inflamed. There are various types of obstructive pulmonary diseases that often occur in combination: emphysema, a type of damage to the lung tissue that results in progressive fixed obstruction to flow; bronchitis, typically producing sputum and adding to obstruction to flow; and airways reactivity, an asthma-like condition of variable rather than fixed airflow obstruction. Most often, these occur together in a particular lung disease that is typical of cigarette smoking called “chronic obstructive pulmonary disease” (COPD). Occupational exposures, such as dusts, second-hand smoke, and irritating gases and fumes, make COPD due to smoking worse more often than they cause airways disease by themselves. Ventilation of the workplace is an effective means of control. Asthma is a form of reactive airways disease in which the obstruction to the flow of air is variable (changing over short periods of time) rather than fixed. It can be provoked by triggers such as irritant dusts or gases in the air, by cold air, and by specific agents to which the worker has become “sensitized” (i.e., the body mounts an immune reaction to it), resulting in episodes of shortness of breath and usually wheezing. The general category of “work-related asthma” falls into two subcategories: “occupational asthma,” which can be caused in the first place by sensitization (sensitizer-induced) or by irritation (irritant-induced), and “work-exacerbated asthma,” which is asthma or conditions of airways reactivity that get worse and occur when there is an occupational exposure that triggers or aggravates it. Many of the chemicals that cause sensitizer-induced asthma are common in the workplace, such as isocyanates (found in paints and coatings), or are materials that are heavily used, such as wheat flour and dust from latex gloves. Similarly, many of the irritants that cause irritant-induced asthma are common in the workplace, such as fire smoke and second-hand tobacco smoke, or solvents. All told, occupational exposures were estimated to account for 9.7% of the total disease burden from asthma. Other lung diseases include a group of diseases called “pneumoconioses” (meaning dust diseases), in which the lung reacts to inhaled dust in a way that creates scar tissue and contributes to chronic obstructive airways disease. Although there are many types of these diseases, three of the most common and severe are asbestosis (which is caused by asbestos and also carries a risk of cancer), silicosis (quartz rock dust, which has many other effects on the body), and coal worker’s pneumoconiosis (from mining and handling coal). These diseases do not occur for the most part outside the workplace, so they are virtually 100% occupational. Skin disorders are among the most common occupational diseases and can be disabling. Like asthma, they may arise from sensitization or irritation. There are many individual causes of each type of skin disorder, but how often they result in disabling diseases in the general population is not known. The most prominent disabling condition is allergy to latex among health care workers. Musculoskeletal disorders other than acute injuries affect millions of people worldwide and include forms of arthritis, low back and neck pain, and disabling conditions often associated with overuse or repetitive movement. These conditions

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are painful and can be disabling, but they are not fatal and are often undertreated or overlooked as a cause of disability. Across all conditions, about 20% of these disorders are occupational in origin. Disorders affecting the next generation include congenital (developmental) anomalies, neonatal conditions, and reproductive outcomes resulting in miscarriage or infertility; sometimes childhood cancer is included in this broad category. These conditions are extremely difficult to quantify, particularly miscarriages and infertility. There are many individual causes of each type of congenital disorder, but how often they result in effects in the general population is not known. Traffic-related trauma is a substantial cause of injury, both in getting to and from the workplace and in transportation of goods or workers by road. About 9.6% of road injuries are thought to be associated with identifiable occupational risks. Traffic accidents are a complicated issue overlapping with community safety issues but also with alcohol and substance abuse, visual acuity, and sleep deprivation, each of which has its own implications for occupation. Vehicle safety and road conditions are important factors in individual accidents. How well the driver is able to control the vehicle may be influenced by fatigue, impairment, long driving times, distraction by mobile phones, stress (such as the perceived need to speed in order to meet deadlines), and medical conditions. Acute, unintentional poisonings result from exposure to toxic chemicals at concentrations high enough to result in short-term illness or death. Approximately 4.7% of such cases are estimated to be occupational in origin, particularly those related to pesticides, toxic gases, heavy metals, solvents, cleaning substances, and fires. These events are most likely to be lethal when the worker is in a confined, poorly ventilated space or immobilized, but they are also major hazards encountered outdoors in agriculture. Unintentional poisonings are often the result of lack of training, poorly labeled products, and inability to read warning labels due to language barriers or illiteracy. Burns are thought to be 8.7% attributable to occupational hazards, including cooking, foundry work, agriculture, work around open flames, and manufacturing. This category is different from conditions related to temperature extremes because the tissue injury in a burn affects a specific body part rather than excessive warming of the body. Burns carry a high risk of disability and often result in permanent scars and limitations of movement. Drownings are an occupational risk for people who work on the water, as by fishing or boating, but also those who travel by water transport in vessels that are unsafe. Occupational risks are estimated to result in 5.8% of drownings. Unintentional injuries resulting in death or disability can be viewed in three categories, each with its own attributable risk: falls (the most common fatal traumatic event) at 8.3%, mechanical forces (such as tools, machinery, and off-road vehicles such as tractors on farms or warehouse fork-lifts) at 7.6%, and other unintentional injuries (such as animal-related incidents) at 5.7%. Specifically, intentional injuries represent homicides. No estimate has been published, but there are established relationships between suicide or interpersonal violence and isolated work, bullying victimization, handling cash on the premises, and night work.

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Prevention of Occupational Diseases and Injuries All occupational injuries and diseases are preventable and therefore avoidable by removing or reducing exposure to the hazard. Control of disease and injury risk factors at work is achieved by primary prevention, by removing or limiting exposure to the hazard. Some occupational hazards have not changed in human history and are known to have existed since ancient times. Finely ground rock dust containing quartz, for example, consists mainly of silica, which when inhaled causes serious lung and other diseases and cancer. Hazards may change with changing technology; for example, silica became an even more serious problem when the use of powered equipment in mines and construction produced smaller and easily inhaled particles of silica. Other hazards are new; for example, manufactured nanomaterials are particles and substances around 100 nm in dimension (a nm, nanometer, is one billionth of a meter) that have very useful properties. Their small size changes their physical and sometimes their chemical properties, which makes their toxicity and health effects unpredictable. A systematic approach to identify all hazards, looking for both safety and health risk factors, refers to an inspection, survey, or audit. All hazards have to be taken into consideration so that important risks that are not targeted will not overlooked.

Box 3 Overview: Types of Occupational Hazards

• Physical hazards involve forms of physical energy. Heat, cold, thermal comfort, noise, vibration, ionizing and non-ionizing radiation (e.g., xrays, radionuclides, UV, electromagnetic fields), and mechanical hazards (involving kinetic energy causing tissue damage, fractures, cuts, wounds, and other work injury) can arise from dangerous machinery, conditions, or tools; encounters with animals (bite, kicks); or contact with other humans (e.g., physical violence). Slips, trips, falls, and cuts are major causes of work injuries. • Ergonomic hazards are positions, conditions, or movements that put a strain on a body part or that exceed the capacity of the human body to respond. Here the problem is not the force alone but the strain on a vulnerable or weak part of the body. Examples include repeated movements (causing repetitive strain injury), posture-related musculoskeletal problems (e.g., causing low back pain), low illumination (causing eye strain), loads such as packages that are heavy or hard to handle, poorly designed instruments that are hard to use or read, and chairs or work stations that are uncomfortable and require awkward movements and position. • Chemical hazards are chemical substances and mixtures of chemicals that make workers sick in the short term (acute poisoning) or that cause illnesses (continued)

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Box 3 (continued)

in the long term as exposure to the chemical continues (chronic toxic effects, such as lung disease or cancer). Chemicals may be gases, liquids, or solids (usually in the form of particles). Aerosols are small particles of solid or liquid material that can remain suspended in the air for a long time and represent an important class of chemical hazards that includes dust, mists, and sometimes infectious droplets that spread disease. • Biological hazards are living organisms or products of life forms. These hazards include bacteria, fungi, and viruses that cause infections (such as tuberculosis, hepatitis, COVID-19), venoms and poisons of natural origin (many plant products), and biological substances that cause allergies (such as asthma or skin rash). Snake bites at the workplace are common in some countries. Occupational infections are common in the health sector. • Psychosocial hazards include mental stress from conditions such as bullying victimization, unreasonable demands, inability to meet expectations, overwork, poor or unclear directions, traumatizing experiences at work, unsafe conditions in which the worker feels trapped, the threat of violence (whether it occurs or not), stigma, discrimination, or unfair employment practices.

Exposure to occupational hazards may also reflect the specific location of the workplace and context of the work, such as dangerous road traffic, endemic diseases such as malaria, epidemic diseases such as dengue, remote or difficult location, lack of access to health care in an emergency, crime or unrest, poor environmental quality (dampness and mold exposure, traffic-related pollution), and likelihood or frequency of disasters. Adverse weather conditions, including extreme and at times physiologically intolerable heat, and the risk of natural disasters, such as floods, mudslides, fires, tsunami, and earthquakes, are hazards that vary from place to place. Extreme weather and fire-related risks, in particular, are increasing in many places because of global climate change and instability. Expatriate, travelling, or migrant workers may be highly vulnerable to unfamiliar hazards in a new location.

Hierarchy of Controls There are different types of interventions to mitigate occupational risks. Extensive research has been carried out on the effectiveness of these interventions has demonstrated that certain types of interventions are more effective. This has resulted in the so-called hierarchy of controls approach, which gives priority to the more effective interventions (see Fig. 1). In occupational health, priority in consideration of mitigation measures is given the most effective ones, and if that is not technically or practically feasible, then

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Fig. 1 Hierarchy of controls of occupational hazard (Guidotti 2014). (©International Commission on Occupational Health, with permission)

interventions with lower level of effectiveness are considered. The controls range from most effective to least, as follows: 1. Elimination, substitution, or removal. If the hazard can be eliminated entirely, this is the best measure to remove the worker from exposure. However, eradication of the hazard is not always possible. 2. Isolation, containment. Another effective control measure is to separate the worker from the hazard by keeping physical distance between the two or creating a barrier that prevents or at least reduces exposure of the worker to the hazard. 3. Engineering controls. Equipment or designs of the workplace that reduce exposure are generally as effective and reliable as the performance of the equipment. In the case of ventilation and dust control, engineering controls are usually highly effective and easily maintained. In the case of machine guarding and locks, they are effective in preventing injury when used but are often removed by impatient workers or managers who see them as obstacles to production. Engineering controls must also be maintained and inspected regularly. 4. Behavioral controls (also called “administrative controls”). These controls are designed to change the behavior of workers who may or may not understand their purpose, may make mistakes, and may or may not cooperate. Therefore, they rank low in priority in the hierarchy of controls. Providing education and training,

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Fig. 2 Personal protective equipment in the workplace. Clockwise from head: respirator, apron, gloves, steel-toed shoes, hearing protection (foam ear plugs), eye protection, hardhat (helmet) with protective face shield. (Guidotti 2014 ©International Commission on Occupational Health, with permission)

monitoring work schedules, posting signs and warning labels, restricting entry to locations with hazards, and limiting time in a location with hazardous noise or radiation are all useful approaches to reducing risk but are much less reliable than engineering controls, substitution, or isolation. 5. Personal Protective Equipment (PPE). PPE protects the worker from a hazard at the location where exposure occurs. Examples include respirators (devices to purify the atmosphere the worker is breathing or to supply clean air), safety glasses (eye protection), hard hats (helmets), protective clothing, steel-toed boots, gloves, aprons, and other such devices (see Fig. 2). The effectiveness of PPE depends on the reliability of the device (most of those commercially available come with ratings of how well they protect workers), how reliably they are used by workers (both in terms of how often and in what circumstances and how well they are fitted and used as intended), how easily it is for workers to access and use the PPE they need, and how vigorously their use is enforced by managers. If PPE is not required of all workers in conditions in which it is needed or recommended, or if managers do not explain and use it themselves, then workers will consider PPE to be unimportant and avoid using it because of the additional effort and time required to take it on and off or to use it correctly. 6. Prevention by design (or “safety by design”). This is a process by which safety and health protections are built into the workplace, materials, technological processes, and work organization beginning at the design, construction, and development stage. Prevention by design emphasizes avoiding the presence of hazards in the first place and depends on a hazard-free workplace culture that is maintained by management and understood and practiced by employees. It is common for hazards to be brought into the workplace, often informally by workers or supervisors who do not understand and are focused on getting the

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job done if not necessarily in a healthy and safe way. One of the most common examples of this occurs when workers remove machine guards because they get in the way (as they are supposed to) and slow production.

Health Surveillance “Surveillance” refers to monitoring the health of workers and employee groups to ensure that primary prevention is working (i.e., that new cases of diseases and injuries are not arising in a workplace or that the rate is going down), that new or emerging problems are not being overlooked (e.g., detection of a new cluster of cases of diseases and injuries), and that individual new cases are not being overlooked and left untreated. Surveillance depends on accurate recognition of new cases and so depends on the performance of the primary health care system in the community and the availability of specialized occupational health services at the workplace. At the enterprise level, surveillance is generally undertaken by periodic medical examinations and tests conducted at regular intervals (usually annually) on all workers exposed to a particular hazard or assigned to a workplace where that hazard may be present. The purpose of these screenings is early detection of diseases caused by occupational hazards, in other words, secondary prevention. For example, a standardized hearing test (audiometry) is performed every year on workers assigned to an area where noise exceeds 80 or 85 dBA (a measure of sound level that is roughly enough to interfere with comprehension when two workers are standing next to one another). The individual worker’s result is compared to their results in previous years. If the worker is losing hearing in the characteristic pattern of noiseinduced hearing loss (NIHL) and above the rate that is typical for someone simply getting older, the workplace must be inspected for noise sources, which must then be controlled to protect not only that worker but other workers in the area. (This is a very common problem.) The presence of NIHL in this working population represents a failure of primary prevention, not a success of secondary prevention (screening) because it did not stop the injury from occurring and NIHL is irreversible. Periodic health surveillance is also undertaken for occupational cancers, chronic respiratory diseases (e.g., silicosis), poisonings, and other health outcomes for workers at risk (e.g., those exposed to pesticides) and is required by law in many countries as part of occupational health standards. Enterprises may also track the health experience of their employees in other ways, such as by sickness absence and insurance claims. Surveillance at the country or subnational level involves tracking trends in occupational injuries and diseases over time. These cases are reported to a competent authority (a government agency), classified, and statistically analyzed to determine trends in space (geography), in time (usually annually), by diagnostic category (see “Global Burden of Disease” section, above), by industry sector, and, when possible, by specific occupation. This information allows competent authorities to determine whether regulations and control measures are working and may identify new

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problems that were previously overlooked or that were introduced by changes in the workplace (e.g., the rising incidence of occupational asthma). Sometimes, the appearance of a single case (a “sentinel event”) or a cluster of cases (e.g., a cancer) is an important sign that that a problem exists at a particular place and time. Surveillance follows the statistical trend of new cases, deaths from that cause, claims for compensation, or health care and disability insurance claims. Surveillance has many pitfalls and potential for errors. Fatal injuries are usually reported most accurately because they are difficult to conceal and are compulsorily investigated. Injuries are sometimes misclassified by a health-care provider or by the employer to make it appear that the injury was less severe than it was or not as workrelated. Occupational diseases often go unrecognized or unreported and are often misclassified, so there is invariably an undercount, often very large and the majority of cases. Numerous studies on have shown that a large fraction and sometimes even the majority of cases of particular disease are not in the statistical data on occupational diseases, even in developed countries with strong health care systems and compensation systems particularly for asbestos-exposed workers and those with asthma, and skin rashes. The problem is even worse with diseases such as occupational cancer, which take years to develop and for which there is not a strong incentive to identify a cause unless there is eligibility for compensation. The need for improvement in surveillance of occupational injury and disease is well recognized in the field.

Employer Responsibility Prevention of occupational injuries and disease is the responsibility of the employer, who is required to follow national regulations but also has an obligation (recognized by ILO Convention 155, adopted in 1981) (International Labour Organization 1981) to provide a safe workplace even when regulation is missing or ineffective. This includes providing protective equipment and clothing as needed. Employers are required to inform their workers of hazards present in the workplace and to train them in how to protect themselves. Occupational health and safety protection is not a benefit of employment but an employer responsibility and an expense of doing business, for which the worker must not be expected or forced to pay. Occupational health and safety is not something that is performed in isolation. It should be an integral part of production management, human resources management, community environmental health, health care, employment policies, and regulation. The principle of employer responsibility for occupational health and safety is similar to the “polluter pays” principle in environmental protection.

Government Responsibility for Occupational Health and Safety Governments are expected to create a competent authority to identify occupational hazards in their country, develop a notification system for occupational accidents and diseases, convene inquiries into specific cases (especially fatalities), evaluate conditions in and needs of the country, and publish data and performance measures in

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pursuit of its policies. Countries do this by maintaining agencies or offices at the national and subnational (states or provinces) level that conduct inspections and surveys, investigate particular problems, monitor the numbers and rates of occupational accidents and diseases, set standards that apply within their country, maintain enforcement mechanisms to ensure that they are followed, and develop a legal framework for holding employers to account. It is not the government’s role to maintain a safe workplace in the private sector, but it is the government’s role to ensure that the employer maintains a safe workplace. However, small- and medium-sized employers may not have the resources to do this without help from government programs to provide the knowledge, management tools, and assistance they need. For those workers who are self-employed, work in the informal and gig economy, are farmers or domestic workers, and are otherwise unorganized, governments and local authorities may provide social support and some basic occupational health services through various programs and initiatives.

Workers’ Participation Occupational health is centered on the workers, their safety, and protection of their health and an understanding that healthy and safe working conditions benefit the worker, the employer, and the community. As part of people-centered care, occupational health focuses on working life and workplace contexts and collaborates with primary care to ensure that the specific work-related health needs are met. Workers have a role to play in their own protection. They are required to cooperate in occupational health protection, for example. Employers have the right to include provisions in an employment contract that require the worker to perform their duties safely and to follow the enterprises standards and procedures as a condition of employment (as long as they do not violate the law and create unsafe working conditions). Employees have the right to refuse to work when they have reason(s) to believe that an imminent serious hazard to their life and health exists. Workers who do so require protection under the law from being fired or harassed. (This is common, regardless.) Workers also have the right to protection from undue consequences if they refuse to work because there is reasonable justification to believe that a serious and imminent occupational health hazard exists in the workplace. Employee representatives should and often do work with management of the enterprise in joint committees to identify hazards, solve problems, and monitor safety performance. This is particularly important because workers have the most intimate and detailed knowledge of their job and the conditions under which they work.

Occupational Health and Globalization Occupational health protection supports the benefits of economic globalization and reduces its negative impacts by providing personal, economic, and social protection to workers at every stage of production and the supply chain. Occupational health

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protection prevents avoidable loss to workers, their families, their community, and the country and so distributes the social good of resilience and security. When combined with worker- or worksite-centered health promotion, occupational health protection can enhance these social goods (LaDou and Harrison 2014; Guidotti 2011; Elgstrand and Petersson 2009). Occupational health in many developing countries is a neglected issue, because of the large informal sector. Protecting health and safety of workers in low income settings reguires integrating ocucpational health into public health and linking it to social justice and national development (Nuwayhid 2004).

Occupational Health and Social Protection Occupational health and safety are fundamental to social protection (UNICEF 2020; The World Bank 2020), extending security and resilience to workers and their families by reducing the risk of catastrophic loss of income and capability due to injury and illness. Occupational health protects workers and their families and dependents from catastrophic loss of income should the primary earner be forced to stop work or take a lower-paying job because he or she cannot perform their regular work. This protection also allows workers to preserve their potential for future earnings and advancement in their jobs which would be cut off by disability. Occupational health and safety protection reduce the risk that economic production will be disrupted or halted due to catastrophic accidents, widespread illness, unanticipated health-related expenses, loss and soilage, and work stoppage. The global cost of work-related injuries and illnesses is very high, comprising about 3.9% of global GDP at EUR 2 680 billion, divided roughly equally between fatalities and nonfatal accidents and illnesses. Among fatalities, death by illness greatly predominates over death by injury at 86%. There is great regional disparity as well, with the lowest costs in high-income countries (but with a higher predominance of illness over death as a cause) and the highest costs in less developed countries (with an increased contribution from accidents but still predominantly from illness, as reflected in fatality rates). (European Agency for Safety and Health at Work 2019) Overall, the cost burden from both accidents and illnesses falls heavily on all regions but disproportionately on workers in Southeast Asia, Africa, the Eastern Mediterranean, and the Western Pacific regions.

Occupational Health and the Environment Occupational health is closely linked to environmental protection and sustainability because many hazards, particularly chemicals in use in the workplace, are also environmental contaminants. Removing them from the workplace removes them from the environment, and controlling them in the workplace may, if properly executed, prevent emissions to the environment. Therefore, many companies

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adopted the so-called environment, health, and safety approach which combines the practical aspects of environmental protection and safety at work. In this way, organizations aim to ensure that their activities do not cause harm to anyone. The workplace itself is one aspect of the so-called “built environment” (including schools and homes) where people spend time and are exposed to potential hazards. Occupational health is therefore closely related to environmental health. Many workers, for example, in construction, agriculture, road repair, and street vending work outdoors most of their time and their health can be adversely affected in cases of heavy air pollution and heatwaves. Production may involve occupational health and safety risks and environmental contamination and pollution at the same time; the worker who lives in a community affected by pollution experiences a “double burden” of health risks due to the effects of each. The workplace is also a social environment, where people meet for a purpose, communicate with one another, and have a common understanding and attitude about what they do and why. The workplace, the connections among workers and between workers and their employers, and the bonds among workers create opportunities for reaching workers and their families with targeted messages and relevant knowledge and with tools that can improve their general health and reduce the risk that they will become injured or ill. Worksite health promotion has proven very effective in reaching communities and families through messaging in the workplace. The workplace therefore plays an important role in social sustainability and development.

Globalization and the Organization of Work The goods and services that are created by work may be limited to the home and family, but even that is part of a wide network of social and economic interactions through commerce and trade. Goods are sold and services are exchanged so that the buyer and seller will each benefit and gain the ability to do more or earn more than they would have otherwise. The networks of trade once extended no further than the local village and neighbors, but today it is rare that workers in these networks are isolated because the economy now spans the world and depends on globalized trade and interdependence. Occupational health problems in one place are just as likely to reflect demand for the goods and services far from where they are produced, materials that were brought from elsewhere, and hazards of technology developed for global use that may or may not fit the needs of a particular place and time. A worker in an isolated village may be working to supply a product that will be shipped thousands of miles away and could be used by someone in a factory that produces something that will come back to that worker in the form of a product that is traded globally. For this reason, occupational health and safety everywhere is linked (Lucchini and London 2014; Landrigan and Fuller 2014; LaDou and Harrison 2014). One aspect of this linkage is that products today are often made from components manufactured and materials sourced from many countries and even assembled in

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several locations. A complicated product such as an automobile may have parts from four continents assembled in modules and put together at a plant near the market for the product. Similarly, global prices, decisions, trades, policies, and services (such as financial services) may affect the worker at the village level as much as in big cities. That is why occupational health standards cannot be separated or treated in isolation. Employers and traders connected to trading networks were once primarily single owners, families, and small groups of investors. Over time, the rise of companies, in which capital was pooled, allowed progressively larger and more efficient enterprises to form. These enterprises are now often multinational entities with production and distribution spanning much of the globe. These enterprises typically rely on long supply chains, the network of producers and suppliers that provide the enterprise with what they need to produce and trade. These supply chains have themselves become global, so that if there is a disruption or choke point or slow delivery at any step along the way, the entire enterprise and its other supply chains may be affected. Large enterprises typically have many contractors, who in turn often have subcontractors of their own. These contractors do work to maintain the plant or provide services that are not in the main line of business of the enterprise or perform specialized functions. Unless the contract requires it, contractors are not subject to the same rules as the company and may not observe the same standards and work practices. Sometimes, contractors are retained so that the enterprise can avoid complying with laws, regulations, or rules by paying someone else to get the work done at lower cost. The contractor who accepts such an arrangement does not provide the same level of training, work protection, protective equipment, or personnel rules as the enterprise. Contracting also may allow managers to escape responsibility for legal liability if there is an accident or someone is hurt. When contractors and enterprise employees are working side-by-side, bad work practices may place all workers on the site at risk. Contracts should specify that the contractor is required to follow the same rules as workers employed by the enterprise and there should be a means of auditing their performance to ensure this standard is upheld.

Globalization and the Worker Workers come out of the communities where they live and where they were raised: the culture, level of education, behavior styles, the influence of their family and their community, and how they understand the problems they face. The health risks of these same workers reflect their personal and family histories; their vulnerability (due to lack of immunity, lack of familiarity with hazards, interrupted medical care, nutrition, lack of social support for health care, or many other factors); the diseases and risk factors of the people they live with, their community and culture; and the hazards they encounter in their community and the workplace. Many workers, particularly in the informal economy, perform their work in their homes, and their family, including children and elderly members, are usually also involved. (The World Bank 2020)

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The profile of workers in formalized jobs in the economy is changing in many countries. People work to older ages than before; more people with disabilities and, in many countries, more women and previously excluded minorities are able to find work (especially in developed countries); and migration to jobs often takes place over longer distances. In urban areas, commuting to work over shorter distances has taken longer, in part because jobs have tended to relocate to the periphery of towns and cities rather than stay in the center. In the informal sector, child labor has become less common although it persists. Certain groups of workers are at particular risk. The informal sector also includes workers who are without regular business arrangements, paying taxes or recognized by their government. These workers have little protection against dangers or abuse and are not covered by insurance or social programs. They are not recorded or registered and just paid by the day or task, not counted for taxes or inspection, and may work in hidden jobs that are not socially acceptable or legal. Many of the most vulnerable workers have migrated within or from outside the country and are not an accepted or protected part of local society. Migrant workers are workers who move from their home country or region to another country or region in search of a job. They usually do not intend to stay if it is possible to return and may work under contract, usually year-by-year. Some migrant workers are seasonal, moving around in a regular route in order to take jobs along the way, most often in agriculture with the harvest season, as in North America (United States and Canada) with migrant workers from countries to the south. Others move to an area because jobs are more plentiful or better and may be important to the local jobs market, as with intracountry migration in India from rural areas to the cities where employment is available. Domestic and childcare workers, construction workers, home and nursing-home care providers for the elderly and disabled, servants, gasoline station attendants, day laborers, packers, and agricultural workers are often positions of employment gaps that the migrant worker can readily fill. Some migrants have emigrated for particular reasons and have status as refugees. Migrant workers are usually employed in jobs with significant hazards, tend to be marginalized within the countries and by unscrupulous employers, and have little legal recourse except to leave the country if they have the means. Female migrant workers are often employed as childcare and domestic workers and are often isolated by living in the employer’s home, restricted in their mobility, and subject to abuse and harassment. As a consequence, almost half (47%) have demonstrated at least one occupational morbidity or injury at the time of study, with a high frequency in various studies of abuse, depression, and workplace injury. Most migrant workers receive little training to protect themselves in occupational health and safety. They often emigrate with their families, because of the circumstances that forced their emigration, and may face difficult problems with schooling their children, obtaining social services, receiving health care, and communicating in the language of the host country (Hargreaves et al. 2019). Expatriate workers are workers who come from another country to do a job, often under contract or through an agency that brings them to the new country under contract with an enterprise. Expatriate workers are held to the terms of the contract between the enterprise and the agency that sponsored their immigration. These

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arrangements provide opportunities for employment from the most skilled (such as nurses) and highly paid workers (such as engineers and other professionals, who usually negotiate their own contracts) to workers who are performing the most basic support services (who are recruited and brought over by agencies). Low-wage expatriate workers are often employed in jobs with significant hazards and receive little training. When low-wage and especially unskilled expatriate workers become sick or injured, there is often no safety net or insurance to help them. They are often not eligible for treatment in local hospitals and are almost never eligible for disability pensions or compensation. In most cases, they must return immediately to their home country, which usually has less resources in health care or rehabilitation than the country they were working in and seldom has compensation or other incomesupport programs for the severely disabled. Most expatriate workers have their employment tied to a particular project or employer and must return home when it is completed. It is common for agencies and employers to confiscate passports and to withhold permission to travel for workers during the period of employment, although this is variable and illegal in many countries. In China, intracountry migration is a means of equilibrating demand in the regional labor markets and is institutionalized in the hukou system of residency permits. Many countries, especially high-income countries with small populations, are dependent on expatriate workers to maintain their services and standard of living. Travelling workers are increasingly common in a globalized economy. These workers include senior managers who travel between different parts of a business enterprise, entrepreneurs, sales representatives, and skilled technicians who may have a certain skill or expertise needed to maintain critical equipment. Although their travel may be relatively brief, travelling workers are exposed to the location risks of their destination. Emergency response personnel and humanitarian relief personnel may be going into locations of acute and severe hazard, often in locations where the infrastructure is weak and there are other locational hazards, such as civil unrest. These travelling workers require preparation prior to departure, such as immunizations, education on unfamiliar risks they may face (such as rabies from dog bites), medications and supplies (such as sterile syringe needles) to take along, contact information on how to obtain health care in country, or other needs as appropriate to the country and situation. Travel medicine clinics are widely available to provide these services, following WHO and other guidelines.

Occupational Health and Sustainability Healthy, safe, and decent work, and the occupational health and safety protection that supports such work, contributes to sustainable development. Work is important in giving meaning to a person’s self-expression and in shaping identity and social interaction. The relationship between work and health is reciprocal: good work protects and enhances the health of workers and protects the health and well-being of their families. Good health and the absence of disability allow the worker to play their appropriate social role within their family and in the community and to be more

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productive at work (The World Bank 2020; Ponsonby 2017; Guidotti 2011; Elgstrand and Petersson 2009). Occupational health and safety protection act powerfully to support both economic and social sustainability. It allows workers to earn a living in order to meet their needs and that of their families with more security and less fear that they will be injured, sick, disabled, or killed because of their work or impoverished because they cannot work (The World Bank 2020; Ponsonby 2017; Guidotti 2011).

Overview: Sustainable Development Agenda 2030 for Action on Occupational Health (United Nations 2020)

• Social protection against occupational diseases and injuries (SDG1, target 1.3) • Reduction of mortality from work-related non communicable diseases and mental ill-health (SDG3.4) • Universal health coverage of workers with financial protection and basic health services for prevention and control of occupational diseases (SDG3.8) • Reduction of work-related deaths from air pollution and unintentional poisonings (SDG3.9) • Elimination of hazardous child labor (SDG 8.7) • Promotion of safe and healthy working environment for all workers and, in particular, women, migrants, and workers with precarious employment (SDG8.8) • Protection of workers’ health through measures for climate change adaptation and mitigation (SDG13)

Occupational health and safety play an important underappreciated role in economic development although one that is seldom considered in development models and rarely quantified separately. It is difficult to quantify because it is a result of economic development with a rising standard of living providing greater protection and expectations of worker survival and benefit (Guidotti 2011). Furthermore, occupational health and safety specifically protect the people who are most productive in the economy at the time because they are employed. When occupational injuries and illnesses are considered, it is usually narrowly in terms of medical care costs, not burden of disability and financial insecurity. The traditional treatment of occupational health and safety in development economics underestimates the value of preventive or occupational health services in early years of economic development because health care costs are low at that stage. However, health care costs rise quickly as prices increase and expectations create demand in economic terms or, in more realistic terms, need expresses itself as demand. As injury, illness, and disability increase during development, the burden of disability and health-related low productivity becomes a drag on the developing economy. However, early in development, the costs of investment in occupational

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health and prevention are also very low. Later in development, costs of engineering prevention and providing health care and support for disabled workers who cannot work are much greater.

Global Occupational Health The United Nations system supports competent national authority in occupational health and safety and provides education, advisement, and standards which are authoritative and widely applied. During the 2018 UN General Assembly High Level Meeting on Non-Communicable Diseases, the heads of state and governments committed to engage with the private sector to prevent and control noncommunicable diseases, including by “promoting and creating safe and healthy working environments, by implementing occupational health measures, including by establishing tobacco-free workplaces, and through good corporate practices, workplace wellness programs and health insurance plans, as appropriate” (UN General Assembly 2018). At the 2019 UN General Assembly High Level Meeting on Universal Health Coverage, the heads of state and government committed to scale up action to promote healthier and safer workplaces and to improve the coverage of occupational health services (UN General Assembly 2019). WHO and the ILO are specialized multilateral organizations within the UN system that deal with occupational health. At this, WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. The Constitution of WHO stipulates that “the enjoyment 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.” Approximately 2.8 billion people, or about one-half of the world’s population, are economically active. Their health is determined by a number of risks in the occupational environment, social factors, behaviors, and access to health services. The main functions of WHO, mandated in article 2 of its constitution, include promoting the improvement of working conditions and other aspects of environmental hygiene. WHO’s action on protecting and promoting the health of workers is also mandated by a number of resolutions of the World Health Assembly. Recognizing that occupational health is closely linked to public health and health systems development, WHO is addressing all determinants of workers’ health, including risks for disease and injury in the occupational environment, social and individual factors, and access to health services. Furthermore, the workplace is being used as a setting for protecting and promoting the health of workers and their families. Protecting and promoting health at the workplace and improving the health of workers contribute to achieving the WHO goal of one billion more people enjoying better health and wellbeing.

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The ILO is a tripartite agency, meaning that it has participation from governments, employers, and workers in member states, charged within the United Nations system to promote rights at work, set labor standards, model policies, and conduct programs that promote healthy, safe, and decent work. The ILO constitution explicitly calls for more than 40 occupational safety and health standards and another 40 codes of practice. These are incorporated in conventions and instruments that cover most aspects of work and the economy. Other issues of concern to the ILO that have some bearing on occupational safety and health deal with child labor, forced labor, working time, and employment security. The ILO was founded in 1919, making it the oldest specialized agency in the United Nations system. The Preamble to its Constitution explicitly mandates “the protection of the worker against sickness, disease, and injury arising out of his employment, the protection of children, young persons and women, provision for old age and injury” together with other critical issues of social justice and labor (International Labour Organization 2004, 2008, 2010, 2020).

Occupational Health Services As the economy grows in complexity and enterprises grow larger, more specialized forms of occupational health services are required. There are many national models of how occupational health services can work. These range from entirely public services to purely private sector providers. In many developed economies, employers provide some services, government agencies others, and private health care facilities others (Guidotti 2013). They mostly reflect the path that each country took historically. In some countries, occupational medicine services are combined with adult primary care so that specialty-qualified practitioners do both. In the other countries, most occupational health services are provided by private medical services and consultancies. Government-managed occupational health programs vary greatly depending on a country’s health care system, public health structure, and the presence or absence of a compensation insurance system. In many developing countries, programs are provided by the few large employers and other workers depend on the primary health care system. They may be completely absent outside of major cities in some countries. A survey of ICOH National Secretaries in 40 countries represented in ICOH, in which 70% of workers of the world lived, determined that 31% of countries had occupational health services covering more than 50% of workers, with a wide range of coverage in individual countries and higher coverage in larger and more developed countries. Of the countries that did have coverage, occupational health in 47% was fully or partly integrated into primary health care. Eighty-two percent provided a more or less standardized set of services including prevention (workplace assessment, enterprise-level worker periodic health assessment, planning), medical services, (diagnosis, treatment, rehabilitation), training and education, or most of these basic services, at the enterprise or individual level. Of the 2.36 billion active workers covered, 1.77 billion had no access to occupational health services. Most were

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financed by employers, some by ministries of health, and some by social insurance or occupational injury insurance carriers (Rantanen et al. 2017).

Box 4 Basic Principles of Occupational Health Services

• Protection and prevention • Adaptation of work to the worker • Health promotion and personal development, for work ability and healthy lifestyles • Cure and rehabilitation, when occupational injuries and illnesses occur • Primary health care, building on the services of the first health care providers in the community the worker is likely to visit when there is a need • Basic functions of occupational health services (surveillance of the work environment, surveillance of worker health, education and training of workers, access to first aid, the ability to interpret and manage occupational health problems)

The provision of occupational health services to small- and medium-sized enterprises (SME) is a particular challenge. These are smaller factories or firms or businesses that may be important to the local economy and that employ many workers taken together but because of their small size and limited capital, they lack the resources to maintain extensive staff or make a big investment in the plant. There have been many models for targeting and providing services to the SME sector, but to be effective and sustainable, these outreach programs are usually either aggregated into local facilities, subsidized by government, or integrated into the primary health care system. To increase further the access of workers to the most essential interventions and basic occupational health services, WHO is promoting the integration of workers’ health needs into people-centered primary care. In particular, WHO recognizes that: • Workers’ health is an integral part of general health and daily life. • Health systems should facilitate local strategies to meet workers’ health needs. • In moving towards universal coverage, those at greatest risk or having greatest needs should be included first. • When developing policies about workers’ health, all relevant stakeholders should be involved. • Training in health and work should be part of all health-care professional training. • Workers should be empowered, and those in authority should partner to promote the health and safety of workers. WHO recommends including certain essential interventions for occupational health and work ability in the delivery of comprehensive, integrated primary care, such as advice for improving working conditions and for promoting health at work, early detection of occupational and work-related diseases, and support for

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return to work and preservation of working capacity (World Health Organization 2001). People-centered care requires putting people in their environment, including work environment, and working life at the center of health care. This requires (World Health Organization 2012): • Strengthening the role and responsibilities of the primary care providers for all health-related aspects of personal life, including early recognition of occupational and work-related ill-health, as well as preserving and restoring working capacity of individuals • Building the capacities of primary care centers to respond effectively to the general and specific health needs and expectations of working populations in the catchment area, including training in basic occupational health and supportive tools for interventions • Linking occupational health services and primary care centers under local primary health care networks, including joint training, referral systems, information on occupational hazards and other mechanisms for collaboration and continuity of care • Providing clinical guidelines and standards for health care professionals that take into account the impacts of work and employment and working capacity • Empowering and supporting individuals and work communities to take over the control of their own health, to protect themselves against occupational hazards, and to promote health at the workplace, for example, by training and developing programs for healthy workplaces, introducing tools for self-assessment and for work improvement, supporting workers’ health and safety representatives and community health activists

Professions Because of its specialized nature, the field of occupational safety and health has developed several distinct professions, each of which play a role in prevention and correction of occupational health and safety problems. Each of these professions has its own qualifications, credentials, and professional organizations. The degree to which their assistance is available depends on the country and what institutions, government agencies, and support are available. The recognized occupational safety and health professionals are occupational physicians, occupational health nurses, occupational hygienists, safety professionals, and specialized occupational safety and health professionals. Occupational physicians are medical doctors who specialize, informally or with formal qualifications, in the management of occupational injuries and illness and their consequences in the workplace. This group does not include primary care physicians who see occupational cases irregularly, but it is common for occupational physicians to provide primary care as a part of their overall practice. Specialty physicians, such as specialists in lung diseases or dermatology (skin diseases),

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often see cases in their practice that arise from work but are not considered occupational physicians because their role is limited to the scope of their specialty. In most countries, there are two pathways to becoming a specialist in occupational medicine: (1) a formal training program lasting several years that leads to a fellowship or board certification for specialists who receive referred cases, have careers devoted to the field of practice, and teach or do research; and (2) a continuing professional development program of variable length leading to a certificate or other qualification that trains primary care physicians or specialists from other fields of medicine at a middle level for community practice or to provide services for enterprises. Occupational health nurses are specialized to provide services at a middle level in enterprises so that they can recognize and refer cases of occupational injury and illness as well as manage the implications of the problem for fitness for duty (especially preplacement and return to work), rehabilitation, and compensation. Many enterprises rely on occupational health nurses to manage their occupational health service, referring cases to physicians as needed. There are training programs leading to special credentials in most countries that have occupational health nurses. Occupational health nursing is a highly desirable nursing field, with considerable autonomy. Some of these functions may be provided by community health nurses on a local level. Occupational hygienists are specialists in the anticipation, recognition, evaluation, and control of hazards in the workplace. Their training programs emphasize chemical hazards, basic engineering for ventilation and other control technologies, basic physics of physical hazards such as noise, measurement of hazards, and program management. Hygienists are heavily involved in conducting audits and inspections, evaluating and solving particular problems, and anticipating problems that may occur during plant design or changes in production so that solutions can be found in advance. Formal certification is usually required, but in the absence of formally qualified hygienists, many of their duties are performed by safety professionals or technicians trained to perform measurements as required. The International Occupational Hygiene Association represents this field and has an affiliate relationship with WHO. Safety professionals are trained to recognize and identify safety hazards, including physical causes of injuries, musculoskeletal conditions, tissue damage (burns), acute poisonings, and other types of common occupational hazards. They conduct audits (inspections), identify problems and design corrections, conduct training for workers, and collaborate with experts in loss prevention, insurance, production management, and human resources to prevent and correct problems. Training programs are increasingly required for safety professionals, many of whom moved into the field when they were assigned safety duties as employees in the same enterprise, although many safety professionals around the world are still self-taught or informally prepared. Most safety professionals work for enterprises; the most highly qualified often become consultants, usually in a particular industry. Among the international resources for training is the Institution for Occupational Safety and Health, a global chartered (UK government-recognized) organization for training that provides short courses with certificates of completion, and the National

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Examination Board in Occupational Safety and Health, a UK-based globally recognized organization that provides longer courses and formal qualifications. Specialized occupational safety and health professionals who deal with noise, radiation, ergonomics, and other hazards are usually less readily available than the main listed above, especially in countries with less developed occupational safety and health regulatory systems. Loss prevention specialists and insurance professionals play an important role in managing insurance risk and guiding management in supervising occupational safety and health measures but are not considered occupational safety and health professionals.

Work Ability “Work capacity” (also called “work ability”) is the capability of a worker to perform the work required and can be thought of as the match between personal factors (such as strength, stamina, cognitive ability, interruptions due to illness) collectively called “fitness” and the demands of the job or the assignment. “Fitness for duty” evaluations are commonly performed when a worker is hired, when the job assignment changes in a major way, after a worker is injured and has undergone treatment to determine if they are fit to return to work, to document permanent impairment (and permanent disability in consequence) arising from an injury or illness (whether work-related or not), for purposes of assessing disability for compensation, and at the end of employment to document their condition at the time of termination. “Work ability” is the capacity to carry out one’s job productively and competently, without risk of overload, injury, or illness. Occupational health measures protect work ability, from the young, untrained worker who is just starting but does not know how to protect him- or herself to the aging worker. A healthy and fit workforce is less likely to experience loss and disruption in production, and so the enterprise and employers stand to benefit from targeted worker health interventions. These may include the provision of medical services for occupational injuries and acute health problems within or near the enterprise, if not in the workplace itself, and programs of health promotion intended to reduce risk factors for ill-health and to encourage self-care. These programs may range from limited educational programming to elaborate wellness programs that include measures to motivate healthy behavior, provision of prevention services on site or paid by the employer, or support and supplemental management of treatment and monitoring for chronic diseases (such as hypertension) at the workplace. These programs are generally effective the more risk factors they modify and the more participation they attract. In some countries, these programs are connected to health insurance. Health promotion programs are primarily concerned with motivating healthy behavior in personal lifestyle, family life, and communities. They depend on supporting and informing personal decision and accept that individuals have discretion in their choices. However, safe and healthy working conditions require adherence to rules and standards that are formulated on the basis of protecting all workers

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in the workplace as well as any individual worker. The employer is held responsible for ensuring that the workplace is acceptably safe and therefore carries the legal responsibility. Therefore, the role of worksite health promotion is significantly different from occupational health and safety because health promotion relies on persuasion and individual commitment while occupational health and safety actively discourages individual choice and requires compliance under terms of employment and regulation. In that way, occupational health and safety measures are like public health measures, affecting everyone, and not like individualized preventive medicine or health care decisions, adapted to the individual.

Disaster Response and Emergency Management During the last five decades, the world has witnessed a wide range of natural and manmade disasters and emergencies that have had important impacts on occupational health. These emergencies include a large number of natural disasters that have occurred across the world, such as the Indian Ocean tsunami, and earthquakes, floods, and cyclones. Outbreaks of infectious diseases have occurred from time to time in different parts of the world with particular risk to health and other workers. Such diseases include severe acute respiratory syndrome (SARS), H1N1 influenza, Ebola virus disease, cholera, Zika virus disease, and the COVID-19 pandemic. Additional key emergencies have included radiation-associated events (e.g., Chernobyl, Fukushima) and chemical emergencies (e.g., the Bhopal toxic gas leak, Deepwater Horizon blowout and oil spill), each of which involved high risk to workers as well as to the community. Management of such outbreaks and emergencies involves close coordination and cooperation between a large number of diverse organizations. The emergency response personnel associated with such organizations comprise professional groups that include firefighters, police officers, emergency medical staff (paramedics, emergency medical technicians, doctors, and nurses), public health workers, and psychologists. In major disasters, rescue workers, technicians from large relief organizations, additional medical staff, military personnel, antiterrorist forces, corpse-handlers, clean-up workers, construction workers, and numerous volunteers are also involved. Each of these categories of workers has specific roles in managing an emergency response that may expose them to various health and safety hazards while carrying out their duties. Employers, including government agencies, responding to a disaster have the duty of care to protect health and safety of emergency responders (Pappa et al. 2020; Liu et al. 2019; Mitchell et al. 2015). In addition to these events, many countries are currently facing humanitarian crises and conflicts that increasingly involve the disturbing trend of attacks on health facilities. Such attacks not only affect the health and safety of health providers but also seriously affect the capacity of health systems to deal with humanitarian emergencies. According to a WHO report, during the two-year period from January 2014 to December 2015, there were 594 reported attacks on health-care workers that resulted in 959 deaths and 1561 injuries in 19 countries with emergencies.

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In view of all these events, the need for better occupational safety and health protection for emergency workers is increasingly being recognized as a major priority. For this purpose, WHO and ILO have developed a manual for protecting occupational health and safety in public health emergencies (World Health Organization 2018). Paradoxically, the health sector, which is supposed to restore, protect, and promote health, is also hazardous to the health of its own workers (WHO 2020, 2019). In the European Union, the health care sector is among the sectors most hazardous for health and safety of workers, together with agriculture, construction, and mining. Fifty-four percent of health workers in low- and middle-income countries have latent tuberculosis, which is 25 times higher than the general population (Joshi et al. 2006). In the 2014–2016 Ebola outbreak in West Africa, the risk of infection among health workers was 21–32 times higher than in the general adult population (World Health Organization 2015). Between 17% and 32% of health care workers in developed countries suffer from occupational burnout (World Health Organization 2019). Between 44% and 83% of nurses in clinical settings in Africa have chronic low back pain compared to 18% among office workers (Semachew et al. 2018). Globally, 63% of health workers report experiencing any form of violence at the workplace (Liu et al. 2019). Medical professions are also at higher risk of suicide in all parts of the world (Dutheil et al. 2019). During the COVID-19 pandemic, 23% of frontline health-care workers worldwide suffered depression and anxiety and 39% of insomnia (Pappa et al. 2020) Unsafe working conditions are among the most often cited causes of strikes among health workers (Russo et al. 2019). Poor wellbeing and occupational burnout among health workers is associated with poor patient safety outcomes such as medical errors (Hall et al. 2016). Unsafe working conditions, stress, or, in some countries, the perceived lack of security are among the mean reasons for attrition of health workers and exacerbating health workforce shortages (Castro Lopes et al. 2017). Poor working conditions resulting in absenteeism and occupational illness and injuries are also a significant financial cost for the health sector. For example, in 2017, the annual costs of the occupational illnesses and injuries in the health care and social services sector in Britain were estimated as 3.38 billion USD (Health and Safety Executive 2019). WHO and ILO recommend the development of national programs on occupational health as a way to improve the organization and management of occupational health and safety in the health sector (World Health Organization and International Labour Organization 2020). The WHO–ILO Global Framework for National Occupational Health Programmes for Health Workers provides strategic guidance for establishing the building blocks of a national programs (see Box 5). Box 5 WHO–ILO Global Framework for National Occupational Health Programmes for Health Workers

The Ministry of Health will need to consult and work together with other relevant Ministries on the development of the National Occupational Health (continued)

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Box 5 (continued)

Programme for Health Workers such as the Ministry of Labour, Social Security, and/or other organization(s) responsible for the protection and promotion of health worker health and safety in the private as well as public sector. 1. Identify a responsible person with authority for occupational health at both the national and workplace levels. 2. Develop a written policy on safety, health, and working conditions for health workforce protection at the national and workplace levels. 3. Ensure access to Occupational Health Services by strengthening existing or establishing new occupational health programs and allocate sufficient resources/budget to the program, occupational health professional services, and the procurement of the necessary personal protective equipment and supplies. 4. Create joint labor–management health and safety committees, with appropriate worker and management representation. 5. Provide ongoing (or periodic) education and training that is appropriate to all parties, including occupational health practitioners, senior executives, front-line managers, health and safety committees, front-line workers and their representatives, and the general public. 6. Identify hazards and hazardous working conditions in order to prevent and control them and manage risks by applying the occupational health hierarchy of controls, which prioritizes elimination or control at the source. 7. Provide preservice and ongoing immunization against hepatitis B and other vaccine preventable diseases in the workplace at no cost to the employee and ensure all three doses of the hepatitis B immunization have been received by all workers at risk of blood exposure (including cleaners and waste handlers). 8. Promote exposure and incident reporting, eliminating barriers to reporting and providing a blame-free environment. 9. Promote and ensure health worker access to diagnosis, treatment, care, and support for HIV, TB, and hepatitis B and C viruses. 10. Utilize appropriate information systems to assist in the collection, tracking, analyzing, reporting, and acting upon data to promote health and safety of the health-care workplace and health workforce. 11. Ensure that health workers are provided with entitlement for compensation for work-related disability in accordance with national laws. 12. Promote research on OHS issues of concern to health workers and translation of research into practice, particularly with respect to combined exposures and applied intervention effectiveness research. (continued)

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Box 5 (continued)

13. Promote and implement greening health sector initiatives that incorporate occupational health, green, and safe jobs while reducing greenhouse gas emissions with a preference for: use of renewable energy; providing safe drinking water; promoting hand hygiene; active transport; environmentally preferable management of hazardous health care waste; and environmentally preferable selection and disposal of chemicals such as pesticides, disinfectants, and sterilants. (World Health Organization and International Labour Organization 2020)

Conclusion Occupational risk contributes a significant part of the global burden of disease and injury and more studies are needed to quantify the role of additional occupational risks and their mitigation for reducing the burden of disease. Furthermore, occupational health is pivotal in sustainable development and addresses virtually all Sustainable Development Goals. The relationship between work and health is reciprocal: good (meaning safe, healthy, and decent) work protects and enhances the health of workers and protects the health and well-being of and support of their families. Good health and the absence of disability allows the worker to play their appropriate social role within their family and in the community and to be more productive at work. Above all, occupational health allows workers to earn a living in order to meet their needs and that of their families with more security and less fear that they will be injured, sick, disabled, of killed because of their work or impoverished because they cannot work. Occupational health therefore acts powerfully to support both economic and social sustainability, because it is closely linked to public health, and these links become even more important with the trends in the future of work and the blurring of the boundaries between working life and family life. The health sector itself is among the most hazardous sectors and all health workers need decent occupational health programs to keep them healthy and safe. Occupational health can contribute to the preparedness and response to and the recovery from global public health emergencies and epidemics of infectious disease by protecting the health workers and emergency responders and increasing the resilience of workplaces to health security threats. Global change, such as trade, migration, technological development, environmental change, and public health threats, requires new ways of working in occupational health. Occupational health institutions need to be strengthened and adapted to the new work organization with increasing small and medium size enterprises, an informal gig economy, and labor migration.

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Planetary Health: Systems Perspectives and Impact of Climate and Environmental Change on Human and Global Health

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health: Past, Present, and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health: Past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health: Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health: Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Is Planetary Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . System Perspectives on Human Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosing the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health as Framework for Treatment and Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attitudes and Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Planetary Health Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Planetary health is an emerging field of transdisciplinary knowledge that uses a systems approach to guide human behavior. It is both a very young field of science, and a very ancient way of being in relationship with global ecosystems. The unifying understanding behind Planetary health is that human behaviors are altering the Earth in ways that threaten human health and human civilization. We must develop a deeper understanding of the ways that human health is impacted by disruption of the planet’s natural systems in order to promote effective policies and encourage changes in behavior. The findings from planetary health research indicate both a sense of urgency and a sense of hope; we are discovering that

T. Potter (*) University of Minnesota School of Nursing, Minneapolis, MN, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_131

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planetary health solutions offer co-benefits to humans and the rest of the planet. This chapter presents an overview of the planetary health field and current best practices. The intent is to provide an origin story, principles to guide effective actions, and resources to support and empower a global movement to ensure a viable planet for future generations. Keywords

Planetary health · Global health · Ecosystem · Sustainability · Environmental health

Introduction Planetary health is many things. It is a framework for thinking about the connectedness of human wellbeing and our planet’s natural systems; it is a lens through which the 17 seemingly disconnected Sustainable Development Goals addressing climate, biodiversity loss, hunger, poverty, marine preservation, and human health come into focus as all part of a single whole. It is a movement whose ranks are growing with people around the world committed to taking both individual and collective action to bring humanity back into balance with natural systems. At its heart, though, planetary health is an interdisciplinary field focused on characterizing and quantifying the human health impacts of accelerating disruption and degradation of our natural systems and translating this knowledge into action – among policy makers, the private sector, and the general public. Planetary health practitioners are a community forged in urgency. The field has emerged with extraordinary speed, launching new journals, developing courses, degree programs, and professorships in universities around the globe, birthing regional planetary health hubs and government initiatives, and catalyzing new scholarship. Stimulating this urgency is recognition that human activity is transforming nature’s life support systems at unprecedented pace and scale and that these disruptions represent immediate threats to human health and wellbeing. Human health and wellbeing are determined by many factors; but once illness occurs, an accurate diagnosis, an effective plan of treatment, and comprehensive and compassionate care are often necessary for full recovery. These elements hold true whether the patient is an individual, a community, or the Earth. When a patient has many systems that are failing at the same time, we say they are in multi-system failure. Currently the Earth is in multi-system failure with many of its natural systems already exceeding or poised to exceed their boundaries (Rockstrøm et al. 2009). An effective response will require rigorous science, transdisciplinary expertise, a supportive and collaborative community, and a shared vision of the behavior changes that humans need to make for the planet to recover health. The field of planetary health provides these essential elements for recovery of the Earth’s natural systems, while at the same time, improving the health and wellbeing of humanity.

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Planetary Health: Past, Present, and Future It’s difficult to know where you are going until you know where you have been. (Anonymous)

Transformation requires knowledge of the past and a vision for the future. Without a clear understanding of where we have been, we can repeat mistakes and fail to recognize innovative solutions. Leaders who want to lead change need to carefully deconstruct the past so that those attitudes and behaviors that are leading toward the collapse of civilization are stopped, and those that benefit humanity are advanced to support a healthy future. Therefore, this overview begins with a discussion of the roots of planetary health, the current status of the field, and a vision for the future.

Planetary Health: Past Six of the seven continents, Antarctica being the exception, are inhabited by Indigenous People, also known as “the People” or “first people.” The People are intimately connected to the biosphere where they live and therefore may be considered the first planetary health experts. Throughout history their very survival has depended on knowledge passed from generation to generation, cultural values that affirm interconnection and community, and behaviors founded on sustainable practices (Hameed et al. 2019). Indigenous thinking represents one end of the continuum of the relationship between humanity and the rest of the biosphere; the other end of the continuum is domination. Manifest Destiny and the Doctrine of Discovery exemplify the domination worldview which sees the environment, including other humans, as a resource that can be owned, manipulated, and exploited. As technology advanced, the domination worldview has had a direct impact on the health of humans as well as that of the biosphere. Rachel Carson’s book, Silent Spring (1962) was one of the first scientific writings to call the domination worldview into question. Carson illuminated the threats of indiscriminate use of pesticides, especially DDT, and questioned the underlying assumption that humans have a right to dominate nature. Public health professionals and epidemiologists have long understood that a domination worldview impacts social and environmental determinants of health. For example, domination is evident when in the name of economic gain, worker safety is ignored or industries producing toxic wastes are located in communities of color. More recently literature reflects a growing understanding of the negative impact that anthropogenic changes to natural systems will have on global health in the future. For instance, Professor Anthony McMichael from the Australian National University was one of the first scientists to issue warnings about the health impacts of climate change. His book, Planetary Overload: Global Environmental Change

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and the Health of the Human Species (1993) links human health to disruptions of the environment. In his article, “Insights from Past Millenia into Climactic Impacts on Human Health and Survival,” McMichael (2012) comments that even though localized shifts in climate have happened throughout human history, “Modern societies, although larger, better resourced, and more interconnected than past societies, are less flexible, more infrastructure-dependent, densely populated, and hence are vulnerable” to the health impacts of global climate change (p. 4730). In the context of these unique and growing vulnerabilities of modern society, emerging models of planetary health would do well to acknowledge that indigenous knowledge, passed on from generation to generation, may play a significant role in restoring planetary health. In fact, the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) recognizes that Indigenous People “are often better placed than scientists to provide detailed information on local biodiversity and environmental change and are important contributors to the governance of biodiversity from local to global levels” (IPBES n.d.). Indigenous knowledge may also promote sustainable livelihoods, improve resilience to climate-related extreme weather events, and mitigate further harm to the biosphere due to loss of biodiversity and disruption of natural systems (Magni 2017). Buse et al. (2018) suggest that moving forward may require us to “participate in the process of (re/un)learning” and questioning the underlying “dominant politicaleconomic discourses and cultural imperialism that have separated humans from nature” (p. 423). Indigenous knowledge may offer guidance as we attempt to renew our relationship with the other members of the ecosystem.

Planetary Health: Present In 2014, the Lancet published a manifesto that recognized the urgent need to shift our values from patterns of overconsumption and unsustainable development to an “attitude toward life” and a “philosophy of living” that supports the health of natural systems (Horton et al. 2014, p. 847). This manifesto was a precursor for a more indepth analysis eventually published as “Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation–Lancet Commission on planetary health” (Whitmee et al. 2015). The report finds that anthropogenic changes to Earth’s natural systems pose a significant threat to global health. The authors state, We have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting nature's resources, human civilisation has flourished but now risks substantial health effects from the degradation of nature’s life support systems in the future. (p. 1973)

The authors cite “highly inequitable, inefficient, and unsustainable patterns of resource consumption and technological development, together with population growth” as the causes of “climatic change, ocean acidification, land degradation,

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water scarcity, overexploitation of fisheries, and biodiversity loss” (p. 1973). All of these disruptions to the planet’s natural systems will have dire consequences for the health of future generations. In essence, the field of planetary health focuses on recognizing and addressing the human health impacts of human-caused disruptions of Earth’s natural systems. In addition to highlighting the extensive human health impacts of degrading the natural systems on which life depends, the report also suggests essential actions to restore the health of the biosphere to preserve human health in the future. Actions include shifting our current patterns of knowledge, attitudes, and behavior including fostering development and application of transdisciplinary knowledge; valuing the health of both future generations and poor and marginalized people living today; and shifting our consumption and uses of technology (Whitmee et al. 2015). Humanity appears to be at a crossroads. We can continue on our current trajectory of biosphere destruction and suffer the consequences, or we can choose to make a commitment to planetary health. The COVID-19 pandemic illustrates the risks of ignoring public health in favor of short-term gains. Human attitudes and behaviors that orient toward domination of the environment and commodification of the biosphere have set in motion the biodiversity loss and ecosystem disruptions that elevate the risk of pandemics (Vidal 2020). Programs like the Planetary Health Alliance (PHA) provide the necessary knowledge, values, and behavior competencies to transition to a path that supports a healthier future. The PHA launched in 2016 with a mission to support the rapid growth of a robust, interdisciplinary field of planetary health through: • Building a global planetary health community that crosses sectors, disciplines, generations, and geographies • Facilitating the training of the next generation of planetary health leaders through the development of mentorship opportunities and foundational open-access educational resources from primary to university levels • Mainstreaming planetary health science through broad public outreach and direct engagement with policymakers (PHA n.d.-a) Based at Harvard University, the PHA is comprised of over 200 member organizations from around the globe including universities, research institutes, and governmental and nongovernmental organizations. Signature PHA initiatives include planetary health education, promoting a planetary health community of practice, and development of future planetary health leaders. For people wanting to learn more about planetary health, the textbook Planetary Health: Protecting Nature to Protect Ourselves (Myers and Frumkin 2020) offers the most comprehensive foundation. Part 1 of the book reviews planetary health foundations and describes the concrete ways that the earth’s natural systems are being disrupted by human behaviors. Part 2 discusses the human health impacts that these disruptions are causing especially the urgent threat they pose to future generations. Part 3 discusses social, political, and economic opportunities that exist if we choose

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to commit to planetary health. Overall, the book sends an optimistic and hopeful message that it is possible to save ourselves by saving the planet.

Planetary Health: Future The future of planetary health is perhaps stated best by Dr. Sam Myers, the Director of the Planetary Health Alliance in the video “Planetary Health: The Future is Now.” The positive vision is right there for us to see for my children and their children. It’s easy for me to imagine a world in 100 years where human population has stabilized, where human populations continue to congregate in cities, but where those cities have been designed with intent and thoughtfulness about how to minimize their inhabitants’ ecological footprints and optimize their health and wellbeing. And it is quite easy to imagine a world that with every passing decade after that there is more room for the rest of the biosphere, not less. That to me is every bit as likely a future for my children’s grandchildren as the catastrophic future, and it all depends on what we decide to do right now, today. That is the urgency of now. (Planetary Health Alliance 2019)

Planetary health offers humanity an alternative to its current road to extinction. It combines Indigenous knowledge and science-based transdisciplinary knowledge with frameworks for practice and action to promote the health of humans and the entire biosphere on which we depend.

What Is Planetary Health? It is important to understand how planetary health relates to other concepts within global health. Announcing the publication of the report by the Rockefeller Foundation-Lancet Commission on planetary health (Whitmee et al. 2015), the President of the Rockefeller Foundation (Rodin 2015) described planetary health as “a new discipline within global health.” Global health is best defined as: 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 emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population- based prevention with individual-level clinical care. (Koplan et al. 2009)

It is noteworthy that according to the definition of global health, the environment does not play a significant role other than being one of the determinants of health. There are, however, seven fields that emphasize the interconnection of the ecosystem, animal, and human health. These include occupational and environmental health, political ecology of health, environmental justice, eco health, One Health, ecological health, and planetary health (Buse et al. 2018). All of the fields employ systems thinking; all emphasize equity; and all encourage transdisciplinary

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collaboration. Buse et al. (2018) do not see one field as being better than the others but instead note the unique contributions of each. They conclude that planetary health is a field of inquiry, a practice, and a movement uniquely focused on understanding and promoting “the health of human civilization and the state of the natural systems that define the safe environmental limits within which humanity can flourish” (Buse et al. 2018, p. 422; Whitmee et al. 2015). Rockstrøm et al. (2009) refer to our current geological period as the “Anthropocene” due to human caused environmental change on a massive scale. The authors provide the most comprehensive discussion of the “environmental limits” or planetary boundaries that must not be exceeded if humans are to continue to survive. They report that three of the nine boundaries; climate change, rate of biodiversity loss, and the planet’s nitrogen cycle have already been exceeded (p. 473). Hence another unique quality of planetary health is the sense of urgency. Rodin (2015) concludes, “We have the opportunity to define this age as an age of extinction or an age of resilience. With a focus on planetary health, we can – and we must – choose the latter.”

System Perspectives on Human Health Diagnosing the Problem The core premise of planetary health is that the ecological impacts of human activity in aggregate now exceed our planet’s capacity to absorb our wastes or provide the necessary resources for life. As a result, we are disrupting the climate system, driving the 6th mass extinction of life on Earth, polluting air water and soil at global scale, transforming land cover, altering biogeochemical cycles, and driving scarcity of resources like freshwater and arable land. These large-scale environmental changes interact with each other in complex ways to alter core conditions for human wellbeing and, as a result, impact nearly every dimension of human health (see Fig. 1). The environmental changes outlined in Fig. 1 – disruption of the climate system; loss of global biodiversity, changes in land use and cover, pollution of air water and soil, alteration of biogeochemical cycles; and increasing scarcity of resources like freshwater and arable land – are already impacting human health. These biophysical changes interact in complex ways we are only beginning to understand to affect the quality of the air we breathe and the water we drink; the quality and quantity of food we can produce; our exposure to infectious diseases and natural disasters; and even the habitability of the places we live. Heretofore disciplinary science has brought us a great deal of knowledge but very little insight on application to complex adaptive systems such as the health of the planet. Considering the previous metaphor of a patient in multisystem failure, our current approach to the planetary health crisis is similar to a cardiologist, a pulmonologist, and a nephrologist only diagnosing their part of the problem but never

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Fig. 1 Schematic illustrating how larger human populations combined with accelerating consumption rates are driving disruptions in natural systems that ultimately threaten every dimension of human health. (From Myers and Frumkin (2020, p. 7), used with permission of Island Press)

considering how the health or failure of one part impacts the others. The problem therefore is not a lack of understanding of the parts but rather a gap in knowledge of complex systems, feedback loops, and how to respond to uncertainty and complexity. In addition to defining planetary boundaries, Rockstrøm et al. (2009) also define three areas of scientific inquiry that will help us further understand the nature of the problem. These include: “knowledge of the essential role of the life-support properties of the environment for human wellbeing, . . .understanding essential earth processes including human actions, . . .and research into resilience and its links to complex dynamics and self-regulation of living systems” (pp. 474–475). Given the complex nature of the planetary health challenges, we need systemsbased solutions. Therefore, the remaining focus of this paper will be on the knowledge, attitudes, and behaviors necessary for an effective coordinated response to our current crisis.

Planetary Health as Framework for Treatment and Care Restoring the health of earth’s natural systems will require several different approaches including transforming the development and dissemination of human knowledge, promoting values and ethics that support planetary health, and encouraging planetary health friendly relationships and governance. Each of these approaches must address both the problem and the solution.

Knowledge The establishment of a new field of knowledge requires key texts that most agree are the foundation of basic knowledge for the field. Planetary Health: Protecting Nature

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to Protect Ourselves (Myers and Frumkin 2020) is that text for planetary health. The editors write, “Planetary health focuses on understanding and quantifying the human health impacts of these global environmental disruptions and on developing solutions that will allow humanity and the natural systems we depend on to thrive now and in the future” (p. 7). Planetary Health: Protecting Nature to Protect Ourselves (Myers and Frumkin 2020) does not simply reveal the urgency of the problem; it also points our feet in the direction of possible solutions. The text concludes with, “Four important elements of the needed transformation will be shared visions that drive hope and optimism, changing the way we generate and share knowledge, deepening the human relationship with the natural world, and building movements for social action to drive change” (p. 480). The book is an essential guide for any person or organization that is serious about understanding the human caused disruptions to natural systems and the resulting impacts on the health of humans today and for generations to come. Transdisciplinarity and open access publications are hallmarks of transformative movements that seek new ways to generate and share knowledge. Since 2017, The Lancet Planetary Health, an open access peer-review journal, has been one of the leading sources for emerging science related to both planetary health problems, and solutions. A commitment to transdisciplinarity is evident in the journal’s call for papers: We particularly favour work that contributes to our understanding of, and transition into, a safe and just space for humanity, respecting planetary boundaries and the social and economic foundations of a healthy life. We are interested in all important aspects of societal development and its interaction with the environment including the drivers of change, the implications of those changes for people and society, and practical policies and interventions for a healthier planetary future. (The Lancet Planetary Health 2020)

In addition to transdisciplinary knowledge, The Lancet’s mission reflects several other elements common to the planetary health field including sustainable development within planetary boundaries and policies and practical interventions that promote social change. GeoHealth is another open access journal that specializes in disseminating high quality research at the intersection of environmental and health science (GeoHealth 2020). Planetary health research can also be found in discipline specific journals and journals associated with professional organizations, especially those that are transdisciplinary. Planetary health knowledge is also disseminated through teaching, in which case learning is often facilitated through use of a curriculum framework. “Cross-Cutting Principles for Planetary Health Education” (Stone et al. 2018) provides an essential framework to foster the development of a planetary health mindset. The framework created by the Planetary Health Alliance (p. 192) is designed to guide planetary health education across all disciplines and all levels of education (see Fig. 2). Of particular note are the principles of systems thinking, movement building, and equity. Absence of these principles in the past may have been a contributing factor for many of the current human caused disruptions of the Earth’s natural systems.

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Fig. 2 Cross-Cutting principles for planetary health education. Source: Carlos Faerron Guzmán and used with permission

The “Cross-Cutting Principles for Planetary Health Education” (Stone et al. 2018) offers a unifying framework for all disciplines. It creates a shared language and identity to support growth of the movement across the globe. Faculty of individual disciplines can use the framework and add specific examples related to their field. For example, Potter (2019) applied the cross-cutting principles to nursing education. One can also see many of these principles illuminated in Goldhagen’s (2019) call for the transformation of pediatrics into Planetary Pediatrics. By exposing students to the Cross-Cutting Principles of Planetary Health, they can learn to see their own discipline as part of a greater system and movement for change.

Attitudes and Values The modern planetary health field was established in response to a growing understanding that the current values and attitudes of society are threatening to reverse all the previous gains in public health. In the Lancet commentary, “From public to planetary health: A manifesto,” (Horton et al. 2014) the authors write: An urgent transformation is required in our values and our practices based on recognition of our interdependence and the interconnectedness of the risks we face. We need a new vision of cooperative and democratic action at all levels of society and a new principle of planetism and wellbeing for every person on this Earth—a principle that asserts that we must conserve, sustain, and make resilient the planetary and human systems on which health depends by giving priority to the wellbeing of all. (p.847)

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This sentiment is echoed in the report of the Rockefeller Foundation–Lancet Commission on planetary health which found, “We have mortgaged the health of future generations to realize economic and development gains in the present” (Whitmee et al. 2015, p. 1973). As previously mentioned, restoring planetary health might provide an opportunity for many humans to (re/un)learn (Buse et al. 2018). This is particularly true related to the human relationship with the natural world. Indigenous People represent 5% of the global population yet occupy 22% of the Earth’s land, land which accounts for 80% of the planet’s biodiversity. Indigenous People are deeply interconnected with natural systems through cosmologies and practices, therefore they represent the longest and most reliable expertise on sustainability. Their resilience in the face of centuries of domination can inspire planetary health activists today (Deranger 2017). The Great Law of Haudenosaunee Confederacy provides an example of Indigenous thinking to move us forward toward right relationship with the environment. “The Seventh Generation Principle today is generally referred to in regard to decisions being made about our energy, water, and natural resources, and ensuring those decisions are sustainable for seven generations in the future. But it can also be applied to relationships - every decision should result in sustainable relationships seven generations in the future” (Indigenous Corporate Training 2020). Regard for the knowledge of Indigenous People and others who have been marginalized or ignored, aligns with the 12th planetary health cross-cutting principle which affirms that “an understanding of the past is necessary to solve the problems of the present” (Stone et al. 2018, p. e193). Another attitude that needs to be challenged if planetary health is to be advanced is the worldview where some humans dominate other humans and the environment rather than participate as partners with nature (Potter 2020). In fact, global health emerged as a corrective to patterns of domination evident in international health. Global health represents a “shift in philosophy and attitude that emphasizes the mutuality of real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries” (Koplan et al. 2009, p. 1995). The Republic of Ecuador serves as a global exemplar of using policy and governance to reinforce attitudes and actions that support planetary health and a partnership with nature. The Constitution of the Republic of Ecuador (2008) dedicates an entire chapter to recognizing and preserving the rights of nature. Article 71 states, “Nature, or Pacha Mama, where life is reproduced and occurs, has the right to integral respect for its existence and for the maintenance and regeneration of its life cycles, structure, functions and evolutionary processes.” The chapter also calls the citizens of Ecuador to protect the rights of nature and promote the respect of all the elements in the ecosystem. Furthermore, the Constitution requires the State to apply “preventive and restrictive measures on activities that might lead to the extinction of species, the destruction of ecosystems and the permanent alteration of natural cycles” (Article 73). Ecuador models the shift in thinking and attitude that needs to occur to honor the planet’s boundaries for the wellbeing of future generations.

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Our cultural narrative is responsible for our relationship with nature and has led to many of the disruptions caused to Earth’s natural systems; therefore, part of the work of planetary health includes a deep critique of our ethics and values. To this end, the Planetary Health Alliance has entered into a partnership with the Harvard Divinity School, the Center for the Study of World Religions, the Harvard Center for the Environment, and the Harvard T.H. Chan School of Public Health on an initiative known as “The Constellation Project.” The project promotes transdisciplinary dialogs that examine the relationships between humans and the rest of the biosphere. “The emerging field of planetary health in partnership with an earth-based spirituality can create a more ethical stance toward life evolving within the era of the Anthropocene. We need new stories for a new era of planetary consciousness” (Myers et al. n.d.). Once knowledge and values align for the purpose of restoring planetary health, it is more likely that our behaviors will be effective and sustained.

Behaviors Behaviors represent knowledge and values put into action, but unlike values, behaviors are observable and measurable. Similar to restoring human health, behaviors must change in order to restore planetary health. To achieve planetary health behavior changes must be scaled from individuals to populations for maximum impact. Therefore, the Planetary Health Alliance is currently convening an interprofessional team of global experts to design a competency framework for planetary health education. The purpose of the framework is: To establish a common understanding of the knowledge, skills, and attitudes unique to planetary health. . . to inspire and inform the creation of future educational programs and assessment resources that will equip the next generation of planetary health citizens with the tools they need to comprehend, promote, and further the science and practice of planetary health. (PHA n.d.-b)

Shared knowledge, attitudes, and behaviors strengthen planetary health research and movement building that promote social, economic, and policy changes. People frequently need to see an idea in action in order to become motivated to change their own behaviors. For this reason, the Rockefeller Foundation in partnership with the United Nations Framework Convention on Climate Change (UNFCCC) started an initiative to illuminate concrete examples of innovative and effective planetary health behaviors; it is called Momentum for Change: Planetary Health (UNFCCC 2020). Nurses Drawdown is another example of a global planetary health behavior movement. Nurses Drawdown is a partnership between the Alliance of Nurses for Healthy Environments (ANHE) and Project Drawdown. Project Drawdown provides evidence-based solutions that can effectively drawdown greenhouse gas emissions (Project Drawdown 2020); however, scaling the solutions requires mass-mobilization of individuals, communities, and nations.

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Nurses are the largest group of health professionals in the world and for the 18th year in a row Gallup has found that Americans rate nurses as the most honest and ethical of all professions (Reinhart 2020). Therefore, leaders from ANHE and other national and international nursing organizations proposed leveraging these factors to scale Project Drawdown’s solutions. Nurses Drawdown encourages global nurses to take action in five key areas: food, mobility, educating girls, renewable energy, and natural solutions (Nurses Drawdown 2020). Nurses Drawdown solutions have co-benefits for the health of humans and the planet. In addition to nurses, physicians, pharmacists, and dentists rank in Gallup’s top five of most respected professions (Reinhart 2020). For this reason, the Planetary Health Alliance (PHA n.d.-c) launched Clinicians for Planetary Health (C4PH). People working in all sectors of health care are taught how to leverage public trust to inspire individuals and families to adopt behaviors to improve their own health while improving the health of the planet. In 1993, Per Fugelli, former Professor of Social Medicine at the University of Oslo’s Institute of Health and Society recognized the role that health professionals can play related to environmental health. He wrote, “The patient Earth is sick. . .Global environmental disruptions can have serious consequences for human health. It’s time for doctors to give a world diagnosis and advise on treatment” (Casassus 2017). However, clinicians for planetary health did not really start to take hold until May 2019 when a call for clinicians to act on planetary health was issued in the Lancet (Veidis et al. 2019). The World Organization of Family Doctors (WONCA) was one of the earliest professional organizations to urge its members to practice planetary health. In 2019, they published the “Declaration Calling for Family Doctors of the World to Act on Planetary Health” (WONCA 2019). As family doctors are on the frontlines of protecting health, it is important that we recognize the interlinkages between environmental change and emerging health impacts. . .We need to prepare and respond to new health threats, address the root causes stemming from demographic shifts and our patterns of production and consumption, and make changes in both our institutional structures and our everyday lives. . .We have a unique capacity to understand and communicate the shifting landscape of planetary health challenges and the strategies that individuals can take to simultaneously safeguard their health and that of the environment. (p. 2)

Today family doctors join other health professionals as Clinicians for Planetary Health (C4PH). C4PH, which is hosted by the Planetary Health Alliance, has over 400 global participants who are dedicated to building a community of practice. Through educational webinars, development of patient teaching materials, and promotion of planetary health policies, C4PH unites health professionals around the world in actions that facilitate an accelerated transition to planetary health. Other organizations offer exemplary models of planetary health knowledge, values, and behaviors in action. Consider the following;

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• Health in Harmony (2020) uses radical listening with local and indigenous rainforest communities “to create the change the planet needs.” • Health Care Without Harm “works to transform health care worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability and a leader in the global movement for environmental health and justice” (n.d.). • The Stockholm Environment Institute (SEI) provides research to support implementation of the Sustainable Development goals. SEI is guided by the principles adopted at the UN Conference on the Human Environment in 1972, where it was established that the environment and human development goals are interconnected (SEI n.d.). • Wellcome acknowledges the importance of planetary health, funding research in the areas of climate change, global food systems, and urban environments (Wellcome n.d.). The Planetary Health Alliance hosts an annual conference that brings together scientists, indigenous leaders, clinicians, governmental and nongovernmental leaders, students, educators, and others. “This is the only conference where the Planetary Health Alliance network of over 150 institutions from over 35 countries and other interested institutions and individuals consistently gather to showcase their groundbreaking work, gain insight into strategies to advance planetary health at their home institutions, and inspire and equip the next generation of scholars and practitioners to take on planetary health challenges” (PHA n.d.-d). One can see that planetary health is more than a specialized field of study. It is also a philosophy, an attitude, and a practice. It applies transdisciplinary knowledge and complex systems thinking to address disruption of earth’s natural systems and propose solutions for the challenges that threaten the health of the entire biosphere.

Planetary Health Case Study Open access Planetary Health case studies can be found at Planetary Health Case Studies: An Anthology of Solutions (Duff et al. 2020a). The anthology “seeks to be part of a learning process that equips planetary health citizens with the knowledge, skills, attitudes, and values relevant to planetary health practice, and enables them to integrate these planetary health competencies into solution-driven actions in the near future” (PHA n.d.-e). Each case study includes the historical context of the issue, the current disruption of a natural system in a particular global context, the health impacts of the environmental disruption, and local solutions that are effectively addressing the challenge. There are ten case studies in the anthology, and each has an accompanying teaching guide to facilitate dialog and illuminate key principles of planetary health (Faerron Guzmán 2020). Each teaching guide includes the following content: an introduction to the case, education objectives, curricular positioning, overview of classroom discussion, case analysis, and concluding comments.

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The following is a brief overview of one Planetary Health Alliance case study. It was selected because it illuminates many of the cross-cutting principles of planetary health and the necessary shift in values discussed earlier in this paper. This case study and teaching guide are used with permission from the Planetary Health Alliance. This case study and others can be accessed at https://www. planetaryhealthalliance.org/case-studies

Case Study: The Interconnectedness of People and Planet: Learning from Maori Worldviews (Duff et al. 2020b)

Indigenous people worldwide are among the most vulnerable related to disruption of natural systems with significant impact on physical, mental, and spiritual health and well-being. “This case reiterates the importance of meaningful relationship-building and partnership in order to learn from Indigenous ways of knowing to strengthen our ability to address the unique challenges faced in the Anthropocene” (p. 469). Introduction Through the experiences of the Māori peoples of New Zealand, this case explores Indigenous worldviews and their conceptualization of health and well-being. It further traces how anthropogenic environmental change exacerbates the ongoing effects of colonialism and their impact on the physical, mental, and spiritual wellbeing of Māori tribes. The case also examines the concept of intercultural health systems and how the New Zealand government has made some progress in recognizing and incorporating Indigenous worldviews into its healthcare and natural resource policies. The case offers the opportunity for readers to reflect on the importance of incorporating Indigenous knowledge into planetary health action. By doing so, the case encourages readers to consider how Indigenous knowledge can be used to complement mainstream views of human health, environmental management, and science in solutions to our collective global challenges. (Faerron Guzmán 2020, Teaching Notes 10)

Learning objectives 1. Recognize the existence of diverse worldviews and cultures, including one’s cultural values, identities, and assumptions, and their effect on the understanding of others in the context of planetary health. 2. Compare and contrast how Indigenous worldviews and traditional knowledge systems differ from dominant western thought concerning the relationship to the natural environment. 3. Describe how Indigenous worldviews and lived experiences determine the extent of the consequences of anthropogenic environmental change. 4. Apply intercultural principles and Indigenous knowledge appropriately to health-related actions, projects, programs, and policies. (Faerron Guzmán 2020, Teaching Notes 10) (continued)

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Case Analysis • What is Health? We suggest that in order to facilitate this section, the instructor should become familiar with the following resource: Webb J, Surette C, Lemire M, (2012) Health – From Multiple Perspectives to an Ecosystem Approach. In: McCullagh S ed. (2012). Ecosystem Approaches to Health Teaching Manual. Canadian Community of Practice in Ecosystem. • Exercise: Within this manual, the instructor should review and incorporate the exercise described in Module 1: “Health - From Multiple Perspectives to an Ecosystem Approach.” The facilitator may choose to modify the exercise to fit the size and field of the class. The main objective of this section is to understand the subjective nature of the experience of health. • Context: The Māori, their History, and their Worldviews: The facilitator should prompt students to describe as much as they can of the Māori. Highlight the main elements that students discuss on the board. The instructor should encourage students to reflect upon the differences and similarities of Māori worldviews with their own. A Venn diagram might be a good graphic tool for this section. Students should describe the different health models used by the Māori and compare them to more conventional health models used in Western societies. It is important that this discussion highlights the main elements of the Māori worldviews described in relation to their understanding of the natural environment. • Challenges to Māori Health: The students should next discuss the main challenges described in the case study and explain why the Māori are more vulnerable to current environmental changes. They should first draw examples directly from the case and then open up the discussion to other examples from other Indigenous groups around the world. • Solutions: Finally, the students should describe some of the solutions and approaches implemented in New Zealand. The instructor should encourage students to extract both the lessons learned, as well as the principals of success. The facilitator might inquire what the guiding elements of intercultural frameworks are in the context of health and well-being, and if students have any experiences in these settings. Lastly, students should consider broader applications and integrations of Indigenous knowledge and traditional ecological knowledge to planetary health challenges. (Faerron Guzmán, 2020, Teaching Notes 10)

Conclusion Earth’s natural systems are in crisis and so too is the fate of humanity. The collapse of human civilization, and maybe even human extinction, are the likely endpoints if we remain on our current path. But there is an alternative future endpoint, one that

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allows humanity and the entire biosphere to flourish; the path to this future is called planetary health. The present chapter outlined planetary health as a unique and constantly expanding transdisciplinary field of knowledge, a system of transformative principles and values, and a framework for shifting human behavior. Planetary health also includes a global community of individuals and organizations willing to work in multilateral partnership to ensure a positive future for generations to come.

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Wellcome (n.d.) Our planet, our health: responding to a changing world. Available at https:// wellcome.ac.uk/what-we-do/our-work/our-planet-our-health?gclid¼Cj0KCQjwgo_ 5BRDuARIsADDEntSS55pFo6cshRLYCSRxX5Umlz9gSZQoIKd65Q05vVj65UXUOCu5vcaAnqhEALw_wcB. Accessed 31 July 2020 Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, Ferreira de Souza Dias B, Ezeh A, Frumkin H, Gong P, Head P, Horton R, Mace GM, Marten R, Myers SS, Nishtar S, Osofsky SA, Pattanayak SK, Pongsiri MJ, Romanelli C, Soucat A, Vega J, Yach D (2015) Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. Lancet 386(10007):1973–2028. https://doi.org/10.1016/S0140-6736(15)60901-1 World Organization of Family Doctors [WONCA] (2019) Declaration calling for family doctors of the world to act on planetary health. Available at the WONCA working party on the environment: https://www.wonca.net/site/DefaultSite/filesystem/documents/Groups/Environment/ 2019%20Planetary%20health.pdf. Accessed 7 July 2020

Part XII Global Health Emergencies

Global Health Security Crises Assessment, Capacities, and Response Management

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Globalization and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Health Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sustainable Development Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Pertinent Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security Reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security: Crises Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security: Capacities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Security: Effective Response Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The concept of global health security refers to the protection of individuals and societies from acute public health events worldwide. Global health security underpins the current framework for international preparedness and response to emerging infectious diseases but has suffered setbacks as epitomized by various epidemics. Transmission of emerging and reemerging infectious pathogens has been aggravated by globalization with inherent increase in urbanization, population, and cross-border travel and trade. Despite the establishment of the World Health Organization’s International Health Regulations, multiple outbreaks have invariably occurred to date. Persistent threats of outbreaks and inherent challenges present an exceptionally compelling case for strengthening global health security. This chapter presents a synopsis of the global health security within the E. Chanda (*) World Health Organization, Regional Office for Africa, Brazzaville, Republic of the Congo e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_99

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realms of crises assessment, capacities, and response management. Notably, strengthening global health security will require embedding International Health Regulation’s requirements into national health systems in pursuit of universal health coverage; establishing multipronged and sustainable support and collaboration among the international health community; and addressing challenges of both globalization and pluralism. Overcoming constraints to global health emergencies and building resilience to future outbreaks is contingent on diligence in executing requisite and pertinent changes. Keywords

Global health emergencies · Global health security · Crises assessment · Capacities · Preparedness · Response · Pandemic

Introduction Emerging and reemerging pathogens pose momentous global challenges for public health (Gao 2018). Global health security (GHS) is the protection of individuals and societies from acute public health events worldwide. The concept of GHS includes access to medicines, vaccines, and healthcare, including reductions in vulnerabilities to global public health events that have potential to spread across international borders (Cáceres 2011). Currently, GHS underpins the contemporary framework for global preparedness and response to emerging infectious diseases (Flahault et al. 2016). Enormous success has been attained in combating infectious diseases since the last century. Much of the gains have been ascribed to advances in technology including identifications of microbes, pasteurizing of daily products, and development of antibiotics and vaccines, as well as eradication of smallpox (Osterholm 2017). Nevertheless, the euphorically celebrated achievements have gradually eroded due to the emergence of infectious pathogens that have invariably eluded the once apt efforts to combat them. Further to the notable HIV/AIDS pandemic that ensued in the 1980s, outbreaks of various emerging pathogens became increasingly recognized (Osterholm 2017). Transmission of infectious pathogens has been aggravated by rapid and unplanned urbanization, ever-increasing absolute numbers of the population in urban areas, international travel and trade, and collapse of public health efforts due to political upheavals in several countries globally. In addition, climate change, disasters, and increasing contact between wild animals and humans have further exacerbated the global threats (Rees et al. 2019). In 2005 the World Health Organization (WHO) adopted the International Health Regulation (IHR) to address the challenges of multicountry-scale outbreaks (WHO 2005). In the last few decades, numerous outbreaks of emerging and reemerging infectious diseases have occurred across the globe with the IHR Emergency Committee declaring six Public Health Emergencies of International Concern (PHEIC) by January 2020. The declared PHEIC include; H1N1 influenza in 2009, Polio in 2014, Ebola in 2014 and 2018, Zika virus in 2016 (CDC 2019), and the recently

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announced coronavirus (2019-nCoV) in 2020 (WHO 2020). Some key epidemics encompass: Ebola virus disease epidemic in West Africa 2014–2016 which claimed more than 11,000 lives in Guinea, Liberia, and Sierra Leone; the 2018–2020 Ebola outbreak in Democratic Republic of the Congo (DRC) with a death toll of more than 2000 (Limb 2020); and yellow fever outbreak in Angola and DRC in 2015–2016 and in South America in 2016–2017, chikungunya in 2013, and Zika virus disease in 2015–2016 in Latin America, South East Asia, and across the world (Osterholm 2017; Palagyi et al. 2019). The Middle East respiratory syndrome coronavirus (MERS-CoV) was the pathogen responsible for severe respiratory disease outbreaks in 2012 in the Middle East and Korea (Zaki et al. 2012). The world was also faced with the Avian influenza (H5N1), the influenza A (H1N1) pandemic in 2009, cholera in Haiti in 2010, and in Yemen in 2017; and the severe acute respiratory syndrome (SARS-nCoV) outbreak in 2002, and 2003 in Guangdong Province, China (Zhong et al. 2003). The SARS outbreak in 2003 posed a threat for global health that caused an awakening and heralded potential ramification of outbreaks (Osterholm 2017), and the human immunodeficiency virus (HIV/AIDS) caused a devastating pandemic in 1980s. In addition, several other outbreaks including Crimean-Congo hemorrhagic fever, dengue, Marburg, Lassa fever, Plague and Rift valley fever keep recurring. Recently, an earth-shattering outbreak of a novel coronavirus (2019-nCoV) in Wuhan, China, in 2019–2020 has been disseminated widely with cases and deaths confirmed in several countries (Zhu et al. 2020; Holshue et al. 2020). While initial cases were linked to sea food market, further epidemiological data established human to human transmission of 2019-nCoV to be occurring (Li et al. 2020). Investigations have continued globally to better understand the transmission dynamics and the spectrum of clinical illness (Rothe et al. 2020). The Covid-19 (SARSCoV-2) virus is the third coronavirus to emerge in the human population in the past two decades following the SARS-nCoV pandemic in 2002 with a 9.5% case fatality rate, and the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in 2012 with a case fatality rate of 34.4% (de Wit et al. 2016). The historic 2019nCoV emergence put global public health institutions on high alert (Munster et al. 2020), and resulted in an unprecedented world-wide lockdown. On 30th January 2020, the WHO declared the new coronavirus outbreak a Public Health Emergency of International Concern following a statement by the second meeting of the International Health Regulations (2005) Emergency Committee on the outbreak of the novel coronavirus (2019-nCoV) (WHO 2020). Clearly, multiple outbreaks of global concern have occurred in the past decade and beyond, including the latest novel coronavirus disease 2019 (now termed Covid19) and other emerging threats despite the establishment of the International Heath Regulations. The risk of climate sensitive and epidemic prone diseases including vector borne diseases is a ticking time bomb that needs to be contained. Unfortunately, the situation is aggravated by the growing phenomenon of resistance to antimicrobial drugs and insecticides for disease vector control (malERA 2017). The continued threat and inherent challenges present an exceptionally compelling case for strengthening crises assessments, capacities, and response. Notably, global health security is a matter of global concern that should be accorded the necessary

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attention and urgency that it deserves. Here a synoptic appraisal of the global health security is presented within the realms of crises assessment, capacities, and response management.

Globalization and Health The global health landscape requires effective global action in the face of trade, travel, urbanization, and disease. The current global era is more plural, with a multiplicity of key actors, and requiring more coordination efforts, priorities, and investments (Ruger and Yach 2014). Infectious diseases can spread in short periods as humans, animals, and goods transfer more frequently and rapidly in the progressing economic and social globalization. As the global trade and travel increases, with rapid and unplanned urbanization and inherent population expansion, there is a parallel increase in the opportunity for greater disease transmission. Globalization offers opportunities and challenges for global health and its distribution (Yach and Bettcher 1998). Transfer of medical and public health knowledge and technology across the globe has enhanced prospects for health improvement. On the other hand, globalization has accelerated the transmission and spread of infectious diseases, as evidenced by the outbreaks that have occurred in the last few decades. Some challenges posed by globalization are substantial and beyond the capacity of individual nations to manage. Mounting effective global health security measures requires multipronged and sustainable support and collaboration among the international health community. Overtime, health debates have traversed the boundaries of health departments and WHO, and have become regular agenda items during multilateral meetings. Nevertheless, it is evident that pluralism had resulted in fragmented, uncoordinated and incongruent global health agenda, creating a leadership gap for an overarching convening and leadership role (Ruger and Yach 2014). Within the multilateral sphere, WHO maintains its unique coordinating function as derived from its constitution. It is the only agency with the authority to develop and implement international health norms and standards and facilitate ongoing dialogue among Member States on priorities (Ruger and Yach 2014).

Global Health Security Frameworks International Health Regulations International Health Regulations (IHR, revised in 2005) are the global legal framework, agreed upon by WHO Member States at the World Health Assembly (WHA) for preventing and responding to international health risks defined by the WHO constitution (Kluge et al. 2018). The WHA regulates the roles of WHO and Member States. While previous regulations required countries to report incidents of cholera, plaque, and yellow fever, IHR (2005) is more flexible and future-oriented, requiring countries to consider the possible impact of all hazards, whether they occur naturally, accidentally, or intentionally (Gostin 2004). With the signing of the revised IHR in 2005, the international community agreed to improve the detection and reporting of

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potential public health emergencies worldwide (WHO 2005). The IHR (2005) is coordinated by the WHO and aims to keep the world informed about public health risks and events. As an international treaty, the IHR (2005) is legally binding; all countries must report events of international public health importance. The IHR (2005) are an essential vehicle for addressing global health security and aim at protecting global health security while avoiding unnecessary interference with international traffic and trade (WHO 2005). Nevertheless, implementation of the regulations has not been devoid of demerits as evidenced by the suboptimal compliance with the IHR by countries. For example, by 2015 only 35% of the countries had met core capacities, and 48 countries had failed to report. Equally, WHO could not independently evaluate how countries performed, relying instead on unreliable self-assessments (Gostin 2015).

Global Health Security Agenda In February 2014 during the Ebola outbreak, the Global Health Security Agenda (GHSA) was established by 29 countries, with the US Government’s initiative, and the United Nations entities, namely, WHO, the Food and Agricultural Organization, and the World Organization for Animal Health (CDC 2014). The GHSA is “an effort by nations, international organizations, and civil society to accelerate progress toward a world safe and secure from infectious diseases threats; to promote global health security as an international priority; and to spur progress toward full implementation of the IHR.” While the GHSA is an entrenched part of contemporary rhetoric, there has been contention regarding the focus of the GHSA and propositions have been put forth to expand its realm from GHS to global health solidarity, security, and sustainability. Flahault and colleagues postulated that the term “global health security” potentially privileges the security of the state rather than the security of individuals and could ultimately have negative unintended effect on the goal of improving health for all (Flahault et al. 2016). Three reasons have been cited to support the contention: first, the current use of the term global security is discriminatory and skewed toward providing resources and protecting high-income countries; second, global health security tends to emphasize disease containment to protect national security rather than the prevention of future local outbreaks; and third, the national health agenda should be underpinned by respect for human rights and values of equity and solidarity (Flahault et al. 2016). The other twofold argument is that while the structures governing global health have largely remained the same, the framings of global health security have shifted the waning consensus regarding the global human right to health (security), and the unresolved allocation of accountability between state and non-state actors (Šehović 2020).

Sustainable Development Goals Controlling major infectious diseases, including HIV/AIDS, tuberculosis and malaria, is an important focus of the Sustainable Development Goals (SDGs) for

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the 2030 Agenda for Sustainable Development (United Nations 2015) that tackle the yet unattained issues from the Millennium Development Goals (MDGs). The SDGs comprise 17 goals and 169 targets, with target 3.3 stating that “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases (NTDs) and combat Hepatitis, waterborne diseases and other communicable diseases.” It transcends the scope of the MDGs and includes the control of NTDs and waterborne diseases. SDGs 1, 2, 3, 11, and 13 include references to health and disaster risk reduction (DRR). The SDGs recommend implementation of DRR strategies to improve national and international resilience to disasters globally (United Nations 2015). While the SDGs are not legally binding, governments should take ownership for meeting each target, with UN agencies taking responsibility for individual target oversight and data monitoring. Countries should self-monitor progress toward these goals and report to the relevant UN agency (Chatham House 2017).

Other Pertinent Frameworks In addition to the IHR, GHSA, and SDGs, several other internationally binding frameworks on GHS exist. The four key ones consist of: The World Organization for Animal Health (OIE) Surveillance, coordinates global animal disease prevention and control. It maintains a list of 116 notifiable terrestrial and aquatic animal diseases for livestock and wildlife, and its 180 member countries are obliged to report all detected occurrences. The Sendai Framework for Disaster Risk Reduction 2015–2030 is a UN agreement adopted by governments recognizing that they have primary responsibility for reducing disaster risk but that other stakeholders have a role to play as well. The Biological Weapons Convention is a multilateral disarmament treaty banning the development, production, or stockpiling of biological weapons, which came into effect in 1975. The Convention on Biological Diversity, spearheaded by UN Environmental Programme was adopted in 1992, to create an international legal instrument for the conservation of biological diversity, the sustainable use of its components, and the fair and equitable sharing of benefits arising from the use of genetic resources (Chatham House 2017).

Global Health Security Reforms In 2015, the Ebola epidemic spurred great criticism of global health preparedness by five high-level global commissions and exposed entrenched flaws in the international systems (Gostin 2015). The commissions included: WHO’s Independent Ebola Interim Assessment Panel; the WHO review committee on the International Health Regulations (IHR); the Harvard/London School of Hygiene and Tropical Medicine independent panel on Ebola; the Global Health Risk Framework Commission of the National Academy of Medicine; and the High-Level panel formed by the United Nations (UN) Secretary-General. In the JAMA, Gostin L, identified three critical challenges for global health security. First, The Sovereignty Challenge – that

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hindered nations to effectively report, flouting recommendations by WHO, and failing to develop requisite core capacities as required by the IHR. Second, The International Corporation Challenge – which encompasses a diverse and complex landscape with more than 175 initiatives, funds, agencies, and donors including the UN health cluster lead by the WHO. Yet there had been patent lack of harmony in response and failure of effective leadership, although WHO is constitutionally mandated to “act as the directing and coordinating authority on international health work.” Third, The Good Governance Challenge – critical features often lack at national and international level. The few powerful Major donors that drive the Global Health Agenda heavily influence the WHO by earmarking their funding to the agency. Many low- and middle-income states exhibit major governance deficits often with decision closed to public scrutiny, shunning of civil society organizations, and resistance to accountability mechanisms (Gostin 2015). Outcomes of a thorough analysis of the situation, together with the recommendations of the five commissions prompted the momentous decisions toward the inevitable sustainable changes in the global health landscape, by the international stakeholders since the establishment of the WHO in 1948 (Aldis 2008). In response, WHO instituted reforms that enabled the organization to detect situations quickly and respond rapidly due to introduction of the incident management system (IMS) which allows information to be shared better across the organization to better coordination and planning mechanisms; the Contingency Fund for Emergencies (CFE) which facilitates quick delivery of money and deployment of people; collaboration across the three levels of WHO (Salama and Fleck 2017); and the revision of the Emergency Response Framework (ERF) to strengthen the capacities of emergiecies (WHO 2017a). Strengthening the entire continuum of global health security from crises assessments and capacities to response management will be critical. An overview of each of the three pertinent categories is discussed as outlined in the following sections:

Global Health Security: Crises Assessment Health crises are events that occur at any specific point in time or place, and usually unpredicted, public in nature and have the potential to cause great harm to health of individuals, health systems, and service delivery. Substantial human suffering and loss of life as well as grave economic repercussions often ensue in the wake of health crises (WHO 2012). Effective operational response to emergencies should be guided by thorough assessments of the situation. The two most significant assessments for initial guidance for emergence operational response are the risk assessment for public health events and situation analysis for sudden onset of emergencies. Public health events requiring risk assessment may include outbreaks of infectious diseases; events resulting from exposure to toxic or hazardous materials; and other unusual or unexpected events representing a risk for public health. Emergencies requiring a situation analysis may include; emergencies due to natural hazards, and emergencies due to human-induced hazards. It should be noted that both risk assessments and

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situation analysis integrate similar elements. A rapid risk assessment comprises; information collection and analysis; event verification; activation of standard operating procedures and use of emergency funding for field investigations and risk assessments. On the other hand, a situation analysis will involve activation of standard operating procedures (SOP) and use of emergency funding for early warning/early detection; criteria for assessing needs; and recommendations regarding situation analysis (WHO 2012, 2017a). The concept of crises assessment is concerned with preparedness, response, managing, and recovering from an unforeseen public health event. The process encompasses risk assessment, a systematic process for gathering, assessing, and documenting information to assign a level of risk. It provides the basis for action to manage and reduce the negative consequences of acute public health risks (WHO 2012). The entire sequence of events proceeds through a risk management cycle that includes risk assessment – hazard, exposure and context assessment and risk characterization in which the level of risk is assigned to the event; recommendation regarding risk assessment/identification of potential control measures – ranked by priority, taking into account likelihood of success, feasibility of implementation, and unintended consequences for the affected population and society more broadly; continuous monitoring and evaluation as the event unfolds; communication of event detection, verification and risk assessment/effective ongoing communication to ensure that risk managers, other stakeholders and affected communities understand and support the control measures that are implemented; and an evaluation of lessons learned at the end of the response (WHO 2012, 2017a). Adequate preparedness and engagement of all relevant sectors can reduce the impact of recurrent public health emergencies. Crisis assessment entails working together with other countries to make decisions in public health emergencies (WHO 2005). National governments are responsible for preparedness and response to health crises. WHO provides technical guidance and operational assistance to countries for developing national risk assessment capacity as required by the IHR (2005). The assessment is specific to the context of countries to enable them to manage and reduce the impact of acute public health risks. The Ebola virus disease outbreak in West Africa highlighted major gaps in IHR implementation (Heymann et al. 2015). In the wake of the 2014–2016 Ebola crises, Zika virus in 2016, MERS in 2012 and the current Covid-19, the potential threat to safety and security from infectious diseases pandemics remains eminent (Olu 2017). Consequently, the global health community has taken steps on preparedness to deal with crises, including reorganization of emergency functions of WHO into the WHO Health Emergencies Programme; strengthening of the GHSA; joint external evaluations of public health capacity; development of the WHO blueprint for research during outbreaks; and creation of the Coalition for Epidemic Preparedness Innovations (Moon et al. 2017). At the highest level, the UN Global Health Crises Task Force was established to support and monitor the implementation of the reports by the High-Level Panel on Global Response to Health Crises (United Nations 2016). It provided quarterly reports on gaps in global health that impact preparedness for recognizing and responding to crises (Chatham House 2017). The G7 and G20 have

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placed global preparedness high on the political agenda to raise awareness and better understanding of the role of the G7 and G20 countries in preparedness for global health crises (Chatham House 2017). In 2017, the meeting co-organized by the Chatham House Centre on GHS and the Graduate Institute Geneva Global Health Center “Global Health crises: monitoring and reporting progress toward preparedness” reviewed the situation over the years and made recommendations for improvement (Chatham House 2017). Recommendations were made to track six broad areas, namely, subnational preparedness; global financing; trade and travel restrictions; research and development; knowledge and data sharing; and linkages between animal and human health. Notably, several initiatives have established targets and indicators to measure strength and progress in preparedness. However, most available metrics are voluntary with country-driven monitoring actions; commitments made by stakeholders including civil society and the private sector in support of national, and global preparedness are not monitored; and holding stakeholders accountable to their responsibilities, actions, and commitments remains a wide gap (Chatham House 2017). Several platforms are currently being harnessed for global health crises assessment. Including; internationally agreed upon frameworks for monitoring and evaluation of global health preparedness, voluntary evaluation initiatives, and independent monitoring and reporting initiatives. The internationally binding frameworks that incorporate monitoring and reporting mechanisms, including indicators and targets for improving preparedness at the national and global level consist of; The International Health Regulations, The World Organization for Animal Health Surveillance, The Sustainable Development Goals, The Sendai Framework for Disaster Risk Reduction, The GHSA, The Biological Weapons Convention, and The Convention on Biological Diversity. Voluntary evaluation initiatives involve two voluntary evaluation tools devised to assist countries to fulfill their obligations on IHR and OIE reporting standards, i.e., the joint external evaluation tool and the OIE performance of veterinary services tool. In addition, many monitoring and reporting initiatives have been established by independent nongovernmental or UN organizations and coalitions. Such as, The Lancet Countdown: Tracking Progress on Health and Climate Change, The Skoll Outbreaks Timeliness Measures, The Rockefeller Resiliency Index, and The Global Health Index (Chatham House 2017). While countries have been fulfilling the obligation of mandatory annual selfreporting of their IHR implementation status to the WHA prior to 2015, three additional voluntary components have been introduced. These include after action reviews, voluntary joint external evaluation (JEE), and simulation and exercise. In 2015, the JEE tool was developed by WHO and partners, based on the existing tools; particularly, the WHO IHR self-assessment questionnaire, the GHSA assessment tool, and the Organization for Animal Health (OIE) Performance of Veterinary Services Pathway tool. The JEE provides an objective basis for the evidence-based formulation of national action plans for health security (Talisuna et al. 2019). Also the WHO supports member states to strengthen their public health surveillance systems. The organization further applies an all-hazard risk assessment approach

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to public health events that require an immediate response and are potentially caused by more than one hazard (WHO 2017a). Other methods of assessment informed by experiences on the ground have been proposed (Erondu et al. 2018; Kluge et al. 2018). The global health crises meeting on monitoring and reporting progress toward preparedness in 2017 highlights two lessons in monitoring from other sectors. These include, “The Access to Medicine Index” (ATM) that ranks the world’s largest pharmaceutical firms on their success in making medicines, vaccines, and diagnostics more accessible in low- and middle-income countries, and “The UN Human Rights Council Universal Periodic Review.” The Universal Periodic Reviews of states human rights records are state-driven processes that allow for monitoring accountability for human rights violations (Chatham House 2017).

Global Health Security: Capacities In the event of health crises, health systems face three-pronged challenges: (1) the prospect of multiple hazards, (2) limited resources for dealing with them, and (3) high expectations regarding their performance. Equally, the abrupt increase in demand often overwhelms institutions involved rendering national and local health systems incapable to handle the crises and leaving communities particularly vulnerable (WHO 2012). The effectiveness of both preparedness and better response to any public health event is contingent on availability of requisite capacities. However, lack of capacity for mounting effective interventions remains a challenge at national, regional, and global levels (Talisuna et al. 2019). Thus, compromising effective combating of outbreaks and epidemics to achieve GHS. International spread and catastrophic outcomes of disease outbreaks prompted the revision of the IHR in 2005. The revised IHR committed WHO Member States to strengthen their capacities in Public health surveillance and response (WHO 2005). Accordingly, assessments of capacity to prepare and respond to the 2004 South Asia earthquake and tsunami, and the Haiti earthquake in 2010, informed a revision of the 2005–2015 Hyogo Framework for Action and the elaboration of the 2015–2030 Sendai Framework for Disaster Risk Reduction (UN 2015). Following the West Africa Ebola outbreak of 2014–2016, WHO and international stakeholders recommended and elaborated measures to prevent future outbreaks from becoming widespread epidemics and to ensure more rapid and effective national, regional, and global response if an outbreak with potential for international spread occurs (Gostin 2015). The UN Secretary Generals “High-Level Panel on the Global Response to Health Crises” also recommended monitoring and follow up to better protect the World from pandemics (UN 2016). Lessons from the 2014 Ebola outbreak, spurred recognition of the significance of strengthening the capacities to comply with the IHR and establishment of a monitoring and evaluation framework (Heymann et al. 2015). The joint external evaluation (JEE) is a voluntary coordination process to evaluate a country’s capacity to prevent, detect, and respond according to the IHR (2005). Countries conduct self-

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evaluations followed by JEE, whose result is set as the baseline, and the progress is monitored. The countries that receive JEE are to establish a plan to strengthen their core capacities (legislation and policy, coordination, surveillance, response, preparedness, risk communication, laboratory, and human resources). The JEE evaluates IHR capacities in 19 technical areas and 48 indicators categorized in four broad themes: “Prevent” (7 technical areas, 15 indicators); “Detect” (4 technical areas, 13 indicators); “Respond” (5 technical areas, 14 indicators); and points of entry and IHR hazards (chemicals and irradiation) (3 technical areas, 6 indicators). The JEE tool and the inherent process has been developed through a highly consultative stakeholder approach and has been widely accepted by most Member States, national and international agencies, and existing institutions and subject matter experts (Talisuna et al. 2019). In the WHO African Region, efforts have been made to proactively address underlying determinants and core capacity gaps to preventing or reducing the impact of outbreaks and other health emergencies. In addition to preparedness to build health system and community resilience to the public health impact of emergencies, the regional efforts encompass information for policy, planning and implementation, including monitoring and evaluation. In this regard, The Country Preparedness and International Health Regulations (CPI) Program was established with three strategic objectives to support risk assessment, mapping, monitoring, and evaluation of countries’ capacity to prevent, detect, and respond to health and humanitarian emergencies; support country planning and build country capacity in the IHR (2005) core capacities; and, serve as the secretariat to guide the implementation of the IHR (2005). Based on an all-hazards approach to prioritize support to the most vulnerable and low-capacity countries, the CPI Program actions are guided by the Regional Strategy for Health Security and Emergencies and the Regional Strategy for Disaster Risk Management (DRM). The CPI Program also provides technical assistance to Member States using the requisite tools in: strategic risk profiling; vulnerability and risk analysis, and mapping; IHR (2005) core capacity assessment; DRM country capacity assessment; country preparedness; all-hazard national action plans for health security and emergencies; scale up and enhancement of Integrated Disease Surveillance and Response (IDSR); Robust Early Warning and Response (EWAR) in emergency settings; institutional capacity building and human resource skill development in emergency management; and monitoring and evaluation (WHO website). Under the IHR, countries are obliged to develop and maintain the required capacities for surveillance and response, to detect, assess, notify, and respond to any public health emergency of potential international concern (WHO 2005). Accordingly, countries must report their IHR implementation status annually to the WHA and the WHO Executive Board (WHO 2005, 2015). To support countries in strengthening and maintaining their capacities for ensuring rapid detection, verification, and response to public health risks, WHO develops and provides tools, guidance, and training. Despite the effort, most countries still do not have all the required IHR capacities (Talisuna et al. 2019). Reports of self-assessments conducted in the WHO African region by 2016 show that no country had all the

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required IHR capacities (WHO 2018b). The situation has largely been ascribed to inadequate health systems in most countries in the region (Kieny and Dovlo 2015). The status quo has been corroborated by an independent JEE of the IHR (2005) capacities in the WHO African region that highlighted diversity in levels of required capacities in various Member States and identified major gaps on pertinent technical areas. The evaluation echoed the need for an urgent collective action and establishment of robust national public health capabilities, infrastructure and processes with regular, objective, and transparent assessments (Talisuna et al. 2019). Often, ill-preparedness to deal with a crisis by pertinent national and local systems worsens, the vulnerability of affected communities. The health system becomes overwhelmed due to sudden increase in the demand of essential health services and rendered unable to provide required interventions. In this regard, a thorough understanding of the country situation is required to strengthen stewardship; implement a continuous multi-hazard preparedness planning process; and establish sustainable crisis management and health-related risk-reduction programs (WHO 2012). The GHS agenda facilitates and promotes strengthening of country IHR core capacities to elevate global health security. Since its establishment in 2014, the GHSA has blossomed into a partnership of more than 60 nations and organizations. The collaboration between governments pursues a multisectoral approach toward strengthening global and national capacity to prevent, detect, and respond to human and animal infectious disease threats, whether occurring naturally, accidentally, or deliberately spread (Osterholm 2017). In May 2016, the World Health Assembly endorsed the establishment of the “Health Emergency Programme” (“Programme”) to add operational capacities for outbreak and humanitarian emergencies to compliment WHOs traditional technical and normative roles (WHO 2016). WHO and other international organizations in charge of animal health are working together to support IHR implementation at the country level. WHO supports countries by providing guidance on harmonizing their existing legal frameworks with the IHR framework. Measuring capacities of health security within the broader sphere of health systems strengthening, responses to public health emergencies, and reducing global catastrophic biological risks has become increasingly significant particularly in the wake of the Ebola epidemic (Ravi et al. 2019). To this effect, several efforts have been made to improve capacities and capabilities. In 2012, the WHO Regional Office for Europe in collaboration with its Member States provided technical assistance in developing and implementing crises preparedness and management programs toward strengthening health system capacity through the development of a standardized toolkit for assessing health system capacity for managing crises (WHO 2012). In 2017, the Emergency Response Framework (ERF) was revised to strengthen the capacities for emergencies (WHO 2017a). Ravi and colleagues conducted a scoping review to aggregate evidence-based principles that capture a country’s baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments. The review synthesized four foundational principles for measuring global health security that could inform

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efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security: measurement requires assessment of existing capacities, as well as efforts to build core public health, healthcare, and biosecurity capabilities; assessments of national programs and efforts to mitigate a critical subset of priority threats could inform efforts to generate useful metrics for global health security; there are measurable enabling factors facilitating health security strengthening efforts; and finally, measurement requires consideration of social, political, and ecological risk environments (Ravi et al. 2019). This will help countries to position themselves better and tackle any eventuality head-on including the devastating SARS-CoV-2 the etiological agent behind the COVID-19. Building capacities in disease surveillance, workforce, emergency response and preparedness, laboratory partnerships, and national public health institutes are essential. While WHO is the international lead agency for global outbreak response, Centers for Disease Control and Prevention (CDC) technical expertise, epidemiology and laboratory workforce development training, and disease detection programs are cornerstones for Ministry of Health and WHO health security activities (Osterholm 2017). It is obligatory that all countries take responsibility to one another to build healthcare systems that are strong and work to identify and contain public health events before they spread (CDC 2014). Despite the agreement to the importance of IHR (2005), only a third of the countries in the world currently can assess, detect, and respond to public health emergencies (WHO 2005). To improve the situation, WHO provides training support to countries for strengthening the competences of professionals. As required by the WHO constitution, the organization identifies core functions such as epidemiological and statistical services, control and elimination of communicable diseases, and establishing international nomenclatures and classifications of diseases and causes of death as essential to a world health information system (Ruger and Yach 2014). Currently, the WHO, Academia, and CDC support countries in strengthening national public health and information systems and integrated global disease detection strategies. The WHO remains central to standardizing methods, integrating information systems, and ensuring reliability and validity of health statistics (Ruger and Yach 2014).

Global Health Security: Effective Response Management Several emerging and reemerging infectious disease outbreaks have precipitated candid calls for strong and resilient health systems (Palagyi et al. 2019). Responding to the threats of infectious diseases is critical, particularly the ones caused by emergency of drug-resistant bacteria and viruses, population growth, and environmental and ecological changes due to global warming and development (Beyera and Paulina 2020). Consequently, continuous surveillance, prompt and efficient diagnostics, development and use of new vaccines and drugs, and research that includes understanding of the ecology of pathogens and organisms are required (de Wit et al. 2016). Experiences from previous epidemics and outbreaks highlight the significance of close collaboration between clinicians and public health authorities at all

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levels, including rapid dissemination of information (Moorthy et al. 2020). Syndromic (symptomatic) surveillance and contact case tracing are key in the containment of infectious diseases as exemplified by SARS and Ebola, including the latest Covid-19 (Munster et al. 2020). Since various developing nations experience challenges in outbreak detection, “WHO focuses on strengthening capacity on detection of outbreaks by introducing ‘event-based surveillance’ in areas with poor access to health facilities.” Informed by the devastating Ebola virus disease outbreak in West Africa and recommendations of the high-level panel on the Global Response to Health Crises in 2016 (UN 2016), WHO reorganized its approach to outbreaks and emergencies. The 69th World Health Assembly endorsed the reform of WHOs work in health emergency management, giving rise to the WHO Health Emergencies Programme (WHE) that defines major functions in health emergency risk and management, program oversight, implementation planning, and funding requirements (WHO 2016). WHE delineates lines of authority to facilitate leadership; operational processes for appropriate tools and requisite expertise, planning and partner coordination; and other pertinent obligations for effective detection and response to outbreaks and emergencies. As the designated lead for the global emergency cluster, WHO developed standard operating procedures and made requisite policy changes and updated the Emergency Response Framework (ERF) to clarify the roles and responsibilities and to provide a common approach in emergencies. The ERF obliges WHO to act with urgency and predictability to best serve and be accountable to populations affected by emergencies (WHO 2017a). The WHO has introduced the incident management system (IMS) which allows information to be shared better across the organization and facilitates better coordination and planning mechanisms. The IMS approach is internationally recognized as best practice for emergency management. It provides a standardized and flexible approach to managing WHOs response to emergencies. To deliver an effective operational response, WHO fulfills six critical functions in the IMS: leadership or incident management; partner coordination; information and planning; health operations and technical expertise; operations support and logistics; and finance and administration (WHO 2017a). Keeping the world safe is one of WHO’s three top strategic priorities in the Thirteenth General Programme of Work. WHO has set a goal to better protect 1 billion more people from epidemics and other health emergencies over the next 5 years. To achieve this goal, a WHO manual on managing emergencies was developed outlining key facts of major deadly diseases (WHO 2018a). The comprehensive global alert and response system by WHO ensures that information is available and response operations are conducted effectively. The functions of the global alert and response system include event-based surveillance, multi-hazard risk assessment and event-based risk communication; critical information and communications platforms for decision support; and operations and logistics platforms for any WHO response to international public health risk (WHO website). The WHO plays an essential role in the global governance of health and disease; due to the core global functions of establishing monitoring and enforcing

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international norms and standards and coordinating multiple actors toward common goals. Global health governance requires WHO leadership and effective implementation of WHOs core global functions to ensure better effectiveness of all health actors. During the public health events, WHO guidance helps countries to manage risk communications. WHO ensures that laboratory services are essential to identify the agents involved in public health events. In the wake of recent epidemics of international public health concern, there has been heightened high-level global discussion on the need for strengthened health systems. Skepticism has surrounded contemporary global consensus on the need for strong health system, due to minimal agreement on effective mechanisms for establishing and maintaining the systems (Erondu et al. 2018). To streamline the response process, several innovative approaches to implementation have been proposed. Such as, the recently formulated concepts for strengthening the bridge between health system and global health security in pursuit of universal health coverage by embedding the IHR requirements into national health systems. The concept is envisioned to be vital in attaining the shared goal of creating resilient health systems through more joined-up thinking between the IHR core capacities and health system functions (Kluge et al. 2018). Motivation has been derived from countries were the JEEs have informed elaboration of national action plans that have facilitated the embedding of health security functions into the health system strategies and budgets. In this regard, policy recommendations have been proposed for close collaboration between the health systems and health security to ensure systematic coordination between universal health coverage (UHC) and global health security (Kluge et al. 2018). Mounting an effective response entails, strengthening epidemiologic investigations to characterize transmission modes, reproduction interval, and clinical spectrum resulting from infections to inform and refine strategies that can prevent, control, and stop spread of infectious diseases (Zhu et al. 2020). To build a case for embedding global health security and universal health coverage, Erondu and colleagues propose a unified health system that includes public health. Erondu et al., note that the IHR and the WHO health system framework have separated the interdependent public health functions and healthcare services that resulted in fragmented national health systems. In this regard, a new conceptualization of a unified health system that incorporates IHR (2005) and public health functions within UHC has been recommended. A broader definition of health system within UHC has also been recommended and includes provision of population level and preventive services, surveillance, disease detection, emergency response, and surge capacity, as well as strong and resilient patient management (Erondu et al. 2018). In 2014, a collaboration between governments launched the GHSA as a global effort toward a world safe from infectious disease threats. The involved governments focus on strengthening their countries’ capacities for detection, response, and prevention. The GHSA calls on countries to develop an interconnected global network of emergency operations centers, with multisectoral rapid response teams. Katz and co-workers noted that both GHSA and IHR are platforms for action, but with notable unclarity on how efforts under each one would complement each other (Katz et al.

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2014). Both GHSA and IHR aim to elevate political attention and encourage participation, coordination, and collaboration by multistakeholders, while leveraging previously existing commitments of multilateral efforts such as IHR and OIE. To strengthen global health security, Katz and colleagues highlighted the intersections of GHSA and IHR and recommended that the mechanisms that measure progress under the two overlapping frameworks could help focusing of resources and sustaining political momentum for IHR implementation (Katz et al. 2014). Emergency situations are known to easily deteriorate into a disaster in the face of a weak health system (Rudowitz et al. 2006; Casamina et al. 2015). On the other hand, resilient health systems could reduce vulnerability to public health consequences of disasters (Kieny and Dovlo 2015). Lately, the calls for the use of resilient health systems as the basis for public health disaster risk management (DRM) have intensified (Aitsi-Selmi and Murray 2015). The Sendai Framework for Disaster Risk Reduction (SFDRR) and Sustainable Development Goals (SDGs) recommend implementation of disaster risk reduction (DRR) strategies to improve resilience to disasters globally (United Nations 2015, 2017). The SFDRR proposes resilient health systems as an opportunity for ensuring effective DRR in the health sector (Aitsi-Selmi and Murray 2016). The World Health Assembly urged countries to strengthen disaster risk management (DRM) programs by incorporating them into national health systems (United Nations 2011). The disease outbreaks experienced lately and prevailing UN agreements make a compelling case for the use of resilient health systems as a conceptual framework for public health DRM (Olu 2017). While crises assessment and building requisite capacity as well as mounting appropriate response are key, finances constitute a pivotal component of the entire continuum of the GHS. Immediate funding, as well as provision of the requisite resources, is key for prompt and effective response. In this regard, the WHO and the World Bank Group established financing initiatives: “The WHO Contingency Fund for Emergencies” and “The World Bank Group Pandemic Emergency Financing Facility,” with a common premise that seeks to avail immediate financing of public health emergencies (WHO 2017b; World Bank 2017). Building on a fund created in early 2000s under the auspices of the Nuclear Threat Initiative, in 2015 WHO established a Contingency Fund for Emergencies (CFE) to enable an immediate release of funds at the beginning of an emergency until resources from other financing mechanisms begin to flow. Thus, allowing WHO to deploy resources and begin emergency operations immediately, financing WHO leadership, national emergency operations and partner coordination in an emergency response (WHO 2017b). The World Bank Group created a Pandemic Emergency Financing Facility (PEF) in response to the 2014–2016 Ebola outbreak that could only be sufficiently financed 3 months after the PHEIC declaration. Like the WHO CEF, the PEF seeks to provide rapid financing for public health emergencies (World Bank 2017). Whereas the CEF is designated to respond to infectious diseases outbreaks, health, and humanitarian events including natural disasters, the PEF is specifically designed as a quick-disbursing financing mechanism to large-scale disease outbreaks with pandemic potential (Chatham House 2017). The current COVID-19 pandemic has

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demonstrated that third world countries, particularly those in Africa would need international debt relief to be able to effectively contain the epidemic.

Conclusion Strengthening the entire continuum of GHS from crises assessment through building of requisite capacity to mounting of effective responses is pivotal and need to be prioritized. Implementation of the internationally agreed upon frameworks such as the International Health Regulations and global health security agenda spurred by Sustainable Development Goals provides a unique opportunity to achieve the goal. Global health security in the context of contemporarily global health landscape requires a well-coordinated multipronged approach. Overall, reforms around the global health security concept have had positive overall impact, including on the WHO as a global leader in emergencies. Overcoming constraints of current responses to global health emergencies and building resilience to future outbreaks are contingent on thorough execution of pertinent changes. Accordingly, integrating and prioritizing health security agendas in national and foreign policies of countries will be critical. Timely sharing of country level data and operational research experiences ought to be encouraged to inform global discourse and decisions (Moorthy et al. 2020). Equally pivotal to the efforts will be advocacy for interministerial, cross-country, and cross-institutional coordination, local funding support and political attention. In this regard, health security agendas should be anchored by long-term approaches based on strengthened surveillance and national health systems (Flahault et al. 2016). Addressing challenges of both globalization and pluralism will be critical for successful global health security. Opportunities and challenges offered by globalization for global health and its distribution need to be considered. Transmission of infectious diseases has been favored by the increasing threat of emerging and reemerging arboviruses, resistance to antimicrobial drugs and insecticides in disease vectors. The climate sensitive and epidemic prone vector-borne diseases including Lassa fever are a ticking time bomb that deserves attention. Countries should strengthen surveillance and develop requisite early warning and response systems including contingency plans. To effectively address the challenges of global health security, engagement with environment and agriculture sectors within the one health framework and leveraging of the private sector will be pivotal.

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Assessment, Risk Management, and Global Health Impact Junaid Ahmad and Haleema Sadia

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Trends in Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Natural Disaster and Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disaster-Induced Mortality Is a Global Health Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disaster-Induced Mortality and Morbidity Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Availability in the Context of Natural Disaster and Global Health . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Globally, the number of disasters have increased during the last couple of decades. However, the common approach to disaster management is often limited to reactive mode. Only recently, research studies were initiated to understand the nature of disasters better and identify appropriate interventions and risks reduction approaches. But limited number of studies have explored the public health impacts of disasters to date. This is evident from the fact that the indicator set for “disaster-induced mortality” in the Sustainable Development Goals has no benchmark value. This chapter explores the link between natural disasters and various global health indicators to inform global health practitioners and researchers as

J. Ahmad (*) Prime Institute of Public Health, Peshawar Medical College, Peshawar, Pakistan e-mail: [email protected]; [email protected] H. Sadia Rufaidah Nursing College, Peshawar Medical College, Peshawar, Pakistan e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_100

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well as to initiate a debate among policymakers about the importance of health data availability in pre- and post-disaster scenarios. Finally, the eminent role of evidence-based decision-making, interventions, and policies for natural disaster and risk management is highlighted. Keywords

Natural disasters · Disaster risk management · Disaster-induced mortality · Health emergency

Introduction The history of disasters is as old as human history. Mankind experienced a number of disasters that are reported in religious scripture and historical documents. In the past, disasters were considered as acts of gods (Wijkman and Timberlake 1984), and no serious attention is ever paid to the mitigation and prevention of disasters. But in the nineteenth century, with the advancement of science and technology, mankind realized that disasters are not acts of gods, but the result of natural phenomenon and/or anthropogenic actions. Although in the case of natural hazards, disasters can’t be prevented; however the impacts of disasters can be mitigated to a large extent, by taking into consideration various aspects of disaster, i.e., risk, hazard, vulnerabilities, etc. With this realization, the emergence of the science of disaster management dates back to early 1900 (Coetzee and Van Niekerk 2012). However, there is still a lack of standard definition and terminologies as various organizations and government bodies have constructed own definitions of disaster, according to their discipline and context (Denis 1995; Keller and Al-Madhari 1996; Turner and Pidgeon 1997; UNISDR 2004). Overview: Definitions of the Disaster from International Organizations

The widely used definition is that of the United Nations International Strategy for Disaster Reduction (UNISDR 2004): “a serious disruption of the functioning of a community or society, causing widespread human, material, or environmental losses which exceed the ability of the affected society to cope using its own resources.” Noji (1997), the World Health Organization (WHO) defines a disaster as “Any occurrence that causes damage, ecological disruption, loss of human life, deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community.” According to Yohe and Tol (2002), the World Bank defines disaster as “A natural event that causes a perturbation to the functioning of the economic system, with a significant negative impact on assets, production factors, output, employment, or consumption.” (continued)

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The Intergovernmental Panel on Climate Change (IPCC), an agency concerned with climate change, has its own definition of disaster. According to which, disaster is “[. . .] Severe alterations in the normal functioning of a community or a society due to hazardous physical events interacting with vulnerable social conditions, leading to widespread adverse human, material, economic, or environmental effects that require immediate emergency response to satisfy critical human needs and that may require external support for recovery” (Seneviratne et al. 2012). The above five definitions are only a few among many, and there are so many other definitions of disaster; there is no universally accepted definition (Shaluf 2007). The gap in the standard definition of disaster and related terminologies, making difficult the understanding of disaster events, recording a disastrous event, and setting guidelines and standard operating procedures to prepare for and respond to disaster (De Groeve et al. 2013). In the mentioned four definitions, two main points for an event to be label as disaster are important: first, exceeding the local capacities to manage the event and second, seeking call for international- or nationallevel assistance. But in the case of Zimbabwe cholera epidemic and Myanmar flood that occurred in 2008, the criterion is disputed; as in both cases, although it is labeled a disaster, the events didn’t call for international or external assistance.

Types of Disaster Disasters are classified by different organizations and institutions (Shaluf 2007) according to the nature of onset (Van Wassenhove 2006), mechanism, and cause of initiation (Beresford and Pettit 2009). Mainly disasters are classified as natural disaster and manmade disaster, but there is also a classification of technological disaster, man-made disasters, economic disaster, and hybrid disaster (Shaluf 2007). The definition of disaster, classification/types of disaster, is very important for researchers and aids organization/agencies, to better understand and record disasters; in the absence of which, there will be inaccuracy in the data and recording of disaster events (Tschoegl, Below, and Guha-Sapir 2006). As the definition of disaster varies discipline to discipline, the same is the case when it comes to the classification of disaster, which varies according to a different organization. The classification of disasters is an emerging area of research for academician and international agencies/organizations in the evolving field of disaster management. Tables 1 and 2 present two different classifications for the types of disasters (Van Wassenhove 2006; Shaluf 2007). The classification made by Van Wassenhove (2006) is in the context of supply chain management and has categorized various events with four main attributes based on the mechanism of onset and cause of initiation, i.e., natural or

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Table 1 Types of natural disasters by the time of onset Natural Earthquake Hurricane Tornadoes Famine Drought

Sudden onset

Slow onset

Man-made Terrorist attack Coup d’etat Chemical attack Political crisis Refugee crisis

Source: Van Wassenhove (2006, p. 476) Table 2 Types and classification of disaster Disaster type Natural

Subdisaster Natural phenomenon beneath the earth’s surface Topographical phenomenon Metrological/hydrological phenomenon

Biological phenomenon

Manmade

Sociotechnical

Warfare

Hybrid

Technological disasters Transportation disasters Stadia or other public space failure Production failure National

International Conventional war Nonconventional Natural and man-made events

Name of disaster Tsunamis, earthquakes, volcanic eruption Avalanches, landslides Tornadoes, hailstorm and snowstorms, floods, sea surges, windstorms (hurricanes typhoons), cyclones, droughts, cold waves/ heat waves Infestations (locust swarms), epidemics (cholera, dengue, Ebola, malaria, measles, meningitis, yellow fever, HIV/AIDS, tuberculosis) Leakages, fire, explosions, toxic release, pollutions Land disasters, air disasters, Sea disasters Fire, crowd stampede, structure collapse

Computer system breakdown, distribution of defective products The civil war between armed groups from the same country, civil strikes, civil disorder, bomb threats/terrorist attacks Wars War between two armies from different countries, sieges, blockades Nuclear, chemical, biological Floods ravage community built on a known floodplain, location of residential premises, factories, etc. at the foot of an active volcano or in an avalanche area landslide

Source: Shaluf (2007)

anthropogenic cause. The International Federation of Red Cross (IFRC), an international organization, provides relief and support to affected population and is working to reduce the impact of disaster; WHO is dealing with health

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issues globally, and several other organizations have made classification of higher income, which is mostly based on their nature and domain of work (Shaluf 2007). Currently, the definitions, concepts, and terminologies are evolving as the knowledge of disaster management is expanding in its own field and entering into other fields. Disasters are now not limited to response and recovery or economic and life loss only; but the study and research of disaster in political, demographic, ecological, business, and security context are greatly realized and have been started (Spence 2004; Turner et al. 2003). The definitions at present are not specific; they are more generic; but it is expected that it will expand in the near future (IPCC 2012).

Global Trends in Disasters In the last couple of decades, the numbers of disaster are on the rise (EM-DAT 2016). The reasons for this rise are many; it may be due to the advancement of science and technology that has improved the reporting system, and that’s why we are recording more and more disasters. It may also be due to climate change impacts that we are experiencing more and more severe weather events frequently that end up in disaster (IPCC 2012); maybe because of increase in population density, more and more people are getting affected by disaster (Wisner et al. 2004). We label an event as a disaster if it affects human life or property like an earthquake inside the sea; if it does not result in human life loss or property damage, it is not a disaster, or a cyclone that end up in the seas is not a disaster; but if it affects human and/or their property, it is labeled as disaster (IPCC 2012; UNISDR 2004; De Haen and Hemrich 2007). As population density is increasing, more and more people are encroaching floodprone area. Also, more and more people are making their habitat on highly vulnerable and hazard-prone areas (Vinh Hung et al. 2007). As a result, the event that may not be a disaster in the past is turning into a disaster now (Sawada et al. 2011). During the last two decades, the number of disasters has been increased twice as much (EM-DAT 2015). According to EM-DAT the number of geophysical disasters (earthquakes, mass movements, volcanic eruptions, and tsunamis) almost remained constant during this period, but climate-related disaster (floods, storm, cyclone) contributes to a significantly higher number of disasters (CRED 2015). Accord to the records of EM-DAT, 341 natural disasters have occurred since the year 2000, which is 44% more than the recorded disaster in the time period of 1994 to 2000 on average and almost over double the number the time period of 1980 to 1989. The reason for this increase in some disasters is a debatable issue. Whatever the reason is, it is certain that the number of disasters are on the rise since the last couple of decades. The detail is shown in Fig. 1. As EM-DAT don’t have the classification of man-made disasters, therefore, the data is referred from the Swiss Re Economic Research and Consulting study (2014) titled “Swiss Re, sigma no. 1/2014, Natural catastrophes and man-made disasters in 2013.” As discussed earlier in the section “Types of Disaster,”

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Fig. 1 Trends of disaster occurrence and reported victims (limited to natural disasters). (Source: Guha-Sapir et al. (2013))

disasters are classified by different organizations according to their nature of work and discipline. For technological and man-made disasters, the Swiss Reinsurance Company Ltd is one of the major organizations compiling and estimating statistics. The Swiss Reinsurance Company Ltd, generally known as Swiss Re (having 3 business units – Reinsurance + Corporate Solutions + Admin Re), is a reinsurance company, operating in more than 25 countries, dealing with property and casualty and life and health (Reinsurance unit), standard risk transfer (Corporate Solution unit), and risk and capital management solutions (Admin Re). Based on their nature of work, they have their classification of disasters, and man-made disaster is one of the significant classifications they have made. They have labeled the following events as man-made disasters; capsize, fire, maritime disasters, terrorism attacks, social unrest, mining accidents, aviation disasters, and rail disaster. Although natural and man-made disasters are entirely different in its nature of origin, mechanism, cause, time of onset, etc., the impacts of both natural and manmade disasters are mostly the same. Both result in life loss, economic loss, loss of livelihood, structural damage, population displacement, and other kinds of indirect losses. Both natural and man-made disasters are on the rise since the last couple of decades (see Fig. 1). Not only the numbers of disaster are increasing, but their severities are also on the rise, resulting in the widespread social, economic, and life loss (Guha-Sapir and Panhuis 2004).

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Natural Disaster and Global Health During disasters, either health facilities are damaged directly or they remain inaccessible because of the road’s blockage and bridge damages, besides the lack of water supply and power failure that also make health facilities inaccessible and nonfunctional (Abbas and Routray 2014). In 2005, about 11,000 of health facilities of China were affected by floods and earthquakes (WHO 2009). The estimated damage of floods in 2010 in Pakistan was US$ 49.67 million or PKR 4222 million (World Bank 2010). Although the majority of the secondary and tertiary healthcare institutions remain unaffected, the infrastructure of public health suffered mild to moderate damage, the most damages borne by basic units of Pakistan health system that are Dispensaries and Basic Health Units (BHU). A total of 515 (5.3% of total) out of 9271 health facilities across the country were destroyed or partially damaged. The damage to health facilities was more in Khyber-Pukhtunkhwah, one of the worst affected provinces, where more than 11% of the total health facilities of the floodaffected districts (Swat, Charsadda, Nowshera, Shangla, and Kohistan) were damaged or destroyed; the same is the case of Sindh province, followed by 8% of health facilities in Federally Administered Tribal Areas (FATA). As disaster happened without any regular pattern time-wise, and the rate of occurrence of both natural and man-made disasters are increasing, it is difficult for the medical and public health system to respond effectively as the capabilities and resources are limited. Disasters often occur in a specific locality. Therefore, its impact on local resources and preparedness is immediate; that’s why response, recovery, and preparedness must be multidimensional. First, preparedness requires horizontal integration between public health, healthcare, emergency management, agricultural, and private sector assets to support the response setup at each level. Second, it needs a vertical integration of federal, state, local, and other government resources. While state and federal resources are not instantly available to local responders, therefore equipping the local responders can significantly enhance their capabilities of the response to an event of any nature. Preparedness and response are principally government roles; therefore, federal, state, and locally elected administrators must work in partnership to better understand the possible risks of disasters and to best safeguard society from them. During the 2005 earthquake in Pakistan and AJK, emergency workers encountered numbers of problems, including confusion over the authority responsible for coordinating the response effort; inability to link the vulnerabilities and risks before, during, and after the disaster; difficulties in getting rescue worker to the disaster site while moving victims away from it; and difficulty in distributing essential resources among those who need it the most. To overcome these problems in the future, steps are to be taken to improve the level of preparedness locally and at the state by providing funding and guidelines for all district and tehsil level. Then we can hope that this will improve the response capabilities for natural and other disasters while overcoming decades of negligence in the public health arrangement with respect to containing infectious disease outbreaks.

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One of the ignored areas in the response and recovery phase of disaster management is the disease surveillance. Disease surveillance in an area affected by disasters is very important to comprehend the impact of disasters on communicable disease, illness, and deaths. Obtaining significant surveillance information in these situations, however, is often challenging. The destruction of the established public health infrastructure can exaggerate or eliminate what may have been weak pre-disaster systems of surveillance and response. Surveillance personnel and other public health workers may be killed or missing, as in 2005 earthquake. Also, population displacement can misrepresent census information, which makes the deviousness of rates for comparison more difficult. Healthcare during the response and recovery phase is often delivered by a wide range of national and international actors, which creates coordination challenges. And the lack of pre-disaster baseline surveillance information can lead to difficulties in accurately differentiating epidemic from background endemic disease transmission. Although post-disaster surveillance systems are designed to rapidly detect cases of epidemic-prone diseases, interpreting this information can be hampered by the absence of standard surveillance data and accurate denominator values. Detecting cases of diseases that occur endemically may be interpreted as a new epidemic. The priority in these settings, however, is the rapid application of control measures when cases of epidemic-prone diseases are identified. Despite these challenges, persistent findings of and response to communicable diseases are crucial to monitor the incidence of diseases, to document their effects, to respond with control measures when needed, and to enhanced quantify the risk for outbreaks after disasters. The long-term health burden of disasters includes loss of medical care, interruptions in the control of communicable disease and other public health programs, and loss of laboratory support and diagnostic capabilities of hospitals. It has been perceived that health infrastructures can be repaired during the early recovery phase, but it has been observed in past experiences that the rehabilitation and reconstruction of critical healthcare infrastructure taking more time than that of other sector reconstruction and rehabilitation such as roads, bridges, telecommunication, housing, etc. Although all sectors of life need to recover quickly, as every system has their own weightage in the community, the health sector should be given priority as it has both immediate and long-term impacts; and the impacts in most cases are devastating (De Ville de Goyet et al. 2006). Malnutrition and communicable diseases are the major factors of high mortality and morbidity rates in the vulnerable displaced population (Watson et al. 2007). In camps, malnutrition along with overcrowding, poor sanitation, inaccessibility to safe drinking water, vector breeding sites synergistically leading to high incidence rates of diarrhea, respiratory infection, malaria, and measles (Checchi et al. 2007). Damage to water and sewage systems can also have a significant impact on health. In severe flooding, the sudden interruption of these services coincides with the direct effect on the transmission of water-borne or vector-borne diseases. In the case of earthquakes, the number of people adversely affected by water shortage may far exceed those injured or

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suffering direct material loss. As in the case of healthcare facilities, the rehabilitation of public water systems is usually slow (Checchi et al. 2007).

Disaster-Induced Mortality Is a Global Health Phenomenon Disaster-induced mortality is not confined to a specific part of the world. In the last couple of years, almost every country of the world experienced deaths as a result of disasters in the different time interval. It is worth to mention that deaths are not limited to only developing and low-income countries like Sri Lanka, Bangladesh, Nigeria, Sudan, Haiti, etc., but developed and higher-income countries such as the USA, Japan, etc. also experienced huge toll of disaster-induced mortality in the year 2001–2015. For example, the earthquake-induced tsunami of 2004 in the Indian Ocean struck more than 10 countries resulted in an estimated 2.5 million deaths; all the deaths occurred in developing and lower-income countries in the global south like Sri Lanka, Bangladesh, Indonesia, India, the Maldives, etc. On the other hand, the Haiti earthquake in 2008 resulted in an estimated 2.5 million deaths in developing and low-income countries in the opposite part of the world in Latin America. Such disaster-induced deaths are not confined to the developing countries only, but developed countries like the USA, UK, Japan, etc. also experience the huge toll of deaths in the past as a result of the disasters. It is evident from the events happened in recent history such as the Tohoku earthquake of 2011 in Japan which resulted in an estimated 18,000 deaths, while the 2005 hurricane Katrina in the USA leads to deaths of more than 1800. Though disaster-induced mortality and morbidities is a global health issue and needs to be studied at the global level. However, unfortunately, the study of disasters in general and more specifically by public health perspective is dominated by the developed world. A bibliometric analysis of the published studies consisted of more than 100 years (1900–2017) undertaken by Sweileh (2019) on disaster-related health literature concluded that their are huge variations in the existing literature in terms of country of origin of the authors, the languages of the published materials, and study area reported in the published papers. Health-related literature on disaster is mostly available in English (86.6%), followed by the Chinese (only 3.4%); while all other major languages (German, French, Arabic, Russian, etc.) made up the rest of the 10% literature. Similarly, there is a huge difference in the author’s country affiliation, as reported in health-related literature in the context of disaster. The same bibliometric analysis concluded that the most active countries which are contributing to disaster-related health literature include the USA, which contributed an estimated 34.5% of existing disasters and health-related literature, followed by Japan (7.7%), China (7%), and Australia (4.3%). It is evident from the analysis by Sweileh (2019) that four countries alone produced more than 50% of the disaster and health-related literature. As disasters are not bound to specific areas and have vast global health impact as evident from the recent coronavirus outbreak, it is crucial for the global health community to study disasters using global health lens.

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Disaster-Induced Mortality and Morbidity Pattern Disasters are a global phenomenon, and the events of disasters in the recent past have been reported from all over the world. Though the research community started tracking disasters to measure the effectiveness of strategies and interventions implemented from time to time for disaster risk reduction, however the scientific community have not yet established any such benchmark, neither have established any pattern which can indicate whether the disaster-induced impacts are decreasing or increasing. This may be due to the fact as well that disasters are occurring without any regular pattern. Some disasters are low probability events but have high impacts such as earthquakes or bushfires, while other types of disasters are high probability but have low impacts such as floods. This may be the reason that the scientific community doesn’t come to a solid conclusion about the pattern of disaster-induced public health impacts. Though there is lacking current literature for the basis in which the patterns in health-related impacts (e.g., number of deaths, number of injuries, prevalence/ incidence of communicable diseases or other health services such as immunization, antenatal, or postnatal care) of disasters can be concluded, it is well-established by researchers across the world that certain people of a society are more vulnerable and bear the greatest burden of public health impacts of disasters. Neumayer and Plumper (2007) reported in their study that in a disaster more women than men suffered in terms of deaths, injuries, and other difficulties. Similar findings were reported by the Institute for Women’s Policy Research (2010) in their published factsheet that during the Kobe earthquakes 1.5 times more women reportedly died as compared to men and similarly, the number of female deaths were three times higher than male deaths in the Indian Ocean tsunami of 2004. There may be multiple reasons for such variations, but certain factors contribute a lot. Women, children, and elderly people often tend to be weak physically, and they are often excluded from training and awareness session which are usually held in vulnerable communities. This is the case in most of the developing world. That’s why globally, the health impacts of disasters are mostly skewed toward such a vulnerable population.

Data Availability in the Context of Natural Disaster and Global Health This chapter reviews how natural disasters impact global health. But the study finds it difficult to find reliable datasets in terms of natural disasters. It is hard to study indepth the linkage of natural disaster and its impact on global health indicators. At present, the only database is that of EM-DAT that maintained the disaster-related epidemiological data, but that too is very limited with many limitations. For example, the EM-DAT maintained only the number of deaths, number of injured, and number of displaced people, and that’s all. The data for deaths and injuries is without basic demographic attributes such as gender, age, etc. Therefore, it is of limited use to draw any conclusion. It is of paramount importance for the greater benefit at the global level that disaster management practitioners and global health practitioners as well scientific

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community from both domains to come together and develop a system so that disaster-induced global health impacts can be tracked. Data from previous events help in understanding the pattern of impacts, and it will also help in measuring the effectiveness of strategies and intervention for tackling the global health issues. The importance of disaster-induced mortality rate comparison across the regions and across the countries is of paramount importance. If a reliable and updated data is available, it will facilitate policymakers and international bodies to prioritize their intervention for highly vulnerable and highly at-risk countries. There is no doubt about this that certain countries are continuously at high risk to a certain type of disasters because of their socio-demographic attributes, but still, it is very important to set priorities on an annual basis, so that the most fragile countries and region can be assisted on a priority basis.

Conclusion Though the Sustainable Development Goal has a specific target and indicators for disaster-related mortality until now, there are no baseline figures available to track the progress of interventions and strategies designed for minimizing the disasterinduced mortality and morbidity both at regional and global level. This chapter concluded that there are several lacks in existing literature and resources which make it difficult to establish a solid foundation for tracking the natural disaster impacts on global health. This study will help in initiating a debate among disaster management community as well global health community to formulate a mechanism, which can help in understating the immediate impact of the disaster on global health and identify the global health security threat well on time.

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Guha-Sapir D, Panhuis WG (2004) Conflict-related mortality: an analysis of 37 datasets. Disasters 28(4):418–428 Guha-Sapir D, Hoyois P, Below R (2013) Annual disaster statistical review 2012: the numbers and trends. CRED, Brussels IPCC (2012) Managing the risks of extreme events and disasters to advance climate change adaptation. A special report of working groups I and II of the intergovernmental panel on climate change (ed: Field CB, Barros V, Stocker TF, Qin D, Dokken DJ, Ebi KL, Mastrandrea MD, Mach KJ, Plattner G-K, Allen SK, Tignor M, Midgley PM). Cambridge University Press, Cambridge, UK/New York, p 582 IWPR Institute for Women’s Policy Research (2010) Women, disasters, and hurricane Katrina. Factsheet #D492. IWPR, Washington, DC Keller AZ, Al-Madhari AF (1996) Risk management and disasters. Disaster Prev Manag 5 (5):19–22 Neumayer E, Plümper T (2007) The gendered nature of natural disasters: the impact of catastrophic events on the gender gap in life expectancy, 1981–2002. Ann Assoc Am Geogr 97(3):551 Noji EK (1997) The nature of disaster: general characteristics and public health effects. Oxford University Press, Oxford, UK, pp 3–20 Sawada Y, Bhattacharyay R, Kotera T (2011) Aggregate impacts of natural and man-made disasters: a quantitative comparison. RIETI discussion paper series 11-E-023. RIETI, Tokyo Seneviratne SI, Nicholls N, Easterling D, Goodess CM, Kanae S, Kossin J, . . . Reichstein M (2012) Changes in climate extremes and their impacts on the natural physical environment. In: Managing the risks of extreme events and disasters to advance climate change adaptation. Cambridge University Press, Cambridge, pp 109–230 Shaluf IM (2007) Disaster types. Disaster Prev Manag 16(5):704–717 Spence R (2004) Risk and regulation: can improved government action reduce the impacts of natural disasters? Build Res Inform 32(5):391–402 Sweileh WM (2019) A bibliometric analysis of health-related literature on natural disasters from 1900 to 2017. Health Res Policy Syst 17(1):18. https://doi.org/10.1186/s12961-019-0418-1 Tschoegl, L., Below, R., & Guha-Sapir, D. (2006). An analytical review of selected data sets on natural disasters and impacts. Louvain: Centre for Research on the Epidemiology of Disasters. Swiss Re (2014) Sigma No 1/2014. Natural catastrophes and man-made disasters in 2013 Turner BA, Pidgeon NF (1997) Man-made disasters, vol 2. Butterworth-Heinemann, Oxford Turner BL, Kasperson RE, Matson PA, McCarthy JJ, Corell RW, Christensen L, . . . Polsky C (2003). A framework for vulnerability analysis in sustainability science. Proc Natl Acad Sci 100 (14):8074–8079 UNISDR (2004) Living with risk: a global review of disaster reduction initiatives, vol 1. United Nations Publications, New York Van Wassenhove LN (2006) Humanitarian aid logistics: supply chain management in high gear. J Oper Res Soc 57(5):475–489 Vinh Hung H, Shaw R, Kobayashi M (2007) Flood risk management for the RUA of Hanoi: the importance of community perception of catastrophic flood risk in disaster risk planning. Disaster Prev Manag 16(2):245–258 Watson JT, Gayer M, Connolly MA (2007) Epidemics after natural disasters. Emerg Infect Dis 13 (1):1–5 Wijkman A, Timberlake L (1984) Natural disasters, Acts of god or acts of man? Earthscan, Chicago Wisner B (2004). Assessment of capability and vulnerability. Mapping vulnerability: disasters, development and people. Earthscan, London, 183-193. WHO (2009). WHO | Save Lives: Make Hospitals Safe in Emergencies. [Online] Available at: [Accessed 23 October 2019]. Yohe G, Tol RS (2002) Indicators for social and economic coping capacity – moving toward a working definition of adaptive capacity. Glob Environ Chang 12(1):25–40

Whose Health Matters: Trust and Mistrust in Humanitarian Crisis and Global Health Interventions

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Andrea Steinke and Sonja Ho¨velmann

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Is Mistrust? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Is Mistrust in Humanitarian Intervention? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colonial Roots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Studies: Trust and Mistrust in Humanitarian Health Interventions . . . . . . . . . . . . . . . . . . . . . . Cholera in Post-Earthquake Haiti: Colonial Continuities, Denial, and Resistance . . . . . . . . Ebola in West Africa and the Democratic Republic of Congo: It Takes Two to Trust . . . Covid-19: Turning the Tables in Global Humanitarian Health Emergencies . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Trust and mistrust are often highlighted when explaining skepticism and resistance to humanitarian health interventions. Mistrust, as manifested through rumors, resistance, or violence against health workers, is often explained as a lack of knowledge and reason, which is countered through education campaigns or marginalization of traditional healing methods. By analyzing three case studies of global humanitarian health interventions – the cholera epidemic in postearthquake Haiti, the Ebola epidemic in West Africa and in the Democratic Republic of Congo, as well as the Covid-19 pandemic – we argue, however, that political-economic origins, postcolonial continuities, and neocolonial practices are strong determinants that coin the relationships in global health interventions. By looking at historical, political, economic, and social aspects, we seek to explain that mistrust can also be interpreted as an experienced-based rational A. Steinke (*) · S. Hövelmann Centre for Humanitarian Action, Berlin, Germany e-mail: [email protected]; [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_101

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reaction shaped by previous atrocities. Normatively framing mistrust in humanitarian encounters as inhibiting the success of interventions avoids addressing more relevant issues able to explain multilevel and multidimensional mistrust as rooted in power asymmetries. Keywords

Trust · Humanitarian action · Global health emergencies · Cholera · Ebola · Covid-19

Introduction Humanitarian health interventions are supposed to help people in need. Yet, they are often met with skepticism, reluctance, and sometimes open resistance. In this article we argue that trust and mistrust are important variables in explaining various forms of opposition to global health interventions. In an interconnected, globalized world, where people and diseases travel easily between countries and continents, it is important to understand the drivers of resistance against global health interventions. The viruses Ebola and Covid-19, for example, have seen an increasing cross-border, cross-continental spread that require international cooperation and, if national health system capacities are overstretched, also international assistance. Trust has been defined as an important explanatory variable directly impacting on political stability and economic success. A crisis in trust is proclaimed cyclically, in public institutions, in political parties, democratic systems, and also aid institutions (Mühlfried 2019). Western medicine, for example, is often met with skepticism and mistrust in many postcolonial societies. While for some this indicates a lack of education and reason, others interpret it as a “result of the instrumentalization of medicine during colonialism” (Mühlfried 2019, p. 7). By selectively providing health care – favoring certain groups or individuals over others – colonialists illustrated and manifested their power. Especially in contexts of foreign intervention or neocolonial practices, the attribution of trust and mistrust are rich in history and inscribed in deeply rooted power asymmetries (ibid.). Yet, mistrust is mostly contextualized as a deficiency of the other, which has to be tackled through educational campaigns and other means of trust building. Thus, strengthening trust in health systems, especially in global health contexts, is often described in the literature as something that will be engendered through the replacement of local understandings of disease and healing via outreach and information campaigns (Chandler et al. 2015; Dhillon and Kelly 2015; Nuriddin et al. 2018). While transparent communication on transmission and protection is central to fighting an infectious disease, it is certainly not an exhaustive measure. Our analysis aims to prompt a consideration that factors in political-economic determinants, postcolonial continuities, and neocolonial practices to understand the high levels

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of mistrust in global health interventions (Frankfurter et al. 2018, p. 536). Issues of trust in health systems are not limited to North–South relationships only but also tangible in doctor–patient relationships, people-and-public institutions in the Global North, as the current Covid-19 pandemic shows. What is more, erosion of trust in systems trickles down on relationships between individuals. To illustrate our point, we look at three case studies – the cholera epidemic in post-earthquake Haiti, the Ebola outbreak in West Africa 2014–2015 and in the Democratic Republic of Congo 2018, as well as some spotlight observations on the Covid-19 pandemic – where we examine the role of trust and mistrust. From a humanitarian and global public health point of view, the lack of trust is paramount when discerning failure in health interventions. Research has identified people’s belief in misinformation and low trust in institutions as reasons for the rapid and uncontained transmission of Ebola virus disease (EVD) (Chandler et al. 2015; Blair et al. 2017; Vinck et al. 2019). Communication and social mobilization were promoted as key means to help contain the transmission of Ebola to counter the negative effects of traditional practices, misinformation, and witchcraft. Mistrust in the health campaigns was portrayed as a result of misinformation, corruption, or irrationality leading to an oversimplified causal explanation chain that a lack of trust was the reason for noncompliance and noncompliance with hygiene measures lead to contraction of EVD (Richardson 2019). A similar dynamic unfolded when cholera was detected in Haiti in 2010. The Vibrio cholerae bacteria was introduced to the Haitian immune system by United Nations (UN) peacekeepers. What first swept through the country as a rumor was soon corroborated by epidemiological analysis. In terms of transparency and accountability, the UN handled the situation exceptionally unsatisfying. The righteous anger and mistrust among big parts of the Haitian population lead to skepticism, resistance, even rejection of preventive and therapeutic measures against cholera, and the overall presence of foreign organizations. Additionally, the current Covid-19 pandemic provides an interesting opportunity to study trust and mistrust in global health interventions not just in the Global South but also in the Global North, in autocratic and democratic countries, in “low-trust” and “high-trust” societies alike. Covid-19 is no longer just a public health emergency but has turned into a global complex crisis. Our analysis thus seeks to contribute to a broader understanding on the role of trust and mistrust by framing skepticism or resistance against humanitarian health interventions as a rational response rather than a lack of reason. We demonstrate that people may have well-founded reasons or stronger determinants that they chose to comply with than certain health interventions imposed by authorities or foreigners. Thereby, this article seeks to help address a critique voiced by researchers that a form of representation, which identifies lack of trust as a particular paradigm of causality why diseases spread, re-enforces and perpetuates ongoing structural inequities by omitting power relations, colonial history, and contemporary extractive political economies (Somparé and Somparé 2018; Richardson et al. 2019).

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Conceptual Background What Is Mistrust? Trust and the absence thereof have been subjected to a rich variety of scholarly scrutiny in the past. Most prominently, sociologist Anthony Giddens (1990) determines trust as a prerequisite for the functioning of modern societies in his seminal work Consequences of Modernity. For Niklas Luhmann (2014), the spiritus rector of system theory, trust is one of many strategies to reduce complexities in human interaction. In a similar vein, for Diego Gambetta trust is “a device for coping with the freedom of others” (Gambetta 2000). Based on game theory concepts, trust is “conceived of as a belief that the other side is likely to be trustworthy and will therefore want to reciprocate cooperation rather than exploit it” (Kydd 2000, p. 326). Andrea Schneiker (2020) examines two types of trust in professional relationships: one manifestation is based on a shared identity whereas the other is experienced based. Notwithstanding, a common identity does not necessarily mean more trust. A high level of familiarity is not automatically equivalent to more trust. Being familiar in and with structures means being entangled and engaged and that means being susceptible to partiality. At least in humanitarian context this is considered prejudicial. Mistrust then is marked by absence: the absence of reliability, control, faith, transparency, and confidence. Corruption and clientelism reinforce feelings of mistrust at least for those parts of society not profiting from those systems. There have been debates whether or not mistrust is the opposite of trust. Mühlfried (2018) argues that mistrust is not the negation of trust, but rather that the qualities co-constitute each other. Also, trust and mistrust are not absolute categories. Trust is relative and not exhaustive. The term as it is commonly used does not refer to a 100% margins of trust but to a subjective and relational dimension of human relatedness to societal systems and the individuals representing them. Notions of trust and mistrust are largely dependent on context. This does not only refer to different conceptions between the “West and the rest” (Hall 1992), the relationships between state and society are inherently different in Euro-American contexts, too. Let us look at the USA and Germany, for example: whereas Germany has established a relatively robust welfare system in the past centuries, the USA has put more emphasis on individual rights and freedoms. While the perceptions of a protective German Vater Staat and the US-American citizens defensive rights vis-àvis the state especially coined in the constitutional amendment rights cannot be directly juxtaposed, preliminarily looking at the responses of the respective populations to Covid-19 measures, these structures relate to the level and extent of mistrust in public authorities and have to be factored in. The anthropologist Florian Mühlfried (2019) proclaims a general culture of mistrust affecting contemporary societies. In his view, trust holds normative functions in society and societal relations: “The normative settings of trust – if not as a normality, then as an absolute necessity for the polity – turns mistrust into the main problem that must be made disappear” (Mühlfried 2019, p. 4). Accordingly, mistrust is framed as failure.

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What Is Mistrust in Humanitarian Intervention? Principle Questions Without a doubt, trust is crucial for the course of humanitarian intervention. Those on the receiving end of humanitarian assistance have to trust in the ones providing it, and in a way also vice versa. If one takes the humanitarian principles seriously the people served by humanitarian action have to trust in humanitarians to uphold the principles, to act neutral, independent, and impartial, overall guided by the shared humanity of everyone involved in the encounter. Essential for negotiations of humanitarian access and protection, parties in conflict have to trust in humanitarians not to side with or favor one conflict party, but to follow certain political agendas or base their actions on anything else than need alone. Those receiving assistance have to trust humanitarians to deliver quality programs and that food, health, and other goods provided are not substandard. Similar to doctors who take the Hippocratic oath, humanitarians commit to “do no harm,” while those affected can rarely hold them to account in case they do not. NGOs while not being profit oriented per se are dwelling in a world of capitalistic accumulation where they have to act as if they are profit oriented (Smillie and Minear 2004). The commodified nature of humanitarianism that marks contemporary interventions does not go unnoticed by the subjects of the intervention. The circulation of goods once set in motion sometimes overrides the primary intention of the intervention itself. In post-earthquake Haiti, for example, the import of transitional shelters (light-weight tent structures inadequate for longer-term housing) continued well into the recovery phase, five years after the disaster, providing an easy win and photo opportunity to INGOs and satisfying northern contractors that sold the shelter structures. Many Haitians publicly criticized this practice as evidently self-serving and driven by capitalist motivations more than by humanitarian ones. Similarly, “Ebola business,” referring to the profiting of a few from the allocated financial resources, was a main source of mistrust in West Africa and the DRC. What is more, NGOs take over governmental responsibilities, yet they are not legitimized democratically in a similar way as elected governments are. Communities and sometimes even local authorities have little to no agency and control over the presence and programs of aid organizations. Yet, transparency and agency are fundamental to notions of trust. Mistrust in NGOs as public institutions often is based in alleged and sometimes proven acts of corruption, fraud, and a general lack of accountability. Evidently, the effectiveness in public authorities is another crucial factor: “people’s trust in the police is related to the legitimacy of police actions and ultimately, to the effectiveness of the police” (Osland 2019, p. 194). Especially in Haiti where so many aid interventions have failed, part of the disapproval of international NGOs and UN actors is grounded in their perceived ineffectiveness. Multidirectional Mistrust Furthermore, mistrust as a signifier in humanitarian action is mutual and not unidirectional (Slim 2019). “What is if the mistrust is our own?,” the humanitarian DuBois (2019) rhetorically asks. Not only do the targets of the intervention often

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mistrust humanitarians, humanitarians also mistrust the recipients of assistance. The latter have to prove their suffering and misery, physically through humanitarian techniques or in the form of testimonies and accounts to be eligible for humanitarian services – not least because of the bureaucratic procedures and donor accountability, but also as a signifier of interpersonal trust. The mutual mistrust is tangible also in the relationships between expatriate and national staff of international organizations. Representatives of international organizations show high levels of mistrust vis-à-vis their national colleagues (Schuller 2016). In Mali, for example, MINUSMA expatriate employees “convey a level of mistrust in Malians working for the mission and how they interpret the country’s conflict dynamics” (Sandor 2020, p. 920). Beyond that, mistrust in the humanitarian sector is not limited to NGO – beneficiary relations but is to be found in a multitude of relationships: between NGOs and donors, between INGOs and national or local ones, between governments and NGOs, the military and NGOs, the UN and NGOs, and between NGOs (Schneiker 2020).

Embodied Mistrust Mistrust in global health context is often determined by the different ontological conceptions of the body encountered in different settings. Especially the discipline of medical anthropology has considered the varying limits, demarcations, and connections of people’s bodies to the outer world, related also to perceptions of purity (Farmer 1988). This is relevant as in the global health sector, mistrust is widespread, even more so when it comes to vaccinations and injections. Here, information campaigning should not only be directed at communities affected, but also at humanitarians involved. A study on the use of injection in Uganda in the context of the HIV/Aids epidemic, for example, has shown that a large part of the population was deeply mistrustful of governmental health care (Birungi 1998). Infectious disease, especially in the form of an unknown or novel life-threatening epidemic like Ebola or Covid-19, is very susceptible to emotions of uncertainty, fear, and neglect not least because of a lack of ad hoc expert knowledge on the origins and spread of those diseases. The course of health interventions is therefore susceptible to misinformation and misunderstandings. The enemy is literally invisible and the trust of the population in health authorities measures it vital to contain it. Normative Power When it comes to humanitarian action, the absence of trust is often framed in normative terms. Mistrust, especially coming from the recipients of aid assistance is framed as a failure. In this article, we argue that the standard framing of mistrust is not productive, because it is mostly analyzed taken out of its political and historical contexts. To really understand mistrust especially in humanitarian relationships it is paramount to factor in the historiocity of the relationship. Bruce-Raeburn notes that white exceptionalism is also inherent in the aid system because the idea that poor people are in need because of bad choices or because of their lifestyle overlooks

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racism, colonialism, and the legacy of slavery that put them in that position in the first place (The New Humanitarian 2020a). All that points to a general misreading of mistrust when the real question is about power and sovereignty. “A lack of public reflection on power can hamper a serious moral discussion with health professionals as important participants of various institutional forms of their relationship to others” (Grimen 2009, p. 17). Grimen (2009) points out to the fact that power as a concept is only rarely factored in when it comes to relationships in health-care provision. The evaluation of global health interventions, marked by profound inequalities in access, resources, and protection certainly is a case in point for including power into the equation. These asymmetric relationships of power are deeply rooted in the histories of colonialism and inscribed into the DNA of humanitarian intervention. As Agier (2010, p. 989) notes “humanitarian workers have taken over from colonial administrations [. . .] to represent the new form of white presence and domination.” The unequal relationships are the main reason why the humanitarian sector is highly susceptible to abuse of power may that be in the form of corruption, sexualized violence, harassment, or fraud or more subtle forms like the prioritization of technical expertise, and the devaluation of local capacities. Trust between people requires vulnerability to the possibility that trust can be broken (van Praag 2019). Yet, the unequal power dynamics in the humanitarian space result in one-sided vulnerabilities of affected people, who need to compensate uncertainty and anxiety by hoping that they will not be let down (ibid.). “Power asymmetries implicitly translate into levels of interpretational sovereignty: those who diagnose pathological mistrust are the (helping) experts; those being diagnosed are the (needy) patients” (Mühlfried 2019, p. 7).

Colonial Roots Mistrust/trust is experienced based, as Schneiker (2020) pointed out. This is key to deciphering the profound lack of trust of communities in the Global South towards international interventions. To understand the presence of global health interventions one has to look back into the colonial history and its present-day continuities. First of all, colonizers have intentionally infected people with pathogens to rob them of their territories and resources. Furthermore, colonies have served as laboratories not only for various kinds of economic and military interventions, but also for medical experiments. The colonized have been used for testing drugs and vaccines which were ultimately meant to protect the health of the colonizers (Gathara 2020). These practices are by far not a ghost from the distant past as exemplified by the testing and use of the contraceptive drug Depo-Provera. The USA had tested the contraception injection first on Haitian women, the descendants of the victims of most atrocious forms of colonial crimes (Maternowska 2006). Later on, the largest US Depro-Provera trial was explicitly targeting US women of color on welfare. To control the sexuality, fertility and last but not least reproductive capacities of poor women of color was the primary objective of the usage of that particular drug. Finally, in the 1990s, Depo-Provera was used to temporarily sterilize Haitian refugee

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women intercepted at international waters and illegally incarcerated in Camp Bulkeley, Guantanamo Bay Naval Base, often without their knowledge and consent (Hannabach 2015). The Tuskegee Syphilis Experiment, taken place in the USA between 1932 and 1972, is yet another case where the health of people of color was seriously hampered with. Similar examples are found in the South African apartheid era: “Since 2003, for example, polio has been on the rise in Nigeria, Chad and Burkina Faso because many people avoid vaccinations, believing that the vaccines are contaminated with HIVor are actually sterilization agents in disguise. This would sound incredible were it not that scientists working for Dr. Basson’s Project Coast reported that one of their chief goals was to find ways to selectively and secretly sterilize Africans (Washington 2007). These are not isolated singular cases but have to be embedded into a wider web of colonial and racist continuities. Recently, two French doctors have triggered public outrage about racism when they suggested on television to “test Corona virus vaccine in Africa” (BBC News 2020). “How are Africans expected to not react to yet another attempt to use them as guinea pigs to develop drugs that would serve the Global North, whose well-funded health systems can afford the hefty-priced lifesaving medication that Africans themselves often die without?,” the humanitarian and lawyer Karsten Noko asks (Noko 2020). It is not by chance that contemporary aid practices, especially in the form of development projects, came to life parallel to the decline of colonial states. Global health institutions in many places are perceived as a continuation of colonial administrations and logics. The divisive effects of colonial indirect rule are still tangible in postcolonial contexts in the form of a profound mistrust in educated elites (Somparé and Somparé 2018, pp. 138–139). In that sense, people’s skepticism of the motives of foreign interventions is not uninformed ignorance but might as well be an expression of a very rational, evidence-based assessment. It is not due to a lack of information but the opposite that people express mistrust in health interventions.

Methods Research for this article is based on a triangulation of methods, ranging from extended ethnographic research in Haiti during the cholera epidemic 2011 over literature review focusing on academic and policy output and expert interviews with health professionals on the Ebola response in West Africa to assessing recent observations on issues of trust connected to the Covid-19 response. While preparing for and writing this article a highly infectious Corona virus spread around the globe. On March 11, 2020, the World Health Organization (WHO) declared the Covid-19 outbreak a pandemic. Issues similar to those we were studying at the time became manifest in Germany and elsewhere. The sudden uncertainty and vulnerability that befell countries not accustomed to such a state of emergency created an opportunity to observe in real time the effects that complex public health crises can have on citizen–state relations and those affected by versus

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those responding to a health crisis. While the majority submitted to state-ordered distancing measures, other reactions ranged from skepticism about the severity of measures to conspiracy theories on the role of the Gates Foundation in the crisis to physical attacks on health-care workers. We were able to connect our research to recent observations and first analysis on a global public health crisis, connect the dots between issues of trust and health intervention on the one hand and issues of colonialization and statehood on the other hand.

Case Studies: Trust and Mistrust in Humanitarian Health Interventions Cholera in Post-Earthquake Haiti: Colonial Continuities, Denial, and Resistance In October 2010, Vibrio cholerae, the bacteria initiating cholera, was identified in Haiti for the first time in more than a century. After the massive earthquake hitting the Caribbean nation in January of the same year, the outbreak of cholera was the second major disaster affecting the Haitian population in 2010. The waterborne pathogen was introduced to Haiti by United Nations (UN) soldiers at a Nepalese battalion near Mirebalais in the center of the country. Failure in wastewater management infused infected faeces into the Artibonite River, one of the country’s water lifelines. It took the bacteria little less than 3 weeks to reach the camps of Port-auPrince, established after the earthquake to house the more than 2.3 million internally displaced people (IDP) (Walton and Ivers 2011). Hurricane Thomas, the third disaster of that year, provided ideal conditions for spreading the bacteria. The epidemic was a major setback in the post-earthquake recovery efforts. Overcrowded encampments with next to no sanitary structure provided fertile grounds for the disease to spread. Medial anthropologist Paul Farmer (2012) has called cholera the worst nightmare of a doctor working in a camp. Cholera is an intestinal infection that provokes acute diarrhoea. The body loses fluids and electrolytes so quickly that they often cannot be replaced without essential medical infusions (Farmer 2012). It can degrade a healthy adult in mere hours, even faster with the more vulnerable: children, the elderly, pregnant women, and those with a weakened immune system due to tuberculosis and HIV/Aids (Farmer 2012). While cholera is generally treatable, in rural Haiti, with its lack of medical infrastructure, this acted as a death sentence in many cases. A lack of knowledge about cholera as well as traditional burial rites amplified the expansion of the bacteria in rural regions. Despite all evidence – including independent epidemiologist research as well as research commissioned by the UN itself that proved the Haitian cholera strain to be a perfect match with one found in Nepal 2009 (Piarroux et al. 2011) – the UN up until today has not taken full responsibility. In 2013, several institutions and individuals filed a lawsuit against the UN for neither testing nor treating its Nepalese soldiers for cholera, nor taking care of correct water waste management during mission. The

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Southern District of New York dismissed the case in 2014, claiming the UN cannot be sued due to its immunity. Then, in 2016, 6 years after the introduction of cholera and 5 years after the study, UN Secretary-General Ban Ki Moon acknowledged that the UN “simply did not do enough with regard to the Cholera outbreak and its spread” (United Nations 2016). This was too little – as he did not take the responsibility for introducing the disease in the first place, allegedly to impede indemnity claims, and too late – as the harm was done and trust in the UN as the representative of the international system in Haiti was lost. The last case of cholera was reported in January 2019. Until then the disease had killed 9792 people and affected over 820,000 people more (PAHO 2020), the UN having left “Haitian lives destroyed by the very people sent to protect them” (Katz 2013, p. 225). Just like the earthquake, the epidemic hit Haiti unprepared. There were no sufficient mechanisms and structures in place to react to a disease unknown to the current Haitian population, its structural and physical immune system. Internationals alike were unable to respond quickly for a variety of reasons, a few of them are touched upon below.

Lack of Trust There is a sociopolitical dimension to infectious disease in general and to cholera in particular. Cholera has its “own preferential option for the poor” (Farmer 2012). The chances to get infected, having access to treatment, and eventually recovering from the severe intestinal infection are largely dependent on the patient’s socioeconomic status. In Haiti, it mainly affected people in the countryside, those without access to clean drinking water, sanitation, and hygiene equipment. Due to the lack of infrastructure, health-care provision, roads and transportation, many could not get to the next treatment facility in time (Koski-Karell et al. 2016). Drivers of moto-taxis, the primary means of transport, often refused to transport sick people because they were afraid of getting infected themselves. The mistrust of Haitians was not only directed towards foreigners, it also went against other Haitians. Especially in the early months after the outbreak representatives of Vodou have been attacked because people conceived them of having poisoned communities with poud kolera, cholera powder (Daudier 2010). NGO fundraising mechanism started swiftly after the outbreak. Lack of money was not the problem for setting up mobile clinics, treatment centres, and community programs. The problem was elsewhere: people did not trust foreign NGOs. CNN quoted Stefano Zannini, former head of mission at Médecins Sans Frontières (MSF) in Haiti, saying “there are a lot of misconceptions and rumours flying around, which has caused panic in the population,” Zannini said. “Some people are staying away from the Cholera treatment centres or are afraid to have them in their neighbourhoods because they think they help spread the disease. We’ve been trying to explain that the opposite is true: The closer a centre is to a population, the better” (Watson 2010). As a result of community resistance, MSF had to discontinue one newly installed 400-bed treatment center. The fact that it was situated in the vicinity of two schools fueled protests by parents fearing for the lives of their children (Frerichs 2017). Especially in light of the way in which the disease entered the

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country these concerns cannot be easily dismissed. Focus group discussions on community beliefs on cholera brought questions and skepticism about the establishment of cholera treatment centers (CTC) to the forefront. People asked about disinfection, water waste management, and the handling of dead bodies at the centers (Grimaud and Legagneur 2011). In another case, aid workers “were prevented physically from approaching children, or to make a list of beneficiaries of the nutrition programme, because some people whose name had been registered on a list, had died of Cholera” (Grimaud and Legagneur 2011, p. 31). Other rumors that the UN was the source of the epidemic started to spread quickly after the first cases were identified. Protests took place all over Haiti, especially in the North of country. Violent confrontations led to several protesters being fatally shot, at least one by UN soldiers, as well as half a dozen injured peacekeepers.

Spreading the Message: The Role of Rumors in the Cholera Response In Haitian society, like in many others, gossip and rumors are a widespread phenomenon and often serve as an unofficial communication channel and a means of sensemaking. After the 2010 earthquake, for example, a disaster unfathomable in its effects that killed roughly 300,000 people, theories surfaced that the tectonic shifts leading to the quake were caused by a subterranean bomb fired either by the USA or by Venezuela that accidently went off half way. Another theory determined the earthquake as resulting from illegal gold mining activities of the USA in Haiti. Considering the geopolitical turf war over the Caribbean as well as the debates surrounding the extraction of mineral resources in Haiti show that certain parts of rumors are always rooted in reality. More recent examples of rumors spreading after the cholera outbreak refer to the UN’s involvement. One reading accused a UN helicopter of ejecting black powder, poud kolera, into the Artibonite River, a sorcerer’s poison causing death or zombification (Katz 2013). Other rumors circled around UN soldiers contaminating the river, too. “The first thing said was, ‘They put something in the river’. . . No one knew who the ‘they’ were. MINUSTAH was mentioned later on,” a community representative was cited (Guillaume et al. 2019). Rumors about foreigners in Haiti are nothing new. Prior to the cholera epidemic, many stories circulated about the UN. One common misnomer often heard on the streets of Port-au-Prince was vole kabrit, goat thieves, blaming UN soldiers to have stolen and sodomized goats. Throughout the 13 years presence of the United Nations Stabilization Mission in Haiti (MINUSTAH), making fun of UN soldiers by referring to them as goat thieves and making “goat sounds” was common practice. In this case rumors serve social functions and can also be interpreted as a “weapon of the weak” (Scott 1985). Amidst accusations of the UN’s partiality, human rights violations, sexualized violence, or sheer ineffectiveness of the UN mission, ridiculing a 10,000 soldiers strong foreign armed force can be interpreted as an act of resistance. Rumors not only relate to postcolonial configurations of power, they are also accelerated by the absence of transparency in communication. The rumors that the UN had actually “put something” into the river became more and more plausible when investigative teams found the water waste management to be faulty at the

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Nepalese base, with broken pipes and sewage water being dumped in close vicinity of the river. While MINUSTAH press officials were quick to denounce the accusations of the disease originating from one of their bases, their official communication was not flawless. Associated Press correspondent Katz described asking the UN spokesperson how many soldiers were tested after a CNN story claimed Nepalese soldiers had been tested for cholera, the spokesman was quoted saying “CNN hadn’t gotten it quite right. It wasn’t that the soldiers tested negative. It’s that none of them tested positive. Because they have never been tested” (Katz 2013, p. 233). When Katz pointed out a puddle of brown liquid resembling faeces next to the UN base at the Artibonite River, the UN spokesman said: “It doesn’t mean it is from the base. The people here they swim in the river. They bath in it. You know how they are” (Katz 2013, p. 234). Ironically, especially the last sentence is a point in case for identity-based trust as pointed out by Schneiker (2020). The UN spokesperson assumes a shared identity with the journalist, both being white expatriates vis-à-vis the Haitian population and therefore entrusts him, the journalist, with a derogatory comment about his perceptions of Haitians and “how they are.” Without a doubt, next to having seriously jeopardized trust in international institutions, the UN’s initial neglect to trace the source of the bacteria has also slowed down the response. “That sounds like politics to me, not science. Knowing where the point source is – or source, or sources – would seem to be a good enterprise in terms of public health,” medical anthropologist and former UN special envoy Paul Farmer cited in October 2010 (Katz 2013, p. 237). The report commissioned by the UN, even though it found the Vibrio cholerae strain in Haiti to be a perfect match with the one from the current outbreak in Nepal, closed with “The source of Cholera in Haiti is no longer relevant in controlling the outbreak.” Yet, exactly that was fundamental for regaining public trust.

Mistrust Inflicted by Postcolonial Wounds The well-known proverb mikwob pa touye ayisien – microbes do not kill Haitians – forms the basis to a generalized mistrust in the existence of the Vibrio cholerae bacteria in general. After having survived most brutal forms of colonial enslavement, a revolutionary war, dictatorship and foreign occupation, plus having the majority of the population currently living in unsanitary conditions, people thought of themselves as resilient and immune and did not believe they could be killed by microbes. Ergo, the reason why so many people were dying must have been poison for which health education and cholera treatment centers are not a cure. Similarly, focus group meetings conducted between November and December 2010 unearthed a range of theories on the background of the disease. Interviewees felt that because they had already gone through so much suffering, the earthquake being the latest event in a long line of hardships, cholera could not have a natural origin. Furthermore, respondents suspected the blan, the foreigners, to be involved in the spread of the bacteria “to divide us” or “to exterminate us and take our land.” Others thought it was brought by NGOs “in order to get more money” (Grimaud and Legagneur 2011, p. 27). The mistrust in NGOs goes even to the point that people have suggested that as hygiene campaigns have been organized before the

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introduction of the pathogen, NGOs must have known the disease would come (Grimaud and Legagneur 2011). Decades of foreign interference have made Haitians very distrustful of the motives of foreign organizations and individuals in Haiti. The wounds inflicted by colonial oppression run deep in Haiti and heavily influence inner-Haitian relationships as well as those to other nations. “People want a future outside of those colonial relationships,” NGO worker and anti-mining activists Nixon Boumba recently explained (Maurer and Pollmeier 2020, p. 1). During a focus group discussion with cholera victims in July 2016, the majority of participants voiced concerns about the way the epidemic was handled and the lack of accountability from those responsible for the situation. In essence, the critique is one of unequal relationships of power: “If that would have happened to Americans, people would have to go to prison for it. But Haitians don’t have the same worth like other nations” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016), one man said. While there are reparation claims that are backed up by a series of human rights organizations and even a group of UN experts, including Philip Alston, special rapporteur on extreme poverty and human rights who stated: “Compensation is ordinarily a central component of the right to an effective remedy, and development projects are simply not a replacement for reparations” (OHCHR 2020), there is more to it than just financial reparation. “For me, it is not about money and compensation in the first place, it is about an honest apology and being treated with dignity” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016), one victim claimed. In his statement in December 2016, UN Secretary-General Ban Ki Moon took partial moral responsibility for “not having done enough” (UN 2016), yet, the UN never took legal responsibility. His successor Antonio Guterres “has systematically avoided addressing that crucial issue in any way” since taking office, Alston said (Charles 2020). Shortly after the outbreak of the epidemic, media reports portrayed protesters as playing the blame game and looking for scapegoats for what was basically their own fault because of poor sanitary conditions and cultural beliefs (Mallon Andrews 2015). In hindsight, looking at the mishandling of the outbreak including intransparent communication on their own wrongdoings, the outrage was a well founded, evidence based, and logical response. “We know they didn’t bring the disease here on purpose,” one cholera victim said, “but that does not mean that they shouldn’t take responsibility for it” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016). The UN’s handling of the epidemic aggravated the already delicate relationship between Haitians and international organizations: “I do not trust MINUSTAH anymore. I won’t be taking any of the medicine they will give to us” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016). This was also connected to a sentiment of not being given the right kind of treatment: “they don’t give us effective medicine” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016), referring to the fact that antibiotics were given only to people in severe condition (the rest was treated with fluids and electrolytes intravenously) and secondly to the scarce use of vaccination in the first years of the epidemic. The criticism of the cholera response then developed into a reckoning of the overall merits of international intervention in Haiti: “All of their efforts are not

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effective, all of what they do doesn’t really help us. Those things do not come to an end” (Interview with cholera victim on the role of the UN, Haiti, Saut d’Eau, July 2016), one cholera victim explained. Haiti, being the “patient zero of development” (Gez and Steinke 2019) after 70+ years of development, humanitarian and peacekeeping intervention still checks most of the boxes in terms of per capita income, food insecurity, child mortality, etc. The criticism raised showed that it is not only about not being effective, it is also about doing more harm than good. Many view the cholera interventions by the UN as somewhat cynical: rat mode w soufle – the rat that bit, now tends to the wound – a commonly used proverb described the situation. The cholera epidemic is but one example of the sector not living up to its own standards, especially its guiding principle to “do no harm.” When in 2018 the so-called Oxfam scandal about expatriate NGO employees’ involvement in several acts of sexual abuse and exploitation was made public, the allegations were no surprise to anyone who had spent a decent amount of time in post-earthquake Haiti. The events described align with earlier wrongdoings by foreigners in Haiti, like the misappropriation of post-earthquake funds, the more than hundredfold cases of sexual abuse and violence against children committed by UN peacekeepers in the 2000s, or the high numbers of civilian causalities in antigang operations (Müller and Steinke 2020). Rumors and especially those confirmed to be true had a negative impact on other international organizations capabilities to provide assistance in the fight against cholera. Thus, many NGOs reacted by sending out community health workers for information campaigning and awareness raising. The Haitian Red Cross, for example, tried to be as respectful as possible to people’s beliefs. “Dismissing people’s ‘subjective truth’, beliefs and perceptions on the grounds that they are based on ‘rumours’, ‘ignorance’, or ‘lack of education’ could, in the current Haitian context, actually lead to more distrust and resistance and can also generate strong, even violent, reactions.” (Grimaud and Legagneur 2011, p. 31). In short, the resistance to cholera treatment centers and the protests against the presence of UN peacekeepers are all manifestations of a profound lack of trust of Haitian communities in the international system itself. Short-term fixes in policy and adaptions in NGO programming can only be fig leaves if those measures are not connected to a more profound engagement with the sectors colonial forbearers and past failures. Wounds do have to be acknowledged for what they are for them to heal and make room for a more honest engagement of the people involved. Only then can meaningful trust be established. Until then the majority of acts of resistance and mistrust can only be framed as an appropriate, experience-based, and rational reaction towards earlier atrocities.

Ebola in West Africa and the Democratic Republic of Congo: It Takes Two to Trust Ebola virus disease (EVD) is a lethal, infectious haemorrhagic fever that occurs in outbreaks across equatorial Africa. The Ebola outbreak in West Africa 2014–2015 is

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considered the largest outbreak to date and triggered a humanitarian health intervention of global scale. The epidemic encompassed about 28,000 documented cases and resulted in 11,000 deaths in Guinea, Liberia, and Sierra Leone (Blair et al. 2017). The national health systems of the affected countries were unprepared to deal with the quickly escalating outbreak of a novel disease. The international response was similarly unprepared and with hindsight critiqued for being too slow and too uncoordinated. Three years later, in 2018, the Democratic Republic of Congo (DRC) faced a large-scale Ebola outbreak in the Eastern part of the country. It is to date the second deadliest Ebola outbreak with about 3400 cases and 2240 deaths as of July 2020 (HPN 2020). In contrast to West Africa, Ebola is not a novel disease in DRC and the 2018 outbreak is considered the 10th since the 1970s. In both contexts – during the West Africa and DRC outbreak – public health measure to prevent the spreading and transmission of the disease were met with skepticism, noncompliance, or open resistance. While contributing factors to high transmission rates include active or postconflict contexts, mass migration, and high density of population, social resistance against containment measures and health responses was also cited as a reason (Masumbuko Claude et al. 2019). Lack of trust if “Ebola was real” quickly became a dominant explanation of resistance against health regulations during the West Africa Ebola outbreak and was perpetuated by many newspapers, research, and humanitarian actors. It framed the spiking transmission rates of the EVD because of people’s belief in witchcraft, sorcery, the low levels of literacy, and their belief in misinformation and conspiracy theories framed as an overall “backwardness” or “uneducatedness.” The same narrative of mistrust was also quickly picked up for the Congolese context when there was similar resistance or violence against health workers. Since 2018 11 Ebola workers have been killed in more than 400 attacks in DRC (Freudenthal 2020). The solution to tackle mistrust was to organize extensive community engagement wherever there was reported resistance against the health interventions. This was done by sending in a team of trained social anthropologists or community workers as skilled interlocutors who could translate the technocratic approach into local languages and build bridges between local customs, practices and rites, and the full force of the international health intervention. A crucial element was the introduction of safe and dignified burials that take account of traditional burial ceremonies while not placing mourners at risk of contracting the virus by placing the deceased in plastic body bags with a transparent “window” (Bledau 2019). The narrative about adaptation to local context and extensive community engagement was framed as a success by humanitarians in the West Africa Ebola outbreak, and subsequently, the outbreak in DRC was approached, by incorporating “lessons learnt” from the former intervention. However, we suggest a more complex reading, namely that people were not necessarily uncooperative because they are “backward” or “uneducated” as a frequent representation by media and others suggested but we stress the necessity to contextualize resistance or noncompliance also with a range of other determinants such as social, economic, political, and historical reasons. Arguably, neocolonial

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practices and historical, economic, and political determinants in a postcolonial context significantly shape factors of trust and mistrust. Public communication strategies to establish the narrative that “Ebola is real” aimed to show that Ebola is caused by a virus, not caused by a curse or witchcraft and that medicine and science are the only cure and not traditional practices (Chandler et al. 2015). But as Chandler et al. (2015) conclude such messages follow an epidemiological framing and pay little attention to historical, political, or economic contexts in which they are delivered. Thus, they reinforce external perceptions that local beliefs and practices are barriers to be overcome through persuasion or counterbalanced with incentives. This sidelining of traditional practices is also demonstrated by the fact that traditional healers and staff of private clinics, who provide a considerable proportion of health services and are at high risk of contracting the virus or spreading it to others, were not included into the list of eligibility criteria of receiving the vaccine in DRC (HPN 2020, pp. 5–6). In fact, to perpetuate the narrative of “backwardness” as a reason for harboring mistrust denies people rationality and neglects the fact that their experience of longstanding misrule, political tumult, and indirect rule – a governance system developed by Frederick Lugard, where colonialists governed colonies by relying on local rulers to execute their affairs – may in fact provide a reasonable explanation for mistrust in global humanitarian health interventions. Rationality of mistrust is framed as a irrationality, denying mistrust as a valid critique of the colonial legacies and obscure how power dynamics factor into contemporary public health emergencies (Frankfurter et al. 2018; Somparé and Somparé 2018; Masumbuko Claude et al. 2019; Richardson et al. 2019; Richardson 2019).

Political and Historical Dimensions Social resistance to EVD control can also be explained by looking at political and historical determinants. Mistrust in public authorities and formal power structures result from civil war, a volatile security situation and overall complex political configurations in the respective countries. Several studies point to the fact that in the affected regions, community mistrust is rooted in decades of conflict and government neglect (Frankfurter et al. 2018; Somparé and Somparé 2018; Bledau 2019). These have resulted in the destruction of social fabric and allow for an instrumentalization of political communication. In Sierra Leone and Guinea, rumors spread that EVD was introduced as to establish a political blame game that can be instrumentalized by the opposition. As interviewees reported in a context of strong bipolarization of political life reflecting ethnic divisions, these rumors fed into old ethnic prejudices and stereotypes from the 14-year civil war era. (Telephone interview with health worker in Sierra Leone, June 2020.) Another rumor frequently spread proposed that the whole epidemic was a conspiracy by the government to secure funding from the West and that ergo the Ebola outbreak was not real (Bledau 2019, p. 68). Politicization of the response has also been evident in DRC. Due to the outbreak, presidential elections were delayed in 2018 in the Eastern provinces Kivu and Ituri. Suspension of voting in the Ebola-affected areas and ongoing violence contributed to an increased popular skepticism and rumors that Ebola was a political

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tool denying people their right to vote (HPN 2020, p. 12), emphasizing a perception of lawlessness and impunity in the Eastern provinces. A low level of trust in public institutions can also be attributed to mismanagement during colonial and postcolonial governance or long periods of state weakness, absence, or predation. For example, Wilkinson and Fairhead (2017) showed that citizens who distrusted their government were less compliant with EVD protection measures but were not more or less likely to hold false beliefs about EVD transmission. This shows that citizens refused to comply not because they did not understand the measures but because they did not trust the capacity or integrity of government institutions. In fact, several studies underline that a legacy of neglect of public health priorities by the state and international agencies was mentioned as a reason of mistrust, ultimately leading to noncompliance or resistance (Frankfurter et al. 2018; Masumbuko Claude et al. 2019). Similarly, lower trust in public health measures and medicine today can also be traced to earlier medical experiments. Lowes and Montero (2020) examine the effects of historical colonial medical campaigns on present-day trust in medicine, vaccination rates of children, and the success of World Bank health projects. Their findings demonstrate that negative historical experiences with the health sector can affect health-seeking behavior in subsequent generations and that these campaigns were not isolated incidents but relevant in many sub-Saharan African countries where millions of individuals were forcibly treated for sleeping sickness. Medical tests and treatments for sleeping sickness included an effective compound of arsenic, which left 20% of patients blind (Lowes and Montero 2020). Perhaps these historical determinants explain why MSF staff had to temporarily close an isolation ward to infected patients because rumors accused the international medical staff of having brought the virus to Guinea (WHO 2014). Arguably, mistrust in medical experiments on treatments or vaccines, which were also carried out during the West Africa Ebola outbreak, can be interpreted a rationale response. For example, patients were hesitant to go to the Ebola treatment centers (ETC) because survival rates were low and the ETCs were “inhospitable and frightening” (HPN 2020, p. 7). However, because few survived and the dead were wrapped in plastic body bags without means of identification, people suspected that the bodies of the deceased were used for medical experiments or that their organs were trafficked (Somparé and Somparé 2018, p. 138). Thus, sick patients avoided the ETCs unless the disease was already very advanced, while chances of survival are higher when the disease is detected and treated early. In fact, the WHO decided to deviate from its standard practice to allow for “monitored emergency use” of experimental interventions including medicines given the high fatality of EVD. Similarly, MSF engaged in clinical trials. Researchers tracing their engagement with experimental interventions quote that “not only was [MSF] willing to assume greater risks from unproven treatments than in previous research, but actually felt an obligation to maximize access to these treatment” (Rid and Antierens 2017, p. 134). Similarly, during the outbreak in DRC a vaccine was still in an experimental stage and an unregistered product. Over 300,000 people got vaccinated during the time span of the tenth EVD outbreak,

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mainly contacts of EVD cases, contacts of contacts, and frontline workers active in the response (ECHO 2020).

Economic Dimension and “Ebola Business” A large factor for mistrust in the Ebola interventions was profit. What has been coined as “Ebola business” describes the manifold practices of how individuals, elites, or foreign agencies have been suspected to profit from the epidemic for personal gain. In all countries rumors spread that Ebola had been deliberately propagated as a ploy to pocket money. Audits and operational reviews in DRC revealed systemic corruption including payments to security forces, kickbacks, and renting vehicles at inflated prices (Kleinfeld 2020). This unearths amidst a massive aid diversion scandal in DRC estimated to be around six million US dollars, which heavily undermined trust in international actors (Kleinfeld 2020; The New Humanitarian 2020b). “Ebola business” has not only undermined a trustful relationship between population and international actors but also impacted on trust among community members and national health workers. Ebola workers were frequently seen as opportunists because their engagement coincided with a huge improvement of their economic situation (Somparé and Somparé 2018). In DRC referred to as “strangers in our midst,” national response teams were assumed to be “well paid, displayed visible wealth, took minimal risks and rarely quit” (Masumbuko Claude et al. 2019, p. 13). Millions of dollars were paid by the WHO as per diem to security forces, triggering resistance against health workers and the “Ebola business” they depended on (Freudenthal 2020). Likewise, during the West Africa outbreak, “all sorts of interest groups mushroomed overnight to collect cash from the Health Ministry” (Masumbuko Claude et al. 2019), placing health workers under general suspicion of opportunism unless proven otherwise. The profiting of few came at a time when the economic pressure due to the epidemic was high. What is often coined as a “shadow epidemic” refers to the unintended consequences of containment measures such as lockdowns, curfews, and closures of factories or schools. Hikes in food prices, loss of informal jobs, and disruption of trade due to closed borders impacted negatively on food security and livelihoods of people (Huber et al. 2018). Research by Frankfurter et al. (2018) demonstrated a relationship between the Ebola outbreak in Sierra Leone and the political economy of diamond mining. It demonstrates how indirect rule by foreign entities in collaboration with local chiefs have great resonance with the original colonial-era practice aiming to politically pacify the rural population and maintain power. In making paramount chiefs central coordinating figures of the health response in Sierra Leone, they had access to enormous financial resources, which were distributed through patronage systems. In 2015 an audit demonstrated that one-third of Ebola relief funds were unaccounted for (Frankfurter et al. 2018, p. 535). The overall public opinion is that significant amounts of resources were diverted by inventing or exaggerating Ebola risks and funneling them through political patronage systems, with foreign entities indirectly profiting. “When a political system that for 120 years has enabled the subjugation of

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rural Sierra Leoneans as well as the extraction of critical financial resources is tasked with orchestrating a complex and at times draconian outbreak response, it is no wonder that patients may prefer to remain in the care of the families and loved ones rather than call for an ambulance directed by the paramount chief” (Frankfurter et al. 2018, p. 536). The political economy surrounding the Ebola response has fueled mistrust of its motives. Resources were diverted for heavily securitized interventions, rather than strengthening overall health-care systems.

International Humanitarian Health Intervention and Neocolonial Legacies Rid and Antierens (2017) suggest that only after a volunteer returning from Liberia to the USA fell sick and was diagnosed with EVD, did the US started to deploy medical and military personnel as well as providing financial resources to support the health systems of affected countries. When cases were spiking in West Africa in August 2014, the WHO declared the outbreak “a public health emergency of international concern” (DuBois and Wake 2015). While the infection rate was already spiralling out of control in May 2014, it took until mid-September for the international community to become active, which some have coined as “criminally late” (DuBois and Wake 2015, p. v). Furthermore, the designation “of international concern” was not only framed as a humanitarian or global health crises but also a threat to international security and stability (DuBois and Wake 2015). Several countries sent troops, for example, the USA deployed troops to Liberia; UK to Sierra Leone because of former colonial relations but also China, Germany, France, and Canada sent military personnel (Benton 2017, p. 30). However, international assistance was “mainly [busy] to protect themselves; in a zero risk, zero casualties approach” (Benton 2017, p. 33). The securitization of the response begs the question whose security matters and security from what is of actual concern? A comparison of the Ebola outbreak with the scale of other diseases reveals that while EVD’s rapid spread and high mortality rate caught international attention, other diseases are arguably more deadly in terms of total numbers of fatal cases. For instance, in DRC 6000 people died of measles in 2019 (WHO 2020a). “Cumulatively in the past four decades, Ebola has claimed less than 3000 lives. By contrast, the death toll in sub-Saharan Africa was 547,322 from diarrhoeal diseases and 222,767 from pneumococcal pneumonia in 2010 alone; many of these deaths could have been prevented through access to basic health care, including cheap vaccines and improved sanitation” (Rid and Emanuel 2014, p. 1896). While massive international aid operations swallowed up resources, more people were dying from other diseases which are receiving almost no funding (Arie 2019). For the population living in those countries it is hard to justify interventions against a single disease while at the same time more people die from measles, meningitis, polio, or diarrhoea. For example, interviewees reported that a severe outbreak of cholera in Sierra Leone in 2012 attracted hardly any international attention or financial support. (Telephone interview with health worker in Sierra

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Leone, June 2020.) But when travelers were infected with EVD and thus the risk of EVD spreading into Western nations increased, a response was quickly initiated. While originally framed as a tropical or African disease, WHO and states of the Global North became active when non-Africans started to be infected and it was taking a toll on the economy. Mistrust in international aid workers, their interventions, and prioritization could also be read as a critique of whose priorities and whose security matter most. It can be interpreted as questioning the sincerity of the response because health interventions were not only perceived to be based on need alone, as the humanitarian principle of impartiality would stipulate. Especially in the DRC locals “have a lifetime of experience watching outsiders – from the capital, the UN, international aid groups – arrive with cash and promises that they can’t keep” (Brown 2020). The same notion is also visible in what Adia Benton has coined the “politics of flight and rescue” (Benton 2017, p. 27). Who gets flown out of the affected areas was based on citizenship evacuation procedures meaning that previous development programming sponsored and implemented by foreign NGOs ceased their operations at the peak of the disease exacerbating unemployment and creating food shortages. Overall, containment measures were very militarized with punitive measures against indignant individuals violating burial or lockdown regulations (DuBois and Wake 2015). The securitized approaches to communities in distress resembled colonial approaches and sponsored acts of resistance rather than an acknowledgment of their fears (Benton 2017). Heavy protection through biohazard suits and armed protection of health workers did not foster trust but rather inspired further acts of defensiveness. By employing “field teams” who explained measures in the local language sat down to talk to communities and tried to break this circle by establishing trust. The lack of communication and adaptation of information into local languages has been stressed by several researchers as a source of animosity. The use of language and concepts that people do not fully understand bred fear and suspicion. People were afraid that Ebola was a weapon to kill them or that misunderstandings would result in a misdiagnosis because information were often provided in official languages which in most cases are colonial languages. According to Somparé and Somparé (2018, p. 139), the use of colonial languages triggered notions of elitism, paternalism, and coloniality and awoke “latent mistrust towards educated people that has been present in many African countries since colonization.” “Ebola people” were suspected of using their cultural capital to take advantage of the situation and impose measures on illiterate people that only they could understand (ibid). However, in a scenario where patient and medical personnel do not understand each other, imagining a trustful relationship is very difficult. Examples and experiences taken from the two largest humanitarian health interventions to fight Ebola demonstrate that resistance against them are arguably a rational response or valid critique of power dynamics in public health emergencies. The continuous Ebola epidemic in Eastern DRC is taking place amid conflict and political unrest. Populations have lost patience with both external actors who have been present in the region for decades while life conditions have not much improved

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as well as their governments who are incapable of containing conflict in the region and regularly accused of corruption questioning their overall effectiveness of interventions. A way of furthering trust is by bolstering general health-care systems. Many communities questioned the sincerity of the response teams that assured that they are there for their health but only helped them with Ebola but not with other diseases such as malaria, measles, or pneumonia, which they were more likely to suffer from. While the Ebola humanitarian care apparatus is receding and funding declining, public health systems are as weak as before, leaving people wondering where all that Ebola money went.

Covid-19: Turning the Tables in Global Humanitarian Health Emergencies The global spread of Covid-19, a Corona virus disease, has generated a medical and public health response unprecedented in scale. Covid-19 is an infectious disease triggering a mild-to-moderate upper respiratory tract illness. From the first detection in Wuhan, China, the virus quickly spread within the country and beyond its borders. Frequent air travel in a globalized world resulted in a rapid transmission around the globe since February/March 2020. WHO declared the spread of Covid-19 as a pandemic on 11 March 2020. While Europe, especially France, Spain, and Italy developed into the hotspot of the disease in March, currently the majority of registered infections are located in the USA, India, and Brazil. As of 11 September 2020, 28,202,363 people have been infected, 910,140 died with the virus. To slow down transmission rates and reduce the burden on national health systems, shelter-in-place and social distancing measures have been recommended, imposed, and enacted all over the world. Travel restrictions, closure of borders, and lockdowns of entire countries have severely impacted on public and private life as well as on national economies. However, compliance with public health measures and containment policies must have large support by the population to be efficient. While still in the middle of a constantly evolving crisis, we offer preliminary reflections on the disease and its relationship to mistrust both from previous epidemics such as cholera and Ebola and from their own perceptions of exposure to the Covid-19 pandemic as it continues to unfold. We will highlight some recent observations.

Multidirectional and Multilevel Trust Trust in governments is an important determinant of citizens’ compliance with public health policies, especially in times of crisis. Looking at emergent practice of grappling the pandemic it seems that those countries who harbor a strong public trust in governance and public institutions are better equipped to deal with the Covid-19 pandemic than other countries. In most countries, special legal and judicial powers for an apparent humanitarian cause have been enacted to prevent the spread of the disease. The use of state powers over the lives and bodies of its citizens brings

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up questions of ethics and human rights. If citizens mistrust authorities to act in their best interest, these measures can ignite noncompliance or resistance. For example, in Germany, anti-vaccine activists organized several “anti-corona” demonstration to express their fear that their right to bodily integrity would be violated by mandatory vaccinations and the mandatory wearing of facemasks in certain contexts. Trust – or the lack of trust – in fellow citizens, their health care or welfare systems, or their governments has been determined as a crucial factor of how people respond to the pandemic. Early survey data shows that German citizens trust in their neighbors, institutions, and authorities (Schulze et al. 2020). Of the survey respondents, 79% indicated their trust in the German health system and 91% stated that they trust in doctors and medical personnel (Schulze et al. 2020, p. 58). German virologist Hans-Georg Kräusslich determines that strong public trust in government and authorities is a reason why Germany’s fatality rate in Covid-19 cases is relatively low: “Maybe our biggest strength in Germany is the rational decision-making at the highest level of government combined with the trust the government enjoys in the population” (Bennhold 2020). Germany’s Chancellor Angela Merkel, a trained physicist, has communicated “clearly, calmly and regularly throughout the crisis, as she imposed ever-stricter social distancing measures on the country. The restrictions, which have been crucial to slowing the spread of the pandemic, met with little political opposition and are broadly followed” (Bennhold 2020). While the trust in public health authorities is stronger in contexts with reliable health-care systems (Birungi 1998), Germany and its citizens are notorious for their obedience of and trust in authorities and Vater Staat in general as portrayed earlier. Yet, in a pandemic of global scale not just domestic but international and multilateral trust play an important role (Ng 2020). International cooperation requires trust between countries but also in international organizations. When the pandemic was unfolding within the European Union (EU), many countries prioritized domestic affairs over international or multilateral approaches. Survey findings indicated that only half (52%) of the respondents trusted their fellow citizens living in Europe to cope with the situation (Schulze et al. 2020, p. 58). On 31 January 2020, WHO declared Covid-19 a “public health emergency of international concern” (WHO 2020b), this being the sixth emergency given that declaration since the founding of the WHO. (The previous five are a 2009 H1N1 flu pandemic, an Ebola outbreak in West Africa in 2014, a polio outbreak in 2014, the Zika virus in 2016 and the ongoing Ebola outbreak in the Democratic Republic of Congo.) Despite the fact that the first case in Europe was identified 6 days (25 January 2020) earlier in France, WHO’s warning went unheeded in many countries outside of Asia and preventive measures were not put in place to slow down or stop the spread across borders. As most Western countries were rather unscathed from the previous five emergency declarations, they defied the threat. Public authorities clearly could not imagine the pandemic to affect their systems in a way similar to what was happening in China. Arguably, a lack of trust in the WHO might be a reason why the warning was not taken seriously, too.

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Rumors and Conspiracy Theories As with cholera and Ebola, rumors and conspiracy theories around the Covid-19 pandemic are impacting on effective responses. Misinformation ranges from a plot developed by Bill Gates jointly with the WHO to vaccinate and implant digital microchips to control the world’s population to blaming 5G networks for the global spread of the virus (Lynas 2020). Similarly, there is a whole range of rumors on how to protect against contracting or curing the disease. These include, for instance, drinking cow urine or eating garlic (ibid.). Social media and sensationalist reporting of the outbreak have generated panic and mistrust in the general public. Because these are so imminent, WHO has dedicated an entire webpage to falsifying rumors and conspiracy theories regarding Covid-19 (WHO 2020c) and is working with social media providers to help filter out such misinformation (Smith et al. 2020). While these examples seem easy enough to detect as misinformation, trust in official communication and scientific evidence is vital for compliance health measures. The use of the anti-malaria drug hydroxychloroquine as a prophylactic against Covid-19 is not substantiated by clinical studies, but has been recommended by state governments and public health authorities such as Brazil’s President Jair Bolsonaro, US President Donald Trump, or India’s health ministry, while the US Food and Drug Administration (FDA) has revoked emergency use of the prophylactic because emergent research shows it could do more harm than good (The Guardian 2020). Trump even suggested that ingesting household bleach might help counter the virus. The misinformation was vehemently countered by experts, however, the harm was done and people died from consumption of chloroquine (Krause et al. 2020). Especially in the early weeks it was difficult to know what to believe with the media coverage of Covid-19 because the pandemic was rapidly unfolding with few scientific evidence-based information to rely on, leaving a lot of room for speculation. Even though research and evidence have started to emerge, it is increasingly difficult to differentiate between fake and factual news, between targeted misinformation and politically instrumentalized knowledge. The “misinfodemic” (Krause et al. 2020) increasingly spreads along bipartisan political geographies complicating trust in the communicator. The politicization of health issues thus contributes to a progressive erosion of trust in health institutions, media reporting, and government authorities furthering the spread of fears, rumors, and speculations. Prioritization and What About-Ism? Prioritizing Ebola responses over other diseases such as the endemic measles outbreak has been identified as a source of mistrust for the Congolese context. Similarly, in the beginning of the Covid-19 pandemic, people compared the lethality to seasonal influenza, claiming that the latter has killed more people in the past and that hence containment measures were excessive. European health systems overwhelmed by the pandemic in fact often did prioritize Covid-19 response over other crucial medical treatment, like chemotherapy, for example. This form of unidirectional response was problematized early on in the pandemic.

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The current pandemic does not only juxtapose different health emergencies, focussing on disrupted consumer economy and summer holiday plans, but also revealed how much this pandemic is a crisis of the neoliberal paradigm. By pitting economy against health, ethically difficult and controversial decisions had to be made. The recent mass outbreak of the virus in the German meat-packing industry among migrant workers forced to work and live under horrendously inhumane and unsanitary conditions is but one example for this flawed dynamic. It also emphasizes that the narrative of Germany doing so well to protect people is only partially true. The pandemic reflects the profound inequalities in German society and shows that certain lives are less protected than others.

Politicization and Geopolitics The Covid-19 pandemic is unfolding against a backdrop of growing nationalism, populism, and anti-multilateralism (Krisch 2020). How much international institutions and multilateral trust are under stress is demonstrated by the recent example of the USA withdrawal from WHO. President Trump announced his decision to stop funding and end cooperation with the WHO because he accused the agency of becoming “a puppet for China during pandemic” (Cohen 2020). Also, within the EU, there was little trust in a multilateral response to the crisis. Instead, each country invoked a “x first” mentality. For example, Italy asked Germany repeatedly for support when their health-care system was stretched beyond capacity. Their request proved futile as it was China not Germany ultimately providing much needed personal protective equipment (PPE). As Mohamedou (2020) argues: “Italy [was] similarly finding itself at the receiving end of coded ‘cultural weak link’ criticism, incriminating the country’s poor response and underperforming healthcare system.” Ebola and Corona virus are both zoonoses, meaning that the pathogen originated in wild animals and was supposedly transmitted via consumption of their meat to humans. In Western depictions, Ebola was framed as a tropical or African disease and the consumption of so-called bush meat, as an origin of the disease, demonstrated the supposed “backwardness” of rural populations. By referring to their sanitary conditions and cultural traditions the countries’ responsibility of causing the crisis were thus invoked. With Covid-19 the same trope was amplified: A widespread sense that the threat of the virus originated abroad – a threat coming from afar – and that the West had to deal with something created by others (Mohamedou 2020) fueled anti-internationalism and mistrust in foreigners. In the beginning of the spread of Covid-19 people suspected to be Asian were met with heightened levels of racist aggression. Similarly, China’s international assistance in form of medical equipment such as PPE was discredited as trying to divert attention away from the fact that it had “caused the crisis.” Can the boy from rural Guinea that is considered “patient zero” be blamed for causing the Ebola crisis in West Africa? Naming and blaming of the sources of the disease as a political tool rather than as an epidemiological strategy to help answer the call seems a recurring factor in health emergencies.

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Western Exceptionalism in Question and Colonial Wounds Reinfected During the Ebola outbreak, cholera outbreak, and many other humanitarian health emergencies, usually countries of the Global North provided expertise, resources, or funding. Covid-19 has somewhat questioned this traditional distribution of roles in the beginning of the pandemic. Due to frequent travel, Northern European states were earlier and heavier affected by the pandemic than for instance African states. These reversed roles of Europeans asking for advice from African experts in tackling public health emergencies and managing a triage of multiple crises simultaneously including crucial knowledge in setting up emergency and decontamination systems sparked jokes and gloating. While most of Europe was still in denial over the severity of the disease and its spread, many countries in Africa had already set up emergency procedures at airports, hospitals, and public institutions. Western media seemed bewildered that African countries have not been impacted more severely and Western humanitarian INGOs braced for the worst while seizing opportunities for funding to mitigate the potentially devastating effects that Covid-19 could have on refugee camps, densely urbanized spaces, and already strained health systems toppled with the triage of multiple health emergencies. Yet, successes of countries such as Ghana and Senegal to implement containment measures early were ignored, while Sweden’s risky public health approach – counting on the reasonable behavior of its citizens rather than imposing strict measures – was commented as “exceptional and gutsy” (Mohamedou 2020). The juxtaposition of Europe and Africa in terms of Covid-19 response has also triggered jokes and dark humor (Tadesse Shiferaw and Mucchi 2020). Especially, the general contain-and-control attitude towards African mobility to Europe is momentarily reversed with regards to changes in who poses a threat to whom. Many airports were closed for European travelers, who usually travel with ease and “visa-upon arrival.” Anecdotes emerged of Italians being sent back because they refused to stay in quarantine in Tunisia and others overstaying their visas in Ethiopia (Tadesse Shiferaw and Mucchi 2020). While dark humor, scapegoating, and gloating around Covid-19 being a “disease of the white and rich” (Büchel 2020) are often accurate portrayals of the infection routes, they also point to postcolonial continuities. To many former colonialized states foreigners bringing infectious disease is reminiscent of a historical trauma; a colonial wound reinfected (Irons 2020; Böhm 2020). Accordingly, rumors, for example, in the DRC proposed that Covid-19 is yet another ploy to further a global humanitarian appeal to raise money which will not reach the people in need or introduced as a strategy of neocolonialization where Western or Chinese companies acquire land or resources (Büchel 2020). Also, strict containment measures triggered painful collective memories. For example, in imposing the strict lockdown for Covid-19, the Indian government invoked the very same Epidemic Diseases Act of 1897, originally passed by the British government during plague outbreaks. This was a unique act, designed specifically to control an epidemic outbreak, giving special powers to the state, which is partly why it has appeared relevant for Covid-19 (Chakrabarti 2020).

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Gathara (2020) criticized that the Kenyan President Kenyatta simply copied advice from WHO on Covid-19 measures and thus repeated the dictates from global elites taking a Western lifestyle as a template for life rather than consulting with citizens how do ensure containment measures in densely urbanized spaces where social distancing, self-quarantine, and other hygienic measures are next to impossible. He argues that the tendency to issue directives rather than consult with citizens has been inherited by the current government from colonial authorities, mimicking containments measures of a twentieth-century plague epidemic. As with plague and influenza pandemics it is the privileged few bringing in the disease and being equipped with better means to survive, while the poor take the toll. In sum, Covid-19 exposes fault lines and inequalities around the world. As the West falls into crisis blinded by historical sentiments of Western supremacy and exceptionalism and profoundly unable to learn from others, Covid-19 could also provide a moment of reflection. Grounded planes and evacuated Western aid workers shed a new light on localization in humanitarian health emergencies. By addressing structural inequalities and acknowledging racism, colonialism, and neocolonial continuities, there is a momentum to rebuild trust through truthful communication and honesty of motifs. A way to rebuild trust of the population is strengthening public health institutions and fostering equal access to quality health care.

Conclusion Examples from the Ebola epidemic in West Africa, the cholera epidemic in Haiti and the spotlights from the current Covid-19 pandemic have shown that rumors and resistance to global health interventions are manifestations of profound mistrust. Mistrust also correlates with weakened state institutions of health care (Birungi 1998), which most certainly holds true for Haiti and the Democratic Republic of Congo. Trust building measures in the form of community engagement and to some extent also the codification of humanitarian principles and standardization of humanitarian action are aiming at (re)building ties within the humanitarian community and in relationship to its stakeholders to ultimately render humanitarian assistance more efficient. Regulations have been implemented that are necessary but did not sufficiently create meaning and accountability to function as a pillar of trust in relation to the people served by the intervention. Trust in humanitarian assistance is important. It is vital for relationships between people and institutions. But perfunctory trust building measures alone will not be the panacea reforming an institutionalized system built on unequal relationships of power. Colonial continuities and contemporary atrocities will not be seldomly overcome by new sets of standardization and compliance systems as continuously promoted in think pieces and policy briefs. To really turn the corner, the humanitarian community has to look deep into the mirror of its history, the continuities deriving from it and not shy away from what is staring

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back. Power is the key to deciphering the question of mistrust that many humanitarians face, especially in global health contexts. In case of noncompliance, humanitarian health workers should not blame the citizens by assuming that they do not understand health-related messages, but rather acknowledge that they may have stronger determinants that they chose to comply with. Trust in humanitarian health interventions means that affected people have to trust humanitarian health workers to act in their best interest. This relationship is not unburdened but tainted by complex historical, political, and economic determinants. Trust building measures are no one-way street. Humanitarians need to listen and reflect, be themselves part of educational campaigns to overcome barriers to global health. Further, it has been shown that mistrust in global health encounters is not the result of an individual flaw, neither of the humanitarian nor the one s/he assists. Mistrust may not be the main issue after all. Normatively framing mistrust in humanitarian encounters as inhibiting the success of intervention overrides and avoids putting more relevant and pressing issues related to power imbalances at the forefront: protection, accountability, and last but not least, structural racism and racist discrimination. The colonial wound is an open wound and it quite literally gets reinfected via contemporary outbreaks of cholera and Ebola or novel diseases such as Covid-19 and subsequent international measures. The demand for financial reparations brought forward by Haitian cholera victims and supported even by representatives of the UN system themselves is but one example for a possible way to tend to that wound. Otherwise, global health assistance in Haiti and DRC, like the one currently underway to counter the Covid-19 pandemic, risk being rejected by the population. Addressing these underlying structural conditions as “the original objects of mistrust” (Mühlfried 2019, p. 7) will help improve the sectors response to global health crisis and interventions.

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Antimicrobial Resistance and Global Health Emergence, Drivers, and Perspectives

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Zulqarnain Baloch, Bilal Aslam, Nafeesa Yasmeen, Amjad Ali, Zewen Liu, Abdual Rahaman, and Zhongren Ma

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Economic Burden of Antibiotic Resistance: Global Economic Database for Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotic Primacy and Discovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Patterns of Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Rationale for Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Drivers and Triggers of Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Super-Resistance Associated with Superbugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathogenicity, Virulence, and Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Molecular Understandings of Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Strategies Addressing Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Measure Plan and Awareness to Control Imperiling Threat of Antimicrobial Resistance: Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Z. Baloch (*) · A. Ali · Z. Liu · Z. Ma Biomedical Research Center, Northwest Minzu University, Lanzhou, China e-mail: [email protected] B. Aslam Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan N. Yasmeen College of Veterinary Medicine, South China Agricultural University, Guangzhou, China A. Rahaman School of Food Science and Engineering, South China University and Technology, Guangzhou, China © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_103

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Abstract

Antimicrobial resistance (AMR) is a plausible rationale of the dynamic “resistome” and a global health threat caused by increased global migration, increased reliance of antibiotics in animal production and clinical settings, overpopulation, international travel, poor sanitation, poor sewerage and waste disposal systems, wildlife spread through manure or feces, and selection pressure. The antibiotic-resistant microbes are imperiling the worth of antibiotics, which have previously transformed medical practice. Comprehensive efforts are required to curtail AMR by exploring emergent-resistant microbes and resistance mechanisms and developing new antimicrobial drugs. Multidisciplinary tactics are needed among medical, environment, and agriculture departments. Alternate strategies such as lytic phage therapy, use of probiotics, and use of de novo synthetic antimicrobial peptides and biological therapeutics should be employed to combat AMR. Increased AMR spread can be sufficiently contained through adequate and effective bio-surveillance and education systems, infective control measures, global awareness and action plans, and cautious use of antimicrobials. Global norms of conduct implementing possible options of action might eradicate AMR as soon as possible. Keywords

Antimicrobial resistance · Antibiotics · Resistance mechanisms · Biological therapeutics

Introduction Antimicrobial resistance (AMR) is a pressing and relevant global health issue caused by increasing global migration, increased reliance of antibiotics in animal production and clinical settings, overpopulation, international travel, poor sanitation, poor sewerage and waste disposal systems as well as wildlife spread through manure or feces and selection pressure. Antibiotic therapy is a leading approach in modern medicine to counteract emerging pathogens of the resulting “resistome” (Singer et al. 2016). The “golden era” of antibiotics promotes the formulation and development of many novel antimicrobials. However, this era shortly ended due to sustained failure of new antibiotic formulations and insensible use of antimicrobials which results in the rapid emergence of resistance, prevailing a serious threat around the globe. Recent global utilization of antimicrobials in the livestock industry has revealed trouble spots across the different continents. Moreover, antibiotics are usually used in food animals like chicken, cattle, and pigs and are estimated to increase up to 67% by the year 2030 (Van Boeckel et al. 2015). Although the antibiotic discovery was a revolutionary moment in the record of mankind and saved billions of lives, these “miracle bullets” have been escorted by newly emerging pathogenic-resistant strains. Recent bacterial genome analysis

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revealed about 20,000 potential resistant genes, emphasizing a real concern to get back to pre-antibiotic age (Davies and Davies 2010). The modern era (1950–1960), for the first time, revealed the resistance pattern to various antimicrobial agents especially among enteric pathogens, namely, E. coli, Shigella, and Salmonella. These resistant pathogens caused immense clinical and economic losses, particularly in the developing states, not in the developed world, where it was assumed to be a minor health problem. However, this concept was changed in the 1970s, when H. influenzae and N. gonorrhoeae showed resistance toward ampicillin, tetracycline, and chloramphenicol. Incidence rates became higher in the developing states where these drugs were easily accessible without doctor’s prescription as well as unhygienic conditions promoted resistance transmission (Rossolini et al. 2014). Regulatory bodies like the World Health Organization (WHO), Infectious Disease Society of America, Center for Disease Control and Prevention (CDC), and the World Economic Forum have addressed the antibiotic resistance paradigm as a “global public health problem” (Spellberg et al. 2016). This problem has also been addressed in a book titled The Evolving Threat of AMR – Options for Action. AMR showed no evidence of decline across the globe. Many efforts have been made to depict various aspects of resistance, and potential measures necessary to deal with this global challenge have been made. However, there is a lack of political coordinated campaign (Prestinaci et al. 2015). Perhaps, modern medicine could not be succeeded without efficient antimicrobial treatment options and adequate measure plans (Laxminarayan et al. 2013).

Economic Burden of Antibiotic Resistance: Global Economic Database for Antibiotic Resistance Accurate estimation of the socioeconomic impact of antimicrobial-resistant infections is still a global concern. In this regard, quantification of the dissemination patterns linked with antibiotic resistance is a fundamental prerequisite. AMR is a considerable financial global burden. In the USA, multidrug-resistant hospitalacquired infections account for 99,000 deaths annually. In 2006, approximately 50,000 people died from sepsis and pneumonia (two common HAIs) in the USA, with a cost estimate of $8 billion (Infectious Diseases Society of America 2011). It has been reported that patients treated with resistant bacterial infection cost up to $29,000, with a total economic loss of about $20 billion annually (Ventola 2015). According to a US global organization, the world could face the worst scenario with no potential antimicrobial therapeutics to treat resistant infections. In this case, total cost burden would be $120 trillion, equivalent to the total US healthcare budget (Gould and Bal 2013). According to an estimate, nearly 444 million people would die due to multidrug resistance. Moreover, the use of antimicrobials in the food and livestock industry made a significant contribution to AMR (Founou et al. 2016). Recent evaluations on resistance-associated costs have restricted scope, and thus, future prospective studies must be employed in an effort to estimate the actual economic burden.

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Antibiotic Primacy and Discovery Microbial control infection has been well documented in different areas (from China to Greece) of the world. The discovery of penicillin in 1928 opened up a new era for modern medicine. In World War II, this “magical bullet” was assumed as a choice of drug to control and to treat bacterial infections among arm forces. Thus, this discovery saved millions of lives and also transformed the history of medicine (Sengupta et al. 2013). Unluckily, resistance also developed against these “magical bullets” and became an important clinical concern. So, in the 1950s, no further advancements in the history of medicine have been made. This problem was then addressed by many scientists; soon after they discovered β-lactam drugs. But in the USA and UK, methicillin-resistant S. aureus (MRSA) was reported in 1968 and 1962, respectively, probably the same decade in which new β-lactam drugs were applied (Spellberg and Gilbert 2014). Unfortunately, resistance has been documented against all the available new drugs developed during that time period. Later on, in 1972, a new drug named “vancomycin” was developed to treat MRSA strains (Sengupta et al. 2013). At that time, resistance against this “vancomycin” was considered unlikely. But in the 1980s, many cases were reported as vancomycin-resistant Staphylococcal strains. Until then, many pharmaceutical industries developed and introduced novel drugs to resolve this burning issue. But regrettably, by the year 2015, the bacterial-resistant infection became once again a serious life-threatening concern (Spellberg and Gilbert 2014). Although emerging trends of antibiotic resistance are a threat worldwide, many breakthroughs of these magical antibiotics have handed to mankind particularly in the area of surgery and medicine (Wright 2014). These magical antibiotics also extended the average life span. During 1920, the average life expectancy in the USA was 56.4 years, but presently this has been extended to 80 years. So antimicrobials have had many powerful impacts in the developing world with destitute public health infrastructure and reduced morbidity and mortality rates (Piddock 2012).

Emerging Patterns of Antimicrobial Resistance Microorganisms develop some austere mechanisms to evade the lethal strategies of antimicrobial agents. Many natural antibiotics are manufactured from saprophytic bacteria and environmental fungi, while others are modified synthetic drugs like sulfonamides and fluoroquinolones (Holmes et al. 2016). It has been known that many microbes developed protective mechanisms against them like enzyme production that catalyzes antimicrobial substances, altered target site, and restriction of drug entry (Forsberg et al. 2014). This is the reason that antibiotic resistance illustrates Darwin’s selection from natural microbial-derived antimicrobial substances (Aminov 2009). The metagenomic analysis of soil microorganisms showed vast diversity among genetic elements linked with antibiotic resistance. Although not much data have

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been reported on this aspect, the production of β-lactams sets an exceptional example and put a huge impact on human health (Martinez 2009). It has been documented that many natural antimicrobial agents produced by saprophytic bacteria hamper the growth of other microbes present in the environment, although some findings suggest their complex interaction. It has also been suggested that there is a very low concentration of these antimicrobial agents in the soil and thus, not able to restrict the neighboring bacterial growth (Forsberg et al. 2014). Such sublethal doses of antimicrobial substances have considerable impacts on microbial evolution and microbial physiology and also induce microbial gene expression by acting as signaling elements (Andersson and Hughes 2014). Another significant suspicion is that some of the saprophytic bacteria produce a diverse array of antibiotics, namely, carbapenems. Carbapenem synthase genes play a key role in quorum sensing and biofilm production. Therefore, the emergence of resistance is not only confined to natural antibiotics but also to synthetic ones (Morita et al. 2014).

The Rationale for Antibiotic Resistance Currently, the etiology of AMR is considered as a multifactorial. Some of them involve inept antibiotic usage and imprecisions, awareness deficiency, increased traveling, inappropriate regulatory systems, online marketing, poor hygienic conditions, and use of antimicrobials as a growth promoter rather than control-resistant infections in livestock and poultry (Bartlett et al. 2013). Misuse of antimicrobials without adequate prescription is a principle and significant reason for resistance evolution as strongly discouraged by “Alexander Fleming” that antibiotics not only kill sensitive bacteria but permit to remain which eventually reproduce and thrive through a process of natural selection, thus making them resistant pathogens. Although the overuse of antibiotics is dejected, the overprescription remains around the globe (Ventola 2015). Moreover, much work has been emphasized on inappropriate antibiotic therapy, choice of agents, duration, and treatment indications in almost 30–50% of cases (Lushniak 2014). Worldwide, about 80% of drugs in the livestock are used as growth supplements as well as for infection control purposes. Another study was conducted in 2010 which demonstrated that the total antibiotic consumption in the livestock was 63,151 t and the estimate will rise to 67% by the year 2030 (Van Boeckel et al. 2015).

Key Drivers and Triggers of Antimicrobial Resistance Understanding the drivers of AMR is very essential to address this global issue. Among the microbes, the incidence of occurring AMR is a natural phenomenon, and the selection process is driven through the use of numerous drugs in the environment, poultry, and healthcare system. While other potential drivers of AMR include

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water hygiene, sanitation settings, drug quality, therapeutics and diagnostics, and migration or travel quarantine. Moreover, chromosomal mutation of the pathogen and genetic material exchange between the organisms play an important and key role in the distribution of AMR (Holmes et al. 2016). Plasmid transmission (transfer of resistant genes) to the host is another important resistance driver. Antibiotics also release and transmit resistance elements which ultimately exert selection pressure to the emergence of resistance (Munita and Arias 2016). Understanding of the resistance transmission has raised awareness as well as the knowledge about how these resistant organisms spread from person to person (Laxminarayan et al. 2013). The fecal-oral route of transmission is another important means of the spread for resistant organisms (Enterobacteriaceae) due to poor sanitation settings. Unhygienic hospital settings and prolonged stay result in the transmission of MRSA ultimately facilitate resistance spread at the community level. Sexual intercourse is another important driver for the spread of N. gonorrhoeae (Wellington et al. 2013). Resistance transmission from animal products to humans is usually associated with the irrational use of antimicrobial growth supplements. In this regard, Salmonella spp. and Campylobacter spp. have an important consideration (Anderson and Lewis 1965). Unknown resistant mechanisms, as well as mobile genetic elements (MGEs), perhaps make their pathway from animals to humans through numerous indistinguishable means (Humphrey et al. 2005). Additionally, certain environmental factors, as well as the use of metals as microbicides, are other significant drivers of antibiotic resistance. Pharmaceutical industrial pollutants, improper waste management skills or procedures, and isolation of resistant pathogens from sewerage settings are well-documented drivers of AMR (Kristiansson et al. 2011).

Super-Resistance Associated with Superbugs Superbugs are microorganisms with high mortality and morbidity incidence rates resulting from mutational resistance against different classes of antibiotics. Curative measures are not available against such resistant pathogens and are associated with higher economic costs and a longer stay at hospitals. Such super-resistant strains showed increased virulence and resistance and higher transmissibility rates (Davies and Davies 2010). Irregular and abnormal antibiotic usage makes many bacterial pathogens susceptible to change their types into MDR types (Sotgiu et al. 2009). Some eminent MDR pathogens include E. coli, S. aureus, S. epidermidis, Mycobacterium, Enterococcus, Pseudomonas, Acinetobacter, Enterobacter, S. pneumoniae, Proteus, Serratia, Hemophilus, Salmonella, Burkholderia, Clostridium, Campylobacter, and Salmonella species (Butt et al. 2016; Davies and Davies 2010; Sohail et al. 2015, 2016). Among these, S. aureus is the most notorious superbug. It is the commensal bacteria in the nose and is responsible for serious skin infections. Currently, community-acquired MRSA is an emerging community concern with improved virulence characteristics as well as different “gene encoding

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Panton-Valentine leukocidin” and “mec gene clusters” (Rasool et al. 2016; Watkins et al. 2012).

Pathogenicity, Virulence, and Antimicrobial Resistance The human skin and the mucous membrane are colonized with different bacteria that are harmless and are beneficial to us, known to be called as commensals, while some of the bacteria are not commensals, harmful to host tissue, and are well known to cause a variety of infections (Beceiro et al. 2013). The ability of an organism to cause infection or disease is termed as “pathogenicity,” and an organism’s ability to carry a number of factors to enhance the degree of pathogenicity is termed as “virulence.” Other significant characteristics that facilitate an organism to cause an infection are invasiveness and toxicity. So, a bacterial disease course is largely dependent upon the balance between the immune status of the host and virulence. With the passage of time, both bacteria and host underwent some kind of evolutionary process. Bacteria somehow have modified the virulence properties to adjust within the host immune system (Martínez and Baquero 2002). But the evolutionary process of AMR is quite different from virulence, and also both of these occur in different eras (Fair and Tor 2014). However, both processes have some common attributes as well, and also both are tremendously important for bacterial survival under unfavorable conditions. Firstly, virulence is necessary to combat the host’s immune system, and antibiotic resistance permits an organism to vanquish the therapeutic effects (Feldman and Laland 1996). Then, both these processes use the mechanism of horizontal gene transmission to spread critical determinants between species and genera. Moreover, mutational adaptations and mobile genetic elements are maybe some other key mechanistic factors for the distribution of both virulence genes and resistance (Handel et al. 2006). In addition, antibiotic resistance is also associated with virulence in the case of intracellular bacteria (Seral et al. 2003). Likewise, some characteristics such as the contribution of efflux pumps, porins, regulation of gene expression system, and cell wall modifications are common to both virulence and antibiotic resistances (Tsai et al. 2011). MDR opportunistic organisms grow in niches or groups with antibiotic-selection pressure where many organisms dislocate host microbiota and also unable to survive. Through this way AMR improves both pathogenicity and virulence of the organism; thus, antibiotic resistance is generally assumed as a virulence factor particularly in hospitals (Sohail et al. 2016).

Molecular Understandings of Antibiotic Resistance Incidence of multidrug-resistant infections has been increased with the passage of time due to β-lactamase production (including MBLs, ESBLs, carbapenemases) leading to third-generation resistance development against carbapenems and

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cephalosporins (Blair et al. 2015; Khurshid et al. 2017). Genes responsible for resistance include bla-CTXM-15, NDM-1, AmpC, VIM-1, bla-TEM-1, tetG, floR, and mcr-1 gene (Hayat et al. 2019; Khurshid et al. 2019; Voulgari et al. 2013). There are two major, well-known mechanisms for resistance, namely, intrinsic and acquired resistance (Lynch III et al. 2013). An organism’s capability to resist particular antibiotic action due to inherent characteristics is termed as intrinsic resistance. Pseudomonas depicts an excellent intrinsic resistance mechanism because of no target site for its specific drug. Triclosan (a broad-spectrum antibiotic) is unable to prevent Pseudomonas growth. Anciently, it was assumed that active efflux is the only cause, but, currently, fabI gene (encoding carrier reductase enzyme the “enoyl-acyl”), a target place for triclosan, has also been documented (Zhu et al. 2010). Similarly, daptomycin shows an intrinsic modification in the cytoplasmic membrane structure (reduced efficacy of Ca+2-mediated insertion), thus ineffective against gram-negative and gram-positive bacteria (Randall et al. 2013). Vancomycin inhibits peptidoglycan linkage in gram-positive bacteria while unable to cross the outer membrane in the case of gram-negative bacteria. Analysis of genome-mutant libraries revealed many genes are associated with intrinsic resistance (Blake and O’Neill 2012). Other mechanisms contributing toward acquired resistance include poor drug penetration, antibiotic efflux, altered target site due to post-translational modifications or genetic mutations of the target, or antibiotic inactivation through hydrolysis (Floyd et al. 2010). Mcr-1 harboring resistant E. coli was isolated from migratory birds, animals, raw meat as well as from clinical human isolates, in Pakistan. ESBLs and quinolone-resistant MDR E. coli were also reported from wild birds, dogs, and poultry farms (Mohsin et al. 2017).

Therapeutic Strategies Addressing Antibiotic Resistance Nowadays, infection control is a serious matter of concern and previous studies mostly focused on the discovery and formulation of fundamental antimicrobials. Unfortunately, these remedial treatments and bio-therapeutics are unable to control the emerging threat of antibiotic resistance (Baloch et al. 2018; Brooks and Brooks 2014). Small molecules based on biological inspirations might always influence infection control strategies. In addition, various other tools for controlled drug delivery were also pursued logistically as an effective candidate for infection control (Choi et al. 2009). Thus, a paradigm shift like the use of bioinformatics must be employed to control antibiotic resistance (Weber 2014). Given the obligatory use of antimicrobials in healthcare settings today, the efficacy of available antimicrobials appears miserable facing the resistance crises. Thus, biomedical research must adopt novel strategies for infection control with the following benchmarks including preventive and anticipated measures to protect host microflora, the discovery of new antimicrobials, and combination therapies with

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controlled smart delivery tools such as liposomes or nanoparticles (Aslam et al. 2018). Nanotechnology is an emerging field of modern medicine with the potential to address the hotspot of AMR. Nanoparticles can be used in a variety of ways like coupling with the available antibiotics to increase their effectiveness against resistant bacteria. Colloidal suspensions of nanoparticles can also be employed as an effective antimicrobial. In addition, nanoparticles are effective in generating powerful reactive oxygen intermediates (ROIs) leading to bacterial death. Nanoparticles can synergistically be coupled with appropriate antibiotics to improve the bactericidal action (Aslam et al. 2017; Kumar et al. 2018). Since the world is facing a serious threat, it is very necessary to timely look afresh to some other possible approaches for tackling AMR such as the use of antibodies, probiotics, bacteriophage proteome (including endolysins, holins, receptor-binding proteins, virion-associated peptidoglycan hydrolases (VAPGHs), and anti-CRISPR proteins), vaccines, and immune stimulators (Aslam et al. 2018). Antimicrobial peptides are recently found to be a new emerging class of antimicrobials with improved and higher antimicrobial activity. Its amphipathic nature permits them to interact and insert into the microbial cell wall and targets cellular proteins, regulatory enzymes, DNA, and RNA, making them a promising substitute for classical antimicrobials (Forde and Devocelle 2015). However, there might be a possibility in the future that resistance could also develop against these AMPs, so deep understandings of their molecular mechanistic factors must be explored for rational planning to use them as possible substitutes to available antibiotics (MariaNeto et al. 2015).

Global Measure Plan and Awareness to Control Imperiling Threat of Antimicrobial Resistance: Future Perspectives The burden of AMR is an ecological calamity around the globe, and many regulatory authorities declared this as a global health concern (Gould 2012). Although many studies have reported the control of resistant infections, the actual reason behind the overall national decline in resistance is still disputed. Consequently, there is an urgent need to take some significant actions on the national level. Since the complete eradication of resistance is quite unattainable, its further progression can be controlled (Gurieva et al. 2012). Furthermore, global authorities like the CDC, Food and Agriculture Organization, or WHO, with the collaboration of the Global Antimicrobial Resistance Surveillance System, must make tremendous advancements regarding resistance control (Sirijatuphat et al. 2019). National plans and approaches must be employed including rational antibiotic usage, effective surveillance system of antibiotics reflecting “One Health” approach, establishment of health insurance policies, development of further healthcare or clinical setups, innovative infection and disease control strategies, stewardship plans, and constrained the drug promotions (Laxminarayan et al. 2013). However, all these proposed plans demand enough time, patience, and huge endorsement from

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the upper authorities and government with spacious funding. All these practices are at a low pace in the developing world, where diagnostics is a pressing issue due to the unavailability of all the abovementioned practices for bacterial identification. Additionally, the availability of modern molecular identification and screening tools must be ensured in clinical setups (Cantón et al. 2012). Furthermore, rational use of antimicrobials, combination therapy, availability of diagnostics, customized control policies, and stewardship systems should be applied in developing countries. Also the use of alternate approaches to control and to treat resistant bacterial infections like biological therapies, vaccines, or anti-virulent strategies must be applied (Coates et al. 2011).

Conclusion The spread of AMR is a global health threat calling for urgent action to expand our understandings regarding its causes, promoting factors, and preventive measures. To address AMR, multidisciplinary and multimodal approaches should be adopted including the development of diagnostic and screening tools and alternate strategies such as lytic phage therapy, use of probiotics, use of de novo synthetic antimicrobial peptides, and biological therapeutics. Furthermore, increased AMR spread can be sufficiently contained through adequate and effective bio-surveillance and education systems, infective control measures, global awareness and action plans, and the cautious clinical use of antimicrobials.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition, Features, and Phases of Complex Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology of Complex Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complex Emergencies and Global Health: A Complex Inter-relationship . . . . . . . . . . . . . . . . Management of the Public Health Consequences of Complex Emergences . . . . . . . . . . . . . . . . . . Preparing for a Complex Emergency in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Responding to a Complex Emergency in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coordinating the Global Health Response to a Complex Emergency . . . . . . . . . . . . . . . . . . . . . Global Health Information Management During a Complex Emergency . . . . . . . . . . . . . . . . . Global Health Services Delivery and Management of Specific Global Health Problems in Complex Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Investigation and Management of Disease Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provision of Health Services for Displaced Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management of Nutrition Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Follow-Up and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vaccine-Preventable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reproductive, Maternal, Neonatal, Child, and Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . RMNCAH Services Along the Continuum of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RMNCAH Services During Adolescence and Before Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . RMNCAH Services for Woman During Pregnancy, Delivery, and Postnatal Period . . . . . Essential Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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O. O. Olu (*) · J. F. Wamala World Health Organization, Juba, Republic of South Sudan e-mail: [email protected]; [email protected] D. Chamla United Nations Children Fund, Kabul, Afghanistan e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_104

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AIDS, Tuberculosis, and Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HIV Prevention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tuberculosis Prevention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Malaria Prevention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health and Psychosocial Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Addressing the Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non-communicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Humanitarian Response to Trauma and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operational Platforms for the Management of Complex Emergencies and Global Health Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health System Recovery After a Complex Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Goal, Objectives, and Triggers for Post-Conflict Health System Recovery . . . . . . . . . . . . . . . Guiding Principles for Post-Conflict Health System Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Steps in Post-Conflict Health System Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Post-emergency Health Situation Analysis and Needs Assessment . . . . . . . . . . . . . . . . . . . . . . . Health System Recovery Option Analysis and Prioritization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Development of a Health System Recovery Strategy and Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health System Recovery Program Implementation, Supervision, Monitoring, and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The relationship between complex emergencies, health systems, and public health is a complex interaction in which pre-existing weak health systems result in poor public health outcomes for affected population while on the other hand complex emergencies negatively impact the health system of affected areas and create further health inequality for affected populations. It is therefore important to systematically manage the public health consequences of complex emergencies. Public health management of complex emergencies include preparedness, response, and recovery interventions which are underpinned by the principles of human rights, the right to health, equity which ensures no one is left behind, community participation, and sustainability. Moving forward, it is critical to regularly build the capacity of humanitarian stakeholders and partners on how to effectively manage the public health consequences of complex emergencies. This chapter summarizes the key principles and processes involved in the planning, implementing, coordinating, supervising, monitoring, and evaluating of public health response to complex emergencies. Keywords

Public health management · Complex emergencies · Humanitarian crises · Preparedness

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Introduction Complex emergencies (CEs) are major causes of excess morbidity and mortality globally. It is therefore important to understand the dynamics of how they impact public health and the health system of affected populations in order to mount effective public health responses to them. This chapter summarizes the key principles and processes involved in the planning, implementing, coordinating, supervising, monitoring, and evaluating public health response to CEs. The chapter begins by defining CEs and describing their features, phases, epidemiology, and impact on the public health and health system of affected population. It then proposes key principles which should guide emergency public health responses during CEs. The chapter goes on to highlight the critical public health interventions which should be implemented in the management of CEs. It concludes by proposing some practical recommendations to guide ministries of health, humanitarian workers, and public health practitioners in effectively managing the public health consequences of CEs.

Definition, Features, and Phases of Complex Emergencies The term “complex emergencies” was coined in the late 1970s and 1980s to describe humanitarian crises which were associated with warfare. At that time, many of such crises occurred in Africa. The terminology has now evolved and has been adopted by several international organizations particularly the United Nations (UN) and international nongovernmental organizations (NGOs) globally to describe humanitarian crises which are caused by wars and civil conflicts and occur in complex political, socioeconomic, and cultural context (Murphy 2011). Several varying definitions of CEs have emerged; however all of them consistently agree on some keywords, namely, “man-made disaster,” “humanitarian crisis,” and “international response” (UNHCR 2001; IFRC 2020) which define the terminology. The Inter-Agency Standing Committee (IASC) on humanitarian crises defines CE as a humanitarian crisis which occurs in the context of breakdown of lawful order and authority as a result of civil conflict, war, or foreign aggression in a country, region, or society that requires international response in terms of its management and coordination that exceeds the capacity or mandate of any single agency to address (IASC 1994). In the health realm, the World Health Organization (WHO) defines CE as a situation in which warfare or civil conflict results in large-scale population displacement and disruption of the livelihoods of affected persons. Emergency response to such situation is often conducted in a very difficult security and political environment (WHO 2020c). Several causes of CE have been described in the literature. The root cause is often associated with differences in tribal affiliations, land/boundary dispute, and disagreement over natural resources, religious beliefs, or political ideologies or a combination of these which pits one group against another. Sometimes several warring groups may be involved in a CE which makes it even more complicated.

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CEs are often characterized by distinctive features such as extensive violence, lack of access to basic social services resulting in excess morbidity and mortality, population displacement into very difficult and insecure environments, socioeconomic disruption resulting in high levels of poverty, and general state of insecurity which hinders free flow of humanitarian assistance. Other features include disruption of family and cultural norms, increased risk to humanitarian assets particularly relief workers, and huge need for humanitarian assistance. Three main phases of CEs, namely, pre-, intra-, and post-emergency, each with its own sets of critical emergency management requirements are recognized (Fig. 1). The three phases are not necessarily linear; in other words, they overlap in several instances. During the pre-emergency phase, the key emergency management activities include vulnerability and risk analysis and mapping (VRAM) for emergencies and emergency mitigation, prevention, and preparedness, while in the emergency phase, public health emergency management activities include rapid health assessments, provision of immediate basic healthcare for displaced populations, and treatment of wounded people. During the post-emergency period, the displaced populations start to return to their original homes where basic services are often not available; hence the critical focus in this phase is rehabilitation and reconstruction. Interventions during this phase are aimed at ensuring availability of basic health services in the return areas and rebuilding the disrupted health system that is usually associated with conflicts.

Fig. 1 Phases of and summary of public health interventions during complex emergencies

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Epidemiology of Complex Emergencies Available evidence shows that CEs are major problem globally with Africa being disproportionately affected. A total of 167 armed conflicts were reported globally from 2005 to 2014 (Culver et al. 2017). Of this, 67% (112) were reported from Africa followed by the Middle East which reported 22% (36) and Asia coming third with 18 complex emergencies (11%). However, the Middle East had the highest population affected by CEs (94.2 million) followed by Africa (78.9 million) and Asia (12.8 million) for the same period (Culver et al. 2017). These findings are similar to those of other studies which showed that majority (53%) of 30 CEs which occurred from 1995 to 2004 were reported from Africa followed by Asia (33%) (Spiegel et al. 2007). Recent data show an increase in the number of all forms of conflicts globally since 2014 following a decline in the 2000s (Uppsala University 2018) as demonstrated by the fact that there were, respectively, 52, 78, and 35 statebased, non-state, and one-sided violence in 2018 as compared to 43, 74, and 28 in 2014. However, there has been a decrease in the number of fatalities associated with violence during the same period mainly due to reduction of violence in Syria and Iraq (Pettersson et al. 2019). CEs often result in both internal and external displacements of populations into camp-like settings. An estimated 10.8 million (39%) persons out of the total 28 million internally displaced persons (IDPs) globally in 2018 were due to conflict; of the 10.8 million, 4.9 million (45.4%), 4.2 million (38.9%), and 0.9 million (8.3%) were, respectively, due to armed conflict, communal conflict, and political violence. Africa again topped the list of global population of IDPs due to conflict with 69.1% (7.5 million) living on the continent. Seven out of the top ten countries with IDPs, namely, Ethiopia, Democratic Republic of Congo, Somalia, Nigeria, Central African Republic, Cameroon, and South Sudan are found in Africa (IDMC/NRC 2019).

Complex Emergencies and Global Health: A Complex Inter-relationship The relationship between CEs, health system, and public health is a complex interaction in which pre-existing weak health systems result in poor public health outcomes for affected population while on the other hand the CE negatively impact the health system of affected areas, further creating health inequality for affected populations. The impact of CEs on the six building blocks of the health system is often catastrophic. Essential medicines, supplies, and medical equipment are often the target of looting during CEs resulting in disruption of the supply chain management system for essential medicines, medical supplies, and equipment. The violence which is associated with CEs often leads to attacks on health facilities resulting in their destruction, displacement of, and injury to and/or death of healthcare workers. This often renders health facilities non-functional, thus limiting access to basic health services. Diversion of available resources to defense and security and reduced revenue generation during CEs usually results in reduction in health budget

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allocation and increased dependence on donor aid which are unsustainable. Other impacts of disasters on the health system include disruption of health information management systems causing lack of data for evidence-based health planning, and reduced capacity for health policy dialogue. Furthermore, poor coordination of health services delivery and reduced oversight for health services delivery have been known to occur because of CEs. All the above usually lead to reduced access to health and its social determinants in areas affected by CEs. The population displacements which are associated with CEs are often into crowded refugee and IDP camps where living conditions are very poor. Overcrowding; inadequate access to social services such as water, sanitation, food, and shelter; and low immunization coverage often lead to outbreaks of waterborne and vaccine-preventable diseases in such settings. Lack of access to means of livelihoods in such camps may result in food insecurity, triggering childhood malnutrition, gender-based violence, poverty and increased mental health and psychosocial problems. Increase in cases of trauma due to gunshot wounds, fractures, etc. is also very common occurrence at the onset of CEs.

Management of the Public Health Consequences of Complex Emergences The foregoing depicts a dire impact of CEs on global health which is an impetus to have well-organized emergency public health response to reduce the suffering and excess morbidity and mortality among the affected population. The planning, implementation, supervision, monitoring, and evaluation of such emergency public health response require clear guiding principles, coordination, and operational platform which are discussed in this section. Overview: Guiding Principles for Effective Management of and Responses to Complex Emergencies

1. Guarantees the humans rights of all conflict-affected persons and protects them from human rights violations. 2. Promotes equity and preserves the right of the affected populations to adequate and good quality healthcare services which does not put any financial hardship on them. These principles underpin the sustainable development goals and universal health coverage which says “leave no one behind.” 3. Ensures a people-centered approach with active engagement and participation of affected populations and communities in making decisions involving the planning, implementation, monitoring, and evaluation of their health services. (continued)

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4. Mainstreams cross-cutting issues such as gender and vulnerable groups (children, women, elderly people, the disabled, etc.) into emergency public health programs in such a way that they are not left behind. 5. Ensures an integrated and sustainable approach which builds on existing local capacities and assets and bridges the humanitarian and development nexus. 6. Ensures that emergency public health programs do no harm neither does it worsen or negatively impact the public health situation or health system, culture, norms, values, or religion of affected populations and communities. 7. Enhances partnerships among various emergency public health responders to enhance complementarity and ensure good impact of the interventions.

Preparing for a Complex Emergency in Global Health Key Elements of Preparedness for Complex Emergencies The United Nations International Strategy for Disaster Reduction (UNIDSR) defines preparedness as knowledge and capacities accrued by government, other responding entities, communities, and individuals for effective prediction, response, and recovery from likely or ongoing events or conditions (UNISDR 2009). The framework for effective preparedness consists of several elements including effective governance, contingency planning, early warning systems, emergency supplies, establishing emergency coordination mechanisms, response arrangements, public information, training and testing of responders on preparedness guidelines and plans. Effective Governance Strengthened and effective governance relies on clear legislation, policies, plans, guidelines, multisectoral engagement, and participation of stakeholders at community, national and sub-national, as well as regional and global levels. Policies and legislation are a major component of effective emergency preparedness and response. It is therefore critical that national and international legislation as well as sectoral and stakeholder policies at all levels integrates emergency preparedness. At the community level, community emergency preparedness should be prioritized and integrated into relevant policies and legislation on emergency risk management (WHO 2017a). Communities should be consulted as the policies and laws are formulated, and community representatives should be identified and involved during implementation (WHO 2017a). At the national and sub-national levels, emergency preparedness should be integrated and funded as part of the existing national health strategic plan. There should be legislation that empowers and facilitates institutions that manage emergencies at national and subnational level. At the regional and global level, countries should be supported by relevant regional bodies and UN agencies to develop tools and provide technical assistance for implementing and monitoring compliance to international emergency preparedness legal frameworks (WHO 2017a).

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Multisectoral Coordination Platforms Institutions and frameworks for coordinating emergency preparedness and response should be designated and mandated by relevant legislation and policies to ensure they are resourced to remain viable to execute their mandate at the community, subnational, national and regional, as well as global levels (WHO 2017a). At the community level, stakeholders including civic leaders and community members should be assigned clear roles and tasks to participate in local and sub-national multisectoral health emergency preparedness coordination mechanisms (WHO 2017a). Multisectoral health coordination mechanisms should be designated, mandated, and strengthened to coordinate emergency preparedness and response at the national and sub-national level with participants drawn from relevant sectors, public, private, civil society organizations, and other relevant stakeholders. In the same way, emergency preparedness should be mainstreamed and integrated into all relevant sectors at national and sub-national level. To augment the coordination of public health emergencies at national and sub-national levels, public health emergency operations centers (PHEOCs) should be established and activated with incident management systems (IMS) constituted to coordinate emergency preparedness and response in collaboration with other multisectoral emergency operations centers (EOCs) (WHO 2017a). Emergency management efforts at the national level should be complemented and supported by regional and global multisectoral coordination mechanisms especially when faced with CEs. Such regional and global mechanism includes the organization of specific emergency arrangements like the WHO’s internal grading of public health events and emergencies that indicates the required level of country operational response (WHO 2017b). The IASC coordinates the humanitarian system-wide activation in response to acute or protracted humanitarian crises that includes response, recovery, and preparedness to emergencies. Regular Assessment of Risks to Inform Preparedness Planning Risk assessment is a systematic process of assessing the probability of occurrence and the likelihood of adverse effects from an event or hazard, the exposure threat, and the availability of capacities for prevention and control with the ultimate aim of characterizing the risk level. Risk assessment is an integral part of the risk management cycle that entails assessing event risk and assigning a risk level; prioritizing control measures; event monitoring and evaluation; and effective ongoing risk communication (WHO 2012b). Risk assessment facilitates the identification of priorities for emergency preparedness at all levels. Event risk and capacity assessments should be undertaken at the community level with the participation of community leaders. The assessment of risks and capacities at all levels should be multi-hazard and multisectoral to facilitate prioritization. The global and regional emergency response partners should coordinate and provide technical support to country risk and capacity assessment and prioritization. International support to countries may include the use of modeling and other tools for emergency forecasting

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(WHO 2017a). The risk information should be disseminated through risk maps and knowledge management portals which should be availed in real time.

Plans for Emergency Preparedness, Response, and Recovery Contingency and preparedness planning are a critical component of all forms of humanitarian response operations, including CEs. Inter-agency contingency planning entails identifying and analyzing potential emergencies and their impact, followed by articulating and implementing the critical preparedness actions to prevent, mitigate, and effectively respond to the emergency (WHO 2017a). Development of these plans should involve all relevant sectors and stakeholders at community, national and sub-national level, as well as regional and global level. At the community level, leaders and resource persons should be actively involved in developing and conducting drills and exercises to test the plans for optimal response readiness and smooth recovery from the emergencies (WHO 2017a). Contingency and preparedness planning should encompass priority hazards and should include multisectoral simulations to test readiness capacities (WHO 2017a). Surveillance, Early Warning, and Information Management Surveillance and early warning systems are critical during CEs given the vulnerability of affected populations to potentially disastrous effects of disease outbreaks, food insecurity, and other adverse public health events. It is important that early warning and surveillance systems during CEs are tailored to detect and respond to priority hazards at all levels. The approach is consistent with the international health regulations of 2005 (IHR 2005) and operationalized through the integrated disease surveillance and response (IDSR) strategy and the early warning alert and response networks (EWARN) (WHO 2019). Effective surveillance and early warning systems at the community level are also critical. Community event-based surveillance systems are now core to surveillance systems for the control of major public health threats in Africa (WHO 2019). Ultimately, communities should be resourced and skilled to actively participate in all phases of the emergency preparedness and response cycle including surveillance. Access to Diagnostics and Laboratory Services Access to diagnostics and laboratory services is critical for early confirmation and initiation of appropriate response to prevent excess morbidity and mortality in populations affected by humanitarian crises (Damerell et al. 2011). As part of emergency preparedness, community health workers should be trained and facilitated to conduct community-level rapid diagnostic testing for common illnesses like malaria. Laboratory networks with laboratory facilities at the national and subnational level are also critical for ensuring availability of diagnostic capacities before and during emergencies. In addition, such systems could be complemented by the deployment of mobile field laboratories for timely sample testing during emergencies. At the regional and global levels, inter-country agreements to facilitate sample sharing and testing at international collaborating laboratories for diagnostics lacking

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at country level and as part of external quality assurance are also important (WHO 2017a).

Mobilization of Resources for Emergency Response Effective emergency preparedness and response at the community level require that communities have access to emergency contingency funds and resources supported through the national budget and donor contributions. National emergency response funding should be equally aligned with emergency funding mechanisms at regional and global level (WHO 2017a). Effective preparedness and response to outbreaks and emergencies also require availability of trained, skilled, and equipped human resources with a multidisciplinary and multisectoral composition at all levels. Consequently, health workers and other emergency volunteers at the community level should be trained and drilled on all-hazards emergency preparedness and response (WHO 2017a). In the same way, multisectoral all-hazard training courses should be rolled out at national and sub-national levels with specialized emergency medical or rapid response teams being established and supported to promptly conduct initial investigations and respond to outbreaks and other public health emergencies or disasters. Logistics and Essential Health Supplies As part of the health risk mapping and emergency contingency planning, all necessary vaccines, emergency health kits, and medical supplies should be identified, quantified, and prepositioned in vulnerable locations to facilitate prompt initiation of response activities. Alternatively, contingency arrangements should be in place to promptly ship the supplies from regional hubs to affected areas. In this regard, there should be arrangements at national, regional, and global level to have ample stockpiles of medicines, vaccines, supplies, and kits to support effective response to major public health risks (WHO 2017a). These arrangements currently exist for major vaccines like epidemic meningitis, yellow fever, and cholera that are accessed through the global emergency stockpiles. Challenges of Preparing for Complex Emergencies Effective preparedness planning requires leadership from government and humanitarian actors. The overall mandate for humanitarian response lies with the government and the line sectors, supported by humanitarian agencies and donors. However, the capacities of government and its sectors to execute this mandate are often compromised during CEs (Sondorp et al. 2001). The absence or inadequate leadership from government may reduce the resources available to implement the preparedness plan. Availability of robust health data is critical for the initial and regular risk assessments, situation analyses, hazard risk profiling, and vulnerability and capacity assessment. However, humanitarian crises are characterized by either weak or absent health information systems (Sondorp et al. 2001). These gaps will compromise emergency risk assessments and situation analyses that should inform an effective emergency preparedness planning process. Inability to effectively plan for emergencies also compromises the capacities for effective intersectoral

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and inter-agency coordination of the response. Lack of political will and commitment is a major limitation to the establishment of emergency preparedness governance structures at all levels (Olu et al. 2016).

Responding to a Complex Emergency in Global Health Coordinating the Global Health Response to a Complex Emergency Overview Due to the vast number of agencies responding to the global health needs during CEs, a strong coordination mechanism is crucial. Coordination can be defined as the orchestration of effort toward appropriate, effective, efficient, and coherent delivery of health services during CEs (Bennett et al. 2016). Recent increases in public health emergencies of international concerns, such as Ebola and COVID-19, have led to a divide of global health response into two distinct but co-dependent governance structures – humanitarian health and global health security, the latter addressing health needs during natural or man-made disasters while the former focusing on emerging infectious diseases. These governance structures became even more complex when a global health security issue becomes a humanitarian crisis, as seen during Ebola outbreak in Western Africa where a new coordinating body was established – UN Mission for Ebola Emergency Response. Cluster Approach for Humanitarian Coordination of Complex Emergencies The current international humanitarian coordination systems were set by General Assembly Resolution 46/186 in 1991. Fifteen years later, through the Humanitarian Reforms, a humanitarian Cluster Approach as a new element in coordination mechanism was introduced. Humanitarian Clusters are groups of organizations led by designated agencies, called “Cluster Lead Agencies” in each of the main sectors of humanitarian actions. They were designated by the IASC, which is the highest-level humanitarian coordination forum of the UN system, bringing together heads of 18 major UN and non-UN agencies called IASC Principals. The IASC is chaired by the Emergency Relief Coordinator (ERC), who is also the executive lead of the UN Office for the Coordination of Humanitarian Affairs (OCHA), and reports to the UN Secretary General. The main role of the IASC is to ensure coherence in preparedness and humanitarian response, formulation of policies, and definition of humanitarian priorities (OCHA 2020). There is a total of 11 clusters, one being health cluster, led by WHO as shown in Fig. 2. Humanitarian and Health Coordination at Country Level In a country affected by a disaster or conflict, the ERC may appoint a Humanitarian Coordinator (HC), who works with the government, affected communities, UN and non-UN agencies to ensure humanitarian response is well coordinated. An OCHA office will then be established in those settings to support the functions of the HC.

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Fig. 2 The United Nations cluster system. (Adapted from UNOCHA)

At national level, the HC coordinates the work of humanitarian agencies through two important forums, the Humanitarian Country Team (HCT) and UN Country Team (UNCT). In countries where humanitarian response is only required in one part of the country, a Humanitarian Regional Team (HRT) could be established. In those situations, sub-offices of OCHA could coordinate the response through HRTs. A health cluster, when activated, coordinates health response targeting population in need of specific health services – usually the most vulnerable such as women and children. Its mission is to provide leadership to humanitarian health response in order to prevent and reduce crisis-related morbidity and mortality; ensure gaps are filled through effective coordination, and support to mobilize resources. In some CEs like the Rohingya refugee crisis in Bangladesh, specific working groups, such as Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) may be established under the health cluster, to address in detail specific issues that is deemed a priority or neglected. Disease outbreaks, such as measles, that are common in CEs are often coordinated by health clusters; however in new emerging infectious conditions, which have far-reaching international implications, a different coordination mechanism is often developed under the framework of PHEOC.

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The Public Health Emergency Operations Center and Incident Management System PHEOC is a physical location for the coordination of information and resources to support incident management activities during a public health emergency. An incident being an occurrence, or imminent threat, of a public health condition that poses a substantial risk of a significant number of human fatalities, injuries, or permanent or long-term disability (WHO 2018a). The PHEOC uses an IMS as an organizational model from national government to frontline levels to manage, respond, and coordinate an outbreak. IMS was established in countries such as Sierra Leone during the 2014/15 Ebola outbreak response, with good success. Civilmilitary coordination mechanisms were also established due to an increasing role of military support during these outbreaks.

Global Health Information Management During a Complex Emergency Health information is critical for effective preparedness planning and response to emergencies and disaster risks. Public health response to CEs requires that information is generated routinely to identify priority health risks, the causal factors, the capacity of existing systems to prevent and respond, and the vulnerabilities in affected populations. This section presents the different approaches that are used to generate health information that informs effective response to CEs.

Vulnerability Risk Analysis and Mapping in the Health Sector Vulnerability risk analysis and mapping (VRAM) is one of the approaches used to conduct risk assessment in the health sector during a CE. It entails an initial hazard analysis that is followed by vulnerability and capacity assessment and then a risk analysis that puts all the attributes together to determine the attributable risk (Nsenga et al. 2019). The health VRAM process in a country is led by the Ministry of Health with a core team comprising expertise in public health, disaster risk management, health systems, and health information management. Critical stakeholders including humanitarian and development partners and donors should be involved in health VRAM as their support will be critical for availing data and resources required to complete the exercise (Nsenga et al. 2019). The designated VRAM team should determine the lowest geographical level at which data should be collected. Also critical to the VRAM planning process is the need to define the minimum set of standard variables, a set of pre-tested tools for collecting the data, and to define the data sources, preferably from existing secondary data sources (Nsenga et al. 2019). Once the requisite data is obtained, the analysis should map the priority hazards, alongside the vulnerabilities, capacities, and overall hazard risk profiles. The VRAM findings should be presented in a report and disseminated to stakeholders to inform prioritization of locations and hazards for contingency planning and resource mobilization to prevent and mitigate risks, optimize community and health system

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response capacities, and address vulnerabilities in the health system and high-risk populations (Nsenga et al. 2019).

Strategic Tool for Assessing Risks (STAR) As part of the overall objective of ensuring countries are adequately prepared to respond to major public health threats, WHO has developed the Strategic Tool for Assessing Risks (STAR). The tool provides countries with a standardized approach to risk assessment before the events occur and is critical for identifying priority health hazards with full engagement of multisectoral stakeholders (WHO 2020a). The findings feed into preparedness planning and programing with the ultimate aim of preventing or mitigating risks and related health consequences. Rapid Health Assessments The Multi-Cluster/Sector Initial Rapid Assessment (MIRA) is a joint needs assessment tool that is triggered in the event of new sudden onset emergencies or following significant sudden deterioration of ongoing emergencies due to new additional risks or changes in access to affected populations (OCHA 2015). MIRA should be initiated within 3 days of an acute crisis and should provide information on humanitarian needs and information required for response planning. The process should ideally be initiated by government, but given the context, the HCT may independently initiate the rapid assessment (OCHA 2015). The assessment includes secondary review of pre-crisis data followed by several options for data collection including observations, key informant interviews, focus group discussions, and household surveys to summarize conditions across sectors, including health (OCHA 2015). The process uses standardized flexible data tools as adapted by participating agencies to obtain data to document the critical needs of the most vulnerable (by age, gender, and other relevant groupings) in full consultation with community representatives. The findings should be shared with government, the HCT, and the affected populations with clear interventions initiated to address the pressing needs (OCHA 2015). Disease Surveillance Systems Populations affected by CEs are at increased risk of epidemics; thus the establishment of disease surveillance systems is critical for early detection and response to such epidemics. The IHR 2005 mandates countries to establish capacities to detect, report, investigate, and respond to major public health threats at all levels including points of entry (WHO 2016). IDSR strategy provides a framework for attaining the IHR 2005 core capacity requirements during emergencies (WHO 2019). In crisis-affected locations, the IDSR is complemented by the EWARN to reduce morbidity and mortality from major health threats. The optimal functioning of the surveillance systems relies on the following: • • • •

A network of trained surveillance focal points at all levels Consensus on a priority disease list for surveillance The development of capacities to detect and report priority diseases The capacities to investigate, respond, and prepare for outbreaks

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The Health Resources Availability Monitoring System The Health Resources Availability Monitoring System (HeRAMS) monitors health service availability to affected populations. The data elements captured include the static and mobile health clinics; the services provided, for example, outpatient, inpatient, maternal, and neonatal care and basic emergency neonatal and obstetric care; number of health workers by cadre; mapping of health cluster partners delivering activities; and the available health infrastructure (WHO 2009). The ultimate aim of HeRAMS is to ensure that health services are matched to the critical health needs of affected populations by documenting and addressing health service gaps on an ongoing basis (WHO 2009). Mortality Surveys A major objective of humanitarian response entails preventing excess mortality that is likely to occur given the vulnerabilities of affected populations and the absence of basic needs and poor access to essential health services. Consequently, effective humanitarian response demands that mortality estimates are derived to benchmark the effectiveness of ongoing humanitarian operations. The crude mortality rate and the mortality rate among children under 5 year are the most commonly used indicators of population mortality in complex emergencies (Kalter et al. 2014). Mortality estimates can be derived through rigorous retrospective household sample surveys requiring epidemiological and statistical expertise to execute and derive the excess mortality estimates (Kalter et al. 2014). Alternatively, in closed populations like camps, community health workers or leaders may be used to record deaths at the community level through regular home visits on an ongoing basis (Kalter et al. 2014). Post-Complex Emergency Health Needs Assessments Post-complex emergency health needs assessments are critical for deriving information on the pre-emergency baseline, the effect of the emergency, and the economic damage and impact of the CE on health (WHO 2014). The findings are used to develop post-emergency health system recovery and reconstruction plans aimed at restoring and building the health system back better. The assessment process should be multisectoral and led by government with focal points identified for each of the relevant sectors supported by recovery experts from key agencies such as WHO, World Bank, and the European Union and other health stakeholders including nongovernmental organizations, donors, and the private sector. The post-complex emergency health needs assessments should be linked to the national health sector coordination platform and the national humanitarian coordination framework (WHO 2014) and should build on all information available prior to the crisis from existing health information management systems, the MIRA, HeRAMS, mortality surveys, etc. (WHO 2014). The health sector assessment uses the changes in disease burden, performance of major health programs, and the six building blocks of the health system to establish a baseline and document the effects of the complex emergency (WHO 2014).

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Presentation and Utilization of Global Health Information The ultimate aim of any health information system is to transform health data into information that is used as knowledge and evidence to shape health decisions (WHO 2012a). The data collected from routine systems like the health information management systems, IDSR, EWARS, needs assessments, mortality estimation and HeRAMs should be analyzed to provide estimates of the crude mortality and under-five mortality rates, estimation of excess mortality, proportional morbidity, and cumulative incidence (WHO 2012a). The analyses can also be used to document trends in risk behavior for common health hazards, for estimating health service coverage, and for documenting the performance of the health system based on predefined program of humanitarian response indicators (WHO 2012a). The information generated can be presented and disseminated through publicly available online dashboards, reports, snapshots, queries, and alert notifications (WHO 2012a). The information generated should be presented during regular health sector working group meetings and reviews and during humanitarian health cluster meetings to inform needs-based allocation of resources and services (WHO 2012a). The other avenues for disseminating health information are through workshops, peerreviewed journals, peer meetings, and the media.

Global Health Services Delivery and Management of Specific Global Health Problems in Complex Emergencies Investigation and Management of Disease Outbreaks A core function of the IDSR system and EWARN is to ensure prompt investigation and response to emerging disease outbreaks (WHO 2019). The aim of the investigation entails identifying the cause and risk factors to facilitate the initiation of tailored interventions to rapidly interrupt transmission and minimize morbidity and mortality. The IDSR strategy vests the mandate of investigating outbreak on the districts where rapid response teams should be designated, regularly trained, drilled, and equipped to investigate emerging outbreaks (WHO 2019). The key steps involved in disease outbreak investigation include establishment of the existence of an outbreak, verification of the causative agent, determination of a case definition, active case search, collection and descriptive analyses of data, development and evaluation of a hypothesis, and implementation of prevention and control interventions. Please refer to the chapter on outbreak investigation and other standard epidemiology textbooks for detailed description on outbreak investigations.

Provision of Health Services for Displaced Populations The aim of providing essential health services in complex emergencies is to reduce excess morbidity and mortality; thus such services should focus on addressing the

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commonest health problems which are most likely to contribute to increased morbidity and mortality such as malaria, diarrhea diseases, respiratory tract infections, malnutrition, vaccine-preventable disease, etc. Given the high level of violence during CEs, trauma is often a major health problem which should also be considered. Such services should be of good quality and accessible with no financial hardship and ensure the privacy, dignity, safety, and confidentiality of the patient. Prioritization of services should be based on the findings of rapid health assessments, available health data in both the affected and host population, the prevailing context, and associated health risks. At the initial stages of a CE, emphasis should be on providing lifesaving healthcare services. Plans for more comprehensive health services should commence as soon as the situation stabilizes. Provision of health services for displaced population should be based on a primary healthcare (PHC) approach which prioritizes provision of basic healthcare services including preventive and curative care at both the community and health facility levels. Such services should prioritize the most vulnerable groups such as women, children, elderly, and disabled people. Depending on the context, available resources such as funds and health staff, and operational feasibility, there are various health services delivery strategies which may be used to ensure good access to and coverage of services in CE situations. This could include community-based health services delivery and mobile clinics in areas where access is a challenge due to insecurity and temporary health facilities in population displacement areas. A nearby district or regional hospital should be designated as a referral center and adequate logistics for timely referrals put in place. Appropriate planning which takes into consideration the estimated number of affected persons (and host population) that will be served and duration for which services will be delivered should be done as soon as possible. This will help to quantify the resources such as essential medicines, medical supplies, equipment, and staffing which are required. The internationally accepted assumption for making such projections and planning is that a population of 10,000 persons should have at least one healthcare facility (this may increase to 1 healthcare facility per 50,000 people in rural areas) while a population of 250,000 should have access to at least one district or rural hospital. In terms of staffing, 1–2 community health workers are required for a population of 1000 people, while a population of 10,000 people requires 23 skilled attendants such as doctors, nurses, and midwives (Damerell et al. 2011). For rapid establishment of health services in CE situations, several pre-packed kits such as the inter-agency emergency health, trauma, severe acute malnutrition, respiratory tract infection kits, etc. (WHO 2020b) are available globally and should be ordered as soon as possible. Depending on the context and available health data, the package of essential health services in CE situations should include neonatal, child, adolescent, and reproductive health services, communicable and non-communicable diseases prevention and control, nutrition including food safety, mental health and psychosocial care, environmental health, management of common

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ailments, etc. These packages are described in more details in the subsequent sections (GHC 2018). The provision of essential healthcare services should be continually supervised, monitored, and evaluated to ensure good quality and access. Low utilization of services may be due to financial or cultural barriers, poor quality of services, and overestimation of the target population, while high utilization may be attributed to underestimation of the target population, outbreak of a disease, or increased healthcare-seeking behavior. It is important to identify such problems quickly and institute the appropriate remedial actions as soon as possible.

Management of Nutrition Problems Malnutrition is a universal issue and affects every country in the world, with more than 150 million children having stunting and additional 50 million presenting with wasting. Overweight and obesity among adults is on the rise affecting 39% of adult population (UNICEF 2019). Many countries, including those caught in CEs, face a triple burden of malnutrition – a phenomenon referring to presence of undernutrition (underweight, stunting, wasting), overweight and obesity, and micronutrient deficiencies. In most man-made disasters, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are common, with children 6–59 months of age being mostly affected. SAM is fatal, usually manifesting in two forms: severe wasting signifying massive loss of body fat and muscle tissues and edema which is swelling of both feet. Both MAM and SAM may be accompanied by micronutrient deficiencies such as iron, iodine, and vitamin A deficiencies. If left untreated, SAM can result in death. The underlying causes of malnutrition include food insecurity due to drought, armed conflicts accompanied by population displacements resulting in cessation of farming activities and poor access to food, and poor dietary practices. The literature shows that in protracted CEs, childhood wasting is a leading cause of disabilityadjusted life years and reduction in life expectancy. Similarly, SAM with underlying medical conditions such as pneumonia or diarrhea is shown to be associated with higher mortality. In one study conducted among internally displaced populations (IDP) in Boko Haram conflict-affected northern Nigeria, children with SAM and comorbidities were ten times more likely to die than those without (Chamla et al. 2019). Community Management of Acute Malnutrition (CMAM) is a proven approach to manage SAM and MAM in children under 5 years and is currently implemented in more than 70 countries and in several CE situations. Under CMAM guidelines, SAM is defined based on the measurement of the mid-upper arm circumference (MUAC) of less than 115 mm and further classified as complicated when accompanied by medical condition such as pneumonia requiring in-patient treatment or uncomplicated – those attended at outpatient treatment program (OTP).

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Overview: Four components of Community Management of Acute Malnutrition (CMAM)

• Community outreach and mobilization services using community health workers to screen and identify children with acute malnutrition using MUAC tapes. • OTP for uncomplicated SAM cases using a trained health worker to treat the child according to the national protocol as an outpatient using ready-touse therapeutic food, a lipid-based, energy-dense, mineral- and vitaminenriched food specifically designed to treat SAM in children 6–59 months. The average length of OTP stay is around 56 days. • Inpatient management of complicated SAM cases using therapeutic milks (labeled F75 or F100) until the complication has stabilized. • Management of MAM using supplementary feeding programs. The flow of client for CMAM that incorporates the four components is presented in Fig. 3.

Follow-Up and Recovery Under CMAM guidelines, there are four treatment outcomes that are recorded, namely, recovery, defaulter, death, and transfer-out from inpatient to OTP. Based on these guidelines, the acceptable threshold for the above outcomes is a recovery rate of 75% and above, death rate of 10% or below, and defaulter rate of 15% or below.

Vaccine-Preventable Diseases Vaccine-preventable diseases (VPD) are group of diseases which require vaccinations, usually during childhood period, for its prevention and control and, if possible, for their eradication. These diseases include diphtheria, pertussis, polio, tetanus, measles, mumps, rubella, and Haemophilus influenzae. Measles is one of the major causes of child deaths in CEs and further contributes to mortality by exacerbating malnutrition and vitamin A deficiency. Most low and middle-income countries have established national Expanded Program on Immunization (EPI) in the 1970s, to prevent and control the VPDs; however in the past decade, re-emergence of some VPDs, in particular measles and diphtheria in countries caught in humanitarian crises, has become a public concern. Various strategies, namely, routine immunization (RI) (Table 1), supplemental immunization activities (SIAs), and selective vaccinations, are used to deliver

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Fig. 3 Flowchart of CMAM

vaccination against VPDs during CEs. Many countries deliver vaccines through standardized schedules from birth to at least 2 years of age. Due to sub-optimal coverage of routine vaccination, many countries adopt other strategies to augment uptake of vaccination, called supplemental immunization activities (SIA). These SIAs are implemented every 3–4 years in different forms which include: • National or sub-national immunization campaigns, which can be through facilitybased or house-to-house delivery of vaccinations • Accelerated or catch-up multi-antigen campaigns that deliver multiple vaccines to bolster coverage Selective use of vaccination includes vaccinations for travelers based on IHR (2005) or local context, such as yellow fever, meningitis, and hepatitis A. Vaccines are also administered in response to major outbreaks, which are common in CEs. In outbreak responses, the targeted age groups are always expanded beyond those used during the primary vaccinations to confer immunity to wider population groups. Vaccination campaigns have been used as prevention and control strategy for outbreaks of cholera, polio, yellow fever, Ebola, or diphtheria.

IPV/ bOPV sequential IPV DTP-containing vaccine

8 weeks 6 weeks

8 weeks (IPV 1st)

Antigen Age of 1st dose Recommendation for all children BCG As soon after birth Hepatitis B Option 1 As soon after birth (24 months old

HIV+ preterm neonatal booster

Considerations Not recommended for children >5 years

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Reproductive, Maternal, Neonatal, Child, and Adolescent Health More than half of all maternal, newborn, and child health deaths have been estimated to occur in fragile or conflict settings, where (RMNCAH) needs are high. Major RMNCAH concerns are widely published and include sexual violence including rape and sexual violence-related pregnancies (SVRP); sexually transmitted infections (STIs) including human immunodeficiency virus (HIV); and unintended pregnancies and abortions. In addition to women and children, most adolescent girls face an increasing risk of sexual and reproductive health (SRH) concerns and barriers to accessing healthcare during CEs. SRH services tailored to adolescents are inadequate, and evidence of their effectiveness remains limited (Jennings et al. 2019). PHC services, including essential newborn care, that are critical in addressing basic health needs for women, children, and adolescents are challenged by lack of qualified health workers, frequent stock-out of essential medicines, and low demand for services. The demand for these services is further constrained by high out-of-pocket payments, in fragile or conflict settings. However, there are some evidence-based strategies that have been shown to be effective in increasing uptake of RMNCAH services (Blanchet et al. 2017), mostly structured in a life cycle model, addressing healthcare needs in a continuum of care.

RMNCAH Services Along the Continuum of Care During emergencies, delivery of SRH services is based on the Minimum Initial Service Package (MISP) which was initially developed by the United Nations Population Fund (UNFPA). MISP is supported by Inter-Agency Reproductive Health kits (RH kits), to implement a series of interventions along the continuum of care. Detailed information of the MISP and related RH kits is available at the UNFPA website.

RMNCAH Services During Adolescence and Before Pregnancy Most interventions delivered during this period focus on raising awareness of RMNCAH needs and services; prevention and treatment of STI and HIV; prevention of unintended pregnancies through modern family planning methods, safe abortions, and management of complicated abortions; and management of the victims of sexual violence including rape. These services are delivered either as a part of the basic package of PHC services or, in some instances, in specialized facilities such as adolescent clubs that provide SRH education and awareness.

RMNCAH Services for Woman During Pregnancy, Delivery, and Postnatal Period Most health facilities provide antenatal care (ANC) services for pregnant women. WHO recommends at least four ANC visits during a pregnancy. Many countries

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have developed national strategies and standardized package of ANC services that is designed to identify maternal risk factors that will likely influence pregnancy outcomes, screen for infections such as syphilis or HIV, and monitor fetal progress. One of the challenges often seen in CEs is low percentage of pregnant women attending all four ANC visits. Innovations like the use of SMS text reminders and cash transfer schemes are on the rise to increase uptake of ANC services and attendance, though outcomes vary depending on context. Childbirth usually occurs in facilities or homes, but facility-based deliveries by skilled birth attendants (SBA) are strongly recommended. Trained personnel such as midwives are needed to perform normal deliveries in facilities and to stabilize patients with obstetric complications, such as eclampsia or hemorrhage, before referring to higher level of care. In instances of obstetric complications, which occur in approximately 15% of all pregnancies, provision of basic emergency obstetric care (BEmOC) in the designated facilities is required. WHO recommends a ratio of 1 BEmOC facility per 125,000 population. One of the major challenges in emergency settings is a lack or uneven distribution of BEmOC facilities leading to poor pregnancy outcomes and deaths. In contexts like Afghanistan, where home deliveries are high, clean delivery kits are distributed to women who are more than 6 months pregnant or to birth attendants. Home deliveries are not recommended, due to poor outcomes, and RMNCAH programs should thrive to increase awareness and reduce number of pregnant women who deliver at home. After normal delivery in the facility, mothers and newborn should receive care in the facility for at least 24 hours after birth; in the case of home delivery, the first postnatal contact should occur as early as possible within 24 hours after birth. Three additional postnatal visits should be scheduled within the first 6 weeks. In addition, community health workers (CHW) should continue to provide home visits for postnatal care for both mother and her newborn, using standardized WHO/UNICEF tools such as Caring of newborn in a community.

Essential Newborn Care Neonatal mortality is highest in low-income countries and in humanitarian crisis where the risks of complications and neonatal infections are high. The three main causes of newborn mortality are preterm complications, severe neonatal infections, and intra-partum complications. Actions to prevent newborn deaths in CEs are guided by Every Newborn Action Plan, a global plan, launched in 2014, and a Field Guide of Newborn Health in Humanitarian settings. The essential newborn care comprises of thermal care such as warming, skin-to-skin care (kangaroo mother care); infection prevention and hygiene including chlorhexidine cord care at home; exclusive breastfeeding support; breathing support, by clearing the airways and including neonatal resuscitations for newborns that do not breath spontaneously; monitoring and assessments of danger signs, such as fast breathing (>60 breaths per minute), convulsions, or high or low temperature; and postnatal care checks.

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Child Health Services Across the world, there is an unprecedented reduction of under-five mortality rate, but this decline has been uneven and less in countries caught in humanitarian crises as a result of CEs. Most of these deaths are preventable using existing interventions and mainly caused by neonatal causes, acute lower respiratory infections such as pneumonia, malaria, and diarrhea. Most child health interventions can be delivered at the PHC level using the integrated management of childhood illness (IMCI) approach which has been shown to reduce under-five mortality and improve nutrition status (WHO 2017c). At community level, integrated case management of a sick child (iCCM) has been adapted and implemented worldwide using CHWs with great success. Details of IMCI and iCCM are available at the WHO and UNICEF websites including revised versions in high HIV and TB settings.

AIDS, Tuberculosis, and Malaria The risk of HIV and AIDS, tuberculosis (TB), and Malaria is high in most emergencies. There is a raft of literature on the risk of HIV transmission among adults, mainly driven through unsafe sexual behavior, sexual violence, and in some instances unsafe drug-injecting practices and blood transfusions. Mother-to-child transmission of HIV also occurs, though data on the burden of HIV in emergency settings is often limited. TB, as an opportunistic infection, is common among the people living with HIV who have weakened immune system. The risk of developing TB is estimated to be between 16 and 27 times greater in people living with HIV than among those without. Emergencies can trigger malaria epidemics in displaced populations, particularly those displaced into new environment, who may have little immunity to malaria and inadequate access to malaria prevention interventions such as bed nets. Malaria is life-threatening and common in tropical regions, with African continent bearing over 80% of the burden. Over 86% of malaria deaths occur among children, followed by newborns and pregnant women. An inter-agency handbook of Malaria Control in Humanitarian Emergencies provides a detailed account of malaria control in these settings (WHO 2013).

HIV Prevention and Treatment There is a large body of evidence on HIV prevention and treatment, with significant advances in interventions and approaches, to reach global targets of providing HIV testing for 90% of population; 90% of those who are positive receiving HIV treatment; and 90% to be virally suppressed. New and potent anti-retrovirus drugs (ARV) are also on the rise and available in most countries in cost-effective ways. One of the most effective strategies in HIV prevention is combination prevention that encompasses behavioral and biomedical interventions. Key elements of

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combination include behavioral change interventions that reduce risky behaviors; provision and consistent use of condoms; voluntary male medical circumcision; antiretroviral therapy (ART); prevention of mother-to-child transmission of HIV (PMTCT) including early infant prophylaxis; pre- and post-exposure prophylaxis; and harm reduction programs that target key populations such as injecting drug users. Efficacy and effectiveness of these interventions have been well established at population level (Jones et al. 2014). Diagnosis of HIV infections is based on HIV testing algorithms of the country, while provision of ART and PMTCT is according to national guidelines which are mainly based on WHO recommendations. Since 2016, WHO recommended the use of ARVs for treatment for all people living with HIV irrespective of clinical or CD4 status.

Tuberculosis Prevention and Treatment In the advent of HIV epidemic, the number of TB cases have increased significantly globally. The BCG vaccine, which is part of routine immunization, is used to protect children, but its efficacy is limited. The WHO TB/HIV framework contains the Three I’s strategy, which is the prevention approach that is scaled up by many countries to address TB among people living with HIV. The strategy includes intensified case finding; isoniazid prophylaxis; and infection control (WHO 2020d). Timely treatment of TB cases is another way of preventing transmission of the disease from one person to another by eliminating TB mycobacteria from the sputum. Tuberculosis treatment is divided into two phases: the initial phase that consists of 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol and the continuation phase, which consists of 4 months of isoniazid and rifampicin. With the introduction of new drugs, these guidelines continue to evolve.

Malaria Prevention and Treatment Long-lasting insecticidal nets (LLINs), when correctly used, are one of the most cost-effective ways of preventing malaria, in addition to indoor residual spraying where sprayable surfaces are available (WHO 2013). High coverage of above 80% of the households is needed to interrupt the transmission. Other preventive methods such as insecticide-treated plastic sheets or blankets have been applied in several settings, but their effectiveness remains limited. Severe malaria is a medical emergency, and patients need prompt treatment or referral to the appropriate level of care. The most at-risk population for malaria include pregnant women, young children, malnourished children, and HIV-infected individuals. For young children and those malnourished, IMCI has been effective in identifying severely sick children and initiating treatment, but confirmatory laboratory diagnosis might also be required. Pregnant women and adults require parasitological confirmation using light microscopy or rapid diagnostic test. Treatment of malaria

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depends on the diagnosis and its classification, either uncomplicated or complicated malaria. Presumptive treatment of suspected malaria based on clinical presentation could be initiated in high endemic areas. For uncomplicated malaria, the drugs of choice recommended by the WHO are artemisinin-based combination therapies, while for complicated (severe) malaria, parenteral artesunate is the treatment of choice, given either by the intravenous or intramuscular route. Depending on complications, adjunctive or supportive treatment might be required to manage conditions such as coma, convulsions, severe anemia, shock, and hypoglycemia. During pregnancy, malaria could be fatal and linked to early termination of pregnancies and stillbirth. LLINs and intermittent preventive treatment in pregnancy are recommended to reduce the risks in malaria transmission in pregnancies.

Mental Health and Psychosocial Support Mental health and psychosocial disorders constitute a major public challenge during CEs. Recent estimates show that 22% of people affected by conflict suffer from various forms of mental disorders such as post-traumatic stress syndrome, anxiety, depression, and schizophrenia with anxiety (21.7%) being the most common form of disorder (Charlson et al. 2019). This high and sustained prevalence of mental health disorders calls for more attention to establishment of mental health services during and after conflicts. Such services should aim at addressing the determinants of mental health and psychosocial problems such as family separation, deaths, loss of properties and livelihoods, stigmatization, disruption of social structures, overcrowding, and inadequate access to social services such as health, water, and sanitation among others (IASC 2010). Four basic levels of care for mental health and psychosocial care in complex emergencies which include both preventive and curative interventions at the community and health facility levels are recommended (IASC 2007). At the bottom of the pyramid is provision of community-wide basic services which could help conflict-affected populations to better cope with the stress which characterizes conflict situations. The second level of support includes interventions such as community mobilization and education on coping mechanisms, establishment of social support networks, creation of opportunities for gainful employment to enhance livelihoods, and reunification of displaced family which are aimed at assisting affected populations who can sustain their mental health and psychosocial health under stressful conditions. The third level involves delivery of focused but non-specialized services such as emotional support, psychological first aid, and basic mental healthcare to individuals and families. Despite these interventions, there will be people either with pre-existing or acute mental health and psychosocial disorders who will require specialized and sometimes institutional care. It is important to establish a full spectrum of activities which span this pyramid during CEs. Several actions are required for establishment of mental health and psychosocial care during CEs(PAHO 2016). First, assessment of the mental health and

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psychosocial problems and the socio-cultural factors which can mitigate or potentiate them are critical for establishing tailor-made mental health programs and should be prioritized. Second, given the huge number of partners who are involved in humanitarian response during CEs, it is important to establish a coordination mechanism for mental health and psychosocial care services. The coordination mechanism should ensure that all the gaps in the mental health services are identified and filled and that mental health is mainstreamed into PHC including community-based health initiatives, school health, protection, human rights, and risk communication programs. Third, humanitarian workers should be trained to be able to identify simple mental health and psychosocial problems and to provide basic psychological first aid and refer those that require specialized services to the next level. Fourth, mental health and psychosocial support messages should be integrated into risk communication messages and community engagement programs. Fifth, efforts should be made to reduce harmful use of alcohol and drugs and ensure that key mental health and psychosocial care is available for high-risk groups (PAHO 2016).

Addressing the Social Determinants of Health The social determinants of health are the conditions in which people are born, grow, live, work, and age with these conditions being shaped by the distribution of power and resources and thus accounting for most of the health inequities. The social determinants of health play a huge role in the public health outcomes during CEs. In the context of responding to CEs, priority social determinants of health interventions include: Water and sanitation: Water and sanitation challenges are particularly common in CEs as large number of people lose access to safe water and sanitation facilities. Consequently, provision of safe water is a top priority. The water supplied should be safe for drinking and should be enough to ensure that each person can access at least 20 litre/day (Damerell et al. 2011). On the other hand, assuring adequate sanitation in CEs entails designating defecation fields in the early phase of the emergency when there is no sanitation infrastructure (Damerell et al. 2011). As the humanitarian response picks up and improves, the target should be worked toward at least 1 latrine per 20 persons and ideally, if feasible, 1 latrine per family (Damerell et al. 2011). Food and nutrition: Continued displacement of populations from their homes and farmland usually leads to loss of livelihoods and acute food shortages ultimately leading to food insecurity, thus rendering children and mothers to be vulnerable to acute malnutrition. The recommended interventions will include general food distributions that should be well planned and equitable with special considerations for vulnerable groups like children, women, and disabled. Other recommended interventions are supplemental and therapeutic feeding (Damerell et al. 2011).

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Shelter: Shelter is a basic requirement that ensures protection, security, and privacy. Shelter allows families to be protected from the health effects of harsh weather, from vectors, prevents overcrowding, and reduces the risk of rapid spread of epidemic-prone diseases. The interventions here entail support toward provision of temporary shelters, use of locally available materials, or rehabilitation of damaged shelters (Damerell et al. 2011). Ensuring sufficient space of at least 3.5 m2 per person in the household with access to water, a kitchen, soap, clothing, and blanket is required (Damerell et al. 2011).

Non-communicable Diseases Non-communicable diseases (NCDs) are the leading cause of mortality worldwide mainly due to cardiovascular diseases, diabetes, chronic respiratory diseases, and cancer. NCDs are common in low- and middle-income countries, where conflicts and humanitarian catastrophe are most prevalent. There are myriad of challenges which preclude effective delivery of NCD interventions during CEs such as weak health systems, lack of data to inform development of NCD programs, and limited prioritization of NCDs by humanitarian partners (attention is usually more on communicable diseases). Widespread exposure to unhealthy diet, tobacco use, harmful use of alcohol, and lack of physical activities are main risk factors for NCDs. Similarly, CEs appear to increase the risk of NCD-related complications. These complications could be a result of physical injuries such as direct trauma that can exacerbate NCDs; forced displacement leading to a loss of access to existing medication or disruptions of treatment; deterioration of living conditions that add to physical and psychological stress; and interruption of health services due to destruction of health infrastructure, inadequate medical supplies, and absence of qualified health workers. Addressing the risk factors for NCDs requires multisectoral interventions that go beyond health interventions that promote diverse, safe, and nutritious food that meet dietary recommendations to curb a growing problem of obesity and NCDs; tobacco control and education on harmful use of alcohol; advocacy for safe and orderly migration; increase uptake of vaccinations such as human papillomavirus (HPV) vaccination against the risk of developing cervical cancers; and addressing risk of some NCDs including cancer among people living with HIV. The effectiveness of NCD interventions in emergency settings varies among countries, but evidence overall remains limited. Most research on NCDs has focused on diabetes and hypertension. Management of NCDs requires regular availability of drugs, laboratory facilities, and trained healthcare workers, yet diversity of NCDs and emergency contexts remains a concern and requires multiple, context-specific approaches guided by available epidemiological information. However, there is strong evidence indicating that primary healthcare is one of the most cost-effective strategies in curbing morbidity, disability, and premature mortality caused by NCDs (Correia et al. 2019). These management approaches should be part of all phases of emergencies – preparedness,

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response, and early recovery/rehabilitation – and be included in humanitarian need overviews (HNO) and humanitarian response plans (HRP).

NCDs During Preparedness Phase The WHO STEPwise surveillance should be used to assess the burden of NCDs; this could be supplemented by information generated by other epidemiological studies or surveys. More importantly is the health system capacity including NCD delivery models that can be assessed and strengthened. This includes ensuring availability of essential medicines for common NCDs and referral mechanisms. Tools such as HeRAM could be adapted in emergency settings to determine health system capacity for NCDs. This tool has been successfully used to assess capacity for NCD management in conflict-affected settings such as Yemen. Efforts should be made to revise or adapt current Interagency Emergency Health Kit, designed for 10,000 populations in the first 3 months of emergency, to ensure NCD supplies are adequately included (WHO 2020b). NCDs During Emergency Response Phase NCDs should be prioritized in HNOs and HRPs and included in humanitarian updates. In addition, common NCDs must form a part of the basic package of health services and delivered as part of PHC services with clear referral mechanisms from the community to the health facility level. One way to ensure NCDs are prioritized is to include specific NCD indicators in emergency response plans or donor accountability mechanisms. Promotion of self-care among patients with NCDs and addressing individual risk factors remains important during this phase. NCDs During Early Recovery and Rehabilitation Phase Comprehensive package of NCDs needs to be considered during a recovery phase when reconstruction efforts commence. This should encompass strategies for addressing risk factors for NCDs at the population level for a long-term impact.

Trauma and Injuries Conflicts in countries such as Afghanistan and Iraq have resulted in short-, medium-, and long-term trauma needs. In Afghanistan, 18% and 47% of trauma cases ended up in death and permanent disability, respectively, in 2019, which was 18 years after the armed conflict started. Brain injuries and massive hemorrhage are the most common causes of deaths among trauma cases. In recent years, civilians are mostly affected in armed conflicts and exposed to direct attacks or to unexploded ordinance, in contrast to nineteenth-century wars, like the battle of Solferino in 1859, where military causalities were more common (Burkle 2019). Evidence shows that modern trauma systems save lives and the survival rates of individuals exposed to war injuries have more than doubled compared to Vietnam war era. Yet, in most humanitarian settings, trauma systems are weak due to collapse of health infrastructure. Among the

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established humanitarian frameworks for trauma management, current evidence points toward a trauma system that is structured in echelon of care. Echelon of care is a tiered system for managing trauma cases from the point of injury to the tertiary level of care that provides advanced surgical management of cases (Garber et al. 2020).

Humanitarian Response to Trauma and Injuries The three echelons model, comprising of trauma stabilization points, field hospitals, and referral hospitals, is recommended for the management of trauma during CEs. This model has been employed in countries such as Iraq and shown to reduce morbidity and mortality. Humanitarian agencies could contextualize this model based on the available health system and logistic capacity.

Overview: Echelons of Trauma Care

This three-tier model was adapted from the military, which used it for the treatment and referrals of war-wounded soldiers. The pathway involves: • Trauma stabilization points, which are the first point of care closer to the point where injuries occur. These are run by NGOs and often situated 10–15 minutes from the frontline. Individuals with injuries are registered, screened, and triaged at this point and receive first aid care, followed by referral to second level for those in need of higher level of care. Other interventions that are provided include resuscitations and bleeding control. • Field hospitals that are situated within 1 hour of the point of injury are the second tier of care for cases that need additional care. The package of interventions at this level might include those offered at trauma stabilization units plus early operative care, diagnostics, early critical care, airways and injury protection, pain control, and referral to the third level of care. Skilled health providers are needed at this level. • Tertiary hospital, which has surgical and intensive critical care capabilities to manage more complex cases. This level is also expected to provide postoperative care and physical rehabilitation services.

Several potential challenges to implementing echelons of trauma care in emergencies have been documented: weakened health system capacity during emergencies with limited number of trained medical personnel, poor referral, and en route medical care; limited capacity of post-operative and rehabilitation services due to poor follow-up mechanisms in insecure and unstable contexts. Coordination of the three levels of care could be a challenge as multiple agencies are involved in the echelons of care; and data collection and flow could also be impaired as multiple information systems might be introduced at each level.

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Risk Communication Risk communication entails the exchange of information that is required by public health experts and communities to identify important health risks and effectively communicate with vulnerable communities to prevent or mitigate the health risks (WHO 2018b). Vulnerable populations and their leaders should be targeted for community risk communication before, during, and after complex emergencies. The aim is to enhance community awareness about the health risks and the behaviors required to prevent or mitigate the risk of a large-scale outbreak or public health problem. At the national and sub-national level, there should be mechanisms for intersectoral collaboration when communicating risk and mobilizing the public to prepare and respond to emergencies. Risk communication should be accompanied by community engagement and participation at the community level. Countries should be supported from regional and global levels with guidance on inter-agency communications as well as technical assistance on improving risk communications, social mobilization, and empowering communities to manage risk (WHO 2018b).

Operational Platforms for the Management of Complex Emergencies and Global Health Impact CEs are usually characterized by insecurity, lack of access, weak national systems and institutions such as banking and financial management systems, disruption of local economies, and weak infrastructure which constitute operational challenges to smooth running of emergency public health operations. Thus, an efficient and effective operational platform is required as a backbone to address these challenges. Sufficient resources such as staffing, funds, and essential medicines, supplies, and equipment are required in the right quantity and quality to facilitate timely and unhindered implementation of planned activities. Planning for these resources is a critical component of the management of CEs and should take into consideration the challenging operational contexts. Such considerations often include availability of critical human resources skills locally, banking systems and cash in operational areas, physical access to operational areas, availability of medical and other supplies in local markets, security, transportation limitations, and communication means. To ensure optimal operational support to public health emergency operations, three main operational platforms are required, namely, general administration and human resources, finance and budget management, and operation support and logistics (WHO 2017b). The general administration and human resources platform supports the development of human resources needs and plans, recruitment, deployment, management, retention, and performance evaluation of various categories of staff who are required to manage the emergency operations. This component should also monitor the implementation and evaluation of the human resources plans. The finance and budget management platform should enable smooth running of

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emergency operations through provision of the required financial management support. This platform involves the development of emergency operation plans and budgets and ensures efficient allocation, usage, tracking, and reporting on the budget utilization and financial implementation. The operational support and logistics platform is critical and provides the logistic functions which are required for program implementation. This platform has three sub-components, namely, procurement and supply chain management, operational support including security, and medical logistics. The procurement and supply chain management sub-component supports the quantification, procurement, transportation, storage, and inventory management and distribution of all non-medical supplies, equipment, and logistics required for effective implementation of the emergency public health projects. Operational support sub-component ensures availability of facilities such as office and residential accommodation, vehicles, information and communication technology, and recreational and other facilities which ensure the welfare, safety, and security of the emergency responders. The medical logistics sub-component is a specialized field which provides the support that is needed to forecast, procure, transport, store, and manage essential medicines, medical supplies, and equipment such as cold chain and laboratory equipment and supplies. Depending on the local context, innovative approaches for the implementation of these platforms are required to overcome the aforementioned challenges. For instance, the issue of cash transfers and availability in areas with no banking systems can be addressed by using third-party cash delivery companies, mobile money transfers, or other innovative means such as food-for-work (Majid 2007; Harvey and Bailey 2011). Furthermore, organizational bureaucracies which retard rapid program implementation can be overcome through delegation of authority, development of emergency standard operating procedures, and implementation of a “no regret” policy (WHO 2017b).

Health System Recovery After a Complex Emergency A systematic and sustainable approach to post-complex emergency recovery of the health system is required given the severe impact that conflicts have on the health system. It is an opportunity to build the health system back better than it was before the conflict and should be implemented as part of the broader conflict resolution, reconciliation, and state building objectives. It should focus on full restoration of health services delivery and should be seen as one of the dividends of peace. Postconflict recovery of a health system involves the rehabilitation and improvement of all the six building blocks of the health systems such as health governance and oversight system, human resources for health, medical supply chain management system, financing of the health sector, health information management systems, and the infrastructure required for health services delivery (unpublished WHO document).

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Goal, Objectives, and Triggers for Post-Conflict Health System Recovery The goal of post-conflict health system recovery is to ensure equitable and sustainable access to health services which should in turn result in reduction in excess morbidity and mortality during the post-conflict phase of a complex emergency. The specific objectives are to determine the extent of disruption of the health systems, address the immediate gaps in health services delivery, build resilience of the health system, and bridge the humanitarian development nexus. Given that the three phases of the emergency management cycle overlap, it is important to commence health system recovery planning and implementation as soon as possible. Recovery interventions should be mainstreamed into humanitarian response efforts as a foundation for future health system recovery. For example, health data which are required for health recovery planning may be collected during the humanitarian’s response phase. Although there is no recommended timeline on when implementation of recovery activities should commence, this could be guided by important conflict resolution events such as the signing of a cessation of hostility or peace agreement, ceasefire with reduction in violence, and return of displaced populations back to their original places of abode. However, a health system recovery strategy and operational plan should have been developed and costed long before this.

Guiding Principles for Post-Conflict Health System Recovery Health system recovery should be guided by some key principles to ensure effectiveness and sustainability. First, national ownership and leadership of the planning, implementation, and monitoring process are critical although the lack of a substantive governance structure immediately after a conflict may make this difficult. Second, health system recovery processes should be evidence-based, aligned with, and integrated into national development and health policies and health sector strategic plans. Third, a bottom-up approach which ensures engagement and participation of all stakeholders including the community and civil society should be deployed for health system recovery. Fourth, health system recovery should be done alongside recovery of the other sectors such as water, sanitation, education, shelter, etc. to maximize its impact. Fifth, cross-cutting issues such as gender, HIV/AIDS, mental health, reproductive health, age, equity, human rights, and right to health should be mainstreamed into all health system recovery efforts. Sixth, realistic goals and targets should be set for health system recovery, and a stepwise approach should be used to progressively scale up health system strengthening and services delivery (unpublished WHO document).

Key Steps in Post-Conflict Health System Recovery There are five critical steps required for systematic health system recovery. It is important to note that these steps are non-linear and could be implemented at the

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same time based on the needs (unpublished WHO document). The six WHO health system building blocks provide a good framework for implementing all the key steps of post-conflict health system recovery.

Establishment of Baseline Status of the Health System and Public Health Gathering of information on the baseline status of the conflict-affected area or country, its health system, and health status is critical for setting goals and measuring progress of the health system recovery efforts and should be one of the early steps in the health system recovery process. It involves collection of background data and information on the affected areas such as the socioeconomic and demographic status, conflict and humanitarian context, performance and status of the health system and public health, health services availability, access and utilization, and pre-existing health risks, including analysis of the social determinants of health, health vulnerability, and analysis of health stakeholder. Various methodologies such as desk review of documents; health facility or community-based surveys such as the HeRAMs or the Service Availability and Readiness Assessment (SARA); workshops with the MOH, together with partners; and semi-structured interview with MOH and provincial/district health authorities, NGOs, UN agencies, donors, etc. should be used to collect the data and information which are required for establishing the baselines. A list of the various sources of data and information for establishing baselines is presented in Box 1. Box 1 Sources of Information for Establishing Baseline Reports

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16.

Post-conflict needs assessment report. Health information management system documents. Integrated disease surveillance and response system documents. Demographic and household survey reports. Services availability and readiness assessment report. Multisectoral initial rapid assessment. Emergency response plans and appeals (e.g., the IASC flash appeal and/or the humanitarian response plans). Nutrition survey reports. Malaria indicator surveys. HIV sero-behavioral surveys. Vulnerability and risk analysis and mapping reports. National health sector strategic plans. Health program-specific reports and strategies. Previous post-disaster/conflict recovery strategies and plans. Context, conflict, and fragility analyses can be found in country-specific publications, such as the International Crisis Group at http://www. crisisgroup.org/, the Economist Intelligence Unit at http://www.eiu.com/ index.asp?&rf¼0, and the “new deal for peace” initiative at http://www. newdeal4peace.org/new-deal-pilots/. Disaster data and trends from the Centre for Research on the Epidemiology of Disasters http://www.cred.be/.

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Post-emergency Health Situation Analysis and Needs Assessment The situation analysis and needs assessment draw data and information from the baseline to describe the impact of the conflict on the health status of the affected population (including numbers of deaths and injured and the burden of disease), performance of the main health programs, status of healthcare infrastructure and their readiness to deliver health services, and pattern of demand for health services. In addition, the situation analysis describes the pre-existing health risks, vulnerabilities, and capacity for governance among others. The situation analysis provides the basis for prioritization of interventions and development of monitoring and evaluation framework for health system recovery.

Health System Recovery Option Analysis and Prioritization Due to the huge impact that conflicts have on health, the post-conflict health system recovery needs often outweigh the available resources, hence the need to prioritize. The prioritization exercise should cut across all sectors and within the health sector to ensure that minimum package of social services is available in the post-conflict period. Recovery option analysis and priority setting should identify the most critical interventions which have the highest impact on improving the public health outcomes of as many of the affected population as possible. Prioritization could be done using consensus or expert opinion; whatever method that is used should have clear criteria such as the burden of disease, cost-effectiveness of interventions, equitable distribution of health services in terms of health services package and geographical coverage, and ease of implementation of the required intervention among other considerations. The prioritization exercise should also take into consideration realistic phased approaches for implementation and sequencing of interventions. This should include identification of immediate interventions to reduce the health impact of the conflict and to address acute health risks, followed by medium- to longer-term health system recovery interventions such as health system strengthening and resilience building. For instance, in the first phase of health system recovery, damaged infrastructure can be substituted with temporary buildings or mobile clinics which are replaced by more permanent structures as the situation improves.

Development of a Health System Recovery Strategy and Plan Translating the priorities identified in the preceding step into concrete actions requires a health system recovery strategy and operational plan which is costed. Both documents are important for decision-making, advocacy, resource mobilization, monitoring, and evaluation. The strategic document broadly describes the goal,

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general objectives, and actions which are required to recover the health system and elaborates the various evidence-based strategies for translating the objectives and actions into concrete health outputs and outcomes, while the plan operationalizes the strategic document. The operational plan should include description of the detailed activities which should be implemented to achieve the goals and objectives of the strategic document and define who will do what, where, and when and how all health partners will work together to achieve the health system recovery targets. Preferably, the strategic document is developed at the national level, while detailed operational plans are developed and implemented at the sub-national levels such as the region, province, or district. Preparatory steps involved in the development of health system recovery strategies and plans include establishment of a coordination structure to manage the process and preparation of a plan and budget for development of the strategy with clear timeline, terms of reference, and budgets. Other critical steps include consultation with stakeholders, gathering of required data and information, and organization of strategy development workshops among others. The main contents of a health recovery plan are highlighted in Box 2, while the key programmatic issues to consider are highlighted in Table 2.

Box 2 Critical Components of a Health System Recovery Plan (adapated from unpublished WHO document)

1. Background information, including pre-disaster baseline and disaster/conflict context. 2. Situation analysis and impact of the disaster/conflict. 3. Priorities and health system recovery option analysis including policy options to address needs; it is important to ensure that the policy options are harmonized and aligned with the national health policies and strategies of the affected country. 4. Evidence-based strategies to recover the health system, including goals and objectives, based on realistic building back better approaches. 5. Institutional framework for the governance and management of the health system recovery. 6. Monitoring and evaluation framework including benchmarks and targets for monitoring progress in the recovery process. 7. Funding mechanism and resources for the health system recovery process; this section should also address how budgetary control issues such as Medium Term Expenditure Framework ceilings will be addressed. 8. Conditions, which have to be met, and the potential risks which have to be addressed for the recovery efforts to take place, such as commitment and allocation of resources from government and development partners to implement the recovery strategy and plan, stability, and security.

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Table 2 Key programmatic issue to consider when planning health system recovery (adapted from an unpublished WHO document) Health system domain Health leadership and governance

Human resources for health (HRH)

Health financing

Medical products, vaccines, and technology

Key programmatic issues Assessment of the governance and leadership performance and capacity of the health sector Establishment or strengthening of health sector coordination structures such as the health sector working group, annual sector, and program reviews Development or review/update of a health sector strategic plan and guidelines for various health programs Establishment or revision of a national supervision, monitoring, and evaluation framework, including accountability mechanisms for health services delivery Strengthening of the health regulatory functions of government Assessment of the impact of disaster on HRH, HRH needs, identification of gaps and resources needed for staff recruitment Development of policy for scaling up HRH production, absorption, and retention Standardization of HRH training packages, accreditation, validation, and licensing Strengthening of health training institutions such as schools of nursing and community health workers training schools to rapidly increase HRH pool Establishment of mechanisms for regular mentoring, monitoring, supervision, and evaluation of HRH Development of health financing strategy Establishment of risk pooling mechanisms such as community and social insurance, social/emergency security funds, subsidization of treatment for children, women, etc. to reduce financial barriers for access. Establishment of National Recovery Trust Fund or MultiDonor Trust Funds Establishment of national budgetary line for recovery and dialogue with Ministry of Finance (MOF) to increase budgetary ceilings where they exist Advocacy for increasing the national health budget to the Abuja declaration target of 15% of the government’s budget Strengthen government financial management systems and establish mechanisms for financial coordination and accountability Development of national essential medicines and medical product list Improvement of the supply chain management system through establishment of logistics information system for monitoring consumption, inventory, and timely quantification and procurement Restoration of national pharmaceutical production capacity Institution of quality assurance mechanisms for medical products, vaccines, and equipment Standardization of medical equipment according to levels of care and strengthening maintenance functions and skills Strengthen the cold chain (assessment, training procurement, and distribution) (continued)

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Table 2 (continued) Health system domain Health Information Management System (HIMS)

Health services delivery

Key programmatic issues Development of a national health information management policy and guidelines Support to establish integrated health information systems such as the health information management system, integrated disease surveillance and response system, early warning, alert and response systems, etc. Development of standardized tools, standard operating procedures, and equipment for data collection, analysis, reporting, and feedback Establish or revise basic healthcare package to address existing post-conflict situation (e.g., mental health, disabilities) Develop a health infrastructure rehabilitation and reconstruction plan Develop and implement behavioral change communication to address health inequity Develop and implement community-based health initiatives such as outreaches and community health workers program to improve utilization and service coverage Establish or strengthen referral services (communication, transport, and logistics) Establish protocols for services delivery; staff/facility performance; patient safety

Health System Recovery Program Implementation, Supervision, Monitoring, and Evaluation Inadequate local capacity for program implementation is often a challenge during the post-conflict situations; hence development of a health system recovery implementation arrangement which focuses on rapidly strengthening capacities of local health authorities to assume leadership of health system recovery program implementation is critical. In this regard, development of strategies for smooth transition from humanitarian to recovery or development programming and coordination is required. This strategy should invest in strengthening of government’s leadership, oversight, coordination, and support supervision capacities to ensure a smooth take-over. To ensure that the health system recovery process is well managed and that its goals and targets are met in a timely and efficient manner, a health system recovery coordination, supervision, monitoring, and evaluation structure which cuts across all the above steps is required. Importantly as well, the health system recovery planning process and plan need to be financed, thus requiring a structured budget. The budget should include the cost of the five critical steps listed above as well as estimation of the cost required for reconstruction; mobilization of required resources such as healthcare staff, essential medicines, medical supplies, and equipment; capacity building; restoring health services delivery; and supporting governance functions

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for services delivery and recovery. The health system recovery financing framework should highlight the strategies for resource mobilization, allocation, tracking, and reporting.

Conclusion CEs have very significant impact on global health and its social determinants, health systems, and the social as well as economic development of affected populations. They are obstacles to the attainment of the sustainable development goals in many countries and contribute significantly to excess morbidity and mortality. It is therefore critical to ensure systematic approaches to the management of their public health consequences. Such approaches should be underpinned by guiding principles such as human rights and right to health, equity which ensures no one is left behind, community participation, and sustainability among others. Moving forward, it is critical to regularly build the capacity of humanitarian stakeholders and partners on the principles of preparing for, responding to, and recovering from the public health consequences of CEs.

Acronyms ANC ART ARV BEmOC CE CHWs CMAM EPI ERC EWARN HC HCT HeRAMs HNO HRH HRP HRT IASC iCCM IDP IDSR IHR 2005

Antenatal care Antiretroviral therapy Antiretroviral Basic Emergency Obstetric Care Complex emergencies Community health workers Community Management of Acute Malnutrition Expanded Program on Immunization Emergency Relief Coordinator Early warning and alert networks Humanitarian Coordinator Humanitarian Country Team Health resources availability monitoring system Humanitarian need overviews Human resources for health Humanitarian response plans Humanitarian Regional Teams Inter-Agency Standing Committee Integrated case management of a sick child Internally displaced persons Integrated disease surveillance and response International Health Regulations 2005

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IMCI IMS INGO LLINs MAM MIRA MISP NCD NGO OCHA OTP PHC PHEOC PIN PMTCT RMNCAH SAM SARA SRH STAR STIs SVRP TB UN UNCT UNFPA UNIDSR VPD VRAM WG WHO

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Integrated management of childhood illness Incident management system International nongovernmental organization Long-lasting insecticidal nets Moderate acute malnutrition Multi-Cluster/Sector Initial Rapid Assessment Minimum Initial Service Package Non-communicable diseases Nongovernmental organization Office for the Coordination of Humanitarian Affairs Outpatient treatment program Primary healthcare Public health emergency operations center Population in need Prevention of mother-to-child transmission of HIV Reproductive, maternal, neonatal, child, and adolescent health Severe acute malnutrition Service Availability and Readiness Assessment Sexual and reproductive health Strategic Tool for Assessing Risks Sexually transmitted infections Rape and sexual violence-related pregnancies Tuberculosis United Nations United Nations Country Team United Nations Fund for Population Activity United Nations International Strategy for Disaster risk Reduction Vaccine-preventable diseases Vulnerability and risk analysis and mapping Working group World Health Organization

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OCHA (2015) Multi-sector initial rapid assessment guidance – revision July 2015 | Humanitarian response [Internet]. [cited 2020 Apr 16]. https://www.humanitarianresponse.info/en/programme -cycle/space/document/multi-sector-initial-rapid-assessment-guidance-revision-july-2015 OCHA (2020) The cluster approach. New York. https://www.humanitarianresponse.info/en/aboutclusters/what-is-the-cluster-approach. Accessed 20 Apr 2020 Olu O, Usman A, Manga L, Anyangwe S, Kalambay K, Nsenga N, et al (2016) Strengthening health disaster risk management in Africa: multi-sectoral and people-centred approaches are required in the post-Hyogo framework of action era. BMC Public Health [Internet]. [cited 2020 Apr 16] 16(1):691. http://bmcpublichealth.biomedcentral.com/articles/10.1186/ s12889-016-3390-5 Pan American Health Organization (2016) Technical guideline for mental health in disaster situations and emergencies. https://www.paho.org/disasters/index.php?option¼com_docman& view¼download&category_slug¼mental-health&alias¼2543-technical-guideline-for-mentalhealth-disaster-situations-emergencies-2016-543&Itemid¼1179&lang¼en. Accessed 15 Apr 2020 Pettersson T, Högbladh S, Öberg M (2019) Organized violence, 1989–2018 and peace agreements. J Peace Res 56(4). https://doi.org/10.1177/0022343319856046 Sondorp E, Kaiser T, Zwi A (2001) Beyond emergency care: challenges to health planning in complex emergencies. Tropical Med Int Health [Internet]. [cited 2020 Apr 16] 6(12):965–970. https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-3156.2001.00821.x Spiegel PB, Le P, Ververs MT, Salama P (2007) Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995–2004). Confl Heal 1:2 UNICEF (2019) The state of the world’s children 2019. Children, food and nutrition: growing well in a changing world. UNICEF, New York UNISDR (2009) 2009 UNISDR terminology on disaster risk reduction | UNDRR [Internet]. [cited 2020 Mar 22]. https://www.undrr.org/publication/2009-unisdr-terminology-disaster-riskreduction United Nation High Commissioner for Refugees (2001). https://www.unhcr.org/partners/partners/ 3ba88e7c6/coordination-complex-emergencies.html. Accessed 31 Mar 2020 Uppsala University (2018) Uppsala conflict data programme. https://ucdp.uu.se/encyclopedia. Accessed 31 Mar 2020 World Health Organization (WHO) (2009) WHO | Health cluster guide [Internet]. WHO. [cited 2016 Jun 13]. http://www.who.int/hac/global_health_cluster/guide/en/ World Health Organization (WHO) (2012a) Framework and standards for country health information systems, 2nd edn. WHO, Geneva World Health Organization (WHO) (2012b) WHO | Rapid risk assessment of acute public health events [Internet]. [cited 2020 Mar 25]. https://www.who.int/csr/resources/publications/HSE_ GAR_ARO_2012_1/en/ World Health Organization (WHO) (2013) Malaria control in humanitarian emergencies: an interagency field handbook. World Health Organization, Geneva World Health Organization (WHO) (2014) Post-disaster needs assessment guidelines [Internet]. [cited 2020 Apr 16]. https://www.who.int/publications-detail/post-disaster-needs-assessmentguidelines World Health Organization (WHO) (2016) WHO | International Health Regulations (2005) [Internet], 3rd edn. [cited 2020 Jan 14]. https://www.who.int/ihr/publications/9789241580496/en/ World Health Organization (WHO) (2017a) WHO | A strategic framework for emergency preparedness [Internet]. [cited 2020 Mar 22]. https://www.who.int/ihr/publications/97892415 11827/en/ World Health Organization (WHO) (2017b) WHO | Emergency response framework (ERF) [Internet]. [cited 2020 Mar 22]. https://www.who.int/hac/about/erf/en/ World Health Organization (WHO) (2017c) Integrated management of childhood illness (IMCI). The World Health Organization, Geneva. https://www.who.int/maternal_child_adolescent/ topics/child/imci/en/

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Humanitarian Crisis and Complex Emergencies: Burden of Disease, Response, and Opportunities for Global Health Benjamin Schmid and Emmanuel Raju

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Humanitarian Crises’ Impact on Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burden of Disease and Humanitarian Health Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burden of Disease Trends in Humanitarian Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-Cutting and Interconnected Themes of Humanitarian Health Efforts . . . . . . . . . . . . . . Case Study: Iraq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Humanitarian needs are at an all-time high due to crises becoming increasingly protracted and complex, with more frequent disasters through climate changeintensified hazards, unprecedented global displacement, and changing social, political, and economic contexts. A new normal of humanitarian settings has emerged, i.e., of increasingly connected and urbanized populations, affecting settings beyond low-income countries, including associated trends in ageing, a progressing epidemiological transition, and the use of digital technologies. Actors are challenged to address these emerging needs, while not neglecting persisting health challenges, demanding for resource-constraint systems to address a triple burden of disease in unfamiliar settings. There is also an increased sense of urgency through elevated risks of global pandemics. The pressure to reform traditional humanitarian health efforts and to include systemic and preventive B. Schmid (*) Global Health Section, University of Copenhagen, Copenhagen, Denmark e-mail: [email protected] E. Raju Global Health Section, Department of Public Health and the Copenhagen Centre for Disaster Research, University of Copenhagen, Copenhagen, Denmark e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_128

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approaches is increasing. However, to fully harness this momentum, there is a need for accelerating research on evidence-based models of care, a more sincere and diverse collaboration agenda and the evolving of a sensible digital humanitarianism. If anything, actors are to expect an acceleration of these trends, through increasingly manifesting climate change impacts, with expanding caseloads and changing needs. Simultaneously, the diversity and heterogeneity of the humanitarian sector are changing, with newly emerging actors and funders, host state assertiveness, and blurring with the development sector. With the interconnectedness of our world, the global health field is to recognize humanitarian crises not as isolated outliers but as fundamental to achieve good health for all. Keywords

Humanitarian crises · Burden of disease · Non-communicable diseases (NCDs) · Disease outbreaks/pandemics · Climate change · Determinants of health

Introduction More people are impacted by humanitarian crises today than ever before in recorded history. Within 10 years the number of people forcibly displaced has risen from around 43 million (2009) to 79.5 million (2019), around 1% of the world’s population, amplifying the need for humanitarian assistance globally (UNHCR 2020). This increase, with a relatively stable number of refugees, was fuelled by a surge of internally displaced persons (IDPs) (UNHCR 2020). Since 2008, the average length of humanitarian crises has increased from 6.2 to 9.3 years in 2018 requiring longerterm humanitarian responses (UNOCHA 2019). The last decades have also seen a major shift of the frequency, severity, and characteristics of humanitarian crises. The number of armed conflicts globally is at a historical low; however, wars are more protracted and intrastate, and violence against civilians more frequent (Spiegel et al. 2010), and, as recent years have shown, these gains are unstable (UNOCHA 2019). Disasters intensified through climate change are increasingly severe and more frequent due to changing patterns of, particularly hydrological and meteorological, hazards (Masson-Delmotte et al. 2018). Yet, disasters are not the mere occurrence of hazards but rather their contextual interplay with the populations at risk and their social, political, and economic realities, shaping the vulnerabilities and exposure of communities (Abubakar et al. 2018). Rapid rates of unsustainable urbanization, coastal land development, and environmental degradation have left large population groups vulnerable to, now accelerating, hazards (Abubakar et al. 2018; IPCC 2014). “Humanitarian crisis,” in the absence of a universal definition, is used here to refer to both disasters and armed conflicts, while “humanitarian setting” is used to refer to an area affected by a humanitarian crisis. The different, often-used categorizations of disasters, into natural and man-made, are artificial and may only be partially useful, as all disasters could be considered human-made with hazards solely turning into disasters in the specific socio-cultural and political contexts. Disasters

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can thus never be “natural.” A more relevant differentiation to give an understanding of humanitarian health approaches is whether a setting is conflict-affected or not, as it shapes actors and their agendas, the power dynamics, risks, and access issues involved. This may also advance the discussion around the universal applicability of the humanitarian principles and the humanitarian-development nexus (Labbé 2012). Furthermore, it may bring more attention to the intersection of disasters and armed conflicts, which are often investigated separately (Jawad et al. 2019) despite their frequent co-occurrence (UNOCHA 2019). “Complex emergencies” describe this overlap and are characterized by a considerable breakdown of authority (including frequent intrastate armed conflicts), needs beyond the mandate or capacity of a single agency, large-scale displacement, access and security issues, human rights abuses, and widespread damage and loss (Inter-Agency Standing Committee 1994). These terms are often applied rather inconsistently in research and practice. Humanitarian crises are also characterized by severe health impacts and the disruption of public functioning, including healthcare services. The populations affected are disproportionally those in low- and middle-income countries (LMICs), constituting 95% of disaster-related deaths from 1970 to 2008 (Field et al. 2012). Lower-resource countries also face greater relative economic disaster-related disruptions, threefold higher for low-income (LICs) and tenfold higher for middle-income (MICs) countries, compared to high-income countries (Field et al. 2012). The disease burden in LICs is dominated by communicable (or infectious) diseases as the biggest contributor to disability-adjusted life years (DALYs) (59% in 2017), followed by non-communicable diseases (NCDs) (33%) and injuries (8%) (Institute for Health Metrics and Evaluation 2020). The differentiation of communicable and non-communicable diseases is typically done by their transmissibility and chronicity. With most humanitarian settings traditionally occurring in LICs, in rural or camp-based settings with a relatively young population, the sector’s health efforts and core capacities were organically streamlined toward short-term episodic care for communicable diseases and injuries and basic human needs (e.g., food, water, shelter) (Tellier et al. 2018; Rabkin et al. 2018). Due to changing characteristics of humanitarian settings in the last decades, some contexts have seen an increasing NCD prevalence in the affected population leading to a double or triple burden of disease and bringing new sets of challenges. This creates a new normal for humanitarian health efforts and further challenges an already stretched system. Despite humanitarian settings often being sidelined in global health as outliers, they affect an unfortunately large number of people globally and cannot be neglected in the global agenda, if the Sustainable Development Goals (SDGs) are to be achieved. At times of increasing humanitarian caseloads and external transitions, there are also disruptions from within the sector due to changing patterns of financing, geopolitical landscapes, technological advancements, and blurring with the development sector (UNGA 2016). The last decades have seen an increasing professionalization and structuring of the humanitarian response, with major improvements in humanitarian logistics and health programming (Dette 2018). Yet, at the same time, the scope of this professionalized humanitarian enterprise has been frequently called into question. The stated aim of reducing the mortality and protecting the dignity of

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vulnerable populations gives rise to several practical questions and dilemmas. Should a humanitarian response only aim at “normalcy,” based on appropriate baselines, or should there be a focus on improving the situation of people affected by a crisis, a build-back-better approach? The trends discussed in this chapter are fitting examples of how these concerns are playing out in practice, such as needs of affected populations that are at odds with a pure focus on mortality reduction and health issues (with their possible solutions) that are at system rather than at individual level. In the past years, there has been an increasing focus of humanitarian actors to engage in longer-term and systemic perspectives in their health programming, particularly through the agendas of sustainability of humanitarian interventions and resilience (Tellier et al. 2018). Such approaches, while valuable, cross into what would traditionally be carried out by development actors, reigniting practical questions around the decade-long discussion on the humanitarian-development nexus and dilemmas around the humanitarian principles of humanity, impartiality, neutrality, and independence (Tellier et al. 2018). Simultaneously, the number and diversity of (international) humanitarian actors responding to different crises as well as those engaged in health have accelerated drastically (Tellier et al. 2018; Raju and Becker 2013). This demands a stronger coordination and collaboration between actors in the humanitarian response while, at the same time, ironically, increasing the competition within the humanitarian sector requiring actors to diversify their financing strategies, despite generally increasing humanitarian funding (UNOCHA 2019; Raju and Becker 2013). A changing set of donors, including the private sector and emerging economies, with their own (geopolitical) agendas and approaches (e.g., favoring bilateral channels) further increase the complexity of the system (Labbé 2012). This trend is accelerated through the technological agenda, reducing the threshold of humanitarian action for informal actors (e.g., remote volunteering) and giving rise to a new set of relevant private sector actors developing technologies (e.g., publicprivate partnerships), both beyond the traditional humanitarian system and its institutionalized coordination mechanisms and likely unfamiliar with its principles (Labbé 2012; Sandvik et al. 2014). Technologies are, in conjunction with the localization agenda of humanitarian aid that emerged in 2016, changing the face of the formal international humanitarian system and the relationship between “helper” and “the helped,” particularly through “remote” programming accelerated by elevated risks for actors (Burkle et al. 2014; UNGA 2016; Sandvik et al. 2014). While most of these “internal” trends are beyond the scope of this chapter and will only be addressed partially, they provide an essential mental frame for contextualizing the discussed trends below. The burden of disease refers to the impact of health conditions measured by a variety of indicators (e.g., DALYs) and their composition in a given population, differentiating at a highest level between injuries, NCDs, and communicable diseases (Institute for Health Metrics and Evaluation 2020). This chapter does not intend to give a comprehensive overview of each one of these disease groups in humanitarian settings but rather has the aim to explore related key trends and their associated challenges, dilemmas, and opportunities. It complements these general trends by examining the impacts of three cross-cutting themes and how they shape

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the burden of disease in humanitarian settings and the targeted health efforts of humanitarian actors. It focuses mainly on health systems and issues but takes a broader perspective where relevant and necessary to understand health in humanitarian settings (e.g., the wider humanitarian sector). It takes point of departure in an expanded view of humanitarian actors, by including the formal national and international humanitarian organizations as well as efforts by the national government and other entities providing humanitarian health aid. Definitions

Armed conflict

Complex emergency

Disaster

“a contested incompatibility that concerns government and/or territory where the use of armed force between two parties, of which at least one is the government of a state, results in at least 25 battlerelated deaths in one calendar year” (Uppsala Universitet 2020) A humanitarian crisis in a country, region, or society where there is a total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and an intensive and extensive political and management coordination (Inter-Agency Standing Committee 1994). “A serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources.” (UNISDR 2017)

Humanitarian Crises’ Impact on Health Humanitarian crises can lead to widespread mortality and may disrupt essential aspects of public functioning of a national society or regional community. While estimates show a promising decline in death tolls from historic levels to recent crises, it is of concern that health impacts remain extensive despite the main burden being attributable to preventable causes (Tellier et al. 2018). The critical pathways of how increased mortality may occur are highly dependent on the unique setting of a given crisis, while some similarities on their impacts exist across events. Characteristics

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that define the health impacts and their severity are the type of disaster (e.g., starvation in droughts vs. injuries in earthquakes); the disaster phase (e.g., injuries in early phases vs. communicable diseases at later stages due to displacement); age/ sex (e.g., higher observed mortality rates in children under five, for women or men); battle-related deaths (e.g., the percentage of battle-related to non-battle-related deaths in intrastate vs. interstate armed conflicts); physical/economic environment (e.g., disruptions of livelihoods); population/health system resilience (e.g., level of education of population and trust into authorities); and forced displacement (e.g., risk exposure due to displacement) (Tellier et al. 2018). Generally, there has also been less of a focus on the morbidity of diseases and longer-term and less tangible health outcomes (e.g., functionality, quality of life), due to the difficulty of assessing these impacts, leading to an underestimation of mental health conditions and chronic diseases (Blanchet et al. 2013). An often-used differentiation of crisis’ health impacts is that of direct versus indirect effects, shaping possible responses. Direct effects describe those immediately triggered by the event and typically capture injuries, such as those caused by collapsing buildings during earthquakes or battle wounds in armed conflict settings. Most health impacts, however, will be caused with a certain degree of mediating factors and complexity of impact pathways, typically through the disruption of the formal healthcare system or informal structures promoting good health. A wellfitting example here is the effects of crisis-associated population displacement, discussed throughout the chapter. “Displaced populations” refer to both refugees and IDPs, while the latter often face worse health outcomes depending on the severity of displacement, particularly compared to non-displaced and host populations (Spiegel et al. 2010). The impacts are moderated through their continuous movement or worse living circumstances limiting access to food, shelter, water, and health services, a greater environmental exposure (e.g., overcrowded camps), more challenging security issues, unclear international mandates, and the disruption of normalcy creating excessive stress (Watts et al. 2015; Abubakar et al. 2018). These conditions create fertile grounds for the proliferation of diseases and social tensions. Multiple other population groups have similarly unique needs in healthrelated matters (e.g., elderly, women, children, young males, persons living with a disability, or people with a certain sexual orientation or gender identity) defining the pathways of indirect health impacts (UNOCHA 2019). An adequate discussion of these group’s dynamics would be beyond this chapter’s scope; however, any health effort is misplaced if not acknowledging such specific needs, and thus respective complementary materials from the various humanitarian actors should be consulted. The disruption of the healthcare system across multiple or all building blocks – as conceptualized by the World Health Organization (WHO) – is one of the key indirect health effects caused by a crisis. This includes impacts on facilities and services (e.g., destroyed facilities), equipment and technology (e.g., damaged transport routes, loss of power), health workforce (e.g., major displacement), financing and governance (e.g., draining of national resources, absence of national authorities, shift in national (health) priorities), health information (e.g., disruption or fragmentation of health information processes), and medicines (e.g., interruptions of supplies, blossoming of

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a black market) (Besanc¸on et al. 2015; Ryan et al. 2015; Jawad et al. 2019). The extent of these effects will be determined by the type and severity of the crises as well as the pre-crises context, including a healthcare system’s emerging and adaptable property to withstand the impact of crises, captured by the concept of resilience (Kruk et al. 2015a). Resilient health systems, according to Kruk et al. (2015a), have shared characteristics of being aware (an up-to-date health information system and knowledge), diverse (capacities to respond to a variety of threats; e.g., primary care systems), self-regulating (appropriate capacities beyond essential services to quickly respond and maintain the functioning of the core system), integrated (effective coordination and collaboration between a diverse set of actors), and adaptive (the ability to respond to changing threats). While the concept is dominated by discussions around communicable disease outbreaks, especially the Ebola crisis in West Africa in 2013, it is applicable more widely including the resilience of healthdefining sectors per the idea of “health-in-all-policies” (e.g., energy, food, agriculture, urban planning, energy) and in the context of climate change adaptation. Beyond formal (health) systems, communities themselves and their structures are at the core of individuals’ health. Thus, these informal health-defining aspects should receive appropriate consideration by any health effort, as they may cause the greatest impact to ill-health of the populations affected.

Burden of Disease and Humanitarian Health Efforts The degree of a crises’ health impacts may be alleviated across the traditional disaster management cycle of mitigation, preparedness, response, and recovery. Next to building a health system’s resilience and other measures falling into preparedness and recovery, the humanitarian response should aim to minimize the consequences of post-crisis impacts. While the concept of post-crisis is limited in the face of settings with frequent, protracted, and recurring crises (when is that separate recovery period?), post-impact measures generally build on three interrelated processes: covering immediate needs, re-establishing an essential service package, and rebuilding the healthcare system itself (Waters et al. 2009). With local (health) systems – per disaster definition – being overwhelmed and often disrupted, external (sometimes international) support may be necessary, particularly to cover immediate needs through substituting existing systems. Where feasible, a complementary approach by humanitarian organizations is to be preferred and presents an essential component of humanitarian action that is increasingly gaining traction (The Sphere Association 2018; Labbé 2012). The merit of such an approach is its contribution to the sustainability of efforts and “post-crisis” transition, countering the risks of supplementary approaches that may duplicate efforts, obstruct competence building, drain the health workforce, have challenging exit strategies, and risk frictions with the surrounding or host populations (Tellier et al. 2018). The challenges and dilemmas of complementary approaches are the maintaining of highquality standards and an actor’s (perceived) neutrality (Tellier et al. 2018). The

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approach chosen is typically determined by organizational mandates and core competencies as well as the pre-existing system and authorities. In humanitarian settings, the needs of affected populations may frequently outweigh a country’s impaired capacities or an under-resourced humanitarian response. All actors in such settings will thus necessarily need to engage in prioritization processes on which services to provide, how to implement them, for whom, what period, and how it relates to other actor’s efforts. These decision-making dilemmas are exacerbated in settings where populations face a triple burden of disease (injuries, communicable diseases, and NCDs). To guide this decision-making, a public health triage should be used, allocating resources according to the greatest likely health gains, while keeping the humanitarian principles and aim, of minimizing mortality and protecting people’s dignity, in mind (Tellier et al. 2018). At the heart of this is the continuous data collection on the affected population’s needs and existing capacities to guide the implementation. There seems to have been a “better safe than sorry” approach to data collection, attempting to collect as much data as possible (Sandvik et al. 2014). To streamline collecting the right data for the right purpose in adequate humanitarian needs assessments, various guidelines were being developed, such as efforts by the Assessment Capacities Project (ACAPS). Despite the merits of data-driven implementation, public health is fundamentally about decision-making in settings with incomplete information; thus, a lack of data should not excuse inaction (Tellier et al. 2018). These decisions are then operationalization through, optimally, evidence-based and effective models of care, which describe how the provision of specific services (for certain diseases or population groups) is organized within a system. Building on the general patterns and relationships of the disease burden and humanitarian health efforts addressed above, the remaining part of this chapter aims to discuss related challenges, dilemmas, and opportunities. The following section is organized into two. An exploration of two key patterns of the burden of disease in humanitarian settings with strong future implications and related humanitarian health efforts is presented. This is followed by an overview of the impacts of three cross-cutting themes – climate change, urbanization, and technologies – on these burden of disease trends. Through these themes, we illustrate the interconnectedness of emerging health challenges in an increasingly dynamic world.

Burden of Disease Trends in Humanitarian Settings Non-communicable Diseases: A New Model of Care Changing epidemiological baselines and shifting characteristics of humanitarian settings led to NCDs becoming increasingly important and an imperative for the health efforts of humanitarian actors and governments. As these systems did not develop to address the specific needs of NCD care traditionally and due to a lack of evidence on the effectiveness of interventions, actors are challenged to implement appropriate models of care. The NCD concept has limitations for successfully

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advocating for and implementing care; thus reflections on approaches and models of care along a disease’s chronicity are worthwhile. Non-communicable diseases globally and in LMICs: NCDs are a major global public health threat. While in 1990, communicable diseases were still the number one contributor to the global burden of disease, NCDs accounted for 73% of mortality or 41 million deaths in 2017 (Institute for Health Metrics and Evaluation 2020). NCDs refer to a group of diseases typically characterized by not being transmissible and their often-chronic nature, also being the reasons for the synonymous use of “chronic diseases” despite differences in their scope. Globally, four diseases account for more than 80% of NCD deaths in 2017: cardiovascular diseases (17.7 million), cancers (9.5 million), chronic respiratory diseases (3.9 million), and diabetes (1.4 million) (Institute for Health Metrics and Evaluation 2020). These four diseases share underlying socioeconomic determinants and four common, modifiable risk factors of tobacco use, harmful use of alcohol, lack of physical activity, and unhealthy diets (Allen and Feigl 2017). At the third United Nations High-level Meeting on NCDs in 2018, a political commitment was reached to move from this 4x4 (diseases and risk factors) to a 5x5 agenda, adding mental health and air pollution as the fifth disease and shared risk factor, respectively. Due to the rise of NCDs first being observed in higher-income countries, they were often perceived as “diseases of the rich” and not typically associated with lower-resource, let alone humanitarian, settings. However, 82% of the global DALYs are shouldered by LMICs, and their burden is rising through a progressing epidemiological transition, the shift from communicable to non-communicable diseases as the main contributor to a country’s disease burden (Institute for Health Metrics and Evaluation 2020). This transition has already changed the disease patterns in MICs and started doing so in LICs. The share of the NCD burden as a percentage of total DALYs has risen across income settings from 57% to 77% in upper MICs, 32% to 54% in lower MICs, and 19% to 33% in LICs (1990 to 2017) (Institute for Health Metrics and Evaluation 2020). Simultaneously, beginning with the Balkan and Caucasus wars in the 1990s, humanitarian crises increasingly so afflicted higher-income settings (Spiegel et al. 2010). Through these two trends, NCD care became too important to be neglected by humanitarian health programming. The key difference in managing NCDs, compared to communicable diseases, is their main characteristics (being non-communicable and chronic) as well as their shared risk factors and the prevalence of comorbidities (Rabkin et al. 2018; Garry et al. 2018; Kruk et al. 2015b). Their chronicity affects the treatment aims of sustaining functionality and quality of life, prolonging life, and reducing symptoms rather than curing, fundamentally requiring continuity of care (Kruk et al. 2015b). The frequent comorbidities encourage integrated approaches across disciplines, while shared risk factors hint towards the importance of a primary prevention focus. The Global Action Plan for the Prevention and Control of NCDs 2013– 2020 by the WHO has outlined the agenda and country’s policy options globally, and the WHO Package of Essential NCD interventions synthesized cost-effective approaches for under-resourced healthcare systems in LMICs. Publications on NCD care in LMICs generally call for integrated, rather than vertical, approaches that are

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centered around the primary care level delivering appropriate and accessible prevention, screening, and treatment services (Maher et al. 2012; Kane et al. 2017; Kruk et al. 2015b). There is consensus that due to the resource constraints in LMICs, there is a stronger need for evidence-based interventions, service integration, innovative service delivery, patient and community centricity, and the adoption of new technologies for health communication (Kruk et al. 2015b). A review of existing primary level care models for NCDs in sub-Saharan Africa identified several promising components including passive case finding, healthy lifestyle advice, equipment and medicines availability, and the use of standardized protocols (Kane et al. 2017). Challenges for the implementation may generally relate to sustaining funding commitment and balancing prevention and treatment approaches (Maher et al. 2012). Concerns have been voiced on the transferability of these best practices of NCD care in LMICs to humanitarian settings, due to additional challenges further complicating health efforts (Ruby et al. 2015). These include competing national priorities, (diminished) existing capacities and infrastructures, resource limitations, logistical issues around mobile populations, fragmentation between actors, shortterm mandates, and diverse operational contexts (Rohwerder 2016; Aebischer Perone et al. 2017), as evinced in the ongoing Syrian conflict (Garry et al. 2018). Non-communicable diseases in humanitarian settings: In humanitarian settings, the pressure on actors to manage NCDs is mounting, fuelled by the increasing burden and the fact that the unique needs in NCD care render the traditional shortterm and episodic health programming of humanitarian actors and LMIC’s public health system inappropriate (Rabkin et al. 2018; Kruk et al. 2015b). Furthermore, donor funding in health continues to be skewed toward selected communicable diseases (Kruk et al. 2015b). Related calls for new models of NCD care were facing a virtually nonexistent evidence base on the effectiveness of such models, as research on NCDs in humanitarian settings was left behind until the early 2000s (Ruby et al. 2015). A decade later, in the early 2010s, public criticism highlighted the continuous insufficient humanitarian response and called for urgent improvements, including comprehensive literature reviews, increased advocacy and awareness, research on morbidity and mortality patterns, the incorporation of NCDs into existing structures (e.g., policies, standards), the development of technical guidelines, greater integration and coordination, and the training of humanitarian health professionals (Demaio et al. 2013). Major elements of their criticism and calls to action remain today, while progress on several of their points has been achieved. These include increased research on NCDs in humanitarian settings as well as the recent publication of systematic reviews (Ruby et al. 2015; Jawad et al. 2019), the raised awareness of the importance of NCDs for the health programming of humanitarian actors (Garry et al. 2018), the integration of NCDs into the Inter-Agency Emergency Health Kit, and the increased presence of NCDs in policy and guidance documents, including the SENDAI framework on disaster risk reduction, the SDGs, WHO guidelines, and the SPHERE standards. Since the strong public criticism in 2013, research has partially clarified potential short-term (e.g., the exacerbation of the illness, complications, risk factors, and increased mortality) and longer-term crisis impacts (for both disasters and armed

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conflicts) on NCDs (Ryan et al. 2015; Nomura et al. 2016; Jawad et al. 2019). However, the short-term effects remain uncertain, and the longer-term effects are questionable with cautionary interpretations, considering the research scarcity and the diversity of crisis’ settings. The NCD burden in humanitarian settings is likely a combination of the crisis-caused exacerbation of conditions and the elevated precrises NCD burden in the affected population. Over the last decade, research has also increased on effective models of care for NCDs in humanitarian settings. A first systematic review on the effectiveness of NCD interventions in humanitarian settings in 2015 noted the severe lack of evidence while highlighting several promising models of care (Ruby et al. 2015). The identified approaches were corroborated by other authors to varying degrees (Aebischer Perone et al. 2017; Jawad et al. 2019). The components of these emerging models of NCD care in humanitarian settings were alike those identified in LMICs. The majority of sources agreed on the importance of a primary healthcare-centered response to NCDs in humanitarian crises, while sometimes at odds with priorities of healthcare systems that are traditionally higher-level-centered, as observed in the Middle Eastern region (Jawad et al. 2019). Promising approaches consisted of algorithmic-based interventions (including adapted clinical guidelines), essential medicine availability, the establishment of monitoring processes, electronic cohort monitoring, training of healthcare professionals, and support to patients for medication adherence. Next to secondary prevention included in some of these models (e.g., health education), primary prevention approaches may be considered despite often being beyond the scope of actors and may be increasingly feasible in post-conflict and rather stable settings (Aebischer Perone et al. 2017). Some potentially valuable models of care anchored outside the formal healthcare system, where nonmedical persons play a critical role, were described in the literature across settings. These ranged from the (cost-)effective NCD care delivery by community-based female health volunteers in disaster-affected Nepal (Krishnan et al. 2019) as well as peer education groups on treatment adherence in the Democratic Republic of Congo, classified as a complex humanitarian emergency (Murphy et al. 2017). One of the most promising components, in its potentials to ensure continuity of care for patients, were health information systems, both digital or paper-based (Ruby et al. 2015). Adaptive systems are needed here to be able to cover also more severe disruptions of continuity, such as for migrants or displaced persons, particularly when in transit (Abubakar et al. 2018). A mobile cohort monitoring system showed positive effects on the follow-up of patients and adherence to algorithmic interventions and clinical guidelines and enabled the evaluation of the quality of NCD care for Palestinian refugees in Jordan (Khader et al. 2013). NCD model of care components were typically applied jointly as part of a comprehensive model often for specific NCDs, such as the delivery of diabetes care by a humanitarian organization in Mali, as an armed conflict setting. Their model included a prioritization of essential medicines and equipment, simplified information collection, healthcare workforce training, and service delivery (Besanc¸on et al. 2015). Arising from the diversity of settings where NCD models of care were implemented, a key theme of “soft” factors emerged from the literature, referring to aspects of the appropriateness and cultural sensitivity of interventions.

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These include the availability, affordability, and acceptability of medication or lifestyle approaches (e.g., certain nutrition recommendations) and their feasibility in the patient’s context (e.g., physical exercises in armed conflict settings) (Murphy et al. 2017). This emerging theme of the importance of considering socio-culturally determined factors of perceptions, attitudes, and practices feeds into the overarching agenda for context-specific and adaptive models of care that are patient-centered, equitable, and accountable (Aebischer Perone et al. 2017; Spiegel et al. 2010). Importantly, this adaptability also needs to reflect that NCD populations, even in one crisis setting, are not a homogeneous group (e.g., people still in conflict-affected areas vs. IDPs in camps) (Besanc¸on et al. 2015). A contextualization will need to build on baseline data, which is often unavailable pre-crises or wiped out at impact, requiring initial and continuous data collection (Tellier et al. 2018). Despite the fastincreasing state of knowledge on NCD pathways and care models, there is to-date no convincing evidence on the effectiveness of such models in humanitarian crises, presenting severe limitations to humanitarian health efforts. The limitations of “NCDs in humanitarian settings”: It is worth flagging here that the concept of “NCDs in humanitarian settings” carries a wide range of meanings, agendas, and priorities, though most commonly it is limited to a set of diseases which usually includes diabetes and hypertension, regularly cardiovascular diseases, and, though rarely, cancers or chronic respiratory conditions (Spiegel et al. 2010; Blanchet et al. 2013). The prioritization of these diseases is often linked to the feasibility, cost, and complexity of care as well as the severity of impacts, which is, for example, why type 1 diabetes has gained more attention than cancers (Aebischer Perone et al. 2017; Spiegel et al. 2010). There are also inconsistencies in what perspectives and set of actors the concept typically refers to, with most publications on models of NCD care in humanitarian settings representing the perspective of international humanitarian actors, with often limited focus on health systems in LMICs or national humanitarian organizations. In contrast to the 5x5 agenda globally, in humanitarian settings, mental health conditions are not typically put together with NCDs or referred to in calls to improve NCD care (The Sphere Association 2018; Aebischer Perone et al. 2017). Mental health faced the same disquieting neglect in global health and humanitarian settings previously and was only put on the map through the uptake of DALYs as a health indicator and in the aftermath of the Indian Ocean tsunami in 2004 (Tellier et al. 2018). However, care for persons suffering from mental health conditions has a long way to go, particularly in humanitarian settings with major persisting challenges, despite improvements in research availability and stronger efforts and awareness across sectors, united through the mental health and psychosocial support (MHPSS) concept (Tellier et al. 2018; Blanchet et al. 2013). Challenges include the appropriateness of epidemiological assessments, differentiation of normal psychological responses to extreme events (which has recently gaining more attention through a focus on a person’s functioning and the use of the simplified distress scale), a clinically centered response limited to a biomedical perspective of mental health, the heterogeneity of mental health conditions, culturally insensitive and short-term models of care imposed by outsiders, and a negativity bias undermining resilience and

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empowerment (Tellier et al. 2018; Blanchet et al. 2013). The emergence of the MHPSS agenda alongside NCDs may hamper the adequate appreciation of their (and other, e.g., mental health and communicable diseases) comorbidity, shared etiology, and pathways (Remais et al. 2013). This may hinder the appropriate integration of care through a life course approach and ignores shared systemic barriers, such as collaboration in humanitarian system and the sustainability of funding (Tellier et al. 2018). The concept of NCDs as a distinct disease category also carries limitations itself, particularly for the operationalization of care, alongside its merit in the wide acceptance and political application. There is acknowledgement in the global health community of its inability to create a sense of urgency (NCDs are the biggest killer), hampering of the global response (the diversity of NCD agendas), capturing of systemic aspects (emphasize individual responses), heterogeneity of included diseases (Allen and Feigl 2017), and the artificial differentiation with communicable diseases (Remais et al. 2013). Thus, Allen and Feigl (2017) suggested the use of “socially transmitted conditions” to emphasize their common upstream drivers (i.e., shared risk factors) as key to curbing its global “pandemic.” This may also promote a stronger appreciation of its interconnectedness with mental health, such as through the existence of risk clusters. In the humanitarian sector and from a model of care perspective, the emphasis on their chronicity may arguably be even more relevant due to the critical needs that differentiate them from the previous orientation of LMIC healthcare systems and humanitarian actors. Using semantics of chronicity would include communicable diseases of chronic nature (e.g., HIV/AIDS, tuberculosis) and may thus facilitate the integration of the two agendas, where synergic (e.g., treatment aims and required healthcare system restructuring) (Kruk et al. 2015b; Spiegel et al. 2010). Often overlooked existing chronic disease programs (e.g., for HIV/AIDS) in LMICs may provide valuable lessons learned and transferrable models of care (Rabkin et al. 2018). These include a focus on active and point-ofcare screening (e.g., opt-out testing for at risk), intensive counselling and patient education (e.g., peer educators), solid follow-up systems (e.g., automated appointments), ease of access to treatment (e.g., community-based drug pickup), healthcare delivery (e.g., roles of health workers), and abolishing of user fees that may help to overcome challenges in the continuity of care and critical healthcare system shortages and generally promote a horizontal health system strengthening approach (Rabkin et al. 2018). A chronicity focus would however not promote an appreciation of the interconnectedness of disease etiologies, such as with other infectious agents or mental health (Remais et al. 2013). Therefore, the potentials of a practical reconceptualization of disease categories should be carefully evaluated by humanitarian health actors and the sector at large, as it may facilitate more integrated health efforts.

Communicable Diseases: Endemic and Emerging Communicable diseases are still the largest disease burden in most low-income countries and humanitarian settings. As they are part of traditional humanitarian response, supported by a solid, though skewed, research base on effective models of

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care, related health outcomes have improved significantly over time. They nonetheless remain a key trend and concern for humanitarian health efforts, as political and structural challenges are offsetting some of these gains and elevate the risk of newly emerging diseases, previously unknown or eradicated locally. These dynamics are further exacerbated through existing vulnerabilities worsening in the face of rapid unsustainable urbanization and environmental change, presenting a critical threat to global health security. Communicable diseases globally and in LMICs: The burden of communicable diseases has dropped significantly from 1990 until 2017 globally. This period has seen a 50–60% reduction for both the crude mortality rate and the crude DALYs rate globally, leading to communicable diseases accounting for less than 20% of deaths in 2017 (Institute for Health Metrics and Evaluation 2020). This trend has been even more pronounced in LICs with reductions of around 61%, while it remains a major contributor to the burden of disease in both LICs (59%) and lower-middle-income countries (37%) in 2017, contributing to a double burden of disease (Institute for Health Metrics and Evaluation 2020). Importantly, the concept of a double or triple burden is often not observed at country but rather at community level. As such, communities with higher socioeconomic status in LMICs are affected by NCDs but may have overcome much of the communicable disease burden, while communities with lower socioeconomic status, still challenged with communicable diseases, are already experiencing increased risk factors and prevalence of NCDs simultaneously (Remais et al. 2013). A reduced communicable disease burden over time is partially attributable to improved living standards as well as access to care and higher-quality health services, particularly for children under five (Tellier et al. 2018). Communicable diseases, used synonymously with infectious diseases, are defined by their cause being a transmittable pathogen, through a variety of direct and indirect routes, hosts, and vectors, and influenced by factors of – among others – extrinsic socioeconomic, climatic, and ecological conditions and intrinsic human immunity (McMichael et al. 2006). Globally the main communicable diseases in 2017, for all ages as well as for children under five, were neonatal disorders, lower respiratory tract infections, and diarrheal diseases with their main risk factors being maternal and child malnutrition as well as unsafe water and sanitation in lower-resource settings (Institute for Health Metrics and Evaluation 2020). The achievements in communicable disease outcomes should not be carelessly interpreted as the end of the communicable disease era or create a new imbalance through efforts to promote appropriate NCD funding. A too early global postmortem declaration ignores that communicable diseases remain a major burden for communities regionally, that risks of an emerging disease outbreak are accelerating, and that there are close interrelations with other disease categories. Emerging diseases describe those that were not present in the area of reference prior and thus spread more rapidly due to limited host population immunity. While their contribution to the global disease burden is comparatively less, their risk of both sparking, the likelihood of it emerging, and spreading, the likelihood of it circulating, has increased over the decades (Madhav et al. 2017). The spark risk is elevated, due to the majority of emerging diseases being zoonotic, by changes of land use, exploitation of the natural environment, and

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livestock production and animal trade, while the spread risk, especially for airborne diseases, is accelerated by trends of globalization and increased human mobility and movement (Abubakar et al. 2018; Madhav et al. 2017). The last decades have seen several public health emergencies and pandemics, including HIV/AIDS (1981), SARS (2003), H1N1 (2009), Ebola (2014), and, most recently, COVID-19 (December 2019), declared a pandemic by the WHO in March 2020. Many communicable diseases, with constantly expanding evidence, were linked to NCDs and mental health conditions with a shared etiology and risk factors, though with a limited integration in their global responses (Remais et al. 2013). Exemplary, human papillomavirus infections were associated with increased cervical cancer risks, and pandemics found to worsen mental health conditions through increased uncertainty, risk to personal life, stigmatization, disruption of the social fabric, and loss of livelihood, as evident during the ongoing COVID-19 pandemic (Fiorillo and Gorwood 2020). Communicable diseases in humanitarian settings: Humanitarian settings are defined by a similar communicable disease pattern to that observed globally, with diarrheal diseases (e.g., cholera and dysentery), acute respiratory tract infections, measles, and malaria as the main burden (Tellier et al. 2018). Successful measles and malaria programs as well as fewer people living in camps may have contributed to the observed improvements in prevalence and incidence, while these reductions were unequally distributed with fewer changes to neonatal conditions, diarrhea, and pneumonia (Tellier et al. 2018; Spiegel et al. 2010). Part of the communicable disease burden are also, though often discussed separately, those of chronic nature (e.g., HIV/AIDS, tuberculosis), addressed in the NCD section above. The communicable diseases that will typically emerge post-crisis impact are those already endemic in the affected areas, rather than emerging diseases (Kouadio et al. 2012). The often-perceived increased risk of disease transmission shortly after a disaster does not have supportive evidence, and major outbreaks in humanitarian settings have been uncommon and decreasing (Kouadio et al. 2012; Spiegel et al. 2010). An increase in communicable disease risk has been observed in settings with a more severe disruption of the healthcare and surveillance system (e.g., affecting access to care and treatment interruption), population displacement, changes to environmental factors (e.g., poor water and sanitation, insufficient food, uncontrolled vectors, poor housing, and overcrowding), and mistrust toward (health) authorities (Kouadio et al. 2012; World Health Organization 2016; Abubakar et al. 2018). These effects will be moderated by the type and characteristics of a given disaster or armed conflict (e.g., floods providing mosquito-breeding grounds). While emerging diseases are typically perceived as secondary to endemic ones in humanitarian crises, their spread risk and potential impact, if occurring, are eminently worrying. Humanitarian settings are notoriously vulnerable to such threats, due to disrupted healthcare and surveillance systems, maxed-out capacities, greater environmental exposure, and worse baseline nutrition levels (Madhav et al. 2017). Such settings, particularly armed conflict, are thus perceived as a critical threat to global health security, with the risk of providing a breeding ground for emerging disease to spread or potentially mutate (Brennan et al. 2020). Global health security is thus fundamentally about addressing drivers of

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poverty and socioeconomic determinants of health in these settings. Pandemics may also, in a reversed manner, increase political stress and tensions such potentially sparking violence or conflict in weak states or causing major setbacks to developmental gains (Madhav et al. 2017). Its possible impacts were observed in the aftermath of the 2010 Haiti earthquake where the already vulnerable disasteraffected population was ravaged by a new cholera strain imported by an aid worker or in the ongoing COVID-19 pandemic, challenging even some of the most advanced health systems globally. Humanitarian health efforts on communicable diseases: Communicable diseases are generally considered preventable, also in humanitarian settings. The traditional toolbox of humanitarian actors to respond to their spread is the implementation of six key interventions: the provision of water, food, sanitation and hygiene, shelter, measles vaccines, and the implementation of basic medical care (Kouadio et al. 2012). Extensive experiences in providing humanitarian relief have been gathered across these areas over the years (The Sphere Association 2018). Looking at these tools, it becomes clear that they are typically highly compartmentalized under the mandates of separated government authorities, clusters, and organizations (e.g., water, sanitation and hygiene, shelter, food security, camp coordination, and management), demanding strong coordination between actors. The models of care applied by humanitarian actors within the “tool” of basic medical care are typically episodic treatments and supportive care (oral rehydration, nutrition, antimalarials, vitamin A, complementary antibiotics), active case finding, health education, and extensive vaccine coverage (Tellier et al. 2018). A recent systematic review of the evidence on communicable disease models of care in humanitarian settings showed the effectiveness of some approaches, including vaccination strategies for polio and measles, the optimal treatment regimen for trachoma, or insecticide-treated protections for malaria (Blanchet et al. 2013). Similarly, to NCDs, considerations of cultural appropriateness and context-specific implementation are critical for these interventions to work (Abubakar et al. 2018). The systematic review also concluded that some diseases, including many of the neglected tropical diseases, received insufficient attention by academia (Blanchet et al. 2013). Next to vertical models, there are several preparedness measures focused on situational awareness and a horizontal health system strengthening, overarching endemic, and emerging communicable diseases, including a strong surveillance system, preparedness plans, routine risk assessments, establishment of laboratory capacities and supply chains, health workforce training, and improved adaptive management abilities (Tellier et al. 2018; Burkle 2010; Madhav et al. 2017). If known measures are implemented well and context-specific, guided by relevant data and risk assessments, they have shown to significantly reduce the burden of communicable diseases post-crisis (Madhav et al. 2017). It is then fair to wonder why do communicable diseases continue to challenge humanitarian settings and why are they still described as a key humanitarian trend to watch (The New Humanitarian 2019), essentially because the spread of communicable diseases and full-blown outbreaks are, as is true for other hazards, at their core a socioeconomic and political phenomenon. A pathogen typically thrives in places of high population density and

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human mobility, lack of infrastructure and economic resilience, and a limited system’s response capacity, indicative of humanitarian and low-resource settings (Madhav et al. 2017). In humanitarian crises, these accelerators may be further exacerbated in complex emergencies complicating the necessary timely response and appropriate preparedness through the disruption of national authority and governance mechanism, the emergence of new or local powers, and access issues (Spiegel et al. 2010). In resource-constraint contexts, any preparedness measure necessarily creates difficult trade-off dilemmas with addressing urgent needs (Maher et al. 2012). These dynamics are becoming worryingly evident during the ongoing COVID-19 pandemic, particularly in informal urban settlements (see respective theme below) and camps for displaced persons and refugees. In camp-based settings (or urban slums), traditional disease prevention efforts effective against SARS-CoV2 transmission are hardly applicable (Raju and Ayeb-Karlsson 2020), leaving them at risk of uncontrollable outbreaks and presenting a threat to global health security. Visualizing these settings elucidates that even the most basic measures (e.g., washing hands, physical distancing, isolation or quarantine, contact tracing) are almost antithetical to the lived realities in these settings (Raju and Ayeb-Karlsson 2020).

Cross-Cutting and Interconnected Themes of Humanitarian Health Efforts Theme 1: Climate Change – A Major Opportunity for Global Health Climate change is a major threat and opportunity to health globally and particularly in exposed contexts such as humanitarian settings. The latter are additionally vulnerable due to often weaker or weakened socioeconomic and governance systems. Thus, while specific predictions remain challenging and contextual, a significant increase in the humanitarian caseload is to be expected. As the impacts and causes of climate change are beyond the humanitarian sector, unprecedented degrees of collaboration across a diversity of actors and levels will be vital. Climate change impacts and humanitarian crises: Climate change will over the coming decades affect the lives of most communities globally. Already, communities are experiencing intensifying patterns of disasters with increased severity and frequency of meteorological and hydrological hazards (Masson-Delmotte et al. 2018) and associated extreme weather events (IPCC 2014), food insecurity, and the disruption of livelihoods and public infrastructure (Watts et al. 2018). With the anthropogenic aspects of climate change, the artificial lines, as discussed above, between disasters triggered by natural and those by human-made activities will become further obsolete (Burkle et al. 2014). Rather, the differentiation discussed in the introduction, between humanitarian crises with and without armed conflict, is valuable here due to differing impact pathways. Climate change will exacerbate the pressures of hazards on regions as well as the vulnerability of affected populations, as its impacts are fundamentally political (Burkle 2010). While no region is immune to these effects, they are and will be, as other themes discussed in this chapter, most strongly felt by people in lower-resource settings, including those with recurring

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disasters and those affected by armed conflicts, through the evincing of existing inequalities (IPCC 2014). Future climate change effects on hazards strongly depend on the degree of global warming, with major differences between 70%) of greenhouse gas emission and thus central to mitigation efforts while at the same time being home to some of the most vulnerable populations to the effects of climate change (World Health Organization 2016; IPCC 2014). Many of the world’s (mega-)cities are in a lowelevation coastal zone and have limited permeable surfaces, leaving them more prone to the effects (e.g., a disruption of infrastructure, economic assets at risk, and direct health impacts) of intensifying hydrological and meteorological natural hazards and sea level rise (Costello et al. 2009; World Health Organization 2016; IPCC 2014). These effects are, again, particularly pronounced for poorer communities in informal settlements or urban slums, as they are typically more exposed (e.g., settlement location, infrastructure resilience, building materials, type of workplaces, existing comorbidities) and have fewer capacities for adaptation (e.g., immobility, price sensibility, weaker governance structures, lack of economic capital or political influence) (Costello et al. 2009; World Health Organization 2016; Ayeb-Karlsson et al. 2020; IPCC 2014). Several disease risks are associated with these patterns through various pathways, including the “heat-island” effect (worsening NCD outcomes), increased stressors on mental health, or overwhelmed sanitation systems through storm surges or inland flooding (increasing communicable disease transmission through fecal-oral route) (Masson-Delmotte et al. 2018; World Health Organization 2016; Burkle et al. 2014). The indirect effects on food systems, water availability, housing, erosion of economic opportunities and migration, immobility, and forced displacement patterns may again present the largest health challenges and opportunities (Watts et al. 2015; Ayeb-Karlsson et al. 2020; IPCC 2014). Exemplary, community populations – compared to camp-based displaced populations – have experienced poorer health outcomes (Spiegel et al. 2010). Any health efforts thus need to address poverty reduction and systemic health inequities to be impactful. Despite clear intersections between these areas, tools to manage their synergies remain limited (IPCC 2014). Urban humanitarian response: Urban settings are challenging traditional humanitarian health approaches that evolved in rural or camp-based settings, with organizations not always being well-equipped to address the needs of an urbanbased population (Labbé 2012). The increasing confrontation with urban humanitarian needs is reflected in the evolution of the Sphere Handbook, which includes urban programming as a cross-cutting theme throughout the 2018 version while being virtually nonexistent prior (The Sphere Association 2018). Urban

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humanitarian settings are fundamentally different from rural ones, in their density (of people, houses, infrastructure, and cultures), diversity (social, ethnic, political, linguistic, and economically), and dynamics (more fluid, changing environments, high mobility, and rapidly shifting power relationships) (The Sphere Association 2018). They are generally also characterized by much more established pre-existing structures such as an increasingly monetized economy, stronger market dynamics, changed patterns of social coherence with potentially diminished safety nets, and fewer coping mechanisms (e.g., for livelihoods) (The Sphere Association 2018). New needs assessments to guide humanitarian health efforts have emerged, such as a technical brief by ACAPS, acknowledging these differences and attempting to capture systemic perspectives, also by utilizing the potentials of digital technologies for dispersed populations (Currion 2015). The unique urban circumstances provide a new set of challenges, dilemmas, and opportunities for humanitarian actors. Challenges include a more complicated identification and access to populations (e.g., challenging the continuity of NCD care) and data on their needs, questions of service integration design with re-emerging dilemmas of host-population equity and quality of care (Burkle et al. 2014; Spiegel et al. 2010), and a lack of access to information for affected populations, rapidly spreading rumors (see technology theme on COVID-19) and mistrust toward authorities (The Sphere Association 2018; Corburn et al. 2020). Thus, voices were amplified recently to implement a context-specific COVID-19 response in informal urban settlements, highlighting the absurdity of a traditional response in these settings (see communicable disease trend). This includes, based on previous lessons learned during the West Africa Ebola outbreak, the easing of rigid economic support criteria, a decentralized response (local informal emergency planning committees, deployment of trusted community health workers and flexible testing units, mobile clinics), and the provision of contextspecific basic services (water, sanitation, food, solid waste collection) and physical distancing recommendations taking urban-rural movements and social networks into account (Corburn et al. 2020). Urban settings are often encountered in MICs with potentially an additional set of challenges, of higher programming costs and requirements (e.g., potable water standards of 50 l per day as a typical minimum), potentially higher expectations, increasingly blurred lines to development efforts, and a stronger nation-state (Rohwerder 2016; The Sphere Association 2018). Urban settings, particularly in MICs, likely require stronger systemic efforts and a focus on prevention and preparedness which often remains uncomfortable for the humanitarian system (Burkle et al. 2014; Flies et al. 2019). In face of these challenges, and as a key opportunity in urban compared to rural settings, the core of health programming by humanitarian actors in urban settings is the integration and complementation with existing efforts in the public healthcare system, as well as with laws, governance mechanisms, and markets (Rohwerder 2016; The Sphere Association 2018). The specific application is moderated by the level of existing services, the extent of crisis-caused disruption, and political agendas and their relationship with humanitarian principles (Spiegel et al. 2010). Such integration and complementation approaches encourage a primary-before-secondary care approach, integration through public health system capacity building, active

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outreach, the establishment of strong referral and follow-up systems, as well as selective supplementation for critical gaps (Spiegel et al. 2010; Rohwerder 2016; The Sphere Association 2018). Thus, urban settings may provide a unique opportunity to the implementation of NCD care, as the agendas of integration and continuity of care are closely overlapping and due to the better availability of higher-level services, skilled health care professionals, and critical infrastructure (e.g., electricity) (World Health Organization 2016). Further potentials arise through communitybased strategies (e.g., community health workers) adapted to urban settings and leveraging other existing capacities, such as private sector involvement, more feasible application of technologies, or cash-based programming (Rohwerder 2016). Interventions in these settings, as is true for rural contexts, fundamentally need to build on a solid understanding of the critical underlying socioeconomic dynamics (Currion 2015), where local experts may play a critical role and help localize the humanitarian response.

Theme 3: Accelerating Technologies – A Matter of Survival for Humanitarian Actors? Technologies have increasingly been shaping humanitarian health efforts, and the extent of external technologies influencing the humanitarian sector and speed of development are creating new dynamics. While tech-optimism is widespread and seen as critical to address an increasing caseload in changing humanitarian contexts, humanitarian actors are facing major inherent dilemmas and emerging challenges. Much of the development is evolving organically and common governance frameworks and new ethics are lacking. Technology in humanitarian settings: It is accepted that technologies are a key component of our global reality today, influenced and influencing all aspects of human endeavor. While technology, in its fundamental meaning of the study and knowledge of the practical use of scientific discoveries, is not a modern concept, the extent of its impact and speed of development are unprecedented. Despite the breadth of this definition, today’s technologies, conceptualized as the Fourth Industrial Revolution or “modern” technologies, are typically associated with the digital realm, data, and innovation (Sandvik et al. 2014). In the humanitarian sphere, the meaning of technology is as diverse and includes imported as well as uniquely developed technologies, including early warning systems, mobile cash-based interventions, electronic medical records, blockchain, unmanned aerial vehicles, supply logistic systems, biometric scanners, geographical information system, and 3D printing. The technological lingo and the leveraging of new technologies as adaptation strategies have entered mainstream humanitarian thinking, despite the absence of a coherent framework of what it refers to or how it should be implemented (Labbé 2012). A catalyst for humanitarian technology is often seen in the 2010 Haiti earthquake response, as one of the earliest examples of the novel role and scale the application of modern technologies, such as social media, satellite imagery, and use of crowdsourcing (Sandvik et al. 2014; Mesmar et al. 2016). The subsequent years have elucidated the need for strengthening the capacities within the humanitarian sector, giving rise to humanitarian technology platforms, such as the “Digital

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Humanitarian Network,” and increased attention and publication by actors, including the “World Disaster Report 2013” on humanitarian technologies and the UNOCHA report on “Humanitarianism in the Network Age” in 2012. This chapter is necessarily limited in the scope of technologies covered, considering their diversity, and, as any specific example or attempt to give an overview of the state of current applications is likely soon outdated, these components are complemented with higher-level perspectives on humanitarian technology. It focuses on digital technologies with direct or indirect impacts on humanitarian health efforts and particularly information and communication technologies (ICTs), as they are typically focused on by humanitarian actors, with a perceived clearer impacts to-date and with them typically being more so available and feasible (Labbé 2012; Dette 2018). Related opportunities have emerged through rapidly increasing access to mobile devices and the Internet across income settings and despite major persisting gaps (International Telecommunication Union 2018). There has been a strong “techoptimism” agenda from humanitarian actors and academia, fuelled by the hopes of more effective and efficient aid, better access to affected populations, and a promised “power shift,” through democratizing aid by “making voices heard,” elevating downward accountability, upward priority setting, and community empowerment (Labbé 2012; Sandvik et al. 2014; Vinck 2013; Abubakar et al. 2018). Some of the hopes have been dampened through emerging research, such as a 10-month ethnography study on the disaster recovery post-typhoon Haiyan in 2013 in the Philippines (Madianou et al. 2015). This study suggested that technologies do not “give voice” or ensure accountability but may only be a facilitator in conducive environments where social capital and a strong civil society are present and a pervasive culture of listening in organizations exists. Importantly, the researchers emphasized its potential to do the opposite by exacerbating existing inequalities through favoring people with greater opportunities or skills (e.g., digital literacy) and leaving others, more vulnerable persons, behind. This notion is critically important because of an increasing gender imbalance in lower-income settings in access to mobile devices and the Internet (International Telecommunication Union 2018) and the risk of leaving nonconnected areas behind through the lack of a digital footprint for big data analyses (Sandvik et al. 2014). These arguments are feeding into the view of technology as an amplifier of pre-existing systems and as a fundamentally social affair, responsible for some of its key challenges and opportunities (Dette 2018). They belong to an equally strong and emerging camp highlighting the associated issues of uncritical adaptation technologies and an unreflective “cyber-humanitarianism.” These calls included demands for more rigorous assessments of technological effectiveness, and, particularly, its risks to the humanitarian principles as technologies and the humanitarian sector are in a mutually constitutive relationship (Sandvik et al. 2014; Abubakar et al. 2018; Blanchet et al. 2013). Humanitarian technologies have evolved despite a lack of new ethics and conventions to guide the implementation, particularly for armed conflict settings (Dette 2018). As ignoring the possibilities of technological advancements is no option and may forfeit potentials to improve care to affected populations, finding practical solutions around these dilemmas is of uttermost importance. While the arguments above are not health-specific, their role and

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implications (on participation, empowerment, agenda setting, relevance, and localization) are as critical and applicable for humanitarian health efforts. Humanitarian health efforts and technologies: Next to health-impacting technologies applied in other sectors/clusters (e.g., meteorological early warning systems or engineering in water and sanitation), a range of technologies have found their way into the health toolbox of actors, across and through vertical disease programs. A recent systematic review on the health impact of digital technologies identified 50 different applications, mostly used in the response phase (60%) and underpinning the typical function of humanitarian actors (e.g., data collection and analysis), ranging from established (e.g., phone calls, Internet-based forms, YouTube) to more specific interventions (e.g., unmanned aerial vehicles or artificial intelligence reports) (Mesmar et al. 2016). For communicable diseases, surveillance systems or social media analytics in combination with GIS mapping were used to support more accurate predictions of disease outbreaks and triggering SMS-based information dissemination for high-risk areas (Mesmar et al. 2016). The potentials of ICTbased information dissemination (e.g., social media, chatbots, messaging services, etc.) are also elucidated during the ongoing COVID-19 pandemic. Importantly, official national health actors and international organizations (e.g., WHO) are not necessarily dominating the public discussion and perception of the COVID-19 pandemic with a flood of (mis)information of rapid global spread and thus termed an “infodemic” (Fiorillo and Gorwood 2020). Such an “infodemic” also carries the potential to worsen mental health (conditions), in connection with disruptions to community support mechanisms (e.g., through lockdowns, physical distancing), increased stressors (e.g., economic uncertainty), and reduced health services beyond direct COVID-19 care (e.g., access to medicines, neglect of other and more indirect population health needs) (Fiorillo and Gorwood 2020). These effects are particularly pronounced for certain groups, including healthcare professionals; those with existing vulnerabilities (e.g., NCDs or age); people with frequent social media use, where safety nets are weak; or those that developed COVID-19 (Fiorillo and Gorwood 2020). Thus, health actors are required to implement a strong communication strategy and task force and provide adapted mental health services. In conjunction with the technology debate, access to value-added information has emerged as a component of relief itself (Sandvik et al. 2014). Portable medical devices were frequently applied in humanitarian settings to strengthen the point of care testing or treatment, sometimes in combination with remote specialist support for both communicable diseases and injuries (e.g., eye examinations, tuberculosis tests, or surgery) (Mesmar et al. 2016; Chaudhri et al. 2019). For NCDs, (cloudbased) electronic health records were used to improve continuity of care (Mesmar et al. 2016), as in the example of Palestinian refugees in Jordan given above (Khader et al. 2013). Internet or SMS-based surveys were applied to establish the impact and prevalence of diseases, including mental health conditions (Mesmar et al. 2016). Chatbots utilizing artificial intelligence (AI) to provide care for people with mental health conditions and to relief strained healthcare systems were used elsewhere, such as the controversial use of mental health care chatbots in the Zaatari refugee camp in Jordan (Wright and Andrej 2020).

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Tools affecting health beyond vertical disease areas included various forms of training (e.g., gamified, telemedicine training), data entry with mobile devices (e.g., the KOBO toolbox), GIS-informed logistics, unmanned vehicles for health equipment delivery, spoken language translators, electronic voucher programs or ICT health information platforms, as well as not health-specific applications by affected populations (e.g., SMS or radio) (Mesmar et al. 2016; The Sphere Association 2018). Access to mobile networks and the Internet (particularly social media) and increasing baseline use, often compromised at crisis impact, has emerged as a critical need in the response and may facilitate capacities in crisis settings (Currion 2015). It can indirectly promote health by creating a sense of normalcy for the affected populations and allowing them to connect to their potentially dispersed families and communities (Madianou et al. 2015; Currion 2015). Thus, situational awareness for humanitarian actors becomes as much about understanding digital spaces and communities as it is about physical ones. A critical theme emerging in this context is the opportunities of gaining access to previously hard-to-reach populations, such as migrants, IDPs, and refugees as well as people cut off by armed conflict or in the immediate aftermath of a disaster, for both research and “remote programming” (Chaudhri et al. 2019; Dette 2018; Abubakar et al. 2018). Challenges for most of these digital technologies are the lack of evaluations or the quality of such paternalistic design processes fitting foremost the needs of humanitarian actors and ethical issues around privacy and equity (Mesmar et al. 2016). The cultural appropriateness called for across humanitarian programming is even more so critical in AI-based technologies, where biases or a contextually inappropriate Western-based epistemology or cultural norms may be coded into a tool (e.g., mental health chatbots) (Wright and Andrej 2020). Privacy issues are especially critical, as they have the potential to do (digital) harm to already vulnerable populations if the data is misused (e.g., through function creep, the reuse of data for a distinct purpose not originally intended or consented to) or becomes available to actors with certain political or military agendas, particularly with humanitarian organization’s increasing role as “intelligence actors” (Madianou et al. 2015; Sandvik et al. 2014; Dette 2018). In armed conflict settings, these dynamics may be even more pronounced and connected to issues of political blockage or censorship hindering equal access to information (Mesmar et al. 2016). The typical remedy of (informed) voluntary consent, applied widely in high-income settings, is obsolete in humanitarian contexts where “voluntary” is hollowed in the face of severe needs, requiring alternate forms of protection of these population groups (Madianou et al. 2015). Thus, there are strong calls for critical evaluations of the necessity of technological applications and the awareness of their effectiveness and implicit trade-offs, improved data security practices, and a technological “localization” (cultural appropriation) movement (Madianou et al. 2015; Sandvik et al. 2014). Conducting research in humanitarian settings is already challenging and arguably even more so for rapidly evolving digital interventions (Blanchet et al. 2013), while technologies may also provide opportunities for conducting ethical research in these settings (Abubakar et al. 2018). The application of action-oriented research frameworks focused on people-centered and participatory, reiterative design processes and monitoring may be appropriate

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and feasible here (Mesmar et al. 2016). Despite criticism, the argument that an actor’s ability to harness its potentials will be defining for future challenges of increasing caseloads, and a changing nature of crises (as per the discussed trends and themes) is gaining traction (Labbé 2012; Vinck 2013; Abubakar et al. 2018).

Case Study: Iraq In Iraq, the discussed trends are collectively impacting a nation recovering from conflict. The health system is challenged by a triple burden of disease (NCDs, injuries, and communicable diseases), ongoing large-scale displacement, and security issues. Iraq’s progressing recovery and development, technological advancements, and an emerging private sector are providing promising opportunities. The government in Iraq is taking the lead in addressing humanitarian needs, while capacities remain limited and external, mostly complementary, support widespread. With continuous volatility and disrupted public infrastructure met by increasing environmental stressors, the risks to health and stability are likely exacerbated. The context of Iraq: Iraq provides an interesting case study of the specific impacts and interrelatedness of the discussed trends and themes in this chapter, as it experiences their clear manifestation in the backdrop of decades of armed conflict. In the WHO Eastern Mediterranean Region, 12 of the 22 countries experience armed conflicts and are housing 43% of people in need of humanitarian assistance globally, despite only representing 9% of the population (Brennan et al. 2020). Iraq has been shaken by protracted periods of armed conflicts and recurring disaster, representative of the changing patterns of humanitarian crises (Spiegel et al. 2010). Amid four decades of continuous cycles of violence, sanctions, invasions, occupations, and armed conflicts (both intra- and interstate), entailing widespread human suffering and displacement, the country has been classified as fragile setting (Al Hilfi et al. 2013). Iraq simultaneously faces a set of natural hazards, including earthquakes, floods, and droughts. This protracted period of volatility has put a heavy burden on Iraq’s public functioning, with much of the country’s infrastructure, including healthcare, yet to recover. Iraq’s healthcare system, readily described as one of the best in the region in the 1970s and 1980s, has been ravaged with many of its facilities destroyed, equipment looted, health workforce migrated, and essential medicines unavailable (Al Hilfi et al. 2013). Large gaps across the health system building blocks remain, while major progress has been achieved, including the increased governance capabilities and health system financing (Burnham et al. 2011; Internal Displacement Monitoring Centre 2020). With more than 1.9 million IPDs and 250,000 Syrian refugees in 2018 unable to return home, health services, particularly in the semi-autonomous Kurdistan region of Iraq, are further strained (Al Hilfi 2014; UNOCHA 2019). The protracted history of armed conflict over the last decades devastated the health of Iraq’s population. The country experiences a large burden of injuries, with conflict and terror being the number one individual cause of death in 2017, overtaking the still significant burden of communicable diseases in crude mortality rates

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within the last decade (Al Hilfi et al. 2013; Institute for Health Metrics and Evaluation 2020). In the shadow of the highly visible conflict-caused injuries, and exemplary for a MIC despite the protracted armed conflicts, NCDs are the main cause of death (55% in 2017), with a high prevalence (36%) of mental health conditions estimated (Al Hilfi et al. 2013; Ministry of Health Republic of Iraq 2014). Common risk factors across diseases – NCDs and communicable diseases – remain highly prevalent including behavioral (e.g., physical inactivity, unhealthy diet, and smoking) and environmental factors (structural access to clean water, sanitation, and nutrition), particularly for the rural population and urban slums (Al Hilfi 2014; Al Hilfi et al. 2013; Ministry of Health Republic of Iraq 2014). In 2014, only 72% in urban and 47% in rural settings had access to safe drinking water and thus enabled, in connection with a weakened health system and suboptimal vaccination rates, the occurrence of multiple endemic (e.g., typhoid fever, cholera) or reemerging communicable disease outbreaks (e.g., polio in 2014) (Al Hilfi et al. 2013; Ministry of Health Republic of Iraq 2014). Malnutrition, virtually nonexistent in the period up to the 1990s, re-emerged due to the conflict (Al Hilfi 2014). Thus, Iraq’s resource-limited health system is facing a challenging triple burden of disease. To this backdrop, the COVID-19 pandemic reached Iraq in early March, threatening the country’s recovering healthcare system. The government reacted with strict lockdowns and the use of ICTs for information dissemination; however, a decentralized implementation is obstructing access for humanitarian organizations (Internal Displacement Monitoring Centre 2020). The persisting challenges of inappropriate living conditions (e.g., housing and lack of access to water and sanitation) leave many populations, particularly IDPs, exposed to COVID-19, and the implementation of basic prevention measures is complicated through regional floods affecting IDP camps and health facilities (Internal Displacement Monitoring Centre 2020). The Eastern Mediterranean region is expected to be among the first affected by the impacts of climate change. Disease modelling predicts increased mortality in the coming decades, particularly through indirect effects (e.g., water and agriculture) but also direct effects of increased heat stress and vector-borne diseases (MassonDelmotte et al. 2018; Watts et al. 2018). These impacts of climate change are already challenging populations across Iraq’s governorates, through increased water stress and reduced agricultural yields. The two main rivers sustaining much of Iraq’s 6% arable land and as major freshwater sources are depleting (Guiu 2020). These effects are likely indirect, with increased water diversion and storage planned in Iraq’s upstream neighbors Syria and Turkey, both predicted to be experiencing lower precipitation levels, threatening to reduce the rivers’ flow levels by 70%, pushing Iraq into an environmental disaster (Burkle 2010; Guiu 2020). The land’s fertility will be further stressed by expected increases of disasters, particularly dust storms and droughts (Burkle 2010), and in the face of low water quality with only 34% of wastewater in Iraq being treated prior to draining it into rivers (Ministry of Health Republic of Iraq 2014). These factors, in combination with perceived governance failures, are leading to environmental degradation eroding people’s livelihoods, particularly in the downstream governorates Basra, Missan, and Thi-Qar (Guiu 2020). Already 67% of livestock owners in these governorates reported having

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suffered economic losses and a perceived deteriorating situation leading to largescale displacement (Guiu 2020). With the severity of their impact and future risks, environmental considerations are a fundamental priority in the country’s current national development plan 2018–2022 and have also trickled down into Iraq’s National Health Policy 2014–2023, with explicit statements around environmental protection (Ministry of Health Republic of Iraq 2014). Health efforts in Iraq: Iraq’s government is thus challenged to address this triple burden of disease in the face of resource limitations and security issues. It has fundamentally chosen an approach of strengthening the healthcare system and the resilience of health-defining sectors, particularly water and sanitation (Ministry of Health Republic of Iraq 2014). Iraq’s National Health Policy 2014–2023 envisions a reform toward a horizontal and integrated health system where services defined in the essential care package are provided through a primary care-centered system, utilizing the promising family-physician model (Ministry of Health Republic of Iraq 2014). However, this provides challenges given that Iraq’s healthcare system is outdated and traditionally centered around hospital-based care and curative services, which are also perceived as of higher quality by the general population (Ministry of Health Republic of Iraq 2014). An additional component of the national strategy includes a stronger involvement of the country’s emerging private healthcare sector. Private facilities have enjoyed similar preferential perceptions on the quality of their care delivery, arising from the periods of armed conflicts where the private sector was less affected (e.g., drug availability) (Al Hilfi et al. 2013; Ministry of Health Republic of Iraq 2014). Because of these public opinions, Iraq’s unique dual-practice policy (allowing doctors to work in both sectors simultaneously), and its largely unregulated development, the private sector became a strong competition for the public healthcare system (Burnham et al. 2011). Furthermore, their perceived superiority led people to accept existing fees and out-of-pocket costs, despite associated access issues of affordability (Ministry of Health Republic of Iraq 2014). Thus, their increased role for the health of Iraq’s citizens, as defined in Iraq’s National Health Policy, is conjunct with policy changes intended to create a stricter framework and regulations (Al Hilfi et al. 2013). Another key opportunity increasingly playing a role in the under-resourced healthcare system in Iraq is the application of digital technologies, particularly ICTs, driven by rapidly increasing access to mobile cellular subscription (87%) and Internet users (50%) (International Telecommunication Union 2018). While much of the e-governance capacities, digital health information systems, m-health, and telemedicine interventions are in their early days and were hindered by years of sanctions, major promising efforts exist, and feasibility studies and pilots have flourished recently (Wagner et al. 2012; Istepanian et al. 2014). The implementation of such tools also seems promising in light of Iraq’s highly centralized healthcare system and sustained access issues, particularly in areas still affected by armed conflict (Istepanian et al. 2014; Al Hilfi 2014). Next to health system strengthening efforts, vertical programs are being promoted. These consist of the “Expanded Program on Immunization” as foremost effort to address communicable diseases as well as NCD efforts including the development of a national NCD strategy that includes prevention (initially centered around diabetes and

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hypertension), the integration of services into primary care facilities (50% coverage in 2014), and the national basic care package (Ministry of Health Republic of Iraq 2014). Mental health programs have been active since 2003 with multiple trauma centers established, while a high estimated treatment gap (94%) remains, and injuries are addressed through efforts to strengthen the emergency and blood transfusion services (Ministry of Health Republic of Iraq 2014). Digital technologies are being evaluated across diseases areas, such as mental health (Wagner et al. 2012) and NCDs (Istepanian et al. 2014), to improve the effectiveness of existing models of care. Extensive support from (international) humanitarian actors is ongoing to address the needs of displaced populations, due to limited governmental capacities to take over. Humanitarian health actors focus on the delivery of care in IDP camps in specific governorates through stationary primary care centers or mobile clinics, as appropriate (Health Cluster Iraq 2018). With a significant proportion of displaced persons residing in host communities, in context of Iraq’s high national urbanization rate (70% in 2012) (Al Hilfi 2014; United Nations 2018), humanitarian actors apply a complementation and consultation approach in these settings by supporting primary care centers with medicine supply and capacity building (Health Cluster Iraq 2018). The case of Iraq depicts the interconnectedness of the discussed themes, where a triple burden of disease is met by a nexus of a history of protracted armed conflict, recurring disasters, and immediate threats of climate change with challenging geopolitical issues. As a middle-income country, Iraq’s healthcare system is attempting a restructuring toward a horizontal primary care-based healthcare system with stronger prevention efforts, the involvement of the private sector, leveraging of health technologies, and increased cross-sectoral efforts. Humanitarian actors apply supplementary approaches to fill critical need gaps, mostly for displaced persons in camp-based settings.

Conclusion Current global trends, such as an advancing epidemiological transition, recurring and emerging disease outbreaks, urbanization, climate change, and emerging technologies, redefine the humanitarian landscape. Through a shifting disease burden in lower-income settings and crises increasingly also affecting higher-income countries, actors are challenged to address a double or triple burden of disease. Simultaneously, the contexts of humanitarian health programming have shifted toward increasingly urbanized settings and widespread use of digital technologies. The new reality will give rise to a host of challenges, dilemmas, and opportunities. Traditional approaches by humanitarian actors and health systems in low-resource countries are grappling with addressing the associated emerging needs, increasing the pressure on actors to develop new ways of working. Partially, this will require the development of new evidence-based models of care for NCDs, as well as improving the existing models for injuries and communicable diseases. The lack of available research and data on the (cost-)effectiveness of humanitarian interventions and the

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general difficulty of conducting research in these settings are complicating this endeavor and are a critical gap to be addressed. Given the frequent triple burden of disease, there is a necessity of moving beyond vertical programming through utilizing model of care synergies previously neglected and by focusing on a solid high-quality primary care-based health system with a reasonable prevention component. The focus on resilient health systems and (cost-)effective models of care may be facilitated through a weighted leveraging of emerging (health) technologies. The implementation of models of care and strengthening of national health systems need to be context-dependent, as exemplified through the Iraq case study, by taking the existing healthcare system capacity, burden of disease, regionality of the armed conflict or disaster, socio-cultural and policy context, and the historical development into account. This chapter presents the interconnectedness of some of the key threats to health in humanitarian crises. It argues that any sensible solution needs to be equally interconnected to leverage emerging opportunities. Any dichotomy that was previously limiting now presents a critical threat to overcoming the cataclysmic consequences of the discussed themes by ignoring synergies in goals and actions. These include but are not limited to natural vs. human-caused hazards, non-communicable vs. communicable diseases, conflicts vs. disasters, humanitarian vs. development, climate change adaptation vs. poverty reduction, or biomedical vs. psychosocial model of health. With a shared responsibility, humanitarian actors are to acknowledge their role of engaging with systemic determinants of health while ensuring contextual and localized efforts, driving a more sincere and diverse collaboration agenda within and beyond the sector, and ensuring a sensible uptake of humanitarian (health) technologies. In synergy with global health actors, there is a need for multiplication of existing efforts to push for health agendas in global governance issues, such as climate change and questions of global equity, as a visible and relatable embodiment of complex and abstract threats. If these global risks are not significantly minimized, no health system, let alone humanitarian health efforts, will be able to cope with its consequences for a population’s health.

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Part XIII Global Health Workforce and Education

Human Resources for Global Health

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Ebele Mogo and Tolu Oni

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Human Resources for Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Training Pipeline for Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Human Resources for Global Health and the Systems Within Which They Work . . . . . . . . . . . Human Resources for Global Health in Healthcare Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Human Resources for Global Health in Systems for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Human resources are key to global health. This chapter presents a critical examination of the input, output, and outcomes of global health endeavors and their implications for the creation of global health human resources. In so doing, we challenge the narrow conceptualization of who is considered a global health professional and the perceived “otherness” of global health practice. We encourage (this broader definition of) global health professionals to engage with global health as a discipline for developing the tools that will help them understand how activities at home influence health globally and vice versa. We present recommendations for strengthening the production, quality, distribution, and impact of global human resources for health. Finally, we present the case for health systems that include but are not limited to healthcare systems and include the non-health E. Mogo MRC Epidemiology Unit, University of Cambridge, Cambridge, UK e-mail: [email protected] T. Oni (*) MRC Epidemiology Unit, University of Cambridge, Cambridge, UK School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_106

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systems that determine the distribution of health outcomes and the implications for human resource production in global health. Keywords

Healthcare workers · Health professionals · Human resource · Healthcare workforce · Global health training

Introduction Contemporary issues such as the spread of Ebola or the coronavirus, the globalization of unhealthy lifestyles, and the planetary crisis have exposed a vital fact: the field of global health needs to be fit for the purpose of promoting health while able to adapt to new health threats. Human resources for global health – the people engaged in this mission – can only be fit to do so if adequately trained, remunerated, and distributed (WHO 2020). The adequacy of human resources production depends on a consideration of the entire lifecycle of their development – the input considered in planning for human resource production, the output of such planning processes, and, subsequently, the outcomes in terms of the quality and effectiveness of human resources produced. One such consideration is clarity about what global health aims for. As its previous names such as “international health,” “colonial health,” “imperial health,” and “tropical medicine” suggest, global health and associated human resources have often been conceived of as an effort from countries of the “Global North” to fight diseases in countries of the “Global South.” This perception has shaped training, decision-making, knowledge creation, and investments in the field. The infectious disease focus of health systems in several countries in Africa traces themselves to the colonial project and its mission to protect settler populations from the diseases of the “natives” (Azevedo 2017). While the names of the field have changed, its roots are still relevant today in terms of how global health is postured and the way that power and outcomes are distributed via diverse actors ranging from government and philanthropy to nonprofits and multilateral consultants. Today, the distribution of power in global health still reflects colonial, imperial, and economic imbalances. This does not come without negative impacts on human resources for health (HRH). These negative impacts can take the form of a workforce unskilled to navigate the terrain it aims to intervene on; policies that are poorly adapted to their context; agendas that are ratified without substantive participation of low- and middle-income countries (LMICs) regions; and deep mistrust of public health workers under situations where this trust is crucial. An example of these problems can be seen in the Ebola containment efforts in Congo, where distrust of efforts to stem the outbreak contributed to the violent deaths of several health workers (Cousins 2018). Interlinkages between the local and global shape the production of HRH. Local policies on access to primary healthcare, for example, determine how diseases and

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their risk factors spread to other regions of the world and thus put pressure on the HRH in other countries. Despite their adoption in global health decision-making contexts, global health agendas such as the Sustainable Development Goals (United Nations 2020), or policies such as the Framework Convention on Tobacco Control (World Health Organization 2004), still need to be implemented locally. Indeed, they often fall short at this critical juncture. Events in the global labor market such as the demand for healthcare workers in powerful economies shape the local labor market in developing countries via migration of existing HRH (Tyson 2018). Therefore, decision-makers involved in planning for human resources for global health need to be capable of considering not just global health but local consequences. On the other hand, a view of the impacts of local decisions on global health must inform the knowledge, partnerships, and actors used in the production of local HRH. Consideration must also be given to the knowledge that is used in planning HRH. Who gets to shape this knowledge? What motive drives the development of HRH? As the history of naming of the field indicates, the privileging of traditions of scientific inquiry in the “Global North,” and their dichotomous ways of engaging with reality, has also shaped how populations have been understood – the metropole versus the colony, the “self” versus the “other,” culture versus nature, modernity versus tradition, man versus woman, rationality versus irrationality, “primitive” versus “modern,” and “local” versus “academic” knowledge (Iroegbu 2010). It has shaped a history of looking at health through a biomedical, individual, and reductive lens (Hankivsky et al. 2017). This is in contrast, for example, to other schools of thought that understand health as a function of interrelationships that span the individual, their relationships, past, present, and future generations, and the planet (Ejizu 1987). Knowledge that informs HRH production provided by the private sector as part of business data collection, by the nonprofit sector according to the priorities of donors, and by governments based on agreed ideas of who is legitimate may all differ. What is perceived by an expatriate is likely to differ from what is perceived by an indigenous healthcare worker about the community. Linear knowledge production to advance academic careers without strong consideration for co-creation with communities, for example, may generate knowledge that is not able to transform the health of communities and not representative of their ways of understanding their health and well-being (Mogo et al. 2020). Investments that do not consider the question of equity – as it relates to gender, socioeconomic status, ethnic and cultural differences, and spatial location – provide no incentive for its adequate consideration and reinforce inequalities in communities. Underlying the equitable delivery of global health are the processes and partnerships behind human resources development for health. Such partnerships inform the content of the training curriculum, the programmatic priorities and processes that are institutionalized, the monitoring and evaluation metrics that are prized, and the extent to which the human resources developed are capable of representing the needs of their communities. At the global level, the flows of resources intersect with prevailing ideologies of the powerful, e.g., neoliberalism, to shape the global health agenda and thus health equity. The International Monetary Fund’s structural

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adjustment reforms, for example, have been related to lower access to the healthcare system and higher rates of neonatal illness (Kentikelenis 2017). International organizations such as the World Health Organization, despite aiming to improve wellbeing for all, are reliant on funding from economically powerful countries contingent on devoting resources to specified donor-determined interests (Gostin 2015). Increasing power - be it due to imperial histories of countries such as the United Kingdom, economic power such as the private sector in United States and China (Titiporn et al. 2019), or local economic power such as ingrown philanthropy shapes what becomes the global health agenda and what subsequently informs the nature of production and focus of endeavors of HRH. At the local level, efforts to develop HRH themselves can also not be divorced from the political infrastructure they have been built upon. For example, North American nations built on labor and experimentation on indigenous and enslaved populations on the one hand and the extraction of land and labor from them on the other hand shaped the kinds of processes, partnerships, and activities taking place as part of human resource production for health. A notable example of this is the Tuskegee syphilis study funded by the US Department of Health and Human Services, in which 299 African American men were infected with syphilis (Alsan et al. 2019). Another is the extraction of HeLa cells from Henrietta Lacks, who was the source of the first immortal cell line and whose tissues were used for research on cancer in perpetuity, without her consent (Lucey et al. 2009). Such cases demonstrate the consequences of a lack of equitable partnerships in human resources for global health which influences the kinds of healthcare workers produced, the types of activities funded, and what is considered valid and ethical knowledge. A consideration of partnerships is needed not only within healthcare but between healthcare and non-healthcare sectors. This is because several health outcomes are shaped by sectors outside healthcare. Examples include the urban planning sectors that shape access to green spaces, or the environmental sectors that influence exposure to air pollution. Throughout this chapter we refer to the notion of “systems for health,” which has been previously published here: https://gh.bmj.com/content/4/ 4/e001717 the broader umbrella of factors and systems that determine health. Within this umbrella, while the healthcare system is a necessary component, it is noted to be part of the wider systems for health that encapsulate sectors that determine health. Addressing inter-generational inequities in health and well-being cannot happen without considering the “non-healthcare” systems for health factors, past and present – for example, historical redlining policies that restricted access to land and social services for black communities in the United States. Likewise, the poor behavioral, mental, and physical outcomes for indigenous populations in Canada cannot be considered in a void. They must consider the drivers in and beyond healthcare – for example, the impacts of exclusion, of human rights violations, and of subjection to poor living conditions over the course of generations (Greenwood et al. 2018). In several African cities, non-healthcare sectors such as urban planning and their histories also shape the current public health landscape. The privileging of “choice” land for settler populations and subsequent social and cultural policing of these spaces and segregationist investments in urban planning (Bigon 2016) reflect

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today in how informal contexts which house most of the population are still considered invisible and violently governed (Alaazi and Aganah 2019) given that they are outside the bounds of inherited colonial spatial planning. It is important to interrogate the boundaries between “here” and “there,” “us” and “other,” and “local” and “academic” knowledge, to situate human resource production for global health more responsively. This requires approaches that are sensitive to how structural inequities such as economics, race, and gender justice shape human resource production. It also requires an inter-generational span of concerns intersecting the past, present, and the future of global health and engaged consideration of the ideologies shaping resource flows toward health. Finally, positionality and interests matter. We must take a critical stance in understanding who should be at the table in planning HRH; how these shape how resources flow into education, financing, and other investments, as well as knowledge products; and then how these influence the human resources that come out of the global health enterprise – from the advocacy efforts to the research efforts, the policies enacted, and the programs executed. The human resources produced and how they are coordinated will determine the kind of impact that the endeavor of global health can make.

Human Resources for Global Health In this section, the training pipeline for global health human resources is discussed with consideration for who is being trained, where this training occurs, how the training is being implemented, and the motivations that drive this training. Thereafter, consideration is given to the human resources needed within the healthcare system, with critical reflections on the input, output, and outcomes of human resource production in healthcare, along with recommendations (Fig. 1). Finally, we discuss human resource production in the non-healthcare systems that affect health outcomes and the training, leadership, and investments needed to navigate these systems for improved global health.

Training Pipeline for Global Health The modern globalized world is one where “the daily lives of people all over the world are impacted by decisions and practices not only of their own governments, private sector and cultural institutions and norms but of transnational companies and governments other than their own” (Ford Foundation 2017). The conditions created by these sets of interdependent relationships and priorities play a significant role both in generating and perpetuating population health inequities and in shaping strategies to respond to new existing disease burdens. However, power asymmetries that define multilateral rules of engagement and structural determinants of health such as trade are mirrored in these partnerships. Against this backdrop, it is, and will increasingly be, important that training of the next generation of global health

INPUTS

OUTPUTS

Higher education institutions • Healthcare facilities

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Who? Where?

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Private: philanthropic, for profit, NPO Multilateral orgs Higher education institutions

Research

Private: philanthropic, for profit, NPO Multilateral orgs Higher education institutions

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Healthcare system actors systems for health actors

Practice

Healthcare system actors systems for health actors

Knowledge products

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Contexts: from historical to contemporary Driving motivation (reflexivity)

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Here->Here Here->Global Global->Here Global->Global

Education

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Finance & Investment

Equitable partnerships & impact M&E Role of knowledge: Systems Target, Transformational Confront, Critique, Challenge

How?

Trainer & Trainee Knowledge publisher Funder & Advocate Practitioneer & Researcher

Training

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Fig. 1 Global health human resources logic model

OUTCOMES

Hegher education institutions Governments Private: philanthropic, for profit, NPO Multilateral orgs Higher education institutions Academic journals Multilateral orgs Private: consultant, think tanks, philanthropic

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workers is fit to address these complex interlinked societal challenges. As such, higher education and healthcare institutions alike have a key responsibility to play in ensuring the pipeline of human resources for global health are up to the task and can present an accurate picture of the who, where, what, and why of global health (Fig. 1).

Global Health Human Resource Training: Who? The emergence of global health education and training purports to respond to these contemporary changes in shaping health globally with courses and degrees focused on understanding diseases of global importance, the movement of people and diseases across borders, as well as building collaborations to conduct research and provide healthcare services navigating the current health governance structures and local cultures. A paper by McFarlane et al. reviewed global health activities conducted at academic institutions and reported these largely fell into the following categories: medical student electives, training students to work in developing countries, and contracts and research grants to conduct research and provide technical expertise in developing countries (MacFarlane et al. 2008). In considering the “who” of global health human resources, in addition to the trainers and trainees, it is important to consider the roles of knowledge producers and publishers, funders and supporters invested in growing a global health workforce, and (further down the pipeline) global health researchers and practitioners. Trainers and Trainees A consideration of who is leading training efforts and who is receiving this training is vital to understand the perspectives represented and the characteristics of the beneficiaries of available training opportunities. Liu et al. (2015) conducted a critical review of qualitative and quantitative articles on global health education and found that 94.6% of all studies on global health education were conducted in North American and European countries. Of these studies, 65.6% were conducted in the United States. Training programs and medical electives were the most commonly used approaches to global health education. The skewed distribution of institutions that purport to cover global health means that both the trainers and trainees are from the “minority world,” largely taught from a position of assumed power in which those from the wealthy nations have greater leverage than their counterparts from low and middle-income countries (LMICs). In this setup, there is a danger that students from these overrepresented countries learn that inequality to be addressed through global health research and practice exists primarily elsewhere. But if global health is about the improvement of health of populations across the globe and action to address the cross-border threats to health that drive health inequity, there is a need for a radical shift in the current landscape of global health academic institutions to ensure diversity in those informing the scope of training curriculum across geographic, disciplinary, and gender boundaries. Similarly, the profile of those undertaking global health training and the impact of this training on career choices is necessary. Disrupting the existing system will

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require radical reflexivity to consider reasons for the current state of play and to proactively develop and implement a strategy to address this imbalance. For example, positioning of global health as requiring travel for experiential learning excludes students who are unable to fund trips to far-flung places. Instead, courses could shift to a focus on systems and structures that drive inequality and a critical examination of how these play out across different global regions, applying theories and a social justice lens to think through implications, successes, and failures at local and global levels as the foundation for seeking solutions to local health problems (Oni et al. 2019). Such an approach may make training opportunities more equitably accessible. Indeed, competencies developed for global health education and training have identified competencies that include an understanding of health, healthcare systems, and health inequalities between and within countries, locally and globally (Johnson et al. 2012). However, if it is accepted that delivery problems define global health (Abimbola 2018), then the disconnect between competencies outlined and the common practice by global health trainees is one in urgent need of addressing. Knowledge Publishers Beyond higher education and healthcare facilities, the producers and publishers of knowledge have an important role in shaping the content of both the training and practice of global health by its workforce. As such, it is essential that the perspectives represented by these role players are diverse and inclusive. An investigation of the composition of editorial teams of 12 major global health journals (including editorsin-chief, section and associate editors, and editorial boards) (Nafade et al. 2018) revealed that 35% of editors were women, 33% were based in LMICs, and 11% were women based in LMICs. While this paper did not include the profiles of journal reviewers, diversity in manuscript reviewers, whose perspectives inform the perceived relevance and priorities of submitted manuscripts, is also vital. Given the role that journals play in creating the platform for knowledge exchange as well as in setting the agenda and priorities for publication that inform global health training resources, this lack of representation could further contribute to a skewed understanding of the global health landscape. Funders Unsurprisingly, funders of global health training research and practice play a significant role in determining the focus of global health activities by researchers and practitioners with a knock-on effect on the systems put in place to support training of and opportunities for practical experience for this workforce. However, the majority of global health funding headquarters are in high-income countries (Global Health 2020) from where funding priorities are driven. Furthermore, few funders direct resources at upstream health and inequity determinants, and there is some critique on the role that these international organizations play in creating and exacerbating health inequalities (Mwisongo et al. 2016). An illustration of a selective and narrow understanding of global health is the motivation for global health that emphasizes protection of sovereign borders from security threats, protection of trade and

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economic growth, mobilization of the private sector to address these issues, and development of medical products and technological solutions (Dzau et al. 2017) at the expense of a more systems-based approach to health and healthcare globally. Additionally, through their choice of eligibility criteria, funding organizations can also influence opportunities for travel and mobility funding, enabling or constraining reciprocity and equitable access to such funds.

Practitioner and Researcher The final component of the “Who” of training for global health human resources relates to the tail end of the training pipeline: practitioners and researchers who have completed training and are working in this field. For this group, the same rationale as for knowledge publishers for the importance of diverse perspectives applies here; and an intersectional approach to diversity, across gender, geographical, racial, and disciplinary lines, is required. The 2020 Global Health 50/50 report explored power, privilege, and priorities in global health (Global Health 2020). This report found that while many global health organizations are committed to gender diversity, this is still not borne out in reality with 17% of CEOs and board chairs hailing from LMICs. This skew in the landscape of global health human resources of this category contributes to an imbalance in global health activities and priorities. For example, it was found that maternal and child and infectious diseases receive high attention while NCDs receive disproportionately lower attention given the global burden of these diseases. Redressing this imbalance would require addressing power imbalances among practitioners and researchers, currently away from the majority world: a good argument for why there is a need for greater diversity and reciprocal mobility among trainees as well as the need for the skills to confront, critique, and challenge the status quo (see later in this chapter) to be considered core global health training skills.

Global Health Human Resource Training: Where? The growing global inequity means that global health training can achieve relevance only by addressing the burden and root causes of disease in all marginalized populations globally, not solely in LMICs. By exploring and understanding the upstream determinants of ill health, wherever they occur, professionals trained in global health should be equipped to intervene to improve the situation. However, global health training has been slow to take on board tackling these more systemic foundational issues such as the political economy of health to tackle new and emergent disease and the challenge of inequity globally. While several global health training resources cover these topics to some extent, there is a disconnect between knowledge and skills competencies with a comprehensive approach to understanding of drivers of inequity within and between countries, but the practice of skills often narrowed in content (to downstream determinants) and geography (to low-income countries). There is a need for a greater emphasis on ensuring knowledge of the ways that global drivers of health play out locally, vital to understanding how these manifest globally.

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Overview: Four dimensions of “Where” that are important to building a cadre of global health professionals skilled to act on the global forces that determine the health of people: • Here->Here: how local drivers of health influence morbidity, mortality, and disease patterns, and how these contribute to enabling or addressing health inequity locally • Here->Global: how local political and economic systems and decisions made by policy, research, funding, and advocacy actors locally influence the health of populations globally beyond one’s borders • Global->Here: how global systems including actions by multilateral and transnational organizations influence health and healthcare systems and systems for health locally • Global->Global: how global systems including actions by multilateral and transnational organizations influence health and healthcare systems and systems for health globally, including variations in how these influences manifest in different settings and populations, protective for some and deleterious for others

Incorporating these four dimensions of “Where?” into global health training is key to ensuring a greater focus on inequity anywhere. Far from being “elsewhere health,” global health practiced with consideration of these dimensions tackles these issues wherever they occur taking a truly global perspective on global health to improve population health inequities (within the Global North countries, or inequities in the Global South and globally) that are driven by unequal distribution of power and privilege.

Global Health Human Resource Training: How? Having considered the “Who?” and “Where?” of the global health training pipeline, we now consider the cross-cutting “How” skills and approaches to global health action.

3C Skills: Confront, Critique, and Challenge In an ever-changing world, there is a greater need to focus on critical thinking and understanding of the hows and whys compared to teaching focused on static content or state of the world, as this is a moving goal post. What is required is the production of professionals who move beyond knowledge and understanding and develop the “3C” skills to confront, critique, and challenge the root causes of ill health and inequity everywhere, not just elsewhere (Oni et al. 2019). These modern global health professionals need to understand who the global stakeholders are and proactively engage with (not just respond to) the injustices and structural problems that

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arise from accepting the current world order and appreciate that these inequities arise both within and between countries. Global health for contemporary times should equip professionals to engage beyond boundaries: sectoral boundaries, with capacity to engage beyond health into social and political sectors, and national boundaries, with skills to challenge the norms within low-, middle- or high-income settings and effect change in national and global systems and structures that drive ill health and inequity to propose new ways of creating more just societies. Global health trained actors are needed who, armed with knowledge and skills, use their agency to engage in the necessary spaces to effect change. It is immediately apparent that: 1. This would require a broader skills base than is in general currently on offer. This should include leadership skills, teamwork skills, and reflexivity, as well as communication, negotiation, and diplomacy skills. 2. This is beyond just medical students or doctors (or even health science professionals). 3. Applying these skills requires action focused on upstream determinants where they originate, not simply addressing the negative consequences of skewed global systems, which manifest as inequitable disease burdens (Oni et al. 2019). This requires a greater engagement by the global health community with social and political sciences, a readiness to act politically and challenge the status quo distribution of power and wealth, to recognize the importance of both bottom-up and top-down approaches that bridge the gap between local and global for effective change (Fran 2016).

Types of Knowledge: Systems, Target, and Transformational It is important for global health trained professionals to reflect on the nature of the knowledge their work (be that practitioner, policy actor, funder advocate, etc.) seeks to contribute. One framework that has been applied in the context of transdisciplinary research categorizes forms of knowledge as systems, target, or transformational (Pohl et al. 2007). Systems knowledge seeks to better understand the current state of affairs and developing empirical or theoretical knowledge to chip at existing uncertainties. Target knowledge aims to clarify what should be and is more concerned with characterizing values and norms that inform prioritization and strategies for change. Transformational knowledge relates to exploring how we go from where we are now to where we ought, should, or want to be. This form of knowledge requires much more engagement with power dynamics and governance tools including policies and regulations and the associated actors that exert (potentiating or constraining) influence and/or interest. The nature of knowledge focus would inform the who, where, and whys as well as the actors (including funder) to engage and the most impactful knowledge products to effectively address a given knowledge gap.

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Equitable Partnerships Equitable global health partnerships require commitment to mutual benefit and synergistic multidirectional exchange of knowledge, skills, and capacity, recognizing that all partners bring relevant expertise and acknowledging and acting upon the tapestry of power imbalances and opportunities within which partnerships are initiated and developed. The notion of reciprocity is central to equitable partnerships. However, this is currently not being achieved across the global health community including inequities in opportunities for student and staff exchanges and publication authorship (Yarmoshuk et al. 2020). Barriers to and enablers of reciprocity that have been cited include funding for bi-directional exchange and mobility, political landscape (global health and science visa restrictions advocacy), and asymmetries in professional registration to practice (Pai 2020). Given this context, global health professionals, particularly those who benefit more from the current landscape, have a responsibility to confront and challenge this status quo. This will require global health actors who are skilled to agitate, disrupt, and dismantle the current system. To this end, global health funders have a role to play to ensure funding provided is equitably accessible; higher education institutions to push for fairer agreements and capacity strengthening and knowledge exchange agenda to avoid the deskilling of any partner professionals; and all actors to monitor and evaluate the distribution of resources and engagement (Pai 2020). Equitable partnerships also should recognize that the global migration of health workers remains an issue of concern for sustainable research and development in LMICs. Technology can also play a role in addressing or perpetuating inequitable partnerships. Digital technologies could address inequitable opportunities for knowledge and resource exchange by providing feasible and costeffective alternatives to in-person classroom instruction for health professionals training and work experience. However, this potential is yet to be harnessed by many global health training programs (Wipfli et al. 2013) with consideration of the realities across the partnerships to ensure the technological platform adopted does not exclude any partners.

Global Health Human Resource Training: Why? It is assumed that people train and work in global health to “help others.” However, this is grossly inadequate and there is often insufficient reflexivity on one’s positionality and how these experiences influence and drive the reasons why and the ways that we actualize this desire for impactful work. From this position, it is important to ask how one’s familiar contexts, experiences, and assumptions interact with a balanced perspective of historical and contemporary contexts that impact global health and health inequity, including whose voices are often heard and who is often unheard. Global health history is littered with examples of a silencing of voices and contributions from global health actors from LMICs. This interacts with the “Who” of trainers, trainees and knowledge publishers to paint a picture of health innovations primarily developed in Western Europe or North America. One example is the case of Lassa fever. A search for “who discovered Ebola” yields the names of Belgian researchers Peter Piot and Guido van der Groen. By comparison, a search for

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the discoverer(s) of Lassa fever reveals yield information of the town it was named after and the fact that it was called Lassa after missionaries were diagnosed of it in the town it was first isolated. While it is fairly easy to stumble upon detailed stories of the first missionaries diagnosed with the disease, there is superficial mention of Dr. Aniru Conteh, a Sierra Leonean physician scientist, as a “Lassa fever expert who died of the disease” (Wikipedia 2020). Global health professionals should always challenge the why of the contexts of global health, juxtapositioned against one’s motivations and biases, with continuous reflection to challenge representations of who is the helper and who is the helped to recalibrate the discourse on global health innovation, past and present. Addressing the lack of diversity – among trainers and the trained, knowledge publishers, advocates and funders, and researchers and practitioners – and therefore the effect of the skewed, largely white gaze, will go a long way to redress these biases in the content of global health training, actions, and outputs. Having considered the who, where, how, and why of global health human resources, we now focus on the systems within which these play out. We distinguish between the healthcare system and systems for health. We discuss output and outcome considerations needed in framing human resource needs around the desired impact on population health.

Human Resources for Global Health and the Systems Within Which They Work Having considered the “who, where, how, and why?” of HRH, we now focus on the systems within which these play out. We distinguish between the healthcare system and systems for health and discuss output and outcomes, important considerations of the logic model to frame human resource needs around the desired impact on population health. We highlight the need to take this systems approach to addressing the Sustainable Development Goals (Fig. 2) and illustrate how this approach can be applied to the production of global health human resources.

Human Resources for Global Health in Healthcare Systems Across the world there are significant imbalances in availability and production of healthcare workers. The world is about 4.3 million physicians, midwives, support workers, and nurses short (WHO 2020). An estimated nine million more nurses and midwives are needed to achieve the 2030 Sustainable Development Goals for health (WHO 2020). Inequities in the supply of healthcare workers affect disease-specific outcomes. A study in 144 LMICs found that an estimated shortage of 1.18 million mental health professionals were needed to treat mental disorders. Maternal health outcomes are also poorly impacted by a shortage in skilled birth attendants. Within countries, whether high- or low-income, there is a consistent maldistribution of needed healthcare workers that leads to shortages in rural and underserved contexts

Fig. 2 Addressing Sustainable Development Goals and global health challenges: a systems approach to human resources for global health

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within the same region. This crisis in availability and distribution of the healthcare workforce contributes to difficulties in getting and retaining healthcare workers in places where there is a greater need for them such as in rural and remote areas and LMICs. This also retards progress in achieving the Sustainable Development Goals for health. This shortage is not just a question of numbers per se. It is also a question of who is at the table in planning for global health; how this shapes priorities, resource flows, and conflicts of interests; how this is informed or not by the reality of various contexts; and how this drives the design and delivery of global health and indeed what is considered global health. In tracking global health funding, McCoy et al. (2009) noted a growing range of actors contributing funding, managing, and spending on health issues on a global scale, with their decisions often being fragmented and poorly tracked and not related to the disease patterns of countries where such funding goes to (Esser and Bench 2011). These actors ranged from businesses, private foundations, individuals, and high-income country governments, to nonprofits, global health partnerships, intergovernmental organizations, civil society, and bilateral official development assistance agencies, often from high-income countries. In addition to being a complex range of actors in many settings, priorities are not only top-down but driven by external interests. Within this ever more complex landscape of diverse organizations and reporting structures, efforts such as the Paris Declaration on Aid Effectiveness (Bissio 2013) and the International Health Partnerships (Kulasabanathan et al. 2017) have tried to improve financial coordination with limited success (McCoy et al. 2009). Because of this, the competitive agenda of funders of global health may prevail over coordinated efforts to plan for human resources that reflect ongoing and future health systems’ needs. Indeed, the framing of global health actions as a means to ensure security is still pervasive, leaving human resource investments to continually be reactive instead of proactive (Wenham 2019). An overreliance on external funding in developing countries also means being privy to the vagaries – often economic and political in developed countries. Economic recessions or changes in political parties can influence what is funded and how much funding is available. This also creates room for vested interests such as an emphasis on medical treatment and commodities at the expense of prevention, to the benefit of pharmaceutical companies; unjustified private sector spending; ineffective bureaucracies; and at times collusion with national leaders that do not promote the interests or the rights of the people. Another challenge is the question of representation, with global agendas often still being discussed and ratified in “away” settings, where less developed countries are not able to participate significantly for reasons of financial, technical, and spatial access. The World Health Organization’s Framework Convention on Tobacco Control (FCTC) was the first public health treaty negotiated by the World Health Organization and thus a template on deliberative decisionmaking beyond traditional state-centric global governance models. However, an analysis of the participation of civil society groups and national delegates across the timeline of the development of the WHO FCTC noted that participation in the FCTC deliberations was proportional to income category. Despite extra funding

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provided, and a call for civil society input, representation of stakeholders from developing countries was still poor (Mogo 2010). At the local level, varied factors also drive healthcare human resources. Research has shown that various levels of power shape HRH planning differently. The shapers of health policy are as varied as politicians, medical professional associations, government, international organizations, civil society, and academics. A study comparing factors shaping policy in Portugal and Brazil found that while evidence was not identified as important in the policy process in Brazil, it was key in Portugal (WHO 2020). Meanwhile, a study in Nigeria found that while government policymakers had leadership power in spearheading the policy process, development partners had financial and technical power, while civil society groups had advocacy power and knowledge power, and academics had power stemming from evidence generation. Planning decisions also shape labor dynamics such as disparities in the availability of workers in rural and urban centers, or between publicly available and privately available health centers, or in the quality of dimensions of workforce management, e.g., recruiting, attrition, and accreditation, which can affect the performance of the healthcare system locally. Proper remuneration and career trajectories for local healthcare workers can reduce their emigration. Meanwhile, local conditions such as the competency of healthcare workers, worker absenteeism, and quality provided across levels of care can influence how rapidly health concerns such as outbreaks may be contained and spread to other countries. Decisions to address local inequities, for example, via greater recruitment efforts in underserved communities may feed into local inequities such as health worker emigration from LMICs. On the other hand, global policies, such as increased investments into research into specific diseases, may also shape local health by way of the kinds of work skillsets that this demand incentivizes. An important component of effective planning for HRH, therefore, is not only about training more workers. Instead it depends on who is at the table globally and locally. Inputs to HRH need to reduce inequity at the decision-making table, through varied approaches – strengthening local institutions, building capacity for more robust critique of the paradigms and vested interests shaping development, creating support for varied voices especially marginalized ones to inform local and global health planning, and a culture of demand for along with data systems that allow accountability in the flows of resources to global health. Strengthening the coordination of the planning process to ensure that it is not only informed by scientific evidence but also informed by self-critical knowledge that is co-created with communities to better reflect their needs is important.

Healthcare Systems Human Resources: Outputs The outputs of such processes influence the nature of human resource production for global health. At the national level, strong policy leadership and implementation can create the will to invest in HRH as part of ensuring universal health coverage. Comprehensive policies that are informed by evidence and well implemented can address the shortage in the quantity and distribution of workers, the imbalance in the

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adequacy of their skills when compared to real and projected demand, and their mobility to ensure they are in the places where they are needed. The right stewardship of public policy along with the right accountability systems can ensure the right configuration of skills – specialists, generalists, advanced practitioners, nurses and midwives, and other mid-level and community-focused workers in the health system. This requires a consideration of how local public health objectives will shape the global health labor markets and of how global public health objectives will shape local HRH. Leadership at this level can create increased funding for healthcare. This can also mandate linkages with other ministries – finance, labor, the civil service commissions, the local government, the private sector, and education – that shape the supply of healthcare workers. Partnerships such as with the civil service commission can ensure that healthcare workers receive robust financial remuneration as well as other incentives – housing, allowances, and increased grade level upon joining the civil service – to make sure that a career in healthcare is attractive to new workers. A competency-focused collaboration between health and education can ensure that there is a balanced ratio of trainees from urban and rural areas, with consideration also for the inclusion of underrepresented and marginalized workers and populations (WHO 2020). Such accommodations can involve the adaptation of training to suit the instructional design, cultural needs, targeted supply to address disparities in access to knowledge, and linkages with traditions of knowledge that already exist within communities to address health needs. Policies in education can shape the number of seats available for healthcare courses and the quality of education received by emerging health workers. The curriculum of such programs can also shape how healthcare workers provide care, for example, providing them with an understanding of the social determinants of health, teaching them to integrate preventive care into routine assessments, and helping them advocate for the local inequities that affect the health of communities. Data architecture plays a role in monitoring, accountability, and strengthening human resource production. Empowering the health workforce with the technical and managerial skills to use and generate data can catalyze ingrown innovations in service delivery, monitoring the labor economics, and tracking the mobility of workers, among others. Such systems can also help to strengthen the feedback loop between evidence and policy and help monitor specified HRH goals while forecasting future needs and existing vulnerabilities in the system. Data can also bring transparency in monitoring investments into the healthcare sector. It is also important to note that this will require initial investments in infrastructure, e.g., training in professional competency, as well as investments in fitting primary care centers with the core technologies, e.g., Internet connection and privacy and safety guidelines around workforce data and patient data. Without calculated stewardship of these infrastructures, there will be major inequities in quality of data systems and thus planning and patient care, like socioeconomic status. Monitoring and evaluation processes can help to align human resources more thoroughly with current and emerging needs. Some critical information gathered by such processes should include (i) the types and number of healthcare workers that will be needed to address current public health needs, (ii) the regulation and

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education policies needed to ensure that they are produced and distributed, and (iii) financial, social, and other strategies to recruit, deploy, and retain workers. The health and safety of workers and the conditions of their employment are also important. For example, policies and strategies should be inclusive and responsible to equity, to ensure that working conditions are optimal and that there are opportunities for financial growth and personal development of employees. These processes should explicitly track inequities in order to address them. For example, while the healthcare sector is about 70% women, a significant edge over the average 41% in other sectors, the same women face critical challenges – they are often working in vulnerable contexts where they are overworked and underpaid and where their health and safety are at risk (WHO 2020). Training, working, and recruitment strategies can ensure that gender-based discrimination and harassment can be reduced in the workplace. Such strategies can include allowances for housing and education, measures to ensure occupational health and safety, merit-based career development pathways, managing workloads, employee satisfaction surveys to continually improve conditions in the workplace, and a workplace culture to allow people to express their concerns and to feel a sense of agency and have the motivation to provide a high quality of care. In addition to mobilizing resources, it is also important to gain the best value for health from existing resources, especially considering the persistent gap in healthcare capacity and healthcare needs. Workforce inefficiencies and governance weaknesses constitute a sizable portion of the 20–40% of health spending that is wasted globally (Glassman et al. 2013). Healthcare systems in many contexts still operate under a hospital-centric acute-care model, which is also driven by poor demand for healthcare and lack of universal health coverage. In addition, while local governments are crucial in the distribution of primary healthcare, poor reporting and transparency at this level, lack of clarity, and conflicts in roles contribute to chronic underperformance. Cost-effective approaches to delivering healthcare can improve the value gained from existing resources and fuel innovation. One of such methods, task shifting of major diagnostic, preventive, and management services is a costeffective way to improve the quality and availability of services, particularly essential primary healthcare services, while also reducing the burden on highly skilled medical workers. Another cost-effective approach to care is the effective integration of care with population healthcare services, specifically investment in preventive services to reduce disease risk factors, promote healthy behaviors, and ensure prevention. This in turn reduces the financial and human resource burden on the healthcare system. The adoption of appropriate, cost-effective approaches to providing community-oriented and integrated care can lead to the institution of healthcare delivery models that have the right mix of skills to meet population health needs.

Healthcare Systems Human Resources: Outcomes Imbalances in decision-making for global health and the policy, training, research, and financial investments shape the human resources produced globally and where their efforts are directed in terms of advocacy, implementation, and research. In

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2013, an estimated 45 million more workers were needed to achieve universal health coverage in LMICs, the same countries with the highest disease burdens (WHO 2020). Without healthcare sector-specific economic growth, these countries will not be able to employ and retain their workers, even if they are able to train more quality workers (WHO 2020). These outcomes play out differently based on positionality. Healthcare worker shortages in high- and middle-income countries often focus on meeting the demand for healthcare services as a result of population aging and chronic conditions. While high-income countries may have a greater economic ability to employ additional workers, they may not be able to meet the rising demand for services from an aging population with chronic diseases. In low-income countries on the other hand, it is typical to see a low demand for and supply of healthcare workers. Some of this low demand may also be a function of quality. Kruk et al. (2016) have noted that health-seeking behavior without the commensurate quality of services provided may still not yield the required increments in global health. As such, this gap in the labor market will contribute to imbalances in the practice of population health. Policy, its development, and its implementation are another outcome of the process of human resources production. Such policies can shape funding decisions and prioritized programs and the skills needed to deliver them. Lassi et al. (2016) note that policy interventions to rapidly decentralize human resources functions, budget, and infrastructure based on evidence in rural and resource-poor locations contributed to reducing spatial health inequalities in Ghana. Improved geographical accessibility and the use and coverage of maternal and child healthcare services contributed to narrowing neonatal and institutional maternal mortality. Interventions to attract and retain doctors and to decentralize training helped to close geographical disparities in the density of doctors and midwives. Research from Cuba notes that declining inequalities in infant mortality rates in Cuba are related to increases in physician density in provinces (Christiansen and Leonard 2019). These cases demonstrate how effective policy that shapes human resource flows can be. Partnerships, both local and global, influence the effectiveness of HRH in strengthening the healthcare system and can help to build and sustain the intersectoral and global linkages needed to ensure the right distribution of HRH. At the global health decision-making level, research indicates that country participation in the Conference of Parties shaping the Framework Convention on Tobacco Control was correlated to having strong tobacco control policies and that where lowincome countries participated, they were highly likely to implement advertising bans (Plotnikova et al. 2019). The capacity for emerging contexts to play a role in the decisions that impact their healthcare systems is important. Communities must also be a core component of HRH. Involving communities, especially underrepresented communities within countries, or LMICs on a global scale, in shared decision-making can help to ensure that healthcare systems can serve their needs. Best practices indicate that well-trained community health workers are capable to delivering child health interventions in ways that can yield benefits for health outcomes such as child health while also yielding cost-savings, which are

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critical in low-resource settings (Wynn et al. 2017). Rather than being passive recipients of local or global health agendas, supporting patients, families, and populations with the knowledge and skills to be key assets to the health system can build the demand for health and ensure the right supply of health. Efforts to improve health literacy in communities and to build partnerships to optimize existing community assets can be critical in times of crisis, helping to control outbreaks, and helping to make evidence-based preventive efforts integrated into social and cultural practices. For this to be possible, health workers need to be representative of the populations that they serve and be equipped with socio-cultural skills and the reflexivity to bridge health systems with community needs and to also create the kinds of knowledge that is needed in communities to address health issues. Advocacy efforts have often framed HRH as an emergency, and while there is indeed a crisis in supply of healthcare workers around the world, there is need to move from crisis mode to long-term focus to address the crisis. System outputs that fund and mandate such linkages and build healthcare worker capacity to leading such cross-sector partnerships and interfacing clinical delivery with social determinants of health can help make this possible. This requires planned and coordinated efforts to strengthen healthcare systems, to implement effective policies, to ensure universal health coverage globally, and to build the technical, geographical, and financial capacity for emerging economies to develop health in their contexts and be represented in global health. Investments in HRH can shape the nature of intersectoral partnerships to achieve these aims. Education and healthcare sector partnerships can inform training to match current and projected needs, strategies to reduce the reliance on foreign-trained healthcare workers, efforts to align education with employment opportunities, innovative financing mechanisms that can provide the funding and subsidies for healthcare worker training and to supplement limited government funds and means to protect human resources with low worker to population ratios. The literature has shown that linkages to conduct training for healthcare workers in the health sector, for example, requiring shifting of this responsibility from the Ministry of Health to the Ministry of Education can help encourage long-range planning, thus avoiding situations where health systems produce workers without well-remunerated jobs, if any. Likewise, such linkages may inform policies in other sectors, such as the economic sector and civil service to enhance workforce remuneration or to shape investment volumes, education policies, etc.

Human Resources for Global Health in Systems for Health While on the one hand there is a need to meet up with healthcare needs in the health sector, there is also need for more sustainable production of health to anticipate and prevent the eventual need for healthcare. For example, the rise of non-communicable diseases poses an emerging challenge for the African region where NCDs are

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expected to be the leading cause of death by 2030 (World Health Organization 2013). The control of the behavioral risk factors that influence NCD risk will require intervention to improve access to social and physical activity infrastructure, for example, which are often not equally distributed, reflecting wider socioeconomic marginalization (Mogo et al. 2020). Planning decisions are not just about what happens in the healthcare sector, but what happens in other sectors that then determine the need for HRH. Lencucha and Thow (2019) note that while research emphasizes how commercial interests affect government decisions, an ignored dimension is how economic paradigms drive development. Health-damaging commodities and food like tobacco that promise economic growth under neo-liberal development paradigms proliferate and enjoy political support in emerging Zambia, Malawi, Kenya, and South Africa. Such decisions impact the demand for healthcare, narrow and sabotage investments made in preventing disease, and influence the political will to create coordinated investments to improve health in all policies. Research comparing opportunities for inclusive physical activity participation with markers of community deprivation noted an association between the deprivation indices of communities and the quantity of listings for inclusive physical activity participation (Mogo et al. 2020). Healthy dietary behaviour is shaped by access to outlets for healthy eating which are in turn shaped by factors such as advertising which primes people to certain foods; trade policies that shape the flow, availability, and affordability of healthy diets; health literacy, itself as a function of education; and socioeconomic conditions. These concerns feed into global concerns – policies globally that shape trade investments in countries, innovations that could help or hinder access to healthy diets, tobacco industry lobbying which can affect the types of activities in agricultural sector, leadership in the global health sector and by funders that shapes the allocation of resources, and the types of policies and regulations made in governments. The scale of the planetary crisis is also going to have significant concerns for health (Whitmee et al. 2015). Exploitation of remote areas and encroachment of human settlements into natural environments are leading to the outbreak of new kinds of diseases that have not yet been encountered. Rising sea levels and global warming are leading to the contact with new disease pathogens. The extraction of natural resources beyond their equilibrium point, thus stopping the ability of ecological systems to repair, is leading to the insufficiency of resources to meet the needs of communities, thus leading to their displacement, violence, and instability in regions, thus reducing health outcomes and weakening health infrastructure. The increasing frequency of natural disasters as a consequence of climate change is also leading to increased pressure of natural resources, increased inequities, and increased vulnerability to mental and physical illnesses. Addressing this crisis and its impacts on health cannot come from the health sector alone – rather it will require actions to rapidly influence divestment from fossil fuels, actions in industries to ensure sustainable practices, regulations in countries

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to protect the planet, diffusion of innovations such as those for carbon capture, diffusion of practices to ensure the transformation of cultural and business norms, and investments and land use regulations to ensure the greening of cities, among others. Addressing all the implications of these challenges on health requires leadership beyond the health sector. Infectious diseases outbreaks in communities, for example, are often shaped by social conditions such as overcrowding, poor sanitary conditions, and poor access to clean water and often a function of poor health literacy which also is influenced by education. Outbreaks like the coronavirus quickly drew attention to the social conditions that would be amplifying the reach of the diseases – poor responsiveness to the risk in governance systems; reduced access health coverage and thus care; poor access to timely testing; socioeconomic vulnerabilities such as unstable income and poor access to housing that made preventive strategies impossible for low-income communities; and travel industry decisions that led to its spread across land and air borders, among others. The outcomes of the efforts to contain Ebola in many ways were not just the function of the presence or lack thereof of treatment but also of existing infrastructure in the health system for contact tracing, of community trust and buy-in in these efforts, and of political leadership and how well resources were allocated to its containment, among others. Leadership that bridges healthcare systems with the systems that shape health may be conceived of as future proofing health – which is making health responsive to challenges and fit for future needs, one the one hand, and as health-proofing the future, which is creating a future with optimal health outcomes for all, on the other hand (Oni 2020). Having human resources fit to achieve these goals with will require proactive planning. First of all, the conception of global health will need to be expanded to take on greater scopes. Healthcare workers, for example, will need to be able to relate their daily encounters with the systems that are driving them, in the built, natural, social environment and at a planetary scale. Likewise, the global health agenda will need to connect local decisions such as emissions to their distal impacts, e.g., to sea level rise in island countries. This requires investments in a different curriculum for future health workers, as well as systems that allow such thinking to be encouraged through funding knowledge, activities, and training that draw these links. Such investments can shape the outcomes of human resources production, for example, influencing clinical activities that prioritize prevention and not just treatment, or advocacy efforts that frame individual behavior change as a product of more complex environmental and policy determinants or established mandates that allow for collaboration between multiple sectors like agriculture and environment, to address systemic barriers to healthy eating while also ensuring sustainability. These are the types of skills that future HRH will be required to develop to address health effectively. This makes it clear that our current thinking of what constitutes human resources for global health needs to be broadened beyond healthcare to include students, practitioners, funders, and researchers whose work impacts on sustainable systems for health (Table 1).

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Table 1 Addressing Sustainable Development Goals and global health challenges: the application of a systems approach to human resources for global health – inputs, outputs, and outcomes Global health challenge Increasing healthy food consumption rates worldwide

Input Examples of human resource inputs

Natural, built, social, and societal environments and healthcare

Local – National urban development policy Universal health coverage policy

Resiliencedetermining factors: food security, air pollution, injury, quality care, water pollution, flooding stress and safety, human settlement encroachment, biodiversity loss, migration

Global – City mayor and advisors Ministry of Health

Disease and risk behavior exposure

Local Ministry of Education Ministry of Health

Cross-cutting considerations: gender, inequalities, consumption, life stage

Local cultural leaders Local government health centers

Output Examples of resulting training, financing, and knowledge production activities Advertising policies to regulate marketing of fast food Training of community health workforce to assess dietary practices and counsel patients on healthy eating Regional funding to develop partnerships between food vendors, urban planners, and architects to redesign grocery stores to stock and advertise healthy food Creation of funding to improve the quality and retention of community health workers Training of educators on regulating the school food environment Identification of highrisk populations for obesity

Collaborative research with communities to develop knowledge on cultural factors fueling obesity for girls Funding of digital innovation to improve access to behavior change tools for underserved communities

Outcomes Examples of resulting global health advocacy, efforts, and impacts Zoning of communities and schools to ban the use of land for fast-food chains Healthy food fairs in communities run by community health volunteers Food sector and urban planning linkages to mandate spaces for food cultivation Access to well-trained community health workers in every neighborhood

Healthy tuck shops in schools Strengthening of healthcare data systems to track dietary practices and identify high-risk patients (overweight, or obese) Social campaigns to break cultural taboos and ensure inclusive and healthy dietary practices Development of telehealth programs to provide affordable behavioral change counselling for hardto-access obese (continued)

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Table 1 (continued) Global health challenge

Foundational disruptions: poverty, peace, partnerships

Input

Global – World Bank funding for health integration into all development projects World Health Organization advocacy for health as a central driver of development

Output

Funding of multisector neighborhood taskforce to develop solutions to tackle poverty and food together Establishment of a business-health coalition with a mandate to align economic development goals with a health-centered and ecologically responsible development

Outcomes patients from their healthcare team Public health and economy partnerships to incentivize healthy food businesses Name and shame advocacy efforts to identify big business brands whose production practices or products compromise health

Conclusion This chapter presented current thinking on human resources for global health through a critical look at the input considered in planning for human resource production, the output of such planning processes, and, subsequently, the outcomes in terms of the quality and effectiveness of human resources produced. Global inequalities in power, often ignored in approaches to global health training, have been discussed, along with their negative impacts on human resources for global health. Cognizant of the global imbalance in power, the boundaries between “here” and “there,” “us” and “other,” and “local” and “academic” knowledge have been interrogated and related to HRH production. Attention has also been drawn to strategies for investing global health through investing in the workforce: from cost-effective approaches such as task shifting that can create more value yet reduce cost, to interventions and incentives in various sectors to train and retain health professionals and stem inequitable out-migration, to data systems to forecast and address health system human resource needs in a timely fashion. Additionally, health outcomes and thus human resources for global health needs have been framed in light of the significant impact of non-health sectors on health. Therefore, the need for leadership linking healthcare with non-healthcare sectors has been emphasized, and recommendations for action that future-proof health as well as actions that health-proof the future (Oni 2020) have been presented. This chapter contributes to expanding the perception of who is a health professional toward a more

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comprehensive definition of global health human resources that embraces students, practitioners, funders, and researchers whose work impacts on systems for health.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Landscape of Global Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Undergraduate Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schools of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical, Nursing, Pharmacy, and Allied Health Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postgraduate Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Faculty Development/Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competencies in Global Health Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Academic Training Modalities Leading to Credentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Undergraduate Degrees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Graduate Degrees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Certificate/Track Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postgraduate Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nonacademic Training Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nonaccredited Courses or Training Modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . On the Job Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation of Global Health Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standards of Practice in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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L. V. Adams (*) Center for Global Health Equity, Geisel School of Medicine at Dartmouth, Hanover, NH, USA Department of Medicine/Section of Infectious Disease and International Health, Geisel School of Medicine at Dartmouth, Hanover, NH, USA e-mail: [email protected] A. Dev The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_107

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Abstract

Global health education is a growing academic field both in terms of the number of students seeking training in the field and the number of institutions offering formal degree and certificate programs. Training and education opportunities are available for people at all career stages, including those who wish to add a global health perspective to their primary professional training. Interdisciplinary by nature and design, global health training requires mastery of core content and competencies which can best be acquired through a combination of interactive classroom work and field-based experiential learning. Several pathways exist for acquiring global health expertise including those grounded in the social sciences, public health, and medicine. Training ranges from formal degree programs and postgraduate fellowships to short-term certificate courses and on-the-job knowledge and skills transfer. This chapter provides a brief history of training in global health, followed by a broad review of the types of educational and training opportunities to which students have access. This chapter also presents the availability and value of training for people in high-income and low- and middle-income countries. Keywords

Global health education · Health workforce · Training · Practice

Introduction When global health emerged as a new academic field 20 years ago, none of us could have predicted how it would become firmly established as its own multidisciplinary specialty present in many undergraduate, graduate, and postgraduate training programs. Since it was first described in 1999 by colleagues at the University of California in San Francisco, it has grown by all conceivable metrics. Consider the following selected measurements: Institutional engagement • Between 2001 and 2011, the Consortium of Universities for Global Health (CUGH) reported that the number of US academic institutions with global heath partnerships increased more than ten-fold, from 6 to 78 (Merson 2014). • CUGH membership has grown from 24 institutions at its inaugural meeting in 2008 to 197 institutional members in 2020 (CUGH 2020). Academic programming • Among 186 liberal arts colleges surveyed in 2016–2017, almost half (43%) offer a public health/global health major, minor, concentration, or independent study while nearly all (90%) offer at least one course in public health/global health (Robinson et al. 2018).

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• The percentage of graduating residents reporting on the national American Academy of Pediatrics survey that their program offered global health training grew from 59.1% in 2008 to 73.1% in 2016 (Pak-Gorstein et al. 2019). Funding levels • Total US global health funding doubled from $5.4 billion in FY 2006 to $11 billion in FY 2019 (Kaiser Family Foundation 2019). Over the last two decades, centers, institutes, and programs in global health have been established across colleges, universities, and academic medical centers to keep pace with the high demand for global health training from students and trainees at all levels, representing an increasingly wide range of disciplines. Training modalities have also multiplied to encompass both classroom learning including didactics and interactive case studies and experiential learning opportunities (often referred to as “field experiences”), leading to global health majors, minors, certificates, and other credentials. This chapter provides an overview of the current landscape of global health educational and training opportunities available to global health professionals. Global health learners and practitioners know that context matters. This is true for understanding the history and trajectory of global health education and training programs as well. Academic global health, derived from the earlier fields of tropical medicine and international health, emerged as an academic discipline firmly rooted in social justice and health equity. Consequently, global health shifted the work of public health and healthcare delivery across borders from the sphere of charity and volunteer work that often, intentionally or unintentionally, mirrored prior colonial relationships, into an academic discipline with established competencies and learning objectives that uses the academic tools of research, education, and practice to promote health and well-being worldwide through equitable partnerships (Wernli et al. 2016; Adams et al. 2016; Steeb et al. 2019). Still, most global health educational programs today are based at institutions in high-income countries (HICs) with the main aim of preparing their students and trainees to build capacity, deliver care, develop health programs, and/or conduct research in low- and middle-income countries (LMICs). Welcome shifts in the growing number of programs hosted at LMIC institutions are discussed in the section on future vision for global health education and training. In this chapter, every effort is made to highlight programs in both HICs and LMICs.

Current Landscape of Global Health Education The current landscape of global health education and training programs is vast and varied. Programs exist for learners as young as those in their teen years and extend to those approaching or well into their retirement years. Program length, depth, and content also cover a wide spectrum. While advanced training in public health and medicine had been the traditional focus, academic institutions now provide a wealth

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of interdisciplinary offerings in health systems, quality improvement, and healthcare delivery science. Furthermore, in response to increasing chronic disease rates, emerging infections, environmental hazards, humanitarian crisis, and our reliance on shared food and economic systems, global health has transnational and national importance in sustaining healthy individuals and communities.

Undergraduate Schools An increasing number of undergraduate programs are offering global health majors or minors as well as certificate programs and other forms of recognition. A recent review of the curricular offerings of 411 top ranked colleges and universities in the USA in 2019 found that 35% offer a general public health, community health, or global health major and/or minor; this number jumps to 55% when various subdisciplines and other population health-related programs are included (Waggett and Jacobsen 2020). With their breadth of courses across the sciences, social sciences, and humanities, liberal arts colleges are especially well positioned to provide a comprehensive study of global health. Many colleges boast both strict disciplinary and interdisciplinary courses that tackle current challenges in global health and healthcare systems, history of health and healthcare, health policy, emerging pathogens, globalization, cultural studies, and the social determinants of health. While anthropology and sociology departments are the most common academic homes for such courses, departments as disparate as geography, economics, engineering, and comparative literature may also offer courses relevant to an early global health learner who wishes to explore lightly or dive deeply into the discipline.

Schools of Public Health Global health curricula grew out of public health training and schools of public health provided the early “homes” for global health departments and programs. According to the Association of Schools and Programs in Public Health, there are currently 50 accredited institutions in the USA offering global health training in some capacity (Association of Schools and Programs of Public Health 2020). This may span the range from coursework, certificate programs, tracks, content area concentrations, or specializations, to practicums and thesis field work. In recognition of the important role that today’s globalization plays in health, some schools are adding introductory courses in global health to their roster of required classes for the degree. The most common public health degree is the masters, but doctoral degree programs are also granted by most schools of public health.

Medical, Nursing, Pharmacy, and Allied Health Schools Medical and nursing schools across the USA have responded to increasing student demand for options to study and practice global health and conduct global health

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research. Many schools now offer electives on various global health topics and even more address global health aspects of disease in the infectious disease or child and maternal health components of their core curriculum. Several schools also offer global health tracks, certificates, classroom-based and field-based electives or internships in community health or research. Many schools also support student-run interest groups to allow a speaker series or other informal opportunities to interact with local and regional global health experts. Global health training is also of interest to students in pharmacy and allied health professions such as physical therapy. In response, some schools are developing overseas training opportunities in the form of advanced practical experiences in LMICs and graduate certificate programs. Students of physical therapy and other rehabilitation services are a newer cohort to join global health training; however, the importance of their role is clear. Given the growing number of individuals living with disabilities globally, the disproportionate number of these individuals who live in LMICs, and the limited access to specialized rehabilitation services in most LMICs (WHO and World Bank 2011), students of physical therapy, and other rehabilitation services can serve an important role in supporting the development of disability care in LMICs. While demand for global health training by health professions students is rising across high-income nations, students often find little orientation or preparation in pursuing international opportunities; this is particularly well documented among medical students (Bozorgmehr et al. 2010; Johnson et al. 2012). Standards for predeparture preparation are being established at many institutions and it is no longer acceptable to simply send students (or faculty) into a global health field experience unprepared (Adams and Sosin 2016). Similar aspirations exist among health professions students in LMICs but opportunities to train in a cross-cultural setting are limited and expectations may be different.

Postgraduate Training Similar exponential growth has occurred in postgraduate training programs across a wide range of specialties. Global health curricula, residency tracks, and specialized fellowships now exist to meet the training needs of those pursuing careers in a variety of specialties including anesthesiology (Kaur et al. 2017; Abou El Ela Bourquin et al. 2018), emergency medicine(Hau et al. 2017), family medicine (Hau et al. 2017), neurology (Deb et al. 2018), oral health (Lambert et al. 2020), oncology (Balogun et al. 2019), obstetrics and gynecology (Trivedi et al. 2018), pediatrics (St Clair et al. 2020; Crouse et al. 2020), pathology (Glynn et al. 2020), and surgery (Abou El Ela Bourquin et al. 2018). While the rigor, time constraints, and Graduate Medical Education requirements can limit a postgraduate’s ability to pursue global health training in the field for more than a month at a time, many programs aim to incorporate their trainees into existing research, capacity building, or care delivery collaborations so that preparation can begin well before the trainee departs their home institution. Follow-up work can also continue more easily once the trainee returns when their work is part of a longitudinal project and a valued, ongoing partnership.

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Global health training is particularly common within certain specialties. A survey of 198 pediatric residency training programs in the USA found that one-fourth of the programs had a global health training track, with over half offering international field experiences in 153 countries, a truly global effort (Butteris et al. 2015). Two-thirds of the programs had a global health faculty lead. Larger programs were able to provide more pretravel preparation, including orientation and cultural competence training, and international research opportunities. International training opportunities can help to fulfill core training competencies in community medicine, health equity, and public health, skills that residency programs aspire to impart (Bazemore et al. 2007). Similar training opportunities are being developed in other high-income countries such as residency training in Canadian family medicine programs with a focus on developing curricula for training abroad (Redwood-Campbell et al. 2011). In Australia, there is greater recognition of the value of integrating global health training in clinical and postgraduate training as a core content area (Mitchell et al. 2013). Most program developers are utilizing international curricula, resident and faculty surveys, and published literature to develop residency curricula that offer global health electives and training. However, gaps in curricula persist and are generally proceeding on an institution-by-institution basis, although there are increasing publications documenting experiences and sharing content and lessons learned.

Faculty Development/Training Faculty at all levels – junior, mid-career, senior, and post-retirement – are seeking opportunities for global health engagement. Those at either end of their career spectrum may find that they have the time as they are less hindered by economic or family commitments, while others are eager to return to prior international work they may have done as a Peace Corps volunteer or on an earlier service trip or medical student elective. Many are also drawn by what they see as a chance to focus on practice of medicine in a system (at least seemingly) less complicated by third party billing paperwork and other burdensome administrative tasks. Finally, the opportunity to have a greater impact on individual patient lives in settings where formally trained specialists may not exist is a compelling ethical draw for many established experts. While there are many entry points for students interested in global health, there are fewer options for faculty to receive such training, especially if they are unable to return to fulltime or even part-time study, such as a master’s degree program. Many will instead choose to find a nongovernmental organization that they can volunteer with or may engage through an established partnership with colleagues at their institution or academic medical center. In those cases, the organization or colleagues may take on the responsibility for providing the necessary training and preparation. There are few formal programs (and none described in the literature) for this growing cohort of global health enthusiasts. This is a notable gap in the global health education and training landscape and it is recommended that global health program

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directors ensure that their established faculty – who may be among the most accomplished in their respective fields – have appropriate faculty development seminars and training sessions to ensure they will be most effective during their global health engagements.

Competencies in Global Health Practice Competencies were established for the health professions to ensure their graduates have the required knowledge base and skillset to practice safely and effectively. Furthermore, they ensure a minimum standard is attained and, in some cases, maintained over time through repeated re-assessment (e.g., recertification exams for physicians and advanced practice nurses). When coupled with standards of best practice, competencies can also promote ethical practices in global health, a critical topic which is discussed later in this chapter. As global health emerged from its early roots of mostly part-time practice through voluntary service and by unregulated, albeit often well-intentioned, individuals, to become an established academic discipline, it became clear that competencies were needed. Discussions about this dire need began at the inaugural CUGH meeting in 2008 and by 2013, CUGH had appointed a multidisciplinary Global Health Competency Subcommittee to address this critical gap. This committee was specifically charged with defining the core competencies in global health that could apply across specialties and disciplines of practice. The result of their intensive two-year work was a published list of 52 interprofessional global health competencies (Jogerst et al. 2015). Their seminal work defines degrees of proficiency organized as competencies for two levels, a Global Citizen Level (13 competencies across 8 domains) and a Basic Operational Program-Oriented Level (39 competencies across 11 domains). These domains extend beyond the obvious areas such as global burden of disease, globalization of health and health care, ethics, professional practice, and project management to include health equity and social justice, and sociocultural and political awareness. For a sample of competencies and domains, see Table 1. At the time this list was published, the authors advised that further work be done to validate and continually refine these competencies to keep them relevant to the evolving field of global health practice. Since their publication, the Global Health Competency Subcommittee has subsequently created an accompanying toolkit, which, updated in 2017, includes teaching strategies, and accompanying educational resources (articles, websites, books, annotated bibliographies, and study questions) for each competency (CUGH Competency Sub-Committee 2018). While the CUGH-produced competencies are among the most commonly adopted, other leading specialty agencies have also developed their own competencies. For example, the Association of Schools and Programs of Public Health developed six global health competencies that build on the 12 foundational knowledge areas and the 22 MPH foundational competencies required for all CEPHaccredited programs (Jacobsen et al. 2019). At a workshop convened in 2014, 30 representatives from the 50-member Association of Pacific Rim Universities Global

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Table 1 List of competencies categorized into 8 domains for global citizen and 11 domains basic operational program-oriented levels Domains and competencies DOMAIN: 1. Global burden of disease Encompasses basic understandings of major causes of morbidity and mortality and their variations between high-, middle-, and low-income regions, and with major public health efforts to reduce health disparities globally. DOMAIN: 2. Globalization of health and health care Focuses on understanding how globalization affects health, health systems, and the delivery of health care. DOMAIN: 3. Social and environmental determinants of health Focuses on an understanding that social, economic, and environmental factors are important determinants of health, and that health is more than the absence of disease. DOMAIN: 4. Capacity strengthening “Capacity strengthening is sharing knowledge, skills, and resources for enhancing global public health programs, infrastructure, and workforce to address current and future global public health needs.” DOMAIN: 5. Collaboration, partnering, and communication “Collaborating and partnering is the ability to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication” with partners and within a team. DOMAIN: 6. Ethics Encompasses the application of basic principles of ethics to global health issues and settings. DOMAIN: 7: Professional practice Refers to activities related to the specific profession or discipline of the global health practitioner. (Domain definition proposed by members of the CUGH Global Health competency subcommittee.) DOMAIN: 8. Health equity and social justice “Health equity and social justice is the framework for analyzing strategies to address health disparities across socially, demographically, or geographically defined populations.” DOMAIN: 9. Program management “Program management is ability to design, implement, and evaluate global health programs to maximize contributions to effective policy, enhanced practice, and improved and sustainable health outcomes.” DOMAIN: 10. Sociocultural and political awareness “Sociocultural and political awareness is the conceptual basis with which to work effectively within diverse cultural settings and across local, regional, national, and international political landscapes.” DOMAIN: 11. Strategic analysis. “Strategic analysis is the ability to use systems thinking to analyze a diverse range of complex and interrelated factors shaping health trends to formulate programs at the local, national, and international levels.” Excerpted from Jogerst et al. (2015)

Health Program drafted 19 core competencies across five domains for masters-level global health training (Withers et al. 2019). These domains spanned from the more traditional public health areas of determinants of global disease patterns and project

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management to include broader issues of globalization such as global health governance and diplomacy and included the critical issues of global health ethics and human rights. Their document also provided guidance on optimal methods to educate students to attain these competencies through a combination of in-class learning, practicums, collaborative research engagement, and strong mentoring.

Academic Training Modalities Leading to Credentials Academic credentials are critical to establishing standards of practice and competency in a field. As discussed above, global health educational opportunities exist at every stage of training; however, some are offered through informal programs while others will lead to a formal accredited degree or credential. The following section outlines the standard degree programs and also discusses common nondegreegranting options that global health learners may seek to fill specific gaps in their knowledge or skillset. (Note: Specific programs and institutions are mentioned for illustrative purposes only and do not imply a particular endorsement.)

Undergraduate Degrees The interdisciplinary nature of global health education is well-suited for undergraduate dual degrees, either as a minor or major with formal training in key concepts, tools, challenges, and solutions. Traditionally, nonmedical fields such as business administration and engineering also offer global health training, recognizing the value of problem-based learning for solving some of the most vexing health issues of our lifetime. For example, undergraduates at the University of Washington in Seattle can major in global health through the school of public health – a program that was refocused to accommodate growing student interest in local and global aspects of health science with options for new course sequences (UW School of Public Health 2018). However, undergraduate majors in global health are still evolving and may differ vastly in terms of content and approach across institutions – something that will need to be addressed in order to align curricular content with standardized competencies. The Council for Education for Public Health (CEPH) has published accreditation criteria for standalone baccalaureate programs in public health but does not include any specific competencies for global health. Academic requirements for an undergraduate degree can vary with respect to final theses, practicums, and international training opportunities (Drain et al. 2017). There are currently no standards for which departments can host a global health degree program for undergraduates, thus adding to the variation in course content and approach. Delivering international training to undergraduate students, while incredibly formative, can also increase the resource burden for home and host institutions, with increased demands for supervision and wellbeing abroad. Additionally, training students from high-income countries in low-income settings raises questions of privilege and reciprocity which must be acknowledged and addressed.

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Graduate Degrees Graduate public health education has included training through masters programs in public health (MPH) and science (MHS or MSc), doctorates in philosophy (PhD) in the social sciences, and professional public health degrees such as a DrPH. Medical schools also offer public health courses and joint MD-MPH programs for integrated training in medicine and public health (Koo and Lapp 2014; AAMC 2020). Advanced global health education is integrated into these formal tracks with core coursework in epidemiology, biostatistics, health policy and management, health financing, social determinants of health, and other theoretical and practical foundations for public health science. Students can target their degrees toward global health by choosing pressing global health issues for thesis or dissertation research, engaging in practicum training under faculty with well-established global health research portfolios, and through interdisciplinary coursework focused on global health challenges and response. For evident reasons, global health education builds on formal public health content given the foundational work in public health research and programming. But there is sufficient need for training that is particular to the morbidity and mortality burden in LMICs, especially when combined with the challenges faced by poorly resourced health systems. Furthermore, any additional shocks in the way of natural disasters, humanitarian crisis, and poorly enforced social and human rights protections also need to be addressed with regard to their impact on health outcomes. Considering the disproportionate adversity faced by many citizens of the global south, graduate training is tailored to address the specific needs of these countries and communities. Within countries, additional effort is required to protect vulnerable people who are at risk of higher disease incidence without much relief from the health system. An example is the global fight against HIV/AIDS where coordinated global funding, advocacy, and scientific investments curtailed the pandemic across the world but where pockets of vulnerability still exist among disenfranchised and neglected populations. Many opportunities exist for graduate training in areas such as infectious disease epidemiology; maternal, newborn, and child health; adolescent health; primary care; health system strengthening; and data science that can deliver training in evidence-based practices for global impact. Students around the globe are eager for experiences outside of their country to help develop their skills as a practitioner. However, students may differ in their interpretations of their experiences. In a survey of US medical students rotating through partner sites in LMICs and vice versa, trainees agreed on the value of experiencing different healthcare systems, resource settings, and cultures but diverged on the educational experiences, with US students pointing to the value of focusing on social determinants of health and LMIC students highlighting the contribution to their career goals (Peluso et al. 2018). These differences in the goals of global health education are important in considering any programs that incorporate reciprocity – but also highlight the value of global health education in uncovering stark inequalities that may be masked in the USA by providing opportunities to students who may not fully appreciate the impact of poverty on health

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inequities. Similarly, a reciprocal training program can offer career advancement for LMIC students that may be lacking in their home institutions.

Certificate/Track Programs Global health certificate programs can provide focused introduction to global health issues and skills. Often combined with complementary programs or offered independently to established professionals, these certificate programs provide an overview of the practical knowledge and skills in global health science. The education objectives can be targeted to professionals who want a global health focus in their professional work or those wanting to explore the discipline without enrolling in a formal degree program. Certificate programs are shorter than masters training and may be run by nonaccredited institutions. They can be easily customized to specific issues such as the portfolio at Unite for Sight which offers a number of online certificates in global health including cultural competency, global health practice, social entrepreneurship, research, monitoring and evaluation, technology, health education, NGO management, program development, public health management, maternal and child health, refugee health, urban health, community development, social marketing and entrepreneurship, community eye health, environmental health, nutrition, surgery, and program delivery (Unite for Sight 2020). Similarly, Johns Hopkins Bloomberg School of Public Health confers online certificates to students enrolled in other degree programs as well as external candidates (Johns Hopkins Bloomberg School of Public Health 2020). Many schools of public health in the USA have this option – and can be researched online. Similarly, universities in Europe, South Africa, Asia, and Canada train a number of candidates in distance learning programs of almost any size and shape (WHO 2020). Certificate programs can quickly develop participants’ capacity to design, implement, support, and evaluate global health delivery programs.

Postgraduate Training While training opportunities are proliferating and providing important experience and skills, there are still gaps such as the preparation of residents prior to international trips. Beyond vaccinations and safety guidelines, trainees are in need of preparatory coursework in tropical medicine, cultural competency specific to the country and setting of travel, guidelines on working in low-resource settings, and ongoing assistance for ethical and mental health issues arising from the challenges that are inherent in global health service delivery. A multisite study of residency practice locations showed that many residents end up working in rural areas of dense poverty, a location which may add extra challenges with regard to context, communication, and resources in addition to the limitations posed by poor health systems (Liaw et al. 2014). International clinical training can demand skills that may not be commonly practiced by residents in the US context such as cesarean sections or

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minor surgeries. Being mindful of cost-effectiveness of interventions, valuing cultural competence and providing care to extremely underserved populations are part and parcel of international placements (Lu et al. 2018). However, having stable, academic partners who can provide clinical supervision is essential to avoid residents taking on unsupervised clinical duties that are outside their expertise or knowledge and skills or that exert extraordinary demands on partner institutions (Arora et al. 2017). Accreditation of clinical training curricula would be an important effort to address many of these concerns as they would clarify the importance of preparatory training, establish substantial supervision capacity at host institutions, and delineate the clinical roles of trainees. It is important that funding accompanies all training efforts, both for sending and receiving institutions. Additionally, reciprocity in training for physicians from LMICs in high-income settings can be equally relevant and important toward addressing global health training inequity – something that needs to be part of any consideration for global health education (Adams et al. 2016). On a country by country basis, through innovative collaborations between universities and research institutes, opportunities are available to build competency in research as well. The George Institute for Global Health in Australia has a postgraduate and visiting fellows training program to recruit, train, and retain researchers from around the world who are committed to tackling global health disparities through high quality research efforts (The George Institute for Global Health 2020). The American Academy of Family Physicians endorses several clinical fellowship programs at US colleges and universities aimed at a host of trained clinicians who wish to expand their global health knowledge and skills through a combination of classroom and applied opportunities in domestic and international settings (AAFP 2020). Several clinical fellowships in global health from US academic centers are listed in the Global Health Fellowship database (Global Health Fellowships 2020). Nonclinical fellowships for nurses, economists, engineers, and post-Bachelor students to gain experience in global health, often offering field experience in a developing country, can be found at ProFellow (ProFellow 2018). Hundreds more global health, policy, and diplomacy training opportunities exist for professionals across the world – best found through a combination of web searches and listserv postings. Unique fellowship programs have been established worldwide to build interdisciplinary, applied skills for professionals from a wide range of fields to achieve greater global health equity and address planetary challenges. The Acumen Fellowship program is one such pipeline – recruiting professionals from Malaysia, Bangladesh, Colombia, India, and East and West African countries to learn about systems change in their home countries (Acumen 2020). Designed to build leadership skills, professionals can address prominent global health challenges through existing or new programs. Fellows have worked on solution driven projects in areas such as telehealth, health insurance financing, youth violence and drug use, housing, and primary health care. The Humphrey Fellowship Program, funded by the US Department of State and administered by the Institute of International Education, matches young and mid-career professionals from designated countries with US

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counterparts for a year of nondegree graduate-level study, leadership development, and professional collaboration (The Hubert H. Humphrey Fellowship Program 2020). In public health, fellows can focus on infectious diseases; health policy and management; HIV/AIDS policy and prevention; and substance abuse prevention, education, and treatment. The Institute for Health Metrics and Evaluation (IHME) has a fellowship program for candidates with a doctoral research degree or equivalent in demography, economics, sociology, health policy, or a related social science field and an active academic appointment at another institution. Fellows investigate the trends and determinants of healthy aging at the international and subnational levels through methods development and estimation efforts with IHME researchers, especially the Global Burden of disease study. The PHI/CDC Global Health Fellows Program in the USA offers recent CEPH-accredited graduates opportunities to engage in six technical areas for a year of global health training (PHI/CDC Global Health Fellowship Program 2020). Technical areas include HIV/AIDS prevention, program management, epidemiology, strategic information, monitoring and evaluation, and surveillance. However, fellowships are only offered to US citizens or permanent residents.

Nonacademic Training Modalities Nonaccredited Courses or Training Modules Nonaccredited or partial-credit courses are offered by several public health institutions. For example the US Centers for Disease Control and Prevention’s (CDC) Field Epidemiology Training Program (FETP) modules invest in building a global health workforce that can quickly respond to disease outbreaks before they become epidemics (CDC 2020). FETP graduates learn to quickly communicate health information about infectious and noncommunicable diseases and environmental hazards that can threaten the wellbeing of communities and have the potential to become widespread catastrophes. Over 80 countries have benefitted from these programs. Some of the most recent responses have included Ebola in West Africa, Zika in the Americas, MERS-Cov, Polio, and the Covid-19 pandemic. The training programs in epidemiology and public health interventions network (TEPHINET) operate as professional membership networks to train and respond to public health emergencies in 100 countries (TEPHINET 2020). Programs are offered in field epidemiology and laboratory and/or veterinary science and accredited by a global body to ensure standardization and quality. Training programs are designed to create an epidemiology service at the level of the national government to ensure that public health officials are able to identify threats to the health and wellbeing of the country’s population and respond with accurate and appropriate tools and materials. For example, TEPHINET disburses mini-grants to indigenous researchers who serve as principal investigators who analyze existing surveillance data on the country’s noncommunicable diseases.

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Short courses are also offered by international organizations in a number of modalities from online learning to self-directed training modules such as LAICOAravind Eye Care System in India which provides training in hospital administration and systems development for Indian and foreign practitioners. Similar, multitopic short courses are also given by AMREF-Nigeria and the Institute of Health Management Research – India, among others (WHO 2020). Courses in LMICs are lowcost, designed to be affordable for people in the country – while courses at European institutions are priced higher, albeit sometimes with financial scholarships for those who cannot afford them. The Global Health Training Centre in Singapore offers free of charge online courses and seminars to teach research methods (Global Health Training Centre 2020). It is endorsed by several bilateral and multilateral donors and stakeholders.

On the Job Training For all health professionals, continuous learning is necessary to stay current in one’s field. Both formal and informal mentoring ensure that professional growth persists. For health professionals in LMICs, on the job training in clinical practices has been expanded through joint collaborations, especially with the USA through programs such as the Global Health Service Partnership and the Rwandan Human Resources for Health Program (see Text Box 1). These two collaborations are funded primarily by the President’s Emergency Plan for AIDS Relief (PEPFAR) to strengthen medical and nursing education. Nurses, physicians, researchers, health managers, and other healthcare professionals are trained in twinning programs and on-site short and longterm trainings to improve the quality of medical and nursing education and care delivery in places with a high burden of disease and a dire shortage of health professionals. Text Box 1: Human Resources for Health in Rwanda (HRH-Rwanda) One of the most ambitious global health training programs was launched in Rwanda in 2012 as a multi-sectoral collaboration between the Government of Rwanda and US academic institutions to train a large, diverse, and competent health workforce in the country. The program sought to upgrade the health workforce beyond the physicians and nurses with low levels of generalized training and very limited specialist access available only in Kigali, the capital. Funded primarily by the US government, the HRH Program sent over 100 US medical personnel to Rwanda for short and long-term placements at health facilities across the country to provide training in clinical care, healthcare management, research, education, and capacity building. The Program also strengthened the capacity of Rwandan academic centers to sustain future training by increasing the numbers and competencies of Rwandan medical (continued)

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faculty, strengthening health systems management capacity; and establishing bilateral academic partnerships. To support ownership, planning, and sustainability, the funding for the program flowed directly to the Government of Rwanda who utilized 60% of the funds to cover costs of the visiting faculty and the remaining funds to improve management, equipment, and supplies at the training sites. Thus, the Rwandan government was given an unprecedented role in global health planning and financing, to set priorities for the training needs of its workforce to address the country’s persistent and emerging health threats. Twenty-two training programs, 12 of which were new, were established across four disciplines including medicine, nursing and midwifery, oral health, and health management and implementation. Through 2019, over 4500 students were expected to graduate from baccalaureate and Masters level training programs. Rwandan faculty were engaged through a “twinning” model to develop the careers and skills of Rwandan specialist clinicians and educators to assume all teaching and care delivery after the initial seven years of implementation. The impact of the HRH Program in Rwanda, combined with additional economic investments and development initiatives are credited for the Rwandan government’s successful response to the Covid-19 pandemic, showing that intersectoral investments in health can have a long-term impact. Sources: Cancedda C, Cotton P, Shema J, et al. Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda. Int J Health Policy Manag. 2018;7(11):1024–1039. Binagwaho A, Kyamanywa P, Farmer PE, et al. The Human Resources for Health Program in Rwanda – A New Partnership. N Engl J Med. 2013;369 (21):2054–2059.

Evaluation of Global Health Training Evaluation in global health educational and training programs is used to assess the acquired knowledge and skills of the students or trainees (and whether levels of competence have been attained across all required domains) as well as to assess value and effectiveness of the educational or training program itself. Standard means of student evaluation (e.g., written exams/quizzes, analytic papers, and research reports) are still the norm but many global health educators recognize the importance of effective communication, advocacy, ethical practices, and teamwork in global health practice. Consequently, oral presentations, written reflections, classroom debates of controversies in global health, and team-based projects are becoming commonplace mechanisms for assessing both engagement and mastery of competencies in global health courses. Evaluation of applied skills is also an important

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aspect of assessing global health professionals. In the classroom, dissection of case studies can be used for this purpose. In the field, reports which go beyond factual summaries to include self-assessment and reflection by the learner as well as feedback from supervisors or colleagues on the ground can be very useful to capture a comprehensive picture of both professional and personal growth. Progress towards achieving the established competencies described above should be monitored and shared with the learner regularly to ensure they are on track for attaining the required knowledge and skills during their program. One set of assessment tools that institutions may find useful is the 16 open access VALUE rubrics produced by the Association of American Colleges and Universities (AAC&U 2007). Developed by US faculty experts and other educational professionals through an iterative peer-review process, these rubrics can be used by educational institutions to assess and guide student learning through a progression of higher levels of mastery including the application and synthesis of new knowledge. Several of the VALUE rubrics are relevant to global health learners, in particular the Global Learning rubric with its assessment areas of global selfawareness, perspective taking, cultural diversity, and understanding global systems. Assessments of training programs typically rely on student feedback provided at the end of the program or occasionally at some regular interval (e.g., annually). To ensure that global health educational programs are comprehensive, established competencies can be mapped onto program curricula and any gaps addressed through targeted planning such as outreach to specific guest speakers or additional field opportunities. Global health educational programs based on partnerships in LMICs can also be evaluated by application of existing guidance documents such as the Fair Trade Learning rubric (Hartman 2015). This tool is designed to guide global partners through early stakeholder assumptions and indicators of engagement toward an aspirational ideal relationship based on equity and a balance of power across the partnership. Such tools that assess partnerships and academic collaborations are utilized too infrequently. Another means of assessing global health programs is by measuring impact. Impact on students and trainees can be measured as either immediate impact (e.g., captured in narratives during or shortly after a global health experiential practicum) or as longer-term impact (e.g., by following the career choices and professional activities graduates engage in). Many global health training programs have numerous testimonials – formally and informally documented – on the immediate impact that global health education has on its students. Global health training often takes students out of their “comfort zone” and into unfamiliar settings, both literally and figuratively. Van Schalkwyk and colleagues have described transformative learning as “learning that challenges established perspectives, leading to new ways of being in the world” (Van Schalkwyk et al. 2019). Global health education provides many transformative learning opportunities and educators and directors of global health education programs should ensure that they have mechanisms in their programs to promote and support such growth and learning; without appropriate support, students can feel adrift and/or overwhelmed. The impact of specific global health training on learners has been most well studied in medical students and residents.

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In Germany, students who pursued electives abroad during their practical year (283 of 554 surveyed) achieved higher scores on their medical licensing exam (Störmann and Angstwurm 2018). Other studies (albeit with small study samples) examining long-term effects have shown that completing a global health elective during an OB/ GYN residency was associated with a career working in global health and/or local health disparities (Patel et al. 2019). Similarly, faculty from a dedicated global health residency program found that of a majority of their graduates were able to continue to engage in global health activities after graduation despite challenges of lower salaries, a lack of mentors, and under-supported career pathways at their institutions (Palazuelos et al. 2018). Such findings suggest that global health training can contribute to long lasting impacts on career trajectories. The other critical area for evaluation is the impact on the communities, institutions, and partners where global health learning and collaborative programs occur. Again, there are many personal anecdotes and nonpublished reports that highlight successful educational programs but almost none in the published literature. This is a gap in documentation of the value of global health education and, without host partner feedback, risks the educational activities and benefits being one-sided. One study that used semi-structured interviews with host partners in Bolivia and India found that they experienced several benefits including improvements in job satisfaction, local prestige, global connectedness, leadership skills, resources, and a sense of efficacy within their communities (Kung et al. 2016). Another study that interviewed medical colleagues in Benin that hosted Canadian medical students found some similar benefits including additional motivation for self-learning and improved patient care (Renaud-Roy et al. 2020). However, both studies noted a desire on the part of the hosts for greater parity in the opportunities provided to their students such as an opportunity for local medical students or professionals to take part in such international electives. This should be a priority area for global health educational programs moving forward.

Standards of Practice in Global Health Universally vetted standards of practice for global health education are lacking. This gap has been well documented and described as the broad lack of a standard curriculum across all of the health professions (Mendes et al. 2020) or the specific absence of learning domains and competencies for nursing practicums (Kelly and Lazenby 2019). The risks associated with not having standards of practice in global health education may seem obvious: the students’ education can be compromised and learning objectives/competencies are not mastered, inconsistent or variable quality of global health education programs that may waste resources and expertise, and because of the direct relationship to host partners, communities, and sometimes patients, the possibility of doing more harm than good. This latter concern, often housed in the broader realm of ethical practices in global health, has, appropriately so, garnered significant attention by ethicists and practitioners alike. This attention has resulted in the development of an oft-cited framework for short-term global

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health experiences (Shah et al. 2019) and guidance for institutions, trainees, and sponsors of field-based global health training developed by the Working Group on Ethics Guidelines for Global Health Training (Crump et al. 2010). Comprehensive standards of practice would go beyond purely ethical considerations to include a consensus on the essential curricular elements and learning formats necessary to achieve the core competencies for one’s respective field of global health practice. Some of this work is being done piecemeal by some programs but the field as a whole would benefit from a universal set of standards developed by an international and multidisciplinary expert panel. Critical to the future of global health education is an overdue shift towards equitable access. As noted at the beginning of the chapter, most global health educational programs are housed at academic institutions and medical centers in high-income countries. Most programs are unilateral, sending learners to LMICs but rarely receiving learners from LMICs in the same numbers. The need to correct this imbalance in programming and to further “decolonize” global health education and practice by developing more equitable partnerships is being brought to the fore with early efforts to challenge the status quo well underway (Martin et al. 2019; Eichbaum et al. 2020). The disparities in global health education will be further disrupted as programs are launched at (and fully owned by) academic institutions in LMICS. One prime example is the University of Global Health Equity in Rwanda which is the first academic institution dedicated solely to training in equitable, quality healthcare delivery from a global health perspective (UGHE 2020). Reports in the literature indicate that global health programs are being established in other LMICS including the development of the first global health bachelor curriculum in Wuhan, China (Guan et al. 2019), and numerous global health certificate and online courses being offered in India (Pati et al. 2017). Mentoring – essential to the professional growth of students in every health profession – has been noted as an area needing further cultivation in many LMICs. Prasad and colleagues propose two conceptual frameworks to foster mentoring in LMICs, while emphasizing the importance of creating enabling environments within institutions (Prasad et al. 2019). Just as global health education has been a growth industry in the USA, Canada, and Europe, LMICs are likely to be the next settings for these programs to expand.

Conclusion Since global health emerged as a new academic field twenty years ago, it has grown by every conceivable measure. Its growth is evident in the rising number of students seeking training in the field and the increasing number of institutions offering formal degree and certificate programs, both degree bearing and nondegree bearing. A myriad of training options exists for learners at all levels and across all the health professions – medicine, nursing, oral health, public health, pharmacy, and rehabilitative care. Beyond the undergraduate and graduate levels, training options span

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from formal degree programs and postgraduate fellowships to short-term certificate courses and on the job knowledge and skills transfer for faculty and established practitioners. Mastery of global health knowledge and skills is best acquired through a combination of interactive classroom work and field-based experiential learning. Interdisciplinary core competencies have been developed and several evaluation tools are available to assist educators in assessing their students and their programs. Efforts to create a standard curriculum and standards of practice are underway, the latter being essential to ensure ethical practices are maintained. A movement to promote equitable access to global health education by decolonizing global health partnerships and practices is shifting us towards a more balanced approach. Global health training programs based in LMICs are on the rise and will further this goal of equity in education.

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Renaud-Roy E, Bernier N, Fournier P (2020) Host perspective on academic supervision, health care provision and institutional partnership during short-term electives in global health. Med Educ 54:303–311. https://doi.org/10.1111/medu.14027 Robinson PA, Orroth KK, Stutts LA et al (2018) Trends in public and global health education among nationally recognized undergraduate liberal arts colleges in the United States. Am J Trop Med Hyg 98:1228–1233. https://doi.org/10.4269/ajtmh.18-0017 Shah S, Lin HC, Loh LC (2019) A comprehensive framework to optimize short-term experiences in global health (STEGH). Glob Health 15:27–27. https://doi.org/10.1186/s12992-019-0469-7 St Clair NE, Abdul-Mumin A, Banker SL et al (2020) Global guide: a comprehensive global health education resource for pediatric program directors. Pediatrics 145. https://doi.org/10.1542/peds. 2019-2138 Steeb DR, Miller ML, Schellhase EM et al (2019) Global health learning outcomes by country location and duration for international experiences. Am J Pharm Educ 84:7682. https://doi.org/ 10.5688/ajpe7682 Störmann S, Angstwurm MW (2018) What do international health electives and state examination scores have in common?–a cohort study to compare the results of written medical licensing examinations with the participation in international health electives during the final year of undergraduate medical education in Germany. GMS J Med Educ 35:Doc54. https://doi.org/10. 3205/zma001200 TEPHINET (2020) Training programs in epidemiology and public health interventions network. In: Training Programs in Epidemiology and Public Health Interventions Networks. https://www. tephinet.org/. Accessed 29 May 2020 The George Institute for Global Health (2020) Research training programs. In: George Institute for Global Health. https://www.georgeinstitute.org/research-training-programs. Accessed 30 May 2020 The Hubert H (2020) Humphrey fellowship program about the program. In: Humphrey Fellowship Program. https://www.humphreyfellowship.org/about-the-program. Accessed 30 May 2020 Trivedi S, Haddad LB, Narvaez J et al (2018) A comprehensive evaluation of obstetrics and gynecology residencies’ global health training programs. Obstet Gynecol 132:1143–1151. https://doi.org/10.1097/AOG.0000000000002935 UGHE (2020) About. In: University of Global Health Equity. https://ughe.org/about/. Accessed 27 May 2020 Unite for Sight (2020) Online certificate programs. In: Unite Sight. https://www.uniteforsight.org/ global-health-university/certificate-programs. Accessed 29 May 2020 UW School of Public Health (2018) Public health major evolves into “Public Health – Global Health” degree. In: UW School of Public Health. https://sph.washington.edu/news-events/news/ public-health-major-evolves-public-health-global-health-degree. Accessed 27 May 2020 Van Schalkwyk SC, Hafler J, Brewer TF et al (2019) Transformative learning as pedagogy for the health professions: a scoping review. Med Educ 53:547–558. https://doi.org/10.1111/medu. 13804 Waggett CE, Jacobsen KH (2020) Global health and public health majors and minors at 411 universities, 2019–2020. Ann Glob Health 86:1–8. https://doi.org/10.5334/aogh.2837 Wernli D, Tanner M, Kickbusch I et al (2016) Moving global health forward in academic institutions. J Glob Health 6. https://doi.org/10.7189/jogh.06.010409 WHO (2020) Short and longer courses of study. In: World Health Organization (WHO). https:// www.who.int/management/newitems/en/index1.html. Accessed 29 May 2020 WHO, World Bank (eds) (2011) World report on disability. World Health Organ 325 Withers M, Lin H-H, Schmidt T et al (2019) Establishing competencies for a global health workforce: recommendations from the Association of Pacific Rim Universities. Ann Glob Health 85:47. https://doi.org/10.5334/aogh.32

Community Health Workers Role, Effectiveness, and Recommendations for Global Health

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evidence of CHW Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recommendations for Quality Improvements and Systems Integration of CHWs . . . . . . . . . . . Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preservice Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Working Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mobilization of Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHWs as Mediators of Health Care Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Community health workers (CHWs) have emerged as an effective way of addressing workforce deficiencies and systems vulnerabilities in global health. Systematic reviews conducted over the last decade have demonstrated CHW effectiveness across a number of domains in public health including: maternal and newborn health, child health, communicable diseases including neglected tropical diseases, and noncommunicable diseases. The World Health Organization has generated 14 unique sets of recommendations which address multiple dimensions of the lived experiences of CHWs around the world. These recommendations include: delineating context appropriate levels of preservice education; addressing gender equity in selection criteria; innovative approaches to preservice training; engendering healthy and sustainable working conditions including appropriate remuneration; opportunities for career progression and transparency in contractual agreements; a focus on data collection by CHWs for M. Goonetilleke (*) School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_108

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both project surveillance and research; consistent and active engagement of community stakeholders at multiple points along the project timeline including in collective decision-making; mobilization of community resources to support the actions and well-being of CHWs. CHWs are mediators of enhanced access to health care through improved availability, accessibility, appropriateness of health care, as well as enhancing follow-up and adherence to management plans. Supporting CHWs must occur at both local and regulatory levels in order to amplify their integral functions across a diversity of health contexts. Keywords

Community Health Worker · Health Workforce · Primary Health Care · Healthcare Access · Health for All

Introduction The global health workforce faces burgeoning pressure to address a number of intersecting structural challenges such as insidious shortages, demographic imbalances, maldistribution, and systemic quality control issues (Ballard and Montgomery 2017; World Health Organization 2018). Over the last several decades, community health workers (CHW’s) have emerged as a potential resource in actively remedying these workforce bottlenecks as well as facilitating health care access to disadvantaged and vulnerable communities around the world (Perry and Zulliger 2012). Definition: Community Health Worker by World Health Organisation

Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers (Lehmann and Sanders 2007).

Globally, CHWs are an extremely diverse group representing the spectrum of ages, genders, and socioeconomic strata (Lehmann and Sanders 2007; Bhutta et al. 2010). The vast majority of CHWs are drawn from the communities they serve, which facilitates and engenders cultural safety in health care through lived understanding of local traditions and socioculturally accepted behaviors and practices (Vouking et al. 2014).

Evidence of CHW Effectiveness A broad range of conditions and sectors have been identified where some evidence for CHW effectiveness exists. Over the last decade, a number of systematic reviews have specifically documented CHW initiatives across health disciplines.

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1. Maternal and Newborn Health In the area of maternal and newborn health, the presence of CHWs has been associated with diminishing risks to the newborn via targeted home-based therapeutic and preventive services as well as health promotion which can directly address both antenatal care and breastfeeding. A systematic review by Gilmore and McAuliffe in 2013 identified five main categories of preventive intervention (Gilmore and McAuliffe 2013). These comprise malaria prevention, health education, breastfeeding promotion, essential newborn care, and psychosocial support. While every category demonstrated some evidence for the effectiveness of CHWs, particular effectiveness was found in promoting “mother-performed strategies,” such as skin to skin care and exclusive breastfeeding. 2. Child Health CHWs have been found to have a beneficial role in advancing child health and development, with positive impacts demonstrated on key outcomes such as uptake of immunisations, improvements in child health literacy for parents, as well as enhancing streamlined integrated management of childhood illnesses such as pneumonia and malaria. A systematic review conducted by Lewin et al. (2010) and then consolidated by the same group of researchers in 2011 found that most of the studies analyzed showed enhanced immunization coverage due to the actions of CHWs, while in some studies CHWs delivered immunizations themselves (Lewin et al. 2010; Glenton et al. 2011). 3. Communicable Diseases Dangerous communicable diseases such as tuberculosis and malaria often have complex frameworks for optimizing prevention, treatment, and diagnostic capacity. CHW’s have been highly effective in integrating the delivery of health care and health promotion for these diseases across many different contexts (Kok et al. 2015). Effective management of the Human Immune deficiency Virus (HIV) requires detailed and personalized counselling to reduce transmission and improve adherence to treatment regimens (Maartens et al. 2014). CHW’s have been employed across a number of diverse settings in the management of HIV (Gupta et al. 2008). Patient support roles for CHW’s in the management of HIV have included counselling, home-based care, education, drug adherence, and livelihood support services (Root et al. 2015). CHW’s have also provided specific support to health services including screening, referral, and health service organization and surveillance. A systematic review by Mwai and Mburu found that across 21 different studies, CHWs improved uptake and dissemination of HIV services as well as demonstrated positive impacts on patient dignity, quality of life, and retention within care regimens (Mwai et al. 2013). In hospital-based settings, the presence of CHWs was attributed to reductions in patient waiting times, improved patient flow, and alleviation of health worker burden. Interestingly, no differences in virologic failure or mortality were seen between patients in facility-based and community-based care. Neglected tropical diseases (NTD) represent a series of diseases for which there is a very high burden of disease and a disproportionately low number of

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treatments available (Engels and Zhou 2020). These are largely diseases of poverty and are exacerbated by social and structural dimensions such as hygiene, sanitation, and access to safe food and water (Molyneux 2016). CHW’s can play an important role in mitigating morbidity and mortality as well as improving quality of life in patients with NTDs. Vouking et al. investigated seventeen studies on the role of CHWs in the care of patients with Buruli Ulcer in sub-Saharan Africa (Vouking et al. 2014) and concluded that CHWs can have a significant impact on control of Buruli Ulcer and that larger numbers were needed to improve detection and case management. 4. Noncommunicable Diseases Health promotion in addressing non-communicable diseases often involves targeting behaviors such as diet and levels of physical activity as well as increasing utilization of services such as screening and ensuring that appointments are kept (Zimmerman et al. 2016). Due to the impacts of globalization on world markets and increasing prevalence of unhealthy substances such tobacco and highly processed foods there has been a dramatic shift in the global burden of noncommunicable diseases to low- and middle-income countries over the last 30 years (Bennett 2017; Byfield and Moodie 2013; Bukhman et al. 2015). CHW’s play an important role in the management of non-communicable diseases such as hypertension, asthma, dyslipidemia and diabetes. Van Ginneken et al. performed a systematic review of the involvement of CHWs in mental health care in 22 lowand middle-income countries (Van Ginneken et al. 2013). They found that the use of non-specialist health workers may increase numbers of adults who recover from anxiety or depression; may slightly reduce symptoms for patients with postpartum depression, post-traumatic stress disorder, dementia, and reduce alcohol consumption in patients with documented excessive alcohol intake. A systematic review by Raphael et al. on pediatric chronic disease focused on the involvement of CHWs in conditions such as asthma, type 1 diabetes, or obesity (Raphael et al. 2013). At this, the most frequently reported improved outcomes were reduced use of urgent care facilities, modest symptom reduction, reduction in work and school days missed, as well as enhanced parental quality of life.

Recommendations for Quality Improvements and Systems Integration of CHWs Systematic reviews of CHW engagement have yielded multiple recommendations for optimal policy approaches for integrating CHWs into existing health systems (Perry and Zulliger 2012). It has been found that CHWs are best able to fulfil their roles and responsibilities when they receive appropriate financial renumeration as well as incentives (financial or nonfinancial) (Vaughan et al. 2015). Policies which encourage regular and supportive supervision, training and education, as well as those which create mechanisms for clear communication and feedback from CHWs have also been found to be beneficial to retention and effectiveness (Bhutta et al. 2010).

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The World Health Organization (WHO) generated 15 unique sets of recommendations by systematically reviewing the available literature on multidimensional aspects of CHW’s experiences and their engagement across a diversity of global contexts (World Health Organization 2018).

Overview: WHO Recommendations for CHW Integration into Existing Health Systems (World Health Organization 2018)

• • • • • • • • • • • • • • • •

Selection Preservice training Training duration Curriculum to develop competencies Training modalities Offer competency based formal certification Supportive supervision Remuneration Contracting agreements Career ladder Target population size Collection and use of data Types of CHWs Community engagement Mobilization of community resources Supply chain

Selection It has been recognized that preservice training is a key area for effective and strategic deployment of CHW’s in the field. The WHO suggests a minimum education level, appropriate to the duties and specific activities which would be performed by the CHW (World Health Organization 2018). It is important to note here that that many CHW’s are “‘lay-people” without health-specific tertiary qualifications and organizations and governments may need to provide context specific training for CHW’s to fully operationalize this recommendation (Vouking et al. 2014). Furthermore many low-income communities may not have the financial or institutional capacity to provide this kind of training de novo (Vaughan et al. 2015). This could potentially be resolved by innovative pedagogy and educational design such as online learning modules that can be cost-effectively disseminated to a large number of low-income contexts (Kok et al. 2015). The WHO also suggests that “membership of and acceptance by the target community” as well as “gender equity appropriate to context” are key criteria for selection of CHW’s (World Health Organization 2018). Implicit in the call for gender equity is a recognition of the profound gender inequities which operate within many societies and are exacerbated by other socioeconomic and structural factors, such as

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poverty and lack of income (AVERT 2018). Advocating for the recruitment of women within the CHW workforce may be an effective structural intervention in addressing systemic gender imbalances which exist within health workforces across nations and contexts (Gupta et al. 2008). Finally “personal attributes, capacities, values, and life and professional experiences of the candidates” are posited within the WHO guideline as integral to the selection of appropriate CHWs (World Health Organization 2018). One apparent potential issue here is that those who are selecting candidates must be chosen for their ability to make impartial choices. Furthermore, a decision-making environment must be engendered where candidates are chosen according to the evidence-based guidelines as opposed to personal favors or nepotism. In addition to these recommendations, the guidelines suggest that age and marital status should not be used as criteria for selecting CHW’s while concurrently abiding by national and international labor laws.

Preservice Training Several recommendations were made by the WHO in regards to both the quantity and quality of pre-service training received by CHW’s. Duration should be determined according to contextual factors including an individual’s previous experience and level of education, the range of roles and responsibilities which the individual may encounter in their work, as well as institutional capacity to provide education (World Health Organization 2018). Certain core competencies are also recommended for each CHW trained including health promotion and prevention, knowledge of their role within the health system, socioenvironmental determinants of health, education related to providing psychosocial support to patients, interpersonal skills such as communication and maintenance of confidentiality and an overview of occupational health and safety. Additionally, education may cover context-specific aspects of diagnosis and management as pertains to their specific roles and responsibilities. This training could be provided in a number of modalities which again largely depend on local institutional capacity (Bhutta et al. 2010). These may range from face to face and online modes and cover a mixture of theoretical and practical components relating to the CHW’s prospective work. Supervision of training is significant and there needs to be a focus on equitable ratios of supervisors to number of candidates as well as focused investment in providing appropriate resources and education to those who will be offering supervision to potential CHWs (Bhutta et al. 2010).

Working Conditions In order to integrate CHWs into a health system, healthy and sustainable working conditions must be encouraged. This includes appropriate remuneration,

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opportunities for career progression, and transparent contractual arrangements which are anchored in an understanding of worker’s rights (Lehmann and Sanders 2007). The WHO guidelines suggest that remuneration should not be purely based on achieving particular performance-based targets but rather tailored according to the specific demands, complexity, and hours of the particular job (World Health Organization 2018). Furthermore, it advocates for written contractual agreements which clearly delineate remuneration, roles, rights, and responsibilities to mitigate the potential for exploitation. It suggests career progression or “a career ladder” be explicitly articulated and offered for CHW’s to promote ongoing learning and career development.

Data Management There is evidence suggesting that data collection by CHWs can enhance health service delivery as well as be utilized for both surveillance and research (Gilmore and McAuliffe 2013). The WHO guideline therefore recommends that CHWs document gather and utilize health data pertinent to the particular roles which they play within community health care. Potential barriers to optimizing data management for CHWs could be excessive reporting burdens and limited levels of digital literacy leading to problems with accurate aggregation, storage, and use of data. Security and confidentiality of collected information are also of paramount importance to safeguarding both CHW and patient safety (World Health Organization 2018).

Community Engagement As most CHWs are derived from the communities which they serve and have lived understandings of sociocultural norms and expectations within their community, they can play a vital role in engaging with communities (Vouking et al. 2014; Root et al. 2015). The WHO recommends a series of strategies for optimizing community engagement in the context of CHW programs (World Health Organization 2018). Pre-intervention consultations could include preprogram meetings with community leaders which sensitize and inform community leadership to upcoming interventions or programs. Engaging community selecting CHWs is a means of enhancing integration of CHWs into the community. This engagement can include development of hiring criteria; community nominations for CHW position and community stakeholders playing a role in the recruitment of CHWs (Vouking et al. 2014). Another area of potential engagement with community is in CHW training. Community stakeholders and organizations could be involved in developing CHW training and informing the generation and implementation of interventions (Lassi and Bhutta 2015). Finally, community members can be involved in CHW project evaluation and oversight. By involving community members in decision-making, quality improvement, and

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evaluation, they are encouraged to feel a sense of community ownership of the CHW programs and therefore enhance community uptake of interventions and programs (McCollum et al. 2019).

Mobilization of Community Resources CHWs can play a role in mobilizing wider community resources for health in a number of ways. CHWs are well situated to identify both, priority health and structural issues within their communities and establish appropriate action plans (Ballard and Montgomery 2017; Lewin et al. 2010). They are also able to mobilize community stakeholders from relevant sectors and nongovernment organizations and galvanize links between community members and health facilities.

CHWs as Mediators of Health Care Access In the context of intersecting global challenges which threaten the integrity of health systems, decentralizing services is a means of addressing barriers to health care access across many contexts (McCollum et al. 2019; Dahn et al. 2015). CHWs offer under-served and rural communities, the opportunity to access primary health care, even in a rudimentary form and guide uninitiated individuals through the health system. CHWs embody many key principles of the primary health care model as outlined in the Alma Ata and re-affirmed by the WHO (Walley et al. 2008). Definition: Primary Health Care Model (World Health Organization)

Primary health care is a whole-of-society approach to health and well-being centred on the needs and preferences of individuals, families and communities. It addresses the broader determinants of health and focuses on the comprehensive and interrelated aspects of physical, mental and social health and wellbeing. WHO has developed a cohesive definition based on three components: 1. meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services; 2. systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors; and, (continued)

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3. empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as selfcarers and care-givers to others (World Health Organization 2020).

Conclusion By adopting a participatory approach which is community based, scientifically sound and culturally appropriate, CHWs are in a unique position to act as an entrance point to the health system for community members who might otherwise find health care inaccessible (Dahn et al. 2015). In order to sustain and amplify the integral functions of CHWs across a diversity of contexts, health policies must reflect the need to appropriately renumerate, educate, and support CHWs. Developing transparent systems of communication and facilitating the mobilization of resources and supplies between CHWs, the communities they serve, and relevant health institutions, is essential for them to continue to fulfil their vital functions within the health care workforce.

References AVERT (2018) Gender inequality and HIV. Available from: https://www.avert.org/professionals/ social-issues/gender-inequality Ballard M, Montgomery P (2017) Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open 7(10) Bennett B (2017) Health, rights and globalisation. Routledge Bhutta ZA, Lassi ZS, Pariyo G, Huicho L (2010) Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Global Health Workforce Alliance 1(249):61 Bukhman G, Mocumbi AO, Horton R (2015) Reframing NCDs and injuries for the poorest billion: a lancet commission. Lancet 386(10000):1221–1222 Byfield S, Moodie R (2013) Addressing the world’s biggest killers: non-communicable diseases and the international development agenda. Australian Council for International Development (ACFID) Dahn B, Woldemariam A, Perry H, Maeda A, von Glahn D, Panjabi R (2015) Strengthening primary health care through community health workers: investment case and financing recommendations [Internet]. WHO. Accessed 29 Sept 2016 Engels D, Zhou X-N (2020) Neglected tropical diseases: an effective global response to local poverty-related disease priorities. Infect Dis Poverty 9(1):10 Gilmore B, McAuliffe E (2013) Effectiveness of community health workers delivering preventive interventions for maternal and child health in low-and middle-income countries: a systematic review. BMC Public Health 13(1):847

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Glenton C, Scheel IB, Lewin S, Swingler GH (2011) Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology. Tropical Med Int Health 16(9):1044–1053 Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A (2008) Structural approaches to HIV prevention. Lancet (London, England) 372(9640):764–775 Kok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M et al (2015) How does context influence performance of community health workers in low-and middle-income countries? Evidence from the literature. Health Res Policy Syst 13(1):13 Lassi ZS, Bhutta ZA (2015) Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev (3) Lehmann U, Sanders D (2007) Community health workers: what do we know about them. The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. World Health Organization, Geneva, pp 1–42 Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, Van Wyk BE et al (2010) Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev (3) Maartens G, Celum C, Lewin SR (2014) HIV infection: epidemiology, pathogenesis, treatment, and prevention. Lancet 384(9939):258–271 McCollum R, Taegtmeyer M, Otiso L, Mireku M, Muturi N, Martineau T et al (2019) Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya. Int J Equity Health 18(1):65 Molyneux DH (2016) The London declaration on neglected tropical diseases: 5 years on. Trans R Soc Trop Med Hyg 110(11):623–625 Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J (2013) Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc 16(1):18586 Perry H, Zulliger R (2012) How effective are community health workers Raphael JL, Rueda A, Lion KC, Giordano TP (2013) The role of lay health workers in pediatric chronic disease: a systematic review. Acad Pediatr 13(5):408–420 Root R, Van Wyngaard A, Whiteside A (2015) Reckoning HIV/AIDS care: a longitudinal study of community home-based caregivers and clients in Swaziland. Afr J AIDS Res 14(3):265–274 Van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera S, Pian J et al (2013) Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low-and middle-income countries. Cochrane Database Syst Rev (11) Vaughan K, Kok MC, Witter S, Dieleman M (2015) Costs and cost-effectiveness of community health workers: evidence from a literature review. Hum Resour Health 13(1):71 Vouking MZ, Takougang I, Mbam LM, Mbuagbaw L, Tadenfok CN, Tamo CV (2014) The contribution of community health workers to the control of Buruli ulcer in the Ngoantet area, Cameroon. Pan Afr Med J 16(1) Walley J, Lawn JE, Tinker A, De Francisco A, Chopra M, Rudan I et al (2008) Primary health care: making Alma-Ata a reality. Lancet 372(9642):1001–1007 World Health Organization (2018) WHO guideline on health policy and system support to optimize community health worker programmes. World Health Organization World Health Organization (2020) Primary health care. Available from: https://www.who.int/ health-topics/primary-health-care Zimmerman RS, DiClemente RJ, Andrus JK, Hosein EN (2016) Introduction to global health promotion. Wiley

Rural Health Developing, Attracting, Recruiting, and Retaining Rural Health Workers

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Is Rural Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Workforce Availability in Rural and Remote Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective Service Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Importance of Health Workers for Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role for Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Although almost half the world’s population is living in rural areas, rural dimensions of health and health care are often neglected in the global health discourse. Leading challenges for health systems in rural areas include the pervasively limited access to qualified health workers. Thus, a health-in-all-policies approach, the assessment of policy impacts as well as policymakers addressing policy changes if necessary, will be the way to ensure that universal health coverage and sustainable development goals are achieved. Keywords

Health workers · Rural health · Primary health care · Health policies · Health in all policies, Universal health coverage

M. McIsaac (*) Health Workforce Department, World Health Organization, Geneva, Switzerland e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_123

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Introduction Globally, 3.4 billion people or 45% of the world’s population live in rural areas (United Nations, Department of Economic and Social Affairs, Population Division 2019). Rural populations are among some of the poorest in the world. Eight out of every 10 people living in extreme poverty, that is, those living on less than US$1.90 per day, live in a rural area. The extreme poverty rate is more than three times higher in rural areas than in urban areas (United Nations Statistic Division 2019). In addition to monetary poverty, the 2020 multidimensional poverty index which takes into account health, education, and standard of living, showed that of the 1.3 billion people around the world that are multidimensionally poor 1.1 billion, that is 84%, live in rural areas (http://hdr.undp.org/sites/default/files/2020_mpi_report_ en.pdf). Rurality, and the high prevalence of poverty in rural areas, intersects with reduced access to the capital needed for development and, in particular, to the key inputs needed for human capital development, notably those related to education and health. The concept of human capital development brings to light the multisectoral challenges involved in rural development (World Health Organization 2019b; Dewalt et al. 2004). For example, education helps people to maintain and improve their health. With education in rural areas less accessible, literacy levels in rural areas tend to be lower than those observed in urban areas, particularly among women and girls. In some countries, there is a more than 50 percentage point difference in the literacy rates between urban and rural areas (United Nations Educational 2016). Access to qualified health workers is considered indispensable to the functioning of the education sector. Poor access to qualified health workers in rural areas is related to absenteeism and attrition of both teachers and students (United Nations Educational 2016). The need for intersectoral collaboration to achieve inclusive and sustainable rural development and redress access gaps notably those related to human capital development is clear. A singular focus on one dimension, be it economic development, education, gender equality, or health, will prove to be less effective than a holistic approach which considers how these elements intersect and how to best capture synergies between policies. Slow progress in achieving sustainable gains in rural health signal the complexity of the issue and a strong need for partnership and coordination. Early in the Millennium Development Goals (MDGs) era, scientific studies revealed a clear relationship between health workforce density and distribution and the achievement of global goals, particularly health outcomes (Anand and Barnighausen 2004). Policies to redress geographical imbalances in the health workforce and evidence of their effectiveness became more prevalent (Joint Leaning Initiative 2004; WHO 2006). In 2010 WHO produced the Global Policy Recommendations: Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention (WHO 2010). A decade on, in the context of Sustainable Development Goals (SDG), with vast improvements in data and evidence, countries are still struggling to meet the health

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needs of rural communities. The WHO Global Strategy on Human Resources for Health: Workforce 2030 suggests that greater and more strategic investment in health workforce is needed and that shortages of health workers are compounded by difficulties in deploying health workers to rural, remote, and underserved areas (WHO 2016), resulting in rural areas lagging behind urban areas across many health indicators. Notably, reproductive, maternal, and child health, with worse outcomes in rural areas compared to urban observed in many regions across the world (WHO 2015). For example, children born in rural areas are still 1.7 times more likely to die before age 5 than children born in urban areas (UNICEF 2016). Challenges and barriers in accessing health services which sit in addition to the often-challenging geographic landscapes and less developed transport systems of rural and remote areas. In many countries, primary health care (PHC) services in rural areas are inadequately developed, as are diagnostic and laboratory networks. Specialized care tends to be clustered in urban areas making accessing such services challenging for rural populations. In addition, the team based approach to health care is more fragmented in rural areas when compared to urban, and referrals systems (including back referrals) can be unsuccessful. This results in gaps in general health service coverage. It is estimated that 51–67% of rural populations have limited access to essential health services (World Health Organization 2019b). This translates into an estimated 2 billion rural people without adequate access to essential health services (World Health Organization 2021 - forthcoming). Adequate access to qualified health workers is a pervasive and continual challenge in rural and remote areas all across the globe. Part of the access dilemma is a result of lower availability of health workers, that is, a distinctly lower supply of health workers in rural and remote areas. Availability remains one of the most notable challenges facing rural health care. In addition to availability and accessibility, there are also distinct challenges with respect to the acceptability and quality of health care in rural and remote areas. A greater focus on rural health within global health is needed. The right to health is a fundamental human right. Leaving no one behind means that access to health care should not be contingent on where one resides.

Global Health Is Rural Health Challenges to health system performance in rural areas are many. They include greater distance to health facilities, and limited access to specialized services, pharmacies, and health promotion and prevention activities. But foremost among the challenges that health systems in rural areas are facing is the pervasively limited access qualified health workers. Policymakers in all countries, regardless of their level of economic development, struggle to achieve the equitable access to health services needed to meet population health needs and reach the most vulnerable and disadvantaged population (World Health Organisation 2010). Availability of health workers at a national level is not sufficient, only when they are equitably distributed and accessible by the population, when they possess the required competency, and

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are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the population, and when they are adequately supported by the health system, can theoretical coverage translate into effective service coverage (WHO 2016). Pervasive insufficiencies in both numbers and types of qualified health workers in remote and rural areas impede access to healthcare services for over 2 billion people worldwide (World Health Organization 2021). With the importance of rural areas cutting across many of the SDGs a lack of health workers in rural areas impeded progress not only toward the SDGs for health and well-being but also SDG 1, no poverty; SDG 4, quality education; SDG 5, gender equality; SDG 8, decent work and economic growth; and SDG 10, reduced inequalities. It is clear a whole of government approach which considers how poverty, health, education, gender, economic development, and inequalities intersect is key to achieving sustainable gains in rural health. Rural health demonstrates a strong need for partnerships to tackle such a complex and pervasive issue.

Defining Rural It is important to be clear with regard to what is meant by rural. Without an internationally set standards of defining rural areas, policymaking and programs for rural populations are difficult to initiate, implement, and monitor; this is because the rural classification is key to (Rural Health information Hub 2019; Coburn et al. 2007): • Determining eligibility for rural grants and programs: donor/funding organizations and agencies may arbitrarily decide or use non-country compatible criteria to select rural communities to invest, which may leave out deserving communities. • Implementing of programs and law: that concerns rural areas requires a clear definition of what qualifies as rural to policymakers, regulators and implementing agencies. • Research and data collection require statistical consistency and accuracy, as well as validation: research and data collection and collation from rural areas is being hampered on the international stage because of inconsistencies and imprecision of definitions, limiting comparable monitoring, and evaluating exercises of activities. • Unintended policy effects: misclassifications of communities have the effects of creating more inequities or depriving other areas of resources. Demographics of rural areas. Box 1 outlines the most recent internationally approach for defining rural areas. Such a definition is key to rural policies in general, but notably important when defining areas for fiscal transfers of eligibility for rural programs and policies.

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Box 1 Definition of Rural

In March 2020, a proposal was made to address the definitional gap of the term “rural” through a Degree of Urbanization method (https://unstats.un.org/unsd/ statcom/51st-session/documents/BG-Item3j-Recommendation-E.pdf). This method uses three classifications: (1) cities, (2) towns and semi-dense areas, and (3) rural areas. It has two extensions. The first extension identifies cities, towns, suburban or peri-urban areas, villages, dispersed rural areas, and mostly uninhabited areas. The second extension adds a commuting zone around each city to create a functional urban area or metropolitan area. This method was endorsed at the 51st meeting of the UN Statistical Commission, but is not yet widely implemented.

Progress toward a global definition will aid in harmonization of indicators and tracking progress toward global goals, but is also key in ensuring that rural areas are counted. Until then, data on rural health, and notably on rural health workforce, remains relatively sparse. Although it is certainly improving, a recent systematic review on the retention of health workforce in rural areas found 106 studies on the attraction, recruitment, and retention of health workers in rural and remote areas (Declaration of Astana 2018).

Health Workforce Availability in Rural and Remote Areas Rural areas, particularly those in low- and middle-income countries (LMIC), continue to be the most underserviced areas around the world. Getting and keeping health workers in rural areas is a global challenge. This gap tends to be even larger when health needs are considered. Without sufficient availability, that is, a sufficient supply of health workers, accessibility to health care cannot be guaranteed. As such goals such as universal health coverage (UHC) will remain out of reach. Health workforce availability is the stock of health workers. Often as a simple head count, sometimes measured as full-time equivalency. With regard to availability, it has been estimated that about 36% of nurses and 25% of doctors around the globe are deployed in rural areas (World Health Organization 2010). Some countries, with more than half the total population living in rural areas, report having even less than 25% of the total health workforce serving these rural populations (Joint United Nations Programme on HIV/Acquired Immune Deficiency Syndrome 2017; Republique Du Niger 2016; Republique Togolaise 2017). This leads to distributional inequality based on population numbers or density ratios (which are the number of active health workers per 10,000 population in a given subnational administrative unit). This issue in services available in some areas of a country but not in others is sometimes called maldistribution. Maldistribution indicates the distribution of health workers is inefficient. Inefficiency in the context of health worker distribution means

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that the scarce resources of qualified and capable health workers are not being put to their best use. If maldistribution of health workers is occurring, then a country is producing less than the maximum possible output of health. This less than optimal outcome is referred to by economists as “market failure.” The inefficient distribution of health workers results because the rational behavior by health workers (i.e., their choice of where to locate) does not lead to rational outcomes for the group (i.e., where they are most needed or where available health workers could produce the most health for the country). Distributional inequality in health workforce between rural and urban areas is a global phenomenon – this is evident even when heterogeneous national definitions of rural and urban are applied. For example, recent data from China show that the density of health workers per 1000 population in rural areas was less than half that of urban areas: 3.9 per 1000 population, compared to 10.2 (China-NHFPC 2015; Zhu et al. 2019). While in Canada the urban vs. rural density of doctors is 2.6 per 1000 population compared to 0.9 (Viscomi et al. 2013), data from Bangladesh suggest that there are 1.8 doctors per 1000 population in urban areas compared to 0.1 in rural areas (Ahmed et al. 2013). In India there were 2.53 million health workers during 2011–2012. A density of 20.9 health workers per 1000 population or 9.1 qualified health workers per 10,000 population (see Table 1). The distribution of qualified health workers was very skewed toward urban areas; 77% of all qualified workers were in urban areas, even though the urban population accounted for only 31% of the total population. In both rural and urban areas, around 70% of qualified health workers were privately employed (rural, 67.0%; urban, 74.0%).

Effective Service Coverage There is a clear issue of the availability of health workers in order to ensure effective service coverage. That is the number of health workers located in rural areas across the world. Distributional inequality is generally the easiest indicator to signal that the is an effective coverage gap, but the issues in rural areas run much deeper. To ensure Table 1 Density of qualified health workers in urban and rural areas, from the 68th round of the National Sample Survey, 2011–2012 Health workers Allopathic doctors Nurses and midwives Dentists AYUSH practitioners Health associates

Mean (95% CI) density per 10,000 population All Rural 3.4 (2.1–4.6) 0.8 (0.3–1.2) 3.2 (2.4–4.0) 1.3 (0.9–1.7) 0.3 (0.1–0.5) 0.0 (0.0–0.0) 0.6 (0.3–0.8) 0.2 (0.1–0.3) 1.8 (1.3–2.3) 0.7 (0.4–1.0)

Urban 9.1 (5.3–12.8) 7.2 (4.8–9.6) 0.9 (0.3–1.4) 1.4 (0.6–2.2) 4.1 (2.7–5.5)

AYUSH: Ayurveda yoga and naturopathy, Unani: Siddha and homoeopathy, CI: confidence interval Source: Rao KD, Shahrawat R, Bhatnagar A (2016) Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey

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effective coverage: availability, accessibility, acceptability, utilization, and quality, all need to be addressed. Accessibility is the ability to access the health worker. Access to health care is critical to the health of populations. Yet rural populations face numerous barriers in accessing health care. Figure 1 draws on the Tanahashi framework to provide a comprehensive overview of types of barriers experienced by specific subpopulations at risk of being left behind (Koller 2020). Addressing barriers to effective coverage, such as those outlined in Fig. 1, is key to making progress toward UHC – with WHO’s Global Programme of Work (GPW13) highlighting that equity in access is central to UHC (World Health Organization 2019b). Accessibility can be thought of an exerting downward pressure on demand of healthcare services in rural areas. This lower demand occurs in spite of the oftenobserved high needs for such services. This results in potentially lower perceptions of needs among socioeconomically disadvantaged subpopulations. With life expectancy, a crude measure of health, in rural areas, remains lower than that in the urban areas (Asaria et al. 2019; Liu et al. 2010; Kingdom of Morocco Ministry of Health 2019). For some rural populations, there has been a recent decline in life expectancy (National Advisory Committee on Rural Health and Human Services 2015) signally increasing health needs. In addition, in low- and middle-income countries under-five mortality ratio is an average of 1.3 higher in rural areas compared to urban areas. However, these health needs are often not actualized into demand for services due to barriers in access. Some of these are geographic, other include a high opportunity cost in seeking care due to travel time, or potential costs of leaving livestock or crops unattended.

Fig. 1 Effective health service coverage. Source: Koller (2020)

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Physical accessibility and availability of good health services within reasonable reach are important considerations. This includes opening hours, appointment systems, and other aspects of service organization and delivery. Financial affordability is another barrier. Also important to consider is the ability to pay for services without financial hardship. This includes the price of health services and also indirect and opportunity costs (e.g., the costs of transportation to and from facilities and of taking time away from work) (Evans et al. 2013). High rates of rural poverty and low levels of financial protection lead to barriers in accessing needed healthcare services due to affordability. Rural populations tend to experience a higher incidence of impoverishing health spending (i.e., spending more than 25% of the household budget on health) than in urban areas (World Health Organization 2019a). Out of pocket costs can act as a barrier in seeking health services. This impacts the demand for health care and results in furthering unmet health needs, even when health care is available. In addition, financial barriers linked to high poverty rates and limited social protection and insurance coverage (WHO 2010). Furthermore, accessibility exerts downward pressure on the demand for services, resulting in lower service utilization. The willingness to seek needed health services also depends on perceived effectiveness of services as well as social and cultural factors such as language or the age, gender, ethnicity, or religion of the health worker. Acceptability can also be community-specific. Understanding the match between local norms and preferences and the healthcare service provided and by whom is fundamental to ensuring the acceptability of health care services. This is an area that is often overlooked but speaks to the need to understand rural communities beyond their geographic delineations. Culturally accepted care and indigenous populations in rural areas, and how investing in the rural workforce means also taking measures to recruit Indigenous health workers, provide culturally appropriate care, etc. This also goes for other rural subpopulations of different ethnic groups, not only Indigenous populations. Finally, the perceived quality of the care matters. The competencies of the health workers and regulation inform trust in the system. It is only with this trust that users will seek care. Health workers’ quality professionalism determines output and productivity (JLI 2004). One of the main problems relating to poor performance of health workers is a long-lasting reduction in demand (Rowe et al. 2004) which has three key dimensions. 1. Financial affordability. This is the financial. . . 2. Physical accessibility. This is the availability of good health services within reasonable reach of those who need them and aspects of service organization and delivery that allow people to obtain the services when they need them 3. Acceptability. This captures people’s willingness to seek services Bringing this all together contact coverage refers to the actual contact between health workers and the user when services are available, accessible, and acceptable. The lack of contact coverage is forgone care (Koller 2020). Effective service coverage ties in the notion of quality. It is defined as the proportion of people in

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need of services who receive services of sufficient quality to obtain potential health gains (World Health Organization 2017).

Importance of Health Workers for Rural Areas Growing the rural health workforce will not only improve global health outcomes but also contribute to wider social and economic growth of those communities. The WHO High-Level Commission identifies the links between health and health sector jobs, in rural communities and social, economic, and health outcomes. The urgent need for more health workers in LMIC, over the next 15 years, presents significant challenges but it also offers the opportunity to generate employment, in areas where decent jobs are most difficult to find (World Health Organization 2016a). SDG3 include a target for “. . .recruitment, development, training and retention of the health workforce in developing countries,” which by international standards, are the most underserved and whose rural and remote communities have the most limited access to healthcare services. But in addition, investing in the health and social workforce will not only accelerate progress on the health SDGs but also stimulate poverty reduction (SDG1), gains in quality education (SDG 4), gender equality (SDG 5), and decent work and inclusive growth (SDG 8). Health workforce plays a pivotal role in improving health and in the wider economy. Improving affordable access to health workers for rural populations is vital to not only reducing the inequity in access to health care but also reducing rural poverty and stimulating inclusive development. Evidence from developing regions for 2000– 2011 shows that around 24% of income growth results from health improvements. The pathways through which good health contributes to development are outlined in Fig. 2. The health and social services are important sources of jobs in rural and remote locations, unlike many other sectors where work opportunities are concentrated in large cities and commercial centers. There is increasing evidence of the benefits of expanding rural and community-based health education and training. In many countries this can link to promoting jobs for women and young people (WHO 2016). The health and social sector is a major employer, comprising 11% of total employment in OECD countries. The importance of the health sector is growing and the demand for health workers is expected to double by 2030. Investment in the health workforce comprises the largest component of health investment, requiring over a third of the resources, needed to achieve the health-related SDGs. Globally, unless we address the growing shortfall of 18 million health workers by 2030 countries will not be able to progress on UHC and global health security. Health workforce has a vital role in building the resilience of communities and health systems. Investment in the health workforce, in improving health service coverage and in emergency and disaster risk management not only builds health resilience and health security but also reduces health vulnerability and provides the human resources required to prevent, prepare for, respond to, and recover from emergencies. Globally, investment in the health workforce is lower than is often

Fig. 2 Economic benefits of investing in rural health. Source: Adapted from WHO/OECD Development Assistance Guidelines and Health Employment and Economic Growth, An Evidence Base

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assumed (WHO 2016) reducing the sustainability of the workforce and health systems. Health workers have a positive effect on rural economies, further reducing poverty and empowering the women and youth. The cumulative effects of these will be an acceleration toward the SDG 10, with the marked reduction of the urban/rural inequality. Without sufficient supply of health workers in rural areas progress toward UHC and the SDGs will inevitably fall short. Nevertheless, rural dimensions are often neglected in analyses of health and health system performance (WHO 2010). Data disaggregated to the rural area is needed to form a comprehensive assessment of all health system functions, governance, and population health. There is a need for increased systematic research on how best to improve and monitor health service provision and use in rural areas.

Role for Policy Unequal distribution of health workers that favors urban area is a global problem. After 40 years of the Alma-Ata Declaration released in 1978, the new Astana Declaration on Primary Health Care was endorsed at a Global Conference on Primary Health Care in Astana, Kazakhstan, by global stakeholders in October 2018 (Declaration of Astana 2018). The Declaration espouses it is “ethically, politically, socially and economically unacceptable that inequity in health and disparities in health outcomes persist.” It clearly articulates that primary care in rural and remote areas is a key issue for achieving UHC and redressing these inequalities. Equitable distribution is important from a social justice standpoint. Equity in access to healthcare services is often a direct aim of UHC. The link between access to health care and health status is strong. The distribution of healthcare services is therefore important due to its link to equity, solidarity, and the wellbeing and health of populations. The distribution of health care remains a main determinant of access to health services and improving access to health services increases social welfare. Even if arguments for equity in access to healthcare services based on social welfare are rejected, it can be argued from an economic standpoint that healthcare markets suffer from market failure. That is that economic forces are not sufficient to distribute health workers to where there is need and that from an efficiency perspective policy intervention is warranted. Therefore, the objective of government intervention is to achieve both an economically efficient outcome and equity in the distribution of healthcare resources. On the supply side, health workers’ unwillingness to take up posts in rural or remote areas is often discussed. A common policy response to address the unwillingness of qualified workers to participate in rural HLM is to increase the financial remuneration. For example, many countries offer additional salaries or incentives to work in rural areas or offer them the opportunity to undertake private practice after working hours. Such policy solutions can have variable effectiveness. Health workers decide to participate in the labor market by comparing their reservation wage with the prevailing wage rate. So, unless the wages are above their reservation

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wage for rural work, it is unlikely to encourage rural labor force participation. Further, estimated supply elasticities from studies on doctors and nurses point that moderate salary increases will elicit only modest increases in labor supply and are most effective for newly entering health workers (McIsaac et al. 2019). Large increases in salaries may not be affordable in LMIC. The solution to the rural supply problem might lie in also addressing the non-wage determinants of labor supply. Health worker participation in labor markets, particularly in rural ones in LMIC, appears to be significantly influenced by non-wage job characteristics. Generally, these interventions are harder to implement compared to increases in monetary benefits. For instance, improving living conditions, providing better educational opportunities for workers and their families, or improving infrastructure in the working environment require sustained investments over a long period and are also costly to implement. So, strategies to increase the supply of health workers, particularly those with higher reservation wages like doctors and nurses, need to include both monetary and nonmonetary elements that are aligned with their preferences. Another solution to increasing the supply of highly trained health workers lies in task-sharing. Health workers with high reservation wages, such as doctors and specialists, require higher wages to participate in rural labor market. Rural HLM may not offer such high levels of remuneration. Moreover, for government posts, fiscal space constraints will likely render offering high wages unaffordable. On the other hand, nurses or community health workers have lower reservation wages and their supply is more responsive to wage increases. Indeed, many LMIC have invested in providing additional clinical training to nurses and community health workers to enable them to take on the clinical functions of highly trained health workers. Studies on such task-sharing have found that it does not result in poorer quality of care compared to that produced by higher trained health workers (Joshi et al. 2014; Kredo et al. 2014; Martínez-González et al. 2015). One of the key issues stated for the undersupply of health workers in rural and remote locations is the relative attractiveness of these locations to health workers. The behavioral approach to health workers location choice sees location choice of health workers as one that maximizes their utility. Utility, with utility being broadly represented as satisfaction. So that health workers chose the location that brings them the most satisfaction. It is clear that employment opportunities and remuneration are important in location choice, but location choice has proven to be much more complex than that. Table 2 suggests that location choice can be influenced by factors such as preferences and values; family and community aspects; working and living conditions; career aspects; finances; and obligations. Location choices made by individuals or households generally adopt such a behavioral approach. Policies that aim to influence these choices and the relative attractivity of rural and remote areas need to acknowledge the complexity of behavioral choices such as location choice. For health workers, the decision to locate in a rural area is complex (see Table 2) and linked to not only personal aspects such as background but also to family. Health workforce policy needs to take account of how those whose behavior

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Table 2 Considerations in health workers choice to stay or leave a rural and remote area Preferences and Values Rural background Values Preferences Altruism Demographics (gender, ethnicity and socio-cultural background, age, etc.) Family and Community Aspects Schooling for children Employment for spouse Sense of community Community facilities Local amenities and attributes Working and Living Conditions Infrastructure Working environment (e.g., team) Access to decent work Working conditions and safety Access to equipment and IT Leisure facilities Housing and living conditions

Career Employment possibilities Access to professional development Access to continuing education Career progression Financial Prices and transport costs Remuneration (salary, benefits, allowances) Payment system Timely payment Access to additional income (e.g., through dual practice) Obligations Social contracts Bonding Mandatory service

Source: Adapted from World Health Organization (2010)

it seeks to change (e.g., to work in a rural area rather than an urban one) are going to respond. In addition, policies aim to make rural and remote locations more attractive to health workers. Policies makers aim to address recruitment (number of health workers who were recruited into a rural or remote area) or retention (number of health worker remaining in a rural are or sometimes measured as length of service or turnover rates) and try to address one or more of the considerations presented in Table 2. Even when health workers chose to locate in a rural or remote area, retaining them in these locations can be a challenge. For example, in Nigeria it has been suggested that attrition rates of doctors in rural areas are triple that of urban areas (Abimbola et al. 2015). Governments play an important role in the health labor market, either through market shaping (i.e., regulation and information sharing), or through direct means as employers (often as monopolies or oligopolies) and setting remuneration packages. Health labor markets typically show inefficiencies which are referred to as market failures. These are generally caused by rigidities in the market with respect to regulatory obstacles, to constraining policies, or wages setting. Rigidities in the market suggest a role for government intervention to mitigate market failures. In light of these market failures and the increasing role of policies to ensure rural populations have access to health care, the WHO produced global policy recommendations in 2010 including a guideline for “Increasing access to health workers in remote and rural areas through improved retention” (World Health Organization 2010). These guidelines were reviewed and updated in 2021. Table 3 presents a

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Table 3 Summary of WHO’s guidance on interventions to improve the attraction, recruitment, and retention of health workers in rural and remote areas Education Enroll students with a rural background in health education and training programs Locate health worker education facilities closer to rural areas Bring students in health worker education programs to rural and remote communities Align health worker education with rural health needs Facilitate continuing education for rural and remote health workers Regulation Enable rural health workers to enhance their scopes of practice to better meet the needs of their communities Expand range of health worker occupations to meet rural health needs Ensure that compulsory service agreements respect the rights of health workers and are accompanied with appropriate support and incentives Tie education subsidies for health workers to agreements of return of service in rural areas and remote areas

Incentives Provide a package of attractive incentives to influence health workers’ decisions to relocate to or remain in a remote or rural area Professional and Personal Support Improve living conditions in rural and remote areas Ensure workplace safety in rural and remote health facilities Ensure decent work for health workers in rural and remote areas Foster the creation of health workforce support networks Develop and strengthen career pathways for rural health workers Facilitate knowledge exchange between health workers Adopting social recognition measures for rural health workers

summary of the WHO Global Guidance on Health Workforce Development, Attraction, Recruitment and Retention in Rural and Remote Areas (ref forthcoming Feb 2021). These evidence-based recommendations are on four spheres of influence. The major push and pull factors resulting in health workers’ decision to work in or leave rural areas are: education; regulation; incentives and personal and professional support. The recommendations should align with other policies at the country level and should be acceptable by local communities. Rural retention policies must be grounded in a costed and validated national health plan. It is also clear that a bundle of interventions is needed to achieve optimal impact, and single isolated interventions are not sufficient to address the multifaced nature of attracting, recruiting, and retaining health workers in rural and remote areas. Engaging the community throughout the planning and implementation is important to ensure acceptability, and consideration of the current health system and financial and political resources is important for ensuring long-term sustainability. The impact of policies on different work occupations, career stage, sociodemographic characteristics (such as gender, age, and ethnicity) and personal expectations is important to determine. Finally, governments need to monitor and evaluate the outputs, outcomes, and impacts of efforts to increase health workers in rural and remote areas. Evidence suggests that the choice of interventions to improve the recruitment and retention of health workers in rural areas should be informed by an in-depth understanding of the health workforce. In addition to comprehensive labor market

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and situational analyses, this requires an analysis of the complex factors that influence the decisions of health workers to leave rural areas, as well as those that influence them to stay. These recommendations do not just address the numbers and density of health workers but also influence acceptability of care, accessibility, quality, and performance. They presented a list of policy recommendations which countries should bundle and adopt based on the feasibility and acceptability of the recommendations in their context. A notable feature of the policy recommendation is that they span education, regulation, incentives, and work life.

Conclusion Health services and other social services need to better account for the poor rural areas and specific populations experiencing social exclusion in rural areas. The need to mainstream rural dimension into social inclusion and social protection policies has been highlighted (EC 2008; ILO 2019). Strengthening rural health systems is fundamental in improving the working conditions of health workers. This is key to attracting and retaining health workers into rural and remote areas. Subnational dimensions, including rural, are far too often neglected in analyses of health and health system performance as well as health outcomes assessment (WHO 2010). Disaggregated data from rural areas is needed to form a comprehensive assessment of all health system functions and population health. There is a need for increased research on how best to improve and monitor health service provision and use in rural areas. A crucial step for rural health within global health will be measuring and monitoring the impact of equitable healthcare access on health outcomes. Also important is the impact assessment of rural health workforce interventions on health equity. Reduced inequity in health workforce distribution is important to measure and monitor its link to health outcomes. Disaggregation by rurality will be key to bringing together global partners to address the persistent rural health workforce gaps across the world. Intensifying the focus, attention, and actions on increasing the number of health workers in rural and remote areas providing primary healthcare services is the key to unlock billions more people benefiting from UHC. Bridging the health workforce access gap will protect the most vulnerable, poorest, and hardest to reach populations. Policymakers need to actualize political commitments to the expansion of UHC by implementing evidence-based strategies that will efficiently increase the health workforce in rural areas. An investment in developing the rural health workforce is an investment in the health of 3.4 billion people, poverty reduction, women’s and girl’s rights, sustainable rural development, descent jobs, economic growth, and ultimately reduced inequalities. At this, national and local authorities, together with rural communities, play an essential part in achieving global sustainable development and health goals. Rural communities should be a part of the policy planning, implementation and evaluation. This is especially relevant where the primary healthcare model cradled by UHC should

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be the fundamental approach to improve the health of rural residents (National Rural Health Alliance 2015). Therefore, a health-in-all-policies approach, the assessment of policy impacts, and policymakers addressing policy changes, if necessary, are crucial to ensure that UHC and sustainable development goals are achieved.

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Mirkuzie Woldie and Kiddus Yitbarek

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Informal Care and Medical Volunteerism Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Production of Health in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History of Village Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of Community Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forms of Informal Care and Volunteer Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lay Health Worker Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Member of Care Delivery Team Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Care Coordinator/Manager Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Educator Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outreach and Enrollment Agent Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Organizer and Capacity Builder Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functions of Community Health Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Education and Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Detection and Adherence to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Care of Common Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Is the Cost of Volunteering? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Factors Affecting Informal Care and Community Volunteer Work . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Caregiver Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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M. Woldie (*) Department of Health Policy and Management, School of Public Health, Jimma University, Jimma, Ethiopia Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia e-mail: [email protected] K. Yitbarek Department of Health Policy and Management, School of Public Health, Jimma University, Jimma, Ethiopia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_110

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Community Level Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health System Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Production and maintenance of health in the community is a very challenging endeavor. This is more so in health systems faced with a shortage of qualified health professionals to reach all segments of populations in need of health services. Several health systems have resorted to the introduction of informal care through community health volunteers (CHVs) as a remedy to this challenge. There are a range of models or forms a volunteer-led health services delivery program could take. Engagement of volunteers in health education and promotion, case detection and adherence to care, and treatment of common conditions in the community is proved to be effective in different settings. One has to bear in mind, however, the fact that volunteer health services are not free; they happen with a cost to the volunteers and the general economy in a country. Success in volunteer health services delivery depends on attributes of the individual volunteers, the community served, and the structural and policy arrangements of the health system which they complement. Keywords

Informal care · Volunteer health services · Community health workers · Community health volunteers · Universal health coverage

Introduction Although the spatial distribution and the pattern are different, populations worldwide suffer from different health problems. Meanwhile, they have various unaddressed health service needs. However, health services in various countries in the world are incapable of addressing the tremendous health service needs. This problem is mainly attributed to a shortage of resources especially in low- and middle-income countries (LMICs). These countries encounter shortfalls of health professionals, serious gaps in healthcare budget, less developed infrastructure, and problems in supply of essential drugs and materials. Compounded with these supply side issues is the poor uptake of available health services by the population. This commonly relates to poor quality of healthcare, problems in acceptability of the services to the community, and low health literacy among the people. These multidimensional problems both in the health system and the community are hurdles that prevent LMICs to achieve a key target of the sustainable development goals (SDG): universal health coverage (UHC). Access to healthcare and health service coverage are not fully ensured in many countries of the world, especially so in LMICs. As one of the major dimensions, UHC demands availing health services within the community. In fact, achieving

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UHC in a country is a long process that takes long time. With this gradual process, health service delivery can grow to comprise a range of preventive, promotive, and curative services. The provision of service and its growth does not take similar nature in different countries. The country’s health service coverage gaps, disease profile, and level of healthcare spending are taken into consideration (World Health Organization 2016). The multidimensional problems related to health and health service call for the introduction and inclusion of informal healthcare and volunteer health service into the healthcare systems of many countries of the world. These are the ways how many countries enhanced access to care, health service coverage, and equity in service use. As experiences from various health systems indicated, community-based services are appropriate and cost-effective strategies to ensure UHC. Moreover, involving community members in health service delivery enhances their feeling of ownership to the health system (Woldie et al. 2018). There are arguments for and against to the introduction of informal care and community volunteer health services. However, all agree that, as a practice, it has a long history. In earlier periods in the seventeenth and eighteenth century, missionaries from different countries of Europe sailed to different parts of the world, especially to Africa and America, providing voluntary medical and health service among their major activities. These efforts continued during the colonialism period. But the services were directed not to the people living in the colonized country, rather to the soldiers and the families of the colonizing country (Mckay 2007). As an organized package of community-based health service delivery, the Chinese “barefoot doctors” approach is the prominent one. A further change in the concept of informal care and community volunteer health service was seen in the primary healthcare period. In 1978 at Alma-Ata, USSR member states of the World Health Organization (WHO) met and outlined the so called Alma-Ata Declaration. The declaration put a comprehensive and broad definition of primary healthcare. It considered community involvement and reduction of health inequalities as key pillars of the primary healthcare system (Whiteford and Branch 2008; World Health Organization 1978). Community health systems are considered as a tire that links the formal healthcare system and the community. Community health workers (CHWs) are the agents who run health activities in the community and liaise with primary level of the health system. CHWs are meaningful assets of the health system who promote health and expand health service access all over the world. As defined by Witmer, CHWs are “community members who work almost exclusively in community settings and who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate health care”(Witmer et al. 1995). CHWs are considered as uniquely qualified health agents because they live in the community, speak similar language, and also know the cultural and livelihood of the community. Besides connecting the community members to the health system, they also inform healthcare providers about the needs of the community (Centers for Disease Control and Prevention 2013). With this system, duplication of efforts by the healthcare providers can be minimized, so that health system efficiency is improved. Using community health

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system has resulted in an enormous achievement to different health indicators among countries in the world. For instance, community-based counseling and HIV testing, sanitation and hygiene, maternal and reproductive health services, and new tuberculosis (TB) notifications can be few examples. Recently, community-based health services became major interventions to tackle non-communicable diseases (NCDs), mental health care, palliative care, and rehabilitation (World Health Organization 2016). These community-based health services are led by either paid or voluntary CHWs. There are various approaches through which community health volunteers (CHVs) intervene in the healthcare system. The service ranges from highly specialized medical services to health promotion activities by lay community members. The vast majority of volunteer community health interventions are given by non-health professionals who got short-term trainings on basic aspects of the service packages they intervene in. These personnel mostly participate in disease prevention, health promotion, and psychosocial support for vulnerable people (Woldie et al. 2018). They also assist physicians and healthcare professionals with many aspects in delivering care. Community-based health services take different forms in different countries. In some countries it is a well-designed and structured approach, and, in some others, it is a kind of sporadic undertaking. The focus also differs based on the health service needs of the specific country. Volunteer activity in developed countries has contributed a lot in different social and welfare areas. In the European Union (EU) countries, there are about 93 to 94 million people older than 15 years who participate in volunteer services. It constitutes more than 22% of the total population older than 15 years (Educational Audiovisual and Culture Executive Agency (EAC-EA) 2010). In well-developed countries, the focus of carers is directed to palliative care institutions, care for elderly people, and care for those living with chronic illnesses. For instance, it is estimated that in 2000 there were around 5.8 million caregivers in England, of whom between 3.4 million and 4 million were providing care to those aged 65 and over (Wanless et al. 2006). Whereas, in LMICs especially in Africa and Asia, the focus of volunteer health services are prevention and control of communicable disease, family planning, reproductive, maternal and child health services, mental health disorders, and treatment of common diseases (Woldie et al. 2018).

Informal Care and Medical Volunteerism Defined It is difficult to get an agreed up on definition to informal care and medical volunteer work. The context of using the concept can be a base for the definition difference. Various authors and organizations use the terms informal care and medical (health service) volunteers interchangeably. However, there are clear differences among the two phrases. But it seems there are overlapping aspects too. The meaning of informal care is better understood by discussing what formal care entails. Related to this Triantafillou and his colleagues have given a definition while listing major formal and informal care activities. Formal care implies “services provided by trained, licensed and qualified professionals in a service [delivery]

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controlled by the state or any other organization.” The caregivers are salaried with a contract mechanism for a defined level of responsibility. More specifically, the caregivers are subjected to working regulations and entitled to social rights. They are expected to adhere to “minimum professional qualifications expected from their position in their workplace.” Whereas an informal care is a care mainly given by family, friends, close relatives, or neighbors where the care providers are non-professionals and not trained to provide care; but in some cases, they may benefit from tailored short trainings. They have no binding agreements regarding care responsibilities, have no limits to time spent on care, and are not paid although they may obtain financial support to compensate for expenses related to travel or others while delivering care. In this approach of care, providers perform a wide range of tasks (some handled by those in the formal health sector) including emotional support and assistance (Triantafillou et al. 2010). Wanless et al., on the other hand, defined informal care as “. . .unpaid care provided to older and dependent persons by a person with whom they have a social relationship, such as a spouse, parent, child, other relative, neighbor, friend or other non-kin.” “Informal care” includes support (looking after or other “special help”) provided to the sick, disabled, or elderly in a non-professional capacity. It excludes instances where only financial support is given to the recipient (Wanless et al. 2006). Medical (health) volunteerism is the application of the concept of volunteerism into the health and medical care systems. Stukas and his colleagues have defined volunteerism as “a form of prosocial behavior that involves a freely chosen decision to commit a sustained amount of time and effort to helping another person, group, or cause, typically through a non-profit organization.” Throughout their life, there are people around the globe who have a major role of helping others unknown to them who are in need of support without expecting any payment, reward, or reciprocal help in return (Schroeder et al. 2014; Schroeder and Graziano 2015). Wilson on the other hand defines volunteerism as “any activity in which time is given freely to benefit another person, group, or organization”(Wilson 2000). This definition has given emphasis to the informal nature of volunteer activities. Volunteerism on the other hand also happens as a formal undertaking. In this regard Penner has propagated volunteer activity as a helping behavior that happens in a formal organizational setting (Penner 2002). Hence, an umbrella review suggested that community health volunteers are “lay individuals of varied background, coming from, or based in the communities they serve, who have received brief training on a health problem they have volunteered to engage with.” It was also noted that these volunteers usually engage in various forms of development activities in the community beyond health and may receive support from formal structures of the state (Woldie et al. 2018).

Production of Health in the Community Community is a group of individuals in a neighborhood extended from rural to urban regions who live and/or work together and share interest and faith. Guttmacher et al., in their book, have shortly defined community as “a group of people connected by visible and invisible links.” The difference in defining community differs according

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to the links that tie the group of people. If we define based on physical proximity, or political boundaries, it can be geographic community. If the base is sharing of interest, characteristics, behavior, and risk, it is a kind of communities of interest (Guttmacher et al. 2010). When we talk and think about health of individuals in the community, it is a complex and multidimensional concept and free for interpretation. Despite a linear understanding of a mere absence of disease, the community itself has its own agreement to define health and healthy community. It can be seen as a physical, mental, emotional, and spiritual well-being. Whether we define one way or another being healthy is an optimal well-being. Optimal health is a product of making sure that people’s potential to live and work in a certain community is maximized. Health can be seen from the human rights’ perspective. According to the WHO’s constitution “. . .the enjoyment 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” (World Health Organization 2006). Meanwhile health can also be seen as an investment. Today’s one dollar investment for health will be paid off with uncountable returns through a healthy individual and community (International Monetary Fund 2004). Therefore, it can be concluded that “one cannot afford not to invest on health.” The factors that are responsible to determine individuals’ and/or community’s health range from individuals natural or genetic factors to the general socioeconomic, cultural, and environmental conditions. It is the wisest and cost-saving measure to work on the determinants of health. It is a point where preventive and promotive interventions are undertaken. On the other hand, the occurrence of diseases and need for medical care is inevitable from everyone in the society. Therefore, a due concern for medical care and rehabilitation service is of paramount importance. When we deal about these issues, certainly one thing comes to our mind. Who is responsible to safeguard the health of the community? There are various angles of view to answer this question. For instance, Resnik D in his paper published on Journal of Medical Ethics in 2007 has put the community itself as the primary responsible stakeholder for their health. According to his review “most of the discussion in bioethics and health policy concerning social responsibility for health has focused on society’s obligation to provide access to healthcare.” There are many different methods that the society use to promote health in their dayto-day life. Individual and family sanitation, improvement in the nutritional habit and food safety, health education, control of environmental pollution, disease surveillance, and occupational health are all possible approaches (Resnik 2007). On the other hand, the Minnesota Department of Health gives the responsibility to the government while identifying the areas of responsibility. Interventions like assuring an adequate local public health infrastructure, promoting healthy communities and healthy behaviors, preventing the spread of communicable disease, protecting against environmental health hazards, preparing for and responding to emergencies, and assuring health services were given to the government (Minnesota Department of Health n.d.).

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Whatever the case and the degree of role, we all agree that everyone has a stake to share. In many countries the government as a peoples’ representative takes the lead in ensuring health and facilitating health services. For better implementation and achievement, the government supports the whole health activities with national and local policies, rules, and general procedures. It also has a mandate to regulate the role and conduct of practitioners at each level in the government’s system. However, the hands of government are limited to perform everything important for the society’s well-being. Limited nature of resources such as trained professionals, materials and equipment and finance; contradiction between what the community needs and what the government has; and cultural and religious characteristics of the community and its discordance with modern medical approaches are the major reasons. Here we need to reconcile the human rights to be healthy and government’s limitation to safeguard the health of the community. Many countries in the world, especially the developing countries, suffer from a significant shortage of highly trained health service providers. On top of the low access to healthcare, these countries are also well-known by the prevailing big health problems. The currently available universities and medical schools are not capable of training adequate number of professionals to keep up with the increasing demand of health service. The high migration and turnover of professionals especially physicians, low efficiency, death from different disease, and the fast growth of population fuel the problem. Therefore, the use of CHWs is not a choice. It is a way to address the biggest proportion of the population with low cost. CHWs, usually volunteers, are mostly members of the community chosen either by the community they serve or the organization that leads community health services. They usually provide preventive, promotive, and rehabilitative services to the community. In various programs and countries, CHWs have different names including community health promoters, village health workers, community health volunteers, health advisors, lay health workers so, and so forth (Internationa Labour Office 2012). Community health workers are the backbone of health development and better access to healthcare. Their effect in improving the community’s health can be enhanced when they are properly trained and updated with new approaches of healthcare (Woldie et al. 2018; Lehmann and Sanders 2007). Countries that used community health workers have demonstrated the use of such programs help them improve health outcomes of highly unaddressed proportion of the population (Siraj et al. 2012). It is an efficient approach of using health human resource in order to improve the well-being of the largest and marginalized portion of the population with a low cost (World Health Organization 2007).

History of Village Health Services The origin of community volunteer health service is argumentative just like its definition. There is a long history of community health services along the world in fact. However, the services were fragmented and were not in a well-established

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system. More systematic approach of community health service delivery is a history of about two centuries. According to Terris, the first example of well-trained non-physician’s community health service providers’ service was started in the late 1800s in the former United Soviet Socialist Republic (USSR). The health workers had paramedical training so as to assist physicians and give service to the rural population where physicians are not available (Perry et al. 2014; Terris 1977; World Health Organization 1974). Some other writers like Rosenthal and Greiner say the origin of community health workers model was based on the Chinese “Barefoot doctors’” model (Rosenthal and Greiner 1982). Referring the speech of Melinda Gates, Kristof and Nicholas in 2012 have uncovered that a government organization in Bangladesh called Building Resources Across Communities (BRAC) is a pioneering for the community health workers’ approach (Kristof 2012). (Lovell 1992), however, writes that the BRAC’s approach of community health services has made its base to the Chinese barefoot doctors’ model. The recognition and respect given to these part-time paramedical practitioners have inspired millions during the time. The team of barefoot doctors was composed of both male and female community health service providers. Even the number of female doctors was greater than the male. They originally were farmers, folk healers, traditional healers, and primary or secondary school graduates who got minimal medical and paramedical training. These personnel were trained with the Westerns’ medical techniques and the Chinese indigenous traditional treatments. Therefore, they could be capable of giving primary care services including preventive, promotive, and basic medical treatments. If they get any rural resident with serious condition, in the village they are caring for, they refer the patient to commune hospital, where specialized doctors were available (Smith 1974). The approach effected in massive improvement of the health and other development matters in the then China. It led to the elimination of venereal diseases and drug addiction, control and treatment of infectious diseases, and significant reduction in infant mortality rate. The program was also well-known in promoting the participation of women in the people’s health matters. Mao’s famous slogan “women can hold up half the sky” was an energy for the improved women’s involvement in the program. Generally, significant improvement in average life expectancy from birth was recorded during the time (Dobson 1981). Although improvements in the health status were recorded in China, the barefoot doctor’s model was not integrated into the health policy and institutionalized up to 1965. Mao Zedong’s healthcare speech “in medical and health work, put the emphasis on the rural areas” in 1965, and the government’s commitment has put a base for lots of changes and fertile ground to expand and strengthen community health service approach (Rosenthal and Greiner 1982). The national health policy of China has given a due emphasis to the barefoot doctors’ program following Mao’s directive in 1968 (Zhang and Unschuld 2008). The program during the time was referred as “rural cooperative medical systems” which worked to enhance community participation in the health matters of rural population and their own family (Core 2012). Paradoxically, when changes occurred in the Chinese economy in the late

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1978, commune hospitals were dismantled and the political importance of barefoot doctors eliminated. The policies were changed to completely marketization of healthcare. This finally effected on complete decline of the rural healthcare and welfare in the country (Huang 2008). Despite the fact that the Chinese barefoot doctors approach disappeared in 1978, its legacy has inspired the initiation of the Joint WHO and UNICEF conference on primary healthcare (PHC) at Alma-Ata, USSR, in 1978 (Lee and Kim 2018). During the conference the so-called Alma-Ata Declaration or the primary healthcare initiative was signed by the member states of WHO. The declaration has made a paradigm shift in the world’s healthcare thoughts. It has given emphasis to participation of the community in making decision on healthcare priorities; participation in preventive and promotive healthcare activities; inter-sectorial actions for health, using appropriate technologies; and equity in utilization of health services (World Health Organization 1978). Furthermore, a link was designed to integrate the efforts of different sectors like rural politics, agriculture, economy, industry, trade, and social sectors to improve the well-being of the society.

Role of Community Health Workers Since the 1978 PHC movement, many countries joined the CHWs approach either in a paid or voluntary modality or both. CHWs in general, volunteers in particular, have provided fruitful preventive and promotive health services to the communities in these countries. For example, health education and information delivery, home-tohome visit for vulnerable population, and serving as a communication channel between the healthcare system and the community were activities performed by volunteer CHWs. Shortly after the Alma-Ata Declaration in early 1980s, Nepal’s government officially launched the female community health volunteers (CHVs) program. But unfortunately, the program failed within few years because of lack of continued fund to sustain the program. Few years after, in the late 1980s, the program was revived with unpaid female CHVs. Their major role was to ensure the distribution of vitamin A supplements. In a few years, the number of these women volunteers became more than 40,000. Later additional service packages were included to the scheme including, detection and treatment of common childhood illnesses, distribution of oral contraceptives, antenatal care, family planning, first aid services, and immunization (Thapa et al. 2005; Gottlieb 1993). Similarly, the Brazilian government introduced a national healthcare program in 1987 with a package of family health program in which a community health agents’ platform was included. The CHWs approach in the country became the largest in the world that addressed 110 million people home to home with about 240,000 CHWs. The coverage of family health program expanded to 36% in 2002. With this program, 12 years after its introduction, infant mortality in the country dropped from 50 to 29.2 per 1000 live births (Macinko et al. 2006).

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Iran is also another example among the early adopters of CHV system with a large quantity of health paraprofessionals called “bahvarz.” They had a “health house” approach of health system as a base for the CHVs. Their major focus of intervention was house-to-house child growth monitoring and immunization. With the help of these CHVs, Iran has recorded a significant achievement in various health indicators. For instance, within 16 years from 1984 to 2000, infant mortality was reduced by half, fertility was reduced from 5.6 children to 2 children per women, and immunization coverage increased from 20% to 95%. The bahvarz extensively participate in birth control services and advice and significantly improved rural women contraceptive use. Maternal mortality, on the other hand, was reduced to 37 per 100,000 in 1996 from 140 in 1985 which progressively fall down to a ratio comparable to developed countries in 2008 (Esscher et al. 2013; Moazzeni 2013). In order to address its shortage of trained health professionals, Ethiopia launched a well-structured scheme for community health services for both paid and voluntary CHWs in 2004 and 2010, respectively. The arrangements are complementary to each other (Betemariam et al. 2017). According to the Ethiopian demographic and health survey, there was a significant achievement in many health indicators which were included in the CHWs service packages. For example, maternal death became 412 as compared to 673 in 2005 and 676 in 2011 per 100,000 live births. Death of children under the age of 5 decreased from 88 in 2011 to 67 in 2016. Coverage of maternal health service packages such as antenatal care, delivery care, postnatal services also changed favorably following the introduction of the CHVs. Antenatal care (ANC) has shown a 28% increase within 6 years from the introduction of CHVs program. Health institution-based delivery and postnatal care shown to increase by 16% and 9%, respectively (Central Statistical Authority [Ethiopia] and ORC Macro 2000, 2006, 2011; Yitbarek et al. 2019). Experience from various countries indicated that the use of CHWs service in general and CHVs in particular is a potential approach to achieve UHC in the face of limited supply of trained professionals. Sustaining the benefits of volunteer-led community health programs is possible if countries integrate the programs to the regular health system and consider it as a policy priority (Tulenko et al. 2013). Woldie et al. concluded that continued training, financial incentive packages, regular supportive supervision and evaluation, and infrastructural support and supplies are additional success factors (Woldie et al. 2018). Hence, as Tulenko et al. put it, “in moving towards UHC much can be gained by investing in building CHWs’ skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are not shortcut to progress” (Tulenko et al. 2013). Shortage of healthcare professionals is a major problem in many countries of the world. It hampers many health systems to address the health needs of their community, so that they could not achieve national and international health goals. As best strategy to enhance access to care, various countries in the globe have adopted community health services approach. CHVs play a vital role at the primary healthcare level. Relying on this approach, several countries have improved access to care and health services coverage at the community level.

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Forms of Informal Care and Volunteer Health Services Remarkable changes in health indicators of the world’s population were seen in many countries as a result of community health volunteers’ intervention. The volunteer health service delivery approach addresses the population in various ways. In one way or another, the role of community health volunteers can be categorized into health education and promotion, case detection, and adherence to care and clinical care. With these service approaches, many countries were benefited and improved the health of their citizens. The description as “volunteer” or “informal” care can be misleading for the bulk of activities and the devotion of the volunteers (Wanless et al. 2006). These personnel are CHWs based and mostly originated from the community itself and give nonprofessional health services. Different naming but generally similar arrangement of activities happens in various countries. Community health workers, volunteers, community health volunteers, village health workers, community health aides, and lay health workers are some of the terms used to name informal carers working in a volunteer basis. There are differences in naming across health systems. CHVs participate in health service delivery based on various approaches according to the respective country’s health system program design. In one way or another, these participants share some basic characteristics. Snyder and Omoto, from the social and psychological viewpoint, have identified six major characteristics of volunteer health service interventions: (1) volunteer action must be performed based on free will and not due to obligation or coercion; (2) volunteering is a deliberative act, requiring careful decision-making, rather than a reactive or spontaneous act as may happen in response to emergencies; (3) volunteering activities continue over time rather than as one-off special event-focused behaviors; (4) volunteering is a function of a person’s goals and not a response to explicit rewards (such as payment) or punishments (such as court orders); (5) volunteering involves service to people or causes that desire help; and (6) volunteerism is usually carried out through organizations or agencies (Snyder and Omoto 2008). Interventions of this kind take different forms based on the activities expected from the service, their objectives, the group of people they address, type of health problem they deal with, and the individual characteristics of the workers. The US rural health information hub puts a toolkit categorizing CHWs into six comprehensive categories (NORC Walsh Center for Rural Health Analysis 2018). The program categories are not in fact mutually exclusive. Some activities of CHWs were found included in more than one category.

Lay Health Worker Model This model includes members of the target community as CHWs. These CHWs share many economic, cultural, and social characteristics with the community they serve. It can be believed that these community health agents are trusted by the community and can provide culturally appropriate services. They play roles like,

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educator, patient advocate, mentor, translator, and outreach workers. These workers are the agents who link the community with the health system, in most cases the primarily healthcare system. This model was tested in the USA and Latin America to serve the Hispanic communities. South Africa has also cadre of lay health workers giving HIV counseling services (Petersen et al. 2014a). This model of community health workers uses members of the community to enhance the acceptability of the services. The practitioners are expected to be members of the society, not those who only speak similar language with the community or share some common characteristics. Predominantly the time of these lay health workers is spent serving in rural areas where the actual target population lives. Therefore, they do not need transportation facilities to the target population that could have been used if the practitioners were outsiders from the community. In their systematic review, Petersen and his colleagues have concluded that, in resource limited countries, implementing behavior change and psychological services provided by lay health workers can be used to promote chronic care at primary healthcare level. Lay health workers have the capacity to provide effective behavior change counseling service and psychological treatment for some major metal disorders like depression in the primary healthcare level (Petersen et al. 2014b). Kennedy et al., on the other hand, have suggested lay health workers to handle HIV testing service based on the results out of their systematic review (Kennedy et al. 2017).

Member of Care Delivery Team Model In this approach of community health service, the community cadres participate in collaboration with medical personnel. These CHWs may get basic medical training to work alongside health and medical professionals. Alongside the actually trained professionals, the community workers serve in different settings like rural health centers, healthcare clinics, pharmacy, and so on. Their focus is to increase service access, improve disease management and adherence to care, and also deliver services. In this approach of care, the practitioners participate on some basic activities like first aid services, blood pressure and pulse measurement, medical counseling, and health screening. They also assist health professionals in mobile clinics while providing services like screening, providing health education, referral, follow-up, and adherence to care. In this approach, it is suggested to have a plan clearly describing the actual roles and responsibilities and how their role contributes to the entire team.

Care Coordinator/Manager Model CHWs may also work as a coordinator of different sectors that contribute for the society’s health. They promote the link between the target population and health, social service, and humanitarian organizations. People with variety of health problems were served by these workers to obtain the appropriate care in the health

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system. Specifically, they participate in activities like providing information on health and community resources, facilitating transportation, making appointments, and giving reminders for the appointments. The CHWs further collaborate with the community members to develop a care management plan and progress tracking tools. Mostly in this model, the practitioners provide services for people with chronic conditions and liaise those who seek care to the health system. The workers have to know the health system very well and resources found in their respective community. Furthermore, they need to understand the cares during emergency conditions. These care coordinators usually obtain disease specific trainings.

Health Educator Model The health education model is the well-known component and applied in various countries volunteer health service programs. The CHWs in this model deliver health information and comprehensive promotion services to the community. They generally provide health education service like health behavior changing, disease prevention, and screening. The areas of intervention for these personnel include, but not limited to, communicable disease, environmental personal hygiene, nutrition, terminating smoking, chronic diseases prevention, stress management, physical activity, and health screening. Their teaching is not limited to the target population. They also teach healthcare providers on community health service needs and bridge the cultural gaps among healthcare providers and the target population. Moreover, CHWs who are extensively engaged in health education should receive training on cultural competency to enable them deliver health information in a manner sensitive to the values and beliefs of the community. The health educator model so far was tested in many programs to raise health service use, adherence to care, and prevention of diseases. We provide further details in relation to the effectiveness of the health education and promotion function of CHWs.

Outreach and Enrollment Agent Model This approach is actually similar with the health education model with some additional outreach community-based home-to-home service package. In the home-to-home visit, the CHWs promote maternal and child health, provide psychological support, undertake both environmental health and household assessment, give an advice for the needy people, and give a referral service. With this approach of care, the community health workers help individuals in the community to minimize social isolation. One of their major objectives of house-to-house visit is to identify patients who suffer from social isolation and supporting them psychologically. A randomized controlled trial conducted by Fylkesnes and Siziya in Zambia has uncovered that using home-to-home voluntary counseling and testing (VCT) for HIV/AIDS was effective as compared to the facility-based services. The uptake and acceptability of VCT service was found higher among those who were provided with

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HIV counseling and testing service in urban Zambia (Fylkesnes and Siziya 2004). The other major undertaking of these individuals is to visit hard-to-reach populations. The outreach and enrolment models were also found effective in lifestyle-changing intervention for effective reduction of blood pressure in Nepal. A team of female community-based health volunteers led a lifestyle-changing intervention and monitoring of blood pressure in the general population of Nepal. This community-based intervention has resulted in a reduction of blood pressure among adult individuals with hypertension (Neupane et al. 2018). The results from a systematic review conducted by Wright et al. have shown that community-based tuberculosis directly observed therapy (TB-DOT) by community health volunteers has obtained better treatment success as compared to the clinicbased TB-DOT service (Wright et al. 2015). Neupane et al., on the other hand, compared the effectiveness of simple home-based measures and highly sophisticated measures in tertiary healthcare facilities by pediatricians to treat low birth weight infants. The results indicated that the home-based care by CHVs are more effective in saving the life of low birth weight infants (Neupane et al. 2017).

Community Organizer and Capacity Builder Model In the community organizer and capacity builder model, the CHWs act as initiators of community actions and collect resources from different community organizations and individual members to undertake new activities. They also initiate the community members to request for changes in the policy. So as to build a coordinated approach of care in their community, these CHWs develop a link with a variety of organizations and individuals. These may include healthcare providers, public health organizations, educational organizations, different government agencies, faith-based organizations, and both international and local humanitarian organizations.

Functions of Community Health Volunteers The focus of most community health programs in various countries is directed to advocating positive health practices. Areas of emphasis for the CHVs include being a role model, provide minor treatment, referral of clients for specialized care and follow-up, social mobilization, community dialogue and action, and community health education. Following is a brief account of three most important functions carried out by CHWs, health education and promotion, case detection and adherence to care, and clinical care common conditions.

Health Education and Promotion Aiming at changing behavior of the community members, health education addresses a variety of health issues. In many developed countries, chronic health

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diseases and their predisposing factors are the major focus of health education interventions. For instance, cancer screening, palliative care, obesity, mental health problems, and predisposing factors and self-management of chronic illnesses are the concerns of health education programs. In developing countries, on the other hand, the programs are directed mostly to communicable diseases and reproductive, maternal, and child health care. For example, health education activities focusing on personal and family hygiene; prevention of prevalent communicable diseases like HIV/AIDS, malaria, tuberculosis, and measles; adolescent and youth-friendly health services; family planning services; utilization of antenatal care; use of institution for delivery; and child immunization are common in developing countries (Hartzler et al. 2018). According to a systematic review conducted by Gogia and his colleagues (Gogia et al. 2011), a community-based health information delivery and comprehensive education by community health workers resulted in reduction in neonatal mortality rate in resource limited setting. Another systematic review by Saeterdal et al. reported that community health education programs led by volunteers are more effective in raising vaccination status in areas or groups of population where there is low child vaccination coverage. However, the services might need a large amount of resource when implemented in a large scale (Saeterdal et al. 2014). These roles of CHVs were also showed effective in chronic patients care at the primary healthcare level. Non-communicable disease prevention and control programs in developing countries were enhanced by community health workers’ provision of health education programs, according to a systematic review by Jeet et al. The topics addressed in the health education and promotion services included physical exercise, smoking cessation, healthy diet, alcohol consumption, awareness on cancer, and management of hypertension and type 2 diabetes. The review has proved that compared to the standard service given by health professionals, health promotion activities led by CHWs is effective in LMICs, especially in hypertension and diabetes control and tobacco cessation (Jeet et al. 2017). Counseling service delivered by lay health volunteers has a potential to effectively deliver a behavior change counseling to people with chronic illnesses. Furthermore, counseling for common mental disorder by these community volunteers was also found effective (Petersen et al. 2014a).

Case Detection and Adherence to Care The other major area of CHVs’ engagement is case detection and adherence to care. In case of outbreaks, for example, CHVs intervene in case detection and prevention activities. In 2011 Madagascar experienced an outbreak of malaria in the southwestern part of the country. The government of the country has tried to control the spread of the case with interventions like distribution of insecticide-treated bed net and indoor spraying. However, the ministry of health was incapable of giving the services with its health professionals. The strategy they have used was CHVs’ intervention. The government of Madagascar decided to promote community participation in preventing the surge occurrence of the case. They have achieved

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eliminating the incidence of malaria with this intervention. As a result they have updated the national community health policy of the country so as to institutionalize CHVs as a base for the country’s healthcare interventions including the combat against malaria (World Health Organization 2013). CHVs then became the major practitioners based in the community. About 6052 CHVs were trained, equipped, and provided with technical support on how to provide birth control and family planning services and community case management for at risk under 5 years children, suffering from malaria, diarrhea, and pneumonia. Similarly, in Uganda services like infection control during disease outbreaks, family planning in the community and referral services have been given by community health volunteers. This approach created a suitable ground for the implementation of primary healthcare services including preventive, promotive, and major curative services (Kimbugwe et al. 2014). Focusing on five major areas of preventive and promotive health services, Kuule et al. have studied the performance of Uganda’s community health service program. The major areas of community health intervention include attendance of monthly community health volunteers’ meetings with community health nurses, household follow-up and reporting, screening and monitoring for malnutrition in under-5 children, immunization coverage, and raising the number of institutional delivery in their respective catchment population (Kuule et al. 2017). In Colombia the case detection of American cutaneous leishmaniasis (ACL) was facilitated by a team that involves CHVs. A clinical prediction rule was used to evaluate ACL and other dermatological diseases. The evaluation team is composed of three types of group, CHVs, program physicians, and practical nurses working independently. It was found that the case detection of ACL threefold of what was seen a year before (Rojas et al. 2002). Routine tuberculosis contact tracing in Kenya was conducted by a multidimensional intervention package implemented through the existing volunteerbased community health strategy. The package was implemented in Western part of the country, and improvements were found in the proportions of index cases traced, symptomatic contacts referred, referred contacts presenting to a facility for TB screening, and eligible contacts started on isoniazid preventive therapy (IPT). The intervention has given a lesson: simple and community-based interventions with the existing community health system improve the effectiveness of routine TB contact tracing activities in TB-prevalent regions. The intervention then was followed by inclusion of routine tuberculosis contact tracing in to routine community health service practices of western Kenya (Volkmann et al. 2016). Similarly, a systematic review to check the effectiveness of strategies to improve community case management of malaria has indicated that community health workers’ intervention was effective in detecting and managing malaria cases at the community level. Therefore, it was suggested that merging the community case management of malaria by CHWs to the formal healthcare system certainly increases the overall care delivery at the primary healthcare level (Paintain et al. 2014).

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Clinical Care of Common Conditions Clinical care is commonly given at healthcare facilities by medical and paramedical professionals. In some cases, medical care is given at temporary mobile care centers within the community. The role of CHWs in this regard varies according to the program they participate in. Their focus can be raising access to medical care through outreach programs, promoting the use of medical services through various communication channels, and referral of cases to the appropriate institution for clinical treatment, and they promote the appropriate use of healthcare services (Goodwin and Tobler 2008). The CHV’s clinical care scheme also takes a form of health assessment and remote care in their respective assignment districts. CHVs who got basic medical training participate in services like assessment of vital signs, lifestyle change interventions, health knowledge enhancement, psychosocial support, and care through routine exams supported by remote communication with physicians. These interventions help healthcare providers and the health system in general with improving the understanding of patients’ preferences, their health status, and background (Hartzler et al. 2018). Direct involvement of the CHWs in the treatment and referral of common conditions also happens in several health systems of LMICs. In Ethiopia, for example, the health extension workers (HEWs) were initially limited to preventive and promotive activities but later entitled to diagnose and treat common childhood illnesses such as diarrhea, pneumonia, acute malnutrition, and malaria when the patient has no any sign of severity. They also do insertion of implants for contraceptive purpose (Tilahun et al. 2017). An overview of systematic reviews also reported that CHVs engage and perform very well in a range of clinical diagnosis and treatment activities for common infectious conditions in LMICs (Woldie et al. 2018).

What Is the Cost of Volunteering? It is evident that volunteer health services are beneficial to those using the services. Volunteer health service has also a social value to the volunteer themselves. On top of that, as recent evidence indicated, volunteering gives an individual health benefit to the volunteer along with the social values. Those who participate in volunteer services have greater functional ability and lower depression and mortality rate as compared to non-volunteers. Age of the volunteers has also affected in their health status. Older age volunteers were found to receive greater health benefits than the younger ones. Generally, volunteers who spend a significant amount of time are more likely to be healthy in their life (Grimm et al. 2007). When we merely understand volunteer health and community volunteer services, it may seem free of cost. It is not the case, however. If it has a cost to the volunteers, “why do these people participate in informal care and community voluntary services?” may come to our mind. The reason looks a bit complex. Evandrou and

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Glaser suggested as a possible reason that people intend to contribute in such a way if they found a high number of people in their area engaged in volunteer services (Wanless et al. 2006). Another possible reason can be a sense of commitment, duty, or an emotional attachment to the people they are caring for (Timmons and VernonEvans 2013). Some others may consider it as a good opportunity to build experience and learn new knowledge and skills. Whatever the reason, the costs related to informal care and volunteer community work can be seen as hidden costs to the individual and the economy in general. The value of volunteer health service cannot be determined by a market price since it is a non-market undertaking. Therefore, analysts and decision-makers consider theoretical and practical perspectives. Since individual volunteers forgo their employment opportunities while participating in volunteer services, they lose their income they could have obtained if they were employed in any incomegenerating activity. The forgone amount of dollar can be considered as cost to the carers. This cost may have a detrimental effect to the volunteers. Practically, however, in most instances volunteer care providers combine their actual work with their caring activities, even if it is hard to manage. Wanless et al. 2006, have presented a result related to this from analysis of the family resource survey conducted by Machin and McShane in 2001. In the survey 75% of volunteers living away the cared for and 19% of people who live with the cared for were economically active (Wanless et al. 2006). Wanless and his colleagues continue describing the cost of volunteer healthcare to the economy in general. They have seen the cost to the economy in two directions “the direct cost of the services provided to careers, and the cost to the economy of the careers not being engaged elsewhere and thus not able to make an alternative contribution to the economy” (Wanless et al. 2006). The cost consideration is not limited to the above two points. Total cost of any program is complex especially when the program is a kind of service. Not only the financial costs actually incurred in the implementation period from both service providers’ and users’ side are considered. We have to consider all relevant costs like direct and indirect, recurrent and capital (investment), and social and intangible. Information of these kind helps to understand the program and its value. Detailed information on cost of intervention is a base for further analysis to determine the efficiency and effectiveness. Decision-making on the programs’ fate to sustain it or terminate or extend to other areas requires cost and cost-effectiveness information (Perry et al. 2014). There is ample of strong evidence showing the cost-saving nature of CHV service both to the service users and the investors. For instance, a systematic review by Mdege, Chindove, and Ali concluded that task shifting of HIV/AIDS care and treatment from physicians to nurses or from health professionals to lay health volunteers could decrease the cost of ART service without compromising the outcome to the patient (Mdege et al. 2013). A cost-effectiveness analysis in Uganda, aimed to determine the cost-effectiveness of a salaried and non-salaried community health services, revealed that the incremental cost-effectiveness ratio (ICER) of CHWs scheme including salary is by far greater than the ICER of CHWs working

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in a volunteer basis (Bowser et al. 2015). Similarly, Vaughan et al. indicated that compared to the existing standard care in LMICs, the volunteer community health workers approach was cost-effective for tuberculosis treatment (Vaughan et al. 2015). Keeping the better cost and cost-effectiveness nature of volunteer community health services in mind, the cost of volunteer health service alone varies because of different contextual factors. A study result from Kenya has identified four major categories of factors that create cost differences among CHV activities. Attrition rates for CHVs, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits are the critical elements that drive variation on cost (Wafula et al. 2017). Volunteer care providers, on the other hand, will suffer from economic hardship. It can be well understood that volunteers have few times for participating in incomegenerating activities as compared to non-volunteers. Therefore, their income-generating ability could be compromised. As a result, they can be exposed to sever poverty. That is why Dintrans concluded that there is major economic inequality between health service volunteers and the general population (Villalobos Dintrans 2019). Generally speaking, so as to have a continuous benefit of informal care and volunteer community work, one should work to sustain the service for long. Those who stay long in these schemes are people with a strong intrinsic motivation. However, these kinds of people are very few in number and hard to find. Volunteers’ decision to remain volunteers depends on their expectation of future reward. Therefore, sustaining these kinds of schemes for long requires provision of reward proportional to the practitioners’ expectation. In sustainable development of informal care programs, reward mechanisms have to consider the nature of the work, the overall work load, and the opportunity costs associated with volunteer health services (Kasteng et al. 2016).

Factors Affecting Informal Care and Community Volunteer Work Although it is less than four decades since the introduction of informal care and volunteer health services in the healthcare system of many countries, their contribution to UHC is excessive. Based on their own experience and good practices from other similar settings, many countries can be benefited if they enhance volunteer community health services. The cumulative effect then improves access to and utilization of essential health services by populations. However, these kinds of service are vulnerable to various problems. Some important factors affect the systems’ functioning either negatively or positively. The provision of informal care is dependent on the personal, social, and contextual factors of both the caregiver and care recipient (van Groenou and De Boer 2016). The caregiving in reality has multiple dimensions and affected by various factors. Hence, factors that could affect the practice of CHVs could be related to individual, community level, and health system characteristics (Woldie et al. 2018).

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Individual Caregiver Characteristics Individuals in the community have their own personal characteristics, behavior, lifestyle, and interaction with others in the community. Their caregiving behavior also depends on the personal characteristics they assume. Individually they may have some level of intrinsic motivation regarding volunteer care, commitment to their volunteer activities, and the social responsibility they carried. Regarding individual caregivers Wanless et al. have listed some important factors that could determine the existence and well-functioning of informal care and volunteer health services (Wanless et al. 2006).

Residence The residence of volunteers affects the care given and the time spent in the services. In relation to the care recipient if the caregivers are living in the nearby or same place, the time spent in caring becomes much higher as compared to those living far away. Covering a long geographical distance so as to provide volunteer service and the associated transport barriers and travel costs are major limits for caregiving. Sometimes, especially in low-income countries, there are also places without road facility and transportation service. Consequently, volunteers might be supposed to walk on foot for long hours. Consequently, in geographically hard to access regions, volunteers’ contribution is much less. Age and Gender Age and gender affect the likelihood of being a volunteer health worker. The burden of care is concentrated among older people especially in developed countries. Since younger population are busy of their day-to-day formal work, most of the volunteer activities are undertaken by retired people. A study by Hirst has indicated in the UK that the likelihood of being a volunteer carer increases with the age of the individual carer (Hirst 2002). This does not hold true in LMICs, however. Volunteers in rural parts of LMICs usually work and live in the community they serve and carryout volunteer services along with their household responsibilities and work in the farm (Kuule et al. 2017). Regarding sex of the carers, volunteer health services are mostly performed by females. In many health systems, there is a structured women volunteer community health workers’ approach of care. For instance, in the Ethiopian health system, the volunteer health service complementing the activities of HEWs is performed by a structured and well-organized group of female volunteers called Women (health) Development Army. These group of women deal with preventive and promotive health services in the community and assist health service delivery by the HEWs, with supervision from the healthcare system (Yitbarek et al. 2019). Economic Status and Employment There are contradictory evidences on how economic status of carers affects participation and volume of volunteer care. Spending time on volunteer health services has its own adverse impact to the monitory income of an individual volunteer. The time

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could have been used in other income-generating activities, so that his/her economic status improved. The volunteers usually consider the opportunity costs of participating in volunteer healthcare delivery. The likelihood of being a carer among fulltime employed is lower than those unemployed and partially working volunteers. Employed volunteers especially those who have their own family are responsible for multiple tasks. They spend time in their paid job, and they have a responsibility to looking after their family and being involved in volunteer services. Therefore, having a paid work limits the volunteers’ role in participating in volunteer activity for longer time as compared to those not employed (Kasteng et al. 2016). On the contrary, there is an argument that those who are economically better off participate in volunteer services. If people have nothing for their personal life, it is expected that they spend much of their time in income-generating activities rather than volunteering.

Education The time spent on caring services and the performance of carers is also affected by the level of education of the volunteer. Those with high level of education are more likely to participate in volunteer health services. This happens because highly educated people spend much of their time in their formal employment. Compared to those who have lower education level, highly educated volunteers have better performance (Chatio et al. 2019).

Community Level Factors People who give volunteer community health service and those who receive the care are both from the community. They share ways of life, culture, belief, and other matters that generally determine their behavior. Recognitions of these kinds of volunteer practice, habit of participation in the community, expectations from the community, availability and functionality of community networks, and support from the community figures can be considered as major determinants that initiate and sustain volunteer health services. Furthermore, some other factors also affect volunteer health activities. The volunteers’ cultural and religious background can be one factor. An individual originally from a culture or religion that values volunteer activities and helping others is more likely to sustain the cultural values to the health service intervention.

Health System Factors Community health volunteer services can be both supported at the service and policy level. The structure of health service delivery affects volunteers’ participation and performance. If the healthcare delivery structure includes CHV approach as its own component, it is more likely that the service and performance of the intervention are enhanced. This then facilitates regular supportive supervision and in-service training

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to enhance capacity of the volunteers. It further clarifies the working modality and communication channels along the health system. Country health policy and political structures can also be mentioned as determinants for volunteer health services. Health policies and strategies in some countries promote voluntary health services. Even in some countries, volunteer community health services are integrated into the primary healthcare system. That really enhances the participation of volunteers in the healthcare setting. A detailed account of barriers and facilitators of successful volunteer-led health programs in LMICs is provided in an umbrella review (Woldie et al. 2018) (Table 1).

Conclusion The challenges to enhance global health and meeting UHC are becoming increasingly complex especially in LMICs. Generally, every population somehow benefits from informal care and volunteer community health services. This has now become a major approach for many countries in the world to compensate for their disastrous shortfalls of human resources for healthcare delivery. Therefore, sustainability of volunteer services has to be the major objective for health systems around the world. Irrespective of the model or form a volunteer-led health program takes, there are compelling evidences that CHVs and their informal care enhances access to and utilization of essential health services by the community. The volunteers may assume the role of health education and promotion, case detection and adherence to care, and treatment of common conditions among others. Volunteer care, however, does not happen without costs. It definitely affects the possible economic gains by the individual volunteers who forego opportunities of Table 1 Summary of factors affecting informal care and community volunteer work Individual caregiver characteristics Socio-demographic: age, gender, residence, education, social support Economic: employment and income Psychological: degree of intrinsic motivation (altruism, social recognition, and satisfaction), confidence, perceived adequacy of training and access to the community

Community characteristics Degree of community awareness and engagement: community participation and ownership, involvement in selection and support of volunteers, disease-related stigma and discrimination, opinions of healthcare quality or availability, support from family members, respect and trust to the volunteers Cultural conditions: norms, values, beliefs, and practices Environmental factors: topography, pattern of settlement, and travel distance

Health policy and systems Nature of health program: clarity of roles, availability of resources and supplies, acceptability, appropriateness, referral pathways, and integration into the formal health system Remuneration and support: incentives and pays, in-service training, supportive supervision, and clarity of career pathway

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financial gain to participate in volunteer health services. This consequently has implications to the general economy to which every individual in the society contributes. Finally, relevant drivers playing for and against the successful role of informal care and volunteer community health services need to be addressed including age and gender, area of residence, level of education, and economic as well as employment status. Policies and health system arrangements in favor of regular follow-up and support to volunteers improve sustainability of success in these programs. Also, the acceptance by the community and presence of supportive community-based structures enhance continued functioning of CHVs.

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comparative effectiveness. BMC Infect Dis 15(210):1–11. https://doi.org/10.1186/s12879-0150945-5 Yitbarek K, Abraham G, Morankar S (2019) Contribution of women’s development army to maternal and child health in Ethiopia: a systematic review of evidence. BMJ Open 9: e025937. https://doi.org/10.1136/bmjopen-2018-025937 Zhang D, Unschuld PU (2008) China’s barefoot doctor: past, present, and future. Lancet 372 (9653):1865–1867. https://doi.org/10.1016/S0140-6736(08)61355-0

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Bobby Joseph and Sakthi Arasu

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthcare Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Workplace Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . People at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory Technicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nursing Aides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Housekeeping Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Computer Operators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cafeteria Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Behaviors of Healthcare Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoking and Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sickness Presenteeism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Government’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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B. Joseph (*) · S. Arasu Division of Occupational Health Services, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India e-mail: [email protected]; [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_111

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Orientation Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Changes in the Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tertiary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

In the current era where countries are working towards “Health for All” as a part of the Sustainable Developmental Goals, it is high time that due priority is given to the health of healthcare workers (HCWs) too. The HCWs are at risk for numerous occupational hazards ranging from infections, injuries, to stress and burnout. The workers at risk are not just doctors but also nurses, laboratory technicians and other paramedical workers, housekeeping staff, and miscellaneous staff. The busy schedule coupled with bad work hours lead to lesser physical activity, poor diet, and increased risk for many non-communicable diseases. The reluctance to seek medical care and the barriers in utilizing healthcare increases occupations risks accordingly. The way forward is prevention, and it involves health education of HCW, complete health checkups during the employment, and specific occupational health service units along with safety officers and administrative decisions to make the hospital a safe workplace environment. A good system of preventive strategies will help in improving the work-related health and quality of life of HCWs. Keywords

Occupational risk · Health promotion · Health care workers

Introduction The thought of Health for All and Universal Health Coverage is such a widespread concept due to the worldwide coverage of the Sustainable Developmental Goals (World Health Organization [WHO] 2018). Every government is working towards achieving this goal, and various policies and programs are in place to achieve the stated targets. To achieve this, adequate resources are required, men, materials, and money. Government policy takes care of money and materials. The human resource, that is, the healthcare workers, is the key resource to take the health to everyone in the country. The people working in the healthcare sector should be the healthiest members of the community, or at least that is the common belief around. Most of these HCWs have good knowledge of diseases and their risk factors, how to prevent them, and the ways of a healthy life. Added to this, they have the access of a healthcare facility at their disposal. But the infamous statement “Doctors are the worst patients” holds good not only for physicians but for every other employee in the healthcare sector.

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Healthcare Workers Healthcare workers are all people engaged in actions with the primary intent of enhancing health, including family caregivers, patient-provider partners, part-time workers, volunteers, and community workers (World Health Organization [WHO] 2006). The healthcare industry is the third largest workforce sector in the United States and also in most other countries (Emmett and Baetz 1987). The numbers are constantly increasing as more health facilities crop up, more people join the healthcare sector (Lewy 1987). These healthcare workers are perceived to be healthier than the general population because of their knowledge and experience, but this is not the reality. They are at risk of various health and safety hazards ranging from microorganisms to macro assaults and violence, physical hazards, and ergonomic issues. A healthcare worker is as much as at risk as a miner or a construction worker if not more. The care for healthcare workers (HCWs) is still an up and coming concept even though they belong to one of the most hazardous workforces in the world. The other edge of the sword is non-communicable diseases and most healthcare professionals do not practice what they preach. Mental health takes a toll with all the stress and tension of patient well-being, and many people resort to smoking and drinking to cope. They do not have time for a proper meal or sleep, let alone regular exercises.

History Galen the Greek physician (130–200 AD) had said, “The physician will hardly be thought very careful of the health of his patients, if he neglects his own.” History says that renowned physicians have often experimented on themselves for the greater good of medicine. Edward Jenner was known for his continued work with smallpox vaccination without any concern over his health (Riedel 2005). It is known that Jenner tried inoculating the vaccine on himself to see the results. The handwashing is such a common and important practice in medical field, and the person who gave up his life for this is Ignatius Semmelweis. Being a young physician, he discovered the possible spread of puerperal sepsis through the fingernails of medical students who attended dissection of cadavers and then proceeded to do deliveries. Since the awareness regarding contagious diseases was low, he was regarded as lunatic and was institutionalized for his suggestion that all doctors wash hands regularly.

Occupational Hazards An occupational hazard is defined as a risk accepted as a consequence of a particular occupation (Simpson and Weiner 2007). Occupational hazard can be defined (Rajan 2014) as the risk to the health of a person usually arising out of employment.

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It can also refer to work, material, substance, process, or situation that predisposes or itself causes accidents or disease at workplace. The different domains (Rajan 2013) of occupational risks are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Organization structure and policy Ergonomics Safety measures Resources Workload and work shifts Environment and hygiene Interruptions in work Patients and communications Training related

The risks in the healthcare sector for the various cadres of employees are manifold (Fig. 1).

Physical Health The health of the healthcare workers is subjected to various risks in the course of employment.

Physical Health • Physical factors • Chemical factors • Biological factors

Mental Health • Stress • Burnout • Job Satisfaction

Workplace Risks • Infections • Harassment • Accidents • Assaults Fig. 1 Classification of health hazards of HCWs

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Physical Factors The physical risks to the health of the HCWs ranges from excess heat or low light to radiation exposures (Gestal 1987). Light is an important factor in the healthcare facility be it for viewing X-ray images or identifying microorganisms using microscopes, and it plays a major role in the well-being of the patients. Crowded wards when not properly ventilated are a high risk for respiratory tract infections for staff working in these environments. The hospital is also prone for accidents, fire, explosions, and electrical accidents (Gestal 1987). Radiation exposure is a serious issue and duly noted by the authorities. The radiation exposure counter badges are provided for all the doctors and nurses working in the radiation zone. But these facilities often do not reach the low-level staffs in the hospital who are often illiterate and ignorant of the seriousness. Radiation exposure leads to cancers of thyroid gland, breast, skin, brain, and leukemia in healthcare workers (Parikh et al. 2017). Other ill effects include skin injuries, cataracts, and cardiovascular diseases (Parikh et al. 2017). When the type of work is not matched with the functional capacity of the employee, it results in various musculoskeletal disorders for the person and increases the risk of accidents and mistakes. Ergonomics is the concept to overcome this hurdle which is defined as the process of fitting the right man to the right job (Park 2019). It is the technology of work design based on the human biological sciences: anatomy, physiology, and psychology (Singleton 1972). This can be done either by adapting the work towards the capacity of the person by changing the design or increasing the working capacity of the employees by vocational trainings. The use of excessive force in lifting, pushing/pulling, awkward postures like bending, twisting, repetitive motions, vibrations, moving heavy objects, and transferring patients from bed to chair is the common ergonomic exposure in the healthcare facility. The risks are compounded by inadequate staff and longer shifts. Uses of computers and handheld devices among the surgeons, laboratory staff, radiologists, and administration staff and billing are at risk of static postures. The health effects of poor ergonomic exposure include fatigue, muscle pain, cramps, joint pain, clumsiness, tingling, lower back pain, Reynaud’s phenomenon, varicose vein, and burning sensations. Chemical Factors Surgeons in the operation theatres to housekeeping staff handling strong disinfectants are at risk of chemical exposure through inhalation or contact. Powdered gloves are potential hazard (Poole 1997) for causing contact dermatitis. The constant use of hand scrubs or sanitizers often cause more harm than good. The strong disinfectants used to scrub the floors or clean the wards are pungent and place strain on the respiratory tract. The common chemical hazards in a hospital are exposures to antineoplastic drugs, aerosolized medications, anesthetic gases, phenols, quaternary ammonium compounds, bleach, ethylene oxide, and formaldehyde, among others (CDC 2019; Barsan 2007). Surgical smoke from lasers and electrical cautery emit pungent gases which are harmful. These chemical agents are known to cause respiratory tract irritation and contact dermatitis and sometimes are a risk factor for malignancies.

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Table 1 Health hazards of commonly used chemicals in the hospital Chemical Detergents Alkaline agents Acids Solvents Disinfectants Preservatives

Health effect Skin, eyes, and nose irritation Skin, eyes, and nose irritation Skin, eyes, and nose irritation Neurotoxins Sensitization Sensitization

There are various chemicals used in hospital cleaning works which are a potential hazard to all the people exposed especially the HCW who are at constant risk. The housekeeping staff are at risk of skin issues when repeated and constant exposure to water (Zock 2005) (Table 1). The surgical gloves which are made of natural latex rubber (NLR) (Cullinan et al. 2003) are a potential allergen and when they are pre-powdered are high-risk chemical hazard via inhalation and contact. Also, when the gloves are dipped into corn starch to reduce the effect of NLR, it provides an ideal environment for bacterial growth. Even after the sterilization process, some of the gram-negative bacteria may persist. The other devices which contain NLR are catheters, electrode pads, shunts, surgical drains, stethoscope tubing, and tourniquets, among others. NLR allergies can be type 1 or type 4 reaction and includes conjunctivitis, rhinitis, asthma, anaphylaxis, and death. The contact dermatitis occurs as dry, itchy, scaly patches on the exposed areas.

Biological Factors Various biomedical wastes, contaminated medical wastes, and soiled dressings pose health threats to everyone concerned if proper protective measures are not taken. The World Health Organization (WHO) estimates that 16 billion injections are administered worldwide in a year, but not all of the needles and syringes are properly disposed of afterwards. Open burning and incineration of healthcare wastes can, under some circumstances, result in the emission of dioxins, furans, and particulate matter. The different health hazards, their causative agents and transmitting vehicle are given in Table 2 (World Health Organization [WHO] 1999). In a report published by the WHO, the disease burden caused by percutaneous sharps injuries among healthcare workers was found to be three million per year (World Health Organization [WHO] 1999). It is estimated that 40% of hepatitis B, 40% of hepatitis C, and 4% of HIV among healthcare workers were due to needlestick injuries (Watson 2004). Even though approximately 1000 healthcare workers die annually from occupational hepatitis B, almost 80% of healthcare workers remain unimmunized against hepatitis B (Nyman 1991). The risk of disease transmission for hepatitis C is much lower (2.7%), while the risk of HIV following a contaminated needlestick injury is very low (0.4%) due to fewer patients with free viral particles, which are usually very low in concentration.

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Table 2 Biological health hazards for healthcare workers Type of infection Gastroenteric infections

Ocular infection Genital infections

Causative agent Enterobacteria like Salmonella, Shigella; Vibrio cholerae; helminths Mycobacterium tuberculosis; Measles virus; Streptococcus pneumoniae Herpesvirus Neisseria gonorrhoeae; Herpesvirus

Skin infections Anthrax Meningitis

Streptococcus spp. Bacillus anthracis Neisseria meningitidis

Acquired immunodeficiency syndrome (AIDS) Hemorrhagic fevers

Human immunodeficiency virus (HIV)

Respiratory infections

Septicemia Bacteremia

Candidemia Viral hepatitis A Viral hepatitis B and C

Lassa, Ebola, and Marburg viruses

Staphylococcus species Coagulase-negative Staphylococcus spp.; Staphylococcus aureus; Enterobacter, Enterococcus, Klebsiella, and Streptococcus species Candida albicans Hepatitis A virus Hepatitis B and C viruses

Vehicle of transmission Faces and/or vomit Inhaled secretions; saliva Eye secretions Genital secretions Pus Skin secretions Cerebrospinal fluid Blood, sexual secretions All bloody products and secretions Blood Blood

Blood Feces Blood and body fluids

Mental Health Like any other profession, there is always the concern about mental well-being of the HCWs, but the added burden is contact with all the sufferings and struggles in the hospital on an everyday basis. Looking at these, every HCW is at risk of thinking about their own personal lives and tend to imagine the worst-case scenarios for their own ill health.

Stress and Burnout Stress experienced by the employees at workplace is called occupational stress. It may be psychological, emotional, social, or job-related. The element that causes stress reaction is called as stressor. Occupational stress is the experience of negative feelings, such as frustration, worry, and anxiety, perceived to arise from work-related factors (Kyriacou 2001). It is the body’s response to physical and mental demands or an interaction between environmental forces and events called stress precipitators, which appear threatening to the person’s reaction to the threat (Rogers et al. 1987).

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It is always difficult to design a fixed time schedule in a healthcare setting as anyone’s work timing can be increased in an emergency patient conditions. Combined with constant worry about patients’ parameters, the possible complications, the potential drug interactions, adverse reactions, and the looming dread on legal problems or violence, doctors are always on the edge during their duty hours which can span for 24 h or more. Nurses are burdened with the care and well-being of the patient apart from their medical duties. The housekeeping staff have to start their work before the outpatients start pouring in and sacrifice their sleep in doing so. Many of the young doctors are already stressed and on the verge of losing steam even before they hit the 40-year mark (Kumar 2016; Wu et al. 2008). HCWs are heavily invested in their work and related issues, so much so that they have little time and patience for everything else. Healthcare professionals also face significant emotional pressures within their work. Doctors may face difficult scenarios involving death and dying, complex psychosocial issues and emergencies. Many practitioners, particularly those involved in psychiatry, treatment of drug abuse, and those in general practice, may face risks of violence and therefore have concern for their personal safety. All medical practitioners face pressure to meet patient expectations and an ever-increasing concern over potential litigation. It has been found that time pressure to see patients was the most frequently cited stressor for general practitioners in Australia, while threat of litigation was rated as the most severe stress (Schattner 1998) (Table 3). The work-related stress also takes a toll on the physical health of the HCWs. It causes an increase in blood pressure leading to cardiovascular problems, gastritis, sickness, absenteeism, decreased vigilance at work, and also potential mistakes or accidents.

Job Satisfaction Many of the HCWs realize that serving people come at the cost of their personal lives and seek alternate fields like administration or think tanks. Doctors are no longer considered equal to Gods, and there is the increasing concern that it is no longer a thankful job. The same holds true for nurses who spend every minute of a patient’s Table 3 Causes of stress among doctors Most frequent stressors Time pressure to see patients Paperwork in general practice Phone interruptions during consultations Too much work to do in a limited time Intrusion of work on family life Patients who are difficult to manage Hours spent doing some visits Earning enough money in general practice Intrusion of work on social life Unrealistic community expectations

Most severe stressors Threat of litigation Too much work in limited time Earning enough money in the general practice Patients who are difficult to manage Paperwork Intrusion of work on family life Cost of practice overheads Time pressure to see patients Unrealistic community expectations Negative media comments

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stay in the hospital with them. Most of the HCWs are dissatisfied with their jobs owing to increased job stress, long work hours due to less manpower, and the various hazards that comes with the job (Khamisa et al. 2015; Krogstad et al. 2006).

Work-Related Quality of Life The mental health of the HCWs directly depends on how they feel about the life they have in their workplace. When they feel they are well treated, have a good work-life balance, have lesser stress, satisfied with their job and career progression, then they may consider themselves as leading a good quality of work life. The major reasons (Rajan 2013) for a poor work-related quality of life among all the healthcare workers are as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Rigid rules and supervision Long static postures Unsafe work environments Inadequate staff Long and unchanneled work shifts Inadequate space to work Pushed to do multiple things at once Time bound work and urgency Emotional patients

Suicide Risk The increasing levels of suicide risk among medical practitioners are both alarming and disturbing. Work stress, the constant on-the-edge life, the lack of support systems, and the denial about being depressed all contribute to this. There is an increased risk of death by suicide for doctors compared to the general population (Torre et al. 2005). The standardized mortality ratio (Balarajan 2016) of 1.72 from suicide among doctors in the United Kingdom which was almost twice that of the general population (Table 4).

Workplace Risks The hospital, nursing home, palliative care center, and a laboratory are the places where the HCWs spend most of the hours in a day, the place which is like a home outside home comes with various environmental and health risks.

Infections Nosocomial infections are the ones which the patient contracts in the hospital on exposure to the hospital environment. On this note, the people who work in these places for most of their lifetime have already donated some of their health for the greater good of patients. From various patient-related infections to the exposure to contaminated wastes, this spares no one from doctors to the housekeeping staff.

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Table 4 Standardised Mortality Ratios of Suicides among HCWs Professional role Doctors Dentists Pharmacists Opticians Nurses Radiographers Chiropodists Porters Ambulancemen Orderlies

Standardized mortality ratio 1.72 2.22 2.42 0.83 2.01 2.61 1.79 1.84 0.77 1.44

Harassment The health sector is full of hierarchy, and it is an essential part the training and learning of young healthcare professionals. However, sometimes the very same hierarchy comes with abuse, being taken for granted, and even personal violations. Bullying (Quine 2002; Yildirim 2009) is a common trend especially towards the junior doctors and nurses from their superiors and sometimes the patients also. This even escalates towards violence from the patient’s family when the dear one departs. Accidents The various accident risks in a healthcare facility are fires, explosions, electrocution, and gas leaks; undesired effects of electromagnetic fields, microwaves, lasers, and vibration; cuts, bruises, and fractures; asphyxia and burns; and the effects of noise (Gestal 1987). Laboratories are the place where most of the accidents happen due to the usage of various chemicals and electrical instruments. The operation theatre and the radiology departments are other places for potential accidents. Assaults The exposure to violence can be identified using the OSHA typology of violence (OSHA 2020; University of Iowa 2001) (Table 5). The HCWs are exposed to all four types but most commonly type 2. Aggressive behavior needs no stimulus, and some forms of aggression are triggered by external stimuli such as frustration. This occurs when the patient or the relatives consider the services from the health care facility unsatisfactory or when there are worse health consequences as a product of standard healthcare. The sources of the patient’s aggressive conduct may be classified in three categories: those arising in the context of his relationship with the doctor, those arising in his own family and working environment, and a residual group of other social sources (Gestal 1987). This culminates as physical assault on the HCWs, damage of property in the health facility, verbal abuses hurled at HCWs and their families. Most countries have reported the rising frequency of assaults on HCWs in recent times.

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Table 5 Types of violence the healthcare workers are exposed to Type 1

Category Criminal intent

2

Customer or client

3

Worker on worker

4

Personal relationship, partner, or domestic

Acts Violence as a result of criminal activity. Usually from a person who has no legitimate business reason for being in the facility Violence arising out of an interaction between the customer or client being served and staff providing the care Violence which occurs between two or more workers, (current or past) while on duty. Violence between individuals who have a personal relationship, at least one of whom is an individual who have a personal relationship, at least one of whom is an employee.

People at Risk The various cadres of HCWs in any settings are classified as follows (Fig. 2).

Doctors Doctors are the brains of any hospital. They are the lynchpin for the effective functioning of the healthcare machinery. They are also the most vulnerable in a hospital as they are always with the patients and doing invasive procedures. The primary concerns for any doctor are respiratory infections from tuberculosis to influenza as they come in close contact with patients. The other serious concerns are needlestick injuries or cuts from infected sharps which have the risks of hepatitis B and HIV (human immunodeficiency virus) (Wyżgowski et al. 2016). Doctors are known for their poorer habits, self-diagnosis, and self-prescription which are discussed later in this chapter.

Nurses When the doctors are the brains, the nurses are the heart of the hospital and provide the soul of the healthcare industry. They stay by the bedside of the patients all through the day and constantly tending to their needs. Apart from the risks of respiratory infections, needlestick injuries, and exhaustion, they also have the risk of being yelled at by the patients. The most common health problem among the nurses is musculoskeletal pains (Attar 2014) especially lower back pain followed by pain of the feet and shoulders. The main contributing factors (Freimann et al. 2013) are prolonged work hours and shifts, role conflicts, and emotional demands of the job. This is a universal health hazard (Munabi et al. 2014; Warnakulasuriya et al.

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Professionals • Doctors • Nurses Associates • Laboratory Technicians • Nursing Aides Others • Housekeeping staff • Students • Canteen Employees • Computer operators • Miscellaneous staff Fig. 2 Classification of healthcare workers

2012; Tinubu et al. 2010) among nurses and takes a toll on the physical and mental well-being of the nursing professionals. The stress among nurses (Cheung and Yip 2015; Smith and Yang 2017) are of a different nature and depends on the clinical speciality they work in. The various reasons, apart from patient-related issues, are the lack of personal time and being underpaid. The continuous worry about the patients and lack of work-life push many of nursing professionals towards depression. The reasons (Cheung and Yip 2016) includes job dissatisfaction, disharmony among the colleagues, and lack of adequate physical activity. All these combined have contributed (Han et al. 2016; Portela et al. 2015) to insomnia and associated sleep-related problems among the nurses.

Laboratory Technicians The laboratory technicians are the eyes of the healthcare sector and provide finer details for the doctors with regard to their patients. They physically handle a range of items from human specimens like blood, urine, cerebro-spinal fluids, serum, and sputum to various instruments like syringes, vacutainers, centrifuge, arterial blood gas machines, and computers. The various risks involved in the job includes needlestick injuries, standing for long hours, awkward bending of the neck while using the microscope, eye straining for focus, and sitting in an ungainly manner in front of computers and more. Added to this are the morbid patients, hurrying doctors, poor human resource management,

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over work, and longer shifts coupled with poor working conditions leading to a hazardous work environment. The common health conditions they experience are parasitic infections, viral infections like hepatitis B or HIV, anxiety, mental stress, depression and emotional disorder, upper respiratory tract problems, low back pain, headache, and body aches (Rajan 2014).

Nursing Aides They are the hands and legs of the hospital and are indispensable in ensuring that given processes and procedures happen in the facility. Most times they may not be aware of the condition of the patient, and the risk they pose to the safety of the aide. Also, the constant strain of pushing gurneys or lifting-shifting patients is never good for the back since most of the aides do not know the proper positioning and weight distribution for lifting patients. They are also responsible for preparing the patients for surgery and have to shave the surgical site – this is often done in a hurried way and sometimes without proper protective measures. They are also involved in carrying infectious samples like blood, serum, pus, and other fluids from the wards to the laboratory.

Housekeeping Staff The invisible workforce who keep the hospital spick and span are often overlooked when it comes to their health and safety. They are the ones who handle medical wastes, soiled linens, and other hazardous items in the health sector. In the event of a blood spill or vomit, the housekeeping staff have to be extra careful in cleaning it. The need for personal protection equipment is mandatory. The other housekeeping staff including the hospital laundry workers who take care of the soiled linen and the staff in the sterile supply department who take care of washing and sterilizing the surgical equipment are also at risk. Their low awareness regarding the hazards coupled with the lack of training by the management makes them very susceptible for infections.

Students The health sector always teems with students of all ages and faculties ranging from medical, nursing, laboratory sciences, or physiotherapy. Almost everyone is deployed into the wards with the patients as a part of their education. Most of the young professionals who are eager to learn forget the necessary precautions for their own safety. In addition, many of these younger professionals have poor nutrition, indulge in smoking or other forms of substance abuse, and are prone to selfprescription (van der Veer et al. 2011).

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Computer Operators Like any information technology sector employee, the computer operators of health sector also are at risk of back pain and other musculoskeletal problems, eye strain (Bhanderi et al. 2008; Blehm et al. 2005), and mental health issues (Blagojević et al. 2012). Added to this, the constant sitting with less activity for legs leads to venous stasis. These employees are overworked, with outdated technology and poor working conditions in terms of ergonomics. This sector is at high risk for obesity and cardiovascular diseases (Mvungi et al. 2009) due to their sedentary work style and increased stress.

Cafeteria Workers The feeding arm of all the people in the hospital from doctors to patients are important when it comes to health and prevention. They are at the perfect point of source for spread of most diseases as food is the perfect medium. They can spread infections ranging from typhoid, cholera, hepatitis A, or any other diarrheal disease (Assanasen and Bearman 2018). These people constantly work in extremes of temperature, humidity, constant noise level, and poor ventilation and lack of timely food. Added to this are poorer working equipment and bad management from the top (Bertin et al. 2009). The most common reason for health hazards due to cafeteria workers is lack of adequate and periodic training (Bertin et al. 2009).

Health Behaviors of Healthcare Workers Despite being educated on the good practices for better health and always advising the patients and public about this, most of the HCWs do not follow what they preach. From diet to exercise and avoidance of smoking or alcohol, many healthcare workers do not do this either due to lack of time, or in the latter case they use some of them as coping mechanisms for their stress. Some of the HCW do not eat on time or get enough sleep or spend enough time with their family members.

Diet Most HCWs do not get meal breaks on time because of the kind of work they do. Many of them skip their meals owing to surgery or rounds or just because a patient’s family kept them occupied. Some HCWs who follow a relatively strict meal schedule and who bring food from home are at comparatively lesser risks. Most others are dependent on cafeteria food and had to settle for whatever is on the menu whether it is healthy or not. The nurses often have their meals well past the usual times because of various patient needs or doctor rounds and consequently suffer from gastric/ duodenal ulcers (Triolo 1989).

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Even if many doctors eat responsibly with low salt, low calorie, and low cholesterol foods (Richards 1999), the same cannot be said about the other healthcare workers in a hospital (van der Veer et al. 2011). The conundrum is whether the hospital cafeteria should be providing healthier food for their employees, or it is the individual’s responsibility of choosing healthier foods. The HCWs are educated and aware about these and should choose wisely (Lesser and Lucan 2013).

Exercise The only physical activity most of the HCWs can afford to do in their busy schedules is the walking around the premises of the facility they work in. Many of HCWs are at risk of non-communicable diseases and borderline obesity. The doctors are the poorest when it comes to regular exercise, and hardly one tenth are involved in regular exercises (Chambers and Belcher 1993). On the other hand, the young doctors and medical students usually maintain a satisfactory level of physical exercise (van der Veer et al. 2011). This shows that the doctors lose their time and will to do physical exercises as they grow up and build their career. Obesity in healthcare workers (Bleich et al. 2014), especially doctors and nurses, is an alarming issue because when added to the prevailing stress and lack of physical activities, it can lead to higher risk of cardiovascular diseases.

Smoking and Alcohol HCWs especially doctors have a reputation for high alcohol consumption with 16% of them misusing it and almost 9% being dependent on alcohol (Rosta and Aasland 2013). The doctors who consume alcohol are biased when it comes to giving health advice to alcoholic patients (Bakhshi and While 2013). Almost 12% male and 5% female doctors have consumed more than 5 drinks a day in the past month on the days when they drink alcohol (Frank and Segura 2009). It was also found that the male healthcare workers drink more quantity and more frequently compared to their female counterparts (Rosta and Aasland 2013). The reasons are numerous, but the most commonly reported one is that this is a coping mechanism for the job-related stress (Voigt et al. 2009). The prevalence of alcoholism (Murray 1976) in HCWs admitted as patients was high with people in administration at 50% followed by general physicians at 37% and surgeons at 33%. The standardized mortality ratios for liver cirrhosis across all health professions studied is high, with the pharmacists having the highest SMR of 254 followed by porters at 232.

Sickness Presenteeism HCWs are likely to overwork, continue working while ill, and deny or minimize the symptoms and consequences of their illness. A report (Chambers and Belcher 1993)

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says that 75% of general practitioners took no sick leave compared to 41% of secondary school teachers. It is a known fact that doctors are less likely to report sickness or take shorter leaves owing to illnesses (McKevitt et al. 1997). Various reasons for sickness presenteeism – self-employment, lack of sickness insurance, and unwillingness to increase partners’ workloads – all lead HCWs to work through illness (McKevitt et al. 1997). Psychologically doctors report pressure to appear healthy for their patients, a strong sense of duty to their patients, difficulty in acknowledging illness and embarrassment at seeking independent medical advice (McKevitt et al. 1997). Healthcare access is difficult for the HCWs even though they are a part of one as they face various barriers in utilizing the health care services. Barriers faced by the HCWs include embarrassment to accept that they are ill, the time and cost involved, insurance coverage, personal attitude, and own medical knowledge. The doctors especially hide their illness from their peers and try to control their sickness; the societal pressure for the doctors should always be healthy and the tight schedule of the doctors with long hours, less personnel constitute the barriers (Kay et al. 2008). Also, the worry about the confidentiality, the quality of care they may receive, and the failed expectation to be treated like a normal patient adds to the hesitancy of doctors to seek medical care.

Self-Prescription Since doctors are very reluctant to seek medical advice and keep working even when being sick, they resort to self-medication to overcome this situation. Among doctors, the most commonly self-prescribed medicine are antibiotics, sleep medicines, nonsteroidal anti-inflammatory drugs (NSAIDS), non-narcotic analgesics and contraceptives, and rarely benzodiazepines (Richards 1999; Shadbolt 2002). The ready availability of medicines and the familiarity with the pharmacy system make doctors skip the part where they get themselves examined or seek medical advice. This habit of self-prescription leads to underestimating their illness and overlooking their health. The other reason for not visiting another doctor’s clinic for a checkup is the availability of corridor consultations.

Government’s Role Every government works hard for the betterment of its people, and the health benefits are the cornerstone in any policy. Universal health coverage and health insurance schemes for the people go a long way in achieving health for all in a country. But, when it comes to the health benefits for the HCWs in a country, the government is lagging in terms of policies and programs. There are rules and regulations for how a health facility should be, and these are focused towards the welfare of patients and only to some extent the employees.

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It begs the question of “who is responsible for the health of the healthcare workers?.” The probable answer should be themselves. Being well educated in the field of health and experienced enough through years of taking care of their patients, the HCWs are expected to lead a perfect life avoiding risks and diseases. Yet this is far from the truth and some of the responsibility falls on the healthcare facility they work in to provide necessary protection.

Prevention The familiar concept of prevention in occupational health can be grouped under the hierarchy of controls, namely, (from most effective to the least) elimination, substitution, engineering, administrative changes, and personal protective equipment. The best controls of all are eliminating the hazard altogether, but this is never easy in a healthcare setting. The process of substitution is possible when everything about safety and hygiene are considered. The engineering controls (Dinardi 2003) include enclosure, redesign, ventilation, and automation. When these three strategies are not possible, the onus is on controlling the hazard and risk reduction. This is done with the help of administrative decisions on training, limiting the exposures, changing the work practices, patient handling, violence, and stress. The need for adequate personnel and enough time allotted for each job will go a long way in preventing mistakes and accidents. The least effective control is the usage of personal protective equipment (PPE) like respirators, gloves, masks, earmuffs, and other protective gears. The use of PPEs are considered unreliable; they require special training and have an issue of inability to fit for some persons, not being completely fool proof and lack of compliance. Common regulations which must be implemented by the administration are: • • • • •

Consumption of food and water should be prohibited in areas of potential hazards. There should be written policies on safe operating procedures. Warnings signs and hazard zones are correctly labelled and signed. Annual inspection and maintenance of equipment. Periodic refresher trainings for personnel operating the machines.

Preventive measures or control strategies depend on the type of patients, treatment facilities, climate, natural resources, construction, among others. Tools that need to be made are injury and morbidity statistics among the employees, accident reports, insurance claim reports, injury data, safety checklists, surface monitoring, radiation dosimeters, and setting benchmarks for safety in the hospital. These should be formulated taking into account the feedback from the HCW themselves. In this chapter, the preventive measures are discussed under the three levels of prevention (Fig. 3) so that it is easier to plan preventive strategies based on the health hazard in question.

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Primary Prevention • Health Promotion • Specific Protection Secondary Prevention • Early Diagnosis and Treatment Tertiary Prevention • Disability Limitation • Rehabilitation Fig. 3 Level of prevention

Primary Prevention Health Promotion This includes the steps taken before the onset of the disease or injury. The health promotion part is discussed based on the different types of hazards in the healthcare facility. Control of Biological Hazards This includes a written guideline for exposure control, engineering controls like safer needles, sharps containers, use of PPE, vaccinating the employees, training on handwashing/safe handling, and post exposure protocols (Siegel et al. 2019). There should be needleless systems wherever possible and avoid sharp objects. Recapping of used needles should be strictly prohibited and should be destroyed using the needle destroyer. There are various substitutes like needle shields, selfblunting needle, and winged steel needle. Wherever possible, blunt tip suture needles (NIOSH 2008) can be used, and when there is absolute need for sharp suture needles, sutureless techniques should be considered. Sharp waste containers should be thick, puncture proof, leak proof, and filled with a sterilizing liquid. It is placed in all areas of sharp waste generation and placed conveniently for the ease of usage. PPE including masks, eye goggles, and face shields should be provided by the administration and train the employees to use them properly. There should be verbal instructions when passing sharps or use instruments for holding them. Hospital wastes can be infectious, hazardous, or both. Different countries have different written protocols for the disposal of these biomedical wastes. This involves four main aims (Rau et al. 2000): 1. Inactivate or destroy the pathogens 2. Destroy sharps

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3. Render waste unrecognizable 4. Reduce the volume of the waste The most commonly used method was incineration, but recently owing to the various complications of it, other procedures like autoclave and chemical disinfection are practiced. Wastes should be separated at the point of generation and should be appropriately labelled, and color-coded. This requires voracious training and orientation for all HCW, but this cuts down the cost of waste management (Lee et al. 2004). It is important to avoid hazardous wastes being wrongly treated as it leads to dangerous toxic liquids and gaseous emissions. Common hospital infections are prevented through contact precautions, use of PPE, (Hart and Complying 2011) hand hygiene, faster reports, and adequate training. The housekeeping staff should be oriented on cleaning the different infected body fluids, and they should be provided with adequate resources like neutralizing agent, disinfectant, and PPE. Judicious use of antibiotics helps in avoiding the drugresistant infective strains. The administrative measures are of paramount importance when it comes to the prevention of airborne infections in the healthcare setting. There should be a written infection control plan followed by environmental controls of LEV in the form of filtered booths for cough inducing procedures.

Control of Chemical Hazards Prevention of latex glove-related hazards is through substitution with non-NLR gloves made of vinyl or polymer and avoid powdered NLR gloves as much as possible. These substitutes should be made available, especially for those who are allergic to NLR (ACAAI 2020). Washing hands with soap and drying them well and avoiding oil-based creams before using NLR gloves should be advised. Spray cleaning should be replaced with wipes to reduce inhalation exposures. Substitution of ready to use cleaners for the ones that needs to be manually mixed, using machines to handle the mixing of chemicals, using strong chemicals only when absolutely necessary are vital (Blumberg 1961). Administrative control on the shift works and provision of PPE training are crucial. Surgical smoke (Alp et al. 2006) is an irritant to the eyes, nose, throat and contains inflammatory, carcinogenic, cytotoxic materials. This is mostly generated in operation theatres and those staff are at high risk of exposures. Engineering controls with LEV, smoke evacuators, suction devices should be installed. Mercury was a vital element in many of the medical instruments like thermometers and sphygmomanometers, but it is being phased out (Karliner et al. 2010) with the arrival of electronic substitutes. Mercury spills should be handled with extreme caution, and areas where mercury is used should be well ventilated with smooth surfaces to tackle the potential spills. It should never be vacuumed as it disperses mercury into the air. As the surgical NLR gloves do not offer complete protection, thicker nitryl gloves should be used for handling spills. The methyl methacrylate (MMA) is a common chemical present in dental and surgical cements (Borak et al. 2011). Exposure leads to irritation, tissue damage, asthma, dermatitis, dizziness, headaches, loss of appetite, and sleeplessness. The operation theatres and dental

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rooms should be equipped with vacuum exhausts or negative pressure hoods for mixing the surgical cements (Borak et al. 2011; Keene et al. 2011). Control of Ergonomic Hazards Computer usage (Andersen et al. 2009) should be equipped with back support, elbows, and knees at 90
, arm support, feet on floor, negative desks, and monitor at eye level. Recommended monitor height is 48–60 in., (ANSI/HFES 2007) and distance between the eyes and monitor should range between 28 and 36 in. (Jaschinski-Kruza 1991). Viewing angle should range between 10
and 30
. HCWs should have a dynamic workstation where the height, tilt, and supports are adjustable. Wherever required, a fully adjustable ergonomic chair should be provided. Commonly used instruments should be installed at reach especially in laboratory stations. Pipettes with neutral grip, easy eject pipette tips, ergonomic safety cabinets with reduced front grille, and non-glare glass and wells to hold the containers should be installed. Manual handling of patients while shifting them should be resorted only to life threatening situations (Nelson et al. 2006). Slide sheets with handles, powered lateral transfer devices, should be substituted for manual transfer of patients. A maximum of 71 kg is the limit for a four-person manual lateral transfer (Reynolds 2014). Control of Radiation Hazards The key to prevent radiation exposure is time, distance, and shielding. The HCWs working in radiation hazard areas should spend as less time possible, as far away and shielded with protection like lead, tungsten, or acrylic plastics. Dosimeters should be provided for all the HCWs encountering radiations, and these should be periodically checked. Training and orientation given for the non-medical HCWs regarding the hazards and importance of protection. Control of Workplace-Related Hazards There should be opportunity for the HCWs to spend their leisure time in a productive way like a gymnasium where they can exercise. Employee Assistance Programs should be established for staff as a part of the occupational health services. A separate staff welfare officer to take care of the issues and problems among the HCWs should be recruited and trained. There should be separate expert counsellors for taking care of the mental health of the HCW as they can guide in stress management. Provision of resting stations/duty rooms for the HCW and maintaining it well will go a long way in boosting the morale of the HCWs.

Shifts Most common problem for HCW is the long work shifts due to various reasons. This leads to irritation, stress, and mistakes and posts a burden on family relationships (ACEP 2020). There are no proper guidelines for shifts for HCW but the European Union Work Time Directive (2003) caps the maximum work as 48 h a week. The

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solution is through administrative control like forward rotating shifts, gradual shift changes, HCW participation in deciding the shifts, providing a dark, quiet room for sleeping. Using dark glasses during the commute home can help night workers achieve a better nights’ sleep (Sack et al. 2007; Lee et al. 2006).

Stress Elimination strategies include reorganization of work structure, review policies, provision of adequate staff and necessary resources, involve staff in decision making, and empower them to meet the demands of the job. Mitigation (Cox et al. 2004) involves breathing exercises, better sleep habits, good nutrition, physical exercise or sports, avoid negative coping mechanisms like drugs and alcohol and avoiding known stressors.

Violence The onus is on the administration to provide a safe environment for all HCW to work. Comprehensive risk assessment that develops mitigation strategies should be done with the HCW involvement. There are various laws in different countries which makes violence against HCW as a punishable offense. The administration strategies include better communication to patients regarding services and wait time; better department layouts and physical barriers; train the staff to identify and avoid escalation of a situation; meet the expectations of patients; and setting up of an emergency task force among the security personnel to intervene a violent situation.

Orientation Training The other part of prevention is educating HCWs especially nursing aides and housekeeping staff about potential hazards in their workplace and how to prevent them. This can be done in an orientation training where the people can also be made aware of the health checkups available for them. This training also provides the opportunity to generate awareness on the importance of personal protection equipment (PPE) like facemasks, gloves, and head caps and how to use them. Training exercises on ergonomics regarding bending, sitting and standing activities should be done. It should be accompanied with relaxation exercises such as breathing exercises and stretching exercises which can be done for neck, knee joints, hip joints, shoulder, elbow, wrist, and trunk. The health education about balanced diet such as importance of taking food in time and the side effects taking place unless the food is taken in time. Health education for the support staff like nursing aids and housekeeping should be a priority about the importance of hygiene and benefits of washing hands with soap and also the risks involved if not done properly.

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Changes in the Health Facility The hospital administration should take all possible steps to ensure the safety of their employees. The health facility should be made a safe environment in terms of secure workplace. It should start with the building structure and appropriate planning of each department of the hospital. The wards should be equipped with appropriate lighting and ventilation. All the wiring of the electrical appliances of the facility should be secured to prevent electrical shocks. A separate safety department under the division of occupational health services should be formed, and they will be responsible in making sure the work environment is safe. They should do periodic rounds and take necessary actions when any aberration is found. Appropriate designing will prevent trips, slips, and other accidents in a healthcare facility. Different areas of a hospital require a different type of flooring and use of friction tiles reduces the slips. The carpets should be nailed down and friction mats placed wherever necessary. The stairways and ramps should be installed with slip resistant coating, non-slip edges, appropriate signage, and disability friendly. The cables and wires should be placed under protective covers, avoid loose cords, and avoid wires across walk areas. Different areas of the hospital demand different levels of lighting and are beyond the scope of this chapter. The hospital should be spill proof with easy access to paper towels and pads, trashcans near water fountains, and using attention grabbing signages to point at areas with spills.

Ventilation This is the simplest and most commonly used engineering control for the prevention and control of infections in the hospital. The local exhaust ventilation (LEV) removes contaminated air from the point of origin. This can be installed in a laboratory or as a smoke evacuator in laser surgery. The American Society of Heating, Refrigerating and Air-Conditioning Engineering (ASHRAE) have formulated guidelines (Fig. 3) for the number of air changes per hour in various hospital premises (ASHRAE 2008; Adams et al. 2008) (Table 6). The hospital should be equipped with fire safety, fire hose network, and emergency exit plans. There should be provision of clean, safe drinking water, and round the clock electricity with backup. The canteen should be strictly adherent to cleanliness and hygiene in terms of food preparation, serving utensils, wash area, and the Table 6 Recommended number of air changes in hospital premises Premise Operation rooms Minor procedure rooms New-born intensive care Trauma room Endoscopy rooms

Minimum outdoor AC/Hr 4 3 2 3 2

Minimum total AC/Hr 20 15 6 15 15

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people involved. There should be regular and refresher trainings for all the employees in the healthcare sector. There should be signboards and labels for biomedical wastes or contaminated region. Whenever there is newer construction or a renovation is in progress, it is a good opportunity to make the building a safe one by proper planning and implementation. The NIOSH and American Society for Safety Engineers have put down guidelines called Prevention through Design (PtD) (NIOSH 2014).

Specific Protection It starts with the complete medical checkup when the HCWs starts work in a health facility. This includes a thorough history of all possible health ailments from allergies, habits, musculoskeletal pains and system-wise issues, viz., respiratory, digestive, central nervous, cardiovascular, and genitourinary systems. This is combined with a head to toe examination, checking vitals, and calculation of body mass index. HCWs are given appropriate health advice regarding lifestyle modifications. This checkup provides a wonderful opportunity to record the health data of an HCW for further references and find out any issues which can be addressed in the beginning itself. This also is the ideal time to check the vaccination status of the HCWs especially hepatitis B. This should be done for everyone working in the hospital from doctors, nurses to the data operators and clerks as anyone can encounter a sick person. After the vaccination schedule is completed, the antibody titers should be checked, and booster doses are given when the titers are less than 10 IU/dl. If the titers are negative, the whole vaccine schedule is repeated. Cafeteria workers deserve a special mention as they should receive a mandatory dose of typhoid vaccine and albendazole. There should be biannual stool examination for the cooks and food handlers. The laundry department employees and the housekeeping staff should receive the hepatitis B and tetanus toxoid vaccine as they are constantly coming in contact with infected materials. The housekeeping staff should not be overlooked regarding hepatitis B and tetanus toxoid vaccines.

Secondary Prevention Early Diagnosis and Treatment The setting up of a separate staff health services unit under the Department of Occupational Health is the first step towards taking care of the healthcare workers. This can be run as outpatient department inside the hospital, and doctors are posted on regular basis. The rationale behind setting such clinic is that this is a dedicated service for the HCWs and they can come in for consultation, treatment, and availing sick leaves. This clinic acts as a liaison between the staff and the various specialities in the hospital. They can refer patients in the situation of hospital-acquired infections, outbreaks like MRSA, electric shocks, injuries, chemical exposures, and also for occupational stress, depression, insomnia, and other job-related mental stressors.

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The data from the pre-placement examination is used as the baseline to assess the health of the HCW during the times of illnesses. The staff should have easier access to healthcare in the facility they work via concessions and reimbursements. Secondary prevention is done after the disease has occurred, and in this case after the exposure to one of the aforementioned hazards, the HCWs are oriented towards identifying their risk factors and symptoms of exposure so that they can seek medical advice from the staff clinic. The HCWs are promptly treated, advised rest, and also health education on how to improve their primary prevention. There should be standard protocols for post-exposure prophylaxis (PEP), methicillinresistant staphylococcus aureus (MRSA) exposure, influenza spreads, and similar outbreaks. The importance of secondary prevention is indispensable when it comes to HCWs because they are in constant contact with patients who may already be with weakened immunity. When the illness is diagnosed at the earliest, it facilitates prompt treatment so that there are no long-term effects and the HCW can return to work at the earliest. A healthcare facility with a good system of taking care of the HCWs will go a long way in improving their job satisfaction and attracting newer employees.

Tertiary Prevention This includes the steps taken to reduce the disability caused due to the different hazards and to make the HCW to return to work as soon as possible. The HCW may face many challenges when they return to work after a long period of sickness absenteeism like lack of self-confidence, disconnect from work, perceived loss of skills, and fitness issues. During the period of absence, the HCW has to go through isolation and lose connection with the work environment, sometimes leading to depression. The answer to these issues is the phased return to work in which the management makes a plan with reasonable adjustments. Their type of work, shifts, and work hours can be adjusted for the returning HCWs so that they ease into their work. The plan should also include for how long this change in work hours and wages for the HCW during this time. There should be support for the HCWs to figure out the challenges and obstacles they are facing on their return after sickness. There should be mandatory counselling sessions and proper physiotherapy (if required) follow-ups for the HCW to regain his abilities. It is mandatory to facilitate health insurance for the HCWs and their dependents so that out of pocket expenditure on health is less. In the recent times of modern medical care, the cost of healthcare is high even for the people working in there. The insurance combined with the benefits from the hospital they work, the HCWs can get quality medical care and rehabilitation services. They should also be provided with some part of the salary during their sickness absenteeism due to occupational hazard, full-fledged disability benefits of remuneration, physiotherapy, prosthesis, and vocational trainings.

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Conclusion The healthcare industry has its own share of risks and hazards, most of which are unique and dangerous compared to other sectors. The people involved are from various professions with different knowledge and understandings of occupational risks. The responsibility is on the management of the health facility to plan and implement a wholesome plan to promote and protect the health of HCW. The course of action should be primary prevention of all levels including specific interventions to prevent biological, chemical, and physical hazards through elimination, substitution, administrative controls, engineering methods, and PPE. Similarly, crucial is the awareness among policy makers about the plight of HCW so that appropriate steps can be implemented to ensure their safety, health, and quality of life.

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Part XIV Global Health Institutions and Organizations

Global Health Governance Institutions, Frameworks, and Interventions

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Mandate and Normative Authority of the World Health Organization . . . . . . . . . . . . . . . . . . . Institutional Norms and Norm Entrepreneurship: Locating the Linkages . . . . . . . . . . . . . . . . . . . . Case Study: International Health Regulations (IHR 2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study: Framework Convention on Tobacco Control (FCTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The evolution of international health cooperation through the nineteenth-century International Sanitary Conferences followed the trajectories of the classic Westphalian international system built on the architecture of primacy of nation-states in international relations. Applied to public health diplomacy, membership of multilateral health organizations like the World Health Organization is open only to states, and only state actors can become parties to multilateral health treaties, conventions and regulations negotiated under the auspices of those organizations. In an age of globalization of public health, global health governance has emerged as a key concept that captures the dynamic roles, interests, and diverse activities of multiple (states and nonstate) actors in global health. In an inter-dependent world, public health raises globalized challenges that require innovative governance approaches in the interactions of nation-states and nonstate actors. The transition from international to global health governance requires aligning the competing values, interests, and motivations of multiple actors towards a coherent cooperative governance framework that effectively addresses emerging and re-emerging global health challenges.

O. Aginam (*) Law and Legal Studies, Carleton University, Ottawa, ON, Canada © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_112

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Introduction The evolution of international health cooperation – public health diplomacy – through the nineteenth-century International Sanitary Conferences followed the trajectories of the classic Westphalian international system. (The Westphalian international system emerged from the Treaty of Westphalia 1648 that ended 30 years of war and conflict in Europe and led to the emergence of nation-states as the primary actors in international relations. Applied to public health diplomacy, membership of multilateral health organizations like the World Health Organization is open only to states, and only state actors can become parties to multilateral health treaties, conventions and regulations negotiated under the auspices of those organizations.) This classic inter-state system was based on a governance architecture dominated by nation-states as the major actors in international relations. In the first hundred years of international health cooperation starting with the first International Sanitary Conference in 1851, nation-states monopolized the governance framework for international health (Fidler 2001). The globalization of the world political economy, a process that integrates markets and services, intensifies transcontinental networks, and adds cognitive, temporal, and spatial dimensions to mutual interdependence of nations (Lee and Dodgson 2000), has transformed the governance architecture of global health. In an age of globalization of public health, global health governance has emerged as a key concept that captures the dynamic roles, interests, and diverse activities of multiple (states and nonstate) actors in global health. The “globalization of public health” refers to the cumulative impact of the cognitive, spatial, and temporal dimensions of global interdependence on public health across various regions and societies of the world. In the infectious disease context, the globalization of the world’s political economy creates opportunities for disease pathogens to travel transcontinental distances with the speed of a jet. On globalization of public health, see Lee and Dodgson (2000), Lee et al. (2002), Yach and Bettcher (1988, 1998), Brundtland (2001, 2003), Woodward et al. (2001), and Fidler (1997a, 2004).) In an inter-dependent world, public health raises globalized challenges that require innovative governance approaches in the interactions of nation-states and nonstate actors. At the global level, public health is now “comprised of numerous and varied actors with competing values, interests, and motivations” (Zacher and Keefe 2008. See generally, Cooper et al. (2007)). The transition from international to global health governance requires aligning the competing values, interests, and motivations of multiple actors towards a coherent cooperative governance framework that effectively addresses emerging and re-emerging global health challenges. This chapter explores these cooperative governance frameworks through the mandate of the World Health Organization.

The Mandate and Normative Authority of the World Health Organization The WHO was established on April 7, 1948, when its constitution adopted by the International Health Conference held in New York in July 1946 and signed by 61 representatives of the participating nation-states entered into force (World Health

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Organization 2001. See generally, Burci and Vignes (2004)). With 194 MemberStates, WHO is a specialized agency of the United Nations (“UN”) with a mandate, among 21 other functions, to “act as the directing and co-ordinating authority on international health work” (WHO Constitution, Art. 2(a-v)). As an intergovernmental organization, WHO’s normative and legal parameters are firmly rooted on a statecentric international system. (The membership of WHO is open only to nation-states. Article 3 of WHO Constitution provides that “membership in the Organization shall be open to all States.”) The WHO Constitution made provisions for the organization to use innovative instruments towards the evolution of ethical and legal norms – treaties, legally binding regulations, and nonlegally binding declarations (soft-law) to pursue its public health mandate. Despite well-founded criticisms that WHO did not fully utilize these legal mechanisms in most of its six decades of existence, there was a significant improvement in the use of legal instruments with two landmark events in 2005: the adoption of the International Health Regulations (“IHR 2005”), and the entry into force of the WHO Framework Convention on Tobacco Control (“WHO FCTC”) in 2005. The legal and normative authority of the WHO falls into three categories: (i) treaty-making powers analogous to the conventional practice of treaty negotiation, adoption, and ratification by states in international law, (ii) the authority to adopt legally binding regulations analogous to legislative or quasi-legislative process in domestic law, and (iii) the authority to adopt nonbinding recommendations analogous to “soft-law” in international law. WHO’s conventional treaty-making authority – very similar to that of most multilateral institutions in the international system – is covered by Article 19 of its Constitution that provides as follows: [T]he Health Assembly shall have the authority to adopt conventions or agreements with respect to any matter within the competence of the Organization. A two-thirds vote of the Health Assembly shall be required for the adoption of such conventions or agreements, which shall come into force for each Member when accepted by it in accordance with its constitutional processes. (WHO Constitution, Art. 19)

Although Article 19 is a conventional treaty-making authority that most international organizations derive expressly from their constitutions, charters, or other constituent instruments, in the case of WHO, some scholars argue that when combined with WHO’s ambitious objective of “the attainment by all peoples of the highest possible level of health,” and WHO’s equally ambitious definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO Constitution, Preamble), Article 19 provides the Organization with virtually limitless treaty-making power that surpasses any treaty powers possessed by the WHO’s precursors: the Pan American Sanitary Bureau, the International Office of Public Health, and the Health Organization of the League of Nations. (David P. Fidler was the leading exponent of this argument in the late 1990s. See Fidler (1998) (arguing that “the WHO is facing an international legal tsunami that will require a sea change in its attitude towards international law. WHO’s lack of interest in international law does not reflect the historical experience

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of states and international health organizations prior to World War II. While WHO has been accused of focusing too little on international law, international relations prior to World War II were plagued by too much international health law).) Article 21 of the WHO Constitution authorizes the World Health Assembly (WHO’s highest policy making organ) to adopt legally binding regulations concerning: (a) Sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease (b) Nomenclatures with respect to diseases, cause of death, and public health practices (c) Standards with respect to diagnostic procedures for international use (d) Standards with respect to the safety, purity, and potency of biological, pharmaceutical, and similar products moving in international commerce (e) Advertizing and labeling of biological, pharmaceutical, and similar products moving in international commerce (WHO Constitution, Art. 21) Regulations adopted by the Assembly under Article 21 are legally binding on all WHO Member States except for those that invoke the “contracting out” procedure in Article 22 of the Constitution. Such Regulations shall come into force for all WHO Member States after due notice has been given of their adoption by the Health Assembly except for such Members as may notify the WHO Director-General of a rejection or reservation(s) within the period specified in the notice. Articles 21 and 22 of the WHO Constitution have been described as creating a quasi-legislative procedure that constituted a radical departure from the conventional international treaty making practice in the late 1940s when WHO was established. (Sharpe 1947. For a study of international legislative process of international organizations “by which an increasingly substantial amount of international law is steadily being created,” see Szasz (2001) and Kwakwa (2002).) Article 23 of the WHO Constitution gives the World Health Assembly the authority to adopt nonlegally binding resolutions (soft-law) with respect to any matter within the competence of the organization. Although soft-law instruments like recommendations and declarations are not automatically legally-binding, international law scholars agree that such instruments have nonetheless catalyzed the evolution of rules of international law (see Paul C. Szasz, Selected Essays, Ibid pp. 26–27 citing Gruchall-Hesierski (1984) and Chinkin (1989).). Soft law instruments “operate in a grey zone between law and politics” (Malanczuk 1997) and are considered a special characteristic of international law especially on emerging economic and environmental issues (Ibid). In sum, the legal and normative authorities of the WHO fall within the three categories of conventional treaty-making authority (Art. 19–20), regulatory authority (Art. 21–22), and nonbinding soft-law authority (Art. 23). The WHO has historically been dominated by medical and public health experts – physicians and epidemiologists. In the first five decades of its existence (1948– 1998), WHO did not significantly elaborate legal norms in the pursuit of its mandate.

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In the 1990s, WHO’s under-utilization of its enormous legal and normative authority became the subject of intense debate by (international) legal scholars. Tomasevski (1995, pp. 859 at 859 (strongly critiquing WHO’s overt bias in favor of non-binding and non-legal norms built upon ethical rather than legal principles. Also observing that an important reason for WHO’s bias for non-binding rules is the traditional reluctance of the medical profession to submit itself to the rule of law. Beginning in the eighteenth century, medical associations developed codes of professional behavior. Self-regulation presumes the exclusion of lay persons, thus reinforcing the traditional paternalism of the medical profession, dating back to the Hippocratic Oath: the assumption that whatever a physician decides is, by definition, correct)), Taylor (1992), and Fidler (1998) – all international legal scholars – criticized the increased “medicalization” of WHO as a result of the organization’s reluctance to use international legal mechanisms in its work. According to Fidler: WHO was isolated from general developments concerning international law in the post-1945 period. This isolation was not accidental but reflected a particular outlook on the formulation and implementation of international health policy. WHO operated as if it were not subject to the normal dynamics of the anarchical society; rather, it acted as if it were at the center of a transnational Hippocratic society made up of physicians, medical scientists, and public health experts. The nature of this transnational Hippocratic society led WHO to approach international public health without a legal strategy. (Fidler 1999a)

Similarly Taylor observed that: WHO’s traditional reluctance to utilize law and legal institutions to facilitate its health strategies is largely attributable to the internal dynamics and politics of the organization itself. In particular, this unwillingness stems, in large part, from the organizational culture established by the conservative medical professional community that dominates the institution. (Taylor 1992, p 303. For a discussion of this theme in other seminal writings, see Fidler (1997b, 1999b), Aginam (2005), Lakin (1997), and L’hirondel and Yach (1998))

WHO’s “medical” approach is understandably influenced by the giant strides made by science in proving the germ theory correct. Once physicians and epidemiologists understood how humans were infected by disease, they automatically turned to diagnosis and healing, and not to international legal norms for solutions. International legal scholars who are critical of WHO’s nonlegal approaches to global health work recognize this viewpoint. As Fidler observed: The common argument used to explain WHO’s antipathy towards international law is that WHO is dominated almost exclusively by people trained in public health and medicine, which produces an ethos that looks at global health problems as medical-technical issues to be resolved by the application of the healing arts. The medical-technical approach does not need international law because the approach mandates application of the medical and technical resource or answer directly at the national or local level. (Fidler 1998, p. 1099)

Although science arguably catalyzed the development of international health law in the 1890s because it provided the breakthrough needed to facilitate agreement by nation-states on common rules and values codified in the International Sanitary

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Conventions (for a discussion of the science and politics of the international sanitary conferences in the nineteenth century, see Howard-Jones (1975), Goodman (1977), Fidler (1999b, 2001), and Aginam (2005)), the antibiotic revolution in the contemporary ear – driven by the germ theory – impeded the sustained deployment of international legal strategies by WHO because doctors and public health officials go directly after pathogenic microbes rather than seek recourse to legal norms, treaties, and regulatory regimes as effective tools in solving medical and health problems. Situating this discourse in the post-1945 world order, the international system has undergone significant and dynamic transformation. The expansive definition of health in the WHO Constitution as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” meant that the necessary linkages must be drawn between public health, and poverty, underdevelopment, human rights, food (in)security, food safety, climatic and related environmental changes, natural disasters, wars and the use of weapons of mass destruction, international trade agreements, and other multifaceted dimensions of the phenomenon of globalization. On almost all of these issues, legal and ethical norms are relevant and important tools in the mandate and work of international organizations. In retrospect, the post-1945 decades since the establishment of the United Nations have witnessed the evolution of international legal norms on human rights (including the right to health), global environmental issues (multilateral environmental agreements), international humanitarian laws, food and agriculture, and trade-related health concerns among many others (see generally, Fidler (1999b) and Aginam (2005)). The WHO, largely due to the “medicalization” of its public health mandate, missed out on most of these normative developments.

Institutional Norms and Norm Entrepreneurship: Locating the Linkages In the theory and politics of international relations, “norms” are generally understood as a “standard for appropriate behavior for actors with a given identity” (see Finnemore and Sikkink (1998) at 891 citing Finnemore (1996), Katzenstein (1996) and Klotz (1995)). Norm entrepreneurs are individuals, NGOs, states, or international organizations which actively promote a norm and seek their acceptance by all the relevant actors, especially nation-states. Although the categories of norms differ across disciplines, “the most common distinction is between regulative norms, which order and constrain behavior, and constitutive norms, which create new actors, interests, or categories of action” (Finnemore and Sikkink (1998), p. 891 citing Ruggie (1998)). Finnemore and Sikkink identified the three stages in a norm’s life cycle as: norm emergence, norm acceptance (“norm cascade”), and norm internalization (Finnemore and Sikkink, p. 895). Of the three stages of a norm’s cycle, norm entrepreneurs play a critically important role in the first stage – norm emergence – through persuasion when they “attempt to convince a critical mass of states (norm leaders) to embrace new norms” (Ibid). There are two preconditions for a norm to successfully emerge: norm entrepreneurs (agents with strong notions

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about appropriate or desirable behavior in their community) and organizational platforms (a platform at the international level for norm promoters to promote their norms). While individuals – as in the widely cited case of Swiss national Henry Dunant and the norms of international humanitarian laws – are often credited with norm entrepreneurship, modern-day norm entrepreneurs would most likely work within the confines of an international organization to facilitate norm emergence. As Finnemore and Sikkink observed: [O]ne prominent feature of modern organizations and an important source of influence for international organizations in particular is their use of expertise and information to change the behavior of other actors. Expertise, in turn, usually resides in professionals, and a number of empirical studies document the ways that professional training of bureaucrats in these organizations helps or blocks the promotion of new norms within standing organizations (Finnemore and Sikkink, p. 899).

Relating this to WHO’s role as either a norm entrepreneur or organizational platform for the promotion of legal and ethical norms, WHO – in over 60 years of its existence – is known to have adopted only two legally binding normative instruments: the International Health Regulations (IHR) and the Framework Convention on Tobacco Control (FCTC).

Case Study: International Health Regulations (IHR 2005) The IHR (then known as “International Sanitary Regulations”) was adopted by WHO in 1951 pursuant to Article 21 of its constitution. WHO renamed the regulations the “International Health Regulations” in 1969 and slightly modified them twice in 1973 and 1981. The IHR represent one of the earliest legally binding regulatory tools for global control of certain infectious diseases. As of 1997, the IHR were legally binding on virtually all of the WHO’s Member-states. The IHR are a regulatory surveillance mechanism for the sharing of epidemiological information on the trans-boundary spread of three infectious diseases: cholera, plague, and yellow fever. The fundamental principle of the IHR was to ensure “maximum security against the international spread of diseases with a minimum interference with world traffic.” To achieve this purpose, the IHR provided for binding obligations on WHO Member States to notify the Organization of any outbreaks of cholera, plague, and yellow fever in their territories. Notifications sent by a Member State to the WHO are transmitted to all the other Member States with acceptable public health measures to respond to such outbreaks. The IHR lists maximum public health measures applicable during outbreaks and provides for rules applicable to international traffic and travel. These measures, among others, largely covered the requirements of health and vaccination certificates for travelers from areas infected by these three diseases to noninfected areas as well as detailed health measures at airports and seaports in the territories of the WHO Member-states. Measures listed in the IHR are the maximum measures allowed in

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outbreak situations aimed to protect the country that suffers an outbreak against the risk of overreaction and unnecessary embargoes, which could be imposed by contiguous neighbors, trading partners, and other countries. These embargoes are often damaging economically, with severe consequences on tourism, traffic, and trade. By the 1990s, it became evident that the IHR has been unsuccessful as a global health regulatory tool. Chief among the reasons for IHR’s ineffectiveness was the fear by countries experiencing an outbreak of disease, specifically, the potential for other nations to take excessive measures if an outbreak is reported to the WHO. Examples of these include the cholera epidemics in South America – first reported in Peru in 1991, which were estimated to have cost over $700 million in trade and other losses, and the 1994 plague outbreak in India that led to $1.7 billion losses in trade, tourism, and travel as a result of excessive embargoes and restriction imposed upon India by other countries. (Taylor 1997 (stating that in the case of plague outbreak in India, such excessive measures included closing of airports to aircraft that were arriving from India, barriers to importation of foodstuffs, and in many cases the return of Indian guest workers even though many of them had not lived in India for several years); Garret 1996 (stating that India lost almost two billion dollars as result of excessive measures following the plague outbreak).) The economic cost of disease outbreaks that are not subject to reporting obligations under the IHR was high. The outbreak of SARS, which first emerged in Southern China and spread rapidly to other countries, was reported to have “rocked Asian markets, ruined the tourist trade of an entire region, nearly bankrupted airlines, and spread panic through some of the world’s largest countries” (The Truth about SARS 2003). In Canada, the economic cost of the SARS outbreak was estimated at 30 million dollars daily. It was estimated that China and South Korea each suffered two billion dollars in SARS-related tourism and other economic losses. Visitor arrivals dropped drastically in Singapore, while Hong Kong carrier Cathay Pacific cut its weekly flights by 45% (Ibid). Apart from the likely economic embargoes, other reasons often cited for the ineffectiveness of the IHR include the WHO’s relative inexperience in the creation and enforcement of norms and legal regimes, the IHR’s inability to adapt to changing circumstances in international traffic, trade and public health, and the IHR’s limited coverage of only three diseases. As the IHR had become ineffective, the 48th World Health Assembly – in May 1995 – passed a resolution calling on the Director-General of the WHO to start a process of IHR revision. Pursuant to this resolution, the WHO held an informal consultation of experts on IHR revision in December 1995 (WHO 1995). The expert group proposed a range of amendments to the IHR, and in February 1998, the WHO circulated a provisional draft of the revised IHR to Member States. The major amendments proposed by the consultation of experts focused on the expansion of diseases subject to the regulations beyond plague, yellow fever, and cholera to include immediate reporting of defined disease syndromes of urgent international importance as well as epidemiological information for their emergence, prevalence, and control, and WHO’s power to request information from Member States based on information the WHO received from other reliable sources: the WHO Collaborating Centers, nongovernmental organizations, mass media, other international organizations, and other nonmember states. Previously, the WHO never had this power; it

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simply waited for a Member State to notify it of an outbreak. The rationale behind this proposal is that few, if any, disease outbreaks can be hidden due to extensive global media networks. Innovations in communications technology have rendered state sovereignty irrelevant in disease outbreaks. Independent global outbreak monitoring sources now abound. Examples of these include the Global Public Health Information Network (“GPHIN”), an electronic surveillance system developed by Health Canada; Pro-MED, a private initiative of the Federation of American Scientists’ Program for Monitoring Emergent Infectious Diseases that creates a global system of early detection and response to disease outbreaks; and PACNET, an internet-based information provider on disease outbreaks in the Pacific region. The implication of these innovations is that disease outbreaks can no longer be hidden under the veil of state sovereignty. The new (revised) International Health Regulations (2005) officially entered into force on June 15, 2007, as a normative tool for global disease outbreak control. The emergence of IHR 2005 was largely catalyzed by the outbreak and global spread of a new deadly and terrifying infectious disease – Severe Acute Respiratory Syndrome (SARS). The provisions of IHR 2005 have been described as innovative (Fidler 2005; Baker and Fidler 2006; Lo 2010).

Case Study: Framework Convention on Tobacco Control (FCTC) The WHO Framework Convention on Tobacco Control (“FCTC”) directly implicates WHO as a norm entrepreneur in global health governance. In May 1999, the World Health Assembly adopted (by consensus) Resolution WHA52.18 urging the Director-General of WHO to start a process of multilateral negotiations for the FCTC (World Health Assembly, Resolution WHA52.18 1999). The FCTC negotiation process was WHO’s first experience to use its treaty-making authority under Article 19 of its Constitution. As a governance/regulatory tool, FCTC was based on the evidence that tobacco use is one of the leading causes of preventable deaths and a leading contributor to burdens of disease globally (Murray and Lopez 1996, 1997). There are over one billion smokers in the world, and it was then estimated that about four million people die yearly from tobacco-related diseases. Although tobacco use is a leading cause of premature death in industrialized countries, the epidemic of tobacco addiction, disease, and death was rapidly shifting to developing countries. (Ibid. See also Taylor (1996) (stating that the absence of effective domestic regulation of tobacco in developing countries has created a lucrative opportunity for transnational tobacco companies to target such countries. In many of the poorer states, aggressive tobacco promotion by the tobacco industry and Western states simply overwhelms underfunded national tobacco control efforts).) Powerful and influential tobacco multinationals targeted growing markets in Latin America in the 1960s, the newly industrialized economies of Asia (Japan, The Republic of Korea, Taiwan, and Thailand) in the 1980s, and women and young persons in Africa in the 1990s (Connoly 1992). Tobacco use is medically associated with a range diseases and fatal health conditions including lung and bladder cancers, heart diseases, bronchitis and emphysema, and increased antenatal and prenatal mortality.

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In May 1999, the World Health Assembly established a working group to analyze potential elements to be included in the tobacco treaty, and an Inter-Governmental Negotiating Body (open to WHO’s 191 Member States) to negotiate and draft the proposed WHO Framework Convention on Tobacco Control and related protocols. The Tobacco Free Initiative of the WHO prepared background documents for the working group enumerating possible elements to be covered by the Framework Convention and other elements of subsequent protocols. Draft elements of the Framework Convention included preamble, principles and objectives, obligations, institutions, implementation mechanisms, law making processes, and final clauses (signatories, reservations, ratification, and withdrawal). Potential elements for subsequent related protocols include: cigarette prices and harmonization of taxes, measures against smuggling, duty-free tobacco products, tobacco advertising and sponsorship, reporting of toxic constituents of tobacco products, packaging and labeling, tobacco, and agricultural policy, sharing of information. The FCTC negotiating process went through different phases: Working Groups (1999–2000); Public Hearings (2000); and Intergovernmental Negotiating Body Sessions (2000–2003). The Intergovernmental Negotiating Body (INB) on the WHO FCTC finalized its work on the first public health treaty under the auspices of the World Health Organization in February 2003. The WHO FCTC was adopted by the 56th World Health Assembly in May 2003 and was open for signature until June 29, 2004. The FCTC was signed by 168 States during this period expressing their willingness to subsequently become a Party to the Convention. In accordance with Article 36 of the WHO FCTC, the Convention entered into force on February 27, 2005, 90 days after the fortieth State had acceded to, ratified, accepted, or approved it (Parties to the WHO Framework Convention on Tobacco Control, http://www.who. int/fctc/signatories_parties/en/index.html). With over 170 State-Parties, the FCTC has been widely accepted by WHO member-states within a relatively short period. Regular sessions of the Conference of the Parties (“COP”) to WHO FCTC are held every 2 years. The WHO FCTC authorizes the COP to adopt Protocols to the Convention (Article 33 WHO FCTC). After 4 years of negotiations, the first Protocol to the WHO FCTC – “Protocol to Eliminate Illicit Trade in Tobacco Products” was adopted by the Parties to the FCTC at the fifth session of the COP on November 12, 2012. As WHO Member-states continue to accept the WHO FCTC and its protocol(s), internalizing the terms of the Convention in the legislative, legal, institutional, and policy frameworks of these states in the years ahead will likely raise serious trade and investment questions especially for developing and least-developed countries where tobacco conglomerates exert influence and continue to exploit the prevailing poverty and underdevelopment to their advantage. The WHO should devise effective policy strategies to counter this.

Conclusion As an international organization, WHO’s role and relevance as the “directing and coordinating authority on international health work” has been challenged in complex ways by the dynamics of the globalization of public health. While the

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organization remains essentially an inter-governmental institution with membership exclusively composed of nation-states, the trends, realities, and dynamics of the phenomenon of globalization have proven that the emerging and re-emerging medical and public health issues defy the territorial boundaries of individual nation-states. As such, WHO has to device innovative normative (legal and ethical) strategies and tools to tackle these issues. Economic globalization has globalized communicable and noncommunicable diseases and related medical and public health threats. The globalization of public health has led to the concept of “global health governance” that looks beyond state-centrism to identify the emerging and other relevant nonstate actors and stakeholders in the global health arena. The relevance of legal and ethical norms in the relationship between WHO as an international organization and these emerging actors whether in terms of the proliferating public-private partnerships or other networks is both intriguing and complex. However, most scholars agree that innovations are needed. As Cooper, Kirton, and Schrecker observed: These innovations will need to come in the realm of ideas, as the prevailing principles and norms that guide global health governance are redefined and reinvented for a comprehensively and instantaneously interconnected, complex world. They will be needed in the realm of institutions, where new rules, decision-making procedures, resources, and participants are required if the expectations and behavior of the world’s countries and citizens are to converge on the reality, rather than just the ideal, of health for all. In both cases, the still dominant Westphalian model – now almost half a millennium old – of sovereign territorial states engaging in limited international cooperation for particular purposes is fast approaching the end of its useful life. (Cooper et al. 2007, p. 4)

Looking beyond the Westphalian (state-centric model), the successor system will be carefully crafted to accommodate all the emergent relevant actors and stakeholders. According to Cooper, Kirton, and Schrecker: Designing, developing and delivering the successor system will require the talents of many from national and sub-national governments, international institutions, healthcare professionals, philanthropists, the private sector, local communities, nongovernmental organizations (NGOs), faith groups, committed groups and victims from around the world. (Ibid)

In both the contemporary (dominant) state-centric model, and the imagined successor system with multiple actors and stakeholders, WHO, as an intergovernmental organization, will continue to play some key role in the elaboration of legal and ethical norms. However, the effectiveness of WHO as a norm entrepreneur would largely depend on how the Organization manages the two inter-linked challenges of: (i) innovatively deploying its legal and constitutional authorities to initiate new norms in a dynamic international/global system and (ii) crafting a symbiotic and cooperative relationship with the new (nonstate) actors in the global health arena. These two inter-linked challenges are critically important for WHO’s continued relevance and legitimacy as a norm entrepreneur for emerging and re-emerging medical and public health issues. To effectively address these challenges, WHO has to collaborate with the other relevant international organizations within and outside the United Nations system whose mandates touch on public

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health: the Food and Agriculture of the UN (FAO), the World Trade Organization (WTO), World Organization for Animal Health, and others.

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Vijay Kumar Chattu and Garry Aslanyan

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The High-Level Global Commitment for Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evidence-Based Policy and Translation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Objectives of Global Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classifications of Global Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Global Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GHPs and the UK’s Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GHPs Impact on Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GHPs and Their Impact on Global Health Training and Research . . . . . . . . . . . . . . . . . . . . . . . . GHPs and Their Added Value to Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Governance Organizations and Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Governance (GHG) Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stakeholders of GHG Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification of Stakeholders in GHG and Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Governance of Global Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Governance for Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Governance Models in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Partnerships for Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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V. K. Chattu Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada Institute of International Relations, The University of the West Indies, St. Augustine, Trinidad and Tobago e-mail: [email protected] G. Aslanyan (*) Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization (WHO), Geneva, Switzerland Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_113

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Knowledge Management and Translation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multilateral and UN System Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coalitions and Multifaceted Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Targeted and Fact-Finding Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The partnerships for sustainable development are voluntarily undertaken by governments, intergovernmental organizations, nongovernmental organizations, and other stakeholders to achieve the United Nations (UN) Sustainable Development Goals (SDGs) by 2030. Building and strengthening partnerships for global health is the key strategy in order to achieve the SDGs as the thematic areas such as water, energy, climate, oceans, urbanization, transport, science and technology are all interrelated. The main objectives of global health partnerships (GHPs) are to develop a clear strategy, build a consensus and to coordinate all the efforts of all the stakeholders. This chapter addresses the critical importance of GHPs and their added value and future challenges in five sections. Section “Introduction” includes an introduction to the UN-SDG-17 on partnerships and on evidencebased policy and translation. Section “Global Health Partnerships” discusses why we need GHP, their importance and summarizes the typology of GHPs. Section “Global Health Governance Organizations and Partnerships” provides a comprehensive outline about the notion of Global Health Governance, the paradigm of Global Health Diplomacy and emergence of new public-private partnerships. Section “Knowledge Management and Translation” includes knowledge management and translation aspects and shares some successful models, before concluding with recommendations for multilateral arrangements and mechanisms allowing GHP to effectively respond to pressing global health treats and risks, and to pave the way forward to global health equity. Keywords

Partnerships · Global health governance · Global health diplomacy · Sustainable development · Multilateralism

Introduction In 2015, when the governments of all the nations adopted the United Nations (UN) Sustainable Development Goals (SDGs), they have in fact agreed to more than the agenda for 2030 (UNDESA 2015). In fact, this summit has opened the door for a new form of global governance which includes multistakeholder initiatives, public private partnerships civil society cross sector collaborations, and of course the private sector which place a major role in many countries and even at global level. Therefore, it was emphasized in this context that governance is a collective action to provide public goods to set and implement rules and manage externalities and no

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longer that’s something governments do exclusively but involves various other nonstate actors working with or governing without governments (Florini and Pauli 2018). According to the UN, “partnerships are voluntary and collaborative relationships between various parties, both public and nonpublic, in which all participants agree to work together to achieve a common purpose or undertake a specific task and, as mutually agreed, to share risks and responsibilities, resources and benefits” (UNDESA 2015). As part of the 2030 agenda the countries and the other stakeholders have agreed to eradicate poverty in all its forms and dimensions which is a global challenge and strengthen universal peace in larger freedom through collaborative partnership. Therefore, the sustainable development in all its three dimensions, namely, the economic social and environmental can only be achieved with stronger partnerships that value the principles of human rights, gender equality, and empowerment of women and girls.

The High-Level Global Commitment for Partnerships The achievement of 2030 agenda of SDG’s will require different sectors and various actors working together in an integrated manner as a comprehensive approach by pooling financial resources, knowledge, and expertise. These partnerships for sustainable development are voluntarily undertaken by governments, intergovernmental organizations, major groups, and other stakeholders who are contributing to the agreed development goals and commitments as included in agenda 21, the Johannesburg plan of implementation, The Millennium declaration, the outcome document of the Rio + 20 entitled “the future we want,” the third international conference on Small Island Developing States (SIDS), and the 2030 agenda for sustainable development (Atkisson 2015). The UN SDG specific for partnerships is Goal 17, which states “Strengthen the means of implementation and revitalize the global partnership for sustainable development” which recognizes multistakeholder partnerships as important vehicles for mobilizing and sharing knowledge, expertise, technologies, and financial resources to achieve these goals in all countries particularly in the developing countries. The goal further seeks to encourage and promote effective public, public private, and civil society partnerships, building on the experience and resourcing strategies of partnerships. Under the subhead of multistakeholder partnerships is SDG 17 has two targets: 17.16: Enhance the global partnership for sustainable development, complemented by multi stakeholder partnerships that mobilize and share knowledge expertise technology and financial resources to support the achievement of SDG’s in all countries, in particular developing countries. 17.17: Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resource strategies of partnerships. (UN 2020)

Since the adoption of Millennium Development Goals (MDGs), partnerships were very critical and involved public, private, and civil society which has resulted

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in some excellent results especially in the domain of health where the cooperation between governments companies and philanthropies has improved the lives of millions across the globe through the delivery of medicines and vaccines. In today’s globalized world partnerships are very important and at the same time the definition of partnership has evolved since the MDG era where it was defined as defined essentially by giving the aid debt relief and trade access by the developed north to the southern nations. However, the SDGs in the current era as highlighted by Harrington essentially emphasize the partnerships forged on more equal footing and on mutual terms as every area from poverty to climate, to peace and security and even social protection are dependent on one another. Another significant difference is that MDG goal 8 invested in partnerships for aid, trade and technology whereas the SDG goal 17 invests in knowledge centered partnerships. Therefore, in order to achieve SDGs, there must be a horizontal cooperation across various sectors and actors which can happen only when there is a dynamic process that builds new evidence on what can work and how will it work which is possible when there is a two way process of mutual learning not just mirror exchanging best practices (Harrington 2015).

Evidence-Based Policy and Translation The term evidence-based policy making gained increasing importance in recent years in global health. It was intended to underline replacing ideologically driven global health policies and decision making with that which is based on research and evidence. For global health partnerships (GHPs), this means that their policies would be based on systematic evidence which will produce better outcomes. The approach has also come to incorporate evidence-based practices. Better utilization of evidence in policy and practice helps save lives, reduce poverty, and improve development performance. For example, the Government of Tanzania has implemented a process of health service reforms informed by the results of household disease surveys – this contributed to over 40% reductions in infant mortality between 2000 and 2003 in two pilot districts (Sutcliffe and Court 2005). But ignoring the evidence can have the opposite effect. For example, the HIV/AIDS crisis has deepened in some countries because governments have ignored the evidence of what causes the disease and how to prevent it spreading (Sutcliffe and Court 2005). Key issues include the quality, credibility, relevance, and the cost of the policy. Policy processes involve various stages, most importantly, they include its implementation. Evidence has the potential to influence the policy-making process at difference entry points. However, different evidence and different mechanisms may be required at each of the policy stages. The reality is that evidence is not the only factor. It is important to acknowledge that at each stage of the policy cycle, a number of different factors will also affect policy. This occurs both at an individual level – for example, a policymaker’s own experience, expertise, and judgment – and at an institutional level, for example, in terms of institutional capacity. There are also a number of constraints, which will limit the extent to which evidence can affect policy – for example, the pressure to process information quickly. Policymaking is neither objective nor neutral; it is an inherently

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political process. Despite these challenges, there is a general consensus in the literature that a more evidence-based approach to policy and practice would be a positive development (Sutcliffe and Court 2005).

Global Health Partnerships Objectives of Global Health Partnerships The main objectives of global health partnerships (GHPs) are to develop a clear strategy, to build a consensus, and to coordinate all the efforts of all the stakeholders. Building and strengthening the partnerships is the key strategy in order to achieve the SDGs as the thematic areas such as water, energy, climate, oceans, urbanization, transport, science and technology are interrelated (Fig. 1). In order to achieve these goals, the stakeholders must feel the ownership of SDGs and translate into a strong commitment for the implementation to achieve a sustainable development. For example, ending poverty and other deprivations must go hand in hand with strategies that improve health and education, reduce inequality, and spur economic growth while tackling climate change and working to preserve the oceans and forests. According to the World Bank, the definition of global programs are those partnerships and other related initiatives who’s benefits cut across regions of the Fig. 1 Global Health Partnerships and its scope in coordination with various thematic areas. (Source: prepared by the authors)

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world and in which the partners reach explicit agreements on common objectives; agree to establish a formal or informal structure/organization; generate new products or services; and contribute dedicated resources to the program (World Bank 2002). As per the evaluation report on global health partnerships by Caines et al., GHPs brought additional funding for communicable diseases and other global public goods and in fact they were successful in leveraging significant amount of funds additionally from various foundations. Around 97% of GFATM are supported by traditional donor countries and it appears that these funds are well targeted towards diseases and countries which represent the highest burden of ill health. Apart from that, some GHPs have also contributed to health system strengthening (Caines et al. 2004).

Classifications of Global Health Partnerships The GHPs can be classified into various types based on the classification of diseases such as communicable diseases and noncommunicable diseases (NCDs). Of course, initiatives to support health systems or research or education or training or support specific programs such as maternal and child health, sexual reproductive health. However, the majority of GHPs focus on communicable diseases as 60% of the GHPs target the three big diseases, namely, HIV/AIDS, tuberculosis, and malaria (Table 1). Overview

Types of Global Health Partnerships according to the British Government’s Department for International Development (DFID) (Carlson 2005). 1. Technical Assistance: GHPs with support improved service access, may provide discounted or donated drugs and provide technical assistance 2. Research and development: GHPs involved in product discovery and development of new diagnostics, drugs, and vaccines. 3. Financing: GHPs which provide funds for specific disease programs for communicable diseases or noncommunicable diseases. 4. Advocacy: The partnerships that raised the profile of the disease or health aspect an advocate far more attention or try for international or national response and resource mobilization.

Types of Global Health Partnerships The global health partnerships at a broader sense can have two distinct organizational types namely independent and hosted though both are at the more formal end of the spectrum (Caines et al. 2004) as shown below (Table 2).

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Table 1 Major Global Health Partnerships involved in HIV/AIDS, malaria, and tuberculosis

GHP HIV/AIDS

Tuberculosis

Technical assistance including discounted drugs 1. Accelerating Access Initiative to HIV Care 2. African Comprehensive HIV/ AIDS Partnerships 3. Concept Foundation 4. Diflucan Partnership Program 5. Hope for African Children Initiative 6. HIV/AIDS Treatment Consortium (Clinton Foundation AIDS Initiative) 7. International Partnership Against AIDS in Africa 8. Maternal to Child Transmission 9. Secure the Future Initiative 10. (international pharmaceutical company initiative to support AIDS orphans) 11. Viramune Donation Program 1. Eli Lilly MultiDrug Resistance Tuberculosis partnership 2. Green light committee 3. Global Drug Facility

Research and development 1. Consortium for Industrial Collaboration in Contraceptive Research 2. Contraception Research and Development 3. Global Microbicide Project 4. International AIDS Vaccine Initiative 5. International Partnership for Microbicides 6. HIV Vaccine Trials Network 7. Microbicides Development Programme

1. Aeras 2. Foundation for Innovative New Diagnostics 3. Global Alliance for TB Drug Development 4. TROPIVAL- French based R&D partnership for Neglected Diseases

Financing Global Fund to Fight AIDS, TB, and Malaria

Advocacy 1. Global Business Coalition on HIV/AIDS 2. Global Campaign for Microbicides 3. Global Coalition on Women and AIDS 4. Global Media AIDS Initiative 5. Global Reporting Initiative

Global Fund to Fight AIDS, TB, and Malaria

Global partnership to Stop TB

(continued)

GHPs and the UK’s Experience The GHPs report by the NHS Director Nigel Crisp in 2007 highlights the UK’s experience and expertise in health systems research, education, and training and in making knowledge, evidence, and best practices from high quality research available

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Table 1 (continued)

GHP Malaria

Technical assistance including discounted drugs 1. African Malaria Partnership 2. Coartem (Artemether/ lumefantrine combination) 3. NetMark Plus (insecticide treated net social marketing program)

Research and development 1. Artesunate 2. Drugs for neglected diseases initiative 3. European malaria vaccine initiative 4. Japanese pharmaceutical Ministry of Health WHO Malaria Drug Partnership 5. Multilateral Initiative on Malaria 6. LAPDAP- Name of antimalarial treatment developed in public private partnership 7. TROPIVAL- French based R&D partnership for Neglected Diseases

Financing Global Fund to Fight AIDS, TB, and Malaria

Advocacy Roll Back Malaria

for public health. The report emphasizes that important needs in developing countries are basically for having integrated health systems with an emphasis on public health and primary care but not hospitals and territory care although they have their place. Partnership is not simply giving people a UK product but it’s more about a process of working together to meet a need. The UK has a long history of involvement in health in developing countries way back from the colonial times and there are many NGO’s Oxfam, Save the Children, the British Red Cross, Care, Christian Aid, Merlin, Plan, ActionAid, and Sightsavers along with other voluntary organizations, National Health Service, Wellcome Trust, and associated academic partners in developing countries who partner on various health projects and programs. Box Overview: Recommendations of Crisp Report on Global Health Partnerships (Source: Crisp 2008)

1. Strong emphasis should be laid on the links between health and development by supporting close working relations between officials of various in developing countries which will help the government’s plan to develop a global strategy for Health Protection security policy development trade as well as International Development. (continued)

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Table 2 Summary of the main characteristics of independent and hosted GHPs No 1

Characteristics of GHP Identity

2

Examples

3

Access GHPs

International Trachoma Initiative

4

Level of independency Level of authority over the secretariat Lines of accountability Time for establishment Access to breadth of expertise Operation costs Time for setting up Access to range of resources Autonomy Authority

Considerable independency Substantial

5

6 7 8

9 10 11 12 13

14

Identity confusion

Independent type of GHPs Have their own identity Global Fund

Clear

GHPs hosted UN bodies/NGOs Hosted by another organization Global Partnership for Stop TB hosted by WHO, Roll Back Malaria are hosted by UN Office for Project Services, Geneva Mostly hosted by WHO Mectizan Donation Program hosted by NGOs Limited Secretariats can be accountable to hosts rather than the GHP

Takes longer time

Sometimes it’s complicated with hosts that dominate Takes less time

It is a limitation

It is an advantage

Costly Longer time

economical Quick

limited

Easy access including technical expertise in WHO/UNICEF May be dominated by the hosts Smaller GHPs lack governing bodies and authority

More Have their own governing bodies and authority No

Yes (between the host and the GHP secretariat)

Source: prepared by the authors

2. To set up a framework for International Development supporting The NHS from the government ministers and statement of benefits to the UK from involvement in partnerships with institutions in developing countries. 3. Establishing global health partnership center as a one stop shop source of information for all stakeholders such as governments and health or nations which aim to make new connections and promote and share good practices and learning. (continued)

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4. Exploring an electronic exchange platform (HealthBay) on the principles of eBay and Freebay which could be used to match request for help with others. This HealthBay could act as a potential source for equipment, books, work experience, volunteering disaster relief, and training. 5. To develop new partnerships with voluntary organizations and support the health workers to work for the health system strengthening, staff training, public health, or service delivery in the developing countries. 6. Commissioning a database in which the health professionals with the required competences could register so that the global health partnership center and the global health exchange can be used as appropriate to support this. 7. The NHS framework for International Development should value the work in developing countries for the UK health workers and encourage the educators, employers, and regulators to make this experience feasible and ensure that such training or experience fits in with the developing country’s plans and needs. 8. The developing countries as part of their poverty reduction plans are encouraged to assess what sorts of partnerships they need and want, and with what organizations they want to be linked. For example, links with NHS, or country-country partnership. 9. To read the maximum possible benefits from health partnerships through developing links with health organizations and by sharing good practices. 10. The DFID should meet with the representatives of other partners such as HPA NICE, HSCIS, HCC, and private sector to review how they could continue to strengthen the health systems and I agree plans for doing so. 11. The UK should support international efforts to manage migration and mitigate the effects on Developing countries of the reduction in training and employment opportunities in the UK by using course of practice country level agreements creating exchange programs for training with limited periods of work of experience in the UK. 12. The UK should assist migrants from developing countries to contribute to health in their home country by enabling migrants to return home through partnership programs and by creating and NHS Service scholarship program to support service improvement in developing countries. 13. The UK should see itself having a responsibility as employer of a global workforce to help developing countries educate train and employ their own staff by committing some aid for training and education of health workers in developing countries and to support in scaling up of education and training in developing countries. 14. To prioritize on the digital health technology and emphasize the use of ICT in improving health and health services in the developing countries. 15. As part of strengthening its development research strategy ensure a focus on the practical application of evidence and good clinical practices in the Health delivery. (continued)

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16. Emphasize on increasing the access ability of knowledge to the practitioners and to the public while working with the international community and help countries develop knowledge systems that can make relevant knowledge accessible to their health workers and public.

GHPs Impact on Health Systems To ensure proper delivery of GHP program, there is a great need to have well-functioning health systems for both the financing and access/donation type of GHPs. For example, the vertical programs such as National Disease Control Program (HIV/AIDS, TB, malaria, etc.) they run as a project-aid from the assistance of financing GHPs. However, if these programs have poor systems or outreach, it will reflect directly on the effectiveness of how GHP funding is used. But in case of access/donation GHPs, they have a less burden on the government programs. Some of the contributions of GHPs to the health systems strengthening are summarized as follows based on the DFID study by Caines et al. 2004. 1. GAVI’s Immunization Services support providing the funding and technical support to national programs. 2. GAVI’s financial sustainability workshops and Multilateral Initiative of Malaria’s (MIM) investment to train and help to build technical capacity and financial systems of developing countries. 3. The role of STOP TB and Global Fund’s support to India’s National Tuberculosis Control Program in scaling up of DOTS regime which as strengthened the health systems by involving the NGOs and private providers as partners. 4. The role of GAVI in Sierra Leone and other African countries helped the governments to take the ownerships of immunization program away from UNICEF which was a good sign. 5. Some GHPs are exploring options to put extra funds directly into health systems strengthening since its very critical if the SDGs are to be achieved. The summary of the types of GHPs and their relationship with health systems are shown below (Table 3). Table 3 Type of Global Health Partnership and its relationship with health systems S No 1

Type of GHP Financing E.g., Global Fund and GAVI

2

Access or Donation E.g., Stop TB, GPEI

Relationship with health system They fit well with the centralized health system as their main aim is to provide aid for project support. They require high reliance on health system for the coordination of various committees, reporting systems and accountability They are flexible with any health system as such through donations or providing access to drugs/kits/vaccines etc. They have to rely on health systems for procurement and ensuing equitable distribution of its products and services

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GHPs and Their Impact on Global Health Training and Research There are numerous GHPs that also emphasize on global health training and research with active collaborations and knowledge transfer as summarized in Table 4.

GHPs and Their Added Value to Global Health Though the world has witnessed various GHPs for the past few decades doing an excellent work amidst many challenges, they have indeed brought the extra added value. Based on the DFID’s experience, the GHPs are found to bring some of the following improvements and additions apart from their funding and technical support (Caines et al. 2004). 1. They have improved the capability of partners through coordination, collaboration, and consensus-building. 2. They bring the advantage of highly talented human resources from diverse sources. 3. They contribute to consistent high-profile advocacy and wide-spread communications. 4. Systems inventions, innovations in processes, and creating the synergy between development and implementation. 5. Identify the funding gaps and generation of information on resource flows. 6. Funding additional support to countries for supplies, operational costs, and mobilization of resources.

Global Health Governance Organizations and Partnerships Global Health Governance (GHG) Organizations These GHG organizations are different from intergovernmental organizations and classified as organizations of global governance. Since global governance is defined as “Collective efforts to identify, understand or address worldwide problems that go beyond the capacity of individuals states to solve” (ECOSOC 2006). Basically, these GHG organizations have some unique set of functions like getting engaged in governance, primarily health oriented, act at global level within global political environment and base their work on a variety of principles and not just intergovernmentalism, for example, managerialism and cosmopolitanism. The organizations like Joint United Nations Programme on HIV/AIDS (UNAIDS), Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) now the Global Fund and Global Alliance for Vaccines and Immunisation (GAVI Alliance) are good examples that fit this model and have been successful in the field of health for the past 15 years. These organizations address the global health challenges by crossing the state boundaries and working independently of them.

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Table 4 Global Health Partnerships and their impact on global health training and research No 1

Name of the GHP NIHR-Wellcome Global Health Research Partnership, UK (www.wellcome.ac.uk)

Partners Funds researchers who focus on health priorities in LMICs

2

Tropical Health and Education Trust, UK (www.thet.org)

3

Teasdale-Corti Global Health Research Partnership Program, under Global Health Research Initiative (GHRI), Canada (www.ghri.ca)

Ministries of Health in Africa (Ethiopia, Somalia, Tanzania, Uganda, and Zambia) and Asia (Myanmar); local partners, academia and civil society in these countries Global health research teams and individual researchers working with researchers in LMICs

4

Canadian Institute of Health Research (CIHR)- Canadian CIHR Institute of Population and Public Health, Canada (www.cihr-irsc.gc.ca)

Global Alliance for Chronic Diseases (GACD). Grand Challenges Canada (GCC) Global Affairs Canada, and Canada’s International Development Research Centre (IDRC)

5

Council on Health Research for Development (COHRED), Geneva

Support countries to build health systems that focus on research and innovation. To strengthen in low- and middle-income countries

Areas of focus/activities International Master’s Fellowships, International Training Fellowships, Investigator awards in Science, Senior Research Fellowships, Collaborative awards in Science Country programs, grant management, policy work, Health partnership scheme (180 partnerships were formed) and provision of Biomedical Equipment Team Grants, Global Health Leadership Awards and Supplementary grants for the following areas: 1. Health policy and systems research 2. Prevention and control of pandemics and chronic diseases 3. Internactions of health, animal health and development Global health research focuses in particular on the health of people living in low- and middle-income countries and also on understanding systematic factors that shape health and are inherently global. The thematic areas are: 1. Globalization 2. Equity 3. Neglected diseases 4. Transnational risks 1. To reduce health in equities 2. improve health sector performance an accountability 3. link research for health with science technology and innovation 4. encourage donor alignment and harmonization 5. generate economic and social prosperity

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UNAIDS UNAIDS was launched in 1996 under the UN structure as a co-sponsored program bringing together the WHO, United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), United Nations Educational, Scientific and Cultural Organization (UNESCO), and the World bank. Later other UN organizations like World Food Programme (WFP), International Labour Organization (ILO), United Nations Office on Drugs and Crime (UNODC), and United Nations High Commissioner for Refugees (UNHCR) also joined as co-sponsors. Thus, UNAIDS became the central coordinating agency and organization for public policy promotion (Oestreich 2007, p. 128) advising stakeholders not only on technical issues but also on policy issues of blood safety, protection and care of children, counseling and testing, empowerment of PLHAs, social and behavioral change, and condom promotion. GAVI GAVI Alliance (now Vaccine Alliance) was founded in 2000 to boost immunization coverage rates in the world’s poorest countries. It is one of the first large scale GHG organizations which served as a base-model for other global organizations for health including GFATM (Jacobs 2001; Brugha et al. 2002). The main characteristics of this institution are: a central decision making body, seats allocated to various types of actors, focus on achieving narrowly defined in a specific health issue and managerial follow-up by working close with the at-risk countries to ensure compliance. This Vaccine Alliance has powerful partnerships with WHO, UNICEF, World Bank, Bill and Melinda Gates Foundation (BMGF), governments, NGOs, private sector, vaccine manufacturers, and a wide range of players (Fig. 2). The partnership plays a significant role in not only providing the vaccines but also in strengthening Primary Health Care and bringing closer to the SDG of Universal Health Coverage (UHC) so that no one is left behind. The partnership is unique in two ways when compared with other GHPs, as it is a public-private partnership and has a robust business model which ensures that generations of children will not be deprived of these life-saving essential vaccines (GAVI n.d). GFATM/Global Fund GFATM was founded in 2002 as a mechanism to gather and distribute funds to nationally planned health projects in the areas of HIV/AIDS, tuberculosis, and malaria which are the main causes of mortality in developing and poor countries. It has received high level attention as it is the first health organization outside UN system that received huge financial resources, promotes highly inclusive decisionmaking structure with cosmopolitan democracy, and has effective performance monitoring of its funds with a managerial approach to global health within a multilateral setting. Roll Back Malaria Partnership “Roll Back Malaria” partnership to “End Malaria” established in 1998 is a good example of Diffusion of Governance where it brings more than 100 countries, eight international organizations, 11 bilateral programs, 22 NGOs, four foundations including the BMGF, private companies, and more than 40 organizations including

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Fig. 2 The Vaccine Alliance and its partnerships. (Source: GAVI Alliance (Vaccine Alliance))

African Malaria Network Trust. Currently, it has over 500 partners and recognizes country ownership and leadership as the key strategy to end malaria (RBM 2020). The RBM’s strategy aims to reduce the morbidity and mortality due to malaria and leads its partners to keep malaria high on the political agenda, promoting and supporting the countries and regions to fight malaria and advocating for sustainable financing at global level thereby reaching universal coverage and strengthening health systems. This GHP shows how the fight against a single infectious diseasemalaria requires contribution from different actors. The ability to successfully accomplish the task is dependent on the collaboration between a wide range of players, representing different sectors of the society and different levels from local to global. The structure is illustrated in Fig. 3 below.

Stop TB Partnership The “Stop TB Partnership” was founded in 2001 with the mission to serve every person who is vulnerable to TB and ensure high quality diagnosis treatment and care. There are around 1700 partners which include international and technical organizations, various governments, research and funding agencies, philanthropic organizations, NGOs, civil society, community groups, and private sector. This GHP is recognized as an international body with the power to align actors all over the world to fight against TB and has seven working groups to accelerate progress on TB diagnosis and treatment research and development new diagnostics drugs and vaccines and tackling drug resistant and HIV associated TB. The secretariat is governed by a board and is hosted by United Nations Office for Project Services

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Fig. 3 Diffusion of governance in antimalaria partnership. (Source: Roll Back Malaria Partnership (2010))

(UNOPS) in Geneva. The notable targets are by 2020 to end the TB epidemic as envisaged under the UN-SDGs and the WHO End TB strategy. There is also the 9090-90 target by 2020 which envisages that at least 90% of all people with TB should be released and placed on therapy; at least 90% of the most vulnerable underserved an at-risk population should be reached, to achieve a treatment success of at least 90% (Stop TB Partnership 2020).

Stakeholders of GHG Organizations “Stakeholders can be defined as actors who have an interest in the issue under consideration, who are affected by the issue, or who because of their position have or could have an active or passive influence on the decision-making and implementation processes. They can include individuals, organizations, different individuals

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within an organization and networks of individual and/or organizations i.e. alliance groups” (Varvasovszky and Brugha 2000). Although there is currently no global governing agency for health that is mandated for all countries to subscribe to, the World Health Organization has evolved to become the predominant force for global health diplomacy. When nations have to address cross-border health issues affecting the wellbeing of multiple countries, they would typically bring their diplomatic concerns to the WHO or one of its regional affiliates for consideration. In doing so, these member nations would gain access to a global network for health assistance, development, and security. This may appear counter-intuitive where national governments would need to come to an international forum to address matters that affect the status of their own nation’s health. An understanding of the present nature of global health governance requires an understanding of the key stakeholders – national governments, IGOs, NGOs, and the global health initiatives they support. Figure 4 below gives a graphic representation of how various stakeholders in global health might be placed in order of distance from a GHG organization, in terms of the extent to which they are either affected by its decisions or influence a related organization’s governance. Stakeholders placed close to the inner circle have a direct stake in a GHG organization and its decisions. These include aid agencies that provide

Fig. 4 Representation of various stakeholders in Global Health Governance Organizations. (Source: Adapted from Schneider 2009)

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funding for GHG organizations and have a desire to see the goals of them reached, either as a justification for their own engagement, or because they have prioritized these themselves and chosen a GHG organization as a best way to address them. Organizations set up to represent patients, or people affected by diseases are also intimately affected by the work of GHG organizations, as are the manufacturers of the products that these organizations aim to distribute, promote or in some cases discourage. Finally, health and finance ministries in the states that are addressed by GHG organizations will also be directly affected, especially when GHG organizations request changes in their policies or actions. Somewhat further out from the inner circle are stakeholders that will be affected by GHG organizations in an indirect way but are still to be classified as stakeholders because they have an interest in the goals and operations of GHG organizations.

Classification of Stakeholders in GHG and Partnerships There are four main categories of stakeholders in GHG, namely, states, intergovernmental organizations, business sector actors, and civil society organizations. The fifth group of dynamic stakeholders may overlap with other categories. For GHG, the civil society organizations can be further classified into eight subcategories as shown in Table 5 below.

Governance of Global Health Partnerships It is concerned with institutions focused on health such as WHO, Global Fund, UNICEF, UNAIDS, and GAVI. They include conventional structures involved on the multilateral and bilateral level, as well as innovative bodies such as public private partnerships with representatives from different stakeholders. The WHO has a pivotal role derived from its constitution, where member states entrust it in Article 2 “to act as the directing and coordinating authority on international health work.” This is increasingly interpreted as a normative role in global health diplomacy ensuring that health issues are addressed at all levels in an informed and ethical but unbiased manner. David Fidler (2010) defines global health governance as referring “to the use of formal and informal institutions, rules and processes by states, intergovernmental organizations and nonstate actors to deal with challenges to health that require cross-border collective action to address effectively.” It refers mainly to those institutions and processes of governance with an explicit health mandate such as the WHO. GHG is primarily concerned with the health-related institutions that govern collective responses to such issues (Moon 2008; Lee 2003). It is concerned with institutions focused on health such as WHO, Global Fund, UNICEF, UNAIDS and GAVI. They include conventional structures involved on the multilateral and bilateral level, as well as innovative bodies such as public private partnerships with representatives from different stakeholders. According to Hein et al. (2009), the contemporary “GHG is characterized by a polycentric, distributed structure and a

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Table 5 Classification of stakeholders in GHG by type of organization Category of actors/ stakeholder States

InterGovernmental Organizations (IGOs)

Business sector actors

Subcategory States with poor health indicators and infrastructure Donor (resource providing) States NA

Industry lobby Associations

Ministries of International Development and Cooperation WHO and its departments; UNICEF World Food program and other health related IGO’s Intellectual Property Committee

Business affected by global health challenges

Businesses active in states burdened by poor health, e.g., Daimler in South Africa, Shell in Nigeria

Business involved in health as part of CSR activities

Members of the GBC, e.g., Standard Chartered Business active in the World Economic Forum’s Global Health Initiative Pharmaceutical and medical equipment industry, e.g., Aventis; Merck &Co Hygiene and nutrition industry, e.g., Procter and Gamble; Nestle International community of Women living with HIV/AIDS (ICW) and Global Network of People Living with HIV/AIDS (GNP+)

Health product manufacturers and service providers

Civil society organizations (CSOs)

Primary stakeholders Ministries of Health and Ministries of Finance

Associations of people living with diseases

Secondary stakeholders Political parties in the government

Tertiary stakeholder Staff members and Department advisors; citizens and voters

UNDP, International Monetary Fund

Global level bureaucrats and advisors

Suppliers and clients of businesses affected by global health challenges, Union and staff representatives

Staff members and advisors Employees and their families

Staff members and advisors

Suppliers and clients of health product manufacturers and service providers

Staff members

local organization branches discussion groups

Persons living with poor health or targeted diseases

(continued)

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Table 5 (continued) Category of actors/ stakeholder

Subcategory Charities and Foundations

CSOs focusing on related issue areas Disaster relief CSOs Grassroots CSOs Health focus CSOs

Medical Professional Associations

Dynamic stakeholders

Primary stakeholders Bill and Melinda Gates Foundation; Clinton Foundation; Save the Children fund

Tertiary stakeholder Staff members and advisors

Greenpeace, Human Rights Watch International Red Cross and Red Crescent Societies The Aids Support Organization (TASO) Oxfam, IPPF, Health Action International, Médecins Sans Frontiers International Council of Nurses

Umbrella groups

People’s health forum

Public Private Partnerships (PPPs)

Health focused partnerships, e.g., Global Alliance for Improved Nutrition Global Health Consultants

Health policy elites

Secondary stakeholders

Staff members field workers

Doctors nurses and medical professionals Staff members and advisors PPPs from related policy fields, e.g., water supply partnerships

Source: Carmen Schneider (2009): Legitimacy and Global Governance

substantive concern with issues that affect populations worldwide directly (e.g., the global spread of infectious diseases or AMR) or indirectly (e.g., political instability, civil unrest, global insecurity arising from socio-economic inequality). GHG now requires management of not merely of specific trans-border epidemics, like SARS, Ebola, or Avian influenza but of the host of issues in health that arise at the intersection of globalized economy and lives lived in particular localities.” WHO is referred to as a GHG institution (Harman 2012; Ruger and Yach 2008; Davies 2010) holding the constitutional authority within the UN system to adopt agreements, issue guidelines, and provide technical assistance to member states to protect and promote global health.

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Governance for Global Health This dimension refers to institutions and mechanisms established at national and regional level to contribute to global health governance and/or to global governance for health such as national global health strategies or regional strategies for global health. It refers to multilevel governance at national and regional levels and even state and local levels as in the case of Framework Convention on Tobacco Control (FCTC) as shown in Fig. 5. This dimension can also apply to the club strategies such as BRICS countries which conclude agreements on health matters and because of the changing nature of global health; this dimension is becoming increasingly important. At the national level, governance for global health must engage ministries concerned with taxation, water, housing, education, agriculture, and energy as well as foreign affairs and aid

Fig. 5 Multilevel governance Framework Convention on Tobacco Control (FCTC). (Source: Mamudu and Glantz, East Tennessee State University 2009)

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which all affect global health. Positioning of health in relation to the environment – see Rio+20 and the SDG process – is an important element of cross-sectorial negotiation.

Governance Models in Global Health Since there are many new actors as mentioned earlier including civil society organizations, private philanthropists, and businesses have entered the global health landscape, they have some degree of autonomy from the governments of the countries from which they originate; they come from different domains and have a different set of interests and perspectives, thereby contribute to the diplomacy of diversity. This diversity of actors has led to multiconstituency governance models in health.

Collaborative Governance Collaborative Governance can be defined as a “type of governance in which public and private actors work collectively in distinctive ways, using particular process, to establish laws and rules for the provision of public goods” (Ansell and Gash 2008). It encourages the cross-boundary nature of governance and can be linked to participatory governance and civic engagement. It also results in including the wishes of “informed” stakeholders (Carver 2010) and therefore considers the function as a stakeholder-representative function rather than a traditional management function. Though the different actors bring unprecedented resources to global health and the ability to connect the global community, there may be concerns about the sustainability of short-term initiatives, competition among the health actors and the lack of coherence on the areas of focus. The WHO pandemic preparedness model is a good example of this type of collaborative governance, as illustrated by Fig. 6. It shows how the preparedness of whole society for a disease outbreak is done through involvement of various actors at different levels and their interdependence. Figure 6 depicts the complex process, which involves three sectors including government, business, and civil society, represented by circles, their interactions at different levels including the community, local government, as well as subnational levels (shown inside the pyramids). The other sectors lie outside with representations from defense, law and order, finance, transport, telecommunication, energy, food, water, and health. Diffusion of Governance It is one of “the key dynamics that shape the understanding of the mechanisms and institutions of governance” (Kickbusch 2011). The concept of diffusion of governance builds on the idea that the functions of the state would diffuse simultaneously in different directions in response to incongruence between its capacity and increasingly complex challenges (Nye and Karmack 2002). The diffusion of governance and power is about the patterns of power-sharing and the analysis of relations between organizations and their contexts, between sectors and policy fields, between

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Fig. 6 WHO Pandemic Preparedness Model. (Source: World Health Organization (2009). Wholeof-society pandemic readiness: WHO guidelines for pandemic preparedness and response in nonhealth sector, Geneva)

states and nonstate entities and most importantly between and within these groupings (Kickbusch 2011) as shown in Fig. 7 below.

Global Health Partnerships for Health Security Global Health Security Agenda Global health security agenda (GHSA) was launched in February 2014 and consists of 69 countries, international organizations, nongovernment organizations (NGOs), and private sector companies which have pledged to achieve the vision of safer world. The GHSA was launched as a response to the global health threat caused by the infectious diseases in this interconnected world and the partnership acknowledges the need for a multilateral and multisectoral approach to strengthen both the global capacity and nations capacity to prevent detect and respond to infectious

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Fig. 7 The diffusion of governance in the twenty-first century. (Source: adapted from Nye and Karmack (2002))

threats. The aim of GHSA is to improve the worldwide implementation of the WHO international health regulations so that the world will be better prepared for the next outbreak in the future (GHSA 2014). Overview: Main Objectives of the Global Health Security Agenda

1. Strengthen the capacities of the countries to prevent detect and respond to infectious disease threats 2. To prioritize global health security as a national priority and galvanize high level commitments to global health security 3. To promote and encourage multisectoral partnerships and collaboration 4. To emphasize on common measurable targets

GHSA Partnership Governance Model The GHSA is governed by the steering group comprised of 15 countries international organizations and NGOs which provides guidance and direction and facilitates target driven multisectoral coordination among the members. The steering group is headed by chair that rotates annually and there are permanent advisors from multiple multilateral nations such as WHO, FAO, and World Organisation for Animal Health, formerly the Office International des Epizooties (OIE). The steering group qualms that time limited task forces to achieve high level strategic objectives which includes: (1) multisectoral stakeholder engagement, (2) accountability and results, (3) action package coordination, and (4) advocacy and communications. This new partnership aims to address the main global challenges with according action packages. Action package working groups are led by technical experts from GHSA member countries to develop and implement the WHO’s IHRs (2005). They include antimicrobial resistance, biosecurity and safety, immunization, laboratory systems, surveillance, sustainable financing, workforce development, and zoonotic

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diseases. The GHSA 2024 target aims at more than hundred countries for improved health security capacity by addressing gaps and implementing the critical activities and to reach a level of “demonstrated capacity” as measured by the WHO’s IHR monitoring and evaluation framework.

Global Health Security Initiative (GHSI) Global Health Security Initiative (GHSI), founded on November 7, 2001, is an informal network of seven countries (Canada, France, Germany, Italy, Japan, Mexico, United Kingdom, and United States) and the European commission with WHO as an observer aimed at confronting novel health threats and risks to global health by exchanging information and effective coordination within the health sector. The partnership has contributed significantly by improving prevention, preparedness and capacities worldwide through effective surveillance, detection and response efforts, thereby improving global health security (GHSI n.d.). This partnership’s intention was not to replace overlap or duplicate existing networks or initiatives. The first ministerial meeting was hosted by Canada’s Minister of Health in Ottawa where the Ministers/Secretaries and senior health officials from the member countries and EU participated and agreed to forge the partnership for protecting public health and security globally in the following areas. 1. Cooperation in procurement of vaccines and antibiotics 2. Development of regulatory frameworks for vaccine development, rapid testing, and research of vaccines 3. Support WHO’s disease surveillance network and coordinated strategy for disease outbreak containment 4. Share emergency preparedness and response plans 5. To agree on international Collaboration on risk assessment and management 6. To enhance linkages among laboratories including level 4 laboratories wherever applicable 7. To cooperate on preparedness and responds to radio nuclear and chemical events 8. Share surveillance data from national public health laboratories and information on other threats. GHSI Governance and Organizational Structure The GHSI has Global Health Security Action Group (GHSAG) which includes senior officials from each delegation whose job is to ensure the ministers’ plans and objectives are translated into concrete action plans. The GHSI secretariat is responsible for planning the meetings, coordination, and priority setting which includes management of Coordination and Liaison Committee and Communicators’ Network (GHSI n.d.). There are currently four technical/scientific working groups focusing on different areas of importance, namely: 1. 2. 3. 4.

Chemical Events Working Group Biological Working Group Radio-Nuclear Threats Working Group Pandemic Influenza Working Group

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Since the mandate of GHSI is to strengthen public health preparedness and response to Chemical, Biological, Radiological, and Nuclear threats (CBRN) as well as pandemic influenza, it has demonstrated a great coordination among the nations through exchange of timely information resulting in strengthened capacity related to CBRN threats and risks. As the nature of health security continues to evolve the GHSI’s preparedness and response also will remain adaptable to the changing health security landscape. Through its trusted forum, partnerships, and capacity building, the GHSI is prepared to address future global health threats.

WHO Strategic Partnership for International Health Regulations (2005) and Health Security (SPH) Way back in 2015, the member states partners and donors mandated WHO to establish a Strategic Partnership Portal (SPP) monitoring the health security capacity of member countries with an objective to help countries to identify their needs gaps and priorities in national, provincial, and local health security. However, in 2018 the SPP expanded from information platform to a mechanism for collaboration and partnership to become Strategic Partnership for Health Security (SPH). The WHO strategic partnership for international health regulations and health security is supported by G7, committed to reinforce the global health architecture by strengthening its responses to various health threats and emergencies (WHO-SPH n.a). The goal is to apply the “One Health” approach and support countries to respond to public health emergencies by strengthening their capacities to detect, prevent, and respond, as enshrined in the IHR 2005, thereby responding to potential public health emergencies of international concern (PHEIC) and reporting such events to WHO. The role of SPH is to improve the relationships, strategic cooperation, and partnership between states, regions, international partners, donors, and networks (Fig. 8). Global Health Security Agenda Private Sector Roundtable Global Health Security Agenda Private Sector Roundtable (GHSA-PSRT) is coalition of private companies which are dedicated to promoting health security and raise voice for the private sector as a member of the international GHSA. The partnership includes the GHSA partners including 69 member countries, CDC, leading companies from various industries such as healthcare, communications, energy, finance, technology, and logistics. PSRT member companies provide technical assistance in data analysis, biosecurity, antimicrobial resistance, supply chain management, communicating about health risks, and in COVID-19 response. The PSRT mainly coordinates private sector response, supports governments, civil society, and multilateral partners, promotes health and economic growth, and strengthens the health security (Martin n.a). EU-Africa Global Health Partnership The EU- Africa Global Health Partnership’s aim is to reduce the social and economic burden of infectious diseases and increase health security in sub-Saharan Africa and by extension both in Europe and worldwide (EU 2019). The partnership aims to develop effective, safe accessible and affordable health technologies; and health

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Fig. 8 Functions of WHO strategic partnership for health security. (Source: WHO Strategic Partnership for International Health Regulations (2005) and Health Security)

system interventions for infectious diseases with its African counterparts. The partnership ensures at least 1 billion Euro contribution from EU and co-investment from African participating states through stronger governance and funding incentives. This initiative is part of the future EU Research and innovation framework program Horizon Europe (DSW 2019).

Knowledge Management and Translation Various tools exist to gather and translate knowledge. The key to any successful knowledge management or translation initiative is its proximity or embeddedness to an existing partnership or initiative. Depending on which partners are involved and how the impact of the knowledge on policy making is possible, these may take various forms and in various settings.

Multilateral and UN System Settings As the WHO is one of the key UN health specialized agencies, it is not surprising that under its umbrella and oversight of the World Health Assembly of its Member States, several initiatives have been used to enhance knowledge management efforts and facilitate its translation. For example, the Global Observatory on Health Research and Development (The Observatory) is a global-level initiative that aims to help identify health R&D priorities based on public health needs, by

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consolidating, monitoring, and analyzing relevant information on the health R&D needs of developing countries. It builds on existing data collection mechanisms and supports coordinated actions on health R&D. This observatory is based at WHO, which allows for it to interact with WHO Member States and help them align investments with global public health demands and needs. As little as 1% of all funding for health R&D is allocated to diseases such as malaria and tuberculosis (diseases that are predominantly incident in developing countries), despite these diseases accounting for more than 12.5% of the global burden of disease (WHO Global Observatory on Health R&D 2020). The outbreak of Ebola virus disease dramatically exposed the lack of investment in products and approaches to prevent and minimize the impact of pathogens with epidemic potential. Recently, the gaps in R&D investments and the pipeline for antimicrobial medicines have also become a cause of global concern in the context of rapidly increasing antimicrobial resistance. Governments, policy-makers, funders, and researchers therefore need an accurate picture of the current situation so as to spot R&D gaps and ensure that funds and resources are used in the best possible way.

Coalitions and Multifaceted Settings The COVID-19 pandemic has highlighted how global health security is reliant on all countries around the world, including low- and middle-income countries (LMICs), having strong health systems and health research capacities. In 2018, the “Money and Microbes” report from the International Vaccines Task Force (supported by the World Bank Group and the Coalition for Epidemic Preparedness Innovations) recommended that research capacity building should be considered an element of pandemic preparedness and a component of the global health security agenda, and that the ESSENCE on Health initiative (ESSENCE) should articulate a mechanism for review of investment in capacity building in LMICs (World Bank 2018; ESSENCE on Health Research 2020). As the sole initiative that brings together a wide range of funding agencies to coordinate funding efforts, it was not surprising that this initiative was asked to tackle this problem. At present, countries with low research capacity tend to focus research attention on their most pressing health issues, but this will not help them prepare for epidemics or pandemics. While Covid-19 and the threat of epidemics and pandemics emphasizes the urgency of strengthening health research capacity, actually doing so will also serve to improve healthcare in general. It will also reduce mortality and morbidity due to disease and help in the drive towards universal health care and achievement of the UN sustainable development goals. The ESSENCE mechanism, proposed by ESSENCE in 2019, gives funders of health research the necessary information to identify gaps in capacity that exist in LMICs and the opportunity to work together to address those disparities. It focuses on three distinct but complementary “workstreams” to inform the funders including: (1) Data and Analysis, (2) Investment Mapping, and (3) Coordination and Collaboration (Kilmarx et al. 2020). This mechanism was devised by ESSENCE, with

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input from the Global Coordination Mechanism for R&D Preparedness and LMIC representatives and follows a consultation with 40 diverse stakeholders involved in health research capacity strengthening in LMICs (including representatives from international scientific academies, research and development organizations, and other funding organizations from Africa, Asia, and Latin America). The goal of the ESSENCE mechanism is to improve efficiency, equity, and overall research capacity while decreasing duplication and decreasing the number of countries with low research capacity. Its impact should be increased research on national health priorities and an improvement in pandemic preparedness. While this three-pronged approach seems simple, there are many complexities – a few of which follow. Firstly, indicators and targets for health research capacity strengthening efforts need to be identified and agreed by all stakeholders. Doing so will help to establish road maps for future investments and mobilize resources within a framework for partner coordination and collaboration – in the same way that they have done for many global health and development programs. Secondly, funding for health research capacity strengthening is not currently differentiated by World RePORT from funding for health research, as health research capacity strengthening often takes place as an integral element of health research (Adam et al. 2020). Future versions of World RePORT will need to identify activities that specifically strengthen health research capacity. Thirdly, funders have very different, well-established approaches to funding. For example, at present many funders focus on research capacity strengthening in specific institutions, while others focus on consortia. While the latter has created some highly competitive centers of excellence, it has meant that some institutions and countries with weaker health research capacity have been left behind. For example, in 2017, 90% of research grants (from the funders in World RePORT) went to just 16 African countries; 11 countries received no grants. The ESSENCE Mechanism could address this by enabling the targeting of a subset of resources to sites/countries with low research capacity so that a minimum capacity to conduct research will exist in all countries.

Targeted and Fact-Finding Settings The final example of knowledge management and translation is the G-FINDER survey which tracks annual investment into R&D for new products and technologies to address priority global health challenges (Policy Cures Research, G-FINDER 2020). The main sponsor of this annual survey is Bill and Melinda Gates Foundation. This includes basic research and the development of new drugs, vaccines, diagnostics, and other tools for global health priorities that disproportionately affect people in low- and middle-income countries, including neglected diseases (NDs), emerging infectious diseases (EIDs), and sexual and reproductive health (SRH) issues. The survey is conducted by Policy Cures Research which puts spotlight on the findings each year by presenting the information in a user-friendly manner and helps demonstrate to the funders where the gaps and needs are in the current landscape.

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Conclusion The importance of global health partnerships and the SDG-17 is undeniable. The most recent pandemic further underlined their relevance and the need for structures and arrangements that can address novel global health threats. This can be demonstrated by access to the COVID-19 Tools (ACT) accelerator, which enabled a ground-breaking global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines, that was launched only few months after the global pandemic was declared (Access to COVID-19 Accelerator 2020). The proponents of this partnership realized that there is no time to waste in the fight against COVID-19 and that no-one is safe until everyone is safe. While WHO led the ACT, it brought together governments, scientists, businesses, civil society, philanthropists, and global health organizations (Bill & Melinda Gates Foundation, CEPI, FIND, GAVI, Global Fund, UNITAID, Wellcome, WHO, World Bank, and Global Financing Facility). These organizations have joined forces to speed up an end to the pandemic by supporting the development and equitable distribution of the tests, treatments, and vaccines the world needs to reduce mortality and severe disease, restore societal and economic activity in the near term, and facilitate high-level control of COVID-19. The existence of multilateral arrangements and mechanisms for global health partnerships allows various stakeholders and partners to come together and act quickly in response to pressing global health treats and risks.

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DSW (2019) Deutsche Stiftung Weltbevolkerung. The next EU-Africa Global Health Research Partnership: building on the success of EDCTP. https://www.dsw.org/en/wp-content/uploads/ 2019/09/THE-NEXT-EU-AFRICA-GLOBAL-HEALTH-RESEARCH-PARTNERSHIP.pdf. Accessed 6 Sept 2020 ECOSOC (2006) Definition of basic concepts and terminologies in governance and public administration. ECOSOC, New York. Committee of Experts on Public Administration, Fifth Session ESSENCE on Health Research (2020) Special Programme TDR, WHO. https://www.who.int/tdr/ partnerships/essence/en/. Accessed 1 Sept 2020 EU (2019) European Commission. EU-Africa Global Health Partnership (Horizon Europe programme). About this initiative. https://ec.europa.eu/info/law/better-regulation/have-your-say/ initiatives/11907-EU-Africa-Global-Health-Partnership. Accessed 6 Sept 2020 Fidler DP (2010) The challenges of global health governance. Working paper, Council on Foreign Relations, New York Florini A, Pauli M (2018) Collaborative governance for the sustainable development goals. Asia Pac Policy Stud 5(3):583–598 GAVI (n.d.). The power of partnership. GAVI, The Vaccine Alliance. https://www.gavi.org/ouralliance/about. Accessed 10 Sept 2020 GHSA (2014) Global Health Security Agenda. https://ghsagenda.org/. Accessed 25 Aug 2020 GHSI (n.d.) Global Health Security Initiative. http://ghsi.ca/about/. Accessed 6 Sept 2020 Harman S (2012) Global health governance. Routledge, London Harrington N (2015) The SDGs call for a revitalized global partnership: what should we do differently this time. https://www.oecd.org/dev/development-posts-sdg-global-partnership.htm. Accessed 15 Aug 2020 Hein W, Burris S, Shearing C (2009) Conceptual models for global health governance. In: Buse K, Hein W, Drager N (eds) Making sense of global health governance. A policy perspective. Palgrave Macmillan, Basingstoke, pp 72–98 Jacobs, Lisa. 2001. The New Global Fund and GAVI: similar approaches or different? Immunization Focus. 2001 Kickbusch I (2011) Global health diplomacy: how foreign policy can influence health. Br Med J 343. http://graduateinstitute.ch/webdav/site/globalhealth/shared/1894/Publications/global% 20health%20diplomacy_how%foreign%20policy%policy%20can%20influence%20health_ Kilmarx P et al (2020) A mechanism for reviewing investments in health research capacity strengthening in LMICs. Ann Glob Health 86(1):92 Lee K (ed) (2003) Health impacts of globalization, towards global governance. Palgrave Macmillan, London Mamudu HM, Glantz SA (2009) Civil society and the negotiation of the framework convention on tobacco control. Glob Public Health 4(2):150–168 Martin R (n.a.) Global Health Security Agenda private sector roundtable. PSRT briefing series: COVID-19 response. https://rabinmartin.com/our-work/private-sector-roundtable-for-globalhealth-security/. Accessed 6 Sept 2020 Moon S (2008) Medicines as global public goods: the governance of technological innovation in the new era of global health. Glob Health Gov 2(2):1–23 Nye J, Karmack E (eds) (2002) Governance.com: democracy in the information age. Brookings Institute Press, Washington, DC Oestreich JE (2007) Power and principle: human rights programming in international organizations. Georgetown University Press, Washington, DC Policy Cures Research, G-Finder (2020). Available at https://www.policycuresresearch.org/gfinder. Accessed 1 Sept 2020 RBM (2020) Roll Back Malaria partnership to end malaria overview. Available at https:// endmalaria.org/about-us/overview. Accessed 20 Aug 2020 Roll Back Malaria Partnership (2010) In Kickbusch I, Gleicher D. Governance for health in: the 21st century. World Health Organization. Regional Office for Europe; 2012. Page 19. Available at https://www.euro.who.int/__data/assets/pdf_file/0019/171334/RC62BD01-Governance-forHealth-Web.pdf. Accessed 24 Aug 2020

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Ruger JP, Yach D (2008) The global role of the World Health Organization. Glob Health Gov 2(2):1 Schneider CH (2009) Legitimacy and global governance in managing global public health. Thesis submitted at University of Tubingen, Germany Stop TB Partnership (2020). Available at http://www.stoptb.org/about/. Accessed 20 Aug 2020 Sutcliffe S, Court J (2005) Evidence-based policymaking: what is it? How does it work? What relevance for developing countries? Overseas Development Institute, London. The Access to COVID-19 Tools Accelerator (2020). Available at https://www.who.int/initiatives/ act-accelerator. Accessed 1 Sept 2020 United Nations (2020) Sustainable development knowledge platform. https://sustainablede velopment.un.org/sdg17. Accessed 18 Aug 2020 United Nations Department of Economic and Social Affairs (2015) Sustainable development goals: sustainable development knowledge platform. https://sdgs.un.org/goals. Accessed 6 Aug 2020 Varvasovszky Z, Brugha R (2000) A stakeholder analysis. Health Policy Plan 15(3):338–345 WHO Global Observatory on Health R&D (2020). https://www.who.int/research-observatory/ why_what_how/en/. Accessed 1 Sept 2020 WHO-SPH (n.a.). WHO Strategic Partnership for International Health Regulations (2005) and Health Security. https://extranet.who.int/sph/#sph11824. Accessed 5 Sept 2020 World Bank (2002) Operations evaluation department. The World Bank’s approach to global programs: an independent evaluation. The World Bank, Washington World Bank (2018) Money and microbes: strengthening research capacity to prevent epidemics. World Bank. https://www.worldbank.org/en/topic/pandemics/publication/money-andmicrobes-strengthening-research-capacity-to-prevent-epidemics. Accessed 1 Sept 2020 WHO (2009) Whole-of-society pandemic readiness: WHO guidelines for pandemic preparedness and response in the non-health sector. Geneva, World Health Organization. Available at https:// www.euro.who.int/__data/assets/pdf_file/0019/171334/RC62BD01-Governance-for-HealthWeb.pdf. Accessed 24 Aug 2020

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cooperation on a Global-International Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MDGs and SDGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G7 (Group of Seven) and G20 (Group of Twenty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Issue-Specific Health Policy Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global-National Level: Financial Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global-National Level: Implementation Coordination to Respond to Critical Situations . . . Cooperation at National-Subnational-Community Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . National and Subnational Level: Coordination Among Different Organizations with Different Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community-Level Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cooperation with Private Companies and Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Private Sector Cooperation: Consigning Functions to Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Level: New Approaches for Cooperation by Connecting Individuals . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Cooperation in global health exists in many different categories, including geographical location, level, actor, purpose, formality, and means of coordination. This chapter outlines a “Coordination Mapping Framework.” According to this framework, we identify and explain several types of cooperative groups. The first group is about global-national level cooperation: MDGs and SDGs G7/8, and the G20 cooperate on a global health policy level; the GF and GAVI are examples of global funding collaboration; and the Cluster Approach and GOARN address a spectrum of coordination, from the global to the national level, related to the H. Akashi (*) Department of Health Planning and Management, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_114

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health crisis. The second group is country level comprising country and sub-country coordination mechanisms and contracts with NGOs for local health service management and community-level village committees for cooperation. The third is the private organization or individual level, that is, individual cooperative approaches such as cloud funding, charity fixers, pro bono, distributed computing, gamification, and social enterprise. Taken together, there are many types of coordination in the field of global health. However, despite continuous innovation and quick implementation of new technologies and tools, those remain dependent on the human cooperation using them meaningfully for the advancement of global health and well-being. Thus, cooperation and collaboration are vital for human survival. Keywords

Multilateralism · Cooperation · Collaboration · Partnership · Network

Introduction Every piece of work among human beings requires cooperation. We survive by cooperation with others, not as individuals. There are several words like cooperation, including collaboration, alliance, partnership, network, and coordination. According to some dictionaries, both collaboration and cooperation mean a group of people working together on a project. However, collaboration focuses on a single shared objective. Definitions differ by dictionary or website; some words to describe the meaning are condition, purpose, or relationship of working together. In this chapter, we will cover not only cooperation and collaboration but also alliance, partnership, network, and coordination as examples of multilevel cooperation. We will use these words interchangeably, but their usage does not exclude other meanings. Alone we can do little; together we can do so much. – Helen Keller

We use the term global health to talk about the humanitarian aid or cooperative activities aimed at addressing health issues worldwide. The development and implementation of health solutions often require global cooperation (Koplan et al. 2008). Cooperation or collaboration in global health can be categorized into different categories. The first is cooperation on geographic differentiation: an international, national, prefecture/province, district, community, or individual level (and combinations thereof). The second addresses several ways to formalize cooperation, including contract-based cooperation through memoranda of understanding (MOU), alliance, and mutual support. The third category refers to the actor; for example, the public sector includes multilateral and bilateral organizations, and the private sector includes non-governmental organizations (NGOs), private companies, individuals, and public-private partnerships (PPPs). All United Nations

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(UN) agencies and multilateral organizations are cooperative and collaborative actors at an international level. The purpose of cooperation is the axis of the fourth category. This includes policymaking, funding, implementation, research, etc. The means of collaboration in the fifth category include ordinary (physically getting together) and online participation utilizing cyber networks. There are several categories of cooperation and collaboration, but all will be categorized by these different axes of entities. However, these categorizations are mutually overlapping. Therefore, we would like to use the following figure to outline coordination in global health: “Coordination Mapping Framework” (Fig. 1). This figure uses the “purpose” axis for the x-axis and the “geographic level and actor” axis for the y-axis to categorize different types of coordination. In addition, we group these several examples into three groups, and then we try to explain coordination groupwise in this figure.

Cooperation on a Global-International Level Overview

Cooperation on a global-international level has different objectives, including policy alliance, financial alliance, and emergency response. They are formulated by UN-based platforms, UN-related organizations’ leadership, initiatives from major influential countries, specialty organizations’ interests, and countries’ needs.

Policy [I] Global [II] National

MDGs and SDGs 1 G7/8, G20 Other policy alliance Country coordination 4 committee

Implementation

Finance GF, GAVI

2

GF, GAVI

GOARN Cluster approach

Contracting

Contracting

5

Sub-National

Provincial coordination committee

Community

Village committee

Community fund

[III] Organization, Company

MOU, Partnership

Contract

Individual

Charity fixer

Cloud funding

Fig. 1 Coordination mapping framework

3 GOARN Cluster approach

6 Village committee Contract 7 MOU, Partnership Gamification 8 Distributed computing Pro-bono

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MDGs and SDGs Notable examples of global levels of policy alliance include the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs). Several countries took part in the formulation of the two agendas. However, they are not purely global health objectives. For instance, the MDG, formulated in 2000 by the UN, included the following: “Reduce child mortality (Goal 4),” “Improve maternal health (Goal 5),” and “Combat HIV/AIDS, malaria and other diseases (Goal 6).” In addition, the MDGs included other issues such as poverty, education, and the environment (Fig. 2). Three of the eight items were health-related (UN MDG Gap Task Force 2015); the eighth item stated the need to “Develop a global partnership for development.” These MDGs focused on support from developed to developing countries. The SDGs included 17 Goals to “Transform Our World” and covered several issues beyond global health (Fig. 2): “The SDGs are a call for action by all countries—poor, rich and middle-income—to promote prosperity while protecting the planet” (UN General Assembly 2015, UN 2020); “The SDGs recognize that ending poverty must go hand-in-hand with strategies that build economic growth and address a range of social needs including education, health, social protection,

No. SDGs’ Goal 1

No. MDGs’ Goal 1 2

Eradicate extreme poverty & hunger Achieve universal primary education

No poverty

2

Zero hunger

3

Good health & well-being

4

Quality education

5

Gender equity

6

Clean water & sanitation

7

Affordable & clean energy

Promote gender equality & empower women

8

Decent work & economic growth

9

Industry, innovation, and infrastructure

4

Reduce child mortality

10

Reduced inequalities

5

Improve maternal health

11

Sustainable cities & communities

6

Combat HIV/AIDS, malaria, & other diseases

12

Responsible consumption & production

7

Ensure environmental sustainability

13

Climate action

14

Life below water

15

Life on land

16

Peace, justice, & strong institutions

17

Partnerships for the goals

3

8

Develop a global partnership for development

Fig. 2 MDGs’ & SDGs’ goals

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and job opportunities, while tackling climate change and environmental protection” (UN 2020). The SDGs tried to build on decades of work, including that at the UN Conference on Sustainable Development (Rio + 20) in Rio de Janeiro, Brazil, in June 2012. Therefore, health issues do not dominate the SDGs as they do the MDGs; instead, they focus on interconnected efforts. Health issues can be addressed by the sectors of the other 16 goals, and in turn, the health sector can contribute to the issues of other sectors. This means that the MDGs and SDGs were formulated by the collective and cooperative efforts of many countries and stakeholders; they required the collaboration of actors in different sectors all over the world to be achieved.

G7 (Group of Seven) and G20 (Group of Twenty) The G7, a group of seven major advanced industrialized countries – or G7 + 1 (Russia) – was formulated as an international intergovernmental economic organization in the 1970s. An agenda on global health was first proposed in 2000 at the Okinawa Summit regarding how to tackle major infectious diseases in the world. Real commitment began to coalesce at the African Union Summit in April 2001, continued at the United Nations General Assembly Special Session in June of the same year, and was finally endorsed by the G8 at their summit in Genoa, Italy, in July 2001. After these processes, the Global Fund to eliminate HIV/AIDS, tuberculosis, and malaria was launched in January 2002 (Global Fund 2020a). This trend is continuous; the G7 is an emerging actor in global health governance (Aginam 2007). For instance, maternal, neonatal, and child health were addressed at the Muskoka Summit in Canada in 2010. Anti-microbial resistance (AMR) and public health emergencies were discussed at the Elmau Summit in Germany in 2015, under the influence of the Ebola outbreak in West Africa. Further, the Ise-Shima G7 Summit in Japan in 2018 addressed universal health coverage (UHC) and AMR related to the architecture necessary to respond to public health emergencies (Missoni et al. 2019). Today, the global health agenda is expanding to other international summits such as the Health Ministers’ Meeting in G7. The Group of 20 (G20) is an international forum for the governments of 19 countries, their central bank governors, and the European Union (EU), founded in 1999. They aim to discuss policy pertaining to the promotion of international financial stability. The Health Ministers’ Meeting started at the G20 in Germany in 2017 (G20 Information Center 2020). This appeared to be a promising sign for the phenomenon of inducing political and economic leaders to cooperate internationally to global health. However, similar agendas were picked up by other global meetings, such as the World Health Assembly (WHA), the G7, the G20, and so on. Agendas included AMR, UHC, and public health emergencies. Some may inquire why different international meetings pick up similar agendas and why the G20 Health Ministers’ meetings are valuable. It appears more useful for each international meeting to pick up different agendas or use different approaches or frameworks to tackle similar issues (Akashi et al. 2019).

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Issue-Specific Health Policy Alliance There are several other cooperative alliances in global health policy. Until the 1990s, international cooperation for global health mainly consisted of initiative-type cooperation led by the World Health Organization (WHO) or United Nations Children’s Fund (UNICEF), such as the Smallpox Eradication Program (1966–1980) (CDC 2016). The aim was to eradicate smallpox from the Earth, which was a political decision. The Primary Health Care (PHC) initiative was launched in 1978 to globally promote the implementation of PHC strategy (Cueto 2004). These initiatives were launched for one specific objective of a movement, not to establish new organizations. However, in 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) was established as a partnership to combat HIV. It is the sole cosponsored Joint Program in the United Nations system and draws on the experience and expertise of 11 United Nations organizations as cosponsors: the Office of the United Nations High Commissioner for Refugees (UNHCR); UNICEF; the United Nations World Food Programme (WFP); the United Nations Development Programme (UNDP); the United Nations Population Fund (UNFPA); the United Nations Office on Drugs and Crime (UNODC); UN Women; the International Labour Organization (ILO); the United Nations Educational, Scientific and Cultural Organization (UNESCO); the WHO; and the World Bank (UNAIDS 2020a; Knight 2008). As such, UNAIDS reflects the UNAIS cosponsor mechanism (UNAIDS 2020b). The Partnership for Maternal, Newborn & Child Health (PMNCH), launched in 2005, is the world’s largest alliance for women’s, children’s, and adolescents’ health. PMNCH brings together over 1,000 partner organizations from 10 constituencies across 192 countries (PMNCH 2020). Another recently launched partnership is UHC 2030: “UHC 2030 provides a multi-stakeholder platform to promote collaborative working in countries and globally on health systems strengthening. We advocate increased political commitment to UHC and facilitate accountability and knowledge sharing” (uhc2030 2020). Evidently, these alliances are established according to world issues that need to be tackled globally. Therefore, the topics of cooperation depend on global needs. There are several cooperations, collaborations, alliances, etc. in the field of global health. We do not mention all of them in this section, but we cannot exclude the following novel trend – financial alliances.

Global-National Level: Financial Alliance New Actors in the Global Health Arena In addition to these policy alliances, finance has been highlighted during the past 20– 30 years. In the global health field, the new actors are from financial organizations. Among these, the World Bank provided financial aid to developing countries for investments to increase their national income originally as a financial institution. However, the World Bank has been slowly shifting from a financial institution to a

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development agency that invests in human development such as family planning, nutrition, health, and education, from the 1960s through the 1980s (Ruger 2005). This was revealed in 1993 in the “World Development Report: Investing in Health” (World Bank 1993). Another newcomer was the Bill & Melinda Gates Foundation, which started to fund global health in 2000. This foundation was established by the famous billionaire, Bill Gates, and put huge financial input into the global health field by using business methods. These monetary introductions to global health mark the beginning of a new era in the field, joining conventional actors on health, multilateral aid agencies such as the WHO and UNFPA; bilateral aid agencies; and NGOs such as the International Federation of Red Cross and Red Crescent Societies (IFRC) and Doctors Without Borders. Financial organizations seem to have louder voices on global health than technical organizations such as the WHO due to their monetary power. Formerly, UN agencies obtained funding for their budget from the countries’ contributions or funding activities, and NGOs obtained funding from donations or countries’ inputs. However, since the participation of these new financial actors began, conventional implementation agencies and policy organizations can proceed with their activities more rapidly. For instance, Doctors Without Borders praised “the TB Alliance, a product development partnership (PDP) funded mainly by the Bill & Melinda Gates Foundation” (Doctors without Borders 2006). The new coordination platforms were developed in the early 2000s based on the participation of new actors such as the Global Fund (GF) and the Global Aliance for Vaccines and Immunization (GAVI). These alliances practice an objective-oriented coordination (collaboration) through monetary inputs.

Global Fund (GF) The GF, created in 2002, is a PPP designed to fight HIV/AIDS, tuberculosis, and malaria. They raise, manage, and invest the world’s monetary resources to respond to three of the deadliest infectious diseases. Partners include governments, civil society, technical agencies, the private sector, and people affected by the diseases. As an international organization, the GF mobilizes and invests more than US$4 billion a year to support programs run by local experts in more than 100 countries (Global Fund 2020b). The GF set several cooperation mechanisms. Its board sets strategies, governs the institution, and approves all funding decisions. The board members are from donor and implementer governments, non-governmental organizations, the private sector, private foundations, and affected communities. Further, The GF initiated the Technical Review Panel (TRP) to evaluate the technical merit of requests for funding worldwide (Global Fund 2020b). At the country level, the Country Coordinating Mechanism (CCM) – a national committee – was established to submit requests for funding on behalf of the entire country and oversee implementation once the request has become a signed grant. CCMs include representatives of every sector involved in disease responses (Global Fund 2020c). However, CCMs are sometimes duplicated with an existing coordination mechanism at the country level.

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Global Aliance for Vaccines and Immunization (GAVI) In the 1990s, international immunization programs tried to cover around ten antigens: hepatitis B, yellow fever, Haemophilus influenzae type B (Hib), Streptococcus pneumoniae, rotavirus, Neisseria meningitidis serogroup A, Japanese encephalitis, human papillomavirus, measles, and rubella. However, there were difficulties reaching communities who needed immunization; reasons included instances of manufacturers being unable to produce high-price vaccines due to market failure (Lee et al. 2013). The GAVI Alliance (formerly the Global Aliance for Vaccines and Immunization), a global health partnership of public and private sector organizations, was formulated in 2000 to respond to the stalled progress of international immunization that resulted. Its innovative approaches to international health and development provide a unique opportunity for several partners to build consensus around policies, strategies, and priorities and introduce solutions to encourage manufacturers to produce lower-price vaccines for the poorest countries (led by the Bill & Melinda Gates Foundation and other funding partners) (Gavi 2019a; WHO 2020a). GAVI uses two key models: a partnership model and an operating model (business model). GAVI’s funding partners include the WHO, UNICEF, the World Bank, the Bill & Melinda Gates Foundation and broader alliance, civil society organizations, developing country governments, developing country pharmaceutical industries, industrialized country governments, industrialized country pharmaceutical industries, and research and technical institutes. The operating model (business model) is a PPP. GAVI represents the sum of its partners’ individual strengths, from the WHO’s scientific expertise and UNICEF’s procurement system to the financial know-how of the World Bank and the market knowledge of the vaccine industry (Gavi 2019b). The meanings of these alliances are not limited to politics; they also reduce inefficiency. The above two models were some of the new approaches to coordination in 2000. Funding Coordination for Research This financing coordination happens at global and national levels. Implementation is not limited to the GF and GAVI; further, it encompasses funding of individual researchers such as the Global Alliance for Chronic Diseases (GACD). “The GACD takes its origin in the Grand Challenges Partnership in 2007 and is focusing on implementation research proposals for the prevention and/or early diagnosis of cancer in low- and middle-income countries (LMIC) and/or in vulnerable populations in high-income countries (HIC).” The GACD allies funding agencies in different countries to foster research on non-communicable diseases (NCDs). This alliance addresses the fact that “the world is facing a critical healthcare problem due to aging societies, unhealthy lifestyles, socio-economic inequalities, and a growing world population. Cancer is becoming one of the most important public health problems worldwide. In 2018, it is estimated that 181 million people were diagnosed with cancer; 9.6 million have died from it. Predictions suggest that by 2030, 30 million people

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will die from cancer each year, three-quarters of which live in LMICs” (GACD 2020). Financial inputs, especially large amounts of money, are very strong driving forces to involve different actors such as the countries, donors, implementing agencies, private sectors, and members of the community. However, the introduction of financial inputs or incentives must be done carefully, as they can sometimes impair or distract from the steady progress of voluntary indigenous efforts. For instance, withdrawal from the GF is an emerging issue that must be tackled in partially developed countries. We will discuss the Bolivian case later, where monetary incentives seem like a “drug” – attractive and even addictive.

Global-National Level: Implementation Coordination to Respond to Critical Situations As cooperation cases, emergency responses are good examples. Emergency responses include disaster relief (for natural or man-made disasters), communicable disease epidemic as a public health emergency, refugee response, etc. The international community uses different frameworks for disaster response and communicable disease response – the Cluster Approach and the Global Outbreak Alert and Response Network (GOARN). Both frameworks function on global and national levels as follows:

Cluster Approach In emergency response, coordination is necessary; recently the Cluster Approach became common for disaster relief. The Cluster Approach was introduced when a major reform of humanitarian coordination, known as the Humanitarian Reform Agenda, was introduced to enhance predictability, accountability, and partnership in 2005 (OCHA 2020). It aims to reduce overlap and fill the gaps in aid activities and lead effective and appropriate disaster relief activities. A cluster is a group of agencies, both UN and non-UN, in each sector of humanitarian action, that gather to work together toward common objectives within a particular sector of emergency response (WHO 2020b; OCHA 2020). Disaster relief activities are divided into several aid clusters, such as health, water, sanitation, logistics, etc., and lead or co-lead agencies are designated in each cluster from UN and/or non-UN organizations (OCHA 2020; IOM 2019) A list of clusters and lead agencies can be seen in figure (Fig. 3). They are designated by the Inter-Agency Standing Committee (IASC) and include clear responsibilities for coordination (OCHA 2020). “At the global level, clusters are responsible for strengthening system-wide preparedness and providing technical capacity to respond to humanitarian emergencies within their respective sectors. At the country level, clusters ensure that the activities of partners are coordinated and harmonized. To the extent possible, clusters mirror national response structures, use terminology that is close or identical to that of the national sectors, and are co-chaired by government representatives” (IOM 2019).

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Affected People

Cluster

Lead Agency

Health

WHO

Nutrition

UNICEF

Education

UNICEF, Save the Children

Food Security

WFP, FAO

Water, Sanitation, Hygiene

UNICEF

Shelter

IFRC, UNHCR

Protection

UNHCR

Camp coordination & management

IOM, UNHCR

Early recovery

UNDP

Emergency Telecommunications

WFP

Logistics

WFP

Humanitarian & Emergency Relief Coordinator

Fig. 3 Cluster approach

In the health field, the WHO is trying to standardize the quality of Emergency Medical Teams (EMT) by providing the following certificates: Type 1 (Outpatient Emergency Care), Type 2 (Inpatient Surgical Emergency Care), and Type 3 (Inpatient Referral Care). “EMTs historically have had a trauma and surgical focus, but Ebola has shown us their value in outbreak response and other forms of emergency” (WHO, Global Health Cluster 2013). Through this approach, we can expect strengthened leadership and accountability in key sectors and enhanced partnerships among aid agencies (WHO 2020b).

Global Outbreak Alert and Response Network (GOARN) Different frameworks such as the Global Outbreak Alert and Response Network (GOARN) led by the WHO are prepared for public health emergencies such as Ebola virus disease outbreaks. “WHO ensures that countries have rapid access to the most appropriate experts and resources for outbreak response through the GOARN. GOARN was created in April 2000 to improve the coordination of international outbreak responses and to provide an operational framework to focus the delivery of support to countries” (WHO 2020c). “GOARN is a collaboration of existing institutions and networks, constantly alert and ready to respond. The network pools human and technical resources for rapid identification, confirmation, and response to outbreaks of international importance” (WHO 2005). In the GOARN framework, based on their specialty, organizations or individuals will register with GOARN and receive training to participate in aid activities to understand WHO standards and frameworks. When an outbreak of an infectious

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disease is recognized, the recruitment of specialists among GOARN Partners will be announced, and registered personnel will volunteer. Based on the needs of the affected countries, members of the GOARN team will be selected and deployed in the field, either as an individual or a group.

Cooperation at National-Subnational-Community Levels Overview

Cooperation at national-subnational-community levels is defined by the relationship between the country’s governmental organizations (such as ministry, local health authorities, and communities) and external organizations (donors, NGOs).

National and Subnational Level: Coordination Among Different Organizations with Different Roles Donor Coordination at the Country Level A noteworthy example of coordination at the country level is donor coordination, especially in post-conflict countries. These coordination mechanisms were tried in different countries for several decades in Cambodia, East Timor, Afghanistan, etc. Here, we use Cambodia and Afghanistan cases as examples. At the Ministry of Health level, a coordination committee was set. High government officials, such as secretaries of State of the Ministry, chair this committee. The WHO and another aid agency serve as co-chairs or supporting administrative offices. The coordination committee is not restricted to donors and multilateral and bilateral agencies; it includes directors of Ministry (Fig. 4). It is recommended that representatives of NGOs or NGO coordination committees in the country should be members of this committee because they should know the country policies and coordinate with other organizations. This coordination mechanism reduces the duplication of aid activities, fills the aid gaps in different areas, and shares aid experiences among stakeholders in order to formulate joint national policies. The policies are subsequently conveyed from the Ministry of Health to donors and aid agencies, including NGOs. Under this coordination committee, several sub-committees can be set for specific topics, such as maternal and child health, health finance, etc. (Table 1). These topics can be selected according to the country’s needs. In these sub-committees and topic-related departments of the Ministry, donors, NGOs, and other stakeholders can hold membership. Ministry officials lead sub-committees with some aid agencies. The Ministerial Coordination Committee can ask the sub-committees to discuss, formulate, and submit proposals and reports. Sub-committees discuss detailed issues, make consensus plans or policies, and submit their results or proposals to the upper Ministerial Coordination Committee (Akashi et al. 2006).

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National level (Ministry of Health level)

Donor support

Coordination committee

Sub-coordination committee for Topic 1

Sub-coordination committee for Topic 2

Working group

Working group

Working group

1

2

3

Sub-coordination committee for Topic 3

Donor support

Donor support

Sub-national level (Provincial level)

Coordination Committee at Province 1

Coordination Committee at Province 2

Coordination Committee at Province 3

Donor support

Fig. 4 Donor coordination structure Table 1 Topics of sub-coordination committee Topic category Personnel Maternal and child health

Cambodia Human resources Maternal and child health

Specific diseases

Mental health Oral health Prevention of blindness Surgical training Health economics Medical technology Laboratory Medical ethics & research

Management, others

Total topic number

10 topics

Afghanistan Human resources Women’ health (safe motherhood, reproductive health) Child health Nutrition EPI HIV/AIDS Communicable dis. & emergency response

Salary & Incentive standardization for NGOs Essential drugs & private sector Health management information system Hospital management IEC 13 topics

This kind of aid coordination mechanism is installed in other non-post-conflict countries. In Lao PDR, the Health Sector-wide Coordination Mechanism, including Health Sector-wide Coordination Group Operational Level (ministry-level coordination committee) and Health Sector-wide Coordination Group Policy Level (above the ministry level, the minister and ambassadors’ meeting), was

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set for ministry and donor coordination (Japanese Team of CDSWC Phase 2. 2016). In some countries, similar committees and mechanisms are set at the provincial/ prefecture level (Akashi et al. 2006). However, the following mechanism may be used in the countries with few human resources at the local level.

Subnational Level: Contracting with Aid Agencies to Strengthen Original Functions In some less developed countries, local public administrative capacities are weak, especially in rural areas. In this case, central or local governments may ask aid agencies to support, strengthen, and improve management capacities at the provincial, district, municipal, or village level as a unit to ensure health and medical services. This is sometimes based on contracts with bilateral organizations or NGOs. There are several options for support, such as asking the aid agency to run the district health services. That is, aid agencies are expected to manage and provide quality health and medical services in certain districts or provinces. This is similar to asking a health organization to run a hospital. The second option is to ask aid agencies to manage and provide health and medical services by fostering local health officials. The third option involves local officials trying to manage local administrative services with support and compensation from the aid agencies. The second and third options include the components of “fostering local staff.” These patterns were tried in Cambodia and Afghanistan in the 1990s and 2000s (Akashi et al. 2006). The Cambodian case is a success story for Afghanistan because many aid workers who worked in Cambodia were working in Afghanistan. Some have criticized the implementation agencies as not having the capacity or experience to run and manage local health administration in their developed countries; therefore, this approach may not be appropriate. Although they may be true, I wonder how many health personnel with such experience in developed countries are willing to work in such difficult conditions in developing countries, especially in postconflict situations. If few experienced personnel are available, we must consider those with at least a master’s degree in public health to be candidates to work in these projects. Funding to the Contracted Agencies Contracted agencies to support the operations of the local health management need funds to work in such difficult situations. Certainly, such agencies can work with their budget. However, an interesting coordination scheme was tried in Afghanistan. The aid agencies, especially NGOs, tried to run or support the local government as implementing agencies, and donors such as bilateral or multilateral organizations provided the funds for implementing agencies. Therefore, each province or district was supported by one NGO for implementation and one donor agency for funding (Fig. 5) (Akashi et al. 2006).

Community-Level Collaboration Communities usually have collaborative capacities and experience for farming, merchandise, and so on. Therefore, they can deal with some issues through mutual

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Central Government (Ministry of Health) Contract

Donor Community Central level Province A (District A)

Coordination

Donor A to fund Prov. A

Aid agency A to manage Prov. A

Aid agency B to manage Prov. B

Donor B to fund Prov. B

Province B (District B)

Donor C to fund Prov. C Aid agency C to manage Prov. C

Province C (District C)

Province D (District D) Aid agency D to manage Prov. D

Donor D to fund Prov. D

Fig. 5 Contracted to aid agencies

communication with the village chief, the religious chief, etc. However, sometimes these efforts function solely within a limited number of families in the community. In addition, relationships may be limited in communities that have experienced armed conflicts or societal trauma because the human relationship has already been disrupted. In these situations, external experts can be good moderators in the community. As these experts are respected by the community and not involved in intense local relationships, they can advise from more neutral points of view. Two examples follow: Overview

Case #1: Village Committee In Bangladesh, Community Support Groups were established by the JICA Safe Motherhood Promotion Project (SMPP) in collaboration with CARE Bangladesh. Group members include the village chief, elders, school teachers, religious leaders, traditional birth attendants, health volunteers, and so on (Photo 1). They periodically meet and discuss their current situation by using community diagnosis and social resource mapping (Photo 2) to identify local resources and locations where pregnant women are experiencing health (continued)

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Photo 1 Village meeting – community support group in Bangladesh -

issues related to pregnancy and birth. Aid agencies can support the formulation of the meeting, modulate the discussion, and advise the management of these collaborative works. This kind of mapping can be done with a participatory approach; community resources can be located through this process. These activities begin when the baby is born. They choose those women who are sent for midwife training in another province to become a community midwife (Kamiya et al. 2013; Tobe et al. 2019). Further, as the baby’s birth was expected, they started a community fund to pay for the birth. Later, the community decided to use the program for education. This participatory mapping can be accelerated through IT (Weyer et al. 2019). Case #2: Health Promotion Health promotion is another form of community collaboration. In Bolivia, health promotion works were introduced and implemented by the JICA project in Santa Cruz Prefecture (Photo 3). The project introduced the “PRECEDEPROCEED Model” (Rural Health Information Hub 2011) for health promotion (Fig. 6) and started community meetings with health center staff voluntarily to discuss the health issues and how to solve these issues collaboratively. Interestingly, the World Bank introduced similar projects in the same village, (continued)

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Photo 2 Social resource map in Bangladesh

but they provided monetary incentives to the village volunteer. Certainly, villagers chose the World Bank project due to the monetary incentives for their participation in meetings and activities. Therefore, the JICA project team had to change their project areas. A year later, the World Bank ended their project, likely due to budgetary limitations. Activities introduced by the World Bank were stopped, as nobody wanted to continue. Conversely, the JICA project faced different challenges. The community and the health center staff had conflicts. Both sides accused the other side’s deficits. For instance, community members accused health center staff of being unkind by not offering services during the night. Health workers accused the community of not understanding the rules. However, health center staff were prohibited from offering services during the night. After discussions, there was a mutual understanding, and a common enemy was recognized: people were dying because of health reasons. They started to devise solutions together, such as (continued)

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Photo 3 Community workshop for planning by using modified PRECEDE-PROCEED model in Bolivia

Phase 5 Administrative Policy Assessment

Phase 4 Educational & Ecological Assessment

HEALTH PROMOTION

Predisposing factors

Health Education

Reinforcing factors

Policy Regulation Organization

Enabling factors

Phase 6 Implementation

Phase 7 Process Evaluation

Fig. 6 PRECEDE-PROCEED model

Phase 2 Phase 3 Epidemiologic Behavioral & Environmental Assessment Assessment

Behavior & Lifestyle Health

Phase 1 Social Assessment

Quality of life

Environment

Phase 8 Impact Evaluation

Phase 9 Outcome Evaluation

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fundraising to purchase community medicine. They initiated a lottery to obtain profits that can be used to purchase community medicines stored in the health center for night use. Through these processes, JICA continued the project. The government of Bolivia recognized their approach and wanted to expand it to other areas. Monetary incentives can foster the introduction of new collaborative activities, but not enough to continue and sustain them (JICA 2017).

Cooperation with Private Companies and Individuals Overview

The cooperation between private companies, academic organizations, and individuals creates the possibility to add new values to develop new approaches.

Cases

Private Sector Cooperation: Consigning Functions to Others Contracting with Private Companies for Implementation For conventional collaborations, big companies are contracting with small companies. For instance, bilateral donors such as USAID, JICA, and others contract with NGOs to implement projects in developing countries. Additionally, international aid agencies and bilateral organizations hire consultants for tasks such as project formulation, surveys, policy recommendations, and sector reports. It is convenient to execute projects by using different workers or organizations with the necessary skills or capacities; it can be effective to add a fresh perspective to the projects. However, there are some risks, including the possibility for the contracted consultants or aid organizations to be evaluated by their short-term achievements; they tend to show their good work to the funding agencies by offering monetary incentives to the community, providing instructions to their local counterparts regardless of their understanding, and implementing new interventions or recommendations that may not fit existing local regulations. These works by the consultants seem to be executed only to receive new contracts after their current mission, not for empowering countries, communities, and people. Use Other Agencies to Add New Functions or Values As another form of coordination, one organization can obtain additional functions or values in collaboration with another that already possesses such functions and

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activities. For instance, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has taken care of Palestine refugees for more than 70 years. As first-generation refugees age, non-communicable diseases (NCDs) increase. UNRWA started to spread healthier habits, including healthier recipes, to the refugees. They recognized that several refugees have smartphones; therefore, they created a website to show the healthier recipes in Arabic. Further, they also cooperated with Cookpad to display the recipes on its website. The homepage of “Cookpad” reads: “Healthy life starts from healthy food. We put many UNRWArecommended health foods & food for diabetes in a big-hit cooking site (Cookpad, Arabic). Please check! Photo is Fattoush: my favorite salad. https://cookpad.com/. . ./ %D9%85%D8%B3%D8%AA%D8%AE%D8%A. . ./4834569” (Cookpad 2016). Moreover, UNRWA hosted a competition to foster entrepreneurs in a Palestine camp in cooperation with the Japan Gaza Innovation Challenge (JGIC) initiative. This was the “Gaza Entrepreneur Challenge: Unleashing Youth Creativity and Innovative Ideas for a Brighter Future.” During the event, UNRWA provided an opportunity for young entrepreneurial refugees to learn the essential skills and knowledge to run a successful business through participating in workshops and lectures on how entrepreneurial ideas could contribute to a brighter future for Gaza. Further, participating teams could present their ideas and connect with Japanese investors and social entrepreneurs. “The event was also supported by local entrepreneurial incubators in Gaza, including the UNRWA social enterprise spin-off Gaza Gateway. Eighty applications of various ideas and initiatives were presented to the panel of JGIC initiative” (UNRWA 2017). In 2017, “the winners were the creators of ECHOHOME, which aims to produce alternative and renewable energy by converting organic matter and manure into flammable methane through anaerobic fermentation, as well as organic fertilizer that nourishes soil to naturally improve crop quality without damaging human health. The team will be rewarded a financial prize of US$ 5,000, along with technical support to start their business and a training trip to Japan. The focus of the 2017 Gaza Entrepreneur Challenge was on entrepreneurship projects that contribute to enhancing living conditions in Gaza. The ideas that were presented spanned various fields, including health care, nutrition, water management, recycling, agriculture, education and manufacturing” (UNRWA 2017). These are useful not only for refugees under the care of UNRWA; this kind of approach in collaboration with other organizations in different fields can lead to innovation. It may be possible to coordinate with other sectors, such as environment or education in SDGs, or other technologies and specialties such as ICT, space technologies, logistics, and so on.

MOU-Bbased or Partnership-Type Collaborations: “Between Organization and Organization” A memorandum of understanding (MOU) is a popular form of cooperation. This is formed between ministry and ministry, organization and organization, university and university, or hospital and hospital, and sometimes between different entities. The purposes are different case by case, such as for collaborative research, mutual

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exchange of staff, training, patient management and care, or other agreed discussion points. Originally formulated for a specific purpose, sometimes the purpose converted to just making MOUs with ceremonious meanings for both parties. Therefore, some organizations only can show the number of MOU, instead of the contents and progression in the agreements. An MOU is typically a nonbinding agreement between the parties that documents a relationship of good will. It is not a binding legal agreement. MOUs spell out the parties’ understanding of the contemplated relationship and can be the first stage in the formation of a formal contract in the business context. However, this can be a general agreement between them, with a detailed agreement (such as a research agreement for each research project) to be made later. “Because an MOU is signed by both parties, it carries a degree of seriousness and mutual respect. MOUs are stronger than a gentlemen’s agreement and have the advantage of documenting in writing each party’s intentions and actions, though frequently without details regarding implementation” (Leader 2017). One example of a partnership between two organizations is the Sister Renal Centers Program organized by the International Society of Nephrology (ISN). This program links emerging renal centers or units in low- and middle-income countries with established centers of excellence in the developed world to improve the practice of nephrology in emerging countries. ISN supplies funding, a framework, and educational benefits (International Society of Nephrology 2020). Another example of partnership happens when companies cooperate to integrate social and environmental concerns in their business operations and interactions with their stakeholders, such as corporate social responsibility (CSR) or philanthropy. In this way, companies can support social enterprises or NGOs to contribute to the betterment of society (UNIDO 2020).

Individual Level: New Approaches for Cooperation by Connecting Individuals Many activities and trials were performed in the field of global health with a great deal of cooperation. Some are already recognized as authentic approaches, for instance, the GF and GAVI with their public-private partnership, which has remained active since 2000. However, enormous amounts of money (like the amount of a national budget) are needed to implement so many projects in different countries. Even as they endeavor to minimize expenses by using their budgets efficiently, funding remains crucial. Naturally, several organizations or individuals would like to join or support the activities or projects, if they are interested in them. For instance, “Last Mile Health” is implementing good community health worker projects in Liberia, and several organizations such as universities, NGOs, private foundations, UN agencies, and individuals support this project through technical advice, financial support, etc. (Last Mile Health 2016). In this session, new trends that can translate individual efforts into meaningful activities on global health will be polled. That is the reason for “Globalization 3.0,”

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which refers to individuals getting together globally to compete individually (Friedman 2005).

New Funding Scheme Today, people can receive budgetary support through crowdfunding sources such as “ReadyFor.” Crowdfunding is “the practice of funding a project or venture by raising many small amounts of money from a large number of people, typically via the Internet” (Prive 2012). In this scheme, a person who has a project idea can post their presentation on the crowdfunding website, and viewers who identify with their ideas can donate a small amount of money through the website. In this way, funding can increase a great deal, even if each donation is small. Some crowdfunding projects are related to health improvement in developing countries. With this scheme, resources like GF or GAVI may not be necessary. This can connect the projects with people who may not be familiar with their particular global health activities. These kinds of investments (cooperation based on sympathy or empathy) are not limited to the Internet. For instance, the social enterprise TABLE FOR TWO (TFT) invented a unique system. This innovative meal sharing program tackles obesity and hunger at the same time: when individuals in developed countries have lunch (in company cafeterias, restaurants, food trucks, vending machines, etc.), they pay for their own food and add 20 Japanese yen (around 25 cents in US dollars) to the total. Those 25 cents are sent to low-income regions throughout the world, where they are applied to one student’s school meal. Through this system, students in low-income regions are encouraged to attend school. The person in the developed country thus eats healthy food while contributing to student education and nutrition (TFT 2020). Another example is a social entrepreneurship-supporting program such as the Ashoka Global Academy Foundation (Ashoka 2020), which identifies and supports the world’s leading social entrepreneurs who have ideas for far-reaching social change. Ashoka started a global system for electing the world’s leading social entrepreneurs to the Ashoka Fellowship. As a result, they created Fellowship Support Systems, where they can contribute to global health as changemakers (Ashoka 2020). Social enterprises have wide spectrums; therefore, they can be actors in global health, because they are willing to solve social issues as a mandate or mission. The spectrum of activities includes funding, management consulting, community financial assistance, human resource development, advocacy, service provision, fair trading, product development, and merchandise (Akashi 2010 presentation). Technical Advisory Similar connecting and cooperating roles related to global health are filled by specialists. Mr. Bill Gates founded the Bill & Melinda Gates Foundation and hired many such specialists. Mr. and Mrs. Gates can ask these specialists to provide advice and oversee implementation of particular projects. In addition, film stars, famous singers, and celebrities can collaborate with “Charity Fixer” to obtain advice on

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international aid activities or appearances at international meetings (Global Philanthropy Group 2010). Furthermore, there is voluntary, pro bono work. Of the collaborative forms, pro bono itself is not a new approach. “Pro bono publico” is a Latin phrase meaning “for the common (public) good,” and it was introduced in the eighteenth century. “Pro bono, or skill-based volunteering refers to the voluntary engagement of people who share their skills for free or nearly free with individuals or organizations who cannot access these skills, or who pursue a social goal” (Global Pro Bono Network 2020; Tardi 2019). In fact, they are willing to provide their individual skills and advice to support start-up organizations, projects, or individuals. Pro bono can be offered by an individual or a group.

Using Information and Communications Technology (ICT) On the other hand, some collaboration platforms are carried out using software or modern technologies. Distributed computing refers to the performance of specific tasks by connecting several individual computers. For instance, “Folding@home™” of Stanford University connects individual computers all over the world as a network to analyze the structure of proteins (McGonigal 2011). Gamification is another way to induce collaboration: several individuals complete tasks through participation in a game. For instance, “The Extraordinaries” is a platform that concentrates the efforts of different individuals to achieve a specific objective (through the “game”). In this game, the organizer gives the mission to the participants. For example, “Your mission is to take photos of ‘secret objects,’ and tag their locations by GPS on the database.” The secret objects are the place of AED. For instance, participants collaboratively search for AED and mark their locations on the maps. An AED map can be easily formulated in certain areas. The “game” is the game; therefore, the players participate voluntarily, with the same incentive as other games – that is, fun! Consequently, they are collaboratively contributing to global health. Another example of gamification is “Free Rice” by WFP. In this game, participants answer questions by WFP, and WFP can receive the rice from the collaborating organizations according to the number of the correct answers by the participants (McGonigal 2011).

Conclusion This chapter presented and discussed the various types of global health cooperation and coordination. We cannot imagine today the state of global health in 10 years. However, we can expect expanding coordination and collaboration efforts, resulting from quickly progressing ICT tools and methods. In the era of SDGs, there are more cooperation and collaboration, not only within the health sector but also among sectors such as environment or education. However, these are just technological tools, and history tells us that an individual, as much as a whole country, cannot survive in isolation. Thus, cooperation and collaboration are vital for human

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survival, and the field of global health is exactly the world of cooperation, that is, the world of human beings. Nothing truly valuable can be achieved except by the unselfish cooperation of many individuals. – Albert Einstein

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Tardi C. (2019) What does pro bono really mean? Investopedia. Available from: https://www. investopedia.com/ask/answers/08/pro-bono.asp. Accessed 10 Feb 2020 The Partnership for Maternal, Newborn and Child Health (PMNCH). About. Available from: https://www.who.int/pmnch/about/en/. Accessed 20 Jan 2020 Tobe RG, Islam MT, Yoshimura Y, Hossain J (2019) Strengthening the community support group to improve maternal and neonatal health seeking behaviors: a cluster-randomized controlled trial in Satkhira District, Bangladesh. Plos One. Published: 28 February, 2019. https://doi.org/10.1371/ journal.pone.0212847uhc2030. UHC2030 is the global movement to build stronger health systems for universal health coverage. Available from: https://www.uhc2030.org. Accessed 20 Jan 2020 UN MDG Gap Task Force (2015) Millennium development goal 8: Taking stock of the global partnership for development. MDG gap task force report 2015. United Nations New York, 2015. Available from: https://www.un.org/millenniumgoals/pdf/MDG_Gap_2015_E_web.pdf. Accessed 20 Jan 2020 UNAIDS The Joint United Nations Programme on HIV/AIDS (2020a). Available from: https:// www.unaids.org/en. Accessed 20 Jan 2020 UNAIDS The Joint United Nations Programme on HIV/AIDS (2020b) Who we are. Available from: https://www.unaids.org/en/aboutunaids/. Accessed 20 Jan 2020 UNIDO United Nations Industrial Development Organization (2020) What is CSR? Available from: https://www.unido.org/our-focus/advancing-economic-competitiveness/competitive-tradecapacities-and-corporate-responsibility/corporate-social-responsibility-market-integration/what-csr. Accessed 20 Jan 2020 United Nations (2020) Sustainable development goals (SDGs): 17 goals to transform our world. Available from: https://www.un.org/sustainabledevelopment/. Accessed 20 Jan 2020 United Nations General Assembly (2015) Transforming our world: the 2030 agenda for sustainable development. Resolution adopted by the General Assembly on 25 September 2015. A/RES/70/1 https://sustainabledevelopment.un.org/post2015/transformingourworld UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East (2017) Gaza Entrepreneur Challenge: Unleashing youth creativity and innovative ideas for a brighter future. Available from: https://www.unrwa.org/newsroom/press-releases/gaza-entrepreneurchallenge-unleashing-youth-creativity-and-innovative-ideas. Accessed 20 Jan 2020 Weyer D, Bezerra JC, Vos AD (2019) Participatory mapping in a developing country context: lessons from South Africa. Land 8(9):134. https://doi.org/10.3390/land8090134 WHO World Health Organization (2005) Strengthening health security by implementing the International Health Regulations. Global Outbreak Alert and Response Network (GOARN). Available from: https://www.who.int/ihr/alert_and_response/outbreak-network/en/. Accessed 20 Jan 2020 WHO World Health Organization (2020a) GAVI – The Global Alliance for Vaccines and Immunization. Available from: https://www.who.int/workforcealliance/members_partners/member_ list/gavi/en/. Accessed 9 Jan 2020 WHO World Health Organization (2020b) The cluster approach. Available from: https://www.who. int/hac/techguidance/tools/manuals/who_field_handbook/annex_7/en/. Accessed 9 Jan 2020 WHO World Health Organization. (2020c) Global Outbreak Alert And Response Network-Goarn: partnership in outbreak Response. Available from: https://www.who.int/csr/outbreaknetwork/ goarnenglish.pdf?ua¼1. Accessed 11 Jan 2020 WHO World Health Organization Health Cluster Norton I, von Schreeb J, Aitken P, Herard P, Lajolo C (2013) Classification and minimum standards for foreign medical teams in sudden onset disasters. Available from: https://www.who.int/hac/global_health_cluster/fmt_guidelines_ september2013.pdf?ua=1 World Bank (1993) World development report 1993 : investing in health. Available from: http:// documents.worldbank.org/curated/en/468831468340807129/World-development-report-1993investing-in-health. Accessed 20 Jan 2020

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Importance of Innovation to Global Health Outcomes: The Role of Vaccines and Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Development and Characteristics of the Current Innovation System . . . . . . . . . . . . . . . . . . . . . . . . . Patents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test Data Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International IPR Obligations Relevant to Medical Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TRIPS Patent Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regulatory Test Data Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trademarks in the TRIPS Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Limitations of IPRs for Generating New Drugs for Neglected Diseases and for Small Markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diseases Disproportionately Affecting People in Developing Countries . . . . . . . . . . . . . . . . . . Antimicrobials and Antimicrobial Resistance (AMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternative Mechanisms to Incentivize Medical R&D and Improve Access . . . . . . . . . . . . . . . . . Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tax Breaks for Companies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advance Market Commitments (AMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Priority Review Vouchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patent Pools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Open-Source Drug Discovery and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Binding Framework for R&D and Pooled R&D Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . Product Development Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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J. Watal (*) National Law University, New Delhi, India Georgetown Law, Washington, DC, USA e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_115

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Abstract

This chapter sets out to critically examine the current system to incentivize biomedical research and development (R&D) and some key alternative ideas. The current market-based system medical innovation, based on intellectual property rights, played a crucial role in generating the new, innovative vaccines and drugs that have dramatically improved global health outcomes over a relatively short period, starting from the mid-twentieth century. This system, however, suffers from major flaws in that the innovative drugs and vaccines are not affordable to many living in poorer countries and, with ever-increasing drug prices, even to some in richer countries. Further, intellectual property, being a market-based system, does not provide a solution for disease areas where the patient population lacks adequate purchasing power – such as neglected tropical diseases – or where the markets are too small to be of interest to commercial entities, such as in the case of new medicines to tackle antimicrobial resistance. Alternative ideas that aim to incentivize the needed biomedical R&D, and to delink price from R&D costs, include prize funds, advance market commitments, and specific product development collaborations. It is clear that, given the urgency to improve global health outcomes, all stakeholders need to cooperate to find win-win workable solutions that would result in low-cost, affordable, socially optimal, and essential vaccines and drugs. Keywords

Biomedicine · Intellectual property rights · Innovation · Neglected tropical diseases · Delinkage

Introduction Without constant and continuing innovation in health-related products and processes since the 1900s, especially in vaccines and medicines, we would doubtless not have had the huge successes we have had in improving global health outcomes. Yet, there is dissatisfaction in the global health community about the functioning of the current system of innovation, which, in its current form, is intrinsically tied in with the market-based intellectual property (IP) system. The categories of IP most relevant to health product innovation are patents (that protect new, useful, and nonobvious inventions) and various regimes of market exclusivity for new medicines that restrict competition for a certain time period in order to meet different health policy objectives. This system is largely seen as having failed the poor in countries with low purchasing power and, with ever-increasing prescription drug prices, even in the richer countries as health budgets get quickly whittled away. Thus, there are, and will continue to be, huge current and anticipated unmet global health needs that require new vaccines and medicines that have either not yet been successfully invented or, if invented, have not yet been fully tested, or if tested

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adequately, not yet widely disseminated in a timely and affordable way to all those who need them. It is for this reason that it is crucial that the international community collectively gets the innovation system for health-related products and processes right, such that it not only produces the needed innovative health-related products but also ensures their widespread access and use by all those who need them. This is an imperative if we are to improve global health outcomes in any meaningful way for human beings no matter where they live in the world. This chapter makes an attempt to describe the current system of innovation in health-related products, including its strengths and weaknesses, and to critically examine the main ideas put forward by the public health community to improve it. (Much of the material in this chapter, where the source is not otherwise mentioned, is taken from the forthcoming second edition WHO-WIPO-WTO: Promoting Access to Medical Technologies and Innovation, 2020, with which the author was also associated, hereinafter called the Trilateral study. This study is freely available for redistribution under Creative Commons Attribution-Noncommercial-Share Alike public license to facilitate adoption and reuse. Given the vastness of the subject, this chapter focuses mainly on innovation (treated throughout as synonymous with the term “invention”) in one key sector of health-related products that has been the focus of the public health community in recent years, namely, pharmaceuticals (which covers vaccines and is treated throughout this chapter as synonymous with the words “drugs” and “medicines”), especially prescription drugs. Global spending on innovative prescription drugs (excluding generics) was US$ 753 billion in 2018, having increased from to US$ 595 billion in 2008, and is projected to rise to US$ 1081 billion in 2024. Vaccines play a crucial role in public health outcomes, and the market for vaccines has grown dramatically. The vaccine market has multiplied more than fivefold since 2000 and was worth more than US$ 31 billion globally in 2016, around 4% of total prescription drug sales (taken from various issues of EvaluatePharma ® up to 2019). Even though medical devices play a crucial role in diagnosis and treatment and are estimated to constitute about half of the prescription drug market, at US $426 billion in 2018 (see https://www.fortunebusinessinsights.com/industry-reports/ medical-devices-market-100085, accessed on 13.02.2020), they are excluded from this chapter primarily because the enormous diversity of products in this sector – ranging from simple ophthalmic glasses to orthopedic devices to large diagnostic imaging machines such as CT scanners, makes it difficult to generalize the innovation and IPR issues that arise in each of these product areas. But also, in this sector, innovation issues are relatively less controversial as compared to their regulation. Although twentieth and twenty-first century innovation in medical and surgical procedures, as well as diagnostic methods, has doubtless played an important role in improving global health outcomes, these are also mainly excluded from this chapter, except in so far as explaining the widespread non-application of patent laws to them.

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Importance of Innovation to Global Health Outcomes: The Role of Vaccines and Medicines That new, innovative vaccines and medicines have played a key role in improving health outcomes over the last hundred years should be self-evident. The global average life expectancy at birth has more than doubled from around 31 years in 1900 to over 72 years today, with improvements seen in every region of the world. To break this up, just over the last six decades, it has increased by one-fifth from 53 years in 1960 to 72 years in 2017 (see https://data.worldbank.org/indicator/SP. DYN.LE00.IN accessed on 13.02.2020). Much of this improvement in life expectancy can be attributed to sharp decline in childhood mortality rates globally, which in turn can be attributed to the invention and development of vaccines against key childhood diseases since about the middle of the twentieth century. Some, but not all of these vaccines, were also protected by patents before falling into the public domain, but given their relatively complex processes of production and distribution, patents would surely not be the sole or even key barrier to their replication and access. Although the first successful vaccine against small pox was invented by Edward Jenner in 1796, it was only in the 1940s – after it could be scaled up to mass production – that serious efforts were made to control this deadly disease. By 1948, vaccines that protect against pertussis (1914), diphtheria (1926), and tetanus (1938) had been combined into one and given as the fundamentally important DTP3 vaccine. This was followed by the important invention and introduction of the polio vaccine in 1955 by Jonas Salk, who famously refused to patent it (see Brian Palmer 2014). In the 1960s the measles, mumps, and rubella vaccines were developed and combined into one (MMR) vaccine by 1971. The 1980s saw the introduction of hepatitis B vaccine as well as of the Hib vaccine (Haemophilus influenzae type B) against meningitis and pneumonia. In the 1990s the varicella or chickenpox vaccine, as well as of the initial rotavirus vaccine, was introduced. The first decade of the twenty-first century saw the introduction of the pneumococcal and hepatitis A vaccine (taken from Children’s Hospital of Philadelphia 2019). Largely as a result of widespread inoculation, childhood mortality has declined by almost 60% from around 93 deaths of children below the age of 5 years per 1000 births in 1990 to around 39 deaths per 1000 births in 2018 (https://data.worldbank. org/indicator/SH.DYN.MORT accessed on 13.02.2020). Some deadly diseases were even eradicated, and their vaccination discontinued. Small pox was declared to have been eradicated worldwide by the end of 1979, and vaccination against it discontinued. The polio vaccine has also been discontinued in almost all countries of the world except three, namely, in Afghanistan, Pakistan, and Nigeria. However, well after their invention and introduction, the degree of access to these vaccines varies according to disease area. It is estimated by the WHO that in 2018, 86% of children across the globe received three full doses of DTP3 vaccine and the final dose of the polio vaccine, while coverage for other vaccines was lower: 86% for the first dose of the MMR vaccine but only 69% for the final dose; only 47% for the final dose of the pneumococcal vaccine; and 35% for the final dose of the rotavirus

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vaccine. By the end of 2018, the HPV vaccine had been introduced in only 90 countries. Nevertheless, immunization prevents 2–3 million deaths every year. Yet there is no room for complacency as 5.3 million children under the age of 5 died in 2018 alone, half of whom were in sub-Saharan Africa (https://data.unicef.org/topic/childsurvival/under-five-mortality/ accessed on 13.02.2020). Many of these deaths were from preventable causes, showing that vaccines or medicines, even if invented, are not always accessible to many living in poorer countries. It is estimated by the WHO that as many as 19.3 million infants under the age of one did not receive even the basic vaccines. (See https://www.who.int/news-room/fact-sheets/detail/immuniza tion-coverage accessed on 13.02.2020). Significant gaps exist in coverage especially for newer vaccines such as for HPV, rotavirus, and pneumococcal disease. They remain relatively expensive, in part due to the limited number of producers (see Access to Vaccines Index 2017 to see how vaccine manufacturing companies are responding to this challenge). There are many reasons for the low number of producers of vaccines. Vaccines are biologicals that are complex to manufacture. Unlike small-molecule chemical-based pharmaceuticals, vaccine production needs access to know-how and needs specialized infrastructure, for example, a dedicated manufacturing facility may be required for each vaccine. As of February 2020, while some vaccines manufactured in several developing countries like Brazil, Cuba, China, Indonesia, and Senegal were of quality sufficient to be prequalified by the WHO, price competition for several of the newer vaccines comes from WHO-prequalified vaccines manufactured in India, including for a new lower-priced pneumococcal vaccine approved at the end of 2019 (see https://extranet.who.int/gavi/PQ_Web/ and https://www.seruminstitute.com/news_ pneumococcal_vaccine.php – accessed on 13.02.2020). It is hoped that this would continue to be the case for newer global diseases such as Covid-19, for which there is not yet any proven vaccine or treatment as of the time of writing. The modern pharmaceutical industry and the current innovation model have produced many new medicines that have not just provided treatments but even complete cures for several deadly or debilitating infectious and noncommunicable diseases. From new antibiotics to steroids invented by the mid-twentieth century to improved cancer treatments and alternative cures for hepatitis C by the first two decades of the twenty-first century, the range and depth of new treatments owe much to the current incentives for innovation. In the early 1900s, there were very few treatments available for infectious diseases, and before the 1930s, the pharmaceutical industry hardly invested in research and development (R&D). The growth of the modern pharmaceutical industry, characterized by large in-house R&D and marketing departments, with large profits derived from sales of a relatively small number of medicines, is largely a post-World War II phenomena. The discovery that certain chemicals and microorganisms could be used to treat infections led to the development of a range of products that were used as antibacterial agents. Penicillin and sulfanilamide are good examples of these early, effective treatments, sometimes referred to as “wonder drugs.”

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500 450 400 350 300 250 200 150 100 50 0

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Approvals pe r ye ar

In 2000, communicable, maternal, perinatal, and nutritional conditions grouped together (CMNN) – mainly prevalent in poorer countries – contributed 43% of the global disease burden in terms of disability-adjusted life-years (DALYs), and noncommunicable diseases (NCDs) contributed 47%, with 10% being made up of injuries and other causes. By 2016, the share of NCD burden had increased to 60%, more than double the burden caused by CMNN diseases, which represented 29% of burden in DALYs. Thus, today poorer countries are also grappling with NCDs. Two of the top three leading contributors to overall DALYs in 2017 globally were ischemic heart disease and stroke, whereas in 1990 all three top causes were from the CMNN category. Figure 1 below, taken from the Trilateral study, shows the new product approvals and novel drug approvals in a key jurisdiction, the United States, over a period of 70 years from 1944 to 2014. In this figure, “new drug products” mean all products approved under new drug applications (NDA) and biologics license applications. “Novel drugs” mean new molecular entities – generally considered to be breakthrough innovations – approved under new drug applications and under new biologics license applications. It can be seen that the number of novel drug approvals was far less than new drug products, even if the former have risen steadily, from a low of below 23 in the 1960s to a record 59 in 2018. One of the key criticisms against the current innovation model is that it tends to incentivize me-too products rather than breakthrough innovations as these are more attractive to the private sector, being less risky with potentially high payoffs. However, among the recent novel drug approvals are breakthrough cures, including for hepatitis C, as well as new treatments for HIV/AIDS and some types of cancer.

New drug products approved

Novel drugs

Fig. 1 Approvals of medicines by the US Food and Drug Administration, 1944–2018. (Source: Trilateral study 2020, Chapter III)

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There is a recent trend toward more biologics, which are often large molecule drugs that are more complex to copy and where generic versions of originator products, called biosimilars, are also expensive to produce. In the United States and other rich country markets, there is also an increasing focus toward innovative drugs to treat rare or orphan diseases. In the United States, orphan diseases are defined as a disease that affects less than 200,000 patients and in Europe as those that affect 1 in 2000 patients. A high percentage of rare diseases (about 80%) affect children. Although rare diseases have by definition a low prevalence, with some having a single identified case worldwide, collectively they affect about 6–8% of the human population with a number of diseases recognized as rare comprised between 6000 and 8000 diseases (See Intini et al. 2019). But with additional market exclusivity incentives available in the United States, EU, and other key markets, these medicines could be highly profitable, even if sold in small volumes. The Trilateral study (Chapter III) has estimated that orphan drugs (i.e., medicines that treat rare diseases), approvals in the United States increased from 20% of novel drug approvals in 1999 to 58% in 2018.

Development and Characteristics of the Current Innovation System It is important to point out upfront that the current system of innovation for healthrelated products is the same as for any other products, be they electronic products or automobiles. It is essentially a system of intellectual property rights (IPRs) based on market incentives deeply rooted in capitalism, the most important legal instrument of which is a patent. We deal below with the evolution of the use of patents, test data protection, and trademarks. Other forms of IPRs such as copyright and design are less important in our discussion here and are therefore excluded. Other forms of market exclusivities such as those to encourage orphan drugs or pediatric formulations are not dealt with in this chapter as these are confined to a few jurisdictions.

Patents Patents represent a legal right granted by the state that allows its owner the exclusive right to make, use, sell, or otherwise distribute the invention covered by the patent. Any new and useful invention or improvement that is not obvious to a skilled person in the particular field of technology is eligible to be granted a patent. A patent is generally valid for 20 years from the date of first filing of a patent application, although some jurisdictions do grant patent term extension to make up for marketing approval or for patent grant delays. And patents are granted on a first-to-file basis in all key jurisdictions. This means that the inventor who is the first to file a patent application anywhere in the world gets the patent, since any subsequent application would no longer be new as novelty was destroyed by the first filing. This leads to a

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patent race among those working on similar inventions to file patent applications at as early a stage as possible. As far back as from the fourteenth century onward, there was an increasing recognition in Europe that market exclusivity needs to be provided to producers and suppliers of new, useful technologies and products to introduce them in foreign markets or even to widely disseminate them in domestic markets, without fear of infringement, rather than to keep them secret. (See https://en.wikipedia.org/wiki/ History_of_patent_law accessed on 13.02.2020). Chemicals and pharmaceuticals came into the fold of the patent system only in the nineteenth and twentieth centuries, and even then, not without controversy. Germany was the world leader in the field of chemistry in the late nineteenth and first decades of the twentieth century. The modern pharmaceutical industry grew out of the dyes and chemicals sector. When medicines were mostly produced in individual apothecaries or small pharmacies, they were not subject to patents. With the introduction of industrial and business processes for the production and marketing of pharmaceuticals, patent protection was sought to be extended to this sector. Physicians and pharmacists in Europe opposed such an extension, fearing that such legal monopolies would lead to higher medicine prices and would also give a stamp of government approval to unproven products. It took a few decades after World War II for much of Europe to grant patents in these sectors. Yet the reluctance to allow patenting of medicines continued in many industrialized countries. For example, Germany allowed patents for pharmaceutical products only in 1967; Japan in 1976; Switzerland in 1977; Italy in 1978; and Spain and Portugal only in 1992 (upon acceding to the European Union). The United States was always an exception as no sector was excluded under its patent law (much of this is taken from Gaudelliere 2008). By 1970 several patents had been granted for the new so-called ‘wonder’ drugs, although penicillin itself was never covered by a product patent. However, in these early years, the preferred method of profiting from patents – both on antibiotics and steroids, was to widely license patented products at fairly low royalty rates, for example, 2.5% of sales revenue. As a result, the prices of both penicillin, which had no product patent, and streptomycin, subject to a product patent but widely licensed on a nonexclusive basis, fell to a low level a few years after the date of their introduction into the US market. In the specific case of penicillin, the US price fell from US$ 4,000 per pound in 1945 to just US$ 282 per pound in 1950 (taken from Temin 1979). By the 1960s, US pharmaceutical companies took the lead in stopping the nonexclusive licensing of their new drugs, relying instead on exclusive in-house production and sales based on patent rights. Data from litigated patent cases shows that this changed business model yielded unprecedented profits of up to 1000% (see Scherer and Watal 2002), making the pharmaceutical sector one of the most profitable among industrial sectors at the time (Trilateral study 2020, Chapter III). As the business model shifted from the earlier widely licensed, price-based competition to exclusive production and product differentiation, and as regulation became stricter with drug approval processes and prescriptions made mandatory, biomedical R&Dbased firms had to spend more to convince physicians to prescribe their products,

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leading to marketing expenses rivalling or exceeding R&D expenses. Licensing or cross-licensing continues to take place today, but this is mostly between biomedical R&D-based pharmaceutical firms based on specialization on the basis of disease categories as this makes for marketing efficiencies. This is the current business model of innovation, with some exceptions, which is increasingly being questioned as it is focused on high prices and profits. As the pharmaceutical industry came into its own in countries such as the United Kingdom, Germany, and the United States and generated new, useful medicines, these countries pushed others to protect patents in this sector. Many of the Commonwealth countries followed the UK patent law of 1949 that introduced product patents for medicines but balanced it with provisions on compulsory licensing, where the state could authorize government departments or agents or third parties who have the know-how to make and sell the medicine without the authorization of the patent owner. There were some countries like India that, postindependence, went even further. India deliberated extensively on this issue and removed product patents for medicines, as well as introduced automatic compulsory licenses for the applicable short-duration process patents. Following advice given by UNCTAD in the 1960s and 1970s, several other developing countries in Latin America, notably Brazil and Argentina; in Africa (notably Egypt and Morocco); and Asia, notably in South Asia, also removed patents for medicines. (The WTO TRIPS Agreement has changed the situation in all these countries, as we shall see in the next section.) That the United States dominates innovation in the medical products sector can be seen from Fig. 2 below of patent applications published by WIPO under the Patent Cooperation Treaty (PCT). The PCT is a treaty administered by the World Intellectual Property Organization (WIPO) in Geneva. This is clearly one of the reasons for the United States taking the lead to push countries toward stronger patent protection for medical products. Among the ten main players, China has made remarkable progress in the 5 years up to 2018, although on a much lower absolute level. The US government also contributes by far the largest amount of resources to biomedical R&D through its National Institutes of Health (NIH). It has been estimated that government agencies worldwide provided around US$ 42 billion in health research funding annually (2011–2014), of which about 60% came from the US NIH. The role of the public sector has mainly been to conduct the basic research based on certain priorities, leaving it up to the private sector to choose to commercialize the candidate drugs or vaccines based on market dynamics. A recent analysis that included basic research found that public funding contributed to all new drugs approved in the United States over the period 2010–2016, and more than 90% of this funding represented basic research related to the biological targets for drug action rather than the drugs themselves (taken from Cleary et al. 2018). Both profit-oriented entities such as R&D-based pharmaceutical companies and nonprofit entities such as educational or government/nonprofit entity-funded R&D institutions mainly depend directly or indirectly on market exclusivity to monetize their innovations. Economists have long held that while patents are not the most

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United States of America

Japan

Germany

China

United Kingdom

Switzerland

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Fig. 2 Ten main countries of origin of Patent Cooperation Treaty (PCT) publications in the field of medical technology, including pharmaceuticals, 2000–2018. (Source: Trilateral study 2020, Chapter III)

important tool through which returns to R&D are appropriated in all sectors, they are uniquely important in the pharmaceutical and specialized chemicals sectors, as well as in biotechnology (this literature is well summarized by Cockburn 2009). Yet there are those who argue for the removal of patents on pharmaceuticals for a variety of reasons, including that competition engenders more innovation than monopolies, even temporary ones (see Boldrin and Levine 2020). The public health community also largely favors the removal of market exclusivity-based innovation incentives as the final prices of needed drugs and vaccines can be unaffordable to many who need them, especially in poorer countries.

Test Data Protection Another key IPR relevant to health-related innovation is test data protection, a legal instrument that grants protection – in the form of market exclusivity akin to patents – to clinical test data that is submitted to regulatory authorities for marketing approval. Regulatory test data protection is increasingly getting to be a crucial form of protection for the R&D-based pharmaceutical sector. It generally provides more legal certainty and predictability than patents.

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There are jurisdictions that require the submission of clinical and other data to regulatory authorities in order to obtain marketing approvals for drugs and others that rely on the marketing approvals given in other jurisdictions. Since the mid1980s, the first company to generate and submit extensive clinical and other data to obtain drug marketing approval in the United States and the EU obtained a fixed period of market exclusivity. In such a case, the second or subsequent applicant for marketing the same product cannot enter that market for a certain period of time. Since the mid-1990s, market exclusivity, generally for a period of 5 years, based on test data protection, has been obligatory in many other jurisdictions, including lowand middle-income countries, mainly through the IP chapters in free trade area agreements (FTAs) led by the US, EU and other European countries, irrespective of whether the country otherwise requires the submission of such data or not. The logic behind protecting regulatory test data is that a considerable financial and managerial investment goes into the production of such data, especially given the more extensive testing required to satisfy the ever-stricter regulation due to the increasingly lower tolerance to drug side effects in key jurisdictions. In order to encourage originators to make the necessary investments to produce such data, policy makers have sought to prevent subsequent applicants of generic products from free riding on these investments for a certain period of time when costs of such investments could be recouped through higher prices. However, such market exclusivity is not without costs to society. This is because such protection delays the entry into the market of competitor generic products that usually rely on originator test data to prove bioequivalence of their products to those of the originators. There are some jurisdictions, whether requiring the submission of clinical and other test data or not, to merely oblige regulatory authorities to keep the submitted data secret while relying on it themselves to approve second or subsequent applicants for the same product, provided these applicants prove bioequivalence needed to satisfy the safety and efficacy requirements. Some jurisdictions view that such secrecy is enough to protect originators against unfair competition. Yet others favor some type of compensation without granting market exclusivity. In the area of biologics, the United States grants test data protection through a period of market exclusivity of 12 years. The United States obtained a period of market exclusivity for biologics amounting to 8 years in the now defunct TransPacific Partnership Agreement (TPP) and a period of 10 years in the more recent USMexico-Canada Agreement (USMCA), a clause that was later rejected by the US Congress. The industry views regulatory exclusivities are the most important IPR to protect innovative medicines, especially biologics, as this type of protection is for a clear period of time without exceptions or limitations. While patents do provide market exclusivity for eligible inventions for a period of 20 years from the date of filing (or an effective market exclusivity of an average of 10–12 years), there are several uncertainties. For one, at the time of patent filing, it is not clear if the drug would ever be commercialized, as it may not clear all phases of the required clinical trials. Secondly, even if it is commercialized, it is not clear – for at least the first few years – if the drug is a marketing success. This is why, given the costs, patents are filed only in some key jurisdictions. However, test data protection

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allows recouping of R&D costs for such successful drugs in other jurisdictions long after the window to file patents there has expired or after granted patents have expired. Moreover, while patents can be invalidated, revoked, or subject to compulsory licensing, this is generally not the case with test data protection. However, as noted before, there are several jurisdictions that are not willing to add regulatory exclusivities to the patent protection that is already available for new drugs. Such differences in protection are the reason why test data protection continues to be one of the most controversial topics in the area of IPRs and public health.

Trademarks The main economic function of trademarks is to allow manufacturers and distributors to distinguish their goods from those of competitors and help consumers make informed choices without being deceived by similarly named products that differ in quality. Trademarks, like other IPRs, are protected under the laws of each country or region, and not globally. It is not unusual for a trademark to be protected in some countries but not in others. Trademarks or brand names are used on medicines by both originator and generic drug companies. This form of IPR has been known to mankind for millennia – ever since humans engaged in commerce, including barter. However, the pharmaceutical industry has been expending large sums of money on brand promotion of its prescription drugs to medical practitioners (and where permitted directly to consumers) ever since regulation made the sale of certain drugs subject to prescription. It is well-known to economists that the first-mover advantage can be significant in the pharmaceutical market. Thus, the first branded medicine to be introduced into the market gains lasting brand recognition even after competitor brands enter the market. Since trademarks can have an unlimited duration if they meet certain criteria, innovator companies use them to gain or retain market share for originator products through brand loyalty long after fixed-term IPRs expire. Trademarks need to be distinctive such that they clearly indicate the source of a particular good or service. They cannot be used for generic terms that use ordinary words to define the category or type of good as these are not distinctive and should remain in the public domain available for all competitors to use. Both originator and generic drug companies use trademarks for their medicines. There has to be a distinction between the generic name of a medicine – for example, ampicillin – which must be available to identify any product, and the proprietary trademarks used by both originator and generic companies to distinguish the product they are responsible for manufacturing and distributing. The WHO provides the generic names for medicines, called international nonproprietary names (INNs), which are universally recognized as unique names that identify particular active pharmaceutical ingredients. While trademark protection is generally not so controversial, newer nontraditional ways of using trademark protection, such as for three-dimensional

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forms, smell, taste, and single colors, are increasingly being used by the pharmaceutical industry in branding their new drugs, provided these marks are not descriptive or functional in nature. This is because, unlike patents and other forms of market exclusivity, trademark protection is potentially not restricted in time. A well-known example is AstraZeneca’s “purple pill,” Nexium ®, a drug used to treat persistent heartburn, whose distinctive purple and gold color scheme used for the pills was registered as a trademark. This mark was used to prevent Dr. Reddy’s Laboratories Ltd. – a pharmaceutical manufacturer from India – from introducing its purplecolored generic heartburn pills into the US market. Dr. Reddy’s eventually brought its drug to market after adopting a blue color for its pills. Some view the use of nontraditional trademarks as creating obstacles to access to medicines, for example, because nontraditional marks may not only perpetuate the monopoly position enjoyed by the branded drugs but also reinforce the myth that generic drugs are low quality (taken from Arul Scaria and S.K. Mammen, 2020).

International IPR Obligations Relevant to Medical Innovation In order to increase legal certainty and predictability for international businesses in IPRs, the World Trade Organization (WTO) established in 1995 introduced the Agreement on Trade-Related Aspects of Intellectual Property Rights, known by its acronym, TRIPS (see https://www.wto.org/english/tratop_e/trips_e/intel2_e.htm accessed on 15.02.2020). The TRIPS Agreement that is obligatory for all 164 WTO members (as of the time of writing) sets minimum standards inter alia on patents, test data protection, and trademarks. Only a subset of the poorest among developing countries, called least-developed country (LDC) members of the WTO, are permitted to delay TRIPS provisions related to patents and test data protection for pharmaceuticals until 2033. The current international IP regime – comprised of the TRIPS Agreement, key pre-existing WIPO treaties incorporated in it – sets minimum standards of IP protection. However, it gives countries responsibility for designing their national IP systems in compliance with these international agreements while also taking into account different considerations, such as the level of their social and economic development, as well as specific interests and needs, including in the area of public health. The public policy options and other options afforded to members under the TRIPS Agreement are commonly referred to as “flexibilities.”

TRIPS Patent Regulations TRIPS set out the obligations of members in this area in Section Vof Part II, Articles 27–34. Patent law, like most other fields of law, is applicable country by country. So, an inventor of a health-related invention must file a patent application separately in each desired jurisdiction. Such patent filing is largely facilitated by the PCT in safeguarding novelty (see https://www.wipo.int/treaties/en/registration/pct/ accessed

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on 15.02.2020), even if each application has to be eventually pursued or prosecuted separately. The main rule introduced by TRIPS into pre-existing international IP law is an obligation (in Article 27) to make patents available for any invention, whether a product or process, in all fields of technology provided that the invention meets the standard substantive criteria for patentability. Thus, with one stroke, countries in the world that are WTO members (except LDCs) were obliged to introduce product patents for pharmaceuticals, biotechnology, and other healthrelated fields at the latest by 2005, if they did not do so as of 1995. At the time of the TRIPS negotiations, 49 countries were said to have excluded medicines from patent protection, some offering only process patents and shorter terms of protection, further subjecting them to stringent compulsory licensing requirements. Certain patentability criteria are common to all national patent laws: (i) the subject matter claimed in the application must consist of patentable subject matter; (ii) the claimed subject matter must be new; (iii) it must involve an inventive step (or be nonobvious); (iv) it must be industrially applicable (or useful); and (v) the invention must be fully and completely disclosed (in Article 29). These requirements apply cumulatively. Failure to satisfy any one criterion could lead to rejection of a patent application. Even though the same essential patentability criteria are found in the vast majority of countries, there is no agreed international understanding about the definition and interpretation of these criteria. This creates some policy space regarding their establishment under the applicable national law. Accordingly, patent offices and courts interpret and apply national patentability requirements on a case-by-case basis within the applicable legal framework. Many patent offices provide patent examination guidelines for consistent and coherent application of patent law with more specific guidance, often basing this guidance on cases previously decided by the relevant courts. TRIPS also lays down that there shall be no discrimination in patent availability or enjoyment on the basis of (a) field of technology; (b) where the invention is made; or (c) whether products are locally produced or imported. This rule ensures that previous provisions in the patent laws in some countries that excluded pharmaceuticals from product or process patent protection; or that excluded the grant of compulsory licenses for inventions when R&D for these was done in the country; or where compulsory licenses were granted automatically for food and drug patents; or if an invention was not manufactured in the country are all now violations of international law. It is worth pointing out that it is understood in most patent laws world over that computer programs, scientific discoveries and theories, mathematical methods, aesthetic creations, schemes, rules, and methods for performing mental acts, playing games or doing business, and presentations of information are expressly not considered to be inventions and therefore cannot be patented. Similarly, trivial inventions that are obvious to an average expert in the field of technology may also be excluded as being obvious. Some jurisdictions, however, could go further and allow

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patents on software, business methods, and on incremental, trivial innovations, especially in the pharmaceutical sector. In addition, TRIPS allows three types of subject matter exclusions to patentable subject matter (Article 27.2 and 3). These may be of interest from a global health perspective: (i) Inventions, the prevention of whose commercial exploitation is necessary to protect public order or morality, including to protect animal or plant life or health An example could be human cloning that is not patent eligible in some jurisdictions on account of moral and ethical reasons. However, the sale of such patent-ineligible products must also be prohibited in that jurisdiction. (ii) Diagnostic, therapeutic, and surgical methods for the treatment of humans or animals This exception is based on the principle that medical practitioners should not be restricted by the concern that a treatment or diagnostic method might be covered by a patent; an example of this exception is a method to surgically remove cataract from the eye or to treat a patient through dialysis. Clearly inventions that are diagnostic, therapeutic, or surgical methods performed on a human or animal body are excludable, but this exclusion does not apply inventions that are diagnostic, surgical, or therapy instruments or products. The EPO in its guidelines (available at https://www.epo.org/law-practice/legaltexts/html/guidelines/e/g_ii_4_2_1.htm accessed on 15.02.2020) explains that Treatment of body tissues or fluids after they have been removed from the human or animal body, or diagnostic methods applied thereon, are not excluded from patentability as long as these tissues or fluids are not returned to the same body. Thus, the treatment of blood for storage in a blood bank or diagnostic testing of blood samples is not excluded, whereas a treatment of blood by dialysis with the blood being returned to the same body would be excluded.

Some have questioned whether CAR-T type of methods of treatment could be excluded under this provision as genetic material is removed from a human body, modified outside, and returned to the same body. The EPO however has long held in its jurisprudence that the legislative intent was only to “free from restraint non-commercial and non-industrial medical and veterinary activities. Interpretation of the provision must avoid the exceptions from going beyond their proper limits.” Nevertheless, there is a question mark raised over the patentability of new genetic therapies, the legal implications of which are best explained in a recent article (Abinader and Contreras 2019). (iii) Certain plant and animal inventions Under this third optional exclusion, inventions that are plants and animals may be excluded from patent eligible subject matter, but those that are microorganisms and microbiological processes cannot be excluded. This has led to a number of countries specifically excluding plants, animals, and parts thereof, including genes, from patentable subject matter in their patent laws. In other jurisdictions,

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including the United States and Australia, courts have, in recent years, overturned the patenting of genes, even if isolated through technical processes, since these are considered to be products of nature and are not inventions.

Box 1 Patenting products of nature: “the Myriad case”

(Source: Trilateral Study 2020, Chapter III) BRCA-1 and BRCA-2 are two genes linked to susceptibility to breast and ovarian cancer. The risk of getting cancer increases if these genes show certain mutations. Identifying the mutations is therefore important for diagnosis and for monitoring women at higher risk. Myriad Genetics Inc., in collaboration with others, obtained product patents on the isolated DNA coding for two genes, BRCA-1 and BRCA-2, on a related screening method and on methods of comparing or analyzing BRCA sequences. As a product patent protects not only the functions disclosed in the patent but also all other possible future therapeutic uses of the gene, concerns were raised that the patents held by Myriad Genetics could serve as a disincentive to carrying out further research on possible functions of this gene and the development of diagnostic methods and impact on access to such tests. Opposition proceedings before the European Patent Office (EPO) led to revocation and restriction of respective European patents in 2004. Where the patents were in force, Myriad Genetics adopted a restrictive licensing policy that, in practice, only allowed Myriad to perform the complete sequence analysis in their laboratories in the United States. Public health concerns were raised about the issue of having only one source for diagnostic testing. In 2013, the Supreme Court of the United States decided that Myriad did not create or alter any of the genetic information encoded in the BRCA-1 and BRCA-2 genes or in their DNA. The court held that a naturally occurring DNA segment is a product of nature and is not patent eligible merely because it has been isolated. On the other hand, the court found that claims relating to “complementary DNA” (cDNA), being synthesized in a laboratory from naturally occurring messenger RNA (mRNA), were patent eligible. In 2015, the patentability of BRCA-1 was also decided in Australia. The High Court of Australia found that the BRCA-1 was a naturally occurring phenomenon and that the isolation of nucleic acid comprising the gene lacked the inventiveness necessary to qualify for patent eligibility. The court also noted the “chilling effect” that the relevant claims, if granted, would have on the use of any isolation process in relation to the BRCA-1 gene. Since the 2013 US Supreme Court decision, the number of BRCA tests offered by laboratories in the United States has grown substantially, although the tests vary in how extensively BRCA genes are assessed for mutations.

A question that is often raised by public health community in the context of pharmaceutical patents is the patent eligibility of incremental innovation. Patenting

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of new chemical forms, or other minor variations, of existing products that have no additional therapeutic value and display limited inventiveness is allegedly used to prolong patent protection by existing patent owners, thus delaying access to generic medicines – a strategy pejoratively referred to as “evergreening.” India has a provision in its patent law that specifically targets this.

Box 2 How India defines and applies patentability criteria

When revising its patent law to comply with the TRIPS Agreement requirement that pharmaceutical products be patentable, India adopted specific patentability criteria for chemical products by introducing Section 3(d) to its Patent Act (Patents Amendment Act 2005). Section 3(d) states: “the mere discovery of a new form of a known substance which does not result in the enhancement of the known efficacy of that substance or the mere discovery of any new property or new use for a known substance or of the mere use of a known process, machine or apparatus unless such known process results in a new product or employs at least one new reactant” is not an invention. Section 3(d) provides the following explanation: “For the purposes of this clause, salts, esters, ethers, polymorphs, metabolites, pure form, particle size, isomers, mixtures of isomers, complexes, combinations and other derivatives of known substance shall be considered to be the same substance, unless they differ significantly in properties with regard to efficacy.” In 2007, the Indian Patent Office, following an opposition filed by a patient organization, refused to grant a pharmaceutical company a patent for the cancer drug imatinib mesylate, based on Section 3(d). In 2013, the Indian Supreme Court rejected an appeal against this decision. It held that, while Section 3(d) did not bar patent protection for all incremental inventions, the invention, in order to be patentable, had to pass the test of enhanced efficacy as provided in Section 3(d) read with its explanation. The beta crystalline form of imatinib mesylate was a new form of a known substance, imatinib, and lacked the enhancement in efficacy required under Section 3(d). The Supreme Court decided that “efficacy” under Section 3(d) of the Indian patent law was “therapeutic efficacy” and stated that the term must be interpreted “strictly and narrowly” and that there was no evidence offered to indicate that imatinib mesylate would produce enhanced therapeutic efficacy as compared with imatinib. Source: Trilateral Study 2020, Chapter III

The minimum rights that must be conferred upon a patent owner under the TRIPS Agreement (in Article 28) follow closely those that were to be found in most patents laws even prior to TRIPS, namely, the right of the patent owner to prevent unauthorized persons from using the patented process and making, using, offering for sale, or importing the patented product or a product obtained directly by the patented process.

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Patent protection, like in the case of most other IPRs, is limited in time. The TRIPS Agreement sets out (in Article 33) that patent protection shall not end before the expiration of 20 years counted from the filing date. Patent owners may, and indeed often do, abandon a patent earlier by discontinuing the payment of maintenance fees, for example, where the commercial benefits of the patented invention do not cover the costs of maintaining the patent. Economists have found that this is rarely the case in pharmaceutical patents, which, if commercialized, tend to get renewed to term. Patents may also be invalidated in judicial or administrative proceedings, thus cutting short the duration of a patent, when a patent validity is challenged on the basis of grounds established under the domestic law. In countries where no patent application is filed on a certain invention, or where a patent application has been withdrawn or refused, or where a granted patent has been invalidated or has expired, the covered invention enters into the public domain and can be freely produced, used, and sold or otherwise distributed. Under the TRIPS Agreement, patent rights are not absolute but can be subject to four types of limitations or exceptions (taken from https://www.wto.org/english/ tratop_e/trips_e/pharma_ato186_e.htm accessed on 15.02.2020). (i) Limited exceptions to patent rights are allowed, provided that such exceptions do not unreasonably conflict with a normal exploitation of the patent and do not unreasonably prejudice the legitimate interests of the patent owner, taking account of the legitimate interests of third parties. Thus, for example, many countries allow third parties to use a patented invention for research purposes where the aim is to understand more fully the invention as a basis for advancing science and technology. The WTO Panel in Canada – Patent Protection for Pharmaceutical Products (known by the dispute number DS 114) – decided that this provision, allowing limited exceptions, covered a provision of Canadian law which permits the use by generic producers of patented products, without authorization and prior to the expiry of the patent term, for the purposes of seeking regulatory approval from public health authorities for the marketing of their generic version as soon as the patent expires. (This provision is sometimes referred to as the “regulatory exception” or as a “Bolar” provision.) (ii) Use by governments or third parties authorized by national authorities (compulsory licenses), including for public noncommercial purposes, without the authorization of the patent owner. Unlike what was sought by some countries in the TRIPS negotiations (Watal 2015), the grounds on which this can be done are not limited by the Agreement, a point clarified in the Doha Declaration on the TRIPS Agreement and Public Health in 2001 (hereinafter the Doha Declaration, available at https://www.wto.org/english/thewto_e/minist_e/min01_e/ mindecl_trips_e.htm). But the Agreement does contain a number of conditions that have to be met in order to safeguard the legitimate interests of the patent owner. Two of the main conditions are that, as a general rule, an effort must first have been made to obtain a voluntary license on reasonable commercial terms and conditions and that the remuneration paid to the right holder must be

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adequate in the circumstances of each case, taking into account the economic value of the license. (iii) The Agreement recognizes the right of members to take measures, consistent with its provisions, against anticompetitive practices, and provides more flexible conditions for the grant of compulsory licenses where a practice has been determined after due process of law to be anticompetitive. For example, the two conditions referred to ii. above for the grant of compulsory licenses may be relaxed in these circumstances. The Agreement also provides for consultation and cooperation between members in taking action against anticompetitive practices. (iv) The TRIPS Agreement makes it clear that the practices of WTO members in regard to the exhaustion of intellectual property rights (e.g., a member’s decision to have a national exhaustion regime, under which right holders can take action against parallel imports, or an international exhaustion regime, under which they cannot) cannot be challenged under the WTO dispute settlement system, provided that they do not discriminate on the grounds of the nationality of right holders, again a point made clear in the Doha Declaration. It must be noted that governments have a range of public policy measures outside the field of intellectual property to address issues of access to and prices of drugs. For example, many countries use price or reimbursement controls. Article 8 of the TRIPS Agreement makes it clear that WTO members may, in formulating or amending their rules and regulations, adopt measures necessary to protect public health and nutrition, provided that such measures are consistent with the provisions of the Agreement, a provision that has been referred to and upheld in several WTO disputes, including in the Australia tobacco plain packaging case.

Regulatory Test Data Protection The TRIPS Agreement (in Article 39.3) involves a twin obligation that requires WTO members to protect test data both against unfair commercial use and against disclosure, provided the member requires the submission of previously undisclosed test data that cover new chemical entities (NCE) only and the generation of which involved considerable efforts (the terms in italics are emphasized to show the conditional nature of these twin obligations). The second obligation is not to ordinarily disclose the data submitted for regulatory approval purposes. Regulatory agencies may, however, disclose the data when disclosure is necessary to protect the public or where steps are taken to ensure that there is no unfair commercial use of the data. Neither obligation applies to countries that rely on marketing approval given elsewhere; or when the data submitted was previously disclosed; or when the test data involved a new formulation or dosage form and not a NCE, for example, biologics; or when the generation of the data did not involve considerable efforts, a term not further defined under TRIPS but which leaves considerable wiggle room to interested WTO members.

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With respect to the first key obligation, the TRIPS Agreement does not define the term “unfair commercial use,” nor does it identify how to achieve this protection. As a result, national practices differ based on differing interpretations of the exact requirements of the TRIPS Agreement. Some like the EU and United States and their supporters argued in WTO negotiations that led to the Doha Declaration that the most effective way to protect test data is to award a reasonable period of exclusivity to the originator companies. Others argued that other forms of protection against unfair competition, including secrecy, compensation, and cost-sharing models, are permissible and sufficient. During TRIPS negotiations, the option of making time-limited exclusivity an explicit obligation under the TRIPS Agreement was proposed, but negotiators instead adopted the general wording of the current Article 39.3. This gap has been sought to be bridged by explicit wording requiring exclusivity in subsequent WTO accession protocols (e.g., for China, Russia, and Ukraine) or in bilateral or plurilateral FTAs that contain an IP chapter with some form of exclusivity provisions, irrespective of whether the country requires the submission of data or not; whether data are previously disclosed or not; and without exceptions for different product or dosage forms or levels of efforts.

Trademarks in the TRIPS Agreement International standards for protection of trademarks that are to be respected by all WTO members are set out in the TRIPS Agreement (Section II, Part III, Articles 15–21). Definition of Trademark and registration obligations

A trademark is defined as any sign, or any combination of signs, capable of distinguishing the goods or services of one undertaking from those of other undertaking. There is an obligation to register eligible signs. Registration of signs that are not inherently distinctive may be subject to distinctiveness acquired through use and may require that signs be visually perceptible, thus making it possible to exclude the registration of some nontraditional signs.

TRIPS does not permit the nature of goods to be an obstacle for registration, nor can the use of a trademark be unjustifiably encumbered by special requirements such as the obligatory display of the trademark in half the size of the generic drug name on the label. In the 1970s some countries like Mexico and India used to have these types of requirements in order to encourage patients to choose generic drugs over the more expensive branded ones. Australia won a dispute at the WTO on its tobacco plain packaging law, which could lead to more countries choosing to encourage generics through labelling or packaging requirements.

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The owner of a trademark must have the right to prevent the unauthorized use of signs that are identical or similar to the registered trademark on related goods or services where such use would result in a likelihood of confusion. The trademark owner, and typically any licensees, may enforce their rights against infringement. However, defenses to infringement exist, including trademark fair use of descriptive terms. Trademarks have a defined initial term of protection but can be renewed indefinitely, provided they remain in use and maintain their distinctive character, and trademark holders see a need to renew them. Rights to a trademark can be lost through cancellation or removed from the registry if the trademark is not used for a continuous period of 3 years from registration, or the renewal fees due are not paid. A mark can lose its distinctive character and can become a generic term. This may happen if either the trademark owner or the public – with no objection from the trademark owner – uses a trademark as a term in common usage. For example, aspirin, once a trademark of Bayer, has become a generic term in most of the world.

Limitations of IPRs for Generating New Drugs for Neglected Diseases and for Small Markets As we have seen, the IPR system is a market-based system that generally provides incentives by conferring upon the IPR holder a degree of market power through the grant of market exclusivity for a fixed duration. The expectation is that relatively high prices can be charged during the IPR protection period, thus generating super normal profits. This could create obstacles to access patented medicines, especially in poorer countries where most patients pay for medicines out of their own pocket. However, as we saw in the streptomycin example in an earlier section, the mere existence of an IPR cannot lead to higher prices. And neither does the absence of IPRs serve as a guarantee of access to the protected product or technology. Much depends on how the acquisition, maintenance, and enforcement of IPRs are regulated under the applicable national laws; how such laws are applied in practice; where IPRs are applied for; for how long the IPRs are maintained and exercised; and how the IPR holders choose to exercise – or not to exercise – their rights, for example, by licensing them widely or not. Setting aside the criticism of affordable access, the IPR system clearly is not meant to incentivize innovation when there is no market at all or a very small market. This is the case when the target patient population have negligible or low purchasing power and are unable to pay or where there are other reasons that make for a small market. In such a case, private actors are not motivated to take the risk to do R&D in these areas. This is the primary reason why there have been very few innovative drugs produced for certain tropical diseases that predominantly affect the poor, the so-called neglected tropical diseases (NTDs). This section begins with this and moves on to another area where markets are small and where the profit motive fails to incentivize R&D-based pharmaceutical companies, namely, new antibiotics. Dealing with emerging pathogens of epidemic potential, such as Ebola or the novel coronavirus disease, could also be considered to

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be an area where special incentives are needed for the generation of new vaccines and medicines, but, given that these special efforts are coordinated closely by the WHO, this chapter excludes this area.

Diseases Disproportionately Affecting People in Developing Countries The Commission on Macroeconomics and Health grouped all diseases into three types: – Type I diseases that are found in both rich and poor countries and affect large numbers of vulnerable populations in both. Examples include measles, hepatitis B and C, diabetes, and cardiovascular diseases – Type II diseases that are found in both rich and poor countries but with a disproportionate number of cases in poor countries. Examples of such diseases include HIV/AIDS and TB. While both diseases are present in rich and poor countries, more than 90% of cases occur in poor countries. – Type III diseases are those that are overwhelmingly or exclusively found in poor countries. Examples of such diseases include Chagas disease, African sleeping sickness (trypanosomiasis), and African river blindness (onchocerciasis). Type II and III diseases are often referred to as neglected diseases. There is, for example, not yet a HIV vaccine nor effective treatments for certain genotypes of hepatitis C. A key factor is the limited purchasing power of such patients individually as well as the small size of market. Often in the case of type III or NTDs, the poor who carry the burden of such diseases are also disempowered due to which governments fail to make these diseases a funding priority in poorer countries. Unlike in some cases of infectious diseases, where the treatments or vaccines have a market in more affluent markets either because of travel or because of the spread of these diseases, NTDs do not have such markets. The spread of NTDs is often restricted by climate, in particular by its effect on the distribution of vectors and reservoir hosts. In most cases, there appears to be a low risk of transmission beyond the tropics. Unlike pandemic influenza, HIV/AIDS and malaria, and, to a lesser extent, TB, most NTDs present little threat to the inhabitants of high-income countries, thus gaining less attention. Pharmaceutical R&D that is needed to develop new diagnostics and medicines for these diseases is vastly inadequate considering the needs. In 1990, the Commission on Health Research for Development found that of the US$ 30 billion global investment in health research in 1986, only 5%, or US$ 1.6 billion, was devoted specifically to health problems of developing countries, although an estimated 93% of the world’s burden of preventable mortality occurred in the developing world at the time. A later analysis in 2015 found that povertyrelated and neglected diseases represent 14% of the global burden of disease but attract only 1.3% of global R&D expenditure.

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The G-FINDER survey reported that the funding of R&D for neglected diseases was more than US$ 3 billion in 2017. However, it is estimated that HIV/AIDS, TB, and malaria received 70% of this funding and contributed 57% of the candidate products. Significantly more of this money is spent on development of new vaccines/ medicines than on diagnostics. Funding comes predominantly from the public sector. In 2016, the public sector provided almost two thirds (US$ 2.0 billion, 64%) of global funding, with high-income countries contributing 96% of this. The philanthropic sector contributes US$ 671 million (21%), and the private sector invested US$ 497 million (16%), again on a philanthropic basis as a part of corporate social responsibility. By 2017, aggregated contributions make the research-based pharmaceutical industry the second largest sponsor of research for neglected diseases, after the US NIH and ahead of the Bill & Melinda Gates Foundation. A number of companies have established dedicated research institutes to develop new products targeting diseases that disproportionately affect developing countries or participate in cooperative projects and product development partnerships (PDPs), thus sharing costs, assets, and knowledge. Of the 109 projects aimed at developing new medicines and vaccines for diseases that have been prioritized by the WHO TDR, 90% are collaborative, involving over 50 universities, NGOs, and other public and private entities. Although there was a decrease in reported number of private-sector R&D projects, from 132 in 2012 to 109 in 2017, private-sector NTD R&D funding increased from US$ 345 million in 2008 to US$ 554 million in 2017 (although this increase represents, in part, a greater number of companies providing data). It must be noted that global NTD treatment, which jumped by 76% from 2008 to 2015, is unfortunately highly reliant on treatment donations by a few pharmaceutical companies. The number of tablets donated quadrupled from 353 million in 2009 to more than 1.5 billion in 2015. (Taken from the Trilateral study 2020).

Antimicrobials and Antimicrobial Resistance (AMR) While it is challenging to come up with concrete numbers, it is increasingly obvious that the disease burden caused by AMR is high and increasing steadily in both high-income countries and LMICs. It is estimated that infections attributable to resistant bacteria result in 33,000 deaths in Europe and 23,000 deaths in the United States annually with several million persons infected. This is comparable to the combined disease burden of influenza, TB, and HIV/AIDS in these regions. While infections with antibiotic-resistant bacteria affect all age groups, the very old and the very young are disproportionally affected and suffer from a significantly higher burden of disease. One study estimated that 214,000 neonatal sepsis deaths are attributable to resistant pathogens each year globally, with the vast majority in LMICs. Many of these infections could be prevented through strengthened infection prevention and control, using available tools and ensuring access to clean water, sanitation, and hygiene in health facilities. Following the period of high discovery rates of new antibiotics in the midtwentieth century (described in the Section “Development and Characteristics of

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the Current Innovation System” above), scientific challenges and a lack of adequate R&D investment have resulted in very few new classes of antibiotics being developed. Of the approved classes of antibiotics, none were discovered in the last three decades. For gram-negative bacteria, which are the more dangerous category, all of the approved classes of antibiotics were discovered before 1965. Private sector pharmaceutical companies have steadily divested from antimicrobial R&D; in 2019, only 3 large pharmaceutical companies were still active in this field, while 23 have abandoned it since 1980. Less than 5% of venture capital investments in pharmaceutical R&D between 2003 and 2013 was invested in antimicrobials research, and investments decreased over this period. As of July 2018, 38 new therapeutics and 4 combinations that target WHO priority pathogens were in the pipeline. However, most of the private sector development remains focused on existing classes of antibiotics, where the risk of failure is significantly lower. In addition, an expert group identified 36 older antibiotics that are no longer manufactured and that may be useful if brought back to the market. Private investments are insufficient to fill the current R&D gap, although the profit potential does vary widely among new, superior and “me-too” antibiotics. The fact that new antibiotics must compete with existing generic treatments and should be used sparingly to slow the development of resistance limits their profit potential. In addition, the market-driven R&D model does not direct investment to the most urgent public health needs, such as fighting multidrug-resistant pathogens, where the patient population is still relatively small. Besides new antimicrobials, new and affordable diagnostics are also urgently needed to support responsible and prudent use of antimicrobials. In addition to product development, critical needs include applied and interventional research on preventing AMR development and transmission, promoting appropriate and prudent use, improving animal husbandry, preventing hospitalacquired infections, and gathering further evidence on antimicrobial residues in the environment and their impact. In many cases, improved infection prevention and control measures offer better value for money and a quicker solution than developing new health technology solutions. One example of AMR is multidrug resistant TB or MDR-TB. Three new medicines – bedaquiline, delamanid, and pretomanid – were approved in 2012, 2014, and 2019, respectively, for the treatment of MDR-TB. These are the first new TB treatments with a novel mechanism of action approved in nearly 50 years. Bedaquiline is now one of the recommended treatments by WHO for MDR-TB. Pretomanid was developed by the product development partnership TB Alliance (see PDPs in Section “Alternative Mechanisms to Incentivize Medical R&D and Improve Access” below).

Alternative Mechanisms to Incentivize Medical R&D and Improve Access The current innovation model based on IPRs has been criticized as creating monopolies that are inefficient in terms of generating low cost, highly productive, socially beneficial, and non-duplicative medical R&D with fair and equitable access to the

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resulting products by all those who need them. Many proposals for incentivizing R&D without the deleterious effects of IPRs, as well as novel models of funding R&D, have emerged to resolve the innovation and ensuing access issues related to neglected disease areas. This discussion received a fillip when it is crystallized in the form of a WHO expert group report. The WHO Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG), in its report published in 2012 (WHO 2012), examined the financing and coordination of R&D and reviewed a wide range of proposals for new and innovative models of financing R&D. It must be noted at the outset that new initiatives aimed at increasing biomedical R&D to find effective treatments for neglected diseases are widely perceived to be necessary. Less widely acceptable and more controversial are alternative ideas that would wholly replace the existing system of innovation incentives based on market exclusivity for all future vaccines and medicines that are of interest for improving global public health outcomes. The fear is that one may be throwing out the baby with the bathwater, since most economic studies find that patents do play a role in the availability of innovative medicines in the market (see Watal and Dai 2019 for their own findings on this and a summary of the literature). For example, an important concept that is strongly advocated by many public health activists is that of delinking the price of the final product from the costs of biomedical R&D. This concept is based on the fact that patents allow developers to recoup the costs and make profits by charging a price far in excess of the costs of production. This way of financing biomedical R&D is considered to constitute a barrier to access to medicines where it results in product prices that the health system, or patients paying out of pocket, cannot afford. The principle of delinkage is based on the premise that the incentives for biomedical R&D should be provided by some means other than through the price of the product. This type of delinkage is particularly more widely accepted in the case of financing biomedical R&D for neglected diseases and new antibiotics, than as an alternative to the IP system altogether. Nevertheless, if delinkage is seen more broadly as any mechanism other than market exclusivity, it already exists in current “push” mechanisms and “pull” mechanisms. Push mechanisms are incentives that provide funding to begin a biomedical R&D project, such as grant funding or tax credits for investments in such R&D. Pull mechanisms are incentives that offer rewards for certain achievements in the biomedical R&D process, such as milestone prizes or end prizes. The following is a non-exhaustive list of alternative key mechanisms to incentivize medical innovation or novel ways of funding biomedical R&D.

Overview: Alternative Key Mechanisms to Incentivize Medical Innovation and Novel Ways of Funding Biomedical R&D

• Grants • Tax breaks for companies • Prizes

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Advance market commitments (AMC) Priority review vouchers Patent pools Open-source drug discovery and development Global binding framework for R&D and pooled R&D funds Product development partnerships

Grants In this context grants are upfront or milestone payments made to fund biomedical R&D to the extent necessary to generate new vaccines and medicines. This is the way public sector research is usually financed. However, grants can also be given to private sector entities in order to “push” research into certain disease conditions where there are less market incentives to do so. For example, a grant may enable an SME to undertake initial research for a medicine on a neglected disease and bring a potential new medicine through Phase I trials, at which stage it may be possible to attract commercial funding. An example of an innovative financing mechanism that utilizes grants to produce needed innovation is Unitaid (see more details here: https:// unitaid.org/about-us/#en, accessed on 15.02.2020). While grants can be useful for stimulating biomedical R&D, they provide no guarantee that a viable drug/vaccine/diagnostic product that is urgently needed will ultimately be delivered. This is because grants are paid irrespective of the results achieved. Nevertheless, grants do provide a way forward in the absence of commercial R&D funding.

Tax Breaks for Companies Many countries provide tax credits for specified biomedical R&D expenditures – which is akin to a subsidy through grants – in order to encourage private companies to engage in biomedical R&D in areas where markets fail to provide the necessary incentives. Tax credits have the advantage of being made only after the company has actually sold the needed product and generated profits. Tax credits cannot by themselves remedy the absence of market incentives for neglected diseases. If a company aims to recover a substantial amount of its biomedical R&D investment through sales revenues of the product, tax credits cannot effectively drive innovation for products for which there is no effective demand. In the United Kingdom, tax credits were introduced with the express goal of incentivizing research on vaccines for HIV/AIDS, TB, and malaria, though this tax credit was discontinued in 2017 due to low uptake. Tax credits also cannot help where companies are operating at a loss – as is the case with some biotechnology companies in their start-up phase, before they have launched any approved product onto the market.

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On the other hand, where tax credits have worked, for example, for orphan drugs that later had other applications or where the number of patients expanded, some commentators have questioned why these were given for profitable products as they simply subsidize biomedical R&D that a company would have undertaken anyway.

Prizes Given the difficulties with “push” mechanisms in producing the desired results, many have come forward with ideas for “pull” mechanisms, of which prizes are among the most popular. The principal authors of a fully fleshed out proposal on a prize fund are Love and Hubbard (see Love and Hubbard 2009). Prizes work as a “pull” mechanism in biomedical R&D by offering rewards for success, thereby making investment more attractive and the delivery of a specific product more likely. There are two categories of innovation inducement prizes: the first is awarded for reaching a specified milestone in the biomedical R&D process; the second rewards the attainment of a specified endpoint (such as a new diagnostic, vaccine, or medicine with a particular profile in terms of performance, cost, efficacy, or other important characteristics). Such prizes pre-specify certain characteristics of the product (i.e., target product profiles) that the winner, it is hoped, will ultimately develop. While prizes would provide incentives for needed drug development, they could also aim to delink R&D costs from the prices of medicines by specifying the price at which the end product would be sold to different market segments. The effect that such prizes could have on innovation and access would largely depend on the size of the prize fund, the application and design of the medicines developed, and the manner in which they align research efforts with health priorities while aiming to leverage access by keeping prices of finished products low. Prizes can have a favorable impact on the development of, and access to, health products. For example, certain requirements relating to IP management may be imposed on a prize winner, including allowing free use of the technology by the public sector or developing countries, in order to promote competition for supply. Some prize schemes include such IP requirements, while others do not. Where IP management is not integrated into the prize mechanism, access to the resulting technology will not be influenced by the awarding body and will depend on the patent holder’s business strategy. An interesting example of the use of prizes is the EU prize for innovative vaccine technology. The European Commission offered a EUR 2 million “inducement prize” to a research team offering novel solutions to improving temperature stability of vaccines, as refrigerating vaccines presents a major challenge in many LMICs. Submissions were received from 49 competitors; the prize was awarded to a German company (see https://www.sciencemag.org/news/2014/03/german-rna-vaccinescompany-bags-2-million-eu-vaccine-prize accessed on 15.02.2020). One criticism of the prize fund system is the difficulties that would arise in administering such a system in a way that is efficient, fair, socially optimal, and free from arbitrariness or corruption. In opting for a prize fund system in lieu

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of market exclusivity, would we be jumping from the frying pan into the fire? (See Wei 2007).

Advance Market Commitments (AMC) AMC agreements aim to create greater incentives for the biomedical R&D of a specific product, through either market creation or risk reduction. AMC agreements operate as contracts between a purchaser (normally a government or an international financing agency) and suppliers. They usually contain some form of agreed guarantee with regard to price or volume. By effectively guaranteeing a market, pharmaceutical companies are incentivized to undertake such R&D. The same purpose would be served by advance purchase commitments. The most interesting example of the use of the AMC to improve global health outcomes was the pilot AMC for pneumococcal vaccines that was launched in June 2009 with a joint pledge of US$1.5 billion by the Governments of Canada, Italy, Norway, the Russian Federation and the United Kingdom, and the Bill & Melinda Gates Foundation. The GAVI Alliance, a public-private partnership created to increase access to immunization in poor countries, and the World Bank co-led the design of the pilot, and they implemented it together with the United Nations Children’s Fund (UNICEF) and the WHO. The GAVI Alliance serves as the secretariat for the AMC and has so far committed US$ 4 billion up to 2021 to support eligible countries to purchase the product. The pilot AMC for the pneumococcal vaccine offered a legally binding commitment to support the market of targeted pneumococcal vaccines with US$ 1.5 billion of funds for which vaccine manufacturers can bid. Each manufacturer had to commit to supply its annual share of doses for 10 years at a maximum price of US$ 3.50 per dose (i.e., “tail price cap” which was set close to the estimated marginal cost of production at the time of the AMC design) to be paid by GAVI and GAVI-eligible countries. Each manufacturer’s share of AMC funds was to be disbursed as a subsidy per dose additional to the tail price – bringing the total price up to US$ 7 for approximately the first 20% of vaccine doses procured from each manufacturer. This “AMC price” is set with the aim to enable companies to quickly recover incremental investment costs incurred to serve the GAVI market. Unfortunately, AMCs may not generate adequate competition to obtain lower prices. Today the pneumococcal conjugate vaccine market is dominated by two companies, namely, GlaxoSmithKline and Pfizer. The Gavi Alliance says on its website that the two manufacturers have thus far committed to supply 1.65 billion doses through 2027. The price of one pneumococcal vaccine was reduced to US$ 2.90 per dose – less than 10% of the public price in the United States (see https:// www.gavi.org/types-support/vaccine-support/pneumococcal accessed on 15.02.2020). By the end of 2018, the pneumococcal vaccine had been introduced in 145 countries, and global coverage was estimated by the WHO to be at 47%. (See https://www.who.int/gho/immunization/pneumococcal/en/ accessed on 15.02.2020). Nevertheless, each year, nearly 400,000 children under 5 years of

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age die globally from pneumococcal disease, mostly in Africa and Asia. Fortunately, by the end of 2019, the Serum Institute’s vaccine PNEUMOSIL ® was WHOprequalified and will reportedly be made available to low- and middle-income countries for a target of US$2 per dose, roughly 30% lower than the Gavi price and dramatically lower for non-Gavi low- and middle-income countries, an unprecedentedly low price for any pneumococcal vaccine (see https://www.path.org/arti cles/new-pneumococcal-vaccine/ accessed on 15.02.2020).

Priority Review Vouchers A priority review voucher (PRV) aims to reward companies that develop health products that address small markets or limited patient groups, as is the case also with neglected diseases. The PRV entitles a company to receive priority review (i.e., quicker review by the responsible regulatory authority) for any additional health products that would not otherwise qualify for priority review. A company can use this scheme to advance the marketing date of a potential “blockbuster” product, thus generating increased and earlier revenues from that product. A PRV scheme was introduced in the United States in 2007. Under this scheme, companies that obtain marketing approval from the FDA for a product to treat or prevent 1 of 16 NTDs are entitled to receive a PRV. The first PRV was issued in April 2009 for the development of an antimalarial drug and the second, in December 2012, for bedaquiline, the first anti-TB drug in 40 years. In 2012, the scope of eligibility was extended to include rare pediatric diseases and, in 2016, was extended to include “medical countermeasures” (health products that could be used for public health emergencies stemming from a terrorist attack or a naturally occurring “emerging” disease). PRVs have now more often been issued for rare pediatric diseases than for neglected diseases. A PRV can be used by the recipient for any future product filing or it can be sold to another company at a rate determined by the market: PRVs have been sold numerous times, for amounts ranging from US$ 67.5 million to US$ 350 million. Some argue that the value of the voucher is too small to have meaningful impact on the allocation of R&D resources by large pharmaceutical companies. A voucher might be attractive for smaller companies, but these companies are less likely to progress a health product through to development phase in view of the large costs of that phase. The value of a voucher is uncertain since it does not guarantee that an additional company product will, in fact, ultimately be approved by the regulatory authority, nor does it guarantee that the time saved by a priority review will actually exceed 1 year. It has been argued that the value of PRVs has decreased because they were granted too often.

Patent Pools A patent pool is an agreement between at least two patent owners to group their patent rights relating to a specific technology and to license the rights to use these

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patents to each other and to third parties, subject to certain conditions, such as the payment of royalties. Pooling the relevant patents necessary to use a technology, or to produce new downstream products, allows licensees to enter into only one license agreement with one legal entity and has been advocated as a tool to be used in R&D for neglected diseases. In the field of pharmaceutical inventions, with funding from Unitaid, the Medicines Patent Pool (MPP) was established to pool patents for ARVs and has since expanded its scope of work first to malaria, TB, and hepatitis C and now to all essential medicines. The MPP voluntary licenses provide the freedom to develop new treatments, such as fixed-dose combinations – single pills composed of several medicines – and special formulations for children (https://medicinespatentpool.org/ what-we-do/, accessed on 15.02.2020). The difficulties in patent-pooling arrangements in furthering medical innovation, where the current system is based on commercial goals, can be seen when, after several years of discussion, in mid-2019 the life-sciences tools division of German pharmaceutical giant Merck KGaA and the Broad Institute of MIT and Harvard University announced that researchers will be able to get nonexclusive rights to patents held on the CRISPR gene-editing technology by both organizations for research purposes with a single license for free. Companies will have to pay an unspecified licensing fee. The agreement however excludes clinical human germline editing. CRISPR is a revolutionary invention being a type of molecular scissors that allows scientists to precisely cut away flawed parts of genes – a technology indispensable to develop genetic therapies. (See https://www.merckgroup.com/en/news/ broad-institute-18-07-2019.html accessed on 15.02.2020).

Open-Source Drug Discovery and Development Open-source drug discovery and development builds on two principles borrowed from open-source software development. First, open-source drug discovery is based on the idea of collaboration, that is, organizing and motivating groups of independent researchers to contribute to research projects. Second, it is based on an open approach to IP that makes the outcome of that research generally available, through either the public domain or the use of customized licenses. The success of open-source models in the IT sector (e.g., web technology and the Linux operating system) and biotechnology sector (e.g., human genome sequencing) highlights both the need and the potential to initiate a similar model in healthcare, such as an open-source model for drug discovery. Several open-source drug discovery projects are currently under way. Most have secured financing either in the form of government grants or from philanthropic sources. These funds are used to cover administrative expenses and may also be used to fund access to laboratories and computer facilities and payment to researchers. Similarly, examples of open-source data platforms are emerging, including the TB-Platform for Aggregation of Clinical TB Studies, Worldwide Antimalarial Resistance Network, and Infectious Disease Data Observatory for Ebola. These platforms can be particularly useful in drug

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repurposing, where an existing drug can be used to treat another disease and where a significant amount of preclinical and clinical data already exists. However, the results of open-source initiatives have been limited to date. Initiatives thus far have been on a relatively small scale, including in terms of funding. While they seem ideally suited to promoting precompetitive research, the model would likely have to be combined with financing models to cover the costly development phases. Biopharmaceutical firms have used different organizational modes (i.e., licensing agreements, non-equity alliances, purchase, and supply of technical and scientific services) to enter into relationships with different types of partners, with the aim of acquiring or commercially exploiting technologies and knowledge. These relationships can include large pharmaceutical companies, biotechnology product firms, and biotechnology platform firms and universities.

Global Binding Framework for R&D and Pooled R&D Funds In adopting the GSPA-PHI, the World Health Assembly (WHA) called for “further exploratory discussions on the utility of possible instruments or mechanisms for essential health and biomedical R&D, including, inter alia, an essential health and biomedical R&D treaty.” The CEWG recommended that WHO member states negotiate a global convention or a treaty under the auspices of Article 19 of the WHO Constitution, aimed at providing effective financing and coordination mechanisms to promote R&D. Countries would, among other things, invest 0.01% of their GDP in R&D for type II and type III diseases and in R&D for the specific needs of developing countries in relation to type I diseases. Part of these contributions would be collected in a pooled fund at the global level. WHO member states agreed to explore, evaluate, and independently monitor existing mechanisms for contributions to health R&D for such diseases and, if needed, develop a proposal for effective mechanisms, including pooling resources and voluntary contributions. The WHO TDR explored implementation of a pooled fund and published concrete proposals to set up a voluntary fund to finance neglected disease research. Six “demonstration projects” were selected as precursors to such a fund, but WHO member states have not, ultimately, pursued the concept as sufficient funding to finance the demonstration projects did not materialize. The difficulty of increasing domestic taxes to fulfil what are essentially global health objectives is amply demonstrated by this funding failure.

Product Development Partnerships Product development partnerships (PDPs) are public-health-driven, not-forprofit organizations that use private-sector approaches to develop new products in conjunction with external partners. The emergence of PDPs since the late 1990s, drawing together actors from the public and private sectors, has been a major

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development in efforts to focus R&D toward diseases that disproportionately affect poorer countries. These new partnerships have been constituted in a number of ways but usually with the involvement of nonprofit organizations, foundations, and industry. Previously, the majority of funds for PDPs were provided by the philanthropic sector, but, in 2017, government funding overtook philanthropic funding. These partnerships have significantly increased the number of products in development for diseases and conditions that predominantly affect developing countries, and they play an important role in identifying pathways and overcoming bottlenecks in research for neglected diseases. In 2017, funding to PDPs involved in research into neglected diseases amounted to US$ 508 million. This represented 14% of global funding for research on neglected diseases. Four PDPs – the Programme for Appropriate Technology in Health (PATH), Medicines for Malaria Venture (MMV), the International AIDS Vaccine Initiative (IAVI), and Drugs for Neglected Diseases initiative (DNDi) – accounted for over half of all PDP funding. PDPs form alliances with stakeholders drawn from the public and private sectors because PDPs and these entities have the potential to capitalize on the opportunities that each may offer the other. PDPs are performing the service of integrating inputs from different branches of a very diverse industry. PDPs also seem to have lower research costs than research-based pharmaceutical companies, for a number of reasons. PDPs benefit from lower capital costs as a result of their capacity to leverage in-kind inputs. They also benefit from the fact that they do not have to fund a fully loaded development pipeline. Instead, they select their projects from a pool of existing projects in the public and private domains. On the other hand, their costs could be expected to increase substantially as more projects enter large-scale Phase III trials. In this case, the PDP cost-efficiency profile would probably change, since late-stage failures are more expensive than early stage failures. DNDi, as well as the initiatives that emerged in response to the 2014–2016 Ebola epidemic, are examples of public-private collaboration and PDPs. PDPs have a pressing imperative during public health crises, such as the Ebola epidemic, that call for strong and efficient collaboration globally and locally – while urgency is often defined and experienced locally, readiness and response require global cooperation. A good example of a PDP that has made meaningful contributions to improve global health outcomes is the TB Alliance. The TB Alliance is a not-for-profit entity dedicated to the discovery, development, and delivery of better, fasteracting, and affordable TB drugs. TB Alliance was established in 2000, at a time when there were no TB drugs in clinical development. TB Alliance manages the largest pipeline of TB drugs, which comprises candidates in all phases of clinical development and is directed to different parts of the TB epidemic, including treatments for drug-sensitive TB, drug-resistant TB, and improved pediatric formulations for first-line TB treatments. Its successes include managing key parts of the later-stage clinical development of bedaquiline, a novel treatment for drugresistant TB, and receiving FDA approval for pretomanid, another treatment for drug-resistant TB.

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Conclusion It is clear that the current market-based system biomedical innovation, based on IPRs, played a crucial role in generating the essential vaccines and drugs that have dramatically improved global health outcomes in a relatively short period from the mid-twentieth century. Nevertheless, the current system suffers from major flaws in that the innovative drugs and vaccines are not affordable to many living in poorer countries and, with ever-increasing drug prices, even to those in richer countries. Further, it does not provide a solution for disease areas where the patient population lacks adequate purchasing power or where the markets are too small to be of interest to commercial entities such as new products to tackle the growing resistance to existing antimicrobial drugs. Alternative ideas to incentivize the needed biomedical R&D include prize funds, advance market commitments, and specific product development collaborations. Some of these ideas are already yielding some results. Yet a lot more needs to be done if global health outcomes are to be made more fair and equitable. The profit motive alone will not yield results, nor a system based on increasing tax collections world over. The answer may lie in tailor-made solutions for each particular disease condition that urgently needs new innovative products. It is clear that, given the urgency to improve global health outcomes, all stakeholders need to cooperate to find win-win workable solutions that would result in low-cost, affordable, and socially optimal vaccines and drugs.

References Access to Medicines Foundation (2017) Access to vaccines index, 2017. https://accesstomedicine foundation.org/access-to-vaccines-index Intini A, Bonifazi D, Migliaccio G (2019) Challenges and new frontiers in the paediatric drug discovery and development. https://doi.org/10.5772/intechopen.85635. https://www. intechopen.com/online-first/challenges-and-new-frontiers-in-the-paediatric-drug-discoveryand-development. Accessed 15 Feb 2020 Scaria A, Mammen SK. Non-traditional trademarks in the pharmaceutical sector, Chapter 15. In: Calboli I, Senftleben M (eds) The protection of non-traditional trademarks. https://www. oxfordscholarship.com/view/10.1093/oso/9780198826576.001.0001/oso-9780198826576chapter-15. Accessed 15 Feb 2020. https://doi.org/10.1093/oso/9780198826576.003.0015 Palmer B (2014) Jonas Salk: good at virology, bad at economics. Slate, April 13 2014. https://slate. com/technology/2014/04/the-real-reasons-jonas-salk-didnt-patent-the-polio-vaccine.html. Accessed 15 Feb 2020 Children’s Hospital of Philadelphia (2019) Vaccine history: developments by year. https://www. chop.edu/centers-programs/vaccine-education-center/vaccine-history/developments-by-year. Accessed 15 Feb 2020 Cleary EG, Beierlein JM, Khanuja NS, McNamee LM, Ledley FD (2018) Contribution of NIH funding to new drug approvals 2010–2016. Proc Natl Acad Sci 115(10):2329–2334. https://doi. org/10.1073/pnas.1715368115. Accessed 15 Feb 2020 Scherer FM, Watal J (2002) Post-TRIPS options for access to patented medicines for developing countries. J Int Econ Law 5(4):913–939, an earlier version of which is available here https:// icrier.org/pdf/jayawatal%20.pdf. Accessed 15 Feb 2020

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Cockburn IM (2009) Intellectual property rights and pharmaceuticals: challenges and opportunities for economic research. In WIPO: economics of intellectual property. https://www.wipo.int/ edocs/pubdocs/en/wipo_pub_1012-chapter5.pdf. Accessed 15 Feb 2020 Love J, Hubbard T (2009) Prizes for innovation of new medicines and vaccines, 18 Ann Health L. 155. https://lawecommons.luc.edu/annals/vol18/iss2/3/. Accessed 15 Feb 2020 Watal J (2015) Patents: an Indian perspective. In: Watal J, Taubman A, WTO (eds) The making of the TRIPS agreement: personal insights from the Uruguay Round Negotiations. https://www. wto.org/english/res_e/booksp_e/trips_agree_e/chapter_16_e.pdf. Accessed 15 Feb 2020 Watal J, Dai R (2019) Product patents and access to innovative medicines in a post TRIPS era, SSRN working paper. https://papers.ssrn.com/sol3/papers.cfm?abstract_id¼3394851. Accessed 15 Feb 2020. An earlier version is at https://www.wto.org/english/res_e/reser_e/ersd201905_e. htm. Accessed 15 Feb 2020 Gaudelliere J-P (2008) How pharmaceuticals became patentable: the production and appropriation of drugs in the twentieth century. J Hist Technol 24(2):99–106. https://www.tandfonline.com/ doi/full/10.1080/07341510701810906?scroll¼top&needAccess¼true. Accessed 15 Feb 2020 Abinader LG, Contreras JL (2019) Utah Law Faculty Scholarship. https://dc.law.utah.edu/cgi/ viewcontent.cgi?article¼1158&context¼scholarship. Accessed 15 Feb 2020 Wei M (2007) Should prizes replace patents? A critique of the medical innovation prize act of 2005. Univ J Sci Technol Law, Boston. SSRN: https://ssrn.com/abstract¼955669 Boldrin M, Levine DK. Against intellectual monopoly: Chapter 9. Pharmaceutical industry. http://www.dklevine.com/papers/ip.ch.9.m1004.pdf. Accessed 15 Feb 2020 Temin P (1979) Technology, regulation, and market structure in the modern pharmaceutical industry. Bell J Econ 10(2) Trilateral study -WHO-WIPO-WTO (2020) Promoting access to medical technologies and innovation, 2nd edn (forthcoming), the original 2012 version is available at https://www.wto.org/ english/tratop_e/trips_e/trilatweb_e/trilat_web_13_e.htm. Accessed 15 Feb 2020 WHO (2012) Report of the consultative expert working group on research and development: financing and coordination (CEWG). https://www.who.int/phi/CEWG_Report_5_April_2012. pdf. Accessed 15 Feb 2020

Corporate Influence and Social Responsibility in Global Health: Evidence from India

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Nayan Mitra, Sumona Ghosh, and Khushboo Mehta

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Concept of Corporate Social Responsibility (CSR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business Case for CSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evolution of CSR: Global and Indian Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of Corporate Influence and Social Responsibility in Global Health: India’s Response to the COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Novel Coronavirus or COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effect of Coronavirus on Migrant Laborers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of the Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of Corporates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business and Corporate Social Responsibility During COVID-19 Crisis . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Corporate social responsibility (CSR) has been defined variously at different times by social scientists. But what is common to all definitions is that it urges corporate entities to think beyond profit maximization. It encourages corporations to view themselves as a social entity with multistakeholder responsibility. Infact, one finds the enormous role that companies and corporate leaders have shouldered worldwide in one of the recent pandemics that has gripped the world – the new coronavirus or COVID-19. Originated in China in December, 2019, it has already, within 7 months, infected 16 million people in 213 countries and rising

Businesses cannot be successful when the society around them fails. – Anonymous. N. Mitra (*) · K. Mehta Sustainable Advancements (OPC) Private Limited, Kolkata, India S. Ghosh Department of Commerce, St. Xavier’s College, Kolkata, India © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_116

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every day. This has had a tremendous effect on the socioeconomic fabric of the world as the measures for curbing this disease through social distancing comes at a huge economic cost which eventually is leading to humanitarian crisis. It is especially hard on the already vulnerable and marginalized communities – the migrant laborers and informal sector workers. This paper seeks to understand not only what construes as CSR, but also the role of corporate influence and social responsibility along with the government in India in combating this pandemic. Incidentally, India is one of the first countries to have a mandated CSR. Keywords

Corporate social responsibility (CSR) · Sustainability · Business ethics · COVID19 · Pandemic

Introduction The Concept of Corporate Social Responsibility (CSR) Leaders and scholars have struggled to define and conceptualize corporate social responsibility (CSR) for decades. However, withstanding all the evolution, there is no single common accepted definition of the same. This has resulted in confusing implications among various parties regarding the legitimacy, obligations, and impact of CSR standards. One has to be careful in understanding and deferring the term “CSR” because it is sometimes mistakenly equated with either corporate philanthropy or simply compliance with the law. CSR is the obligation of each business entity to account for the way its activities impact the economic, social, and environmental dimensions of its environment; to ensure that this impact generates equitable and sustainable benefits and there is no harm to any of the stakeholders involved. Companies should be seen as having an obligation to consider the society’s long-run needs and wants, which implies that they engage in activities which promote benefits for the society and minimize the negative effects of their actions. The mission of a company should not be restricted to the creation of profit for shareholders alone. Rather, it should be acknowledged as that of identifying opportunities that are beneficial both for the company and for the community and society at large. Some of the definitions of CSR as put forward by various social scientists at various times have been enumerated in Table 1:

Business Case for CSR With the spread of the phenomenon of globalization more than ever before, business leaders began to realize that we live in an interconnected world where mutual interdependence forms the basis of our existence and progress. For the survival

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Table 1 Select CSR definitions, concepts, and models (1991–2016) Sl. No. 1

Researcher(s), Year Carroll 1991

Perspective Corporate citizenship

2

Frederick et al. 1992

Sustainability

3

Kay 1993

Corporate social performance

4

Reder 1994

Corporate citizenship

5

Elkington 1994

Sustainability

6

Hart 1995

Sustainability

7

Mitchell et al. 1997

Stakeholder theory

Key findings “For CSR to be accepted by a conscientious business person, it should be framed in such a way that the entire range of business responsibilities are embraced. Four kinds of social responsibilities constitute total CSR – economic, legal, ethical and philanthropic, that forms a pyramid” (Carroll 1991) “CSR can be defined as a principle stating that corporations should be accountable for the effects of any of their actions on their community and environment” (Frederick et al. 1992) “Reputation, closely related to brand awareness, aids in brand differentiation and ultimately helps a company gain (through a good reputation) or lose (through a damaged reputation) competitive advantage. CSR aids in reputation building” (Kay 1993) “An all-encompassing notion, [corporate] social responsibility refers to both the way a company conducts its internal operations, including the way it treats its work force, and its impact on the world around it” (Reder 1994) “First coined the term, triple bottom line (TBL), that strove to measure sustainability by focusing on comprehensive investment results – that is, with respect to performance along the interrelated dimensions of profits, people and the planet” (Elkington 1994) “Proposed a natural-resource based view of the firm, based upon the firm’s relationship to the natural environment. Three interconnected strategies (pollution prevention, product stewardship and sustainable development) were presented in detail along with accompanying propositions concerning their connections to sustained competitive advantage” (Hart 1995) “Managing stakeholder relationships is challenging because of power, legitimacy, and urgency of diverse stakeholders’ sustainability interests” (Mitchell et al. 1997) (continued)

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Table 1 (continued) Sl. No. 8

Researcher(s), Year Hopkins 1998

Perspective Stakeholder theory

9

Maignan et al. 1999

Corporate citizenship

10

World Business Council for Sustainable Development 1999

Corporate citizenship

11

Khoury et al. 1999

Stakeholder theory

12

Woodward-Clyde 1999

Corporate citizenship

13

Kilcullen and Kooistra 1999

Business ethics

14

Piacentini et al. 2000

Business ethics

Key findings “CSR is concerned with treating the stakeholders of the firm ethically or in a socially responsible manner. Stakeholders exist both within a firm and outside. Consequently, behaving socially responsibly will increase the human development of stakeholders both within and outside the corporation” (Hopkins 1998) “Market oriented cultures along with humanistic cultures lead to proactive corporate citizenship, which in turn is associated with improved levels of employee commitment, customer loyalty and business performance” (Maignan et al. 1999) “CSR is the commitment of business to contribute to sustainable economic development, working with employees, their families, the local community and society at large to improve their quality of life” (World Business Council for Sustainable Development 1999) “CSR is the overall relationship of the corporation with all of its stakeholders. These include customers, employees, communities, owners/investors, government, suppliers and competitors. Elements of social responsibility include investment in community outreach, employee relations, creation and maintenance of employment, environmental stewardship and financial performance” (Khoury et al. 1999) “CSR has been defined as a „contract‟ between society and business wherein a community grants a company a license to operate and in return the matter meets certain obligations and behaves in an acceptable manner” (Woodward-Clyde 1999) “CSR is the degree of moral obligation that may be ascribed to corporations beyond simple obedience to the laws of the state” (Kilcullen and Kooistra 1999) “CSR is the voluntary assumption by companies of responsibilities beyond purely economic and legal responsibilities” (Piacentini et al. 2000) (continued)

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Table 1 (continued) Sl. No. 15

Researcher(s), Year Business for Social Responsibility 2000

Perspective Corporate citizenship

16

Commission of the European Communities 2001

Sustainability

17

Jackson and Hawker 2001

Stakeholder theory/ sustainability

18

Marsden 2001

Corporate citizenship

19

McWilliams and Siegel 2001

Business ethics

20

Foran 2001

Stakeholder theory/ sustainability

21

Pinney 2001

Corporate citizenship

Key findings “Operating a business in a manner that meets or exceeds the ethical, legal, commercial and public expectations that society has of business. Social responsibility is a guiding principle for every decision made and in every area of a business” (Business for Social Responsibility 2000) “CSR is a concept whereby companies integrate social and environmental concerns in their business operations and in their interaction with their stakeholders on a voluntary basis” (Commission of the European Communities 2001) “CSR is how a Company treats its employees and all its stakeholders and the environment” (Jackson and Hawker 2001) “CSR is about the core behaviour of companies and the responsibility for their total impact on the societies in which they operate. CSR is not an optional add-on nor is it an act of philanthropy. A socially responsible corporation is one that runs a profitable business that takes account of all the positive and negative environmental, social and economic effects it has on society” (Marsden 2001) “CSR are the actions that appear to further some social good, beyond the interests of the firm and that which is required by law” (McWilliams and Siegel 2001) “CSR can be defined as the set of practices and behaviours that firms adopt towards their labour force, towards the environment in which their operations are embedded, towards authority and towards civil society” (Foran 2001) “CSR or corporate citizenship can most simply be defined as a set of management practices that ensure the company minimizes the negative impacts of its operations on society while maximizing its positive impacts” (Pinney 2001) (continued)

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Table 1 (continued) Sl. No. 22

Researcher(s), Year UK Government 2001

Perspective Stakeholder theory

23

Lea 2002

Stakeholder theory

24

Andersen 2003

Sustainability

25

Strategis 2003

Sustainability

26

Van Marrewijk 2003

Sustainability

Key findings “CSR recognizes that the private sector’s wider commercial interests require it to manage its impact on society and the environment in the widest sense. This requires it to establish an appropriate dialogue or partnership with relevant stakeholders, be they employees, customers, investors, suppliers or communities. CSR goes beyond legal obligations, involving voluntary, private sector led engagement, which reflects the priorities and characteristics of each business, as well as sectoral and local factors” (UK Government 2001) “CSR is about businesses and other organizations going beyond the legal obligations to manage the impact they have on the environment and society. In particular, this could include how organizations interact with their employees, suppliers, customers and the communities in which they operate, as well as the extent they attempt to protect the environment” (Lea 2002) “We define CSR broadly to be about extending the immediate interest from oneself to include one‟s fellow citizens and the society one is living in and is a part of today, acting with respect for the future generation and nature” (Andersen 2003) “CSR is generally seen as the business contribution to sustainable development, which has been defined as development that meets the needs of the present without compromising the ability of future generations to meet their own needs, and is generally understood as focusing on how to achieve the integration of economic, environmental and social imperatives” (Strategis 2003) “In general, corporate sustainability and CSR refer to company activities – voluntary by definition – demonstrating the inclusion of social and environmental concerns in business operations and in interactions with stakeholders” (Van Marrewijk 2003) (continued)

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Table 1 (continued) Sl. No. 27

Researcher(s), Year Kanter 2003

Perspective Corporate social performance

28

Goodpaster and Matthews Jr 2003

Business ethics

29

IndianNGOs.com 2003

Corporate citizenship

30

Ethical Performance 2003

Business ethics

31

Global Corporate Social Responsibility Policies Project 2003

Business ethics

32

CSRwire 2003

Stakeholder theory

33

Ethics in Action Awards 2003

Stakeholder theory

Key findings “Now companies are viewing community needs as opportunities to develop ideas, locate and cater to new markets, and solve long overdue business problems” (Kanter 2003) “Corporations that monitor their employment practices and the effects of their production processes and products on the environment and human health show the same kind of rationality and respect that morally responsible individuals do” (Goodpaster and Matthews Jr 2003) “CSR is a business process wherein the institution and the individuals within are sensitive and careful about the direct and indirect effect of their work on internal and external communities, nature and the outside world” (IndianNGOs.com 2003) “At its best, CSR is defined as the responsibility of a company for the totality of its impact, with a need to embed society’s values into its core operations as well as into its treatment of its social and physical environment. Responsibility is accepted as encompassing a spectrum – from the running of a profitable business to the health and safety of staff and the impact on the societies in which a company operates” (Ethical Performance 2003) “Global CSR can be defined as business practices based on ethical values and respect for workers, communities and the environment” (Global Corporate Social Responsibility Policies Project 2003) “CSR is defined as the integration of business operations and values, whereby the interests of all stakeholders including investors, customers, employees and the environment are reflected in the company’s policies and actions” (CSRwire 2003) “CSR is a term describing a company’s obligation to be accountable to all of its stakeholders in all its operations and (continued)

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Table 1 (continued) Sl. No.

Researcher(s), Year

Perspective

34

Daugareilh and Isabelle 2008; Sobczak 2004

Stakeholder theory

35

Chapple and Moon 2005

Corporate citizenship

36

Prahalad 2006

Corporate social performance

37

Sen et al. 2006

Stakeholder theory

38

Collier and Esteban 2007

Corporate social performance

39

Sirsly and Lamertz 2008

Corporate social performance

Key findings activities. Socially responsible companies consider the full scope of their impact on communities and the environment when making decisions, balancing the needs of stakeholders with their need to make a profit” (Ethics in Action Awards 2003) “Employees’ participation in framing CSR policies cannot be ignored because OECD guidelines on employment and industrial relations and ILO Tripartite Declarations specify the same; Companies should be cautious in using CSR tools, such that while protecting consumer rights, labour rights should not be compromised” (Daugareilh and Isabelle 2008; Sobczak 2004) “Community involvement is the largest part of established form of CSR in India. This is now being followed by socially responsible production process and employee relations” (Chapple and Moon 2005) Propounded the “bottom of the pyramid” model, where he argued that one must “stop thinking of the poor as victims or as a burden and start recognizing them as resilient and creative entrepreneurs and valueconscious consumers, a whole new world of opportunity will open up” (Prahalad 2006) “Stakeholders from consumption, employment and investment domains react positively to a company’s CSR initiatives” (Sen et al. 2006) “Many businesses understand that the willingness to assume responsibility for people and the environment can determine the achievement of the company’s profitability” (Collier and Esteban 2007) “CSR initiatives of a company can lead to a sustainable fist-mover advantage provided it is central to the company’s mission, provides company specific benefits and is made visible to external audiences” (Sirsly and Lamertz 2008) (continued)

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Table 1 (continued) Sl. No. 40

Researcher(s), Year Visser 2008

Perspective Corporate citizenship

41

Peterson and Jun 2009

Corporate social performance

42

Doh et al. 2010

Corporate social performance

43

Kapoor and Sandhu 2010

Corporate social performance

44

Kitthananan 2010

Corporate social performance

45

Porter and Kramer 2011

Corporate social performance

46

Stephen et al. 2012

Business ethics

Key findings “The formal and informal ways in which business makes a contribution to improving the governance, social, ethical, labour, environmental conditions of the developing countries in which they operate, while remaining sensitive to prevailing religions, historical and cultural contexts” (Visser 2008) “A company which has incorporated CSR philosophy in its business model has better reputation and this leads to better financial performance, since both are closely related” (Peterson and Jun 2009) “Institutional intermediaries (nongovernmental organisations – NGOs, rating agencies, certifying agencies, think tanks, public institutions etc. appear to influence market assessments of a company’s social responsibility” (Doh et al. 2010) “There is significant positive impact of CSR on corporate profitability and insignificant positive impact on corporate growth” (Kapoor and Sandhu 2010) “Successful corporate responsibility requires an integration of CSR into business’s strategy as well as its inprocess operations. Business should be able to deliberately identify, prioritize, and address the social causes that matter most, or at least the ones on which it can make the highest impact to society and business’s future” (Kitthananan 2010) Propounded the concept of “creating shared value,” that states: “Companies could bring business and society back together if they redefined their purpose as “creating shared value” – generating economic value in a way that also produces value for society by addressing its challenges. A shared value approach reconnects company success with social progress” (Porter and Kramer 2011) “The institutional theory stated that corporate social activities are not only voluntary activities but it is a part of (continued)

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Table 1 (continued) Sl. No.

Researcher(s), Year

Perspective

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Eccles and Serafeim 2013

Corporate social performance

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Mitra 2014

Corporate citizenship

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Rangan et al. 2015

Corporate social performance

50

Örtenblad 2016

Business ethics

Key findings interface between business and society. Regulation/governance are necessary for enhancing the corporate performance of businesses through CSR. The theory also suggested that in what form companies should take its social responsibilities whether historical, political or legal form” (Stephen et al. 2012) Contend that by “focusing on the environmental, social and governance (ESG) issues that are most relevant – or “material” – to shareholder value, firms can simultaneously boost both financial and ESG performance” (Eccles and Serafeim 2013) “In an emerging country like India, the ideal model, would be to generate the continuous “cycle of conversion” and transform the population to reap demographic dividend through a mutually beneficial relationship with the Government and the Corporation” (Mitra 2014) “Companies’ CSR activities are typically divided among three theatres of practice, viz., focusing on philanthropy, improving operational effectiveness and transforming the business model” (Rangan et al. 2015) “The motives behind CSR initiatives have both moral and strategic imperatives” (Örtenblad 2016).

Source: Collated from Dahlsrud 2008; Maurya 2013; Mitra 2019

and sustained growth of business itself, apart from anything else, it is not sufficient to limit our thoughts and concerns within the boundary of the organization. Thus, the spectrum of initiatives around CSR is an ever-expanding one that may start from employees and shareholders, but include customers, suppliers, the social milieu, the government, the natural environment, and even competitors. Moreover, with increasing thrust on responsible corporate governance, there has been a shift from a preoccupation with the interests of shareholders to an engagement with the concern for multiple stakeholders from diverse constituencies. At a microlevel, with transparency being regarded as a value that demands availability and the smooth flow of information, companies can no longer afford to manipulate the customers and armtwist the vendors. At a macrolevel, corporate leaders are compelled to consider the impact of their business decisions on the community and the environment at large.

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Further, with increasing dependence on the stock market for equity financing, there is also the growing need to attract and fulfill the expectations of conscious investors who value the goodwill of companies that invest in CSR initiatives. Corporate social responsibility today is not just a part-time philanthropic activity, but a strategic imperative directly linked to business results for long-term sustainability of organizations. It may also be mentioned that the scope of CSR is no longer limited to monetary donations for a social cause. Companies need to reconsider their new role as partners and facilitators in the development and participate in capacity building programs for the disadvantaged sections of society. This will raise the overall standard of living, increase the purchasing power of the people, and thereby expand the markets for selling their own products and services. Incidentally, such initiatives by any company also boost the morale of employees by instilling in them a sense of pride and ownership. This has a direct and positive impact on their levels of motivation, and enhances their productivity and contribution towards the achievement of organizational goals and objectives. After all, engagement with CSR activities does make “good business sense.” It may be mentioned here that companies in which the level of employee satisfaction is low are likely to be the least effective in CSR initiatives. It is not possible to generate goodwill in the external environment without taking good care of the needs and aspirations of the employees. Besides, the financial costs of unethical business practices domestically and globally run sky-high. Unethical business practices produce intangible costs as well, including stakeholder dissatisfaction reduced cooperation and support for business initiatives and eroded domestic and global business reputations. Business leaders who neglect to control such tangible and intangible losses are and will continue to be held accountable economically, legally, and ethically. Domestic and global business stakeholders have begun to demand that businesses exhibit higher levels of ethical performance and social responsibility. In addition to the conventional stakeholder expectations of business making a profit, paying taxes, creating jobs, and obeying the law, business stakeholders are increasingly demanding that businesses set higher ethical standards of self-regulated performance and improve society rather than merely privatize gains and externalize costs onto public taxpayers. Progressive business leaders acknowledge that when corporations uphold ethical standards, consumers will conduct more business with them and investors in turn will benefit. Being ethical and CSR oriented builds stakeholder trust for business leaders and if this trust is broken, the unethical party may be shunned, ignored, and marginalized, thereby depriving the business of the benefits of future business partnerships. The opportunity costs of lost cooperation can be overcome by sustaining trustworthy relations with market and nonmarket stakeholders through demonstrated ethical behavior on a regular basis. Being ethical and socially responsible allows business to operate more efficiently in a domestic and global free market. When business acts unethically, it invites excessive external government regulation oversight that protects victimized business stakeholders by increasing standards of accountability, transparency, and

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punishment that inevitably increases the cost of doing business. When this unethical business activity becomes prevalent in global environments, institutionalized corruption adds to the cost of doing business results in the loss of high-quality human and financial capital. Besides, ethical business leaders who build principled organizations in morally sound environments are able to attract and retain the highest quality human and financial capital. Business market stakeholders want to do business with an ethical company and business nonmarket stakeholders provide the supportive social capital to nurture future business success. Therefore, in the long run, being ethical and CSR oriented pays. There is an accumulating body of evidence suggesting that ethical and socially responsible behaviors increase the trustworthiness of a firm and strengthen its relationships with various stakeholders. These positive stakeholder relationships are likely in turn to decrease transaction costs according to Barnett (2007) and lead to financial gain (as in increased employee commitment and motivation, decreased turnover, union avoidance, and increased customer loyalty). Ethical and responsible business conduct helps a company build reputational capital and enhances long-term competitive advantage.

Evolution of CSR: Global and Indian Context The first time period of 1920–1950s concentrated on the social responsibilities of businessmen which was quite evident from some of the works worth noting like Chester Barnard’s “The Functions of the Executive” (Barnard 1938), J. M. Clark’s “Social Control of Business” (Clark 1939), and Theodore Kreps’s “Measurement of the Social Performance of Business” (Kreps 1940), to point out just a few. In the second time period of 1950s corporate social responsibility as a concept started taking shape. Most scholars point to Howard Bowen’s “Social Responsibilities of the Businessmen” (Bowen 1953) as the first attempt to theorize the relationship between companies and society (Carroll 1999; Preston and Post 1975; Wartick and Cochran 1985). For him, CSR “refers to the obligations of businessmen to pursue those policies, to make those decisions, or to follow those lines of action which are desirable in terms of the objectives and values of our society” (Bowen 1953). The decade of 1960s “marked a significant growth in attempts to formalize or more accurately, state what corporate social responsibility means” (Carroll 1999). He suggested that some of the most prominent writers during that time were Keith Davis, Joseph W McGuire, William C Frederick, and Clarence C Walton. The notion of business ethics to corporate social responsibility was introduced during this era. The time period of 1970s was an era of enlightened self-interest. A breakthrough in conceptual development was observed during this period when a new study on corporate social responsibility was commissioned by the Committee for Economic Development. The committee described corporate social responsibility as being “related to products, jobs and economic growth; related to societal expectations; and related to activities aimed at improving the social environment of the firm”

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(US Committee for Economic Development in Wheeler et al. 2003). There was enthusiasm and research in the field of corporate social responsibility in the 1970s (Ackerman 1973; Fitch 1976; Murray 1976). The era of 1980s paved way for the development of complementary themes to CSR. A prominent development in terms of corporate social responsibility was the global debate on sustainable development that emerged in this decade (Tilbury and Wortman 2004; World Commission on Environment and Development 1987). The era of 1990s was that of imbibing the concept of CSR in the field of strategic management. CSP, stakeholder theory, business ethics theory, and corporate citizenship were the major themes that took center stage in the 1990s (Carroll 1999). Corporate social responsibility advanced with more practical applications in mind by strategic management scholars such as Philip Kotler, Nancy Lee, Michael Porter, Rosabeth Moss Kanter, and Stuart Hart. In the twenty-first century expansions, the theoretical contributions to the concept and meaning of CSR had given way to empirical research on the topic and a splintering of interests away from CSR into related topics such as stakeholder theory, business ethics, sustainability, and corporate citizenship. The most optimistic perspective during this era was depicted well by Lydenberg (2005) in his book “Corporations and the Public Interest: Guiding the Invisible Hand.” Lydenberg saw CSR as “a major secular development, driven by a long-term re-evaluation of the role of corporations in society.” From the Indian perspective we observe that the Vedantic philosophy with its strong focus on morality and community involvement partly explains corporate India’s tradition of prolific philanthropy and “do-good” approaches (Mohan 2001). It also encompasses the essence of modern-day corporate social responsibility that is “prosperity for all” and “in harmony with nature.” Gandhi’s theory of social trusteeship epitomizes this “prosperity for all attitudes” and thus his theory can be considered as a basis to all the corporate social responsibility practices that we observe in modern India. If we look at the development of CSR in India, we find that it can be divided into four main phases. The first phase was an era where CSR was motivated by charity and philanthropy. The pioneers of industrialization in the nineteenth century in India were a few families such as the Tata, Birla, Bajaj, Lalbhai, Sarabhai, Godrej, Shriram, Singhania, Modi, Naidu, Mahindra, and Annamali, who were strongly devoted to philanthropically motivated CSR (Mohan 2001). Arora and Puranik (2004) observed that “The early pioneers of industry in India were leaders in the economic, as also in the social fields.” The second phase of Indian CSR (1914–1960) was dominated by the country’s struggle for independence and influenced fundamentally by Gandhi’s theory of trusteeship. Businesses, especially well-established family businesses set up trusts for schools and colleges, they also established training and scientific institutes (Mohan 2001). Many of the upcoming and prominent business leaders contributed to the causes of social reforms, poverty alleviation, women empowerment, and caste systems (Sundar 2000). After independence in 1947, the overall socio-political goal focused on building a solid industrial base while nurturing the Indian cultural traditions. The third phase (1960–80) was characterized by a strict legal and public regulation of business activities. The 1960s have been described as an “era of command and control”

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(Arora and Puranik 2004). During this phase businesses were asked to play their part as respectable corporate citizens, and the call went out for regular stakeholder dialogues, social accountability, and transparency (Mohan 2001). In the fourth phase (1980 until the present) Indian companies and stakeholders began abandoning traditional philanthropic engagement and, to some extent, integrated CSR into a sustainable business strategy, partly adopting the multistakeholder approach mainly due to economic liberalization in 1991 and greater levels of privatization. At present we find that CSR and its reporting in India which was voluntary till 2013 has been made mandatory as per section 135 of the Companies Act of 2013, perhaps the only country in the world to do so (Ghosh and Mukherjee 2020).

Role of Corporate Influence and Social Responsibility in Global Health: India’s Response to the COVID-19 Pandemic A recent study showed that over 95.5% of deaths occur due to disease, epidemics, and unexpected events while only 0.5% of all deaths combined are due to terrorism, war, and natural disasters (Ritchie and Roser 2019). Infact, nothing has killed more human beings than the adverse attack of “virus” on our immune system. These viruses are then considered to be more dangerous than natural disasters like earthquakes or volcanoes as they can spread worldwide and lead to a pandemic as well. The World Health Organization (WHO) defines a pandemic as an epidemic of an infectious disease that has spread across a large region, for instance multiple continents or worldwide, affecting a substantial number of people (WHO n.d). A single pandemic can have disastrous effect in all walks of life as these pandemics have the history of collapse of empires, weakened preeminent powers, and institutions and have created social and economic upheaval in the society (Stanly 2020). It was estimated, the Black Death of the fourteenth century killed up to 200 million people and is considered to have brought enormous societal, economic, artistic, and cultural reforms. This demonstrated how infectious diseases like a pandemic can be a major turning point in history. Widespread death posed labor shortages across the kingdom, and eventually resulted in higher wages, cheaper land, better living conditions, and increased freedoms for the lower class. During this time, people started questioning the long-held certainties around societal structure, traditions. In the 1918 influenza pandemic (known as the Spanish flu), over 50 to 100 million people died. This number surpassed the death toll of the World War I. It was caused by an H1N1 virus with genes of avian origin. The 1918 flu virus infected almost one in every three people on the planet. However, public health interventions such as quarantine, use of face masks, and ban on mass gatherings were taken to reduce the containment of the pandemic. The Spanish flu in the early part of the twentieth century made people and governments all over the world realize the importance of public health care system, wrote the Nobel-winning economist Angus Deaton in his 2013 book, “The Great Escape: Health, Wealth, and the Origins of Inequality.”

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In fact, viruses that have caused past pandemics typically originated from animal influenza viruses. Others such as the Spanish flu, ebola, and Black Death have killed millions of people for being contagious in nature and due to lack of a good public health care system. Since 1980 alone, the number of outbreaks per year has more than tripled. However, one of the most recent pandemics that has shaken the world is the novel coronavirus or the COVID-19 that originated in late 2019.

Novel Coronavirus or COVID-19 Retrospective investigations by Chinese authorities have identified human cases with onset of COVID-19 symptoms in early December 2019. While some of the earliest known cases had a link to a wholesale food market in Wuhan (China), some did not. It was declared a pandemic by the World Health Organization affecting millions of people worldwide. This pandemic has been able to reach rapidly to almost all the continents across the globe (Lau et al. 2020) and its sudden outbreak has shaken all the religious and financial structures of the whole world. Even the developed and prosperous economies such as United States of America (USA), Germany, France, United Kingdom (UK) are deeply affected, where millions of people are succumbing to this contagious disease. This novel coronavirus or COVID-19, like other pandemics in history, is leading to global economic downturn, as, in order to stop the spread of this contagious disease, imposition of social distancing, self-isolation, and restriction on mobility are considered to be some of the effective measures. This has turned out to be the biggest health crisis in history since World War II as all nonessential services and businesses including public utility and government offices supply chains have been disrupted. Most of the nations are going through recession and the collapse of their economic structures. Barely 7 months from its inception, almost 80 countries have already requested International Monetary Fund (IMF) for financial help. Early estimates of the economic damage from COVID-19 have already crossed the trillion-dollar mark as this novel coronavirus has been able to spread across the world in a matter of months. In just a week of this widespread, 3.3 million Americans applied for unemployment and a week later another 6.6 million people started looking up for jobs. The World Health Organization (WHO) chief acknowledged that the COVID-19 spread is the first pandemic to be caused by a coronavirus (i.e., any of the large variety of viruses that cause illnesses ranging from the common cold to more severe diseases). The virus has created havoc, and as on July 26, 2020, it is affecting over 16 million persons in 213 countries; India reported almost 1.4 million confirmed cases, 32,063 deaths, and 886,000 cured cases, as per the latest report released by the Worldometer (2020), and is increasing each day. The pandemic and the measures taken by states and other institutions to counteract it are having severe consequences for health systems, economies, and society everywhere in the world as reducing close contact and promoting social distancing comes at a huge economic cost which eventually is leading to a humanitarian crisis. It is especially hard on the already vulnerable and marginalized communities – the migrant laborers and the informal sector workers.

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Effect of Coronavirus on Migrant Laborers Bustamante (2011) points out that “migrants are inherently vulnerable as subjects of human rights from the time they leave home to initiate theirmigration.” In other words, any human being is less vulnerable at home than right after he leaves it to become a migrant. De Varennes (2003) is of the opinion that “living in host states where they (migrants) may not master the official language(s), are unfamiliar with the workings of the legal system and administration, detached from traditional support and family networks, exposed to a society with ways of life or cultures which they may find at times alien, they may face trials that can leave them disoriented and disturbed.” This is especially true in the times of a pandemic, when they have temporary shelter and uncertainty of livelihood. Many countries adopted the “lockdown” strategy or immobility to circumvent the spread of coronavirus. This closure severely affected the marginalized communities all over the world – for example, some migrant domestic workers in Hongkong and Macau have lost their source of livelihood because their employer left their place leaving them with no source of income. In addition to this, social distancing can have a great psychological impact on the mental well-being of the people as vulnerable population such as homeless are already grappling with chronic economic and medical crisis. There is a higher possibility of being overlooked for availing health care services to fight this COVID-19 pandemic. Also, many countries are already facing the issues of lack of infrastructure and resources to shelter in an eventual quarantine. Examples are Colombia which has almost six million internally displaced persons and, in the last few years, approximately two million Venezuelans who have migrated into the country as migrant workers are prone to lack of access to basic health care services and clean sanitation and hygiene. The majority of this migrant population lack adequate housing, health care, and social support. They are also victims of ostracization and exploitation, often being accused to spread the COVID19 in their country (Daniels 2020).

Effect of Coronavirus on Migrant Laborers in India Indian economy is majorly categorized into two sectors – formal and informal. While the former belongs to an organized sector, the informal sector is mostly governed by the migrant workers coming from rural areas seeking better livelihood and standards of living in cities. They work in the construction, tourism, transportation, and textile industries among others. India has the largest informal sector in the world which contributes almost 50% to its overall gross domestic product (GDP). Among over 465 million workers, 422 million were informal workers in 2017–18 (Table 2). Thus, migration is not a new phenomenon in India. These migrant workers keep moving from one place to another for better employment and to reduce their poverty. National commission for enterprises in the unorganized sector (NCEUS) reports around 92% of India’s workforce with informal employment as migrant labors.

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Table 2 Distribution of total employment

Worker Informal Formal Total

Distribution of total employment 2011–12 Unorganized Organized Total 82.6 9.8 92.4 0.4 7.2 7.6 83.0 17.0 100.0

2017–18 Unorganized 85.5 1.3 86.8

Organized 5.2 7.9 13.2

Total 90.7 9.3 100.0

Source: Computed from NSS 68th unit level data on employment unemployment, 2011–12 and Periodic Labour Force Survey 2017–18

Though they contribute substantially towards economic growth, this marginalized community often face discrimination, exploitation, and socioeconomic crisis such as lack of proper education, health facility, housing, and better working conditions. The Economic Survey of India 2017 estimates that interstate migration in India was close to nine million annually between 2011 and 2016, while the 2011 census pegged the total number of internal migrants in the country (accounting for inter- and intrastate movement) at a staggering 139 million, according to a report by the World Economic Forum (Sharma 2017). Largely invisible in the census and in national sample surveys – and consequently to policymakers – seasonal migrants are a dark and discomfiting reality of urban India. COVID-19 worsened their already prevailing situation. They have lost their livelihoods during the 2-month long lockdown. Mass exodus of migrants then started walking back to their respective villages with many dying on the way – there was a harrowing story of a 12-year-old boy who, after being on the road for 48 h, died just before he reached his village (Kakar and Nundy 2020). The reason behind this was that, the central and state governments sealed the borders to prevent this infection from spreading from the metro cities to the villages. About 50% of the migrant workers stated that they had rations for less than a day when interviewed. Further, the study by Stranded Workers Action Network showed that 89% of the stranded workers had not been paid wages by their employers during the first 21 days of lockdown and that 74% had less than half their daily wages to live on (Gopalan and Misra 2020). Before Lockdown, India was already under employment crisis and was grappling with agrarian crisis too. Almost 90% of the workers in the informal sector have survived with no minimum wage or any kind of social security (Sharma 2020). Even after the unorganized worker’s Social Security Act (2008), only 5–6% enrolled themselves for social security. According to the Periodic Labor Force Survey (PLFS) of 2017–18, 71.1% had no job contract, 54.2% are not eligible for paid leave, and 49.6% had no social security (Mohanty 2020). Now, the return or reverse migration amid the agrarian crisis in the agricultural sector from urban to rural areas pose big challenges on the rural economy. According to International Organization of Migration (2011), “return migration is the act or process of going back to the point of departure, is the returning of people to their origin or place of habitual residence after spending some time at another place.” Irrespective of the reason for migration, the return poses a significant impact on the demography, society, and economy of rural areas.

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As per the latest 2011 census, the internal migrant laborers in India are around 450 million (De 2019). Field realities show migrant laborers are relatively higher in case of Uttar Pradesh (U.P) and Bihar followed by Madhya Pradesh (M.P), Punjab, Rajasthan, Uttarakhand, Jammu & Kashmir, and West Bengal. Currently, returnees surviving on hands-to-mouth income are coming back to save their lives from poverty and hunger. The International Labor Organization (ILO) estimates around 400 million workers in India in the informal economy are at the risk of falling deeper into poverty during the crisis. For most of the urban migrants, homecoming is a difficult choice to make as the rural is often associated with less working opportunities and limited resource availability. Some are of the opinion that rural life is associated with hard, rigorous physical labor and is hard to handle by them (Athar 2020). For example – Hari Kumar, who scrambled for a seat on a shramik special train (special train for migrant laborers to reach their villages run by the government during lockdown) to take him from Delhi to his village Pilakhana in western Uttar Pradesh in the first week of May, is one of those trying to adjust to his new life (Athar 2020). Nirmalya Choudhury, senior researcher with Vikas Anvesh Foundation, a nongovernmental organization (NGO) working in the rural development sector, said it is important to understand that returnee migrants are not a homogenous entity. “They could be skilled, semiskilled, unskilled” (Athar 2020). The Indian constitution contains basic provisions relating to the conditions of employment, nondiscrimination, right to work, etc. (for example, Article 23 (1), Article 39, Article 42, Article 43) which are applicable for all workers including migrant workers within the country. Migrant laborers are covered under almost all laborers laws and policies. These laws include the Minimum Wages Act, 1948; the Contract Labor (regulation and abolition) Act, 1970; the Equal Remuneration Act, 1976; the Building and Other Construction Workers (regulation of employment and conditions of service) Act, 1996; the Workmen’s Compensation Act, 1923; the Payment of Wages Act, 1936; the Child Labor (prohibition and regulation) Act, 1986; and the Bonded Labor Act. But often in reality, they are subjugated to exploitation and humiliation by various government authorities. In fact, the Interstate Migrant Policy Index 2019 (IMPEX 2019), an index compiled by India Migration Now (IMN), a Mumbai-based nonprofit that analyzes state-level policies for the integration of out-of-state migrants, has revealed apathy and discrimination toward migrants by state-level policymakers (Lal 2020). However, after witnessing the arduous journey of these invisible communities and grappling with humanitarian crisis, some of the state governments did come forward to take their citizens back to their villages.

Role of the Government The COVID-19 could be devastating for immigrants and refugees in both developed as well as developing countries. In less developed countries, having inadequate sanitation and infrastructural facilities can cause huge strains on public health

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systems which can impact hundreds of millions of people especially immigrants, refugees, internal migrants, and displaced populations (Seth Sharma 2020). To mitigate the effect of the lockdown on the vulnerable groups, the Government of India on March 26, 2020, announced a US$13 billion package under the Pradhan Mantri Gareeb Kalyan Yojana (Prime Minister’s Food Security Scheme for the Poor). This includes, within its ambit, health workers, farmers, Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) workers, economically vulnerable categories, especially women, elderly, and the unorganized-sector workers, Jan Dhan account holders, and Ujjwala beneficiaries (families that are below poverty line when it comes to the provision of clean cooking fuel). The scheme entails an additional 5 kg of wheat or rice and 1 kg of preferred pulses every month to 800 million beneficiaries for the next 3 months. Central government also gave an order to the state governments to use Building and Construction Workers Welfare Fund of INR 310 billion to provide relief to construction workers through direct benefit transfer (DBT) (DHNS 2020; Government of India 2020; Seth Sharma 2020). The Reserve Bank of India (RBI) joined later with a sharp cut in interest rate along with a series of unconventional measures to lend to besieged businesses (Bloomberg Quint 2020; Mathew 2020). Ministry of Home Affairs (MHA) also asked the landlords not to charge rent during this crisis and employers to make the payment of wages of their workers without deduction for the period of closure (Government of India 2020; Dubey 2020). MHA set up a control room to monitor the situation 24X7 to ensure the access to essential commodities to anyone (Press trust of India 2020b Bhagat et al. 2020). States were allowed to utilize money in the State Disaster Relief Fund (SDRF) to provide food, accommodation, and medical care to the homeless, including migrant workers, stranded due to lockdown and sheltered in relief camps and other places (Joy 2020; Press Trust of India 2020a). Till March 31, 2020, 660 thousand migrant workers were accommodated in the 21,604 relief camps with provision of food, shelter, and other basic necessities. Additionally, arrangements for food were made for 2.3 million persons (Kulkarni 2020; Bhagat et al. 2020). Under pressure to address the growing emergency, the central government took certain developmental steps: • INR 2000 to be transferred to 87 million farmers under PM Kisan Yojana Scheme (Prime Minister’s Scheme for Farmers) in 10 days • Increase in MGNREGA wages to INR 202 from INR 182 • INR 500 per month to 200 million female Jan Dhan account holders (special bank account for female marginalized) for next 3 months • Ex gratia of INR 1000 to poor senior citizens, widows, and disabled • INR two million collateral-free loans to women self-help groups • Government to contribute employee provident fund (EPF) to companies with less than 100 workers • Nonrefundable advances of 75% or 3-months wages from provident fund (PF) account • States to use INR 310 million from construction workers welfare fund • States to use district mineral fund for medical activities

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However, not all worked with the government. There were well intending actions with loopholes. During the second phase of the lockdown, on April 29, 2020, the central government announced it would run Shramik Express trains to ferry migrant workers to their home states. The policy was sound and well meaning in concept, but in a country like India with illiteracy as a major issue, there were lacunas in implementation. Moreover, the beneficiaries were also hungry, angry, frustrated, panic stricken, and easily convertible to mob psychology. According to the Stranded Workers Action Network (SWAN), migrants were confused about the exact procedures to register themselves for travel – “many state registration portals were either in English or the local language of the states they lived in, which very few migrants could understand. Further, general lack of information from the government to the migrants had resulted in them paying large sums of money to register themselves” (Saxena 2020). Moreover, post-lockdown, there was a mayhem among this sector to return to their villages. According to the railway protection force, there have been almost 80 deaths on board the Shramik Special trains between 9 and 27 May, 2020 (The Wire 2020a) due to various factors. A train from Goa to Manipur reported a 58-hour delay, no proper food or sanitation facilities on the train, and stone pelting (Bhowmick 2020; Haksar 2020). Others who received food packets and water reported that the provisions were simply dumped at the entrances, leaving workers fighting with each other for their share (Khandelwal 2020). Those people who died became the victim of violation of “Right to life” guaranteed under Article 21 of the constitution of India (Batra 2020).

Role of the State Government Renowned economist, social scientist, and activist Jean Drèze stated that the lockdown had been “almost a death sentence” for the underprivileged of the country, further stating, “The policies are made or influenced by a class of people who pay little attention to the consequences for the underprivileged.” In order to deal with this pandemic, each state has adopted its own ways and strategies so that this infectious disease does not spread (Nanda 2020). Some of the examples are as follows: • Kerala, drawing on an experience with the Nipah virus in 2018 is able to use extensive testing, contact tracing to contain the virus and thus has been able to retain the low fatality rate. It has also set up thousands of temporary shelters for migrant workers. • Odisha in the past has often faced natural calamities requiring preparedness and disaster management in advance and that meant crisis precautions were taken to be considered seriously. • Maharashtra having the largest number of coronavirus cases in India has used drones to monitor physical distancing during lockdown and applied a cluster containment strategy: if three or more patients are diagnosed, all houses within 3 km are surveyed to detect further cases, trace contacts, and raise awareness. Also, many known celebrities such as Sonu Sood and Amitabh Bachhan also came to the rescue. They arranged chartered flights and buses to send these

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migrant laborers back to their villages safely. Sonu Sood has fed over 45, 000 migrants on the streets. He arranged buses for thousands of them to reach back to their native villages safely. He initiated a toll-free helpline to help migrants and with this number they could reach out to his team to avail help. Only a few Indian states including Kerala, Uttar Pradesh, Haryana, and Punjab have been able to provide financial assistance to daily wage workers (The Quint 2020). Maharashtra, accounting for one of the largest number of migrant workers announced a relief package of INR 450 million for the provision of accommodation and food for its migrants. A status report filed by the Ministry of Home Affairs (MHA) in the Supreme Court proved that while the Kerala government operates over 65% of the total number of active shelters and relief camps for stranded migrant laborers, the Maharashtra government comes in second with 1,135 camps. On April 6, 2020, the Maharashtra chief minister announced that the government has set up 4,653 relief camps sheltering 454,142 migrant laborers and is providing food to 5,53,025 migrant laborers and homeless people across the state. Examples such as the Delhi government and some nongovernmental organizations (NGOs) started providing food daily at homeless shelters while Maharashtra, armed with a roster of nearly 30,000 migrant workers stranded in Mumbai, created temporary shelters that also provided food. • West Bengal government issued an order which says, “Adequate arrangements of temporary shelters and provision of food etc. shall be made by the District administration for the poor and needy people, including migrant workers stranded due to lockdown measures in their respective areas. District administrations should explore the option of involving NGOs/civil society/other voluntary organizations to support and augment the services” (The Wire 2020b).

Role of Corporates COVID-19 has resulted in fear and panic in all sections of the society. In fact, the 2019 Global Health Security Index that measures countries’ pandemic preparedness on a score of 1–100 based on their ability to prevent, detect, mitigate, and cure diseases ranks India at 57 out of 195 countries (Devnani 2020). What is evident here is that the government is not equipped to handle this responsibility alone. It needs the intervention of the Corporations in terms of corporate influence and social responsibility. Chatterjee and Mitra (2017) also propounded that corporate social responsibility (CSR) should contribute to the national agenda in developing countries. Moreover, even without the pandemic, India has its own challenges as an emerging nation. On one hand it has the world’s second largest human population next only to China and predicted to have one of the world’s youngest and thereby the largest working population by 2026; yet, on the other hand, it ranks 129 among 189 countries in the Human Development Index (HDI) (Human Development Report 2019). On the other hand, India is also home to the seventh largest super-rich population (billionaires) in the world. The total billionaire wealth was estimated to be US $284 billion (Wealth-X Billionaire Census Report 2019), bringing India’s

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billionaire population to 82 (Mitra 2014, 2015; Mitra and Schmidpeter 2017; Chatterjee and Mitra 2017). Therefore, the population is divided between the haves and the have-nots. The country has India on one side and Bharat on the other. The private sector therefore has responsibilities and a role in creating broad based growth and furthering opportunities for individuals in poverty to move up. Involvement of the private sector in development efforts should be encouraged, not only to spur growth, but to make the state more effective by providing competition, increasing equity, and supplementing the resources of the state (The Aspen Institute Conferences 1997; Chatterjee and Mitra 2017).

CSR and Companies Act 2013: The Pre-COVID-19 Era Incidentally, India is the first country to require that some firms spend a percentage of their profits (as designated by law) on CSR activities or explain why they could not. This rule is part of section 135 of the Companies Act 2013. Section 135 divides the approach towards CSR into two broad steps – first, by specifying which firms are subject to mandatory obligations under section 135, and second, by specifying the obligations of these firms. According to section 135(1), mandatory CSR obligations under section 135 of the 2013 Act apply to every company having: • A net worth of INR 5 billion or more or • A turnover of INR 10 billion or more during any financial year or • A net profit of INR 50 million or more during any financial year All publicly traded and privately held firms with operations in India (including foreign-owned firms) are subject to section 135 if they cross any of the thresholds. Besides this, another highlighting aspect is the fact that companies covered by section 135(1) are required to comply with the following obligations laid down by section 135: • • • • • •

To form a CSR committee of directors To formulate a CSR policy based on CSR committee’s recommendations Duties of the directors To undertake activities included in CSR policy To spend at least 2% of net profit on CSR To disclose CSR policy in board of director’s report as well as on the website

Failure to meet the 2% spending requirement would not result in any kind of liability if an acceptable explanation for failing to meet that 2% was provided. If such an explanation is not provided and the firm fails to spend at least 2% of average net profits on CSR activities then liability would be triggered here. The penalty on the firm and every officer of the firm who violates section 135 is INR 10,000 for the first day of the violation plus an additional INR 1,000 a day if the violation continues (section 450, Companies Act 2013). It is also to be noted that if the violation is repeated within a 3-year period the fine amount doubles (section 451, Companies Act 2013).

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Finally, the Ministry of Corporate Affairs (MCA) has promulgated a set of rules in 2014 that provides a list of the activities that satisfy the requirement for CSR spending. Rule 4 of the companies (corporate social responsibility policy), 2014, provides the following: • The CSR activities shall be undertaken by the company, as stated in the CSR Policy, as projects or programs or activities (either new or ongoing), excluding activities undertaken in its normal course of business. • The board of a company may decide to undertake its CSR activities approved by the CSR committee, through a registered trust or a registered society or a company established by the company or its holding or subsidiary or associate company under section 8 of the Act or otherwise. • Such trust, society, or company which is not established by the company or its holding or subsidiary or associate company shall have to have an established track record of 3 years in undertaking similar programs or projects. • The company has specified the project or programs to be undertaken through these entities, the modalities of utilization of funds on such projects and programs, and the monitoring and reporting mechanism. • A company may also collaborate with other companies for undertaking projects or programs or CSR activities in such a manner prescribed by the CSR committees. • Companies may build CSR capacities of their own personnel as well as those of their implementing agencies through institutions with established track records of at least three financial years but such expenditure shall not exceed 5% of total CSR expenditure of the company in one financial year.

Schedule VII Moreover, activities specified in schedule VII to the 2013 Act specifies activities which companies may include in their CSR policies. These are activities relating to: • Eradicating hunger, poverty, and malnutrition – promoting health care including preventive health care and sanitation including contribution to the Swatch Bharat Kosh setup by the government for promotion of sanitation – making available safe drinking water • Promoting education, including special education and employment-enhancing vocation skills especially among children, women, elderly, and the differently abled – livelihood enhancement projects • Promoting gender equality – empowering women – setting up homes and hostels for women and orphans; setting up old age homes, day care centers and such other facilities for senior citizens; and measures for reducing inequalities faced by socially and economically backward groups • Ensuring environmental sustainability; ecological balance; protection of flora and fauna; animal welfare; agro forestry; and conservation of natural resources. Maintaining quality of soil, air, and water including contribution to the Clean Ganga Fund set up by the central government for rejuvenation of river Ganga

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• Protection of national heritage, art, and culture including restoration of buildings and sites of historical importance and works of art; setting up of public libraries; and promotion and development of traditional arts and handicrafts • Measures for the benefit of armed forces veterans, war widows, and their dependants • Training to promote rural sports, nationally recognized sports, paralympic sports, and Olympic sports • Contribution to the Prime Minister’s National Relief Fund or any other fund set up by the central government for socioeconomic development and relief and welfare of SC/ST/OBC, minorities, and women • Contributions or funds provided to technology incubators located within academic institutions which are approved by central government • Rural development projects • Slum area development – the term slum area shall mean any area declared as such by the central government or any state government or any other competent authority under any law for the time being in force The activities that are not included as CSR under this Act are as follows: • Activities undertaken in normal course of business • Activity undertaken outside India • CSR projects or programs or activities that benefit only the employees of the company and their families • Contribution of any amount directly or indirectly to any political party under section 182 of the Act shall not be considered as CSR activity • Activity not covered within schedule VII of the 2013 Act • One-off events such as marathons/awards/charitable contribution/advertisement/ sponsorships of TV programs, etc. would not qualify as part of CSR expenditure • Expenses incurred by companies for the fulfillment of any Act/statute of regulations (such as Labour Laws, Land Acquisition Act, etc.) would not count as CSR expenditure under the Companies Act • Contributions to National Defence Fund will not be counted as CSR spends

CSR Under the Present Era of COVID-19 Over the last 5 years, companies have mobilized their resources to meet the mandate of corporate social responsibility and do their bit for the society in India. But today, we are looking at life in times of COVID-19, a pandemic that is impacting everyone world over. We find casual laborers are leaving cities in hordes and moving to their villages. The central and state government has been taken by surprise. This is a situation they had not envisaged. Providing shelter and food is now a major concern for the government. Daily wage earners have been thrown out of their jobs, their homes, they are confused and distraught. Also, on returning to their hometowns these migratory populations are facing difficulty to enter their villages due to prohibitory orders made by the village administration to contain the spread of the virus in their villages. Due to lack of food, shelter and proper hygiene, health is one aspect which is bound to get affected. Under such circumstances, it is challenging to

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stop the spread of COVID-19 to rural areas; but, it is difficult for the government alone to take such a huge initiative in a vast, populous country like India. Therefore, contributions from the corporate sector will prove to be very crucial. The public and private partnership here becomes really essential. The government of India is also inspiring the companies to provide social support in this age of COVID-19. The Ministry of Corporate Affairs (vide its General Circular No. 10/2020 dated 23rd March, 2020) have clarified that spending of CSR funds for COVID-19 shall be considered as an eligible CSR activity. CSR funds could be utilized for various activities related to COVID-19, including those relating to preventive health care and sanitation, says a circular by the government. CSR funds could be used for direct expenditure to contain the spread, morbidity, and mortality due to the disease. According to General Circular No. 15/2020, F. No. CSR-01/4/2020-CSR-MCA Government of India, Ministry of Corporate Affairs, the following aspects have also been clarified: What constitutes CSR expenditure? • Contribution made to “PM CARES Fund” shall qualify as CSR expenditure under item number (viii) of schedule VII of the Companies Act, 2013, and it has been further clarified vide office memorandum F. No. CSR-05/1/2020-CSRMCA dated 28th March, 2020 • Contribution made to State Disaster Management Authority to combat COVID19 shall qualify as CSR expenditure under item number (xii) of schedule VII of the 2013 and clarified vide general circular No. 10/2020 dated 23rd March, 2020 • Ministry vide general circular No. 10/2020 dated 23rd March, 2020, has clarified that spending CSR funds for COVID-19-related activities shall qualify as CSR expenditure. It is further clarified that funds may be spent for various activities related to COVID-19 under item numbers (i) and (xii) of schedule VII relating to promotion of health care including preventive health care and sanitation, and disaster management. Further, as per general circular No. 21/2014 dated 18th June, 2014, items in schedule VII are broad based and may be interpreted liberally for this purpose • If any ex gratia payment is made to temporary/casual workers/daily wage workers over and above the disbursement of wages, specifically for the purpose of fighting COVID 19, the same shall be admissible towards CSR expenditure as a onetime exception provided there is an explicit declaration to that effect by the board of the company, which is duly certified by the statutory auditor What does not qualify as CSR expenditure? • Chief Minister’s Relief Fund or “State Relief Fund for COVID-19” is not included in schedule VII of the Companies Act, 2013, and therefore any contribution to such funds shall not qualify as admissible CSR expenditure • Payment of salary/wages in normal circumstances is a contractual and statutory obligation of the company. Similarly, payment of salary/wages to employees and workers even during the lockdown period is a moral obligation of the employers,

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as they have no alternative source of employment or livelihood during this period. Thus, payment of salary/wages to employees and workers during the lockdown period (including imposition of other social distancing requirements) shall not qualify as admissible CSR expenditure • Payment of wages to temporary or casual or daily wage workers during the lockdown period is part of the moral/humanitarian/contractual obligations of the company and is applicable to all companies irrespective of whether they have any legal obligation for CSR contribution under section 135 of the Companies Act 2013. Hence, payment of wages to temporary or casual or daily wage workers during the lockdown period shall not count towards CSR expenditure The announcement by the government to allow funds spent on COVID-19 relief work as CSR spend was welcomed by corporate India. It was a win-win situation for companies having an existing CSR obligation, who wanted to contribute to relief work and meet statutory requirements of the Companies Act at the same time.

Business and Corporate Social Responsibility During COVID-19 Crisis This segment will highlight on how businesses both global as well as in India have embraced corporate social responsibility during COVID-19 crisis.

Global Scenario In the present era of COVID-19, it has been observed that some companies are indulging in CSR activities by promoting social awareness for social distancing. The most significant contribution has been made by Mc Donald’s, Audi, Coca-Cola, Volkswagen, and many more. The Mc Donald’s company sent the message to the society by bifurcating the logo “m” into two parts representing social distancing. Similarly, the logo of Audi is represented by four separate rings to make people understand the importance of social distancing. Volkswagen has presented their new logo by creating a gap between V and W to make awareness about the necessities of the social distancing to prevent the expansion of pandemic virus in the human body. Companies are also changing their advertisement slogans to make people understand the importance of social distancing. The new slogan of NIKE is “if you ever dreamed of playing for Millions around the World,” Now is your Chance. “Play Inside, Play for the World.” Again, the new slogan logo of Pizza Hut denotes “Pizza Home.” Companies are also supporting the society by encouraging mental wellness, providing financial security and supporting small businesses. Starbucks announced that it will expand mental health benefits to include up to 20 therapy sessions for all employees. Lulu lemon, which is temporarily shutting down all stores in North America, have decided to continue paying employees and provide access to a pay relief fund. Shopify has decided to provide its employees a US $1,000 stipend to work from home. Microsoft has decided to pay its hourly workers their regular pay, even as demand for their services slows down, and Wal-Mart, Apple, and the Olive Garden have decided to update their sick leave policies to provide additional

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coverage and support for their most vulnerable workers. Large corporations are stepping in to support small and medium enterprises (SMEs) during this difficult time. Amazon announced a US $5 million relief fund for small businesses near its headquarters, while Google has decided to pledge US $1 million to organizations in Mountain View, California, impacted by the pandemic. Many businesses are standing up in order to help fight COVID-19. AnheuserBusch is producing and distributing hand sanitizer by using its supply and logistics network. Masks and other supplies for medical workers are being made by Zara and Hanes. Netflix has created a US $100 million corona virus relief fund. The elderly is particularly at risk of contracting this virus. Hence Dollar General has decided to dedicate its first hour of operation to senior customers only. Schools have been forced to move into online learning overnight. Zoom made its video conferencing platform available for free to K-12 institutions.

Indian Scenario The Bengal Beverage company has not only changed their logo by creating a gap from each letter but the company also shares their message as “Staying apart is the best way to stay united.” Indian famous dairy brand Amul motivated people to wash their hands, greet others using “Namaste” method, and to work from home to prevent novel coronavirus from social transition through their messages. Hindustan Unilever Limited, through its product Lifebuoy soap, spreads the message of “washing hands frequently with Any Soap or Hand-wash or Alcohol based Sanitizer” to combat against the spread of coronavirus. SBI Foundation of State Bank of India has launched a COVID-19 relief fund for implementing various initiatives to strengthen the health care infrastructure and diagnostics facilities, ensure effective patient management, and meet the nutritional requirements of individuals infected, capacity building of health care professionals, and a helpline to address psychological concerns that have arisen due to the pandemic. A certain portion of this fund would also be allocated to promote research and innovation efforts to combat the corona virus (SBI Foundation 2020). SBI employees provide INR 1 billion to the PM CARES fund. SBI also announced to provide 0.25% of its net profit of financial year 2019–20 to combat against COVID19 (The Economic Times 2020). Infosys Foundation, the philanthropic and CSR arm of Infosys, committed INR 1 billion to support efforts towards fighting COVID-19 in India. The foundation contributed half of this commitment (INR 500 million) to the PM CARES fund. This sum will primarily be utilized for the following area: • To expand hospital capacity for treatment and enable hospital stays for COVID19 patients across India, especially the ones belonging to the economically weaker sections of the society • To provide ventilators, testing kits, and personal protective equipment (PPE) like masks and other protective gear for frontline health care workers • To ensure better access to food and nutrition for the underprivileged section of the society, that is, bearing the adverse economic impact of the current situation.

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Infosys Foundation has also announced support for creation of an exclusive hospital in Bangalore for COVID-19 patients (Infosys 2020). ITC Limited set up a COVID-19 contingency fund of INR 1.50 billion to provide financial assistance to the district and rural health care for the poor Indian citizens. This fund will be used to provide relief to the most vulnerable section of the society, people who faced significant disruption in their livelihoods, and to provide assistance to rural health care by providing protective gear to the medical staff. In addition, the fund will collaborate with district authorities to provide assistance to the district health and rural health care ecosystem that reaches out the weakest sections of the society (ITC 2020). Moreover, ITC has partnered with UNICEF to create a large-scale awareness campaign on social distancing and hygiene, which are critical steps for a nation to fight the disease. In partnership with UNICEF, ITC is extending the #BreakTheChain program to tea-growing communities in Assam, to positively impact their health and well-being during the crisis. HUL, (Hindustan Unilever Limited) pledged INR 1 billion towards fighting coronavirus in India as well as announced plans to slash prices of its personal care and home hygiene brands – Lifebouy sanitizer and liquid hand wash, and Domex floor cleaners – by 15%. It also donated Lifebuoy sanitizers, Domex bathroom and floor cleaners, soaps, hand washes, and health kits to the hospitals and underprivileged persons. To ensure safety, Lifebuoy sanitizers have been given to local police in cities such as Delhi, Mumbai, Kolkata, Lucknow, Chennai, Indore, and Bangalore. In partnership with United Nations Development Programme (UNDP), sanitation and hygiene products have been distributed to sanitation workers across 15 cities in India including Mumbai. In partnership with United Way, Lifebuoy Soaps have been distributed to 40,000+ sanitation workers across Mumbai as well as hygiene and sanitation products to about 13 hospitals. Through Project Prabhat, the sustainable community development initiative, 100,000 migrant labor families are being supported by donation of food kits and essential hygiene products. Soaps to 500,000 families in communities around the factory sites have been distributed. To augment the quarantine system instituted by the government, HUL has tied up with Apollo Hospitals, State Bank of India, Oyo, Lemon Tree, and others to create isolation facilities that are equipped with medical supervision. This will help reduce the burden on hospitals while providing acute care for the patients in need apart from giving 74,000 testing kits to tackle spread of COVID-19 in India through early detection and 29 ventilators to government hospitals in Maharashtra. Together with the local administration in Haridwar, HUL has helped set up a 30-bed isolation facility in record time of 3 days to help curb the spread of COVID-19 (The Hindu 2020). Tata Consultancy Services (TCS) is prioritizing itself in providing COVID-19 patient trackers, health kits, and ventilators for the poor persons. TCS iON Digital Class room software empowers students for online learning facilities (TCS 2020). RIL (Reliance Industries Limited) is providing the first 100-bed COVID-19 hospital five million free meals, 100,000 masks, free fuel for emergency vehicles, and daily wise 1000 PPE for health care workers. It has also provided INR 5.35 billion to the PM CARES fund. Through Mission Anna Seva, RIL aims to provide

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over 30 million meals to marginalized communities and frontline workers across the nation. Mission Anna Seva will be the largest meal distribution program ever undertaken by a corporate foundation anywhere in the world. The beneficiaries of this program include daily wage earners, slum dwellers, urban service providers, factory workers, and residents of old-age homes and orphanages. In partnership with the BMC, Reliance has set up India’s first 100-bed exclusive COVID-19 Hospital in Mumbai in just 2 weeks – a national record. They are now expanding this facility to a capacity of 250 beds. Reliance is also providing free fuel to emergency vehicles to help ensure COVID-19 patients quickly get the medical care they require. Reliance Life Sciences has enhanced India’s COVID-19 testing capabilities by developing its own confirmatory tests and is in the process of expanding this testing capacity for India even further. RIL will produce 100,000 masks and hundred thousand PPEs (personal protective equipment) daily for health workers and caregivers across India (Financial Express 2020). Vedanta has joined hands with the Ministry of Textiles to import 23 machines for manufacturing personal protective equipment (PPE). It has pledged one million meals for daily wage workers, a segment which has been very badly affected, as well as has pledged to feed 50,000 stray animals, which have no access to food during the lockdown. Vedanta has provided more than 100,000 masks and another 2,00,000 N-95 masks are being imported, which will be handed over to the government and is also collaborating with district hospitals to provide them with medicines, medical equipment, markings, and disinfectant sprays. It has tied up with Apollo Hospital for a 24/7 helpline for their employees to give them basic health information and guidance (Vedanta 2020).

Role of Individual Social Responsibility Among Corporate Leaders However, going beyond the realm of CSR, companies are now looking at the concept of “Individual Social Responsibility” (ISR). Individual social responsibility includes five principles, i.e., donations, investing in socially responsible funds, ecoconscious decisions, allocating time for a social cause, or doing any philanthropic work or altruism. Such prosocial behaviors have their own set of interdependent motivations. They are driven by intrinsic altruism – aspiring to work for a good cause. Secondly, material incentives also play a crucial role in this as one is more likely to give to charities if contributions are tax deductible. Thirdly, social and selfesteem concerns come into picture as well. Carroll (1979) defined these responsibilities for companies as those “socially defined expectations of business behavior that are not part of formal law but nevertheless are expected of business by society’s members.” In the case of personal social responsibility, ethical responsibilities also include those additional behaviors and activities that go beyond strict legality and pertain to actions determined as “fair” and “moral” (Accar et al. 2001). These prosocial behaviors by reflecting genuine altruism and donations play a decisive role in combating this novel coronavirus as humanitarian crisis cannot be overlooked during this time as in order to contain the spread of this communicable disease, lockdown and social distancing are considered to be the solution. This calls for

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immediate leadership actions from all stakeholders of the society – government, corporates, private sectors, and individual contributions. Some of India’s business leaders have come forward during these trying times and taken bold commitments to minimize and do their part in combating the pandemic. Some of them deserve special mention.

Anand Mahindra (Mahindra Group) Industrialist Anand Mahindra, the managing director of Mahindra Group, pledged to donate his entire salary over the coming months to fight COVID-19. One of his companies, Mahindra Holidays offered to provide the facility as quarantine centers for COVID-positive patients. Moreover, using the facilities of his automobile plants, he took a conscious decision to manufacture ventilators for the country (Panday and Pathak 2020). Anil Aggarwal (Vedanta Group Limited) Vedanta Group chairman, Anil Aggarwal made a decision to provide financial aid to daily wage workers, employees, and contract workers by allocating one billion. In addition to this, he ensured due assistance to the employees working in its various plant locations of the country. The group also decided not to negatively affect the salary of their workers including temporary workers in these uncertain times. This included one-time insurance to the Vedanta employees and their families during this COVID-19 pandemic. Moreover, all mobile health vans in operational areas were required to provide assistance in preventive health care and each business unit to look after casual laborers and daily workers around plant locations by making contributions towards their livelihood. Mukesh Ambani (Reliance Industries Limited) India’s richest man and World’s fifth richest man, Mukesh Ambani, chairman and managing director of Reliance Industries Limited announced a multipronged plan that contains prevention, mitigation, and ongoing support for COVID-19. His Reliance Foundation set up India’s first dedicated COVID-19 center with 100 beds in Seven Hills Hospital in Mumbai. All these beds have access to patient-monitoring devices in addition to ventilators, pacemakers, and dialysis machines. Reliance Foundation also set up a fully equipped quarantine facility in Lodhivali, Maharashtra. According to the government list, it provides free meals to people in various cities affected by the pandemic and free fuel for the transportation of COVID-19 patients. Reliance Foundation announced that in order to provide help to health care professionals, they decided to manufacture 100,000 face masks along with all the necessary protective items. The Foundation also proposed to operationalize a communication hub for all lessons in a school year, with free storage available for individuals and teams. Ratan Tata (Tata Group) Ratan Tata, the chairman of Tata Trusts has committed five billion to meet the excessive demands of personal protective equipment, testing kits, ventilator, respiratory systems, and training of health workers, as per the statement issued by Tata Trust.

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Conclusion Thus, we find that during a pandemic of the stature of COVID-19, which needs multistakeholder intervention, the corporate entities played a significant the role in combating the same along with the government. It is not always the funding that is needed, but also timely, dynamic decision-making and mobilization of resources that is required in such a situation. The government with its bureaucratic structure takes time to contribute, but, here, the role of the corporation is paramount. The business leaders are often risk takers and adept in taking challenging decisions. Indian corporations have come forward to show their solidarity in such trying times by wholeheartedly contributing to the government funds through the PM Cares fund and State Disaster Management Authority to combat COVID-19. The CSR mandate under the Companies Act, 2013, has come to help in these trying times in fighting this pandemic hand in gloves with the government. Apart from that, they do have a critical role in lubricating the socioeconomic fabric during the onslaught of the global financial crisis apparent due to the novel coronavirus pandemic by creating job opportunities and innovative products to cater to the new normal. After all, a sustainable development does call for a multistakeholder approach.

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Benefits, Enabling Factors, and Challenges Hurriyet Babacan

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nature of Public–Private Partnerships (PPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PPP in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Benefits of PPP for Global Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constraints and Challenges of PPPs in Global Health Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impacts of PPPs for Global Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The struggle for accessible and inclusive health care systems and policy is a major battleground across the world. Global health issues include infectious diseases; mortality from reproductive, maternal and child health; the shift in the global disease burden toward noncommunicable diseases; weak institutional arrangements to tackle these challenges; and reduced medical expenditures together with increase in health care costs. Meeting these challenges requires new and innovative approaches and initiatives. Public–private partnerships (PPPs) have increasingly been utilized as a mechanism to address global health issues, although there is no agreed unifying definition of PPP in the context of global health. The emergence of PPPs in global health is situated in the complex analysis that accompanies global health markets. PPPs have been initially adopted as mechanisms to address the financial gap in health care delivery; however, they have increasingly become vehicles to open up health markets to private sector. PPPs have transformed the architecture of global health with increasing range of private, civil society, and other actors engaging in global health issues. This H. Babacan (*) The Cairns Institute, James Cook University, Cairns, North Queensland, Australia e-mail: [email protected] © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_117

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chapter provides an overview of the key issues in PPPs and provides an analysis of benefits and challenges in addressing global health issues. The chapter concludes with priority focus areas in the future. Keywords

Public–private partnerships · Global health governance · Health architecture · Health markets

Introduction The 2030 Agenda for Sustainable Development, adopted by United Nations, with its Sustainable Development Goals (SDGs) serves as a blueprint for global development. Sustainable Development Goal 3 has the focus “health and wellbeing for all” (UN 2019). Universal access to health care, performance and cost of health care systems, and cost-effective health care delivery is a major concern of many countries around the world (Torchia et al. 2015; Jamison et al. 2013; OECD 2008). Health care systems, particularly public health care systems, have experienced significant reform with a focus on enhancing efficiency, cost-effectiveness, and flexibility as national health governments struggle to meet health care demands and achieve quality outcomes (Asquith et al. 2015). In developing nations, the sheer inadequacy of financial and human resources, the lack of state capacity in under-resourced settings have made it extremely difficult to achieve significant improvements in equity in health and access to health care (Asente and Zwi 2007) and a renewed global focus on universal health care coverage. Addressing these challenges requires multipronged approaches and a collaboration of a range of stakeholders and sectors. This is reflected in the UN approach on cooperation between government, civil society, businesses, and other stakeholders to achieve these goals. Public–private partnerships (PPP) have been promoted as an important development financing mechanism for the Sustainable Development Goals (Gideon and Unterhalter 2017). Contemporary issues in health care are “wicked problems” (Mason and Mitroff 1981) that are too complicated for governments or the private sector to resolve. Health issues have increasingly gained significance on the global agenda (Ollila 2005). At the turn of the century, international health was grappling with a range of global health issues including AIDS/HIV; resurgence of malaria and tuberculosis; influenza; noncommunicable diseases (e.g., heart disease, cancer, diabetes); mental health; climate change health risks; lack of universal health coverage; weak primary health systems; and social, economic, and environmental determinants of health (e.g., poverty, housing, nutrition, and other disparities). The recent COVID-19 epidemic has highlighted the need for global health responses, cross-sectoral collaboration and the need for strengthening health systems. The World Health Organization (2020b) has highlighted the most urgent global health challenges for 2020 and beyond. These include elevating health in the climate debate, delivering health in conflict and crisis, making health care fairer, expanding access to medicines,

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stopping infectious diseases, preparing for epidemics, preparing people from dangerous and unsafe products, investing in the health workforce, keeping adolescents safe, and earning public trust. Global health issues transcend geopolitical borders and impact on health service planning, delivery, and governance (Balcius and Novotny 2011). Processes of globalization have resulted in instant communication and porous borders, resulting in crossborder vulnerabilities in health (McInnes et al. 2020: Babacan and Gopalkrishnan 2015). Global health is not only a health issue but also a national and global security issue. This perspective has led to many nations contributing funds to global health initiatives. The “global health” concept is understood as health determinants and outcomes being extended outside of the domestic sphere of nations to beyond geographical borders and boundaries of states to the whole world (McInnes et al. 2020:3). The need to address emerging global public health issues continue to be tabled on the international and within-country policy agendas (Nishtar 2004). Health systems are confronted by a range of issues including limited financial resources, complex social problems, rapid disease transmission across national boundaries, increased longevity and aging populations, technological developments, and reduced state institutional capacities to address complex health care challenges (McInnes et al. 2020; Clarke and Paviza 2018; Reich 2000). The World Health Organization (WHO) identifies that nearly half the world’s population do not have access to essential health services (WHO 2017:1) and the world is facing a projected shortfall of 18 million health workers (WHO 2017:3). The UN report on the progress toward Goal 3 (relating to health outcomes) of the Sustainable Development Goals clearly highlights the nature of the health systems challenges that face the world. The report points out that from 2013 to 2018 approximately 40% of all countries had fewer than 10 medical doctors per 10,000 people, and more than 55% had fewer than 40 nursing and midwifery personnel per 10,000 people. All least developed countries had fewer than 10 medical doctors, fewer than 5 dentists, and 5 pharmacists per 10,000 people, and 98% had fewer than 40 nursing and midwifery personnel per 10,000 people (UN 2019:11). Globalization of health has led to significant expansion of actors taking an active role in global health concerns (Youde 2014; Buse and Tanaka 2011). Global partnerships for health have emerged as key actors in global health architecture. Global partnerships for health take many forms. The major global alliances are structured independently, outside of the national government or international health organizations. For example, the Global Fund to Fight Aids, tuberculosis (TB), and Malaria is not within the auspices of the World Health Organization or other governance arrangement of national governments. They are a “partnership of governments, civil society, technical agencies, the private sector and people affected by the diseases” (Global Fund 2020). Numerous partnerships have also been initiated at national levels under a range of arrangements. The factors that have led to their development include recognition of the scale and complexity of global health challenges, disillusionment with the structures in place to respond to them, the need to accelerate and support the distribution of health products across populations and lack of leadership (Buse and Tanaka 2011).

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The growing complexity and scale of health challenges is a major consideration as identified by Buse and Tanaka (2011:3) “As they transcend national boundaries, global health challenges compel global collective action and complementarities of players with different expertise and resources to address determinants of ill-health.” Global partnerships are said to have increased the resources for health, brought health issues into policy and development agendas, and addressed urgent health needs. Global partnerships have also come under criticism identifying that they have also led to confusion, duplication, competition, and exerting pressure on national governments (Youde 2014; Buse and Tanaka 2011). Some have identified that the role of national governments has been weakened with a rise in the involvement of donors on key decision making processes, donors from other sectors such as civil society and private and commercial sector (Balcius and Novotny 2011; Youde 2014). Global health partnerships exert considerable influence and leverage on country level health policies and programs (Buse and Tanaka 2011; Jamison et al. 2013). Health service delivery is located along a continuum that goes from fully public provision at the end of the spectrum to the fully privatized delivery at the other, with a mix of delivery options in between. Increasing pressures on public sector efficiency and public financing pressures have resulted in reforms and incremental disengagement of the state from some sectors of health activity. Governments have increasingly come to rely on the market mechanisms for provision of goods and services or for direct provision of services (Youde 2014; OECD 2008). Public–private partnerships (PPPs) are part of this trend (Bayliss and Van Waeyenberge 2018). Public– private partnerships have increasingly been explored as a mechanism to mobilize resources and address key health challenges. PPP are being increasingly utilized by governments all over the world (World Bank 2018). At the global level, bodies such as United Nations, World Health Organization, the World Bank, and the Organization for Economic Cooperation and Development encourage PPP partnerships between global bodies or member nations with private providers in financing; researching; and the provisioning of goods, infrastructure, and services (Baru and Nundy 2008). PPPs are subject to intense public debate, often accompanied by strong public opinion, political sensitivities and media scrutiny (Asquith et al. 2015; Martin 2013). There have been serious concerns about their efficacy, benefits, risks, transparency, and partnership arrangements (Bayliss and Van Waeyenberge 2018; Asente and Zwi 2007; Buse and Harmer 2007; Nishtar 2004) and whether it provides the long-term outcomes for all stakeholders involved (government, community, tax payers, investors) (Regan et al. 2011). This chapter explores the public–private partnerships for global health outcomes. The chapter begins by exploring what is meant by PPPs, why they emerged and their characteristics in a general sense. The focus then shifts to PPPs in global health contexts, exploring PPPs in global health and identifying their benefits, challenges, and disadvantages. The final section of the chapter reviews the impact of PPP for health outcomes and provides an analysis of the value of PPPs for global health outcomes.

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Nature of Public–Private Partnerships (PPP) The term “public–private partnership” is a complex one and arriving at an agreed definition, in health and other settings has been problematic (Buse and Harmer 2007; Asquith et al. 2015; Hodge and Greve 2017). Collaboration across different sectors is not new and PPPs gained popularity since the 1980s and is having a revival more recently (Bayliss and Van Waeyenberge 2018). The use of PPPs in the developing world has grown rapidly since 2004, with investments through PPPs increasing by a factor of six, from US$25 billion to US$164 billion over 8 years (Romero 2018), instigated by major international bodies such as UN, WHO, and the World Bank as well as bodies such as philanthropic foundations (UN 2003; World Bank 2017; WHO 2020a). PPPs have been linked with public sector reform, arising from the primacy of neoliberalism, characterization of public systems as “inefficient” and the entrenchment of new systems of public management that is led by market mechanisms, emphasizing efficiency, competition, deregulation, and demonstration of return on investment (Babacan 2019; Martin and Halachmi 2012). The nation state, across the world, has increasingly become entangled in market process (Birch and Siemiatycki 2016) with the creation of new institutions, permeation of policies and governmentalities that consolidated the market’s role in economic decision-making (Pusey 2017; Chiu 2017). Driven by philosophical approaches of neoliberalism, public sector and social service reforms have been undertaken using different political justifications, processes, and discourses and speeds (Spolander et al. 2014). Importantly, the state has increasingly become marketized with market forces transforming the way state enterprises, agencies, and funding programs undertake their core business (Birch and Siemiatycki 2016; Spolander et al. 2014). Key aspects of these reforms have been contracting out, privatization and public–private partnerships, replacing the core functions that the state would have carried out (Pusey 2017). At the global institutional level, the United Nations General Assembly adopted a resolution in 2001 to “give greater opportunities to the private sector, non-governmental organizations (NGOs) and civil society, in general, to contribute to the realization of the Organization’s goals and programmes” (UN 2003:3). A major justification for this approach was directly linked to the financial needs of the development process, particularly at a time when development funds lagged behind needs, necessitating a new relationship between Governments and the private sector, as a primary source of investment UN (2003:4). The United Global Compact, established in 2000, was an attempt to encourage businesses worldwide to adopt sustainable policies, and to report on their implementation. This was a formal way to recognize the role of the private sector in good corporate citizenship and a major framework has now developed across 170 countries, as a mechanism for facilitating private sector engagement in sustainability and development agendas. While the UN system has advocated PPPs in the last two decades, there is no single agreed definition of PPPs (Richter 2004a). In a report commissioned by the UN Global Compact Office on PPPs, the following definition was suggested:

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Definition: Public–Private Partnerships (PPP)

“Partnership is a voluntary and collaborative agreement between one or more parts of the United Nations system and non-State actors, in which all participants agree to work together to achieve a common purpose or undertake a specific task and to share risks, responsibilities, resources, competencies and benefits” (Nelson 2002:47).

The UN argues that such partnerships recognize that by bringing the strengths, capacities, approaches, skills, and methods of different actors together can create powerful synergies and overcome many of the barriers to sustainable development (UN 2003). Showing the diversity of definition, the World Bank’s understanding of PPPs has a slightly different emphasis: “A long-term contract between a private party and a government entity, for providing a public asset or service, in which the private party bears significant risk and management responsibility and remuneration is linked to performance” (World Bank 2017:1).

The World Bank (2017) has argued that PPPs complement public sector financing and allows projects to go forward that otherwise would have been discarded due to fiscal constraints. They posit that PPPs create an incentive mechanism that aligns private and public interests. There is no uniform model for public–private partnership (Asquith et al. 2015:182). There are three broad types of PPPs in global health: global alliances and health initiatives such as the Global Fund, PPPs that are in-country arrangements, and demand-related financing schemes to provide services (Languille 2017:145). Overview: Activities and relationships of PPPs

• • • • • • • • •

Fund raising from the private sector. Policy dialogue and interagency decision-making. Advocacy. Research and knowledge sharing. New infrastructure development. Operational delivery including services and infrastructure. Promotion. Co-regulatory arrangements. Contracting out (World Bank 2017; Torchia et al. 2015; UN 2003; Richter 2004b).

The various arrangements of PPPs often reflect the different appetites for risk and the role of the private party varies based on the sector and the nature of the market (Farquharson et al. 2011). The World Bank (2017:6) points to three important parameters in PPPs. These are the type of asset/service involved; what functions the private

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party is responsible for; and how the private party is paid. The key features of a PPP contract may bundle together multiple types of projects and functions. PPPs are usually long term but may vary in duration. The functions for which the private party may be responsible for under PPP contractual arrangements can include aspects such as design from the initial concept; build and rehabilitate, particularly for infrastructure or asset; financing capital expenditure; maintain service or asset over the life of the contract; and operate service or asset (World Bank 2017; Regan et al. 2011). The PPP payment mechanism is a fundamental element of the PPPs to enable the right incentives to the private sector. The private sector can be paid by user-chargers from service users, by the government, or by a combination of the two. User-pay systems can include tolls, tariffs, fees, and other charges. Good practice guidelines suggest payment being linked to performance measures (World Bank 2017; OECD 2012). Numerous elements constitute the basis for successful PPP outcomes. These include commitment to a common vision and goal; effective and trusting relationships; streamlined processes; justification of the need and value for money; effective multi-criteria cost benefit analysis (not just economic); regulatory and policy stability; agile and efficient procurement and contracting processes; transparency in decision making; and clarity about risk allocation (Asquith et al. 2015; Torchia et al. 2015; Buse and Tanaka 2011). The Organization for Economic Cooperation and Development (OECD 2012) provides guides for member nations on PPPs. The key features of the guide in relation to PPPs are: (i) establish a clear, predictable, and legitimate institutional framework supported by competent and well-resourced authorities. This means that the political leadership should ensure public awareness of the relative costs, benefits, and risks of PPPs, active engagement with stakeholders as well as involving end-users in defining the project, monitoring service quality, identifying key institutional roles and responsibilities, and ensuring that regulatory process are transparent and enforced; (ii) that the selection of PPPs are grounded in value for money. The key elements of assessing value for money involve the assessment of investment projects at senior levels among competing priorities and alignment with government strategic goals. Careful assessment needs to be made of the method that is likely to yield most value for money, key risk factors, ensuring a competitive process and procurement options. An important consideration is identifying risk, assessing who will manage it best, and determining the arrangements for bearing the risk burden between the public and the private sectors (Roland et al. 2018; Asquith et al. 2015; Buse and Harmer 2007). The operational (implementation) phase requires vigilance and is an important factor in achieving value for money; and (iii) Using the budgetary process transparently to minimize fiscal risks and ensure the integrity of the procurement process (OECD 2012).

PPP in Global Health Jamison et al. (2013), in looking at global health to 2035, identify three key domains of global health challenge. The first domain is the ongoing high rates of infectious disease and mortality from reproductive, maternal, and child health; the second

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domain is demographic changes and the shift in the global disease burden toward noncommunicable diseases, mental health, and injuries, particularly associated with the rise in behavioral risk factors such as smoking, alcohol consumption, and sedentary behavior; the third domain is weak institutional arrangements to tackle these challenges, inadequate financial arrangement, and reduced medical expenditures together with increase in health care costs. The key international institutions for global health, such as WHO, face significant budgetary crisis, with budgets steadily decreasing in real terms, resulting in in the organization struggling to fund its basic administrative functions (Jamison et al. 2013:1910). As noted earlier, international bodies have increasingly turned to address the financial and knowledge gap by turning to other sectors, in particular toward the private sector (Clarke et al. 2019; Romero 2018, 2019). Wide range of definitions of PPPs is considered in the context of global health. Buse and Harmer (2007:259) posit that it is a set of “institutionalised initiatives, established to address global health problems, in which public and for-profit private sector organisations have a voice in collective decision-making.” PPPs are increasingly popular as it avoids the often-negative effects of public ownership of health services, on the one hand, or unbridled privatization, on the other. PPPs are viewed combining efficiency and capital of the private sector with the public interest and policy frameworks of the public sector as a win-win outcome (Phua 2017). Central to the PPPs in health context is the question of governments engaging with corporations in order to promote and address public health and whether this is possible in the light of public interest versus private gain (Hernandez-Aguado and Zaragoza 2016). Clarke and Paviza (2018:5) point out there is a lack of conceptual clarity about the role of the private sector in health systems and in private health care. The authors identify (Clarke and Paviza 2018:6) that the term “private sector” is highly heterogeneous and includes individuals and organizations providing health services or products that are not owned or directly controlled by government. The private sector can be further broken into subcategories, e.g., for-profit and not-forprofit, formal and informal, domestic and foreign. The subcategories represent a wide spectrum of entities with very different attributes and purposes. The development of PPPs in global health contexts in the 1990s was a response to neoliberal, market-oriented economic paradigm (Harmer 2011; Richter 2004). They arose from a range of reasons as summarized by Hamer (2011:704): “Numerous studies . . . ask why questions: why did the change from public and private to publicprivate global health interventions occur? Answers to that question cite changes in ideology, lost legitimacy in international institutions, the monopolistic position of transnational pharmaceutical industries, the growth of non-government organisations, new technologies, increased support from private foundations and globalisation as causes.” The emergence of PPPs in global health is situated in the complex analysis that accompany global health markets. The key markets in health care include core markets for clinical services and medical products; financial coverage and protection; and supporting markets for workforce development, information technology, catering, facility management, waste management, construction, and

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electromechanical services (Clarke and Paviza 2018). It is argued that health care markets are not the same as traditional economic markets and are more prone to market failures (Clarke and Paviza 2018; Watts and Segal 2009) due to inherent features such as information asymmetry that creates unequal power relationship between experts and clients, intertemporal factors, externalities, and other distortions. Market failure in health care results in distributional and inequity considerations, as health care provision is also a public good and may be undersupplied if left to the market, such as universal access to basic hospital, medical, and emergency services (Clarke and Paviza 2018; Watts and Segal 2009). In many countries, there are behaviors in the health market by the private sector that threaten equity and quality including abuse of market power, monopolistic behavior, and predatory pricing (Clarke et al. 2019), while at the same time there are gaps in governance and regulatory mechanisms to limit the detrimental impacts of such practices. The need for strengthening governance frameworks has been identified as a major issue for quality health care, role clarification between public and private health providers, and in improving accountability (Clarke et al. 2019; Bayliss and Van Waeyenberge 2018; Balcius and Novotny 2011; Buse and Tanaka 2011). Examples of public–private global health partnerships and the purpose they serve have been categorized by Nishtar (2004), comprising over 90 global PPPs with the purpose of product development, improving access to health care products, mechanisms for global health coordination, strengthening health services, public policy, and education and regulation and quality assurance (Nishtar 2004:3). Partnerships focus on infectious disease prevention and control in areas such as AIDs, TB, and malaria; reproductive and child health; nutritional deficiencies; and other areas such as chemical and injection safety and blindness and cataract. In national contexts, they have focused on infrastructure development and national insurances (Roland et al. 2018). Some examples of global PPPs include Global Alliance for Vaccines and Immunization (GAVI), Safe Injections Global Network (SIGN), Global Polio Eradication Programme (PEI), International Aids Vaccine Initiative (IAVI), Global Alliance for TB Drug, Development (GATBDD), Concept Foundation, Global Alliance to Eliminate Leprosy, Global Alliance for Improved Nutrition, and Alliance for Health Policy and Systems Research. These partnerships have complex arrangements and may be housed in public or private sector agencies or new institutional arrangements. PPPs in global health have three key elements. First is that partnership is established around addressing a specific health issue as its central concern. Resources and skills are focused on addressing the resolving of particular issues. The second element is that the partnerships are institutionalized (in a variety of ways) to share resources and manage risks. The third element is it involves a range of public and private actors, including governments, nongovernment organization, philanthropic and private sector agencies. (Youde 2014; Buse and Harmer 2007). The key question has been whether different actors have common interests and whether there is a risk of irreconcilable interest and/or conflicts of interest between the public and private sectors. Can PPPs deliver a “win-win” outcome for the different stakeholders is often posed (Ollila 2005; Richter 2004a). WHO articulates the critical challenge of reconciling interest in the context of developing Universal

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Health Coverage (UHC) 2030: “an important challenge in governing mixed health systems relates to the diversity of characteristics and interests of stakeholders involved. All these stakeholders respond in very different ways to government’s efforts to achieve UHC. It is necessary to use a variety of tools and incentives to steer different providers toward the UHC goal “(WHO 2020). PPPs in global health are usually transnational arrangements and partnerships vary across a range of variables including their functional aims, the size of their secretariats and budgets, their governing arrangements, and their performance (Nishtar 2004; Buse and Harmer 2007). Increasingly, hybrid and transnational, partnerships have become a common approach (Hernandez-Aguado and Zaragoza 2016; Nishtar 2004). The World Health Organization (WHO 2000) has identified that it will interact with commercial entities in numerous ways including commercial enterprises and alliances, exchange of information, product research and development aimed at improving health, generation of cash and in-kind donations, and advocacy for health. WHO’s recent focus on Universal Health Coverage 2030 supports engagement with the private sector entities, arguing that most health systems are mixed systems, where a mix of public and private providers deliver health-related goods and services (WHO 2020). The types of partnerships that WHO identifies as critical include cash contributions, funding for clinical research or health technology development, other joint projects, staff secondment, in-kind contributions, financing travel of WHO staff, financing of staff salaries, and contributions toward publications (WHO 2020). PPPs have transformed the global health landscape through a paradigm shift in engagement and interaction between public, commercial, and civil society to address global health issues. PPPs are said to have energized the way global health issues are addressed and has brought a branding style communication and promotion, which has enabled these agendas to be in public attention (Buse and Harmer 2007). Jamison et al. (2013:1909) point to a change in global health architecture brought about by a collaboration focus across diverse actors: “Since 1993, an unprecedented mobilisation of DAH [development assistance for health] has occurred, . . .The explosive rise in DAH was made possible by the arrival of new public and private actors that could not have been imagined in 1993. These actors, such as the Global Fund, the GAVI Alliance, the Bill & Melinda Gates Foundation, and UNITAID, have created a new global health architecture characterised by tremendous experimentation and innovation in mobilisation and channelling of money, pooling of demand, shaping of markets, and improvements in the security of commodity supply. This architecture has supported the national introduction of important new technologies into routine systems at affordable prices”

However, there is vibrant debate on the roles of public, civic, and commercial entities in society and on the appropriate modes of interaction among them (Buse and Waxman 2001). The large global mechanisms have raised concerns about coordination, inefficiency, duplication, and fragmentation and skewing of policy priorities (Jamison et al. 2013; Youde 2014). The benefits and challenges of PPPs for global health are explored in the next two sections.

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Benefits of PPP for Global Health Outcomes There is considerable debate about the benefits and challenges of public–private partnerships for health outcomes, with both support and substantial criticism of the use of these partnerships in health care (Barlow et al. 2013). There is no general agreement on their main benefits toward achieving health outcomes (Torchia et al. 2015:238). As aptly argued by Hernandez-Aguado and Zaragoza (2016), the range of the collaborations in purpose, design, and composition is so broad that it challenges the efforts to evaluate their merit and efficiency in improving health outcomes. The research on this topic is patchy with limited demonstration of health outcomes. One of the main benefits is that it brings together different sectors to address complex health issues, which no one sector can address on their own. There is an underlying perception that the private sector is more creative, agile, can bring access to finance and knowledge, technologies, managerial efficiency, entrepreneurial spirit, is better at performing economic tasks, innovating and adapting to change (Rosenau 1999; Nishtar 2004). Different sectors offer diverse skills, abilities, and advantages to bring about results. “PPPs avoid the often-negative effects of either exclusive public ownership and delivery of services, on the one hand, or outright privatization, on the other. In contrast, PPPs combine the best of both worlds: the private sector with its resources, management skills and technology; and the public sector with its regulatory actions and protection of the public interest” (UNECE 2008:iii). WHO (2009) argues that public–private partnerships, in the context of global health, provides efficiency, equity, value for money, and supports the achievement of positive outcomes in global health. PPPs have been encouraged by national governments and global organizations as vehicles for overcoming failures of both market and state, offering numerous benefits (Stevenson 2015). The fragmented literature on the topic identifies a long list of health outcomes benefits of PPPs, as espoused by the proponents of PPPs, in global health settings.

Overview: Key Benefits of PPP in Global Health

• The magnitude of issues is too great for any one sector to address alone. PPPs is an effective way to capitalize on the strengths of different sectors by leveraging the ideas, resources, and expertise of the different partners. • PPPs enable attention for specific health issues and getting these neglected or complex health issues onto national international agendas. • PPPs enable raising profile of neglected diseases across a range of sectors and the broader population with consistent advocacy and messaging. • PPPs enable access to private sector capital and facilitates new or additional funding for health issues which will otherwise not get priority in health budgets. (continued)

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• PPPs leverage resources for research and development on key global health issues, bringing in expertise, research capabilities, and new knowledge. • Facilitates the development of health products and technologies that may not otherwise happen. For example, 75–85% of all research and development projects for addressing infectious diseases in middle and low-income countries were funded by PPPs (Jamison et al. 2013:1908). • Allows risk sharing in addressing health outcomes by transferring risk to the private and other sectors. • Trialing new and innovative ways to address key health challenges and gaps in health care. • Brings about efficient use of resources and cost-effective health service delivery, through private sector processes of cost reduction, agility, and business acumen. • Provides access to health care for population groups who are disadvantaged and have limited ability pay. • Supports advocacy to global health organizations, governments, and the private sector for policy, regulatory, and program reform. • Private sector engagement provides organizational renewal and strengthening of the capacity of national health systems to deliver. • Through PPPs, other sectors are engaged in health issues leading to further leveraging of resources and support. • Frees up public resources to be used for other program areas. • Improves planning and project development for private and public sector. • Allows public agencies to focus on core business and speeds up the development of programs in other related areas run by government such as poverty alleviation. • Establishes long-term relationships across different sectors and actors. • Improving national health policy design and implementation, particularly in situations of poor and fragile capacity of the public sector. • Sets international norms, standards, and improvements in the quality of public sector health systems (Top and Sungur 2019; World Bank 2017, 2018; Fréchette 2016; Hernandez-Aguado and Zaragoza 2016; Torchia et al. 2015; Martin and Halachmi 2012; Farquharson et al. 2011; Sharma and Seth 2011; Buse and Harmer 2007; UN 2003). In an Inquiry into financing public infrastructure, the Productivity Commission (Australia) noted, “PPPs also appeal to governments for another reason. There is a perception that they offer a way to increase the provision of public infrastructure without drawing on a government’s purse, thereby circumventing budgetary and borrowing constraints” (Productivity Commission 2014:13). It is also identified that PPPs enable governments to not show debt on their accounts.

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Overall, PPPs are attractive in its potential as a strategy to leverage advantages of different sectors to address complex problems. Partnerships are seen to bring expertise and resources for complex and diverse problems. There are widely held views that the private sector is more efficient, the benefits of public providers collaborating with the private sector can bring about a leveraging technical or management expertise and encourage technology transfer that can lead to quality improvements (Nikolic and Maikisch 2006).

Constraints and Challenges of PPPs in Global Health Contexts The Productivity Commission (2014:13) states that PPPs “are not magic pudding.” A range of barriers, limitations, and negative impacts of PPPs are identified and doubts remain concerning their actual effectiveness, efficiency, and usefulness in addressing health issues (Torchia et al. 2015; Boussabaine 2014). The euphoria over the benefits of PPPs is not shared across the world with a chorus of voices objecting to their increasing use. For example, in 2017, 152 civil society organizations across 45 countries signed the PPP Global Campaign Manifesto, sounding the alarm on detrimental impacts of PPPs, cautioning about high debt, high risk of PPPs, lack of accountability and inequality impacts of PPPs. Buse and Harmer (2007:259) posit that the PPPs “ . . .result in sub-optimal performance and negative externalities. These are skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions of the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonisation; and inappropriate incentives for staff engaging in partnerships”

A significant concern about PPPs relates to the safeguarding of public interest and managing expectations by the private sector or donors. It is argued that compelling reasons for the private sector to enter PPPs and global health go beyond philanthropy and corporate social responsibility (Martin and Halachmi 2012; Richter 2014). Corporate involvement in PPPs is a commercial entry strategy to facilitate market entry (Martin and Halachmi 2012). Differentiation is made between earlier and latter forms of PPPs. The earlier forms were concerned with addressing the financial gaps and efficiency outcomes, while in the latter forms the discourse has shifted to where “policy is framed in terms of investment opportunities for financial investors and institutional arrangements . . .are reconfigured to facilitate their entry into the sector” (Bayliss and Van Waeyenberge 2018; Harmer 2011). Richter (2004, 2014). In her analysis of PPP within global contexts, Nishtar (2004) notes the tendency toward weakening rather than strengthening safeguards for public interests when building these public–private interactions.

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The Productivity Commission (2014:64) argues “realising benefits from increased private sector involvement depends on being able to align the incentives of firms and individuals with the public interest. Given the varying prevalence of market failures across sectors, this is not always possible and so there should be no presumption that a higher level of private involvement is necessarily better.” Private sector investment is generally based on an analysis of the expected with commercial benefits and returns on investment. Writing in the context of the UK Private Finance Initiative, (UK government model of capital funding of public health and other infrastructure), Lieberherr et al. (2016:143) point out that it is “difficult for the ‘consumers’ (patients) to evaluate the quality of service provision (due to information asymmetry), which may lead to incentives for the service provider (with private actor involvement and hence a profit motive) to act opportunistically (e.g., saving money by providing lower-quality services).” Other authors point to the lack of congruence between public and private sector interests and the risk avoidance and pursuit of commercial outcomes may undermine public interest outcomes (Top and Sungur 2019, Romero 2018: Martin and Halachmi 2012; Zhang et al. 2009). As the private sector pursues goals of profit maximizing, it is believed that this may happen at the expense of quality and flexibility in projects or programs (Top and Sungur 2019). Zhang et al. (2009) identify that unlike more traditional arrangements, PPP partners do not share a common organizational structure and, therefore, can pursue different broader strategic goals while engaged in PPP. Due to a range of reasons such as market failures, economic costs of externalities, and equity issues, such investment decisions may not align with what is in the public interest. The International Finance Corporation reflects that “charting the political waters; balancing the needs of governments, consumers, investors, and lenders; and making the transaction transparent and sustainable are challenging tasks and not for the faint of heart” (IFC 2010:1). The move away from social state concepts has raised concerns due to potential of depleting public interest and state institutions (Top and Sungur 2019). PPPs have been criticized for implying privatization by stealth (Lee et al. 1997). Evidence suggests that public financing of health has generally produced more effective results for the poor and vulnerable populations (Hawkes et al. 2017; Gupta et al. 2012). A body of evidence points to mixed results of costeffectiveness of PPPs with studies indicating that the private sector is not less costly or more efficient than public provision (IFC 2010; Eurodad 2017; NAO 2011, 2015). A note issued by the Fiscal Affairs Department of the International Monetary Fund states “while in the short term, PPPs may appear cheaper than traditional public investment, over time they can turn out to be more expensive and undermine fiscal sustainability, particularly when governments ignore or are unaware of their deferred costs and associated fiscal risks”(Irwin et al. 2018:1). Rosenau (1999:13) asserts that the most optimistic estimate of saving is 30–50%, however, when externalities are created this offset the cost advantages. The need to navigate public–private partnerships carefully is evident in the various guides that have been developed by global institutions. This has risen in the midst of concerns about partnerships, which violate different human rights and act against human health interest (e.g., alcohol, tobacco, fast food industries)

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(Romero 2018; Rochford et al. 2019). The UN guidelines for partnership with the business sector stipulates that “The United Nations should not partner with business sector entities that systematically fail to demonstrate commitment to meeting the principles of the United Nations Global Compact or the United Nations Guiding Principles on Business and Human Rights” (UN 2015:5). WHO World Health Assembly adopted the Framework of Engagement with non-State Actors (FENSA) in 2016. FENSA aims to strengthen WHO’s engagement with non-State actors to benefit global public health, while protecting its work from potential risks such as conflicts of interest, reputational risks and undue influence (WHO 2018:7). The document does not provide guidance on how other health system actors should approach business (Rochford et al. 2019). This concern is applicable across global partnerships. For example, in 2018 the Global Fund commenced a partnership with the global alcoholic beverage company, Heineken and rapidly suspended the partnership due to use of young girls to promote beer in “in ways that expose them to sexual exploitation and health risks” (Beaubien 2018). The Global Fund partnership with Heineken was also severely criticized by public health advocates as inappropriate for a health agency to align with a product that can be detrimental to people’s health (Beaubien 2018). Corporate capture of global health policy agendas has been a major criticism of PPPs and more generally global health partnerships. The partnerships in global health across different sectors modify the decision-making processes (Martin and Halachmi 2012). Power analysis highlights the disparity in power relations between public and private actors and the global concentration of power in global corporations (Harmer 2011; Bruno and Karlinger 2000). The emergence of a global and highly concentrated corporate service has altered the power balance in the international political economy with the dominance of transnational capitalism (Babic et al. 2017). For example, nearly 40% of the control over the economic values in the world is held, via a complicated web of ownership relations, by a group of only 147 multinational corporations (Vitali et al. 2011). Contemporary power relations in the global political economy needs to recognize the role of multinational corporations as global health actors, along with the state as embedded actors in a networked globalized power relations (Babic et al. 2017). The globalization of capital has stripped finance and production from nation-state and has elevated them to transnational environments. Babic et al. (2017:21) argue that this has resulted in complex global value chains that are difficult to regulate, and often circumvent state attempts to regulate them. “As a result, big business has developed a profound structural power position on the global scale” (Babic et al. 2017:21). The implications for global health is that there is an overexpanding of the influence of business corporations and venture philanthropies over global public health matters, as well as reinforcing a trend toward fragmented, plutocratic, global governance and weakening of influence of nation-states. (Boussabaine 2014; Romero 2019). While national governments have public accountability to their citizens and constituencies, the global partnerships are free from such requirements. Accountability in the private sector is handled differently than in the public sector and PPPs operate with limited direct public oversight (Martin and Halachmi 2012). The growth in the number of

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partners and the relative power imbalances across partners makes it difficult to establish effective horizontal and vertical accountability, and partnerships are not held accountable to synchronize their activities in line with the directions and processes of the countries (Nishtar 2004). There are no global norms or frameworks to govern how global public health goals can be pursued in partnership arrangements (Nishtar 2004:3). Absence of a clear mandate, lack of clarity about partnership roles, transparency, trust, engagement, representation, and legitimacy are major challenges of PPPs (Languille 2017; Babic et al. 2017; Martin and Halachmi 2012). An important consideration in PPP is the question of what the risk is and who bears it. Different scenarios are at play depending on the nature of PPP partnerships. The PPP discourse states that the private sector bears the risk in PPPs (Asquith et al. 2015; Buse and Harmer 2007). However, this idea is contested as private sector is risk averse and without a clear effectiveness of risk allocation arrangements, and the implicit/perceived government guarantees may pose significant challenges to health outcomes delivery. The capacity to absorb or manage risk (by either the private sector partner or public agency) is critical in PPPs (Productivity Commission 2014:10). The private sector partners, in many projects, were making large gains in low-risk public service provision or public sector projects (Top and Sungur 2019; Boussabaine 2014). In a study of European PPPs in health infrastructure, Barlow et al. (2013:150) argue that public organizations have paid a significant premium for the contractually stipulated risk transfer to the private sector, as well as ultimately bearing project risks if the private companies are unable to deliver the project. Additional considerations are the management of short- and long-term risk to consumers or other public interests resulting from the PPP. Where there are usercharge arrangements, there is a need to justify these with effective cost-benefit analysis and coverage of what happens if there is a demand-side failure, i.e., not enough demand to generate revenue to finance returns on the investment (Top and Sungur 2019; Boussabaine 2014; Barlow et al. 2013). While the PPP literature, as outlined above, highlight the potential of PPPs for success, issues pertaining to equity, access, participation and democracy remain unresolved (Eurodad 2017, 2019; Rosenau 1999). Addressing health issues have a value base and are not impartial (Languille 2017). Health inequities are widely documented (Jamison et al. 2013). PPPs have the potential to reorient the objectives of the public sector and displace focus on marginalized and vulnerable and maybe in conflict with the fundamental concept of equity in health (Romero 2018; Nishtar 2004). Shifting discourse from a broad public health one to a disease-based approach has had negative impact on health inequalities (Koivusalo and Mackintosh 2011; Harmer 2011). The shifting discourse in global health is intricately connected to trade, pharmaceutical, and aid/development agendas (Koivusalo and Mackintosh 2011). A range of examples of inequity is presented in the literature. For example, the unwillingness of PPPs to provide health services in remote rural areas or diversion of resources from rural areas at times, as was the case with Lesotho hospital (Webster 2015). PPPs have been criticized for their gender blind approaches that have perpetuated women’s inequality (Hawkes et al. 2017). Women have disproportionate reliance on public sector for services, caring responsibilities and

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work and have lower incomes. This makes them more vulnerable in PPP arrangements where the onus for gender transformative public service provision is lost and government resources are constrained in the cost of meeting PPP payments (Eurodad 2017). Engaging in PPPs provides the public sector with an opportunity to abrogate their responsibilities and may result in the reduction or withdrawal of social protections and social safety nets, with impacts on the most vulnerable (Nishtar 2004). Another example is provided in the PPPs for vaccines. As argued by a number of authors, new vaccination is not grounded in principles of equity, their vertical systems have less focus on long-term sustainability and have redirected national policies and resources (Nishtar 2004; Yamey 2001). The ambitious health agendas of global philanthropic foundations push new vaccines and often squeeze out cheaper and quicker solutions (McGoey 2015). Engagement and representation are critical points in addressing key equity and sustainability issues. An important criticism has been the limited representation particularly by low-income countries in PPP and global alliances. The questions of who is deciding key policy agendas and whose interests the governance processes is protecting are raised (Buse and Walt 2000:706). United Nations member agencies have expressed concern that the focus on PPPs divert attention away from key goals and undermine formal intergovernmental processes (UN 2003:18; Boussabaine 2014). Hall (2015:34) provides examples of how PPP projects are being prioritized, which would not have been considered otherwise, with the overall distorting policy directions. The notion of “partnership” is challenged, where the public sector often has minimal role in decision making in global health initiatives (Languille 2017). Public–private partnerships are attractive for the private sector because they provide business stability and a long-term revenue stream paid by a government (Fréchette 2016). As noted by Farquharson et al. (2011), note that PPPs are difficult to deliver in an unstable policy and regulatory environments. On the other hand, the agendasetting power of global corporations in PPPs, the ability to mobilize resources and transition out global partnerships may have detrimental impacts on policy stability and long-term sustainability of countries (Martin and Halachmi 2012; Global Fund 2016). On the issues of representation, the voices of the beneficiaries of PPPs are glaringly absent in the decision-making processes and the public debates (Languille 2017). There is a large body of literature on the operational and management challenges of PPPs. These include poor planning and coordination across partners, poor project selection and assessment, poor contract management, and lack of communication. The shift of philosophy toward market orientation of the public sector changes the roles of the institutions and policy makers. It is argued that the transition from “‘doing’ to ‘facilitation’ puts policy-makers and public managers in new shoes” (Singh and Prakash 2010:851). The development and management of PPPs are quite distinct from public procurement processes (Farquharson et al. 2011). Realizing the benefits from private sector involvement requires the presence of strong institutional and governance arrangements (Productivity Commission 2014). If not managed properly, there is significant risk of being locked into inefficiently designed contractual arrangements (Barlow et al. 2013). Often, PPPs fail due to poor contract

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management (Top and Sungur 2019). PPPs are typically long-term projects (most often with terms up to 30 years) and there is a need to management of contracts and complex relationships over considerable periods of time (Barlow et al. 2013). Ideas about what constitutes performance management may differ. Productivity in the public sector often differs from other sectors and strong performance frameworks and indicators are often lacking (Martin and Halachmi 2012; Roland et al. 2018; Romero 2019). Institutional, governance and personnel capabilities are critical in the management of PPPs. Unique skills are needed in these types of output-based projects. Key skill areas needed include setting priorities, project analysis and selection, cost benefit analysis, decision making, procurements, managing contracts, institutional strategy development and planning, managing transactions, and negotiation skills are some of the key areas in which public providers often lack capacity (Martin 2013; Farquharson et al. 2011; Sanghi et al. 2007). A related management issue is the processes of management and transparency of PPPs in areas such as the project selection, value for money assessments, the potential for corruption and malpractice, lack of transparency and accountability (Jomo et al. 2016). It is alleged that PPPs are used to conceal public borrowing, while providing long-term state guarantees for profits to private companies (Hall 2015; Jomo et al. 2016). Examples of projects being prioritized according to their suitability for PPPs to benefit from some corporations, not their importance for the social, environmental, and economic objectives of public policy are identified (Hall 2015:29). For example, the Global Fund identified 207 allegations of fraud in 2017, with secretariat reporting increased by 26% and implementer reporting by 138% (Global Fund 2017a:19). Finding the right PPP partners, fit for purpose, can be also be challenging. As noted by Top and Sungur (2019:243), finding the necessary private sector financing, at the expected time or capacity, is a major challenge for the public sector. Challenging the notions that PPPs bring efficiency and cost-effectiveness, Bayliss and Van Waeyerberge (2018:577) identify that PPP critics point to “their high costs, the long-term and rigid nature of contracts, the difficulty in finding sufficient appetite on behalf of private investors, and varying assessments of their performance in terms of efficiency, risk transfer and social impact.” While espousing market principles and mechanisms for health care, there are many behaviors in PPPs that are, in practice, contrary to market principles. The market distortion effects of large-scale PPPs and the market expansion motives have been highlighted. KPMG argues that PPPs “can effectively shape provider markets by influencing future private investment,” (KPMG 2017:8) and monopolistic behavior, predatory pricing, and regulatory capture (Clarke et al. 2019). One of the key criticisms of PPPs is that it restricts competitive behavior, which in turn can have contradictory impacts on the market (Barlow et al. 2013). This is particularly the case with large-scale projects for which many private sector entities do not have the capacity to bid for or implement. The processes of procurement may also restrict competition, where particular private firms are approached without appropriate competitive tendering process. The challenges and constraints of PPPs, as can be seen from the above discussion, go to core principles as well as operational and management aspects.

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Impacts of PPPs for Global Health Outcomes There are divergent views about the results of global partnerships for addressing health outcomes. As noted above, some assert that it has delivered remarkable results and improved the health of millions of people and shaped global agendas for health. The achievements attributed to the global health partnerships are: • Creating novel institutional spaces for more inclusive global health governance through innovative shared decision-making, risk sharing, knowledge, and resource pooling. • Forging consensus on policy, strategy, programmatic responses, and international norms and standards. • Positioning health, and specific health issues, at the core of national and global development agendas. • Increasing the visibility of and mobilizing unprecedented resources. • Expanding availability of, and access to, free or reduced cost, quality-assured medicines and vaccines through the mobilization of R&D, large-scale funding, improved distribution networks and revisions to international trade, and intellectual property regulations. • Strengthening health systems and national health policy processes. • Transforming the way many international health organizations fulfill their mandates, particularly through pressure to improve transparency and accountability (Buse and Tanaka 2011:4). Whether global health partnerships would have achieved these outcomes without PPPs is not known. While PPPs have increasingly been utilized as mechanisms for delivery of global health outcomes, their impact and outcomes are not well documented. As noted by Kostyak et al. “there is an absence of empirical data it is difficult to identify and evaluate critical issues” (Kostyak et al. 2017:126). There is insufficient evidence to support many of the claims surrounding the presumed benefits of PPPs and their contribution to goals relating to health outcomes and inequities (Gideon and Unterhalter 2017; Jomo et al. 2016; Hall 2015). The complex nature of global health issues, the disparate range of PPP arrangements, and the lack of transparency regarding partnerships conceal the impact and outcomes, particularly in the absence of effective evaluation mechanism (Kostyak et al. 2017; Hernandez-Aguado and Zaragoza 2016; Jomo et al. 2016). There are over 90 global alliances (Nishtar 2004) and it will not be possible, in the scope of this chapter, to review them. Some examples of global health partnerships are briefly covered in this section to provide an overview of impact and achievement. The Global Fund to Fight Aids, TB and Malaria, for example, disbursed US$3.2 billion in 2018 across 124 countries (2019b: 62). The Fund provided 20% of all international financing for HIV programs, 69% of all international financing for TB and 65% of all international financing for malaria programs (Global Fund 2019b:12, 24, 36). Significantly, the Fund reports significant global health outcomes with 32 million lives saved globally, with 18.9 million antiretroviral therapy for HIV

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provided, 5.3 million people for TB treated, and 131 million mosquito nets distributed (Global Fund 2019a:2). The Fund points out that the “overall number of deaths caused by AIDs, TB and malaria has been reduced by 40% since 2002 in the countries where the Global Fund invests” (Global Fund 2019b:8). While reporting these impressive outcomes, the Fund, in a review conducted in 2015, identifies significant challenges. These include: • Global Fund processes are not yet fully aligned with, and supportive of, countrydriven planning processes or national systems. • Progress and impact is hindered by largely undifferentiated processes and procedures. • Global Fund performance management problems and high transaction costs. • Sustainability and transition planning, beyond Global Fund activities, remain poorly operationalized within many countries. • While population and human rights approaches are taken, certain areas of focus are weak, such as gender analysis (Global Fund 2015). Gender is recognized as a determinant of health status – influencing, risk factors in ill-health, health-care seeking patterns, and the nature of the health system’s response to illness (Hawkes et al. 2017). Issues of long-term sustainability are raised in the evaluation of Global Fund activities. The revenue of the Fund are 93% public funds from donor governments or public sources and only 7% from the private sector including philanthropic donations such as the Bill and Melinda Gates Foundation (2019b:64). Of relevance is that conclusion, by the strategic review of the Fund, that inadequate support has gone towards mobilizing resources from the private sector and towards ensuring that nongovernmental contributions to the health sector can be sustained” (Global Fund 2015:4). While over the years, there is an impressive private sector agency participation, the buy-in has not been a significant part of the overall budget of the Fund, indicating a number of issues such resources needed for the promotion efforts of the key health issues to appeal to the private sector and the alignment of interests between public and private sectors. An additional sustainability relates to what happens once the Global Fund programs exit from the countries of operation and the dependencies that may have been created. Many states have been engaged with the Funds and will not have resources to devote to the specific diseases. A review conducted in 2017 highlights the key challenges around sustainability and transition from the Global Fund programs. These include how best to ensure the sustainability of key programs after exit (particularly those that engage civil society); addressing complex issues related to country absorptive capacity; ensuring country ownership over the transition process; addressing a lack of clarity on the extent to which principles of country ownership apply; a lack of engagement to discuss issues where country and Global Fund objectives do not meet and align; and the need to better leverage partnerships that support the achievement of tangible results and long-term impact (Global Fund 2017:2). The Fund identifies that the support takes time and involves addressing

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complex issues such as changing legislation and procurement processes to allow for the public sector to contract with non-public sector providers to support ongoing domestic provision. Key considerations of transition are timely notification of potential transition, support for transition readiness assessments, and the availability of transition funding service to ensure that future activities are well planned and supported. The national governments may or may not give priority to the health issues post transition and the Fund identifies that there is often also significant political advocacy needed to ensure that the interventions appropriate to a particular country’s disease epidemiology are eventually transitioned to be supported in their entirety through domestic country budgets (Global Fund 2015, 2016, 2019b). Gavi, The Vaccine Alliance is a public–private global partnership established in 2000 with the purpose of providing vaccines to the children in 73 countries. Gavi has outlined four strategic goals: (i) accelerate equitable uptake and coverage of vaccines; (ii) increase the effectiveness and efficiency of immunization delivery as an integrated part of health service strengthening; (iii) improve the sustainability of national immunization programs; and (iv) shape markets for vaccines and other immunization products (Gavi 2019). In terms of global health outcomes, Gavi has identified that it has vaccinated 49% of the world’s children (2019), i.e., 760 million children, and, estimates it has saved 13 million future deaths through the immunization programs (Gavi 2020:1). Gavi identifies that due to long-term supply agreements with manufacturers, it has been able to secure very low prices for vaccines for different diseases (e.g., rotavirus, polio, human papillomavirus, pentavalent, pneumococcal, typhoid, Japanese encephalitis, meningitis, cholera, yellow fever, and measles,) making them affordable and accessible across the world. Gavi has launched more than 490 vaccine introductions by the end of 2018. The return on investment has been estimated to be $US54 per $US1 spent (Gavi 2020:3). In 2001, five vaccine manufacturers produced prequalified, appropriate Gavi vaccines, with only one based in Africa. In 2018, 17 vaccine manufacturers produced prequalified, appropriate Gavi vaccines, with 11 based in Africa, Asia, and Latin America (Gavi 2020:4). Gavi argues that the PPP model allows it to provide program predictability to the countries to deliver vaccines and shape vaccine markets. Gavi’s PPP model is 79% contributions from the public sector and 21% from the private sector. The private sector component boasts a range of key private sector agencies including Bill and Melinda Gates Foundation, Netflix, TikTok, and numerous others. Leveraging from private sector funding, Gavi uses a range of financing mechanisms such as issuing vaccine bonds in the capital markets to raise funds, incentivizing vaccine production to ensure supply chains in developing nations, matching fund schemes to double private partner’s investment in immunization, and affordable loan schemes. Partnerships were forged with pharmaceutical suppliers, banks, and a wide range of corporations. There was no evaluation of the public–private partnerships frameworks of Gavi. In a review of the eligibility, transition, and co-financing policies of Gavi, the Cambridge Economic Policy Associates (CEPA) identified a range of issues in implementation. These included rigidity of policy frameworks (seen as a negative and positive by different stakeholders), lack of flexibility for application in different

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settings and criticism of a one size fits all approach and the need for more tailored approaches, lack of integrated domestic financing across Gavi’s areas of support and a holistic approach for countries to co-finance, confusion about post-transition arrangements, numerous exceptions to the policy frameworks with high transaction costs, lack of transparency in the decision-making criteria, policy weakness of lack of focus on vulnerable populations, and need for country level deeper engagement including better coordination and less “top-down” approaches. (CEPA 2019). The development of new vaccines has been criticized as vaccinations are not grounded in principles of equity, their vertical systems have less focus on long-term sustainability and have redirected national policies and resources (Nishtar 2004; Yamey 2001). The ambitious push new vaccines and often squeeze out cheaper and quicker solutions (McGoey 2015). Drugs for Neglected Diseases initiative (DNDi) is a collaborative, patients’ needs-driven, nonprofit drug research and development (R&D) organization that is developing new treatments for neglected diseases including leishmaniasis, sleeping sickness, chagas disease, pediatric HIV, filarial disease, mycetoma, hepatitis C, and malaria. DNDi’s objective is to deliver 16–18 new treatments for neglected patients by 2023. Since 2003, DNDi has worked with its worldwide network of partners to develop a new chemical entity (fexinidazole) into the first all-oral treatment for sleeping sickness; develop seven new treatments from existing molecules and recombining drugs to bring better treatments to patients for malaria, Chagas disease, leishmaniasis, and pediatric HIV. DNDi has initiated the Global Anti-biotic Research Development Project, a not-for-profit research and development organization developing and delivering new or improved antibiotic treatments. DNDi uses public– private partnerships to achieve their mission, operates through a virtual model, and argue that its R&D activities are outsourced, enabling development costs to be kept under control while providing a high level of flexibility. DNDi partners for R &D wide and include pharmaceutical companies, biotechs, research institutes, universities, national research centers, spin-off companies, government organizations, contract research organizations, hospitals, and NGOs. The ratio of private to public partners DNDi worked with in 2018 was 56% private versus 44% public (DNDi 2018). DNDi point out that successful partnership agreements require the management of divergent interests by solving critical issues like licensing rights, confidentiality concerns, intellectual property (IP) management, and/or lack of profitability. DNDi has developed various models of collaboration, in order to manage the respective interests of its partners so as to reach well-balanced agreements. Key issues that DNDIi identifies as critical include defining the field (the diseases), territory (the geographical area), and the market (public vs private distribution) are important issues that must be agreed upon by both parties in order for a private partner to provide DNDi access to a compound or technology (DNDi 2020). Harnessing Non-State Actors for Better Health for the Poor (HANSHEP) was created by a group of aid agencies including UK DFID, USAID, Germany’s KFW, the World Bank, and Gates and Rockefeller Foundations in 2010. Its purpose was to support developing and implementing public–private partnerships. It provided funding to African Health Markets for Equity scheme for 2734 service outlets

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covering a range of health issues and diseases; training of public servants and created a private equity fund, the Global Health Investment Fund, using public aid money to accelerate the development of products to address global health challenges. Multinational pharmaceutical companies and banking group sponsored the Fund. Critics identify that there is no evidence of the impact of HANSEP, in terms of health care facilities and that the initiatives “delivered almost nothing” (Hall 2015:23). Universal Health Coverage (UHC) is one of the most pressing global priorities, and is prominent in the Sustainable Development Goals defined goal 3.8. UHC is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services in order to achieve health outcomes. Accessible and affordable health care for everyone, i.e., benefit maximization, is the key objective of UHC (WHO 2014). While there is no single pathway for countries to achieve UHC, PPPs have increasingly been used to finance efforts toward UHC. WHO (2020) posits that most health systems are a mix of public and private providers around the world and harnessing the benefits of PPPs is critical to providing UHC. KPMG (2017) identifies that PPPs in health care are increasing in Asia, Latin America, and Africa. The dominant PPP model that is currently being adopted for UHC entails health services are purchased prom private providers under public contracts, often through new national health insurance (NHI) schemes such as those being rolled out by India, Indonesia, Kenya, South Africa, Egypt, and many others (Roland et al. 2018:4). Securing private sector collaboration for UHC is not easy as is demonstrated by the World Innovation Summit for Health (WISH) who surveyed private investors in health care to see if they were interested in the opportunities scalable business and service models to achieve universal health coverage. They surveyed 20 of the largest health private provider chains operating across 40 low- and middle-income countries, representing the operators of more than 500 hospitals and 7,000 clinics or lab facilities. They found that only “a quarter of providers expressed a clear intention to shift their business and service delivery models toward publicly financed universal care services. A further quarter expressed a clear intention not to do this. The remaining half either expressed a desire to work with governments without significantly changing their mix of patients and reach of services or planned to broaden their delivery model but without public partnerships (Roland et al. 2018:5). Studies found that there is a mismatch between what the public sector wanted and the private sector offered in delivery of UHC. The public purchasing decisions in a number of countries, as interviewed by WISH, identified less focus on infrastructure and episodic care and more on integrated pathways of care, primary care in rural and underserved populations, and in new ideas and expertise (Roland et al. 2018:13). Comments by the Global Chairman for Infrastructure, Government and Healthcare, KPMG International in relation to PPPs for UHC highlights the alignment challenges: “we found that there is a stark mismatch between where these actors said they have the greatest need for innovation, investment and new partnerships, and what they said is offered by their current private sector. They wanted last mile access, but were offered urban islands

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of excellence. They wanted scale and standardization, but were offered fragmentation. They wanted new models of primary care for the poorest, but were offered episodic services that were either overpriced or under-regulated” (Britnell 2019:1).

While harnessing effective PPPs for UHCs is central for states, many governments do not have an explicit government policy position on the role of the private health sector, nor concrete plans to implement public policy on the private sector (Clarke et al. 2019; Roland et al. 2018). Some of the major problems identified include selecting the wrong kinds of priorities and projects as applications for PPP; not setting objectives that incentivize; an overly narrow focus on service targets rather than high-value health care; choosing the wrong partners to work with; making erroneous or overly restrictive assumptions about the future, and failing to generate sufficient competition and contestability. (KPMG 2017). Building the capacity of the public sector and to secure the trust of the private sector to invest requires a range policy and business environment needs to be aligned including coherent health system plans, effective pools of public financing, supportive regulatory environments, capable project management, and rules to support fair competition (Roland et al. 2018; Clark et al. 2019). Looking at PPPs from a national lens has also revealed that the PPPs in health are riddled with challenges. For example, the UK Government adopted the Private Finance Initiative (PFI) in the 1990s as a model of capital funding of public health and other infrastructure. It was concluded that the PFI has not fulfilled the objectives of increased capital funding and value for funding, particularly due to unwillingness of banks and other investors to support PFI projects after the financial crisis in 2008. The UK government has had to support the use of PFI for investments by lending tax payers’ money to private sector parties to enable them to invest under PFI (Lieberherr et al. 2016:145). The National Audit Office (2011, 2015) is increasingly critical of the higher cost of finance in PFI than that of conventional borrowing. The costs of financing of PPP-operated services or infrastructure facilities were twice as high for the UK public purse, compared to if the government had borrowed from private banks or issued bonds directly (Romero 2018). The payments by the UK Government under PFI means that there is less total budget for the Government. These annual payment obligations has had detrimental impacts on budgets by locking governments into high taxpayer funded long-term debt; has negative impact on the number of jobs and distorted clinical priorities (Lieberherr et al. 2016; Barlow et al. 2013; Pollock 2012). Since the introduction of the policy in 1992, there has been a reduction of hospital beds by 30%, closures of hospitals and reduction in community and clinical services, leading Pollock (2012) to state that “PFI, once trumpeted as the largest hospital-building programme, was in fact the largest NHS hospital and bed closure programme.” Focus has been brought on the lack of transparency and accountability in PFI. The creation of value for money and the risk transfer to the provider has not happened (Treasury Committee 2011), with the Treasury Committee concluding that the “the claimed risk transfer may be. . . illusory” (2011:2). Pollock (2012) criticizes the lack of transparency and the masking of PFI contract challenges for hospitals behind claims of commercial

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confidentiality. The lack of accountability and transparency, coupled with policy capacity is responsible for the failure to achieve value for money and efficiencies (Lieberherr et al. 2016). The overall impact of PPPs is unclear and the quality of evaluation and assessments weak. The literature on the topic suggests that the value for money assessments of PPPs are not effective and there is a lack of clear evidence to indicate how PPPs bring efficiency and cost-effectiveness relative to public provision (Jomo et al. 2016; Gideon and Unterhalter 2017; Languille 2017; Rosenau 1999). Most of the assessments consider financial feasibility and fail to take into consideration other social and policy objectives (Hall 2015). Existing evaluation and performance of PPPs have been based on narrow conceptions of health and health outcomes. These have failed to consider the other dimensions of health, and deny their broader embeddedness within the economy and society (Languille 2017; Gideon and Unterhalter 2017). Narrowly defining health objectives in PPPs can encourage squeezing out, whereby the private partner is incentivized to divert certain costs, such as complex patients, onto others in the health system (KPMG 2017:16). Conversely, they can find themselves responsible for treatments they did not expect to have to fund. The value for money assessments need to include considerations of a PPP, including wider fiscal and equity considerations. The stark case of hospital built in Lesotho by a global consortium under PPP arrangements cost three times more than the public system of procurement, consumed more than half of the country’s national health budget, and diverted scarce public funds from primary health care services in rural areas, where three-quarters of the population live (Webster 2015:1930). The impact of PPPs needs to be undertaken within a broader set of parameters. Assessments need to go beyond an appraisal of specific contracts and examine broader implications both within a particular sector and the country (Bayliss and Van Waeyenberge 2018) with a deeper assessment of benefits and costs in the long term. While quantitative evaluations are used to legitimize the fiscal imperatives of PPPs, their “efficiency is hardly analysed in comparison with their full cost to achieve better learning achievements or health status” (Languille 2017:157). There is a need for comparative assessment with public sector options, sources of finance and their long-term impact, how labor and capital are being transformed through PPPs and data on the corporate sector (Languille 2017; Hall 2015). There are suggestions that PPPs are more suited to sectors where there is a clear demand predictability such as transport and that it does not yield benefits in social sectors such as health and education where equity considerations are paramount (Jomo et al. 2016; Joseph 2012).

Conclusion The struggle for accessible and inclusive health care systems and policy is a major battleground across the world. Global health issues provide the most serious challenges and the greatest opportunities. The major global health challenges the world faces include infectious diseases; mortality from reproductive, maternal, and child

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health; the shift in the global disease burden toward noncommunicable diseases; weak institutional arrangements to tackle these challenges; and reduced medical expenditures together with increase in health care costs. Meeting these challenges requires new and innovative approaches and initiatives. Public–private partnerships have increasingly been utilized as a mechanism to address global health issues, although there is no agreed unifying definition of PPP in the context of global health. International bodies such as the UN, WHO, and the World Bank call for cooperation, collaboration, and partnership between government, civil society, and businesses to address the major global challenges. The emergence of PPPs in global health is situated in the complex analysis that accompany global health markets. PPPs have been initially adopted as mechanisms to address the financial gap in health care delivery have increasingly become vehicles to open up markets to private sector. The main reasons for PPPs include product development, health infrastructure development, improving access to health care products, mechanisms for global health coordination, strengthening health services, public policy, and education and regulation and quality assurance (Nishtar 2004:3). PPPs in global health are usually transnational arrangements and partnerships vary across a range of variables including their functional aims, the size of their secretariats and budgets, their governing arrangements, and their performance (Nishtar 2004; Buse and Harmer 2007), although there are state-based PPPs across global health issues. Increasingly, hybrid and transnational partnerships have become a common approach (Hernandez-Aguado and Zaragoza 2016; Nishtar 2004). There is considerable debate about the benefits and challenges of public–private partnerships for health outcomes, with both support for PPPs and substantial criticism of the use of these partnerships in health care (Barlow et al. 2013). There is no general agreement on their main benefits toward achieving health outcomes (Torchia et al. 2015:238). One of the main benefits of this is that it brings together different sectors to address complex health issues which no one sector can address on their own. There is an underlying perception that the private sector is more creative, agile, can bring access to finance and knowledge, technologies, managerial efficiency, entrepreneurial spirit, diverse skill, is better at performing economic tasks, innovating and adapting to change, and addressing market failure to bring about value for money health care outcomes (Rosenau 1999; Nishtar 2004; WHO 2009; Stevenson 2015). Other benefits of PPPs include attention to specific health issues or diseases via products, research, and services; advocacy in international agendas; capital and new funding for neglected health care areas; new technologies and expertise; risk sharing by the private sector; strengthening of the country health system to deliver policy and regulatory reform; long-term relationships across sectors; and overall enables the provision of access to health care for population groups who are disadvantaged and have limited ability pay (Top and Sungur 2019; World Bank 2017, 2018; Fréchette 2016, Hernandez-Aguado and Zaragoza 2016; Torchia et al. 2015; Martin and Halachmi 2012; Buse and Harmer 2007). A wide range of criticism is leveled at PPPs. One of the key criticisms is related to the incongruity between public and private interests. As the private sector pursues goals of profit maximizing, it is believed that this may happen at the expense of

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quality and flexibility in projects or programs (Top and Sungur 2019). PPP partners do not share a common organizational structure and, therefore, can pursue different broader strategic goals while engaged in PPP that may not be aligned to the policy objectives of the public sector. Due to a range of reasons such as market failures, economic costs of externalities, and equity issues, such investment decisions may not align with what is in the public interest (Bayliss and Van Waeyenberge 2018; Richerter 2014; Zhang et al. 2009). Other criticisms include powerful private sector players influencing discourses surrounding the need for the partnerships; poor value for money outcomes; biased determination of which health issues to address and the justification of the urgency in relation to particular health problems; lack of risk sharing by private sector agencies, weakening state public health systems; lack of resource commitment from partners; complex and weak governance and accountability structures; competition, duplication, and fragmentation; problematic nature of collaboration and relationships; relative power inequities across key actors; significant conflict of interest of key stakeholders; exertion of power to influence nation state polices/programs; high transaction costs; lack of representation of low income countries; lack of beneficiary voice; lack of equity outcomes; and lack of accountability and transparency (Clarke and Paviza 2018; Youde 2014, Harmer 2011; Buse and Tanaka 2011; Ricter 2004; Reich 2000). As we look to the future, it is clear that the private sector is going to continue to play a role in national and global health care and hybrid arrangements, and partnerships will continue dominate the architecture of global health. Most existing national health care provision around the world is facilitated along a continuum of the mix of public and private provision. There is a lack of clarity about the role of the private sector in health care (Clarke and Paviza 2018). Governments and international bodies such as the UN and WHO and governments need to have very clear definition of the role of private sector in health care and type of influence they should exert in determining health care objectives for public benefit. Given that many actors are transnational players, beyond the national states, there are significant considerations about the use of power to influence policy and program initiatives and effectiveness of regulation. Safeguards toward the public interest need to be strengthened through a range of mechanisms. An important element of this strengthening is the effectiveness of the policy and regulatory frameworks in which the PPPs take place. The establishment of a transparent and sound regulatory framework is a necessary precursor to private sector participation, providing protection for both the private and the public sectors (Roland et al. 2018; Romero 2018; Torchia et al. 2015; Pongsiri 2002). Moreover, because of the stronger position of the private partner in PPPs, more strengthened and active public sector participation is needed (Scharle 2002). The public sector should continue to set standards and monitor product safety, efficacy, and quality, and ensure that citizens have adequate access to the products and services they need (Torchia et al. 2015). There is considerable doubt about the cost-effectiveness of PPPs (Romero 2018, 2019). The benefits of using PPPs need to be offset against other costs relating to addressing complex health issues. Future PPPs need to strongly assess value for money considerations including which health issues are addressed (e.g., diseases,

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vaccines), the total benefits in the long term, access and equity considerations, and options for other forms of health care delivery. Narrowly defining health issues for PPP projects denies their broader embeddedness within the economy and society (Languille 2017; Gideon and Unterhalter 2017); can encourage squeezing out, whereby the private partner is incentivized to divert certain costs, such as complex patients, onto others in the health system (KPMG 2017:16); ignore equity considerations and put a financial long-term burden on the public sector. The capacity of the public sector to assess and manage PPPs in terms of value for money and health outcomes must be strengthened to optimize the effectiveness of PPPs. As noted above, the complex transnational nature of global health partnerships, the inequitable representation and participation of states, relative power inequalities across different actors, and global agendas being increasingly shaped by the private (for profit) actors necessitates the development of global principles and norms (Nishtar 2004). This requires clear specification of conditions for participation in PPPs and global alliances, development of clear frameworks, legislative authorization mechanisms, comprehensive operational and administration strategies, and strengthening capacity for management of PPPs. Ensuring transparency and accountability are fundamental tenets of protection public benefit. Finally, a strong evidence and research base is needed about the impacts and outcomes of PPPs. As PPPs refer to a range of the collaborations in purpose, design and composition, the definition is so broad that it challenges the efforts to evaluate their merit and efficiency in improving health outcomes (Hernandez-Aguado and Zaragoza 2016). There is a lack of clear evidence to indicate how PPPs bring efficiency and cost-effectiveness relative to public provision in global health (Jomo et al. 2016; Gideon and Unterhalter 2017; Languille 2017; Rosenau 1999). Existing evaluation and performance of PPPs have been based on narrow conceptions of health and health outcomes. The impact of PPPs needs to be undertaken within a broader set of parameters, and assessments need to go beyond an appraisal of specific contracts and examine broader implications both within particular sectors and within the country (Bayliss and Van Waeyenberge 2018). While quantitative evaluations are used to legitimize the fiscal imperatives of PPPs, their “efficiency is hardly analysed in comparison with their full cost to achieve better learning achievements or health status” (Languille 2017:157). A stronger set of metrics needs to be developed to assess PPPs, highlighting a deeper assessment of benefits and costs in the long term. Effective evaluation and research on PPPs will need to provide a strong evidence base regarding the ethical and practical issues of PPPs in global health contexts. In concluding, PPPs can be a useful mechanism for achieving health outcomes if there are appropriate safeguards in place. The future PPPs must clearly articulate what is the public health objective (including prioritization of health issues, outcomes, and impacts), demonstrate the need for such partnerships and the value-add of PPPs; unpack delivery considerations such as ownership, alignment with policy objectives of states; and establish clear governance arrangements including representation, transparency, and accountability (Buse and Tanaka 2011: Roland et al. 2018, KPMG 2017). In a globalized world, the health challenges are of scale,

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magnitude, and speed that it affects us all, as is demonstrated by the recent COVID19 pandemic. Many disadvantage and vulnerable people across the world do not have access to basic health care. Achieving health outcomes in the most innovative and effective manner is critical. We need to continue to open up spaces for independent thinking, evaluation, and scholarship to actively examine, debate, and understand the risks and merits of PPPs as a mechanism to address global health challenges.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nongovernmental Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Goals and Strategies of NGOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of NGOs in a Globalizing World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Global Health Diplomacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NGOs in Schools of Public Health (SPH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of NGOS in Global Health Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Global health refers to “inherently global health issues,” that is, healthdetermining phenomena that transcend national borders and political jurisdictions, such as globalization and climate change. Nongovernmental organizations (NGOs) include charitable and religious associations that mobilize private funds for health care, family planning services, food supply, and community development. They also include independent cooperatives, community associations, water-user societies, women’s groups, and pastoral associations. This chapter presents the diversity and various roles of NGOs in global health including their goals and strategies, to encourage new thinking on how NGOs can further their impact in global health diplomacy. To contribute to shared global health objectives, NGOs should work in close partnership with a wide array of international agencies and institutions to shape global health policies and to fund, implement, and evaluate programs. Furthermore, their participation in international organizations ensures the latter’s political legitimacy. Thus, participation of

S. Anbazhagan (*) · A. Surekha Department of Community Health, MGMCRI, SBV University, Puducherry, India © The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_118

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international public opinion and the mobilizing powers of NGOs are an essential and basic element in the multilateral representation of the modern world. Keywords

Nongovernmental organizations · Nonprofit · Philanthropic · Partnerships · Global health diplomacy

Introduction Global health is essential for development. A major issue is the inequitable distribution of research efforts and funds directed toward populations suffering the world’s greatest health problems. This imbalance is fostering major attempts at redirecting research to the health problems of low and middle income countries. This chapter presents the diversity and roles of various NGOs in global health to encourage new thinking on how NGOs can further their role in global health diplomacy.

Nongovernmental Organizations World Bank defines NGO as – The diversity of NGOs strains any simple definition. They include many groups and institutions that are entirely or largely independent of government and that have primarily humanitarian or cooperative rather than commercial objectives. They are private agencies in industrial countries that support international development, indigenous groups organized regionally or nationally, and member-groups in villages. NGOs include charitable and religious associations that mobilize private funds for development, distribute food and family planning services, and promote community organization. They also include independent cooperatives, community associations, water-user societies, women’s groups, and pastoral associations. Citizen groups that raise awareness and influence policy are also NGOs. According to the Human Development Report, there were in 2002 over 37,000 NGOs in the world, a growth of 19.3% from 1990. Their purposes differ, but overall two categories dominate: economic development and infrastructure (26%) and research (23%).

Goals and Strategies of NGOs NGOs have the following characteristics: 1. Engaging in suffering relief activities 2. Promoting interest of the poor 3. Protecting the environment

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4. Providing basic social services 5. Advocating community development Key issues addressed by NGOs include: Key Issues 1. Environment 2. Labor Standard 3. Poverty 4. Globalization 5. Animal Rights Three major types of global health actors: 1. Multinational organizations (A) Organizations within the UN system relevant to health (B) Organizations outside of the UN system relevant to health 2. Bilateral - government-to-government or to subgovernment levels. 3. Non-governmental organizations (NGOs). NGOs defined by their extraordinary diversity: • • • • • • • • • • •

Nonprofit and profit-based Religious and secular Narrow and broad scope programs Wealthy and shoe-string operations Big NGOs are called BINGOs Well paid, marginally paid, and volunteer staff Long- and short-term commitments Single-country, multi-country and regional focus Single problem and multi-problem focus Single sector and multi-sector focus Emergency relief and development focus Charitable (secular) organizations:

• • • • • • • • •

Oxfam CARE Save the Children/UK (& US) International Red Cross Doctors without Borders Project Hope International Rescue Committee CARE Freedom from Hunger

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• Child Family Health International • Doctors for Global Health Faith-based organizations (FBOs): • • • •

Catholic Relief Services Christian Aid Lutheran World Relief Unitarian Universalist Service Society Philanthropic foundations:

• • • • • • • • • • •

Bill & Melinda Gates Atlantic Philanthropies Carnegie Rockefeller Clinton Global Initiative Carlos Slim Josiah Macy, Jr. Kellogg Ford MacArthur Seva Membership organizations (including their international/global health sections):

• • • • • •

Global Health Council American Public Health Association American Academy of Family Physicians American Academy of Pediatrics Rotary International Global Health Education Consortium Consulting and contracting organizations (PVOs):

• • • • • •

John Snow International Management Sciences for Health Abt Associates IntraHealth International Family Health International Academy for Educational Devt Rapid increase in global health centers and programs:

• A 20010 CUGH survey found >200 such Programs. • Involvement in training, research, and service.

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Some major university programs: • • • • • • • • • •

Duke University Emory University Oxford University Harvard University Vanderbilt University University of Toronto University of Washington Johns Hopkins University University of California at San Francisco London School Hygiene & Tropical Examples of work done by philanthropic foundations: Bill and Melinda Gates Foundation, Carlos Slim, & others

• Collectively, these foundations have increased global spending for HIV/AIDS (from $250 M to $7B 1996–2004). Clinton global initiative (CGI) Involving the private sector and getting participant commitments for involvement: • If no follow-up by a CGI participant, no further invitation to the CGI. • Increased investment in research and development. • 10/90 gap: Only 10% of the world’s R&D is spent on problems affecting 90% of the population. Rotary clubs and polio eradication: • A success, maybe, since small pockets of prevalence are resistant to immunization for religious or other reasons Foundation can significantly influence government and inter-governmental Organizations. Gates – grand challenges in global health: • • • • • •

Create new vaccines Improve childhood vaccines Cure latent and chronic infections Improve nutrition to promote health Improve drug treatment of infectious diseases Control insects that transmit agents of disease

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• Measure disease and health status accurately and economically in developing countries • Perhaps improve health systems and their human resources Nonprofit NGOs Strengths: • • • • • • • •

Great variety of programs to meet many needs Potentially very flexible with fast response times Volunteers and non-profit status, lower operational costs Staff with high personal commitment to providing help Can easily relate to host country organizations Less tainted by association with government Lower corruption potential Campaigns help educate the public to human needs Potential critiques:

• • • • •

Limited accountability and ability to evaluate effectiveness High motivation not necessarily matched by expertise May have high volunteer turnover and short stays May compete or not coordinate actions with similar NGO and country programs Programs often narrowly focused on specific diseases or problems, with limited attention to infrastructure development

– Specific diseases and problems are more marketable to donors. – Program results are easier to document with limited, measurable, though not necessarily meaningful, objectives, e.g., meals delivered, educational talks given, persons trained, medicines handed out, and books delivered. Many organizations interested in and advocate for global health but do not provide direct assistance: • • • • • • • • •

Global Health Council (in reorganization as of 2013) UN Association of the USA Council on Foreign Relations Returned Peace Corps Volunteers Commissioned Officers Association Academic Alliances in Global Health Global Health Education Consortium Consortium of Universities for Global Health American Public Health Association & many others.

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Global Health Global health also refers to “inherently global health issues,” that is, healthdetermining phenomena that transcend national borders and political jurisdictions, such as globalization and climate change. Many US-based international NGOs are actively engaged in international health projects. The relief agency CARE, for example, participates in a joint CARE-CDC Health Initiative (CCHI), which makes best use of CDC’s technical and scientific expertise and CARE’s on-the-ground capabilities to address critical health issues in countries around the world. The eradication of Guinea worm and the prevention of river blindness throughout the world top the Atlanta-based Carter Center’s list of global health concerns. Through The Carter Center’s efforts, community-based intervention programs primarily in Africa have greatly reduced the burden of these diseases among some of the world’s poorest people. Combining forces with the CDC, WHO, UNICEF, and others, the Carter Center helps make the idea of publicprivate partnership in global health a reality (Global health partnerships 2015).

Role of NGOs in a Globalizing World Nongovernmental organizations are a basic element in the representation of the modern world. And their participation in international organizations is in a way a guarantee of the latter’s political legitimacy. From the stand point of global democratization, we need the participation of international public opinion and the mobilizing powers of nongovernmental organizations. Nongovernmental organizations (NGOs) in the health sphere have gained strength, momentum, and numbers over time. The Director General of WHO,1973–1988, recognized the ability of NGOs to influence policy makers, as noted by Narayan, Wise, and Ghebrehiwet: Dr. Mahler, Director General of WHO at the time, publicly states that it was the nongovernmental organizations (NGOs) who pressed WHO strongly to move beyond a disease-focused, expert-dependent, and technomanagement approach, based on the dominant system of medicine, to one wherein community participation, inter-sectoral coordination, and appropriate technology were important. A recent (2010) acknowledgment by Laaser and Epstein of the power of NGOs in the health arena states that the fourth phase of the internationalization of health – is characterized by the growing influence of health-related, nongovernmental organizations (NGOs). . . which include those in the arena of public health, such as the World Federation of Public Health Associations (WFPHA), the International Union for Health Promotion and Education (IUHPE), the International Association of National Public Health Institutes (IANPHI), national and regional public health associations, and national and regional associations of schools of public health. In May 1977, the World Federation of Public Health Associations (WFPHA) accepted an invitation from the World Health Organization (WHO) and the United

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Nations Children’s Fund (UNICEF) to develop a position paper representing views of nongovernmental organizations about primary health care for presentation at the International Conference on Primary Health Care to be held in September 1978 in Alma-Ata, Kazakh, SSR. The WFPHA consulted a large number of nongovernmental organizations (NGOs), both those in official relationship with WHO and UNICEF and many other interested NGOs, national and international. In the field of health, NGOs have long helped to set standards for practice, training, and continuing education and to define the role of health workers in national programs. Others have concentrated on a particular disease or activity (e.g., cardiovascular diseases, leprosy, tuberculosis, programs for the disabled, etc.). The diverse programs and competencies of numerous organizations, not directly involved in health care, also contribute in one way or another to total human development. They include projects to improve nutrition, food production, and housing; provide safe water; promote literacy; provide educational and other instructional materials; further community development; provide training in a broad range of skills; protect the environment; etc. In short, they are helping to create conditions conducive to the protection, promotion, and maintenance of health and the prevention of illness. Recent years have seen a growing capacity of nongovernmental organizations to develop patterns of cooperation among themselves locally, nationally, and internationally, for consultation and exchange of information, or for joint action. Role of NGOs in primary health care (Laaser and Epstein 2010): 1. At all stages in the development of primary health care programs, NGOs can be effective. Recognition by government of the contributions NGOs can make in support of primary health care will ensure maximum benefits of these contributions to the national health program. 2. NGOs can work for greater understanding and positive attitudes toward primary health care by: (a) Promoting dialogue both within and among NGOs (b) Sustaining dialogue with governmental authorities (c) Providing information and creating new ways of explaining primary health care to the general public (d) Strengthening means of communication to accomplish this 3. NGOs can assist national policy formation in the areas of health care and integrated human development. They can present health care needs based on their contacts with communities, and they can also interpret primary health care plans to relevant donor agencies. 4. NGOs can establish means for greater collaboration and coordination of primary health care activities. This can be done among NGOs and between them and governments, locally, nationally, and internationally. 5. NGOs can contribute to primary health care in many ways through program implementation. They can: (a) Provide assistance to develop and/or strengthen local NGO capabilities and activities with particular attention to local community development groups

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(b) Conduct reviews and assessment of existing health and development programs and assist communities in the exercise of their own role in such reviews; a greater emphasis on evaluative techniques will render all new programs more accountable to real community needs (c) Develop innovative programs placing primary health care in the context of comprehensive human development (d) Ensure that their existing programs and new initiatives promote full participation by individuals and communities in the planning, implementation, and control of these programs (e) Expand their training efforts to respond to the needs of primary health care programs, e.g., training of health workers, supervisors, administrators, planners, and various agricultural and development workers; included would be training schemes which build on the skills of traditional healers and midwives (f) Extend their efforts to develop locally sustainable and appropriate health technologies and use of resources, with particular attention to energy, water, agriculture, sanitation, and medical care (g) Contribute to the creation of new and effective methods of health education which enable both individuals and communities to assume greater responsibility for their own health (h) Recognize the essential role of women in health promotion and in the full range of community development concerns (i) Further extend their capacity to work with poor, disadvantaged, and remote populations, enabling them to break the cycle of deprivation and in this way contribute to the search for greater social justice

Global Health Diplomacy To engage in the discourse of global health diplomacy, NGO diplomats are immediately presented with two challenges: to convey the interests of larger publics and to contribute to inter-state negotiations in a predominantly state-centric system of governance that are often diluted by pressures from private interests or mercantilist self-interest on the part of the state itself (Lencucha and Kothari 2010). NGOs are an important part of global health diplomacy, and their strong presence on the global stage represents one of the trends that have been attributed to the emergence of the field itself (Adams et al. 2008). Frist (2007: 225) notes that health diplomacy can mean building a culture of discourse and collaboration between governments and those NGOs that operate at the grass-roots, community level, and have the greatest access to people in need. Whether and how such ideals have been enacted has not yet received systematic study in the global health diplomacy literature (Frist 2007). The most prominent allusion to NGO contributions to global health diplomacy is their role in injecting ideas into dialogue. Fidler (2008) asserts, although implicitly, governments represent power in diplomacy whereas NGOs represent ideas and knowledge (Fidler 2008). Canadian NGOs engaged in the FCTC negotiations by gathering and brokering knowledge to delegations – knowledge about the technical process of

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policy-making as well as about the substantive topic of tobacco control – while working to enhance the representation of NGOs from different regions of the world.

NGOs in Schools of Public Health (SPH) A few other organizations have provided direct funding recently for the development and capacity building of SPHs, although there often is a need for additional funding partners for particular aspects of a school. One well-documented example is BRAC (formerly Bangladesh Rural Advancement Committee), the largest NGO in the world (World Health Organization 2007), and the establishment of the James P. Grant School of Public Health in 2004. Great strides have been made over the last century to supply a trained public health workforce. Much of this work has been accomplished through direct involvement and funding by NGOs, but the lack of funding and initiative remains a global issue. More government and NGO funding is needed to continue establishment and expansion of schools and programs of public health education.

Role of NGOS in Global Health Research NGOs are contributing at all stages of the research cycle, fostering the relevance and effectiveness of the research, priority setting, and knowledge translation to action. They have a key role in stewardship (promoting and advocating for relevant global health research), resource mobilization for research, the generation, utilization, and management of knowledge, and capacity development. Yet, typically, the involvement of NGOs in research is downstream from knowledge production, and it usually takes the form of a partnership with universities or dedicated research agencies. COHRED (Council for Health Research in Development) works in partnership with WHO, the World Bank, and other organizations to strengthen the role of health research at the country level. The Canadian Coalition for Global Health Research. CCGHR is developing into a network of health researchers, funding agencies, NGOs, and other stakeholders committed to support the pursuit of effective global health research by ensuring that all these groups work together as effectively as possible with researchers in developing countries. NGOs often play a critical role in interpreting the evidence and translating its relevance for local communities. Inevitably, the level of involvement by the community depends on relevance and opportunity for action and advocacy. Assessing and evaluating opportunities for advocacy and action occur as NGOs work with communities on these issues. Effective involvement of the community and its participation are a “matter of reciprocity and continuing dialogue in which participation takes different forms and influences change in several directions” (Neufeld and Johnson 2001). Médecins sans Frontières (MSF) was the first NGO to both provide emergency medical assistance and publicly bear witness to the plight of the populations they

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served. MSF is at the forefront of emergency health care as well as care for populations suffering from endemic diseases and neglect. MSF has undertaken an initiative on drugs for neglected infectious disease which combines advocacy, research and capacity development, and networking. In contrast with private sector research, it is need-driven rather than profit-driven. Research for International Tobacco Control (RITC) is an International Secretariat based at IDRC headquarters (Ottawa) that fund multidisciplinary tobacco control research projects in developing countries. There is a need to more effectively include NGOs in all aspects of health research in order to maximize the potential benefits of research (Delisle and Roberts 2005).

Conclusion The scope and intensity of global health challenges ensures that no single country or agency can work alone to meet them. To contribute to shared global health objectives, NGOs should work in close partnership with a wide array of international agencies and institutions to shape global health policies and to fund, implement, and evaluate programs.

References Adams V, Novotny TE, Leslie H (2008) Global health diplomacy. Med Anthropol 27:315–323 Delisle H, Roberts JH (2005) The role of NGOs in global health research for development. Health Res Policy Syst 3:3 Fidler DP (2008) Global health jurisprudence: a time of reckoning. Georgetown Law J 96:393–412 Frist WH (2007) Medicine as a currency for peace through global health diplomacy. Yale Law Policy Rev 26:209–229 Global health partnerships: Centre for disease control and development. Available from: http:// www.cdc.gov/globalhealth/partnerships.htm. Accessed 1 Oct 2015 Laaser U, Epstein L (2010) Threats to global health and opportunities for change: a new global health. Public Health Rev 32:54–89 Lencucha R, Kothari A (2010) The role of non-governmental organizations in global health diplomacy: negotiating the Framework Convention on Tobacco Control. Health Policy Plan 26:405 Narayan T, Wise M, Ghebrehiwet. NGO coalitions for global health promotion. Available from: http://www.phmovement.org/pha2/issues/documents/ngocoalitionsforglobalhealthpromotion. Accessed 1 Oct 2015 Neufeld V, Johnson N (2001) Forging links for health: perspectives from the Council on Health Research for Development. IDRC, Ottawa UNDP (2002) Human development report, deepening democracy in a fragmented world. UNDP, New York World Federation of Public Health Associations (1978) Non-governmental organizations and primary health care position paper – passed by the WFPHA General Assembly World Health Organization (2007) Public health schools: six portraits. Bulletin: World Health Organization 85:907–909

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Doris Kirigia and Augustine Asante

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UN Specialized Agencies and High-Level Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UN and Global Health Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Global Health Initiatives of UN and its Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Health Care: Alma Ata 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Millennium Development Goals (MDGs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sustainable Development Goals (SDGs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Major Achievements of UN and its Agencies in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promoting Responsible Use of Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eradicating Smallpox and Polio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fighting HIV/AIDS, Tuberculosis and Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preventing and Controlling Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges in Protecting Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Growing Inequities in Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rising Threat of Epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fragile Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Global health, regardless of how one defines it, is rapidly becoming a field of interest to many health and non-health sector actors, including governments and nongovernmental organizations, public health practitioners, policy-makers, D. Kirigia World Health Organization Regional Office, Brazzaville, Congo e-mail: [email protected] A. Asante (*) School of Population Health, University of New South Wales (UNSW), Sydney, NSW, Australia e-mail: [email protected] © World Health Organization under and exclusive license to Springer Nature Switzerland AG, part of Springer Nature 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0_119

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research academics, and funding agencies. The deepening inequalities in health worldwide, changing demographic and epidemiological trends, rising threat of deadly cross-border infectious diseases such as Ebola and the COVID-19 pandemic, and disparities in health systems’ ability and preparedness to respond to critical public health emergencies have reinforced the need for a stronger and more concerted global action on health. The United Nations (UN) and its specialized agencies, particularly the World Health Organization, have long been regarded as natural custodians of global health. Since its inception in 1945, the UN has positioned itself as the leading voice in global health. The UN Charter (1945) and the Universal Declaration of Human Rights – UDHR (1948) both highlight the need to promote human health through international cooperation. The right to a standard of living adequate for the health and well-being of all people is enshrined in the UDHR. The question is how has the UN lived up to its role as a leader in global health? This chapter reviews the stewardship role of UN in global health governance. It starts with a brief introduction to the organization, then it reviews the key global health initiatives since its inception, before examining the major global health achievements and challenges. The chapter concludes with an assessment of what the future holds for UN in setting the global health agenda in an increasingly complex geopolitical environment. Keywords

United Nations · World Health Organization · Global health · Leadership · Health inequalities

Introduction Global health, regardless of how one defines it, has become a field of interest to many health and non-health sector actors, including governments and nongovernmental organizations, public health practitioners, policy-makers, research academics, and funding agencies. The deepening inequalities in health worldwide, changing demographic and epidemiological trends, rising threat of deadly crossborder infectious diseases such as Ebola and the COVID-19 pandemic, and disparities in health systems’ ability and preparedness to respond to critical public health emergencies have reinforced the need for a stronger and more concerted global action on health (Heymann et al. 2015; Hosseinpoor et al. 2018; The Lancet 2020). Like many concepts, global health has no universally accepted definition. Some people refer to it as “those health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people” (Kickbusch 2006). Koplan and colleagues define global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al. 2009). Common to these and several other definitions of global health is the need to ‘improve health worldwide, reduce inequalities, and protect populations against global health threats

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that transcend national borders.’ These attributes make the United Nations (UN), a post-World War II organization established to maintain global peace and security and foster friendly cooperation among nations (Simma 1995), an indispensable voice in the protection of global health. This Chapter reviews the role of the UN as a steward of global health and the key global health initiatives put forward since its inception. It examines the contributions the organization has made to advancing global health and challenges it faces in setting the global health agenda in an increasingly complex geopolitical environment of today. The UN was founded in 1945 with an initial membership of 50 countries (Simma 1995; Blanchfield and Browne 2014). Its formation was heralded by the collapse of the League of Nations, the first international governmental organization created in 1920 after the first world war to promote world peace (Rosenthal 2005). The breakout of the second world war in 1939 signaled the failure of the League of Nations and the need for a new body with the mandate of ensuring a peaceful coexistence of nations. This includes taking effective and collective actions to prevent and remove threats to peace, and suppressing acts of aggression or other breaches of peace (Simma 1995). The UN is today comprised of 193 member nations with South Sudan being the last country to join in 2011 (Blanchfield and Browne 2014). The UN has six main organs all of which were established in 1945 when the organization was formed. These six organs are the General Assembly, Security Council, Economic and Social Council, Trusteeship Council, International Court of Justice, and the UN Secretariat (Simma 1995). Each of these organs plays a unique role to support the UN implement its mandate of safeguarding world peace and promoting friendly relations among countries. The General Assembly leads the deliberative processes within the UN as the main policy-making and representative arm of the organization. Every member state is equally represented in the General Assembly, making it the only UN organ where the voice of every member country is heard (Simma 1995). In addition, the General Assembly has the power to make and terminate appointments of member states to various positions within the UN such as membership to the Security Council. It also provides oversight role in relation to the budget of the UN and collates reports from other organizations working in the UN system (Johnson et al. 2017). Many important global health debates and resolutions are held and passed in the General Assembly. Some of these resolutions are passed with a simple majority vote while others considered to be critical by members must be passed with a two-thirds majority (Joyner 1981). It is worth noting that resolutions passed by the General Assembly are not binding upon UN member states. Thus, the General Assembly functions by and large as a “global town meeting” where vital international issues are discussed and are brought to the attention of the world (Claude and Claude Jr 1971). The Security Council is the principal organ of the UN charged with the responsibility of maintaining global peace and security. It has the authority to accept new members to the UN and can also make changes to the UN Charter (Simma 1995; Berdal 2003). The Security Council has a membership of 15 members – five permanent and 10 appointed non-permanent members. The permanent members include the United States, United Kingdom, France, Russia and China. Unlike

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resolutions of the General Assembly, the resolutions passed by the Security Council are binding and must be complied with by all member states (Weiss 2003). All Security Council resolutions require a positive vote of at least nine members to pass. However, each of the five permanent members retains a veto power and a negative vote by any of them on any resolution is an effective veto (Fasulo 2015). The Economic and Social Council (ESC) coordinates and dialogues on economic, social and environmental policy matters and makes recommendations on implementation of internationally agreed-upon development goals (UN Economic and Social Council 2009). The ESC, under the UN Charter, has the mandate to promote higher standards of living, including identifying solutions to international economic, social and health problems (Rosenthal 2005). The ESC is comprised of 54 member states, 14 specialized agencies of the UN system, and more than 3200 non-governmental organizations (NGOs) partnering with the UN. The ESC is elected by the General Assembly for a term of 3 years (Johnson et al. 2017). The remaining three organs of the UN: the Trusteeship Council, International Court of Justice, and the UN Secretariat are not critical for global health and hence would not be discussed in this Chapter.

UN Specialized Agencies and High-Level Panels In addition to the six organs, the UN works in close collaboration with a number of specialized agencies and affiliated organizations (Fig. 1). These are autonomous international organizations involved in global health that have their own governing bodies, protocols, membership, and funding sources (Blanchfield and Browne 2014). Some of these organizations were directly created by the UN while others were independently established but operate under the umbrella of the UN. The key ones that are vital for global health include the World Health Organization (which is discussed in detail in the next section), World Bank, International Monetary Fund (IMF), United Nations Children’s Fund (UNICEF), the United Nations Development Program (UNDP), Joint United Nations Programme on HIV and AIDS (UNAIDS), United Nations High Commissioner for Refugees and the World Food Program (Volger 2010; Johnson et al. 2017). It is through these specialized agencies and Funds/Programs that the UN plays its global health stewardship role. The next paragraphs provide a brief profile of a selected number of these specialized agencies and their roles in global health. The World Bank has emerged over the last three decades as a significant force in global health. The World Bank was created in 1944, a year before the UN was formed, and begun operations in June 1946 (Ruger 2005). It was primarily formed to support the reconstruction of Europe after the second world war. However, its functions have evolved over time to include poverty alleviation through the provision of low-interest and interest-free loans, credits, grants, and technical assistance to other developing countries destroyed by war and those that are economically stressed such that they are unable to secure credit in the international market (Ruger 2007; Johnson et al. 2017). The World Bank has two main branches; the

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Fig. 1 The United Nations and Specialized Agencies. (Source: United Nations Department of Global Communications 2019)

International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA). The IBRD provides loans and technical assistance to middle-income countries and low-income countries it considers creditworthy. The IDA, which was formed in 1960, provides loans and grants to the poorest countries in the world (Sridhar et al. 2017). Just like its other operations, the World Bank’s role in global health has evolved considerably over the years. With almost no noticeable footprints in the health sector prior to the 1980s, the World Bank is today the largest funder of global health within the UN system and the second largest funder overall. The bank’s health, nutrition and population (HNP) funding grew from around US$1.4 billion in 1985–89 to US$32 billion in 2010–15 (Sridhar et al. 2017). Based on information provided in its 2020 Annual Report, the World Bank has committed to provide up to US$160 billion in the 15 months ending June 30, 2021 to help countries respond to the COVID-19 pandemic (World Bank 2020a). The UNICEF is another UN organization that has a prominent role in global health. Created in 1946 by the UN General Assembly to provide food and health care to children in countries affected by the second world war (Horton 2004), UNICEF today operates in more than 190 countries supporting the provision of life-saving and wellbeing services ranging from immunization to nutrition and child protection services to children and adolescents. In 2019, UNICEF and its partners reached

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307 million children under-five years of age with services to prevent malnutrition (UNICEF 2020). Funding for the organization comes from contributions of UN member states and private donations. Another UN agency that plays an important role in global health is the UNHCR, which focuses on the protection and wellbeing of refugees. The UNHCR was founded in 1950 to help millions of Europeans who fled or lost their homes during and aftermath of the second world war. Today, the organization works in more than 135 countries leading and coordinating international action for the worldwide protection of refugees (UNHCR 2019). Health is central to UNHCR’s work; the 1951 Refugee Convention states that “refugees should enjoy access to health services equivalent to that of the host population, while everyone has the right under international law to the highest standards of physical and mental health” (Fitzpatrick 1996). In collaboration with its partners, the UNHCR supports refugee health by providing services ranging from mental health to maternal and child health in refugee camps. In some countries in West and Central Africa, the UNHCR has been influential in expanding the enrolment of refugees in health insurance schemes by covering the payment of their premiums (UNHCR 2020). Aside from the specialized agencies, the UN has also established or convened several short-term high-level panels on specific global health issues or diseases. Examples include the UN High-Level Panel on Access to Medicines (UNGA 2016a) and the UN High-Level Panel on the Global Response to Health Crises (Kikwete et al. 2016). The UN High-Level Panel on the Global Response to Health Crises (HLP) was formed in 2015 to “propose recommendations that would strengthen national and international systems to prevent and respond effectively to future health crises” (Kikwete et al. 2016). Its establishment was motivated by the Ebola outbreak in West Africa in 2014 and other epidemics of public health concern that preceded Ebola, including the Middle East respiratory syndrome (MERS), the H1N1 and H5N1 influenza pandemics, and the severe acute respiratory syndrome (SARS). These epidemics exposed the weaknesses in the systems including the mechanisms in place for responding to public health emergencies at the country, regional and global levels (UNGA 2016b). The HLP made 27 recommendations and all but five were to be implemented at the international level. Following the establishment of the HLP in 2015, the UN Secretary-General established a Global Health Crises Task Force with a one-year mandate to monitor, coordinate, and support the follow-up and implementation of the recommendations of the HLP (UNGA 2016b). The outbreak of the novel coronavirus SARS-CoV-2 (COVID-19) in late 2019 is a testament of the extent to which the UN and its specialized agencies, especially the WHO, have succeeded in implementing and monitoring the recommendations of the HLP.

UN and Global Health Governance While the maintenance of world peace and security was the main reason for the creation of the UN, good health was recognized at the outset as something that should be promoted across nations. The UN Charter (Article 13) includes the

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promotion of international cooperation in health as part of the responsibilities of the Economic and Social Council, and Article 55 mandates the UN to promote solutions to international health problems (Simma 1995). The centrality of health to the achievement of UN’s mission of maintaining global peace and security became entrenched in 1948 when health was recognized as a basic human right in the Universal Declaration of Human Rights (UDHR). Article 25 of the UDHR 1948 states unequivocally that “everyone has the right to a standard of living adequate for health and wellbeing of himself and his family” (UNGA 1948). Like the UN Charter, the UDHR highlights the need to promote human health through international cooperation. To operationalize the health mandate of the UN, the WHO was created in 1948 as a specialized UN agency responsible for global public health (Grad 2002). The WHO formally came into being when 26 member states of the UN rectified its constitution at the first World Health Assembly in Geneva, Switzerland in 1948 (Brown et al. 2006). The inclusion of the right to health in the UDHR and formation of the WHO in the same year defined the stewardship role of the UN in global health.

The Role of WHO The primary goal of the WHO as stated in its constitution, is the “attainment by all peoples of the highest possible level of health” (WHO 2020d). The preamble of the constitution defines health as “complete physical, mental and social well-being, not merely negatively as the absence of disease or infirmity” (Grad 2002). To achieve its objectives the WHO undertakes a range of functions specified under Article 2 of the constitution (Box 1). Collectively, the 22 functions underscore the preeminent role of the WHO as a coordinating authority and leading voice in global health. They also indirectly place the WHO in the center of global diplomacy as it needs the full cooperation of all member countries to achieve its goal. The preamble of the constitution implicitly enjoins the WHO to advance cooperation among governments and take measures to improve the health of all the peoples whose governments subscribe to its constitution. In the same token, WHO members states are to advance the health of their own populations and support WHO’s cooperative efforts to improve the health and wellbeing of all the people in the world (WHO 1995; Grad 2002). WHO member states are divided into six regions – African Region, Region of the Americas, South-East Asia Region, European Region, Eastern Mediterranean Region, and Western Pacific Region (WHO 2016a). Over the years, the WHO has taken practical steps in the areas of health policy-making, research, health education initiatives, and disease surveillance, monitoring and intervention to stop the spread of infectious diseases and reduce the burden of noncommunicable diseases (NCDs) (Johnson et al. 2017). As an intergovernmental organization, the WHO is accountable to 194 member states. It receives funding from these member states in the form of annual dues, which is based on each country’s wealth status and population (WHO 2016a). In addition, the Organization (WHO) is also financed through voluntary contributions

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by member states and partner organizations such as foundations and civil society. Voluntary contributions account for more than a quarter of WHO total funding. Contributions from the private sector account for less than 1% of the total budget of the WHO and are usually in the form of in-kind donations (WHO 2016a). A recent investment case put forward by WHO reveals that the Organization would need about US$14.1 billion over a 5-year period from 2019–2023 to implement its general program of work (WHO 2018b). The United States has been the largest funder of the WHO, contributing about 15% of total WHO budget in 2018–2019. Other major funders include the United Kingdom and the Bill and Melinda Gates Foundation (WHO 2020d). Since its creation in 1948, the WHO has been regarded by many as the custodian of global health. However, the Organization’s unquestioned global health leadership status has come under intense scrutiny over the past decade. Some have wondered whether the WHO has what it takes to be the global voice for health in today’s complex and changing geopolitical environment. The achievements and challenges of the WHO are part of the discussions in the final two sections of this Chapter. Box 1 Functions of the WHO as Specified Under Article 2 of the WHO Constitution

In order to achieve its objective, the functions of the Organization shall be: 1. to act as the directing and co-ordinating authority on international health work; 2. to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; 3. to assist Governments, upon request, in strengthening health services; 4. to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; 5. to provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories; 6. to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; 7. to stimulate and advance work to eradicate epidemic, endemic and other diseases; 8. to promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; 9. to promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; 10. to promote co-operation among scientific and professional groups which contribute to the advancement of health; (continued)

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Box 1 (continued)

11. to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective; 12. to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment; 13. to foster activities in the field of mental health, especially those affecting the harmony of human relations; 14. to promote and conduct research in the field of health; 15. to promote improved standards of teaching and training in the health, medical and related professions; 16. to study and report on, in co-operation with other specialized agencies where necessary, administrative and social techniques affecting public health and medical care from preventive and curative points of view, including hospital services and social security; 17. to provide information, counsel and assistance in the field of health; 18. to assist in developing an informed public opinion among all peoples on matters of health; 19. to establish and revise as necessary international nomenclatures of diseases, of causes of death and of public health practices; 20. to standardize diagnostic procedures as necessary; 21. to develop, establish and promote international standards with respect to food, biological, pharmaceutical and similar products; 22. generally, to take all necessary action to attain the objective of the Organization. Source: Constitution of the World Health Organization, Article 2 in WHO Basic Documents, 49th Edition

Key Global Health Initiatives of UN and its Agencies Since its creation 75 years ago the UN has been a strong advocate for health and an active participant in the effort to protect global health. Working directly or indirectly through its specialized agencies (especially the WHO) and numerous partners, the UN has used its unique platform to mobilize global action to tackle some of the key health challenges of our time. The UN’s involvement in global health is based on the recognition that health is the foundation of global peace and security and that there is the need to safeguard human health, particularly the health of the most vulnerable populations. Some of the key UN global health initiatives are discussed below.

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Primary Health Care: Alma Ata 1978 Perhaps the most prominent of all the global health initiatives of the UN and its agencies is Primary Health Care (PHC). Since the landmark Declaration of Alma Ata that gave birth to PHC some 40 years ago, the PHC concept has remained pivotal in the global effort to attain health equity and operationalize the right to better health for all agenda (WHO 1978). PHC emphasizes a society-wide approach to maximizing health and well being by prioritizing people’s needs and preferences. It takes people at the earliest opportunity along the continuum of better health from health promotion and disease prevention to treatment, rehabilitation and palliative care, and it does so in the closest proximity possible to where people reside and work (WHO 2018d). Underpinning the PHC concept are the principles of social justice, equity and participation. These principles are germane to the objective of the WHO as enshrined in its constitution – “the attainment of the highest possible level of health by all people” (WHO 1995). They also reflect the proclamation of health as a “fundamental right of every human being without distinction” as stipulated by Article 25 of the Universal Declaration on Human Rights (see page 6 of this chapter) (UNGA 1948). The Alma Ata PHC conference was jointly organized by the WHO and UNICEF and the resultant declaration (Alma Ata Declaration) was endorsed by 134 WHO member states and a host of multilateral and bilateral agencies and NGOs. They all affirmed their commitment to the basic ideals of health as a human right and committed to protecting and promoting human health worldwide (WHO 1978; Gillam 2008; Kluge et al. 2018). The Alma Ata Declaration provided a much broader scope for examining health care that goes beyond doctors and hospitals to incorporate social, economic and political determinants of health. The conference acknowledged that good health is not only the result of good medical treatment but also of factors such as access to services, education, social and economic status, and political and individual choices (Cueto 2004). These determinants of health that are outside the health sector were noted as contributing to large inequalities in health and without addressing them it will be difficult to move people towards that state of “complete physical, mental and social wellbeing” envisioned by the WHO (2008a). The declaration classified PHC as essential health care that should be made universally accessible to individuals and families in the community through engagement and participation at an affordable cost (Rifkin 2009). It conceptualized PHC as an integral part of a country’s national health system, the first level of contact where no referral from a “gatekeeper” provider is required (WHO 1978). Box 2 provides a summary of the Alma Ata Declaration. Box 2 Summary of Alma Ata Declaration on PHC

The Conference reaffirm that: 1. health is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity 2. health is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal (continued)

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Box 2 (continued)

3. realisation of the highest possible level of health requires the action of many other social and economic sectors in addition to the health sector 4. existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable 5. people have a right and duty to participate individually and collectively in the planning and implementation of their health care 6. PHC is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community 7. PHC forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community 8. PHC is the first level of contact of individuals, the family, and community with the national health system, bringing health care as close as possible to where people live and work 9. an acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of resources 10. a genuine policy of independence, peace, and disarmament could and should release additional resources that could be devoted to peaceful aims, in particular, to the acceleration of social and economic development of which PHC, as an essential part, should be allotted its proper share. Source: WHO (1978). Declaration of Alma Ata. International Conference on Primary Health Care. Kazakhstan, USSR

Following Alma Ata PHC became the core of health policy in WHO member countries, and many of them embarked on reforms to align their health systems with the goal of PHC (Bhutta et al. 2018). However, the enthusiasm to implement the PHC concept at the country level did not last long as serious implementation challenges were encountered. These included inadequate investment, confusion over how to operationalize the PHC concept, and continued preference for acute (hospital) care over PHC (Exworthy 2008). The poor resourcing of PHC, both in terms of funding and human resources, was and is still a major obstacle to fulfilling the goals of Alma Ata. The 1980s when PHC was on top of the global health policy agenda coincided with neoliberal economic and development policies promulgated by global financial institutions, notably the World Bank and International Monetary Fund (IMF). The Structural Adjustment Programme (SAP) which was implemented widely in LMICs, particularly in sub-Saharan Africa, had a devastating impact on the social sector and rendered many countries incapable of funding social services including health care (Thomson et al. 2017). Under the SAP, countries borrowing money from the IMF and the World Bank were required to privatize and deregulate

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their economies, including reducing social sector spending (Keshavjee 2014; Kentikelenis et al. 2020). These market-driven neoliberal policies seriously undermined PHC delivery in LMICs, especially in terms of expanding access to quality and affordable services and maintaining sufficient number of skilled workforce. The inadequate funding necessitated cost recovery through the introduction of user fees in the health sector (Gilson 1997; Jacobs and Price 2004). In addition to the poor funding, there were conceptual issues around what PHC encompasses and how to operationalize it on the ground. Although the Alma Ata Declaration was universally hailed as visionary, there was no realistic plan for translating the laudable goals into meaningful actions and results (Bhutta et al. 2018). This led to fragmented and weak implementation of PHC in many countries. For example, a debate ensued not long after Alma Ata about whether PHC would be better achieved by focusing on a narrow set of high impact and cost-effective interventions or whether to adopt a comprehensive approach focusing on a wide variety of services (Walsh and Warren 1979; Bhutta et al. 2018). The selective interventions approach which was largely propagated by the World Bank and other funding agencies, became the most favored approach. Both the 1993 World Development Report “Investing in Health” by the World Bank and the 2000 World Health Report by the WHO gave some credence to the selective interventions perspective (World Bank 1993; WHO 2000). Overall, the lack of standard implementation protocol contributed significantly to the limited achievement of PHC in the last 40 years. Furthermore, the dominance of biomedical model of health care undermined the PHC concept. The overwhelming preference for acute care at the expense of PHC did not change with the Alma Ata Declaration. Many countries continued to allocate significant shares of their government health budgets to hospital-based services despite embracing the PHC concept (Castro-Leal et al. 2000) and that has continued till today. Only half of government health spending in LMICs is currently allocated to PHC services (Stenberg et al. 2019). After 40 years of underdevelopment of PHC in many countries, the adoption of the Sustainable Development Goals (SDGs, discussed in detail below) in 2015 provided new impetus to push the better health for all agenda as envisaged in Alma Ata (The Lancet 2018). The WHO and member states met in Astana, Kazakhstan in October 2018 to renew the 1978 Alma Ata commitment (WHO and UNICEF 2018). The aim of the Astana conference was to renew political commitment from WHO member states and global organizations to develop people-centered PHC, building on the principles of the Alma-Ata Declaration (The Lancet 2018). The new comprehensive PHC for all, labelled the Astana Declaration, was adopted by 2000 delegates from more than 120 countries. The declaration affirmed the “commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind” reiterating the core principles of the Alma-Ata Declaration (WHO 2018a). It recognized that achieving healthy lives and wellbeing has been challenging for many people, particularly the poor and vulnerable, and echoed the urgent need to address the persisting inequities in health and health outcomes (WHO and UNICEF 2018). It emphasized the increasing importance of noncommunicable

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diseases especially mental health, injuries and the health impacts of climate change as determinants of health (Rifkin 2018).

Millennium Development Goals (MDGs) The Millennium Development Goals (MDGs), adopted by the UN General Assembly 22 years after Alma Ata, was another ground-breaking global health initiative of the UN. The Millennium Declaration was endorsed by 189 UN member states and 149 international leaders who attended the global millennium summit in New York in September 2000 (UNGA 2000). The MDGs was lauded as the most comprehensive development goals the world has ever set and committed UN member states to tackling the problem of extreme poverty, hunger, maternal and child mortality, communicable disease, education, gender inequality, environmental damage and the global partnership for development (UN 2000, 2002). The eight interrelated development goals agreed upon had measurable fixed-term targets which were to be achieved by 2015 and through the establishment of strong global partnership and solidarity (Travis et al. 2004). The first of the eight goals sought to eradicate extreme poverty and hunger by halving the proportion of people with an income of less than $1 a day and halving the numbers of people who suffer from hunger. The second goal aimed to achieve universal primary education by ensuring full primary schooling for boys and girls alike. Third goal focused on promoting gender equality and empower women while the fourth was to reduce child mortality through ensuring reduction of under-five mortality by two-thirds. The fifth goal targeted improving maternal health through reduction of maternal mortality ratio by three-quarters. Goal six focused on combatting HIV/AIDs, malaria and other diseases whereas the seventh goal aimed to ensure environmental sustainability through integration of sustainable development. This goal was to halve the proportion of poor people without sustainable development, sustainable access to safe drinking water and sanitation and aimed to achieve significant improvement in the lives of at least 100 million slumdwellers. The final goal was to develop a global partnership for development (UN 2015; WHO 2015c). Health was central to the MDGs, representing three of the eight goals: reducing child mortality (goal 4), improving maternal health (goal 5), and combating HIV/ AIDS, malaria, and other diseases (goal 6). The health-related goals were seen as contributing to the attainment of all the other goals, especially those concerning eradication of extreme poverty and hunger, education and gender equality (Chan 2007). However, this was not a one-way traffic with only the health MDGs influencing the other goals, the reverse was also true. For example, better health enables children to learn and adults to contribute to economic development (Hahn and Truman 2015). On the other hand, gender equality is an essential ingredient to achieving better health outcomes, while reducing poverty, hunger and environmental degradation positively influences health and wellbeing (WHO 2000, 2005). For both developed and developing countries, there is consensus that the MDGs engendered a

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united front in addressing health and wellbeing with several determinants of health status benefitting from the millennium declaration (WHO 2015c). Significant progress was made in attaining some of the key MDG targets, though progress was uneven across regions as much as between and within countries. Much of the gains were recorded in the non-health sector, particularly in reducing poverty and hunger and improving access to basic education. Data from monitoring and evaluation studies suggest that more than one billion people were lifted out of extreme poverty. Equity between men and women at the basic and secondary education levels, and access to water also showed clear improvements (De Maeseneer and Twagirumukiza 2010; WHO 2018f). Progress was slow and below expectation with regard to the health-related MDGs. Child mortality for example declined, with under-five mortality rate dropping from 90 to 43 deaths per 1000 live births globally between 1990 and 2015. Similarly, there was a reduction in maternal mortality; global maternal mortality ratio declined by 45% between 1990 and 2015 (WHO 2015c). The progress was, however, not uniform across all regions and countries; Southern Asia, for example, experienced the highest reduction in maternal mortality ratio (MMR) at 64% between 1990 and 2013 whereas in sub-Saharan Africa MMR declined by 49% (WHO 2016b). In countries such as Gambia, Liberia and Nigeria, MMR was above 700 deaths per 100,000 live births in 2015, the year the MDGs came to an end (WHO 2016b). The limited and uneven progress with the health MDGs led to calls for a more integrated approach to addressing social, economic and environmental issues that affect health. Critics of the MDGs contended that achieving all the goals would require fundamental transformation in society, one which transcends macroeconomic, sectoral and institutional models (Kumar et al. 2016). They argued, for example, that moving towards gender equality or improving maternal health will take more than applying just a few technical solutions or replicating lessons learnt elsewhere. To them, it requires governments scaling up investments in health, education, agriculture, water and sanitation, and infrastructure, as well as fostering good governance, equity and social justice (WHO 2015c). It is from this unfinished business of the MDGs that the post-2015 sustainable development goals (discussed below) arose.

Sustainable Development Goals (SDGs) The UN Sustainable Development Goals (SDGs) are another transformative intiative with significant potential for improving global health. The SDGs were launched by the UN General Assembly in September 2015 as part of a broader UN 2030 Agenda for Sustainable Development and was adopted by 193 UN member states and more than 150 world leaders. The Agenda, according to the UN, is a “plan of action for people, planet and prosperity” (UN Economic and Social Council 2020). The SDGs consisted of 17 interconnected goals, 169 time-bound targets, and 232 unique indicators. Unlike the MDGs, the SDGs were meant to be transformative, people-centered universal goals premised on an outcome concept of

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“leaving no one behind” (WHO 2015c). The goals were to be achieved by ensuring that every individual achieves the full package of rights and opportunities to improve their welfare, and they are to be achieved by 2030 – thus, within a 15-year timeframe (WHO 2017a). To guarantee that no one is left behind, explicit and practical steps must be taken to ensure that populations already behind are targeted with interventions and participate in the implementation of the SDGs from the outset (Kumar et al. 2016). Although the SDGs continue the unfinished work on poverty eradication from the MDGs era, they reflect a more holistic approach to international development and sustenance of human life on this planet (Woodbridge and Zimmermann 2015). One feature of the SDGs that distinguishes them from the MDGs is their applicability to all countries – rich and poor; they were not crafted to generate action only in developing countries like the MDGs (UNGA 2015). This was achieved through broad consultations and inclusion of a range of stakeholders in the process of developing the goals (Kickbusch and Brindley 2013). Overall, the SDGs have visible and robust health goals supported by measurable indicators (WHO 2015c). Although the SDG 3 – ensuring health and wellbeing for all at all ages – is the main health goal, 12 of the 17 goals, 33 targets, and 57 indicators have been identified as health-related; meaning they are connected to health outcomes, health services, and well-established environmental, occupational, behavioral, and metabolic risks (Asma et al. 2020). The health SDG (goal 3) is itself underpinned by 13 targets, one of which is target 3.8 which calls on nations to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” (WHO 2015c). UHC means ensuring that all citizens have access to the health services they need without the risk of financial hardship (Kutzin 2013). It is estimated that at least half of the world’s population do not have access to the essential health services they need, and nearly 100 million people are pushed into extreme poverty every year as a result of paying for health care out-of- pocket (WHO 2019c). The UHC target reflects the maxim of leaving no one behind which underpins the SDGs. Monitoring progress towards the SDGs is critical to ensure that the goals are successfully reached by 2030. However, monitoring progress across the wide variety of goals, targets and indicators that make up the SDGs is not an easy task. The UN Economic and Social Council convenes a high-level political forum on sustainable development to discuss progress made. The 2020 progress report, delivered by the UN Secretary General, suggests that progress continued to be made in certain areas of the SDGs but in other areas progress has either stalled or reversed. For example, the report notes that global poverty has continued to decline, albeit at a slower pace. However the number of people suffering from hunger has been on the rise (UN Economic and Social Council 2020). A similar picture of slow and stagnating progress has been observed with the health SDGs. Prevention and control of noncommunicable diseases, for instance, registered inadequate progress, especially when compared with the advances against communicable diseases (WHO 2020a). The COVID-19 pandemic is expected to stifle progress further and get the world offtrack to achieving the SDGs (UN Economic and Social Council 2020). Overall, the

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SDGs, like the MDGs that preceded it, has strenghtened the indispensable role of the UN in global health.

Major Achievements of UN and its Agencies in Global Health Global health indicators have improved substantially over the last 50 years but how much of this can be credited to the leadership of the UN and its specialized agencies? The improvements in health, which are well-documented, have culminated in a significant decline in mortality and morbidity worldwide. For example, average life expectancy at birth increased from 66.5 years in 2000 to 72 years in 2016 – a rise of 5.5 years over a 16-year period (WHO 2020f). Progress has been particularly strong in low-income countries where there was a 11-year gain in life expectancy between 2000 and 2016 compared to a 3-year increase in high-income countries (WHO 2020f). Reduction in child mortality has been identified as a key factor in the expansion in life expectancy. Neonatal mortality, for instance, declined by 51% from 36.6 deaths per 1000 live births in 1990 to 18.0 deaths per 1000 in 2017 (Hug et al. 2019). Similarly, the proportion of children in low-income countries dying before their fifth birthday (under-five mortality rate) declined significantly from 145 deaths per 1000 live births in 2000 to 68 per 1000 in 2018 (WHO 2020f). These improvements in health did not happen by accident – they are the result of years of concerted efforts to improve health outcomes by the global community led, in many respects, by the UN and its specialized agencies, especially the WHO, working in collaboration with numerous funding agencies, NGOs, academic institutions, and civil society organizations. Some of the main achievements by UN and its agencies are discussed below.

Promoting Responsible Use of Antibiotics The discovery of antibiotics (penicillin) in the first half of the twentieth century marked the beginning of a major transformation in the prevention and treatment of infectious diseases (Adedeji 2016; Hutchings et al. 2019). The antibiotics boom continued through the 1950s and 1970s, signaling a potential end of infectious diseases (Davies 2006). However, the expansion in antibiotics production triggered an increased consumption of the drugs in humans and for nontherapeutic use in animals (growth promotion) (WHO 2018e). This raised concerns about a potential development of resistant bacterial pathogens with negative consequences for prevention and treatment of infections (Davies 2006; WHO 2018e). The high rate of consumption of antibiotics has continued until today and antimicrobial resistance (AMR) has become a major global concern. To put this in perspective, the global consumption of antibiotics increased from 21.1 billion defined daily doses [DDD] (the assumed average maintenance dose per day) in 2000 to 34.8 billion on 2015 – a rise of about 65% (Friedrich 2018). The use of antibiotics in low- and middle-income

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countries in particular has substantially increased, driving the overall rise in consumption globally (Van Boeckel et al. 2014). The WHO has been at the forefront of promoting responsible use of antibiotics since the 1950s (WHO 2016a). The 1996 World Health Report identified AMR as one of the three priority areas requiring attention (WHO 1996). Since then, there have been successive World Health Assembly (WHA) resolutions dealing with AMR (Shallcross and Davies 2014). For example, the WHO Director-General’s report on emerging and other communicable diseases which was discussed at the 51st WHA recognized AMR as a priority area. The report noted, among other things, that the extensive use of antibiotics in food production may further accelerate the development of AMR (WHO 1998). The WHA urged WHO member states to develop sustainable systems to detect AMR pathogens and increase the awareness of AMR in general. It also urged member states to monitor volumes and patterns of use of antimicrobial agents and the impact of measures put in place to tackle the problem (WHO 1998). The WHO, in collaboration with the UN General Assembly and other sister organizations, has continued its mission of promoting responsible use of antibiotics to date. Much recently, at the 68th WHA in 2015, the medical and public health threats posed by antimicrobial resistance was once again recognized, and a global plan of action was adopted (WHO 2017b). The WHO Global Action Plan on Antimicrobial Resistance outlines interventions needed to control AMR, including reducing the unnecessary use of antimicrobials in humans and in animals (WHO 2015b). The Plan was supported by the Food and Agricultural Organization of the United Nations and the World Organization for Animal Health (Laxminarayan et al. 2016). The WHA Resolution 67.25 (WHA67.25) called on the DirectorGeneral to develop a draft global action plan to combat AMR and to report on progress in implementing the resolution (WHO 2015a). Following the 68th WHA, the UN General Assembly convened its first ever High-level Meeting on AMR in September 2016 (PLOS Medicine Editors 2016). Member states adopted a political declaration on AMR which mandated the UN Secretary-General to convene an Ad Hoc Interagency Coordination Group (IACG) on AMR (WHO 2019b). The IACG brought together partners across the UN system, international organizations and individuals with expertise in human, animal and plant health, trade, development, and environmental science to develop a blueprint for the fight against AMR (WHO 2019b). While AMR remains a major threat to public health globally today, the persistent engagement with the issue by the WHO and organizations in the UN system, and the high-level meeting at the UN General Assembly have contributed significantly in focusing attention on the problem and this has motivated increased public funding for AMR research (Kelly et al. 2016).

Eradicating Smallpox and Polio Another major contribution to global public health by the WHO and its partners is the eradication of smallpox in 1979 and the near eradication of poliomyelitis (polio) (WHO 2016a). Smallpox is an acute contagious disease caused by variola virus. The disease is

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believed to have originated some 3000 years ago in India or Egypt (Fenner et al. 1988). Transmitted from person to person mainly via infected aerosols and air droplets that spread through direct contact with an infected person, smallpox is one of the most devastating diseases in human history (Breman et al. 1980). In 1967, the WHO launched a global smallpox eradication campaign which ended in 1979 after an independent committee of experts certified that smallpox has indeed been eradicated. The independent committee of experts’ announcement was ratified by the WHO and a declaration on global eradication of smallpox was adopted at the 33rd WHA in 1980 (WHO 1980). The last documented case of a naturally acquired smallpox occurred in Somalia in 1977 (Moore et al. 2006). The successful eradication of smallpox has been hailed as one of the landmark achievements in global public health of the twentieth century. The WHO celebrated the 40th anniversary of the smallpox eradication in 2019 (Kirby 2020). The smallpox success story was the result of a WHO-led global endeavor that included standardization of vaccines, vaccination technique, laboratory diagnosis, and approaches to outbreak control (Moore et al. 2006). It highlights the effectiveness of WHO leadership in global health at that time. Working with a multitude of partners, WHO officials were involved in difficult multilateral negotiations, and sometimes overseeing the distribution of resources to tackle the contagion, including vaccines, vaccinating kits, funds and personnel (Bhattacharya 2008). Nearly one decade after the smallpox extinction the WHO embarked on another global campaign targeting the eradication of poliomyelitis (polio) (Maurice 2014). Polio is a debilitating and highly infectious viral disease that primarily affects children under five years of age. The poliovirus is spread predominantly through the faecal–oral route, and most cases are asymptomatic or present with non-specific symptoms. About one in 200 polio infections leads to irreversible paralysis and among those paralyzed, 5% to 10% die when their breathing muscles become immobilized (WHO 2019a). The 41st WHA adopted a resolution on worldwide eradication of polio followed by a launch of the Global Polio Eradication Initiative (GPEI) under the leadership of the WHO (Global Polio Eradication Initiative 2019). Since then, the WHO has been working with national governments, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF. Other key partners including the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance have joined the campaign (Cochi et al. 2016). Through the GPEI, polio is today over 99% eradicated worldwide, with the WHO regions of the Americas, European, and South-East Asia all certified as poliofree (WHO 2016a). Global cases of wild polio have dropped from an estimated 350,000 cases in 1988 to 22 cases in 2017 (Cochi et al. 2016; Global Polio Eradication Initiative 2019). Few countries, including Pakistan, Afghanistan, Nigeria and more recently Papua New Guinea, have recorded polio outbreaks in the last 3 years (Hall et al. 2013; WHO 2020f).

Fighting HIV/AIDS, Tuberculosis and Malaria The UN has been instrumental in combating communicable diseases, most notably HIV/AIDS, tuberculosis (TB) and malaria. HIV/AIDS has been one of the most

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challenging global health problems in the last half century. Since its emergence on the health scene in 1981, HIV/AIDS has grown from few isolated cases to become a global pandemic reaching every corner of the planet (Fauci and Folkers 2009). Nearly 40 years after its discovery it still has no cure, and until recently it was one of the leading causes of mortality and morbidity in the world, especially in sub-Saharan Africa. The number of people living with HIV globally increased from 24 million in 2000 to 38 million in 2019. However, AIDS-related deaths declined from 1.4 million to 690,000 over the same period (UNAIDS 2020). This marked improvements in HIV mortality has been attributed largely to the availability and accessibility of treatment (WHO et al. 2011). Around 25.4 million people living with HIV (67%) in 2019 were accessing antiretroviral therapy (UNAIDS 2020). This is where the role of the UN and its specialized agencies has been particularly prominent. The establishment of UNAIDS by the UN Economic and Social Council in 1994, and subsequent recognition of the disease as a threat to global security by the Security Council in January 2000 brought HIV/AIDS to the top of the global health agenda (McCracken and Phillips 2017). These initiatives of the UN helped to galvanize the global community into action, and in 2001 the UN General Assembly Special Session on HIV/AIDS in its Declaration of Commitment stated that “the global HIV/AIDS epidemic is a global emergency and one of the most formidable challenges to human life and dignity, as well as to the effective enjoyment of human rights” (Kickbusch 2011). More recently in 2016, the UN General Assembly made a political declaration to end AIDS by 2030, and endorsed the UNAIDS’ fasttrack approach to tackling HIV (UNAIDS 2014; UNGA 2016c). This declaration resolutely categorized AIDS as “a paramount health, development, human rights and social challenge” (Poku 2016; UNGA 2016c). In addition to HIV/AIDS the UN, through the WHO, has contributed significantly to the global fight against TB and malaria. Tuberculosis kills more than one million people every year, mostly in LMICs (Kyu et al. 2018). In 2015 there were 10.4 million new cases of TB worldwide, including more than 9500 cases in the United States (National Academies of Sciences and Medicine 2017; Sahu et al. 2020). TB became a top global health issue after WHO declared it a global emergency in 1993. This followed a period of a lukewarm approach to TB control in the 1970s and 1980s which led the resurgence of the disease in the 1990s (Ogden et al. 2003). The WHO, after declaring TB a global emergency, developed the Directly Observed Therapy (DOT) which calls for TB patients to complete the course of treatment under direct observation of a treatment supporter who is trained and overseen by health services to ensure that patients take their drugs as scheduled (WHO 1999; McLaren et al. 2016). The 67th World Health Assembly in 2014 adopted the global strategy and targets for TB prevention, care and control designed by WHO. This global TB strategy (dubbed ‘End TB Strategy’) had a vision to rid the world of TB; thus to achieve zero TB-related deaths, disease, and suffering (Uplekar et al. 2015). In 2018 the UN General Assembly made a political declaration which marked a turning point in the global campaign to end TB. This involved setting a range of new targets including diagnosing and treating an additional 40 million people with TB by 2022, generating US$13 billion per year for TB care and prevention, and raising US$2 billion per year for research and development (Sahu et al. 2020).

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Malaria is another global health concern that the UN and its agencies have played a critical role in combating. Although still a life-threatening disease, malaria mortality worldwide has been declining – from 585,000 in 2010 to 405,000 in 2018 (WHO 2019d). Nevertheless, malaria still causes a lot of suffering in LMICs, especially in sub-Saharan Africa. In 2001 the UN General Assembly adopted resolution 59/256 - “2001–2010: Decade to Roll Back Malaria in Developing Countries, particularly in Africa” (UNGA 2008). This resolution reaffirmed UN’s commitment to fight not only malaria but also TB and HIV/AIDS. Through this UN initiative the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), a new partnership and funding mechanism based initially within the WHO, was created in collaboration with other UN agencies and major donors (WHO 2016a). In 2007, the GFATM reported that ‘its programs had treated nearly 3 million TB patients, distributed more than 30 million insecticide-treated bed-nets, and were providing antiretroviral drugs to more than 1 million people infected with HIV (McCarthy 2007).

Preventing and Controlling Noncommunicable Diseases Noncommunicable diseases (NCDs) are the leading cause of death and a growing concern worldwide. According to the WHO 41 million people die from NCDs in 2016 (nearly 71% of all deaths globally), mainly from heart attacks, stroke, cancer, chronic respiratory diseases, diabetes or a mental disorder (WHO 2020b). Over 15 million of these deaths occurred prematurely between the ages of 30 and 70 years and could have been prevented. Low- and middle- income countries continue to experience a steady rise in NCDs. In 2016, about 78% of all global deaths from NCDs, and 85% of premature adult NCD deaths occurred in LMICs (WHO 2018c). There is evidence that a significant proportion of the NCD morbidity and mortality can be prevented or their onset delayed through lifestyle modifications (Lachat et al. 2013). The determinants of NCD, just like those of other health conditions, include individual and societal level factors as well as the general socioeconomic, cultural and environmental conditions (Marmot and Bell 2019). Prior to 2010, NCDs were not widely recognized as a barrier to development in the same way as HIV/AIDS, TB and malaria, and hence, were not included in the MDGs (WHO 2017a). However, the WHO was working with countries to gather standardized data on the burden of NCDs using its STEPwise approach. It is the insights from these earlier works that elevated NCDs to the fore of the global health and development agenda (WHO 2017a). In 2011, the UN General Assembly held a high-level meeting on NCDs in Moscow and adopted a political declaration (the Moscow Declaration on NCDs). The declaration acknowledged the threat of NCDs as constituting one of the major challenges for development in the twenty-first century, undermining social and economic progress throughout the world, and made WHO the principal agency for leading the global response (UNGA 2011). A year after the UN General Assembly declaration, WHO member states for the first time set global targets to prevent and control NCDs in the WHO Global Action Plan

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for the Prevention and Control of Noncommunicable Diseases 2013–2020. The Plan provided a roadmap and a range of options necessary for taking coordinated and coherent action to attain the targets. A comprehensive global framework was adopted at the 2013 WHA to monitor progress towards achieving the set targets (WHO 2013). The UN reaffirmed its commitment to NCDs prevention and control in the SDGs- target 3.4 that seeks to reduce premature mortality from NCDs by one third [relative to 2015 levels] by 2030 (UNGA 2015; Bennett et al. 2018). Despite the strong commitment to NCDs prevention and control globally and the availability of proven interventions, progress has been slow and unevenly distributed, and this prompted a third UN General Assembly high-level meeting in 2018. The meeting undertook a comprehensive review of the challenges and opportunities in the implementation of existing commitments to prevent and control NCDs among other things. It reaffirmed the political commitment to accelerate the implementation of the 2011 declaration and the 2014 outcome document of the previous high-level meetings of the General Assembly on the prevention and control of NCDs (UNGA 2018). While NCDs continue to be the leading cause of death globally, there is no doubt that the actions taken by UN and the WHO in conjunction with other agencies in the UN system have gone a long way to elevate NCDs to the top of the global health and development agenda and created increased awareness that could be the foundation for a successful prevention and control of NCDs.

Challenges in Protecting Global Health The UN General Assembly has labelled the 2020s “the decade of action” and called for accelerating sustainable solutions to the world’s biggest challenges, which include global health challenges (UN 2020). The WHO has also released a list of what it calls “urgent global health challenges” identifying 13 key health priorities that warrant attention in the next decade. They range from challenges pose by climate change to access to treatments, epidemic preparedness, and under-investment in health workers, among others (WHO 2020c). This section discusses three key challenges – growing health inequities, rising threat of epidemics, and fragile health systems. These challenges have the potential to undermine efforts to protect global health in the years ahead.

Growing Inequities in Health Despite the marked improvements in health, inequities within and between countries and regions persist, and are getting worse in some places (Friel and Marmot 2011). A recent Lancet Editorial on taking urgent action on health inequities noted that in England “inequalities in life expectancy have widened and life expectancy has fallen in the most deprived communities” (The Lancet 2020). England is not unique in this situation; many countries – rich and poor – are struggling to address inequities in health. In Australia, life expectancy for indigenous Australians is almost 10 years

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lower than that of non-indigenous Australians (AIHW 2020). At the global level, there is significant gap in life expectancy between high and low-income countries. In the OECD, for example, life expectancy at birth averaged 80.4 years in 2018 compared to 61.3 years in sub-Saharan Africa (UNDP 2019). Inequities in health are more pronounced in LMICs than high-income countries. A child born in subSaharan Africa is 14 times more likely to die before the age of five (CSDH 2008). Inequity in access and utilization of health services by socioeconomic groups are particularly common. About half of the world’s 7.3 billion people do not receive the health services they need (WHO 2015c). The UN has taken steps to address global health inequalities through the SDGs. The SDG target 3.8 calls on nations to “achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” While UHC is a laudable goal, achieving it by 2030 is certainly not an easy task. Recent progress monitoring studies suggest some improvements have been made in key areas such as child mortality, but overall progress towards UHC has been slower than anticipated and vary significantly across countries (Wagstaff and Neelsen 2020). UHC simply means everybody, regardless of their ability to pay, gets the health services they need without suffering undue financial hardship in the process (Kutzin 2013). Financial barriers are a major obstacle to accessing health services. Worldwide, some 100 million people become impoverished every year as a result of paying for health care from their pockets, and a further 1.2 billion, already living in poverty, are pushed deeper into it (WHO and World Bank 2017; Wiseman et al. 2018). Making sure everyone gets the health services they need requires not only significant additional funding for the health sector but also a well-functioning health financing system that distributes the burden of paying for health care according to ability-topay, and ensures health care benefits are shared on the basis of need (Mills et al. 2012; Asante et al. 2017). A looming challenge for global health in the next decade is how to sustainably raise additional funding for health and ensure it is allocated and used efficiently.

Rising Threat of Epidemics New and resurging infectious diseases are breaking out with increasing scale, duration, and effect, posing a significant threat to humanity (Lee et al. 2020). The recent outbreaks of diseases such as Ebola, Zika, Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), and the ongoing coronavirus pandemic (COVID-19) underscore the magnitude of the threat from infectious diseases (World Bank 2017). Apart from their health impact, these epidemics have also demonstrated their capacity to destroy national, regional and global economies. A World Bank baseline forecast estimates a 5.2% contraction in global gross domestic product (GDP) in 2020 as a result of the COVID-19 pandemic – the deepest global recession in eight decades (World Bank 2020b). These epidemics, particularly COVID-19, have raised questions about the capacity of the current

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global health architecture to deal with disease outbreaks (Bloom and Cadarette 2019). In general, preparing for the threat of epidemics is a national affair and depends largely on how each country perceives the risk of a disease, however it requires global leadership. The WHO, as the directing and coordinating authority for health within the UN system, is expected to provide such leadership (WHO 2009). In 1996, the WHO introduced the International Health Regulations (IHR) aiming to prevent the spread of specific diseases between countries. The IHR outlines preparedness measures at international borders to stop the spread of diseases (WHO 1997; Lee et al. 2020). The IHR was revised in 2005 to reflect the changing landscape of infectious disease outbreaks, and urge countries to develop preparedness capacities to detect and respond to outbreaks where and when they occur (WHO 2008b). The effectiveness of the IHR and the current global health system in preventing the spread of epidemics across national borders is coming under growing scrutiny following the COVID-19 pandemic five years after the Ebola outbreak in West Africa (Lee 2016). The rate of emergence of infectious diseases appears to be accelerating and suggest the world is not adequately prepared for these epidemic as several leading scientists had warned long before Ebola and COVID-19 (Sansom 2017; Piot et al. 2019). The COVID situation in countries with advanced health systems such as United States lends some credence to such assertion (Bearman et al. 2020). Emerging epidemics will remain a challenge in the years ahead and it is imperative that appropriate measures are put in place to strengthen the global preparedness to deal with these challenges. Strengthening WHO’s leadership capacity should be the starting point but countries need to invest more in pandemic preparedness and should see it as a national priority.

Fragile Health Systems Another challenge in protecting global health is the fragility of health systems, especially in LMICs. Fragile health systems are those that get easily overwhelmed during public health emergencies as they are unable to maintain core functions needed to respond effectively to crises (Nuzzo et al. 2019). The Ebola outbreak and COVID-19 pandemic have exposed not just how fragile health systems around the world are but also the economic and social costs of having such a health system. The weakness of health systems, especially in resource-poor settings, was wellknown before Ebola and COVID-19. The WHO devoted its entire 2000 World Health Report to health systems and the need to improve their performance (WHO 2000). The WHO in 2007 proposed the health systems building block framework for strengthening key components of health systems – service delivery, workforce, health information systems, access to medicines, financing, and leadership and governance (WHO 2007, 2010). Much of the efforts to improve health systems performance to date has focused on LMICs, especially in sub-Saharan Africa. However, the COVID-19 pandemic has revealed that even of the so-called advanced

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health systems in Western Europe and North America, have their weaknesses. The number of health workers who have been infected by COVID-19 and since died from the disease in these countries illustrates the fragility of health systems in these locations. The rate of COVID-19 infection among health workers in Italy and Spain stood at 9% and 14% respectively in the early months of the pandemic (Nava et al. 2020). Amnesty International reported in May 2020 that more than 3000 health workers have died from COVID-19 across 79 countries (Amnesty International 2020, McCauley and Hayes 2020). Lack of personal protective equipment (PPE) in many countries has been a major contributor to the high infection and death toll among health workers. Across the 79 countries surveyed by Amnesty International, shortages of PPE for front-line health workers such as nurses were reported in 63 of them (Amnesty International 2020). Other systemic issues such as inadequate financing, insufficient number of skilled health workers, and poor access to essential medicines are entrenched in many health systems. Protecting global health into the future requires intensifying efforts to address health systems’ performance gaps, especially in poor countries. WHO and World Bank, together with other organizations, have been supporting global efforts to improve health systems, particularly in LMICs. Rich countries need to do their own soul searching about how to strengthen their health systems post-COVID.

Conclusion Global health is about improving health and achieving equity in health for all people, regardless of where they live, at least, if we accept Koplan and colleagues’ definition. Achieving this goal requires international cooperation and action, and there is no organization better placed to lead this effort than the UN. The UN has the ears of 194 heads of states and the biggest platform to debate and bring attention to pertinent global health issues. Since its creation some 75 years ago, the UN through its specialized agency for health, the WHO, has provided leadership on key global health matters – from PHC, through combating infectious diseases, to universal health coverage. However, UN’s leadership in global health is increasingly being challenged, with the WHO, the directing and coordinating authority for health within the UN system, seen by many as ineffective. Among the recent criticisms levelled against the Organization is its handling of the Ebola outbreak in West Africa (Gostin and Friedman 2014) and the on-going COVID-19 pandemic (Lee 2020). As many players enter the global health space, the challenge to WHO’s leadership will only intensify and the criticisms will grow louder until the Organization changes the way it does business and re-asserts itself as the natural custodian of global health. These will not be easy to do in today’s complex and rapidly changing geopolitical environment. With China fast becoming a global super-power and stepping up its role in the global health field, and the United States – the biggest funder of WHO – appears to be growing wary of multilateralism (at least going by the pronouncements of the Trump Administration), the WHO has a difficult task ahead, especially in terms of raising additional funds to implement its activities. Globalization and free trade

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tensions between the United States and China in the non-health sector could easily play out in the global health space. The accusations of the WHO for its handling of the COVID-19 outbreak by the Trump Administration and some governments and threats to suspend US funding for the Organization by President Trump highlight the complex geopolitical environment in which the WHO operates and the need for the Organization to tread more cautiously. This requires not only technical expertise in health and disease prevention but also strong diplomatic and fund raising skills. It worth noting, however, that the WHO can only perform its roles as a global health steward effectively if constraints on its finances are loosened and funding for the Organization is enhanced. It is clear, looking at WHO’s annual budget, that the Organization’s funding does not commensurate with the responsibilities entrusted to it. Gostin and Friedman (2014) observed that WHO’s operating budget is just about one-third of the US Centers for Disease Control and Prevention’s budget, and that funding shortfall has occasionally forced the Organization to scale back its operations and reduced staff numbers. Expecting the WHO and its UN sister agencies to live up to our expectations without bearing our fair share of the financing burden of these organizations is in itself not playing fair.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Who Is WHO? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Governing Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secretariat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Member States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO’s Predecessors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Creation of WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The WHO Constitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regional Arrangements (Fig. 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Director General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO Priorities, Successes, and Failures over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Political Issues and Controversies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trade and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Geopolitics and Sovereignty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics and Societal Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Horizontal and Vertical Health Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technical or Political Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intellectual Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functioning of WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collaborating and Partnering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The World Health Organization (WHO), the United Nations specialized agency for health, was created on 7 April 1948 as “directing and coordinating authority of international health work.” The WHO consists of its 194 member states and a secretariat with 8000 staff working in its headquarters in Geneva, 6 regional offices, and 150 country offices mostly providing technical assistance to low- and middleincome countries. With its issued norms and standards, the WHO affects all aspects of health, including food, air, water, noise, chemicals, and many other fields the life of every human being as well as the laws and economies of each country. This chapter provides the historical background of WHO, its visionary constitution defining health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, the WHO’s successes such as the eradication of smallpox and its failures, the political challenges WHO has to navigate as well as WHO’s engagement with multiple other organizations and modes of financing. In 2020, the need for a strong WHO has never been more pronounced as evidenced by the global COVID-19 pandemic. Keywords

World Health Organization (WHO) · World Health Assembly · Global Health Governance · Global Health Security

Introduction The World Health Organization was created on 7 April 1948 as the “directing and coordinating authority of international health work” (WHO Constitution 1948, Art. 2a) with the objective of the “attainment by all peoples of the highest possible level of health” (WHO Constitution 1948, Art. 1); defining health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO Constitution 1948, preamble). The COVID-19 pandemic has illustrated this close relationship between physical, mental, and social well-being. While many people are physically infected and affected by the virus, many others suffer mental health and nearly everyone is affected in their social well-being. This very broad and universal mandate, and ambitious objective, has led, throughout the history of WHO, to tremendous successes, as well as a level of frustration that may have arisen due to challenges in meeting very high expectations. While WHO’s founders wished to keep the organization as apolitical as possible, the mandate inevitably puts WHO in the political sphere, as it touches on power, prosperity, equity, trade and economy, security, sovereignty, human rights, societal values on sexuality and life and death, ethics, environment, intellectual property, finances, migration, etc. The desire to keep the organization apolitical is reflected in its name as the world’s health organization. The link to the United Nations is purposely not mentioned in its name. WHO is technical in its nature as initially a

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“doctors organization” working on a scientific evidence base, building on expertise, with its headquarters in Geneva and not New York, and where board members must be “technically qualified in the field of health” (WHO Constitution 1948, Art. 24). WHO also has a very decentralized structure with important decisions taken at the headquarters level but also at the regional and country level. WHO is an intergovernmental organization consisting of 194 member states and is the UN’s specialized agency for health. WHO’s history is a reflection of global politics, ideological tensions, progress, and changing approaches in health and social sciences. Several fault lines and tensions have been present throughout WHO’s history. These existed well before the creation of WHO and will undoubtedly continue into the future. These fault lines include trade and health; geopolitics and sovereignty; health and security; ethics and societal norms; and social science versus natural science and technology. Due to WHO’s history of preexisting regional organizations and the technical need to provide health-related advice at the country level, WHO has the most federalist structure of any UN agency. WHO has achieved a lot throughout its history. Its biggest achievement was the eradication of smallpox in 1980, a disease that killed more people in the twentieth century than all the wars combined in that century. Other major achievements include the international classification of diseases, the model list of essential medicines, the landmark treaties of tobacco control, the control of the international spread of diseases, and, most recently, the Ebola response in the Democratic Republic of the Congo. WHO has also had its failures; from the unsuccessful efforts to eradicate malaria in the 1950s to the initial response to HIV/AIDS in the last decades of the twentieth century, and to the delays and shortcomings in the response to the Ebola virus outbreak in West Africa from 2014 to 2016. Due to WHO’s very ambitious mandate, the expectation from the organization is often unrealistically high, especially in comparison with its budget WHO and its brand are among the best known not-for-profit brands in the world and enjoy a very good reputation, especially in low- and middle-income countries. The critique of the organization comes more from those who are closer to it and who identify more with WHO’s ambitious mandate. WHO thus suffers more from overexpectation than from underperformance. This is understandable when one sees that the name and emblem of WHO stands for a solid evidence base and is a global organization known for proclaiming the scientific truth on health. WHO has a strong convening role, bringing together all relevant actors and the best expertise in the world and being relevant for each and every country of the world. At the same time WHO is a member state governed, owned, and led organization, subject to all the political realities and challenges of its time.

Who Is WHO? The WHO is an organization made up of 194 member states represented through the governing bodies and served by a secretariat. WHO is a specialized agency of the United Nations (WHO Constitution 1948, preamble). Unlike UN programs whose

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heads are appointed by the UN secretary general, specialized agencies have their own constitutions, budgets, and rules, and directly elect their director general. WHO coordinates its work with the UN in accordance to the agreement between the United Nations and the World Health Organization (WHO 2020a, p. 44) and aligns staffing and many other administrative policies very closely with the UN. The work of the Organization shall be carried out by: (a) The World Health Assembly (herein called the Health Assembly); (b) The Executive Board (hereinafter called the Board); (c) The Secretariat. (WHO Constitution 1948, Art. 9)

Governing Bodies The World Health Assembly (WHA) is the highest decision-making body of WHO. It consists of delegates from all 194 member states and determines the policies of the organization, supervises the other bodies, reviews, and approves the multiannual strategy called the General Program of Work and the Biennial program budget, and elects the director general. It adopts resolutions, conventions, regulations, and issues recommendations. The WHA meets annually in the third week of May in Geneva. (Five assemblies were held in other locations: 1949 in Rome, 1954 in Mexico City, 1958 in Minneapolis, 1961 in New Delhi, and 1970 in Boston.) A proposal in 1950 by Denmark, Norway, and Sweden to have only biennial WHAs did not find support. The WHA in 2020 was held virtually in two parts in May and November due to the COVID-19 pandemic. The Executive Board (EB) initially consisted of 18 members. This number increased over time to 24, 30, 31, 32, and finally after the collapse of the Soviet Union and Yugoslavia, to 34 members. Members are designated for a 3-year term selected by the WHA on the recommendation of the regional committees. An informal arrangement is provided to the five permanent members of the UN Security Council (China, France, Soviet Union/Russia, the UK, and the USA) with a quasipermanent seat being reelected within a year. In the European region, this arrangement has been modified over time to a membership for France, Russia, and the UK for 3 years out of 6 (decided by resolution EUR/RC53/R1). Up until 2003, board members would sit behind a name plate carrying their name without the name of their country being mentioned. The board member would speak of “the country I know best.” In 2003 this practice changed and now the name plate indicates the country and EB members (WHO 2003) tend to refer to “we” clearly and explicitly representing their country. Since 2003, all member states are authorized to participate as observers to EB meetings. They have the right to speak and to make proposals after the EB members. To be formally considered, these proposals have to be seconded by an EB member (WHO 2003). This reform has made the EB into a mini health assembly with the good intention of inclusiveness. However, it has also had the consequence of leaving WHO without a more traditional board, one which has the oversight functions, including strategic, open, and frank discussions, with the director general.

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Fig. 1 WHO Governing bodies annual cycle (WHO 2020i)

While the EB had created several permanent subcommittees in the past, in 2004 these subcommittees were merged into a single Program, Budget, and Administration Committee (PBAC) (resolution EB114.R4). The meetings of plenary and committees A and B of the World Health Assembly, the EB, and regional committees are public and broadcasted, while drafting groups and the PBAC are not public (Fig. 1).

Secretariat WHO is often wrongly reduced to its secretariat of 8000 staff members. The secretariat is only the core serving the organization as a whole. The constitution describes its function as follows: The Secretariat shall comprise the Director-General and such technical and administrative staff as the Organization may require (WHO Constitution 1948, Art. 30). The Director-General shall be ex officio Secretary of the Health Assembly, of the Board, of all commissions and committees of the Organization and of conferences convened by it. He may delegate these functions. (Art. 32)

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The director general is the chief technical and administrative officer of the organization. (S)he appoints the secretariat staff in accordance to the staff rules and regulations (Art. 31 and 35) which are very similar to those of the UN. Staff members are international civil servants accountable only to the organization. In practice, staff members have one or more nationalities and while many fully embrace international impartiality, others remain more or less loyal to their country and government. Appointments are merit based but also take into account gender and geographical distribution targets. In reality and especially with respect to senior positions, political pressure plays a role in the appointment decisions or in protecting underperforming staff. Some countries are overrepresented while others are underrepresented compared to a target determined by the size and contribution of each country. The term of office for the director general and the regional directors is 5 years. In 1996 a limitation of two terms was introduced. WHO has six official languages (Arabic, Chinese, English, French, Russian, and Spanish). The Americas and African Regions also have Portuguese, and the European Region has German, as official languages.

Member States WHO member states play multiple roles. They are WHO – its owner and decisionmakers. They have the constitutional rights to participate and vote in the Health Assembly and their regional committee, propose items for the agenda of the Health Assembly, are the main beneficiaries of the work, and they technically advise the organization. By ratifying the constitution and thereby joining the organization, member states have agreed on several obligations, including the payment of their membership fees, called assessed contributions (AC); they are legally bound by the regulations adopted by the WHA unless they explicitly object, and they are politically bound to the recommendations decided through WHA resolutions, reporting to the organization on progress improving health, actions taken and implementation of WHA resolutions, national health laws adopted, statistical and epidemiological reports, and other pertinent information (WHO Constitution 1948, Art. 61–65). Collectively, member states make commitments through resolutions. They are the primary beneficiary of WHO’s work, as WHO implements its policies by advising governments. Member states are also the main funders of the organization. Any sovereign country can join WHO as a member, while the constitution does not foresee the possibility of leaving the organization or being expelled. This reflects the universal nature of WHO as control of epidemics can only work if all parts of the world are covered. The only exception is the USA, which made a reservation when joining, to keep the possibility to leave the organization with a 1 year’s notice. Member states who have not paid their AC may see their voting rights suspended by the Health Assembly (WHO Constitution 1948, Art. 7). In 1948, at the end of the first WHA, there were 55 member states. By 1950, at the end of the second WHA, and after the approval of the agreement between WHO and

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PAHO which took more than 2 years to negotiate, most countries of the Americas joined (Beigbeder 1998). Nine countries of the Soviet block were “nonparticipating” members from 1950 to 1957. China was nonparticipating from 1950 to 1953. The Chinese seat was occupied by the Chiang Kai-Shek government until 1971 and from 1972 by the People’s Republic of China. Many new member states, especially in the African region, joined in the 1960s. The Federal Republic of Germany was admitted in 1951, while the German Democratic Republic was only admitted in 1973 after several rejected applications. From 1964 until 1994, the WHA suspended the voting privilege of South Africa because of apartheid. After the disintegration of the Soviet Union and Yugoslavia, membership increased to 194 member states in 2020. The only sovereign country member of the UN which has not joined WHO is Liechtenstein.

History WHO’s Predecessors To understand both the creation of WHO in 1948, and the current organization, one has to understand the history of global health. The first documented international negotiations in health diplomacy were in 1839. The account is not only remarkable for its language, but also for several similarities and challenges, with which the world is still facing today with the COVID-19 pandemic. The Sultan, moved by the paternal solicitude and humanity which distinguish him, bestows benefits of every kind upon the subjects resting beneath the shade of his scepter of justice. His Highness, desiring to put an end to the terror inspired in his people by the presence of plague, has decreed a quarantine throughout his realms. The adoption of this system is in the general interest, that is to say it will contribute to the well-being of the Ottoman Empire and will preserve its relations with friendly Courts. (. . .) The European powers pointed out that a unilateral application of quarantine measures to their ships arriving in Ottoman ports would be in conflict with certain rights that they enjoyed as a result of earlier treaties. It would therefore be necessary to the government under whose flag a ship sailed to consent to any such measures. Further discussions resulted in the establishment of the Conseil supérieur de Santé de Constantinople, which was composed other ottoman Health Council and delegates of the maritime powers, who together signed on 10 June 1839 the text of an agreement regulating the sanitary control of foreign shipping in Ottoman ports. (WHO 1958)

This Superior Health Council of Constantinople was soon thereafter followed by the Conseil sanitaire de Tanger established in 1840, by the Emperor of Morocco, Egyptian Sanitary, Maritime and Quarantine Board in Alexandria in 1843 and the Conseil sanitaire de Teheran in 1867 (WHO 1958). In Europe, the first International Sanitary Conference was opened in Paris on 23 July 1851. This coincided with the first international exhibition in London, also in 1851, both symbols of the industrial revolution. This also led to increased international travel and trade which contributed to the spread of cholera in Europe (WHO 1958). In 1853 at the first International Statistical Conference in Brussels, Belgium

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recommended the establishment of an international nomenclature of causes of death (WHO 1958). The first sanitary conference lasted 6 months. It was unsuccessful in regulating the handling of cholera, plague, and yellow fever, as the scientific understanding was simply not yet available (WHO 1958). Throughout the second half of the nineteenth century, ten such sanitary conferences were held. The 11th sanitary conference in Paris in 1903 managed to unify four earlier conventions into the International Sanitary Convention which was called “the marriage of diplomacy and medicine” and led to the creation in 1907 of the International Office of Public Health – the Office International d’Hygiene Publique (OIHP) in Paris (WHO 1958). The hygiene organization of the League of Nations was created in 1922 in Geneva. Attempts to merge this new organization with the OIHP failed. During the same period, sanitary conferences in Montevideo in 1873, in Rio de Janeiro, Brazil in 1887, in Lima, Peru in 1888, as well as the first International Conference of American States, in Washington, DC in 1889/1890, ultimately led to the American Republics establishing in 1902 in Washington, DC the International Sanitary Bureau, renamed in 1923 the Pan American Sanitary Bureau, and renamed in 1958 the Pan American Health Organization (PAHO) (PAHO 1999).

The Creation of WHO During the Second World War, in 1943, under the leadership of the USA, the United Nations Relief and Rehabilitation Administration (UNRRA) was created with health as one of its primary responsibilities. In April 1945, the San Francisco Conference brought together 50 allied nations elaborating the United Nations Charter with the idea to rebuild world peace on a firm foundation and confident that science would provide the means to do so (WHO 1958). Brazil submitted a memorandum describing “Medicine is one of the pillars of peace,” leading to the inclusion of health in Art. 55 of the UN Charter as one of the problems to be considered by the United Nations (UN 1945). Later a joint declaration by the delegations of Brazil and China called for the early convocation of a general conference to create a single health organization within the UN. A Technical Preparatory Committee consisting of 16 individual experts met in Paris in March and April of 1946 to consider proposals for a constitution submitted by the members of France, the UK, the USA, and Yugoslavia. This committee submitted a report to the International Health Conference which was convened in New York from 19 June to 22 July 1946 and agreed on the constitution of WHO. It was the first international conference held under the auspices of the UN bringing together all 51 UN member states and 13 other states. Observers included the Food and Agriculture Organization; International Labor Organization; Provisional International Civil Aviation Organization; the United Nations Educational, Scientific, and Cultural Organization; the Office International d’Hygiene Publique; Pan American Sanitary Bureau; United Nations Relief and Rehabilitation Administration; League of Red Cross Societies; World Federation of Trade Unions; and the Rockefeller Foundation. This conference agreed on the constitution of WHO, on a protocol terminating the Rome Agreement of 9 December 1907, on the creation of

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the Interim Commission managing affairs until the creation of WHO in 1948, and on the integration of the functions and assets of the League of Nations Health Organization, the OIHP and UNRRA, as well as the preparation of the First World Health Assembly (WHO 1958). The Interim Commission integrated preexisting technical activities; quarantine and epidemiological services established under the International Sanitary Conventions; the international lists of diseases and causes of death; and biological standardization and the international pharmacopoeia. It further decided that there were certain diseases of sufficient importance to warrant immediate action. These diseases were malaria, tuberculosis, and venereal diseases. Furthermore, field services from UNRRA and several publications (Weekly Epidemiological Record, Epidemiological and Vital Statistics Report, the Bulletin, and Library and Reference Service) were integrated (WHO 1958). Membership of the WHO reached 26 member states on 7 April 1948, which was the minimum number required by the constitution to bring the constitution into force. This number rose to 48 member states by 24 June at the opening of the First World Health Assembly, and to 55 member states by the time the assembly closed 1 month later. This first World Health Assembly established a program, based mainly on the recommendations of the Interim Commission, with the following order of priorities: 1. Malaria, maternal and child health, tuberculosis, venereal diseases, nutrition, and environmental sanitation 2. Public health administration 3. Parasitic diseases 4. Virus diseases 5. Mental health 6. A varied group of other activities (WHO 1958) 7 April is the anniversary of WHO and has therefore become the World Health Day • Headquarter location The selection of the headquarters of the organization was done at the first World Health Assembly in 1948. There was a debate between those favoring proximity with the parent body (the UN in New York), while others stressed the importance of dissociating the organization from political influences that had the fate of the League Health Organization. It was thought that proximity to other specialized agencies which were not likely to be established at the seat of the United Nations would be the best (WHO 1958). The first WHA had to choose between New York, Geneva, and Paris. The ultimate choice of Geneva as the headquarters location brought WHO close to many other international organizations but distinct from the UN’s New York headquarters. Geneva had already become an international city thanks to Henri Dunant, who gathered a group of Geneva businessmen to create the International Committee of the Red Cross (ICRC) in 1865, followed by the Interparliamentary Union in 1889, the League of

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Nations in 1919, the ILO in 1919, and the European headquarters of the UN in 1945. While New York is the political hub of the UN, Geneva is its more technical and social hub.

The WHO Constitution The speed of the development of the WHO Constitution was remarkable. It shows how historic windows of opportunities make all the difference to be able to make progress in diplomacy. The overall spirit was to rebuild a broken world. In several health ministries, in the existing international health organizations and among experts, a lot of pre-thinking had happened which ultimately was able to be brought together. Without strong opposing forces at the table, circumstances allowed for the constitution to be drawn up and agreed upon. The text drawn up then is still visionary today and to some extent it was well ahead of its time. It “built on the European tradition of social medicine in proclaiming a positive and all-encompassing notion of health as both a human right as well as a contributing factor to international peace and security” (Burci 2019). The Preparatory Committee and the International Health Conference had to agree on multiple aspects to be reflected in the constitution: • Name of the organization Different options for the name of the organization were debated. Ultimately the broadest possible formula for the title, World Health Organization, was chosen instead of International Health Organization or United Nations International Health Organization (WHO 1958). The name also reflects the idea that while it is part of the UN system, it is also a universal organization on its own. • Preamble As the preamble is so visionary, and at the core of understanding WHO, and speaks for itself, it is reproduced here: The states parties to this constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations, and security of all peoples: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The enjoyment 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. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and states. The achievement of any state in the promotion and protection of health is of value to all. (continued)

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Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development. The extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health. Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. Accepting these principles, and for the purpose of cooperation among themselves and with others to promote and protect the health of all peoples, the contracting parties agree to the present constitution and hereby establish the World Health Organization as a specialized agency within the terms of Article 57 of the Charter of the United Nations (WHO Constitution 1948).

• Functions Art. 2 continues with a list of 22 paragraphs of functions. This reflects the extremely broad mandate of WHO, which creates the challenge that WHO will never be able to fully satisfy such high expectations. “The powers entrusted to the organization also reflect the ambitions of its founders and a ‘managerial’ vision of global health requiring strong and uniform rules and centralized oversight” (Burci 2019). The most important function is in Art. 2a: “to act as the directing and coordinating authority on international health work” (WHO Constitution 1948). • Normative role WHO was given a very strong normative mandate that to some extent is quasilegislative in nature (WHO 1958). This reflects the vision of a global rather than domestic nature of public health creating a need for uniform standards (Burci 2019). The power to pass conventions in Art. 19 (“hard law”) and make recommendations to member states in Art. 23 (usually as WHA resolutions; “soft law”) are common to most international organizations. WHO can do so in respect to “any matter in its competence.” Art. 21 and 22 give additional authorities, i.e., the ability to pass regulations in five defined areas (prevent the spread of disease, nomenclatures, diagnostic standards, safety standards for products, and advertising and labeling of medical products). A regulation is like a convention binding international law. However, unlike conventions which need an explicit opt in through ratification of each state party, a regulation uses an opt out mechanism where the regulations enter into force automatically after a defined period for all WHO member states except if they notify the director general of their rejection or

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reservations. This power is only given to a limited number of international organizations usually for very technical subjects, such as air traffic security for the International Civil Aviation Organization (ICAO), meteorological procedure for the World Meteorological Organization (WMO), radiocommunication norms for the International Telecommunication Union (ITU), or norms of several fishing organizations (Boisson de Chazournes 2007). WHO has passed two regulations: On 24 July 1948 it adopted World Health Organization Regulations No. 1 regarding nomenclature (including the compilation and publication of statistics) with respect to diseases and causes of death. This nomenclature regulation was revised in 1967 through resolution WHA20.18 into its current form, which provides the basis for the International Classification of Diseases (ICD11), adopted in 2019 through resolution WHA72.15. The International Health Regulations (IHR) was first adopted in 1951 and revised in 1969, 1973, and 1981. These earlier versions were mostly of a technical nature regulating the control of plague, cholera, and yellow fever (Boisson de Chazournes 2007), while the scope of the IHR 2005 became much broader and similar to a major convention. • Universality WHO clearly aims at and has broadly reached universality. Art. 3 describes that the membership is open to all states. Member states of the UN are automatically admitted if they apply, while other states are admitted by simple majority at the WHA (Art.4–6). Art. 8 allows for territories not responsible for their international relations to be admitted as associate members (WHO Constitution 1948). In practice disputes arise when entities are not recognized as independent states, mostly by their neighbors, and therefore not admitted by the WHA. These rules allow for inclusiveness. In addition, the absence from the constitution of any clause of withdrawal of a member or the expulsion of a member should be noted (WHO 1958). Only the USA had submitted a reservation requiring the right to withdraw with 1 year notice provided their contributions have been paid in full (UN 1948). The constitution also treats all member states equally and does not define any differences in board membership, voting rights, or otherwise. This universality which is particularly important with regards to infectious diseases was further reinforced with Art. 3.3 of the International Health Regulations (IHR): “The implementation of these Regulations shall be guided by the goal of their universal application for the protection of all people of the world from the international spread of disease” (WHO 2008b). • Sovereignty/Noninterference in domestic affairs Intergovernmental organizations are based on the collaboration and consent of governments of sovereign states. International organizations tend to respect the noninterference in domestic affairs of states, while the drafting of the WHO Constitution was inspired by the mentioned notion of universality. This balancing can be felt with the first function being the directing and coordinating authority of international health work, while the following functions make the provision of technical assistance subject to the request or acceptance of the government concerned (WHO 1958). The authority to pass regulations however provides some supranational competence to the organization.

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• Cooperative arrangements The importance of cooperative arrangements is reflected in many passages of the constitution. WHO is mandated to cooperate with the UN and its agencies, and with other intergovernmental organizations. It can also cooperate with international and, with the consent of the government, national nongovernmental organizations, as well as with scientific and professional groups. While this mandate is very large, its implementation has often been controversial (see section on “Collaborating and Partnering”). • Reporting Chapter XIV of the constitution establishes a strong system of oversight and accountability by requiring member states to report regularly on a broad range of topics, from national laws, regulations, and statistics to “action taken and progress achieved in improving the health” of their population (Burci 2019). • Regional arrangements The regional arrangement discussed below is also strongly reflected in the constitution, through Art. 44–54 in Section XI. Since amendments to the constitution require a ratification by two-thirds of all member states, usually through a parliamentary process, any fundamental change to it, such as a radical change to the role of regions, is very unlikely to be successful. On the other hand, many reforms have been achieved and are still possible without requiring any wording changes in the constitution.

Regional Arrangements (Fig. 2) At the time of the creation of WHO, regional organizations were already in existence and the relation with them had to be addressed. PAHO had existed since 1902. The office of the Egyptian Quarantine Board was created in 1843 in Alexandria, Egypt. Under the terms of Article 7 of the 1926 International Sanitary Convention, the Egyptian Sanitary, Maritime, and Quarantine Board and its Regional Bureau of Epidemiological Information had acted as a regional bureau of the Office International d’Hygiene Publique in the Eastern Mediterranean area. In 1938 its functions were taken over by the Egyptian Ministry of Health, and in 1946 the countries adhering to the recently established League of Arab States decided that it should again act as a regional bureau, the Pan Arab Regional Health Bureau (WHO 1958). Therefore, arrangements for the relation with and integration of regional organizations had to be worked out at the creation of WHO. This became the most complex question to be resolved during the creation of WHO. While a majority of delegates argued in favor of an absorption of regional bodies to form an integral part of the central organization, others pressed for more flexible provisions allowing for a high degree of autonomy while maintaining a close connection with headquarters. The Interim Commission included both options into the report to the International Conference (WHO 1958). As no full agreement could be found, the following compromised language made its way into Art. 54 of the constitution: “The Pan American Sanitary Organization represented by the Pan American Sanitary Bureau

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and the Pan American Sanitary Conferences, and all other inter-governmental regional health organizations in existence prior to the date of signature of this constitution, shall in due course be integrated with the Organization. This integration shall be effected as soon as practicable through common action based on mutual consent of the competent authorities expressed through the organizations concerned” (WHO Constitution 1948). The functions of the Alexandria Regional Bureau were ultimately integrated within those of the regional organization of WHO by resolution of the Executive Board passed at its third session in 1949. The relationship with PAHO is regulated through the “Agreement between the World Health Organization and the Pan American Health Organization” approved by the second WHA in resolution WHA2.91 (WHO 2020a). This represents a unique status, where PAHO continues to exist as an entirely separate regional organization outside the UN system but serves at the same time as WHO’s regional committee and office for the Americas. This unprecedented arrangement, under which an international organization places itself permanently at the disposal of another organization while continuing to operate as a separate institution, raises delicate questions of attribution and responsibility and has generated much ambiguity in the day-to-day relations between WHO and PAHO (Burci 2019). Opinions differ whether this represents a full integration. The above relationship allows for PAHO to continue to directly elect its director, who, at the same time, acts as WHO regional director for the Americas. This situation caused other regions to demand the same right to select their own regional directors. While initially the regional directors were supposed to be appointed by the director general, under Brazilian Director General Candau a system of direct selection by the respective regions was introduced (Fee et al. 2016). The distribution of countries among the six regions as decided by the first few WHAs reflects geography on the one hand and political fault lines on the other hand and triggered several corrections during WHO’s history. Throughout the history of WHO some countries have changed in their attribution to regions while others have participated in more than one region due to their overseas territories and former colonies. The federalist nature of WHO has remained a particularity and a challenge throughout its history. There are federalist and centralist nations, which show that federalism or centralism are not per se good or bad but part of the history and DNA of an organization, with each approach having its advantages and disadvantages. Most attempts to radically centralize a federalist country or vice versa tend to fail. Therefore, WHO’s question should not be on abolishing its regional structure but how to make it work best. Federalism brings challenges in coordination and coherence especially in situations where command and control are important, while it also brings decisions closer to those affected, is better on cultural diversity and responsiveness to local needs. To reflect the above, WHO’s country offices report primarily to the regional offices with a secondary link to the director general, while the regional emergency directors directly report to both the global executive director for emergencies and to the regional director. The fact that regional directors are selected by the countries of

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their regions makes them accountable to these countries and to the regional committees, while formally reporting to the director general. Subordinating a separately elected official to another elected official inevitably creates tensions, however it also creates incentives for a more inclusive collective leadership style, reflected in the role of the Global Policy Group (GPG), bringing together the director general, deputy director general, and the six regional directors.

Director General Overview: WHO director general over time

1948–1953 1953–1973 1973–1988 1988–1998 1998–2003 2003–2006 2006 2006–2017 Since 2017

George Brock Chisholm (Canada) Marcolino Gomes Candau (Brazil) Halfdan Mahler (Denmark) Hiroshi Nakajima (Japan) Gro Harlem Brundtland (Norway) Lee Jong-wook (Republic of Korea) Anders Nordstrom (Sweden, acting director general) Margaret Chan (People’s Republic of China) Tedros Adhanom Ghebreyesus (Ethiopia)

The person, leadership style, and background of the director general have shaped WHO a lot over time. Dr. Brock Chisholm, a psychiatrist, shaped the constitution by proposing the name of the organization and the definition of health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Dr. Marcolino Candau launched and oversaw the vertical technical programs, both the failed malaria eradication initiative and the hugely successful smallpox eradication. The charismatic strategic leadership of the public health giant Dr. Halfdan Mahler learned in his decade of work on tuberculosis the importance of health determinants and community health services. Dr. Mahler shifted the organization’s approach from vertical programs to horizontal approaches culminating in the Alma Ata Conference on Primary Health Care. Dr. Gro Harlem Brundtland was the first DG who was a former prime minister. This was both an expression of and a further reinforcement of WHO’s highly political role where the interaction with heads of government and other key ministries illustrated that they are as important as the interaction with health ministries. Both Japan with Hiroshi Nakajima and China with Margaret Chan actively reentered the global multilateral stage by having their first major director general positions in WHO. The current Director General Dr. Tedros is the first African DG, and the first DG who is not a medical doctor (though he does have a Master’s in Science and a PhD in community health). Dr. Tedros, as a former health and former foreign minister, brings both the

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technical and the political angle WHO needs to be successful. Dr. Tedros was also the first director general to be elected from multiple candidates by the Health Assembly (previous candidates were confirmed by the WHA after an election by the EB).

WHO Priorities, Successes, and Failures over Time Describing 72 years of priorities, successes and failures of WHO would go well beyond the scope of this chapter. Rather this chapter will provide an overview while illustrating a few highlights. The World Health Assembly, on the proposal of the Executive Board, sets the long-term priorities by adopting a General Program of Work (GPW) “covering a specific period” (WHO Constitution 1948 Art. 28g). In practice these GPWs have varied in duration, format, and importance for the actual work of the organization. • Early years The first priority objectives concerned: malaria, tuberculosis, venereal diseases, mother and child health, and nutrition (Beigbeder 1998). The first large diseasespecific campaign in the early 1950s was on yaws, a crippling and disfiguring bacterial disease. The discovery that it could be cured by a single injection of longlasting penicillin allowed a global campaign which reduced the prevalence from about 50 million to 2.5 million worldwide (WHO 1988). In the 1950s WHO was a pioneer recognizing the health impact of environmental changes (Beigbeder 1998). Initially the majority of WHO staff were European, often with experience in colonial medicine. The recruitment of a few medical experts from developing countries to WHO’s staff was criticized for depleting precarious health systems of valuable individuals. Thus training became a priority. By the early 1950s, WHO had developed and approved a 4-year plan for fellowships, and by 1956 had provided more than 5000 fellowships to health professionals from 149 countries, thus helping to build and/or reconstruct public health systems (Fee et al. 2016). In the 1960s decolonization led to a focus on development and in particular human resources for health with the strengthening of the WHO fellowship program. From 1948 to 1988, 90,000 WHO fellows were trained abroad and returned home (WHO 1988). WHO-led research proved the effectiveness of home-based tuberculosis treatment rather than requiring yearlong hospitalization. In 1958, 60% of the global population was infected by TB with one to two million deaths per year (WHO 1988). “During the 1950s and 1960s, teams of WHO experts had led campaigns against communicable diseases. Their weapons were technical knowledge, drugs and pesticides from the industrialized countries. It was then realized that such campaigns had to be reintegrated into an infrastructure of basic health services” (Beigbeder 1998). In the 1960s WHO promoted mass campaigns against infectious diseases such as endemic syphilis, leprosy, and trachoma, and helped control major cholera outbreaks in Asia, and a large epidemic of yellow fever in Africa (WHO 1988).

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By 1970 WHO was involved in family planning by launching its Expanded Program of Research, Development, and Training in Human Reproduction, which was to focus on fertility regulation and birth control methods (WHO 1988). In 1974, WHO launched its Expanded Program on Immunization, aiming to vaccinate children worldwide against diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis (WHO 1988). • The failure of malaria eradication In 1955 the Health Assembly decided on a program with the ultimate goal to eradicate malaria. Initial progress was achieved with 65 countries having eradication programs in place by 1960, and two-thirds of the world’s population previously exposed to malaria were covered by the program in 1964. However, the program, which was mostly based on insecticide spraying campaigns, started to experience multiple problems ranging from inadequate national health services, development of insecticide resistance, and inadequate community participation to a lack of managerial and financial resources. During that decade 27% of WHO’s budget went into the malaria program. The Health Assembly in 1969 recognized the failure of the campaign. Malaria control and an integration of the vertical program into the health system had to replace the failed eradication program (Beigbeder 1998). • Low tech with high impact In 1971 the Indian pediatrician Dr. Dilip Mahalanabis showed the effectiveness of the oral rehydration solution (ORS), a mixture of water, sugar, salt, and bicarbonate, in the treatment of a major cholera outbreak among refugees of the Bangladesh independence war, which he had to use as there were not enough trained staff and not enough supplies to administer intravenous saline solution. While several medical journals rejected to publish Dr. Mahalanabis’ findings, WHO’s cholera specialist Dr. Dhiman Barua visited the refugee camp and saw the success firsthand. Dr. Barua organized further clinical trials which led to the acceptance of ORS not only for cholera, but as treatment of other forms of severe diarrhea. This was then reflected in the WHO clinical guidelines and formed the basis of a global campaign. It is estimated that over 50 million people owe their lives to the introduction of ORS (WHO 2011b). In 1969 a UN working group observed a decline in breastfeeding. Following this, during the 1970s, there was a fierce controversy between several NGOs and breast milk substitute producers, including a hearing in a US congressional committee chaired by Senator Robert Kennedy. This led to a proposal to entrust WHO with the matter. WHO and UNICEF convened a meeting in October 1979 on Infant and Young Child Feeding, which recommended that WHO should elaborate a code. As the proposal to have this code as a legally binding regulation did not find sufficient support, it was finally adopted as a recommendation. The WHO International Code of Marketing Breastmilk Substitutes was adopted in 1981 by the World Health Assembly (WHA34.22) to promote safe and adequate

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nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes, when these are necessary. • The biggest success: Smallpox eradication Smallpox eradication is the single biggest achievement of WHO and could on its own justify WHO’s existence. Smallpox killed about 300 million persons in the twentieth century alone (WHO 1988). This is more than all persons killed by wars in the twentieth century. In 1958, the USSR proposed a WHO-led smallpox eradication program. WHO’s intensified program for the eradication of smallpox from 1967 to 1977 dominated the third decade of WHO. In 1977, the last confirmed case of smallpox was identified in Somalia. In 1980, the Global Commission for Certification of Smallpox Eradication recommended a halt to routine smallpox vaccination. The smallpox eradication campaign cost the world US$330M. The fact of no longer needing global vaccination and smallbox control saved since then US$1 billion annually (WHO 1988). • Health for all As WHO’s director general from 1973 to 1988, Dr. Halfdan Mahler worked to shift WHO’s focus from targeting single diseases like malaria and tuberculosis, to promoting and implementing primary health care, an approach that focused on education, promoting proper nutrition, providing safe water and basic sanitation, maternal and child health care, immunizations, and access to essential drugs (with the first list of essential medicines published in 1977). As Dr. Mahler said later in an interview: “The goal was not to eradicate all diseases and illnesses by 2000; we knew that would have been impossible. Our goal was to focus world attention on health inequities and on trying to attain an acceptable level of health, equitably distributed throughout the world.” While this faced resistance and backlashes, it became the backbone of the current priority of Universal Health Coverage enshrined in the sustainable development goals (Snyder 2017). The landmark Alma Ata Conference in September 1978 in the midst of the Cold War set the focus on primary health care with the ambitious objective of “Health for all by the year 2000.”

Overview: Declaration of Alma-Ata specifying that primary health care must include at least the following eight components: • Education concerning prevailing health problems and the methods of preventing and controlling them • Promotion of food supply and proper nutrition • An adequate supply of safe water and basic sanitation • Maternal and child health care, including family planning • Immunization against the major infectious diseases (continued)

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• Prevention and control of locally endemic diseases • Appropriate treatment of common diseases and injuries • Provision of essential drugs Equally important, services in all these areas are to be provided “to individuals and families in the community through their full participation in the spirit of self-reliance and self-determination” (WHO 1988). These priorities were then translated as organizational objectives in the sixth GPW for the period 1978–1983 as follows: • • • • • •

Development of comprehensive health services Disease prevention and control Promotion of environmental health Health manpower development Promotion and development of biomedical and health services research Program development and support (WHO 2011a)

• Health promotion Building on Alma Ata and on the developments of society and lifestyle, WHO further embraced what was already foreseen by the constitution describing health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. In 1988 the Ottawa Charter for Health Promotion opened this field. In the 1990s, growing awareness of the threat of “lifestyle” diseases, such as cardiovascular disease, cancer, and diabetes, led WHO to launch programs promoting healthy living and tobacco-free societies. Following the 1992 UN Conference on Environment and Development (the “Earth Summit”) in Rio de Janeiro and its Agenda 21, WHO launched initiatives addressing the health hazards posed to environmental degradation (McCarthy 2002). • Maternal and child health In 1987, WHO launched the Safe Motherhood Initiative, which aimed to reduce maternal morbidity and mortality by 50% by the year 2000. The initiative did not succeed, and maternal health continues to be a major focus of WHO efforts (McCarthy 2002). The challenge of maternal and child health illustrates well that the approach of WHO’s constitution is the right way to go, but difficult to achieve. A purely technical biomedical approach does not work, but strong health systems and work on societal norms and health determinants are needed at the same time. Maternal and child mortality are a tracer indicator of wellfunctioning health systems, and thus became MDG priorities and continue to remain high on the priority list today. • HIV/AIDS First reports of a strange unknown illness started popping up in New York and California in 1981. One year later this illness was named AIDS. Later research

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showed that the origins of this new epidemic started decades earlier. In 1985, soon after the broad onset of the HIV epidemic, WHO organized, together with the US Department on Health and Human Services, the first International AIDS Conference in Atlanta, Georgia. In 1987 WHO launched the Global Program on AIDS led by the dynamic Jonathan Mann with a human rights–oriented approach to health and HIV. In 1990 Mann left in conflict over the orientation of the AIDS program which contributed to WHO losing the leadership on the global AIDS response. This led to the creation of the Joint United Nations Program on HIV/AIDS (UNAIDS) in 1994–1996. By the year 2000 AIDS appeared out of control with 27 million persons living with HIV, 3.1 million persons affected per year and 1.5 million persons dying per year. This crisis led to a Security Council resolution in 2000, a UN General Assembly Special Session in 2001, and the creation of the Global Fund on AIDS, Tuberculosis, and Malaria in 2002. With the three by five initiative in 2003 WHO finally made AIDS one of its top priorities again and contributed, together with UNAIDS, the Global Fund and US President’s Fund for AIDS relief (PEPFAR) and others, towards the start of the decline of this deadly epidemic which remains until now one of the top challenges of global health. • Polio eradication In 1988, WHO formulated an ambitious plan to achieve global eradication of poliomyelitis by 2000. This goal has not yet been met, but efforts continue, with now only two countries, Afghanistan and Pakistan, still having endemic polio. The Global Polio Eradication Initiative is a joint effort of WHO, Rotary, the US CDC, UNICEF, the Bill and Melinda Gates Foundation, and GAVI. The initiative has thus far cost $17 billion and has decreased the global incidence of polio by 99%. Another $4 billion is needed for the next 4 years. Although this figure is high, a permanent control strategy would over time be much more expensive and the benefit of the global public good of eradicating a major disease like polio is enormous. • From MDGs to SDGs The 1990s brought fundamental changes to the world. During the Cold War, WHO had to forge a space for itself in “low politics.” In 1991, with the end of the Cold War, the global political landscape fundamentally changed towards a more cooperative international environment. The enormous quantities of resources that had been channeled towards armaments would now be partially directed towards peaceful development. Apolitical mobilizations and renewed thinking about the concept of development moved away from the narrow orthodoxy centered on economic growth. The approaching new millennium galvanized a longer-term view on development goals (UN 2016). At the same time the Rwanda genocide in 1994 and the Srebrenica massacre in 1995 painfully reminded all that peace was not a given and highlighted the failures of the UN to react. As the preamble of the WHO Constitution states: “The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.” The formulation of the MDGs shifted the emphasis from economic growth to a broader development agenda prioritizing issues related to poverty reduction,

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education, health, and gender (UN 2016). Health was very prominent in the adopted goals with MDG, with MDG Goal 4 Reduce child mortality rates, 5 Improve maternal health, and 6 Combat HIV/AIDS, malaria, and other diseases. The initial proposal of including primary health care as a goal was not retained. The MDG era brought an unprecedented increase in funding of global health, with development assistance for health increasing from $12 billion in 2000 to $40 billion in 2013, with a slight halt in the aftermath of the financial crisis of 2008. The sustainable development goals with SDG 3 (“Ensure healthy lives and promote well-being for all at all ages”) and several other goals relevant for health further mainstreamed health across all policy areas. • Tobacco control A whistleblower in 1994 revealed thousands of internal documents from the tobacco industry showing the tobacco industry’s strategy to deny the addictiveness and harmfulness of tobacco as well as undermining WHO and scientific evidence (WHO 2010a, 2011b). This triggered a development leading to US states filing lawsuits, which culminated in what is known as the Master Settlement Agreement, the largest civil settlement in the history of the USA (WHO 2011b). In 1998 WHO DG Dr. Brundtland made tobacco control one of her top priorities and created the Tobacco Free Initiative. An internal report in 1999 “alerted her that tobacco companies had for many years undermined WHO’s tobacco control efforts, spying on staff and infiltrating the Organization.” To examine the allegations, Dr. Brundtland established an expert committee to assess the documents which had become public through this settlement. In July 2000, the committee published a report entitled “Tobacco company strategies to undermine tobacco control activities at the World Health Organization.” (WHO 2000). The following quotes some passages from this report, as it was not only key to tobacco control efforts but also illustrates WHO’s experience and challenges when dealing with private commercial interests more generally. “The documents show that tobacco companies fought WHO’s tobacco control agenda by, among other things, staging events to divert attention from the public health issues raised by tobacco use, attempting to reduce budgets for the scientific and policy activities carried out by WHO, pitting other UN agencies against WHO, seeking to convince developing countries that WHO’s tobacco control program was a ‘First World’ agenda carried out at the expense of the developing world, distorting the results of important scientific studies on tobacco, and discrediting WHO as an institution.” The report also found that “tobacco companies had, in some cases, had their own consultants in positions at WHO, paying them to serve the goals of tobacco companies while working for WHO.” “Tobacco companies used ‘independent’ individuals and institutions to attack WHO’s competence and priorities in published articles, and presentations to the media and to politicians, while concealing its own role in promoting these attacks.” “A key part of tobacco companies’ strategy to undermine tobacco control activities at WHO in the 1980s and 1990s was to redefine the mandate of WHO, or at least redirect its priorities away from tobacco. To this end, tobacco companies used ‘independent’ academic institutions,

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consultants, and journalists to undermine the organization’s credibility, to question its ‘mission and mandate,’ and to divert its priorities from tobacco control to other health needs. These individuals and institutions were, in fact, secretly paid by tobacco companies to promote pro-tobacco or anti-WHO opinions” (WHO 2010a). This report allowed WHO to move forward in tobacco control by negotiating the Framework Convention on Tobacco Control which was signed in 2003 as the first convention negotiated under WHO. It was complemented in 2012 by the Protocol to Eliminate Illicit Trade in Tobacco Products. • The epidemics of the twenty-first century At the turn of the century people and politicians in high-income countries were convinced that infectious diseases, except HIV, were a problem of poor countries and poor people. This impression was proven wrong by several major outbreaks in the early twenty-first century. Changes in the way humanity inhabits the planet make the emergence of more new diseases inevitable. Constant mutation and adaptation are the survival mechanisms of the microbial world. In 2003, a coronavirus outbreak starting from China caused the Severe Acute Respiratory Syndrome (SARS) epidemic infecting over the course of 8 months 8000 persons, killing 774 persons and also creating an economic loss in the tens of billions of US$ with WHO having to give travel advice without clarity on its legal basis. This was a wake-up call leading to the rapid revision of the International Health Regulations (WHO 2008b), significantly expanding its scope to cover the spread of all international diseases. Soon afterwards the avian influenza H5N1 outbreak in birds across Asia, with sporadic animal to human transition, created the fear of a deadly influenza pandemic. In the summer of 2006 two events turned that latent risk into a global panic dominating the global media: A dead bird had been found in Romania and US president George W. Bush mentioned the risk in a speech based on an article on the Spanish flu in Foreign Affairs. Neither of these events changed the epidemiological situation, but they made Western countries understand the risk and created a global panic dominating global media over several months. It was simply a question of luck that the mutation of the H5N1 virus towards a strain with sustained humanto-human transmission did not happen. Against this background, the reaction to the outbreak of another novel influenza virus H1N1 in 2009, this time coming from pigs in the Americas, was immediate and strong. This first pandemic of the twenty-first century was much milder than feared, but nevertheless caused between 150,000 and 500,000 deaths worldwide. WHO was thereafter criticized of having overreacted. In 2014, the first ever Ebola outbreak in West Africa, a hemorrhagic fever known in central Africa, was underestimated for months. Neither the countries nor the international community, nor WHO were prepared and thus did not react timely. The 2-year outbreak infected 28,646, killed 11,323 persons, and devasted the societies and economies of Guinea, Sierra Leona, and Liberia. In this instance, WHO has been heavily criticized for having reacted too late and for not being strong enough.

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These events, together with the next deadly coronavirus disease starting in 2012, the Middle Eastern Respiratory Syndrome (MERS), which originated from camels in Saudi Arabia, showed that WHO needed to significantly strengthen its emergency program. A reform and strengthening of the emergency program were implemented which helped the organization to react much better when the feared new deadly pandemic arrived with the COVID-19 outbreak, first reported on New Year’s eve 2019. Nevertheless, the manner with which this pandemic is affecting the unprepared world and destroying lives and livelihoods has triggered an understanding that much more investment is needed both in pandemic preparedness and in WHO’s capacities. WHO does not only have to prepare for major pandemics, but it needs to prepare for all kinds of emergencies. In 2020 alone, WHO responded to more than 60 emergencies, including major outbreaks of chikungunya in Chad, yellow fever in Gabon and Togo, measles in Mexico, flooding in Sudan, storms in the Philippines and Vietnam, a major blast in Beirut, Lebanon, a fire in an asylum center in Lesvos, Greece, and many more. • Impact of norms and standards One of the biggest and least-discussed successes of WHO throughout its history is the impact its norms and standards have on the daily lives of each human being on the planet and on the economy. Every person is impacted daily by WHO through the quality of the air and water, to recommendations promoting a healthy diet and physical activity to prevent diabetes, cancer, lung, and heart disease. WHO makes recommendation to countries who base their policies on the monitoring of child growth, vaccination, the availability of safe, modern contraceptives, road safety such as the use of seat belts and helmets, the needs of older people, the prevention of secondhand smoke and anti-smoking policies, HIV testing, the recruitment of health personal, ensuring access to safe and affordable medicines, protection of people from catastrophic health expenditures, reducing inequalities, and many more recommendations. WHO’s norms and standards have also had direct impact on many economic sectors from the health sector, including the pharmaceutical and MedTech industry, to the agriculture, food, and retail sector, to the travel and tourism sector, to transport concerning air pollution or noise, to the chemical industry, and to many more sectors. • The triple billion While WHO’s mandate has remained the same, priorities have evolved and shifted over time. The current priorities are defined in the 13th General Program of Work (GPW 13) (WHO 2019), firmly anchoring WHO’s priorities in the SDGs. With the broad mandate of WHO it has always been difficult to define what WHO is about. The GPW13 has clarified WHO’s mission so that now staff members and people working with WHO know in simple terms what WHO’s mission is: Promote health, keep the world safe, and serve the vulnerable, including the triple billion target to be achieved over the 5 year’s period to 2023. The GPW13 is summarized in Fig. 3.

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Fig. 3 Overview of WHO’s 13th General Program of Work 2019–2023: Strategic priorities and shifts (WHO 2019)

Political Issues and Controversies While the previous chapter gives historical elements from a health and programmatic point of view, to understand WHO better, this chapter looks at the political, ethical, and societal challenges and disagreements the organization is constantly subject to.

Trade and Health As shown in the history section, the first health diplomacy negotiations in modern history were held in Constantinople in 1838 and concerned the trade and health

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interface. “In 1949, a communist delegate to the World Health Assembly declared that WHO was the battleground of two opposing points of view [that of the Soviet Union] standing for the interest of humanity, which demands that the attainment of medical science should serve the whole human race while the capitalist camp represents the interest of a minority who consider science as a source of income and as a weapon of war.” “The United States was not particularly interested in this approach and instead promoted the concept of ‘technical assistance’” (Fee et al. 2016). This interface has constantly remained with WHO, be it through particular industries’ interest, broader sanitary measures, or on questions of access to medicine.

Geopolitics and Sovereignty WHO has to constantly navigate geopolitical realities. The visionary constitution was only possible during the short window of opportunity of hope after the atrocities of the Second World War and before the start of the Cold War. This allowed a fundamentally universal and to some extent even supranational ambition for the organization. Soon afterwards though WHO was taken into the East–West conflict where the Soviet bloc did not participate in WHO between 1950 and 1957. China did not participate from 1950 to 1953 and then its seat was occupied by the Chiang Kai-Shek government until 1971 and from 1972 by the People’s Republic of China (WHO 2020c). The trans-strait relationship has resulted in challenges for WHO since this time. With decolonization the North–South relationships became an issue in WHO. While the group of 77 is less active in Geneva than in New York, many debates have been along a North–South divide. Also other geopolitical fault lines and questions of sovereignty or independence of territories, such as the separations of Korea, Vietnam, and Germany, and conflicts or civil wars wherever they occur, reach WHO, both in its governance and in the field. It can indeed be very tricky when two sets of credentials for a governing body meeting are submitted to the secretariat by different governments. On the other hand, WHO’s work has often contributed towards détente or even peace. Smallpox eradication was one of the most successful collaborations between the USSR and the USA and the Taliban government in Afghanistan agreed to a cease fire to allow for a vaccination campaign. Global epidemic control can only fully work if it is covering the entire human population. Therefore, WHO’s mandate and membership is universal and the constitution does not even foresee the possibility for a state to leave the organization. The International Health Regulation (IHR), with 196 state parties, is one of the most universal treaties of international law. It states in its article 3.3 on principles: “The implementation of these regulations shall be guided by the goal of their universal application for the protection of all people of the world from the international spread of disease,” while the next principle upholds the sovereign rights of states.

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Health and Security The WHO Constitution states in its third preambular paragraph: “The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and states.” This notion combined individual and collective security. WHO has always had to walk the fine line of being the responsible agency for health security while not getting politically involved in matters of military security. This is well reflected in the IHR Art. 1 on definitions: ““health measure” means procedures applied to prevent the spread of disease or contamination; a health measure does not include law enforcement or security measures”; and in Annex 2.I.2.: “Spread of toxic, infectious or otherwise hazardous materials that may be occurring naturally or otherwise that has contaminated or has the potential to contaminate a population and/or a large geographical area.”

Ethics and Societal Norms Ethics and societal questions, especially concerning sexuality and beginning and end of life are highly political and ideological in nature, but inevitable for WHO, an organization which by definition is about life and death. At the third World Health Assembly in 1950, significant controversies came up when the delegate from the then Ceylon proposed work on population growth. The strength and challenge of WHO’s mandate in such fields can be illustrated in the words of one of its first Assistant Director Generals Milton Siegel explaining to opposition to the proposal of Ceylon: “Well, the position simply was that population-growth control, family planning, or whatever you want to call it, was not a health problem and therefore should not even be debated. That was the position of Ireland, Italy, Lebanon, and later on Belgium. The issue of population growth came up at every meeting WHO held. You couldn’t separate population problems from health in the minds of most of the delegates. But these few countries – particularly those which were dominated by the Vatican – didn’t want to see that discussed in a health organization. Because as soon as you introduce anything under the subject of health – whether it’s peace, security, or family planning – it’s pretty hard to argue against improving the health of people. These countries knew that, and they tried to defend themselves by saying, ‘These are political considerations and shouldn’t be discussed in a health arena.’” Countries even threatened to withdraw the organization and take steps to destroy the Organization (Mumford 1996). Similar controversies on societal norms erupted on the proposal to include an agenda item on “Improving the health and well-being of lesbian, gay, bisexual, and transgender persons” in 2013 where member states did not even manage to agree to debate the question.

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Horizontal and Vertical Health Service Delivery Preventive and curative health services can be delivered in a horizontal or vertical mode. Horizontal refers to the integration of a particular service into the publicly financed health system, while vertical delivery refers to a selective targeting of interventions not fully integrated into the health system. Both approaches have accompanied WHO since the formulation of the constitution and refer both to the strengthening of health services and the eradication of diseases. Vertical programs have had their greatest success in the eradication of smallpox, and their biggest failure in the early malaria eradication program. Vertical programs are also attractive for donors and politicians, because they are easier to manage, control, and demonstrate in order to reach quick and measurable results. However, they also divert financial and human resources from constrained health systems and lead to fragmentation. During the Cold War the legitimate debate over the merit of both approaches was further politicized, as the West tended to favor vertical programs to show quick successes of their assistance to newly decolonized developing countries, while the Communist bloc saw the horizontal approach as a reflection of their egalitarian ideology. WHO constantly attempted to overcome this divide. An example of each is the Soviet-initiated smallpox eradication program, and the Alma Ata Conference on Primary Health Care (PHC) which was initiated by the Danish Director General in 1978, in collaboration with the more US-led UNICEF. The following year, at a conference in Bellagio, Italy by the Rockefeller Foundation, the World Bank and USAID, the PHC was criticized for being too broad and idealistic, and having an unrealistic timetable. With the change of the executive director, UNICEF promoted the art of the possible with “Selective Primary Health Care” as a strategy for disease control and an immediate return of the pendulum towards a vertical approach. Health for All by the year 2000 was a clear horizontal effort. The strong focus on health with three of the eight millennium development goals was vertical, while the SDGs are horizontal having a single health goal (SDG3) “Ensure healthy lives and promote well-being for all at all ages” with Universal Health Coverage (UHC). The adoption of the SDG led to a debate in global health between advocates of the vertical approach arguing that health had been lost from three in eight MDGs to only one in 17 SDGs while advocates of the horizontal approach were happy with the focus on UHC and the mainstreaming of health with more than 50 indicators across most of the 17 goals being relevant to health. The horizontal approach gains additional relevance with the rise of the One Health approach recognizing the intertwined nature of health for people, animals, and our environment, as illustrated by the frequent occurrence of zoonotic diseases, and the fact that Antimicrobial Resistance (AMR) can only be addressed by the close collaboration of the human health, veterinary and agriculture sectors, and the health impacts of climate change. The UHC focus shows that the horizontal approach needs to be the backbone, while vertical programs intervening in this health system with universal coverage are also needed.

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Technical or Political Focus WHO’s headquarters where deliberately kept apart from the UN headquarters in order to protect WHO’s technical work from politization and avoid some of the deadlocks. This contributed to many successes, the continuous solid technical work WHO could perform despite global political tensions, and the fact that the FCTC and the WHO (2008b) could be adopted overcoming important political differences. However, this also decreased the political influence of the health sector on issues which can only be decided at the highest political level. This started to change in 2000 with the first UN Security Council resolution on HIV/AIDS (Resolution 1308 (2000)). Health ministries tended at the national level to be secondary in importance despite their growing budget shares. In the last 20 years more and more influential politicians came from or passed through health ministries. The Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand launched in New York in 2006 the Global Health and Foreign Policy Initiative, with the Oslo Declaration of 2007 stating “In today’s era of globalization and interdependence there is an urgent need to broaden the scope of foreign policy.” “We believe that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time” (Ministers of Foreign Affairs 2007). This initiative now sponsors an annual Global Health and Foreign Policy resolution at the UN General Assembly. Until recently, no textbook on diplomacy contained a chapter on health. The term Global Health Diplomacy was only introduced in 2007 (Kickbusch et al. 2007). Following this, countries started to nominate more health attachés to their missions in Geneva and more recently, in New York and elsewhere. Some countries have nominated capital-based Ambassadors for global health. Health is now regularly on the agenda of the G20, G7, BRICS and other summits. On the other hand, the timing of actions in Geneva, New York, and in other countries has to be carefully managed. While the UN highlevel meetings on NCDs, which started in 2011, have raised the profile of the problems, they have not yet led to the much-needed massive increase of funding to prevent and fight NCDs. Thus, WHO can no longer be technical or political, it has to be both.

Intellectual Leadership WHO does not only work technically and politically, it is also frequently providing intellectual leadership to position topics for longer perspectives. This started with the visionary constitution which continues to shape and inspire global health developments. The Alma Ata Declaration, which has had difficulties in its implementation, continues to shape global health more than 40 years after its commencement. The Ottawa Charter on Health Promotion of 1986 also framed a new key concept of public health which has been in use for decades. WHO has convened several highlevel commissions, whose reports have significantly framed the global debate on particular topics.

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Overview: WHO high-level commissions and reports • Our Planet, our Health, the report of the WHO Commission on Environment and Health in 1992 which contributed to the Rio earth summit and its Agenda 21 and initiated systematic work on the environment and health, especially in WHO’s European office. • The WHO Commission on Macroeconomics and Health chaired by Jefferey Sachs in 2001 and its report: Investing in health for economic development compellingly made the cost of the economic losses of ill-health and the contribution of health investments to economic growth. • The Commission on Intellectual Property Rights, Innovation, and Public Health (CIPIH) in 2006 put public health at the center of the debate on access to medicines and intellectual property. • The 2005 Commission on Social Determinants of Health inspired the understanding on the economic, social, environmental, and political determinants of health.

Functioning of WHO WHO Functions Art. 2 of WHO’s Constitution mandates the organization to fulfill no less than 22 functions, which illustrates its very broad mandate. These functions were summarized at the 11th General Program of Work in 2006 into the following six core functions (WHO 2019) • Providing leadership on matters critical to health and engaging in partnerships where joint action is needed • Shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge • Setting norms and standards and promoting and monitoring their implementation • Articulating ethical and evidence-based policy options • Providing technical support, catalyzing change, and building sustainable institutional capacity • Monitoring the health situation and assessing health trends This illustrates the challenge of having to run three sets of very different functions in a single institution. At the same time, WHO has to be a global norms and standard setting body, provide technical assistance to countries, especially through its 150 country offices, and prepare and respond to emergencies. This is comparable to a situation where the managerial and administrative decision-making and support structure of a university and parliament, a development agency, and a fire department

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have to be in the same organization, with a budget which is smaller than those of some individual hospitals. Proposals to disentangle or even separate those three different organizational functions within WHO have not been pursued as each of them depend on the others. Generating global norms and standards would have much less impact if they were not applied and implemented at the country level. Detecting signals of outbreaks and responding rapidly to emergencies need to build on a strong relation with and presence in countries. The COVID-19 pandemic has shown more than ever before the delicate link between emergency response, the gathering of scientific evidence, and the setting of norms and standards. More than 600 guidance documents have been produced in the first 10 months of the outbreak. Technical assistance in and for countries would be meaningless if it is not based on global normative work and could not respond to countries in emergencies when WHO is needed most. To understand the workings of an organization, one has to understand its key organizational policies. For WHO, many of them are gathered in the basic document (WHO 2020a). Starting from the constitution they provide the relevant Health Assembly–approved collaboration agreements with the UN, PAHO, many UN agencies, and other intergovernmental organizations. Negotiating in the Health Assembly and the Executive Board requires an understanding of the rules of the game defined in the Rules of Procedures. The Framework of Engagement with nonstate actors described in the next section regulates engagement with organizations not dependent on a state. The “Regulations for Expert Advisory Panels and Committees” provide the basis for the hundreds of committees advising WHO in its normative work, such as the elaboration of guidelines, where WHO convenes the best experts in the world for a particular field. The “Regulations for Study and Scientific Groups, Collaborating Institutions and Other Mechanisms of Collaboration” provide the basis for the earlier stages of assessing evidence and for the over 800 collaborating centers in research institutes, universities, and academies supporting WHO’s work through their agreed research efforts. The Financial and Staff Regulations provide the basis for the administrative management of the Organization (WHO 2020a).

Collaborating and Partnering WHO can only achieve its ambitious objective by collaborating and partnering with the majority of actors of society. As mandated by the constitution, WHO has been partnering with multiple organizations throughout its history. At the International Conference of 1946 several UN agencies, the League of Red Cross Societies, World Federation of Trade Unions, and Rockefeller Foundation attended as observers. The International Health Division of the Rockefeller Foundation had field offices in many countries and played a dominant role in global health during the League of Nations and up to the creation of WHO, a role to some extent similar to the role of the Bill and Melinda Gates Foundation in recent years. At its first session, the Health

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Assembly established principles for relations with nongovernmental organizations and the EB created a committee on nongovernmental organizations. One of the earliest close collaborations of WHO was with UNICEF. This collaboration was initially created as an interim mechanism for the post-war support to children. The WHO–UNICEF Joint Committee on Health Policy (JCHP) was intended to organize the transfer of the health programs of UNICEF to WHO but then became the coordination mechanism of the two organizations for decades (Beigbeder 1998). In 1997, this committee was extended to include UNFPA and changed its name until 2003 to Coordination Committee on Health (CCH). This collaboration, as well as the close collaboration with UNDP and with the World Bank, represented a constant oscillation between close cooperation and competition. Overview: Interagency joint programs created and (often) hosted by WHO • 1963 Joint FAO/WHO Codex Alimentarius Commissions (Secretariat hosted by FAO) • 1972 UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP) • 1974: UNICEF, UNDP, World Bank, and WHO Special Program for Research and Training in Tropical Diseases (TDR) • 1974 FAO, UNDP, World Bank, and WHO Onchocerciasis Control Program (OCP) • 1980 ILO, UNEP, and WHO International Program on Chemical Safety (IPCS) • 1992 Inter-Agency Standing Committee (IASC), an inter-agency forum of UN and non-UN humanitarian partners hosted and chaired by the Office for the Coordination of Humanitarian Affairs (OCHA) • 1994 Joint United Nations Program on HIV and AIDS (UNAIDS), administratively hosted by WHO, but reporting to the UN secretary general

Throughout its history WHO also encouraged or participated in the creation of many entities, starting in 1949 with the Council for International Organizations of Medical Sciences (CIOMS) (an international, nongovernmental, nonprofit organization established jointly by WHO and UNESCO) (WHO 1958). • In 1965 WHO established its own specialized cancer agency, the International Agency for Research on Cancer (IARC) in Lyon, France. • In 1988 the Global Polio Eradication Initiative (GPEI) was launched by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, and the Bill and Melinda Gates Foundation.

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• In 1990, building on WHO’s Expanded Program on Immunization (created in 1976), the Children’s Vaccine Initiative (CVI) was launched by UNICEF, UNDP, WHO, the World Bank, and the Rockefeller Foundation. CVI was the precursor to GAVI, the Global Vaccine Alliance created in 2000. • In 1997 the Alliance for Health Policy and Systems Research; in 2005 the Partnership for Maternal, Newborn, and Child Health (PMNCH) and in 2006 UNITAID was launched as WHO hosted partnerships. • In 1998 Roll Back Malaria Partnership and in 2000 the Stop TB partnership were created as WHO hosted partnerships. Both partnerships are now hosted by UNOPS. • In 2002 WHO helped incubate the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM or the Global Fund). • In 2016, WHO and Drugs for Neglected Diseases initiative (DNDi) initiated the Global Antibiotic Research and Development Partnership (GARDP). WHO is also involved in more than a 100 other partnerships and collaborative arrangements. In 2020 at the initiative of WHO, an independent “Foundation in support of WHO” (WHO Foundation) was created, to allow for the general public, high-net-worth individuals and private sector entities to provide support to WHO and its partners implementing the General Program of Work.

The Landscape of WHO’s Engagement The landscape of entities with which WHO is interacting is very diverse and complex. While the constitution speaks simply of government and nongovernment organizations, the current reality is more diverse and terminology has evolved. When speaking of a private company nobody would call it an NGO (nongovernmental organization). It is therefore worth looking at all types of actors WHO is collaborating with, often on a daily basis. WHO’s member states are not only WHO’s owner and highest decision-makers and main funders, but also its most important partners. States are not monolithic blocks, but in themselves a universe of diverse actors. While ministries of health are traditionally WHO’s main interlocutors, WHO is expanding its engagement across governments. This was already the case and has become even more true in current times. WHO leadership is engaging with heads of state and government. Many political decisions are also health decisions and health is a political choice. The key ministries relevant for WHO’s work besides the ministries of health are the ministries of foreign affairs, finance, planning, and development. Many other ministries are also relevant, including trade, economy, environment, transport, social affairs, agriculture, intellectual property offices as well as others. While one often wrongly assumes that a member state has only one position, one of the biggest challenges of each member state is policy coherence in national and global health policies. WHO is working with parliaments on legislation and budget allocations, with regional and local governments and other parts of the state’s systems. WHO is part of the UN family as one of the largest specialized agencies. WHO works and partners with the UN itself and the WHO director general is a member of

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the UN’s Chief Executive Board (CEB). WHO works closely with many of the UN programs and agencies including UNICEF, the United Nations Development Program UNDP, Food and Agriculture Organization FAO, World Food Program WFP, International Labor Organization ILO, United Nations High Commissioner for Refugees UNHCR, United Nations Framework Convention on Climate Change UNFCCC, regional economic commissions, and many more. Furthermore, the World Bank and IMF are also key to WHO’s work. Other regional and interregional international organizations play a more and more important role and work closely with WHO, ranging from the European Union (EU), the African Union (AU), Organization of American States (OAS), Arab League, Association of South East Asian Nations (ASEAN), Nonaligned movement (NAM), and the Organization for Economic Cooperation and Development (OECD), to name a few. The EU plays a particular role as a regional economic integration organization where its member states have shared important parts of their sovereignty in fields including those relevant to WHO such as trade with the EU itself. The UN system including WHO is built on the concept of individual sovereign states, each having a voice and one vote. From a legal point of view the overall relationship of the EU with the UN is not yet clarified as other powers do not accept that the EU itself would also have a vote, while the EU’s treaty requires some issues to be defended by the EU and not its individual member states. Therefore at each governing body, an ad hoc arrangement is proposed that the EU can also attend drafting groups otherwise only open to member states, and many resolutions contain a footnote where they urge member states to take action saying “And, where applicable, regional economic integration organizations.” Key groups or forums of member states or “clubs” often not formally structured as international organizations are key global policy drivers, including the G20, G7, BRICS, and APEC. The political positioning of WHO, especially in such high-level fora, become more and more important. Nonstate Actors Nongovernmental organizations (including civil society, faith-based organizations, professional groups, disease-specific groups, and patient groups), the private sector (including private companies, company foundations, and business associations), philanthropic foundations, and academic institutions play a key role in global health. WHO’s engagement with them and the policy regulating these engagements is described below. Partnerships and Collaborative Arrangements Since the 1990s a multitude of partnerships have been created on global health issues. The WHA has adopted a resolution WHA63.10, a policy on WHO engagement with global health partnerships and hosting arrangements, defining “formal partnerships” as those “partnerships with or without a separate legal personality but with a governance structure (for example, a board or steering committee) that takes decisions on direction, workplans, and budgets” (WHO 2010b). Partnerships can be their own legal entity or hosted by another public or private legal entity, be it WHO, another international organization, or a private entity. Collaborative arrangements

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are similar arrangements of collaboration of several actors which have not been formalized as formal partnerships. These networks and alliances have informal governance arrangements and often operate within the managerial control of WHO. Special Cases Even with this diversity of groups of actors there are several special cases not falling into any of those groups. The International Committee of the Red Cross (ICRC) is legally constituted as a Swiss association but is often recognized as an international organization. The Interparliamentary Union (IPU) is not an intergovernmental but is an interstate organization, as it brings together another branch of the states. Similarly, Interpol is an organization of police, and organizations of regional and local governments are constituted like NGOs, but represent parts of governments. Media The media are constituted in a different manner, often as private for-profit companies, but also as government linked or mandated entities or non-for-profit entities. WHO will interact with media on communication independent on how they are structured. Individuals WHO distinguishes its interaction with individuals whether they act as representative of one of the entities above or in a personal capacity. The same person can in one interaction represent a government or a nonstate actor and in other interaction act in their individual capacity as an expert who has to provide a declaration of interest. WHO works with thousands of experts servicing in their individual capacity on committees and advising WHO. WHO communicates with and provides advice to the general public. Individual celebrities can be nominated as WHO Goodwill Ambassadors or otherwise promote WHO’s causes.

Framework of Engagement with Non-state Actors (FENSA) (WHO 2016) WHO’s engagement with NGOs and with the private sector has been important but controversial throughout its history. WHO’s normative role and the way WHO has been undermined by the tobacco industry explain its historically very cautious or even negative approach to interacting with the private sector. Several governments have also been reluctant throughout WHO history to allow too close engagements with NGOs. The first WHA could not fully agree on the principles governing the relations between WHO and nongovernmental organizations. Discussions continued until the third WHA when there was initial agreement on the collaboration with NGOs, not yet specifically focusing on health, but rather on, for example, women’s organizations and the scouts movement. These principles were revised in 1987 to reflect the broader approach of engagement coming from the Alma Ata Declaration. In 2000 the fact that a proposal to intensify collaboration with the private sector was so controversial resulted in the “Guidelines on interaction with commercial enterprises to achieve health outcomes” being only noted by the EB as opposed to being approved by the governing bodies. The Civil Society Initiative, launched in

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2001, also raised opposition from some member states and was abandoned in 2005. An article in 2008 suggested to create a Committee C for the World Health Assembly to allow for a better dialogue with nonstate actors while respecting the intergovernmental nature of WHO (Silberschmidt et al. 2008). In the WHO reform initiated by Dr. Chan after the financial crisis, it became clear that the modalities of engagement with nonstate actors needed to be addressed. However, for some, mostly industrialized countries, this primarily meant allowing for stronger and greater engagement, including with the private sector, while others, primarily low- and middle-income countries were concerned that WHO needed to improve its protection from undue influence from the private sector and major philanthropic foundations such as the Bill and Melinda Gates Foundation. The secretariat tried to first consult both member states and nonstate actors to be able to draft a compromise text. This attempt failed as some member states insisted on negotiating line by line what ended up being a 35-page operational policy. What followed was the longest intergovernmental process of WHO’s history, with 200 working hours of informal and formal intergovernmental negotiations both in drafting groups during governing body meetings and in intersessional meetings. Finally, all sides came to understand that it was not a question of either engaging more with nonstate actors “OR” better protecting the integrity and reputation of WHO from any undue influences, but WHO must do the one “AND” the other. The framework of engagement with nonstate actors (FENSA) was approved in 2016 through resolution WHA69.10 (WHO 2020a, Basic Documents). FENSA is the first intergovernmental negotiated engagement policy in the UN system. FENSA provides the rationale, benefits, and risks of engagements with NGOs, private sector entities, philanthropic foundations, and academic institutions, and defines how these engagements should be managed through a process of due diligence, risk assessment, risk management decision, and transparency. FENSA also defines how NGOs, international business associations (a subgroup of private sector entities), and philanthropic foundations can be admitted into official relations with WHO. FENSA consists of an overarching framework applicable to all nonstate actors and four specific policies for NGOs, private sector entities, philanthropic foundations, and academic institutions. FENSA provides some clear red lines such as WHO’s nonengagement with the tobacco industry or nonstate actors that work to further the interests of the tobacco industry, as well as with the arms industry. For most engagements, FENSA does not define WHO’s risk appetite, but the manner how these risks should be managed, leaving the definition of the risk appetite to the director general and manager deciding on engagements.

WHO Financing As in any organization, WHO finances determine priorities and are linked to power and influence. Initially WHO was mainly funded through its membership fees called assessed contributions (AC). Over time the budget has increased and has become more and more funded from voluntary contributions (VC) (Fig. 4).

Fig. 4 WHO program budget from 1990 to 2019, in US$ millions

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The WHO Constitution foresees the possibility of receiving such VC as follows: “The Health Assembly or the Board acting on behalf of the Health Assembly may accept and administer gifts and bequests made to the Organization provided that the conditions attached to such gifts or bequests are acceptable to the Health Assembly or the Board and are consistent with the objective and policies of the Organization” (WHO Constitution 1948, Art. 57). The competence to administer VC was subsequently delegated to the director general. Starting in the 1950s, WHO experimented with selling world health stamps to the public in order to raise money. In 1960, the World Health Assembly established a Voluntary Fund for Health Promotion (Daugirdas and Burci 2019). The budget for the first full year of WHO in 1949 was US$ 5 million (5M) (WHO 1958). It grew to 26M in 1960 (15M assessed contributions, 2M voluntary contributions, 6M technical assistance from UNDP, and 2M miscellaneous). In 1966 the total figure was 61M (39M AC, 2M VC, 13M from UNDP, and 7M miscellaneous) (WHO 1968). In 1979 AC had grown to 208M and VC to 40M. By 1988 AC had grown to 300M and VC to about 210M for total annual expenditures of 510M. Since the 1980s, key influential governments adopted a zero-growth policy to suppress increases in assessment contributions (Beigbeder 1998). This situation was worsened by important arrear of payment. In a compromise between the republicans and democrats in the US Senate in 1999 the Helms-Biden Act was passed, which led to US paying its arrears to the UN system in return for a requirement for a zero nominal growth policy. While the zero-growth policy still has its impact, more recently the US administration started again to accumulate arrears to parts of the UN system (Lynch 2019). As the above illustration shows AC increases since 1990 were for the most part symbolic, while voluntary contributions have more than tripled between 2000 and 2010. This has led to a certain vulnerability which was painfully felt after the 2008 financial crisis. There was a 2-year delay as public budgets including for development cooperation were reduced. WHO lost 250M income per year compared to the anticipated budget and had to take several cost-saving measures. This showed that the total budget figures were simply “aspirational” as there were no guarantee or obligations from VC donors to continue to provide similar levels of contributions. The WHO budget process was split into an upstream governing body process on the budget and a nearly unrelated downstream process of fundraising mostly by individual technical departments (Daugirdas and Burci 2019). Some technical departments never managed to raise the anticipated resources, while others raised and could spend significantly more than budgeted. While this decentralization contributed to a significant increase in VC, it also led to “kingdoms” and provided strong incentives for a silo culture. As in other UN organizations, voluntary contributions have for a long time been treated as extrabudgetary resources (Daugirdas and Burci 2019). For WHO this meant that the Health Assembly took only formal decisions on the AC and simply noted the expected VC. Up to the period of 1990–2000, this worked well in the initial phase with a clear majority of AC, with roughly equal shares of AC and VC. Since then however the proportion of AC and VC have inverted with now only

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17% being funded by AC. This led to a situation by the 2010s where the approval by the Health Assembly of the budget concerned less than a quarter of the organization’s income and expenses. This decision was therefore no longer setting strategic priorities of the organization and further restricted its flexibility by appropriating this small proportion to specific activities while having no say on the majority of the funding. The real budget and financing of the organization no longer reflected collective decision-making but rather crucial policy choices would simply reflect the aggregate results of numerous individual decisions made by donors about which activities to fund and how generously to fund them. This situation led to further distortions of the financing. While a majority of these voluntary contributions still came from governments, they came mostly from development agencies with other priorities and constraints than the health ministries, which are mostly leading the delegations to WHO’s governing bodies. These donors also tend to have different methods to evaluate the impact of their funding focusing on measurable results and requesting particular reporting requirements. This tendency was further reinforced by the pressure faced by development agencies, since they must make sure that the OECD Development Assistance Committee will count their contribution as official development assistance (ODA). Much of WHO’s main normative work serves all countries and therefore not considered “developmental” by the OECD accounts, while WHO’s technical assistance work does count as ODA (Daugirdas and Burci 2019). The actually implemented program became more and more distorted compared with the priorities set by the Health Assembly through budget allocation and request of work to the director general through resolutions. The key example of a chronically underfunded program is NCD (includes cancer, diabetes, cardiovascular diseases, and chronic respiratory diseases). NCDs are systematically considered in resolutions and in interventions from many member states as a top priority but budgets remain relatively small and underfunded. This seems to be further reinforced by lobbying of interested industries against NCD funding (Daugirdas and Burci 2019). This heavy reliance on voluntary contributions, decentralized resource mobilization, high number of grants, strong earmarking, and limited authority of the director general to reallocate funds caused WHO’s activities to diverge more and more from the programmatic priorities set in the budget and through resolutions with some programs chronically overfunded while others were chronically underfunded (Daugirdas and Burci 2019). This was even further reinforced as the director general would have no interest in proposing further needed budget increases for programs such as NCDs which could already not raise the previous budget level. Against this background Director General Margaret Chan launched a financing reform under the title “The future of Financing for WHO” (WHO 2010a) confronting member states with the fact that de facto priority setting was done by level of voluntary contributions. She told them: “Current financing practices make WHO a resourcebased and not a results-based organization. Money dictates what gets done. It should be the other way around. Money should be allocated to support the work that Member States have prioritized” (WHO 2012). After 3 years of intensive debates on the financing model, the 2013 Health Assembly approved through Resolution 66.2 a new model with the following

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changes: The Health Assembly now approves the entire budget including assessed and voluntary contributions. It sets separately the level of assessed contributions. It allocates the total funding to six categories with the authority of the director general to shift 5% between these categories, but no longer appropriates assessed contributions, thereby giving the director general full flexibility on the use of AC and finally allows the director general to spend funding for emergency responses beyond the approved budget. It also for the first time sets a ceiling for the total budget and the six categories (WHO 2013). This was a sort of compact (Daugirdas and Burci 2019) moving from an aspirational to a realistic budget. Member states gained more control over the activity of the organization, but gave the director general flexibility on the use of AC. Major donors would commit to more sustainable, long-term predictable, and more flexible funding and WHO in return improved the realistic implementation of the budget with higher budget discipline and measurable impact. The four key words of WHO financing became, predictability, flexibility, alignment (of VC with the approved budget), and transparency. This transparency has been implemented through the WHO Program Budget Portal (WHO 2020b), providing detailed information on each dollar received, from whom, for which program, spent in which office, and what results are achieved. The following overview of the last concluded biennium illustrates several achievements of the financing reform and its remaining challenges (Fig. 5). Overall the budget that has been implemented in 2018/2019 and reported in 2020 is much closer aligned to the budget approved in May 2017 than what was the case in the past (this refers to the first six bars representing the categories of the base budget subject to a budget ceiling, while the last three bars are governed differently). One can however still observe that the categories which attract most voluntary contributions (communicable diseases and health systems) received initially the highest budget allocation and still ended the biennium slightly overfunded. On the other hand, noncommunicable diseases initially received the lowest budget allocation, was financed at 50% by flexible funding, and still remained underfunded. While emergency response attracts a lot of funding, emergency preparedness is the most underfunded category. As corporate services and enabling functions (such as the running of the Health Assembly or directing, external relations, and accountability functions) have to be mostly funded from flexible funding, they are in competition for the same limited amount of flexible funding with the underfunded programs. This shows that a combination of this new budget approval with a strategic use of the flexible resources could reconcile the collective governance with a heavy reliance on voluntary contributions, if a minimal proportion of flexible resources were available, which is not yet the case. In addition, there is a risk of an incentive for the secretariat to build their expectations regarding downstream resource mobilization into the upstream budget planning processes in order to present a “realistic budget” (Daugirdas and Burci 2019). Furthermore, there is still resistance against un-earmarking from within the secretariat, where in some cases technical directors have encouraged governments to earmark funds towards their programs instead of providing them un-earmarked. The new model if fully implemented represents a shift of power and influence from

Fig. 5 Program budget 2018–2019; financing by categories (http://open.who.int/2018-19/budget-and-financing/details)

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technical areas towards the corporate interests of WHO and serves to reinforce director general’s supervision and management authority within the organization by reining in the autonomy of its technical units (Daugirdas and Burci 2019). With the 13th GPW the budget structure was further adjusted to reflect instead of the 6 categories four strategic priority areas (for the triple billion and enabling functions), while the 2013 rules on the budget remained valid. While the approved budget estimate for the 2018–2019 biennium was US$ 4.421 billion, the allowed increases in the unforeseeable parts of emergency response and polio led to overall contributions for the biennium of $5.681 billion distributed as follows: AC Flexible VC for base program Specified VC for base program Specified VC for emergency response and polio

991 (17%) 463 (8%) 1.729 (30%) 2.496 (44%)

(WHO 2020d)

As previously explained 17% of AC and 25% overall flexible resources are simply not sufficient to run the organization as planned despite the strategic allocation of flexible funds. At first sight one could argue that WHO should return to be mainly AC funded. This seems to be politically very difficult to implement and would also bring certain other risks. It is likely that needed overall budget increases would be more difficult to get agreement if all member states would have to agree to pay for them. During WHO’s history relying heavily on voluntary contributions might also have dodged the damage of countries withholding AC or threatening to do so (Daugirdas and Burci 2019). Paradoxically an overly heavy reliance on member states contributions also creates a form of dependence. Collective multilateral decision-making can best be protected by a balanced and varied distribution of funding sources. Therefore, member states will have to decide on how this proportion can be increased to somewhere between 35% and 50% and what part of such increases should come from AC and what parts can be generated from other sufficiently flexible sources of funding. Initial steps for other more flexible funding sources have already been taken in the past. In 2004 the concept of core voluntary contributions was introduced where countries agreed to give in addition to their AC flexible funding. Because this funding usually comes from development agencies, it needs to be used in a manner which is accountable as ODA, but is otherwise totally flexible. Later other highly flexible funding models were introduced. Some programs such as the prequalification of medicines and vaccines and the management of the International Non-Proprietary Names have introduced fee for service models providing a longterm reliable funding source (Daugirdas and Burci 2019). The Pandemic Influenza Preparedness Framework requires companies to contribute to a funding pool in return for the service of WHO identifying and making the seasonal flu vaccine strains available.

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The current administration of Dr. Tedros has initiated a series of measures to improve the financing of the organization, building on the 13th GPW with a Results Framework (WHO 2020f). It includes the first ever investment case for WHO (WHO 2020e), a strengthening of the resource mobilization team, a more robust results reporting (WHO 2020g), and the creation of a WHO Foundation to allow funds to be raised from high-net-worth individuals, the general public, and the private sector (WHO 2020h). The following illustration shows the source of VC. It shows that the vast majority of funding comes from member states, all of AC, half of VC directly, and a significant proportion of funds from intergovernmental organizations and partnerships which are themselves mostly government funded. The illustration also shows that WHO still receives significant funding from nonstate actors (Fig. 6). One should also put WHO’s budget in relations with other institutions. While WHO’s annual financing is below $3 billion, Hôpitaux de Paris have $7.5 billion, the New York Presbyterian Hospital $8.3 billion, and the US CDC $11 billion. The following describes some other developments of the WHO budget and financing process. In the initial period WHO was working with an annual budget. The principle of changing towards a biennial budget was agreed upon in 1969. As it

Fig. 6 Revenue from voluntary contributions for 2019, by source (WHO 2020d)

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needed a constitutional change it only entered into force in 1980 (WHO 2008a). A further important and politically contested change came with Resolution WHA29.48 introduced by the Group of 77 in 1976, which requested that at least 60% of the budget be allocated for technical cooperation and provision of services. This resolution was adopted in a vote with 82 in favor and 26 abstentions (WHO 2008a). Even though the 60% was not fully achieved, it led WHO to have one of the strongest country presence among UN agencies, with country offices in 150 countries and territories. The challenge of priority setting was already recognized long before the major shift from AC to VC reliance. Member states all throughout the history of the organization did not make the resources available which would have allowed it to fulfill the work needed to satisfy their expectations. As an example, “a brief discussion, in January 1975, about whether the Board should consider where savings might be made, led the Director-General to express the hope that “at the appropriate time the Board would be willing to discuss with the secretariat which sectors of the programme should be cut down and which enlarged, and at least to indicate which it considered to be the most important directions in which future efforts should be oriented.” The secretariat, he said, “was constantly finding itself obliged to make drastic economies simply to keep abreast of current commitment, and thus there was virtually nothing left in reserve for innovation”” (WHO 2008a). In conclusion, the WHO Financing model has significantly improved over recent years but still needs further improvements. While the Secretariat can drive some of these improvements, member states will have to take their responsibility and decide on what kind of organization they want, what they want this organization to do and if they are ready to pay for what this mandate costs to be implemented.

Conclusion How much of the global increase of the average life expectancy from 48 years in 1948 to 72 years in 2019 might be attributable to WHO? Of course, WHO cannot attribute all of the value chain to its own work. But most global health programs and initiatives would not be successful without WHO’s normative basis, technical guidance, and statistical documentation of results. The best approach to appreciate WHO’s importance for global health is to imagine a world where WHO would not exist. Most would say that if this was the case, WHO would simply be created. The central role WHO plays in global health and for the global community at large might also be a reason why it seems so easy to criticize WHO and why the organization has fewer active advocates than other organizations whose existences are not simply a given. This argument does not mean that WHO does not have significant weaknesses. Some weaknesses are linked to the intergovernmental nature of WHO, with governments favoring their short-term interest over the global public good, and others to its UN bureaucracy where the quality of staff inevitably varies. There are also weaknesses which are not inevitable and should therefore be corrected.

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While the WHO is very well known, its complex organization is also very difficult to really understand. The history of WHO is a history of reform efforts. The two most recent ones were the WHO reform under Dr. Chan, with its financing reform, strengthening of accountability functions, creation of the WHO Emergency Program and the adoption of FENSA, and the current Transformation Agenda under Dr. Tedros with a new strategy towards the triple-billion target, a redesign of multiple processes, a new operating model and results framework, strengthening of partnerships, the definition of a value charter, the creation of a science and data division, the WHO Academy and the WHO Foundation, definition of an Investment Case and of standardized Global Public Health Goods. The forthcoming reform debate induced by the COVD-19 pandemic will show if member states are ready to equip WHO with the resources and competencies allowing WHO to meet the expectations that member states and the public have towards the organization. Ultimately, health is a political choice of investment, wealth redistribution for equity of access, social policies to improve health determinants such as education, gender equity, employment, working conditions, and income, economic policies of favoring healthy behavior and limiting unhealthy consumption patterns, protecting climate and the environment, investing into biomedical research and development, etc. At the same time, WHO has to avoid party and country politics, and has to navigate a very political world while not becoming politicized. Finally, WHO also has to prepare for the future, both technically and politically, with m-health and digital health, with the global challenges such as climate change, with shifting geopolitical power distribution, and with engagement in where decisions are being shaped be it in UN organizations or “clubs” such as the G20, G7, BRICS, or new upcoming fora. In face of these future global challenges, WHO will have to position itself much more proactively.

References Beigbeder Y (1998) International organization and the evolution of the world society, vol 4. The World Health Organization/Martinus Nijhoff Publishers, Geneva Boisson de Chazournes L (2007) Le pouvoir réglementaire de l’Organisation Mondiale de la Santé à l’aune de la santé mondiale: Réflexions sur la portée et la nature du Règlement Sanitaire International de 2005. In: Droit du pouvoir, pouvoir du droit: mélanges offerts à Jean Salmon. Bruylant, Bruxelles, pp 1157–1181 Burci GL (2019) The World Health Organization at 70: challenges and adaptation. Int Organ Law Rev 16:229–241 Daugirdas K, Burci GL (2019) Financing the World Health Organization – what lessons for multilateralism? Int Organ Law Rev 16:299–338 Fee E, Cueto M, Brown TM (2016) At the roots of the World Health Organization’s challenges: politics and regionalization. Am J Public Health 106(11):1912–1917 Kickbusch I, Silberschmidt G, Buss P (2007) Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health. Bull World Health Organ 85:243–244 Lynch C (2019) Trump administration takes down Biden’s legacy – at the U.N. foreign policy, Sept 23, 2019. https://foreignpolicy.com/2019/09/23/trump-administration-takes-down-bidens-leg acy-at-the-u-n/. Accessed 24 Oct 2020 McCarthy M (2002) A brief history of the World Health Organization. Lancet 360:1107–1182

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Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand (2007) Oslo Ministerial Declaration – global health: a pressing foreign policy issue of our time. Lancet 369:1373–1378 Mumford SD (1996) The Vatican and World Population Policy: an interview with Milton P. Siegel by Stephen D. Mumford. https://www.population-security.org/29-APP3.html. Accessed 9 Nov 2020 PAHO (1999) The Pan American Sanitary Code toward a hemispheric health policy. https://iris. paho.org/handle/10665.2/5668. Accessed 1 Nov 2020 Silberschmidt G, Matheson D, Kickbusch I (2008) Creating a committee C of the World Health Assembly. Lancet 371(9623):1483–1486 Snyder A (2017) Halfdan Mahler: obituary. Lancet 389:30 UN (1945) Charter of the United Nations, 1945 UN (1948) United Nations Treaty Series – treaties and international agreements registered or filed and recorded with the Secretariat of the United Nations, vol 16 UN (2016) World Economic and Social Survey 2014/2015. Learning from national policies supporting MDG implementation, E/2015/50/Rev.1 ST/ESA/360 WHO (1958) The first ten years of the World Health Organization WHO (1968) The second ten years of the World Health Organization 1958–1967 WHO (1988) Four decades of achievements, highlights of the work of WHO WHO (2000) Tobacco company strategies to undermine tobacco control activities at the World Health Organization: report of the committee of experts on tobacco industry documents, July 2000 WHO (2003) Resolution EB112.R1: ad hoc open-ended intergovernmental working group to review the working methods of the Executive Board WHO (2008a) The third ten years of the World Health Organization 1968–1977 WHO (2008b) WHO, International Health Regulations (2005), 2nd edn WHO (2010a) The future of financing for WHO, EB 128/21 WHO (2010b) WHO; WHA63.10 partnerships WHO (2011a) The forth ten years of the World Health Organization, 1978–1987 WHO (2011b) WHO: bugs, drugs and smoke: stories from public health WHO (2012) Director-General addresses reforms in WHO financing, opening remarks at the Programme, Budget and Administrative Committee of the Executive Board, Second extraordinary meeting in Geneva, 6 Dec 2012. https://www.who.int/dg/speeches/2012/reforms_ 20121206/en/. Accessed 25 Oct 2020 WHO (2013) Programme budget 2014–2015, WHA Res 66.2 WHO (2016) Framework of engagement with non-state actors, WHA Res 69.10 (also in WHO basic documents) WHO (2019) Thirteenth general programme of work, 2019–2023, approved in resolution WHA71.1. https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf. Accessed 10 Nov 2020 WHO (2020a) Basic documents, 49th edn. World Health Organization, Geneva WHO (2020b) WHO programme budget portal. http://open.who.int/2020-21/home. Accessed 25 Oct 2020 WHO (2020c) COVID-19 virtual press conference – 15 April 2020 – transcript. https://www.who. int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-con ference-15apr2020.pdf?sfvrsn¼1b9ed28d_2. Accessed 25 Oct 2020 WHO (2020d) A73/25 audited financial statement for the year ended 31 Dec 2019 WHO (2020e) A healthier humanity, the WHO investment case for 2019–2023. https://apps.who. int/iris/bitstream/handle/10665/274710/WHO-DGO-CRM-18.2-eng.pdf. Accessed 31 Oct 2020 WHO (2020f) WHO results framework. https://www.who.int/about/what-we-do/thirteenth-generalprogramme-of-work-2019%2D%2D-2023. Accessed 31 Oct 2020

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Index

A Accessibility, 1296 Accidental workplace injuries, 2259 Accidents, 838 Accountability, 1642, 2769 Accountability and aid effectiveness (AAE) research contribution to global health practice, 274–277 improvement for global health, 266 legal basis, 265–266 methodology, 280–285 practice steps to conduct, 286–290 principles, 270–272 Accra Agenda for Action, 268 Active Living’ programme, 800 Activities of daily living (ADLs), 1100, 1845–1847 Actor-network theory (ANT), 1889 Acute lower respiratory infection (ARLI), 723 Adaptive cycle, 2135 Adaptive management, 2101, 2135, 2139 Addis Ababa Action Agenda, 269 Adolescent health, 979, 1073, 1081 adolescent-friendly healthcare, 982 adolescent nutrition, 979–980 mental health, 980–982 sexual and reproductive health, 980 Affordability, 1296 Africa challenges, digital transformation, 157–159 digital divide, 152–153 digital health, 144–152 emerging technologies, 155–156 Health workers, 154–155 information and communication technology workers, 155 mobile phone ownership, 153 public health reform, 160–162

African Physical Activity Network (AFPAN), 801 Age-adjusted mortality, 453 2030 Agenda for Sustainable Development, 269 Age-specific fertility rates (ASFRs), 370, 372 Age weighting, 187 Aging, 1014–1020, 1027, 1030, 1034, 1036, 1037 Agriculture, 1972–1975 Agriculture, nutrition and health (ANH), 767 AIDS, 1157, 2417 Airflow obstruction, 441, 442 Air pollution, 2235–2237 AAP, 720, 724–729 controlling and mitigating measures, 733 environmental protection agencies, 721 HAP, 720, 722–724 meteorological factors, 721 mitigation strategies, 729–733 multilateral agencies, 734 national standards, 721 quality monitoring systems, 721 Air quality guidelines (AQG), 721 Air quality management system (AQMS), 729 Air quality monitoring (AQM), 729 Airway hyper-responsiveness, 442 Alcohol, 830, 1279, 1285, 1290, 1292, 1303 consumption, 1098 Alcohol use, 1162 chronic disease categories, 690 consumption level, 696 definition, 682 disease and injury categories, 687 in early history, 681–682 economic wealth impacts, 710 exposure to, 683–686 fetal alcohol syndrome, 702 health and social harm, 711

© The Editors and the World Health Organization 2021 R. Haring (ed.), Handbook of Global Health, https://doi.org/10.1007/978-3-030-45009-0

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2882 Alcohol use (cont.) health outcomes, 703–705 ischaemic heart disease and ischaemic stroke, 699 mental disorders, 701 mortality and burden of disease, 705–707 pancreatitis, 698 per capita consumption, 684, 686–687 prevalence, 685 risk factors, 681 social harm, 710–711 sociodemograhics, 686 trends, 707 types of, 682 unintentional and intentional injuries, 700 Algorithm bias, 1802 Alma Ata Declaration, 9, 266, 2555, 2810–2813 Alpha-1 antitrypsin deficiency (A1ATD), 443 Alternative medicine (AM), 1461 Ambient air pollution (AAP), 447, 720 health impacts, 728 industrial emissions, 727 landfills and incineration, 728 life expectancy, 732 power generation, 728 sources and physicochemical characteristics, 724 vehicular emissions and re-suspended road dust, 727 Andago, 1841 Animal health, 1973, 1974, 1981 Antenatal care, 958 Antibiotics, 1110, 2380 molecular understandings of resistance, 2385–2386 primacy and discovery, 2382 therapeutic strategies, 2386–2387 Anti-citizen acts, 38 Anti-malaria partnership, 2640 Antimicrobial peptides, 2387 Antimicrobial resistance (AMR), 2317, 2331, 2380, 2661 associated with superbugs, 2384 drivers and triggers of, 2383–2384 economic burden, 2381 emerging patterns, 2382–2383 future perspectives, 2387–2388 pathogenicity, virulence and, 2385 rationale for, 2383 Antipsychotic medications, 753 Antiretrovirals (ARVs), 218

Index Antiretroviral therapy (ART), 85, 216, 575, 577–579 in adolescents, 580 in children, 580 goals, 576 immune reconstitution syndrome, 579–580 patient adherence, 580 Argentine haemorrhagic fever, 1976 Armed conflict, 2438, 2439, 2442, 2447, 2451, 2453, 2454, 2461, 2463–2468 Armeo Power, 1837 Arsenic poisoning, 2237–2238 ART, see Antiretroviral therapy (ART) Artificial intelligence (AI), 1669, 1778 data, 1788 definition, 1778 ethics of, 1802–1804 healthcare examples, 1797–1799 systems, 1179 ARVs, see Antiretrovirals (ARVs) Asbestos, 2238–2239 Ashoka Global Academy Foundation, 2677 Asia Pacific Forum on Sustainable Development (APFSD), 1907 Asia Pacific Initiative on Reproduction (ASPIRE), 901 5As model of physical activity Counselling, 809 Assessed contributions (AC), 2838, 2868, 2870 Assisted reproduction technology advocacy organizations, 900–901 history of, 898–899 rights, 899–900 Assistive robots, 1845 physically-assistive robots for ADLs, 1845–1847 robot prostheses, 1847–1851 safety, 1852 Assistive technology (AT), 1845 Astana Declaration, 1653 Asthma, 446, 2265 Asylum seekers, 391 Atherosclerosis, 1153 AVA 500, 1825, 1827 Avian influenza (H5N1), 1979, 2317 Ayurveda, 109

B Baby-friendly Hospital Initiative (BFHI), 2081 Bacterial genome analysis, 2380 Bangladesh, 1424

Index challenges, 1426 demographics, 1424 disease burden, 1424 environment, 1424 healthcare system, 1425 healthcare workers, 1425 Barcelona superblock model, 56 Bariatric surgery, 749, 757, 758, 771 Basic Emergency Obstetric Care (BEmOC), 2416 Battle-related deaths, 2442 Beclometasone, 451 Behavioural controls, 2269 Be He@lthy, Be Mobile, 654 Behvarz program, 2088 Beliefs, 1314, 1315 Bengal Beverage company, 2743 Beveridge model, 1373–1374 Bibliometric analysis, 2343 Big data, 323, 328, 1668, 1669, 1685, 1687, 1700, 1704–1705 analysis, 1791 challenges, 1799 description, 1789 evolution of, 1791 visualization of, 1790 Big Data analytics, 1669 Biodiversity, 1976–1979 Biodiversity and health, 2172–2173 agrobiodiversity, food and nutrition, 2176–2177 landscapes, health and healing, 2179–2180 one health, 2178–2179 policy developments in, 2174–2175 traditional medicine, health and livelihoods, 2177–2178 Biodiversity for Nutrition (BfN) initiative, 2176 Biodiversity-pathogen regulation, 2131 Biological hazards, 2268 Biological health hazards, 2268, 2586 Biomass fuels, 447, 727 Biomedical research and development, 2706–2707 advance market commitments, 2710–2711 global binding framework, 2713–2714 grants, 2708 open source drug discovery and development, 2712–2713 patent pool, 2711 priority review voucher, 2711 prizes, 2709–2710 Biomedicine, 1281 Biopower, 1136–1139

2883 Biosocial analysis, 1129 Bismarck model, 1374–1375 Black carbon, 1953 Bloomberg Philanthropies (BP), 655, 656 Blue bloaters, 442 Body mass index (BMI), 499, 747, 762, 2066, 2074 Body sanctification beliefs, 1324 Bolsa Familia program (BFP), 2082 Bradley classification, 2214, 2215 Brazil, Russia, India, China South Africa (BRICs), 79 Brazil Family Health Strategy, 2082 Breastfeeding, 2080, 2081 Bribery, 1293 BRICs, see Brazil, Russia, India, China. South Africa (BRICs) Broad-based national and international coordination and collaboration, 2056 Bronchopulmonary dysplasia, 446 Budesonide, 451 Building Healthy Communities (BHC), 1992 Building Resources Across Communities (BRAC), 2560 Built environments, 55 Bupropion, 755, 756 Burden of disease (BoD), 1399, 2071, 2198, 2200, 2202, 2444 and climate change, 2455–2456 definition, 2440 in humanitarian settings, 2444–2453 Burns, 977–978 Business ethics, 2728, 2729 Business market stakeholders, 2728 Bus rapid transit (BRT) systems, 733, 1962 C Cadmium, 2239–2240 Calcium supplementation, 965 Calculus, 242 Cancer, 1151 breast, 474–476 cervical, 488–490 childhood, 477–479 colorectal cancer, 479–482 esophagus, 483–484 global burden of, 466–470 global incidence, 461, 463 global trends and pattern of, 470–472 Globocan data, 462 incidence, 460 liver, 484–485 lung, 473

2884 Cancer (cont.) mortality, 461, 463 prevalence, 461, 463 prostate, 485–486 reliable estimation, 460 statistics, 466 stomach cancer, 486–487 urinary bladder, 487–488 Capacity building, 1552 Capitalism, 1278 Carbon dioxide (CO2) emissions, 1953 Carcinogens, 177 Cardiovascular diseases (CVDs), 424, 782, 2264 age, 428 community-based interventions, 434 diabetes, 430 diet and low physical activity, 429 economic burden of, 430–432 fiscal and intersectoral interventions, 432–433 health system interventions, 434 high low-density lipid cholesterol, 429 hypertension, 428–429 interventions to reduce, 432–434 ischaemic heart disease, 427 public health interventions, 433 risk factors, 427–430 stroke, 427 tobacco smoking, 429 Carebots, 92 Care cascades, 1449, 1450 Care coordinator/manager model, 2564–2565 Care delivery team model, 2564 Care delivery value chains (CDVCs), 1562 Case-control study aetiological/risk factors, 178 criteria, 178 microcephaly, 179 personal recall process, 179 public health control measures, 178 Case disability ratio (CDR), 2201 Case fatality rate (CFR), 183 CCGHR, 2798 CCR5 antagonists, 576 Cervical cancer, 488–490, 1152 Charismatic authority, 1134 Chemical, biological, radiological and nuclear (CBRN) threats, 2650 Chemical hazards, 2267, 2585–2586 Chemicals and toxic substances, 2229, 2250 air pollution, 2235–2237 commercial purposes, 2228

Index commercial use, 2233 heavy metals, 2237–2244 noncommunicable diseases, 2234 pesticides, 2228 Stockholm Convention, 2248–2251 WHO, 2235 Chest pain in women, 1150 Chikungunya, 2317 Child-centered approach (education), 2042 Child-focused initiatives, 1290 Child health effective emergency care, minimum requirements for, 971 high quality health care systems, 968 injuries (see Injuries) nutritional disorders, 964–967 pediatric emergency care, in resourcelimited settings, 970–971 pediatric resuscitation and hospital guidelines, 971–973 quality of hospital care, 968–970 services, 2417 UHC, 982–983 Childhood cancer, 477–479, 973–974 Childhood pneumonia, 446 Child restraints, 830 Child-woman ratio (CWR), 372 Chinese barefoot doctors model, 2560 Cholera, 2355, 2356 lack of trust, 2356–2357 rumours, role of, 2357–2358 Cholera treatment centres (CTC), 2357, 2358, 2360 Chronic bronchitis, 723 Chronic diseases, 176, 496, 527, 995, 1002, 1005 management services, 1737 Chronic limb ischemia (CLI), 1847 Chronic obstructive pulmonary disease (COPD), 723, 2265 airflow obstruction, 441, 442 assessment, disease severity, 444 continuous predication equations, 441 definition, 440 diagnosis, 440 environmental exposures, 441 exacerbations, 449, 450 global burden and trends, 452, 454 inflammatory disease, 441 LMICs, 440 lung injury, 445–449 multi-morbidity, 454 phenotypes, 442

Index prevention and treatment, 450–452 spirometry, 441, 443 symptoms, 443 Chronic renal insufficiency (CRI), 514 Chronic respiratory diseases, 441, 451, 763, 1153 Ciclovías initiative, 56 Citizen-based reporting, 1750 City of Fortaleza, 811 City resilience approaches, 56 Civil registration and vital statistics system, 322, 1754 Civil society organisations (CSOs), 638, 655 Clean air solutions, 733 Clean birth kits (CBKs), 959 Client financial transactions, 1750 Client health records, 1752 Client identification and registration, 1752 Climate Action Plan (CAP), 2003 Climate change and burden of disease, 2455–2456 cases, 2023 and humanitarian crises, 2453–2455 mitigation strategies, 732 water-related disease frameworks, 2213–2216 Cluster approach, 2665–2666 Clustered random sampling, 201 Codebook, 204 Coercive adoption, 1357 Cohort analysis, 352 Cohort life expectancy, 362–363 Cohort study confounding factors, 176 methodological approach, 177 Collaborative governance, 2646–2647 Collaborative trans-national research, 172 Colloidal suspensions of nanoparticles, 2387 Colorectal cancer, 479–482, 1312, 1318 Commerce, 1276, 1278 Commercial and corporate determinants of health (CDOH) abstinence-focused approaches, 1277 capitalist markets, 1277 constructive dialogue, 1302–1305 consumer choice, 1283, 1284 CSR, 1294, 1295 demerit goods, 1279 direct effects, 1277 engagement and exclusion, 1285 indirect effects, 1277 industry arguments and framing tactics, 1296–1302

2885 industry denialism, 1288 lobbying, 1291–1294 marketing, 1289–1291 maximise profits, 1282, 1283 negative externalities, 1279, 1280 power, 1286, 1287 public health engagement, 1279 social vs. individual responsibility, 1280–1282 socioeconomic inequalities, 1278 supply chains, 1295 transcontinental corporation, 1278 unhealthy commodities, 1296, 1297 Commercial determinants of health, 619, 620, 635, 644, 653, 658, 659, 669, 672, 673, 1170 Communicable diseases, 2527–2528 diarrheal diseases and enteric infections, 961–962 humanitarian health efforts on, 2452–2453 in humanitarian settings, 2451–2452 LMICs, 2450–2451 lower respiratory tract illness, 960–961 Communities for a better environment (CBE), 1989 Community-based ethno-cultural services, 126 Community-based HIV testing services, 562 Community-based interventions for behaviour change, 930 Community care, 1652 Community health, 2177 Community health worker program, 127 Community health workers (CHWs), 2091, 2533, 2555 case detection and adherence to care, 2567–2568 child health, 2527 clinical care of common condition, 2569 communicable diseases, 2527–2528 community engagement, 2531–2532 data management, 2531 definition, 2526 functions, 2566–2569 health education and promotion, 2566 maternal and newborn health, 2527 mobilisation of community resources, 2532 non-communicable diseases, 2528 origin of, 2560 pre-service training, 2530 role of, 2561–2562 selection, 2529–2530 women volunteer, 2572 working conditions, 2530–2531

2886 Community-level collaboration, 2669–2674 Community management of acute malnutrition (CMAM), 2411 Community mobilization, 1642–1643 Community of practice, 770 Community organizer and capacity builder model, 2566 Comparative effectiveness research application in drug development, 2153 definition, 2152 implementation in low to middle resource countries, 2156–2162 medical devices, 2155–2156 Comparative risk assessment (CRA), 2202, 2203, 2206, 2207 counterfactual scenario, 2204 exposure assessment, 2202 health data identification, 2204 health outcome, 2204 Complementary and alternative medicine (CAM), 124 Complementary medicine (CM), 1461 Complementation, 2459 Complex adaptive system, 1543 Complex emergencies, 2439, 2453, 2455 access to diagnostics and laboratory services, 2401 challenges of, 2402 cluster approach for humanitarian coordination, 2403 contingency and preparedness planning, 2401 definition, 2395 effective governance, 2399 epidemiology, 2397 features, 2395 follow-up and recovery, 2411 and global health, 2397–2398 global health response, 2403 health services for displaced population, 2409 humanitarian and health coordination, 2403 investigation and management of disease outbreaks, 2408 logistics and essential health supplies, 2402 malnutrition, 2410 management of, 2424 mobilization of resources, 2402 multisectoral coordination platforms, 2400 phases of, 2395 post complex emergency, 2407 preparedness for, 2399 presentation and utilization, 2408

Index public health consequences, 2398–2399 public health interventions during, 2396 risk assessment, 2400–2401 surveillance and early warning systems, 2401 Complex sampling, 201 Complex systems science, 2104, 2133 Comprehensive risk assessment, 2601 Computer-controlled surgery robots, 1819–1822 Concealment, 180 Concurrent mixed method design, 246, 247 Conference of Parties (COP), 641, 642 Confidentiality, 1075 Confront, critique, challenge (3C skills), 2484–2485 Consortium for Health Research in Transition Societies (COHORTS), 2071 Constructive dialogue businesses, 1303–1305 community-and international-level sporting participation, 1303 environmental health, 1302 human health, 1302, 1303 internal and external processes, 1303 Constructivism, 242, 243 Contemporary globalization, 30 Contestation, 1917 Continuing medical education (CME), 180 Continuity of care, 2460 Continuous positive airway pressure (CPAP), 960 Contraception, 754 Contra Costa Interfaith Supporting Community Organization (CCISCO), 2005 Control knobs framework, 1444 Conventional oxygen therapy (COT), 960 Convention on Biological Diversity (CBD), 2170 Convention on the Elimination of Discrimination Against Women (CEDAW), 267 Convention on the Rights of the Child, 267 Convergent/parallel study design, see Concurrent mixed method design Cooperation, global health aid agencies, 2669 cluster approach, 2665–2666 community-level collaboration, 2669–2674 contracted agencies, 2669 donor coordination, 2667–2669 funding coordination, 2664 G7 and G20, 2661

Index GAVI, 2664 Global Fund, 2663 GOARN, 2666–2667 ICT, 2678 issue-specific health policy alliance, 2662 MDGs and SDGs, 2660 MOU-based/partnership-type collaborations, 2675–2676 new funding scheme, 2677 private companies for implementation, 2674 technical advisory, 2677–2678 COPD assessment test (CAT), 451 Coping, 113 Coronary artery disease (CAD), 510 Coronary heart disease, 177 Coronavirus, 2476, 2496 Coronavirus disease 2019 (COVID-19), 1156, 2093, 2367, 2371, 2372, 2452, 2453, 2457, 2462, 2465, 2731 effect on migrant labourers, 2732–2734 individual social responsibility, 2745–2746 multidirectional and multilevel trust, 2367–2368 outbreak, 2856 politicization and geopolitics, 2370 prioritisation, 2369 role of corporates, 2737–2738 role of state Government, 2736–2737 Corporate citizenship, 2729 Corporate determinants of health, 1276 Corporate social responsibility (CSR), 635, 1294, 1295, 1305, 2676 Bengal Beverage company, 2743 business case for, 2718–2728 and Companies Act 2013, 2738–2740 definitions of, 2718–2726 evolution of, 2728–2730 Infosys Foundation, 2743 ITC Limited, 2744 State Bank of India, 2743 Correlational study, see Ecological study Corruption, 1293 Cost-effective approaches, 2492 Country coordinating mechanism (CCM), 2663 Country Preparedness and International Health Regulations (CPI) Programme, 2325 Coupled human-natural systems, 2135 CR2-Haptic, 1840 Cross-sectional study macro-structural factors, 175 public health planning, 175 temporal relationship, 176

2887 Cross-validation, 1787 Crude birth rate, 368 Crude death rate, 356–357 Crude migration intensities (CMIs), 375–376 Crude migration probability (CMP), 376 Crude migration rate (CMR), 376 Cryptococcal meningitis, 546 Cultural acceptability, 1296 Cultural capital, 1351 Cultural competence, 118–120, 129 benefits, 1267, 1269 improvement of sensitivity, 1267 knowledge and self-awareness, 1267 reflexivity, 1268 Cultural determinants of health, 1251, 1267–1269 Cultural diversity, 104, 105, 108, 118 Cultural health capital, 116 Cultural humility, 119 Culturally distinct approaches to health, 111 Culturally dynamic partnerships, 121 Culturally recognized illnesses, 1261, 1262 Cultural relativism, 1253 Cultural safety, 120 Cultural sensitivity, 1254 Culture, 104, 1250 aetiology and experience of disease, 109–111 awareness and sensitivity, 1267 competence, 1267–1269 emic perspective, 1253 ethnocentrism, 1254 factors, 1251 folk healing system, 1263–1265 folk illnesses (see Culture-bound syndrome) global mental health, 1257–1259 health care providers, 1253 health, illness, and well-being, 1254–1257 health-seeking behaviour, 111–113 idioms of distress, 1259–1261 idioms of resilence, 1259–1261 impacts on healing relationship, 114–117 insider’s view, 1253 patterns of behaviour, 1251 racism and discrimination, 117–118 stress, coping and resilience, 113–114 and values, 1655 Culture-bound syndrome, 1261–1263 Cyberknife system, 1821 Cycling, 777, 789, 803, 811 Cytomegalovirus, 547

2888 D Data analysis, 209–210 bias, 1803 coding, 1755 collection, 998, 1755 dictionary, 204–205 exchange, 1755 governance, 1764–1767 mining, 1784 normalization, 1803 ownership, 1807 saturation, 228 services, 1755–1757 sharing, 1876–1877 DDT spray, 2245 Decision support systems, 1737 Declaration on the Right to Development (DRD), 267 Decolonise global health movements, 15 Degrees of freedom (DOF), 1831 Delinkage, 2707 Dementia, 1154 Demographic assessments, 555 Demographic dividend, 93 Demographic transition colonial age, 77–79 emerging market, 79 geo-economic world multipolarity, 80 Dengue, 2317 Depression, 753 Descriptive analytics, 1791 Determinants of health, 1046, 1072, 1950, 2452, 2468 DHIS2 system, 278 Diabetes, 1152 Diabetes mellitus age-standardized prevalence, 504–509 blood glucose control, 526 built environment, 526 in China, 520–521 and co-morbidities, 510–514, 519 complications, 500–501 diagnosis and early detection, 526 diagnostic criteria, 499 economic impact, 516, 519 fiscal and legislative measures, 526 healthier eating and physical activity, 527 health impact, 510 in India, 521–523 life course approach, 525 management, 526 and mental health, 515

Index pathophysiology, 498 population-based prevention, 525 prevalence, 497, 505, 508, 509, 519 and quality of life, 515–516 risk factors, 499–500 social impact, 518–519 in United States, 523–525 Diabetic ketoacidosis, 500, 502 Dialectics, 243 Diarrheal diseases, 961, 962 Diet and physical activity (DPAS), 801 Dietary approaches to stop hypertension (DASH), 751 Diet-related noncommunicable diseases, 2071 Diets, 1312 adherence, 750 behavioural techniques, 750 macronutrient compositions, 750 nutritional issues, 751 ultra-processed foods, 751 Diffusion of innovations theory, 1345 Digital health, 1735, 1739, 1778, 1785, 1794, 1808 evaluation of, 1768–1770 innovation ecosystem, 150 taxonomy and applications, 1749–1757 Digitalization, 1713, 1719, 1748–1758, 1760–1762, 1764, 1768–1770 Digital marketing, 768 Digital media, 52 Dilution hypothesis, 2131 Dioxin, 728 Direct benefit transfer, 2735 Direct end-user technology, 1343 Direct-use gatekeeper technology, 1343 Disability, 995, 1002, 1005, 1006, 1008 Disability-adjusted life years (DALYs), 185–187, 453, 454, 1830, 2198, 2199, 2201, 2206, 2212, 2439, 2445 Disability-free life expectancy (DFLE), 1100 Disability weights, 186, 2200 Disaster, 2336, 2438, 2442, 2443, 2446, 2451, 2453–2455, 2461, 2463–2465, 2467, 2468 See also Natural disasters Disaster-induced mortality, 2343–2344 Disaster relief activities, 2665 Disaster risk management (DRM), 2325 Disaster risk reduction (DRR), 2320 Disease outbreak, 2450, 2462, 2465, 2467 Disease surveillance practices administrative data, 321 civil registration and vital statistics data, 321

Index clinical data, 320 diagnostic testing and long-term capacity development, 331 ethical concerns, 332–333 limitations, 323, 330–333 modeling and satellite estimate, 329–330 national system innovation, 334 negotiating partnership, 333 non-health digital data, 328 point of care data, 324 real time sequence data, 327 representativeness, 331 sero-surveillance, 325–326 symptomatic data, 326–327 syndromic data, 328 telecommunications data, 329 verbal autopsies, 324 Disease surveillance systems, 2406 Displaced populations, 2442 Distributional inequality, 2540 Diversity, 173, 1180 Donor coordination, 2667–2669 Donor funding, 1636 Double burden of malnutrition (DBM), 763, 2066, 2071, 2091 adults, 2073–2074 school age children and adolescents, 2073 under-five year olds, 2072 Drivers-pressure-state-impact-response (DPSIR) framework, 1231 Drowning, 977 definition, 841 environmental factors, 843 human factors, 841 Drugs for Neglected Diseases initiative (DNDi), 2776 Dynamic equilibrium hypothesis, 1094 Dyslipidemia, 728 E Earmarking funds for health, 1635 Ebola, 2476, 2496 outbreak, 1178, 2855 virus, 1974, 2317 Ebola Treatment Centers (ETC), 2363 Ebola virus disease (EVD), 2360–2362 economic dimension and Ebola business, 2364–2365 international humanitarian health intervention and neo-colonial legacies, 2365–2367 political and historical dimensions, 2362–2364

2889 Ecohealth, 2172 Ecological community, 2131 Ecological study healthcare organisations, 174 hypothesis, 175 public health problem, 174, 175 Economic development, 1097, 1098, 1118 Economic disparities economic and social interventions, 1216 maternal and child health, 1221 mortality rate, 1223 Economic globalization, 10, 2621 Economic integration, 32 Economic libertarians, 1299 Economic migration, 77 Ecosystem, 2131, 2296–2298, 2303 Education, 1058–1059 and employment, 1068–1069 and migration, 1069–1070 student enrolment, in secondary and tertiary education, 1075–1076 Educational attainment, 1095, 1098, 1103, 1107, 1121 Effective coverage (EC), 1451 Effective humanitarian aid, 263 Effectiveness, 305, 310 eHealth, 1749, 1758, 1759 definition, 1732 diffusion of ehealth solutions, 1739–1740 evolution of, 1735 policy, 143 rise in public health, 1734–1735 sources, 1736–1738 success factors for solutions, 1741–1742 Elderly population, health status of causes of death, diseases and risk factors, 1002–1005 death/mortality, 994 health status, disability, and health expectancy, 1005–1008 life expectancy at birth, 1000–1001 eLearning services, 1738 Electronic health records, 1710, 1713–1714, 1736 Electronic medical records, 1736 Electronic medication services, 1738 Electronic nicotine delivery systems (ENDS), 629, 666–668, 672 Electronic non nicotine delivery systems (ENNDS), 629, 666–668, 672 Elemental mercury, 2242 Elmau Summit, 2661 Embodiment, 1994

2890 Emergence, 2103 Emergency medical services (EMS), 975 Emergency medical teams (EMT), 2666 Emergency response framework (ERF), 2326 Emergency triage assessment and treatment (ETAT), 970 Emergent property, 2135 Emerging infectious diseases, 2108, 2114, 2115 Emerging zoonoses, 2112, 2115 Emigration dispersion index (EDI), 381 Emigration spread, 381 Emissions inventories, 731 E-mobility, 1959 Emollient therapy, 929 Emphysema, 440, 441, 448 Employer responsibility, 2272 Employment, 1059–1061 and education, 1068 and migration, 1070 End-effector therapy robots, 1838–1841 Endemic diseases, 1400 Endemic zoonoses, 2109, 2112 Endocrine disorder, 770 Endophytes, 449 Endoscopic surgery robots, 1822–1823 Endotypes, 443, 447 End stage kidney disease (ESKD), 514 Energy balance, 744 Engineering controls, 2269 Environmental and Community Investment Fund (ECIA), 2001 Environmental burden of disease (EBoD), 2198, 2205–2207 health indicators, 2201–2202 Environmental determinants, 916–918, 935, 937, 938, 940 Environmental health, 1234, 2298, 2305, 2306 challenges, 1241 inequalities in (see Environmental inequality) Environmental impact assessment (EIA), 1932 Environmental inequality, 1234 definition, 1234 dynamics, 1235 and environmental justice, 1235–1236 paradigm for global health, 1240–1243 urban perspectives on, 1236–1240 Environmental injustices, 1997 Environmental justice, 1235–1236 Environmental risk factors, 1951–1958 Environment and health, 2170 Epidemic, 2100–2103, 2108, 2112, 2120, 2126, 2143

Index injustice, 1565 intelligence, 334 zoonoses, 2109, 2112 Epidemiological assessments, 555 Epidemiology analytical studies, 174–179 DALYs, 185–187 descriptive studies, 173, 174 diversity, 173 HALYs, 184 incidence, 181, 182 intervention, 179–181 low-and middle-income countries, 172 mortality, 182, 183 prevalence, 182 QALYs, 184, 185 strengths and limitations, DALYs and QALYs, 187 Equipment and asset management, 1754 Equitable distribution, 2545 Equitable financing coverage for poor and vulnerable groups, 1630–1631 general tax funding, 1625–1626 public sources of, 1624–1625 risk-pooling and redistibution, 1627–1629 voluntary health insurance, 1631–1632 Equitable partnerships, 2485–2486 Equity, 1380, 1489 and gender-based interventions, 2056 Ergonomic hazards, 2267 Erigo, 1840 Erikson-Goldthorpe-Portocarero scheme, 1096 Esophagus cancer, 483–484 ESSENCE on Health initiative, 2652 Essential Newborn Care (ENC), 971, 972 Essential nutrition actions, 2074 adults and older people, 2087 first 1000 days, 2079–2081 preconception, 2077–2078 pregnant and lactating women, 2078–2079 preschool years, 2083–2084 school age, 2085–2087 Essential trauma care, 975 Estimation methods, 998 Ethanol, 682 Ethics of artificial intelligence, 1802–1804 Ethnicity, 1198–1201, 1404 Ethnocentrism, 1254 Ethnomedicine, 1263–1265 EU-Africa Global Health Partnership, 2650–2651

Index European Community Household Panel (ECHP), 1114 European Health & Life Expectancy Information Systems (EHLEIS), 1114 European Health Expectancy Monitoring Unit (EHEMU), 1114 European Respiratory Society, 454 European Social Survey (ESS), 1114 EU Statistics on Income and Living condition (EU-SILC), 1100, 1114 Evaluation design experimental designs, 304 non-experimental designs, 305 quasi-experimental designs, 305 Every Newborn Action Plan (ENAP), 957 Evidence-based global health, 219 Evidence-based medicine, 1777 definition, 2150 integration approach in primary healthcare, 2150 intersection with comparative effectiveness research, 2152–2156 See also Comparative effectiveness research Evidence-based policy and translation, 2628–2629 Evidence-based practice, 120 evidence-based medicine, 219 global health practitioners, 220 mental healthcare, 221 qualitative research, 220 scientific research, 219 Evidence-based strategies, 2079 Evolutionary biology, 1284 Executive Board (EB), 637, 2836 Exoanthropic’ zoonoses, 2108 Exoskeleton therapy robots, 1832–1837 Expatriate workers, 2277 Experimental designs, 304 Exposure-response function (ERF), 2202 Externality, 1279

F F-75, 966 Facility-based HIV testing services, 561–562 Facility management, 1754 Fair financing, 1381 Faith-based organizations, 2792 Falls, 978 in children, 833–834 definition, 832 in older people, 835–837

2891 False empowerment, 1358 Family caregiving, 88 formation, 1066–1068 Family Justice Center, 2003 Fasting blood sugar (FBS), 523 FCT, see Fundamental cause theory (FCT) Feature extraction methods, 1783 Fee-for-service (FFS), 1590 Fellowship support systems, 2677 Female genital mutilation (FGM), 1166 Fertility, 343, 348, 350, 351, 353–355, 366–374, 376–378, 382, 383 Fetal alcohol syndrome, 702 Fiduciary duty, 1282, 1283 Finacialisation, 32 Financial affordability, 2542 Financial alliance, 2662 Financial protection, 1171 Financial resources, 763 Financial RWD, 1862 Fire-related burns age risk groups, 838 gender, 839 physical environment, 839 Fire-related mortality rates, 837 Fluid Expansion as Supportive Therapy (FEAST) trial, 963 Foetal origins of adult disease, 1095 Folk healing system, 1263–1265 Food environments, 767 intake regulatory system, 744 and nutrition, 2420 security, 2022 subsidies, 1974 Food Environment Policy Index tool (Food-EPI), 767 Forced displacement, 2442 Foreign direct investment, 33 Formal care, 2556 Formal sector, 2732 Formative evaluations, 297 Formative research, 1327 Foundation for a Smoke Free World (FSFW), 669 Fourth Industrial Revolution, 2460 Fragile health systems, 2823 Framework Convention on Tobacco Control (FCTC), 1290, 2477, 2489, 2493, 2619–2620, 2645 Framework of Engagement with Non-State Actors (FENSA), 1303, 2867–2868

2892 Framingham Heart Study, 199 Freedom of choice, 1807 Frontier technology solutions, 156 Fundamental cause theory (FCT), 1346

G Galtung’s theory, 1546 Gamification, 2678 Gandhi’s theory of social trusteeship, 2729 Gates Foundation, 657 Gender, 61 barriers to mobility, 64–65 gaps, 1068 in health and humanitarian emergencies, 1176–1177 and health behaviours, 1158–1165 in health research, 1178–1179 and health workforce, 1179–1186 inclusive spaces, 68 inequalities, 345, 955 intersectionality, 62–63 pay gap, 1184–1186 policy implications, 66–69 society and culture, 1165–1170 travel patterns, 63–64 women’s mobility, 65 Gender-based violence, 1166–1167 General Agreement on Tariffs and Trade (GATT), 660, 2011 Generalization, 1787 Geographical distance, 381 GeoHealth, 2301 Geometric aggregation, 381 Germany, 1421 demographics, 1399 environment, 1422 healthcare system, 1423 health facilities, 1423 quality and outcome measures, 1423 workforce, 1423 Germ theory, 8 Gestational diabetes, 500 complications, 503 Gini coefficient, 1098 Global Activity Limitation Index (GALI), 1100, 1114 Global Adult Tobacco Survey (GATS), 204, 522, 649, 657 Global Alliance for Chronic Diseases (GACD), 2664

Index Global Alliance for Vaccines and Immunisation (GAVI), 2638–2639, 2664 Global Alliance on Physical Activity (GAPA), 802 Global burden of disease (GBD), 1863, 1867, 2204, 2228, 2232, 2233, 2235 diabetes mellitus (see Diabetes mellitus) 2018 Global Compact on Migration, 1080 Global development goals (GDGs) power of numbers in, 1890 Rio+20 Summit, 1897–1902 Global Energy Balance Network, 1292 Global Enteric Multicenter Study (GEMS), 961 Global expenditure on health, 1217–1220 disparities, 1219 first scenario, 1225 GDP, 1217, 1218 index of dissimilarity, 1218 second scenario, 1226 South East Asia Region, 1218 third scenario, 1226 total health expenditure per capita, 1225 Global financial crisis, 1061 Global Fund, 2663, 2760 activities, 2774 programs, 2774 Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), 2638 Global health, 2295, 2296, 2298, 2303, 2757, 2761–2779, 2795 in COVID 19, 4–6 definition, 17–19, 172 human resources (see Human resources, for global health) issues in, 21–23 malnutrition in (see Malnutrition) partnerships, 5 population dynamics (see Population dynamics) principles of, 20–21 UN initiatives in, 2809–2816 Global healthcare, 1497 Global health certificate programs, 2513 Global health diplomacy, 2641, 2642, 2790 Global health education certificate/track programs, 2513 evaluation, 2517–2519 faculty development/training, 2508 graduate degrees, 2512 on the job training, 2516–2517 medical, nursing, pharmacy and allied health schools, 2506–2507

Index non-accredited courses or training modules, 2515 post-graduate training, 2513 post-graduate training programs, 2507 schools of public health, 2506 standards of practice, 2519–2520 undergraduate degrees (programs), 2506, 2511 Global health financing, 1286 Global health governance, 1128, 1129, 1131, 1133, 1134, 1136 Global health governance (GHG) organizations, 2636 GAVI Alliance, 2638–2639 GFATM/Global Fund, 2638 Roll Back Malaria partnership, 2638–2640 stakeholders, 2640–2644 Stop TB Partnership, 2639–2640 UNAIDS, 2638 Global health partnerships (GHPs), 2628–2630, 2636 characteristics, 2633 global health training and research, impact on, 2635–2637 health systems, impact on, 2635 HIV/AIDS, 2631 malaria, 2632 tuberculosis, 2631 Global health security action group (GHSAG), 2649 Global health security agenda (GHSA), 2319, 2647–2649 Global health security agenda private sector roundtable (GHSA-PSRT), 2650 Global health security (GHS) capacities, 2324 concept of, 2316 contemporary framework, 2316 crises assessment, 2321 effective response management, 2327–2331 globalization, 2318 transmission of, 2316 Global health security index, 2737 Global health security initiative (GHSI), 2649–2650 Global health security reforms, 2320–2321 Global health training, 2481–2484, 2486, 2487, 2498 Global Initiative on Decent Jobs for Youth, 1076 Globalisation, 6, 21, 24, 764, 2757 Global life expectancy, 2200 Global lifespan inequality, 1110

2893 Global mental health, 1257–1259 Global mental health peer network, 593–596 Global migration and population health biological factors at migrant origin, 399 economic factors at migrant origin, 400 evolution of, 394–396 geographic and environmental factors at migrant origin, 399 health issues, 407–412 history and development of migrant health, 396–398 infectious diseases, 407–410 interface of national and global migrant health, 404–406 migrant workers, health issues in, 412 modern global migration, 390–394 non-communicable diseases, 410–412 refugees and displaced population, health issues in, 413 social and cultural factors at migrant origin, 399 Global Observatory on Health Research and Development, 2651 Global Outbreak Alert and Response Network (GOARN), 2666–2667 Global pandemics, 31, 34, 42 Global policy measures Key Global Policy Gaps, 2193–2194 Paris Agreement, 2191–2192 Sendai Framework for Disaster Risk Reduction, 2192–2193 Sustainable Development Goals, 2192 Global warming, 2495 Global Youth Tobacco Survey (GYTS), 657 Gobal health of ageing, see Population ageing God-mediated control, 1325 Governance, 1997 of data, 1800 Governance Alliance for Race and Equity (GARE), 1999 Governance models, in global health collaborative governance, 2646–2647 diffusion of governance, 2646–2648 GPW13 tobacco control agenda, 645 Graduate public health education, 2512 Great Law of Haudenosaunee Confederacy, 2303 Greenhouse gas emissions, 1953 Gro Health, 1799 Gross domestic product (GDP), 516, 1097, 1098, 1103, 1104, 1106, 1113, 1114, 1118, 1119, 1121, 1217 Gross migraproduction intensities (GMR), 377

2894 Gross regional product, 1097 Grounded theory, 245 Group of Seven (G7), 2661 Group of Twenty (G20), 2661 Growth retardation, 2068 Gut microbiome, 741

H Haddon Matrix, 826 Hantavirus pulmonary syndrome, 1978 Harmonization, 270 Harnessing Non-State Actors for Better Health for the Poor (HANSHEP), 2776 Hazard control biological waste, 2598–2599 chemical, 2599–2600 ergonomic hazard, 2600 health facility, 2602 orientation training, 2601 radiation exposure, 2600 specific protection, 2603 stress, 2601 ventilation, 2602–2603 violence, 2601 workplace, 2600–2603 work shifts, 2600 HEAL-TecH model, see Health Inequality and Technology model (HEAL-TecH model) Health-adjusted life expectancies (HALE), 2198, 2201 Health-adjusted life years (HALYs), 183, 184 Health and well-being, 2216–2218 Health and wellness element (HWE), 1991, 1992 Health architecture, 2757, 2764 Health behavior chronic conditions, 1313 lack of participation, 1313 quality of care, 1313 religious beliefs, 1315 socio-structural factors, 1313, 1316 structural differences, 1313 Healthcare (Health care), 57 access, 107 budget allocations to performance, 1708 collaboration for innovations, 1720–1726 community based response, 126–128 constituent-involving strategies, 127 costs, physical inactivity, 788 culturally diverse populations, 115

Index education and training, 122–123 efficiency and value, 1706 evidential strategies, 127 financing, 1378, 1396 health data governance (see Health data governance) intercultural frameworks of practice, 118–120 linguistic strategies, 127 medical pluralism and integrative medicine, 123–126 payment mechanisms, 1706–1707 peripheral strategies, 127 personnel, 1409 professionals, 112, 760 research and evidence, 120–122 routine data, 1703 sociocultural strategies, 128 technologies, 1227 workforce, 1395, 2489 Healthcare delivery system building blocks, 1394–1397 economic and political environment, 1407 governance and leadership, 1396–1397 healthcare financing, 1396 healthcare workforce, 1395 health information, 1395 medical technology, 1395–1396 physical environment, 1401 service delivery, 1394 social and cultural environment, 1405–1431 social determinants of health, 1400–1409 system inputs, 1409 system outputs, 1411–1418 system processes, 1409–1411 Healthcare provider, 1752–1753 communication, 1752 decision support, 1752 training, 1752 Healthcare systems Beveridge model, 1373–1374 Bismarck model, 1374 burden of disease, 1399 carbonated beverages, 765 challenges of, 1381–1384 characteristics, 1371–1372 components, 1377–1380 demographics, 1399 endemic disease, 1400 essential medicines products and technologies, 1379 goals, 1380–1381, 1397

Index health financing, 1378 human resources, for global health, 1379, 2487–2494 information on health, 1378 leadership and governance, 1377–1378 MAPPs, 759 meta-conditioners, 764 models, 1373–1377 National health insurance model, 1375–1376 nutrition transition, 764 obesity rates, 766–770 opportunities, 1384–1385 out-of-pocket model, 1376–1377 physical environment, 1398 policy and regulation, 1400 pragmatic consequences, 758 preparedness, 759–762–764 prevalence, 766 social environments, 1398–1399 systems approach to, 1397–1398 transnational food industry, 765 undernutrition, 766 universal health coverage, 758 Healthcare workers (HCW), 2477, 2478, 2487, 2490, 2491, 2493, 2494, 2496 hazards (see Occupational health hazard) health behaviour, 2594–2596 health benefits, 2596 Health data governance, 1709, 1711 coherent and standardised electronic health record systems, 1713–1714 data linkages, 1715–1716 data security, 1711, 1716 digital skill development, 1718–1720 digital transformation, 1716–1717 privacy, 1701, 1709 Health determinants, 405, 411, 412, 1057–1063 Health determinants index, 1240 Health disparities, 106, 403, 1337 behavioral interventions, 1326 determinants of health behavior, 1314–1315 health behavior, 1313–1314 Health domain, 1312 Health education model, 2565 Health equity, 31, 42, 1549, 1551, 1988, 1992, 1997, 2006, 2151, 2163 HiAP, 1998–2006 planning processes, 1993 trainings, 1993 Health expectancy, 1005, 1008 Health expenditure, 93–95 Health financing, 1445–1446, 1754

2895 Health hazard prevention health promotion (see Hazard control) secondary, 2603–2604 tertiary, 2604 Health house approach, 2562 Health impact assessment (HIA), 1932, 1964, 1966 Health impacts of climate change drought, 2187 extreme temperatures, 2185–2186 extreme weather events, 2186 floods, 2186–2187 Health in all policies (HiAP), 50–53, 1242, 1549, 1928, 1986–1988, 1992, 1997, 2006, 2039, 2443, 2550 approach, 1643 assessment and engagement, 1551 capacity building, 1552 co-benefits for health and education, 2054 contribution, 2048 at country level, 2055 country ownership and leadership, 2055 definition, 1933 drafting, 1992–1993 economic development and education, 2000–2001 environmental health and justice, 2003–2004 evaluation and monitoring of, 1942 frame planned action, 1550 full service and safe communities, 2001–2002 governance and leadership, 1999–2000 health and health equity, 2049 health promoting schools, 2049–2053 implementation of, 1939, 2054 international governance, 1929–1933 monitoring, evaluation and reporting, 1552 multiple toxic stressors, 1996 operational guidance, 1941 policy relevant urban indicators, 52 political commitment to operational commitment, 1941–1942 quality health care and services, 2004 relational equity measures, 1994 residential and built environments, 2002–2003 schools in SDGs era, 2056 in South Australia, 1929, 1942, 1944 supportive structures and process identification, 1550–1551 as strategic tool and approach, 1937–1938 transportation (see Transportation)

2896 Health in all policies (HiAP) (cont.) urban and transport planning policies, 51 urban population health, implementation on, 2004–2006 Health inequalities, 1102, 1327, 1337, 2822 health expectancy, 1099–1100, 1113 individual level, socioeconomic differences, 1094–1095 inequality measures, 1102 life expectancy, 1103 lifespan inequality, 1107–1108 lifespan variability, 1101 macro level, socioeconomic differences, 1097–1099 Health Inequality and Technology model (HEAL-TecH model), 1338, 1343, 1360 Health inequities, 58, 1986–1989, 1997, 2006, 2486 Health informatics, 1735 Health information, 1395 systems, 1738 Health insurance, 1074–1075 Health knowledge resources, 1738 Health literacy, 2090 health behaviors, 1322, 1323 health information and services, 1321 indirect effect, 1322 interventions, 1322 mediators, 1323 personalized medicine, 1321 socio-demographic factors, 1322 validated questionnaires, 1321 Health markets, 2762, 2780 Health policy, 799, 814 Health professionals, 2484, 2486, 2487, 2498 Health promoting school (HPS), 2043 challenges and realities, 2058 children and adolescent in transformative society, 2039–2040 “Education for all”, 2041 healthier schools for sustainable development, 2042–2043 health in all policies, 2039 health literacy, 2041 Jakarta Declaration, 2038 schooling and education, 2040–2042 in Thailand, 2042 Health promotion, 2671–2674 Health-proofing trade policy, 2028–2029 Health purchasing, 1637 Health-related quality of life, 184, 515 Health-related tax, 1300 Health resilience, 2193, 2194

Index Health Resources Availability Monitoring System (HeRAMS) monitors, 2407 Health services, 2016–2018 Health surveillance, 2271–2272 Health system performance assessment (HSPA), 1442 Health system recovery after complex emergency, 2425 strategy and plan, 2428 programme implementation, 2431 Health systems, 268, 272, 273, 276, 2757 accessibility, 1554 care performance at sub-national and facility levels, 1452–1454 control knobs framework, 1444 data from CIA World Factbook categories of information, 1392, 1393 definition, 1439 delivery and external context integration, 1564 and ecological thinking, 1544–1545 functions, 1442–1449 gender-responsive, 1171–1179 governance, 1440–1444 health financing, 1445–1446 health service coverage, 1449–1452 health services and outcomes, 1439–1440 health systems strengthening, 1447–1449 inter-cultural competence in, 1564–1565 and inter-sectorial imperative, 1545 interventions, 1072–1074 neglected tropical diseases, 1557–1559 political economy of essential medicines, 1557 quality-driven, 1561–1562 resource functions, 1446–1447 sexual and reproductive health and rights, 1175–1176 status quo in, 1553–1554 and structural interventions, 1548 structural violence, 1545–1548 universal health coverage, 1556–1557 value-based healthcare, 1555 WHO’s 100 core indicators, 1393, 1394 Health technology assessments (HTAs), 2153 Health tourism, 2017 Health worker activity planning, 1752 Health workers, 2536–2540, 2542, 2543, 2545–2549 Health workforce, 1179, 2515, 2526, 2530 discrimination, bias and harassment, 1182–1184 gender pay gap, 1184–1186

Index and leadership, 1180–1181 occupational segregation by gender, 1181–1182 Healthy ageing, 59, 82 Healthy life expectancy, 1093, 1099, 1100 Healthy life-years (HLY), 1113–1116, 1118–1120, 2198, 2201 Healthy migrant effect, 403 Healthy public policy (HPP), 1930 Heated tobacco products (HTPs), 629, 666–668, 672 Helping Babies Breathe (HBB), 971 Helping Babies Survive (HBS), 971 Herbal medicines definition, 1460 inclusion of, 1474 monographs and herbal pharmacopoeia, 1475 registration of, 1474 HFA2000, 266 Hierarchy of controls approach, 2268–2270 High-income countries (HICs), 621, 622, 626, 631, 762, 1097, 1098, 1105, 1817, 1818 Highly pathogenic avian influenza (HPAI), 1973 Histoplasmosis, 547 HIV testing services (HTS) community-based, 562 facility-based, 561–562 goals, 560 HIV partner notification services, 562 HIVST, 562 HIV testing strategy, 563–565 quality HIV testing, challenges of, 563 Homo economicus, 1283 Homo sapiens, 1284 Hospital robots, 1823, 1824 fill and pack delivery robots, 1824–1826 safety, 1829 targeted service robots, 1827–1828 telepresence, 1825–1827 Host, 2121 Household air pollution (HAP), 447, 720 SFU, 722, 723 solid waste burning, 723, 724 sources and physicochemical characteristics, 722 Household solid waste management, 723 Housing and urban development (HUD), 1987 Human bias, 1803 Human capital development, 2536

2897 Human development index (HDI), 2737 Human health, 741 Human immunodeficiency disease, 754 Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), 541–542, 545, 1050, 1052, 2417 acute HIV infection, 543–544 ART, 575–580 in children, 551–553 chronic HIV infection, 543–545 condom use, 564–566 cryptococcal meningitis, 546 cytomegalovirus, 547 diagnosis, 549–550 distribution, 553 EMTCT, 569–572 fusion inhibitors, 576 global response, 567–568 histoplasmosis, 547 HTS, 559–563 interventions, 581 and key populations, 553–559 life-cycle, 542–543 modes of HIV transmission, 548–549 origin of, 541 people living with HIV, 551 Pneumocystis jirovecii pneumonia, 546 pre-exposure prophylaxis, 570–574 prevention and treatment, 2417 regional HIV and AIDS statistics, 552 risk factors for transmission, 566 severe bacterial infections, 546 sexual transmission risk, 582 structure of HIV, 542 talaromycosis, 547 toxoplasmosis, 546–547 tuberculosis, 545–546 VMMC, for HIV prevention, 574–575 Humanitarian agencies, 2423 Humanitarian crisis, 2438 and climate change impacts, 2453–2455 impact on health, 2441–2444 Humanitarian intervention, 2351 Cholera, 2355–2360 Covid-19, 2367–2372 Ebola, 2360–2367 embodied mistrust, 2352 multidirectional mistrust, 2351–2352 normative power, 2352–2353 Humanitarian Reform Agenda, 2665 Human mortality database, 996 Human resource management, 1754

2898 Human resources, for global health, 2483 confront, critique, challenge, 2484–2485 equitable partnerships, 2486 funders, 2482–2483 healthcare systems, 2487–2494 knowledge publishers, 2482 leadership, 2496 logic model, 2480 planning decisions, 2495 practitioner and researcher, 2483 systems knowledge, 2485 target knowledge, 2485 trainers and trainees, 2481–2482 transformational knowledge, 2485 Human resources for health (HRH), 2476–2479, 2487, 2490, 2491, 2493–2496, 2498 Human rights approach, 602–605 Humidified high-flow nasal cannula (HHFNC), 961 Hypercholesterolemia, 429 Hyperosmolar hyperglycemic coma, 500 Hyperosmolar hyperglycemic state (HHS), 502 Hypertension, 753 I Idioms of resilience, 1265 Illicit drug abuse, 1163 Immigration diversification index (IDI), 381 Immigration spread, 381 Immunization, 443 Impact evaluations, 298 Implementation of digital health programs, 1757–1767 Implementation research, 2142 Incineration, 728 Income inequality, 174, 1096 Index of dissimilarity (ID), 1218 Indian integrated disease surveillance project, 326 Indian-Ocean Tsunami of 2004, 2344 Indirect-use gatekeeper technology, 1343 Individual social responsibility, 2745–2746 Indoor air pollution, 1170 Industrial emissions, 727 Industry 4.0, 142 Industry-engagement approach, 1285 Inequalities dignity and human rights, 1216, 1217 global disparities, 1217 governments’ achievements, 1216 health inequity, 1224, 1225 life expectancy, 1220

Index MMR and NNMR, 1221 mortalities, 1223 NCDs, 1222 non-skilled health professionals, 1221 reproductive health, 1222 RTA, 1224 Inequity, 1224, 1225 Infant health augmented infant resuscitator, 931 changes in, 929–931 childbirth and first week of life, 924 contextual and sociocultural factors, 939 donor human milk, 933 educational programmes, 928 environmental factors, 938–939 first month of life, 925 global goals and targets, 913–914 home-based care, 932 innovations, 917, 941 Innovative Multi-partner Research Program, 934 integrated sample-to-answer, quantitative PCR system, 932 issues and challenges, 922 low resource settings, 913–917 mobile health interventions, 931 open innovation collaborations, 934 point of care diagnostics, 932 pre-natal period, 922–924 private sector distribution model, 933 progress in, 918–922 SDG goals, 941 socio-economic and environmental determinants, 917 socio-economic and environmental drivers, 942 socio-economic factors, 935–938 surviving and thriving, 925–926 Infectious diseases, 172, 407–410, 1975–1977, 2101–2104, 2106–2108, 2114, 2115, 2117, 2126–2128, 2144 Infertility assisted reproduction technology, 897–901 behavioral causes of, 890 biological causes, 889–890 definition, 886 economic consequences, 895 education, 902 government policies, 903 marital instability, 893–894 methodological challenges, 887 prevalence of, 887 prevention of, 901

Index primary and secondary, 888–889 psychological consequences, 891 research, 904 social consequences, 891–893 stigma and discrimination, 893 support of women, 903 traditional treatment, 896–897 violence and abuse, 894–895 Influenza, 450 viruses, 2113 Influenza A (H1N1), 2317 Informal care, 2556 definition, 2557 factors affecting, 2571–2574 forms of, 2562–2566 and medical volunteerism, 2557 Informal sector, 2732 Information and communication technologies (ICTs), 1734, 2461, 2678 Informed consent, 1806 Inhaled corticosteroids, 450 Injuries care of injured child, 975–976 causes of, 825 classification of, 825 drowning, 841–844 falls, 832–837 global epidemiology, 974 poisoning, 844–849 prevention, 975 road traffic collisions, 826–832 treatment, 976–979 and violence, 1163–1165 InMotion system, 1840 Innovation, 1757, 1758, 1761, 1762, 1770 Innovation system medicine, 2687–2688 neglected tropical diseases, 2703–2706 patents, 2689–2692 test data protection, 2692–2694 trademarks, 2694–2695 vaccine, 2686–2687 Inorganic substances, 2244 Insecticide resistance, 2317, 2331 Institute of Medicine (IOM), 2086 Institutional norms, 2616–2617 Instrumental activities of daily living (IADL), 1100 Insurance coverage, 1075 Integrated air pollution control, 732 Integrated approach elements of, 1657–1660 integrated community care, 1659–1661

2899 Integrated care, 1652 Integrated case management of a sick child (iCCM), 2417 Integrated community case management (ICCM), 2092 Integrated information ecosystem, 52 Integrated management of childhood illness (IMCI), 972–973, 2088 Integrated Nutrition Program (INP), 2084 Integrated sample-to-answer, quantitative PCR (qPCR) system, 932 Integrated School Health Programme (ISHP), 2043 Integration, 2459 Integrative medicine, 125 Intellectual property (IP) rules, 2015 Intention-to-treat approach, 180, 181 Interactive voice response system (IVR), 149 Inter Agency Standing Committee (IASC), 2395, 2665 Inter-continental migration, 395 Intergovernmental Negotiating Body (INB), 2620 Internally displaced persons (IDPs), 2355, 2438, 2442, 2448, 2463, 2465, 2467 Internal migrant labourers, 2734 International Committee of the Red Cross (ICRC), 2841, 2867 International Consumer Support for Infertility (ICSI), 901 International diabetes federation (IDF), 501, 516 International Federation of Red Cross and Red Crescent Societies, 2663 International health, 5, 9–10 International health cooperation, evolution of, 2612 International Health Partnership, 268 International Health Regulations (IHR), 2316, 2318, 2617–2619 International investment regimes, 2013–2015 International Labour Organization (ILO), 2662 International Monetary Fund, 2477 International Network for Food and Obesity/ NCDs Research, Monitoring and Action Support (INFORMAS), 769 International non-proprietary names (INNs), 2694–2695 International Organization for Migration (IOM), 414 International Organizations, 2866

2900 International Sanitary Conference, 2839 International Society of Nephrology (ISN), 2676 International Tobacco Growers Association (ITGA), 634 International Trade Agreement, 1559–1560 Intersectionality, 1146, 1174, 1185 Intersex health, 1158 Interstate Migrant Policy Index 2019, 2734 INTERSTROKE, 199 Intervention mapping, 248 Intra-continental migration, 395 Intra-individual traits, 179 Intra-partum related events, 958 Intrauterine growth restriction (IUGR), 2071 Iran community-based programme, 2088 Iraq, 2464 health efforts in, 2466–2467 resource-limited health system, 2465 Iron deficiency, 967 Irregular and undocumented migrants, 413 Ischaemic heart disease (IHD), 427, 1095, 1098, 1150 J Joint external evaluation (JEE), 2324 Joint-stock model, 1279 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2638, 2662 K Kangaroo mother care (KMC), 929, 959, 2080 Kaposi sarcoma (KS), 547–548 Key populations and HIV, 553–554 developing, implementing and monitoring programmes, 555–559 services, 555 structural barriers for prevention, 554–555 Knowledge management and translation coalitions and multifaceted settings, 2652–2653 multilateral and UN system settings, 2651–2652 targeted and fact-finding settings, 2653 Knowledge support, 139 Kobe earthquakes, 2344 L Laboratory and diagnostic imaging, 1752 Labour force, 1061 Labour markets, 1061, 2491 Lancet Commissions, 2236

Index Lancet High Quality Health Systems Commission, 967 Landscape, 2131 Land use, 1972, 1975, 1980 Lassa fever, 2317, 2331 Lay health worker model, 2563 Lead, 2240–2242 Leadership, 2816, 2818, 2823 Leaving no one behind policy Global North and Global South divide, 56–57 health inequalities, 58 natural, built and social environments, 54–56 Leptin, 745 Lexis diagram, 346, 347 Life course, 1046, 1072 age-period-cohort model, 863 approach, 1095 dynamics of health, 875 emergence and characteristics, 864 epidemiology, 863, 867 and global health, 858 high-income countries, 858 inclusion of genetic factors, 866 policy considerations, 878–880 principles, 860, 872–875 social determinants, health framework, 876 theoretical developments, 859 Life-cycle approach, 769 Life expectancy (LE), 360–362, 995, 1000– 1001, 1099, 1103, 1114–1116, 2199 cohort, 362–363 period, 363–364 Lifespan inequality, 1107–1108 Lifespan variability, 1093, 1101 Linguistic diversity, 115 Liraglutide, 755, 756 Liver cancer, 484–485 LMIC, see Low-and middle-income countries (LMICs) Lobbying bribery, 1293 consultants, 1291 corporate finances, 1293 corruption, 1293 industry-backed organisations, 1292 informal payments, 1291 microcosmic scale, 1292 national sovereignty, 1294 policymakers, 1291 pro-active transparency, 1291 trade liberalisation, 1293

Index Location mapping, 1755 Lockdown strategy, 2732 Logic model, 301, 2142 Logics, 245 Logistic planning, 206 Lokomat, 1838 Longevity, 994, 995, 997, 998, 1000–1003, 1005, 1008 Longitudinal study, see Cohort study Long lasting insecticidal nets (LLINs), 2418 Long-term care (LTC) activities for daily living, 1511 ambulatory care clinics, 1514 balancing in-home and institutional care, 1534 classification, 1521–1527 community-based social care services, 1515 components, 1513 cost sharing, 1533 definition, 1512 economic and demographic changes, 1512 emerging private sector, middle-income settings, 1525 financing of, 1518–1521 formal and informal caregivers, 1536–1537 formal workforce, 1516 global population aging, 1508 government entitlements and services, 1527 in home assistance services, 1515 home health care, 1514 hospitals, 1513 informal care, 1517, 1526 institutional settings, 1513 life expectancy vs. healthy life expectancy, 1510 means-tested safety net, 1524 means-testing and financial protection, 1529 mixed systems, 1523 nursing care charges, 1529 in OECD countries, 1511 in older populations, 1509 personal care services, 1515 policy initiatives, 1533–1537 preventing catastrophic spending, 1534 public spending on, 1519–1521 quality of care, 1535 raising revenues, 1533 rapid population ageing and health spending, 1531–1533 rehabilitation facilities, 1514 single universal coverage, 1521 skilled nursing facilities, 1513–1514 technology, 1530–1531

2901 Lorcaserin, 756 Low-and middle-income countries (LMICs), 440, 497, 619, 621, 622, 624, 626–628, 631, 720, 749, 762–764, 887, 1361, 1668, 1817, 1863, 1864, 1867, 1869– 1875, 2439, 2447–2449, 2456, 2476, 2481–2483, 2486, 2487, 2490, 2493 communicable diseases, 2450–2451 non-communicable diseases, 2445–2446 Low-calorie diets (LCD), 751 Low Carb Program, 1797–1798 Lower respiratory tract illness, 960–961 Low maternal education level, 956 Low resource settings, 913–917 Lung cancer, 473, 723 Lung injury early life exposures, 445, 446 exposure in adulthood, 446–449 risk factors, 445

M Machine learning, 1669, 1676, 1685, 1779–1780 bias, 1802 evaluation of projects, 1795–1797 performance of, 1785–1787 tasks for, 1781 types of, 1781 vs. traditional programming, 1780 Macroeconomic global recession, 79 Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), 2735 Malaria, 2417 prevention and treatment, 2418 Malnutrition, 770, 964, 2065, 2067, 2075, 2410 diet-related noncommunicable diseases, 2071 double burden of malnutrition (see Double burden of malnutrition) overweight and obesity, 2070–2071 stunting, 2067–2069 undernutrition, 2067 underweight, 2069–2070 wasting, 2069 Management and advocacy for patients, providers and systems (MAPPS), 758, 760, 761 Marburg, 2317 Marketing, 1289–1291 Mass transit systems, 733 Maternal health, 1155 Maternal mortality ratio (MMR), 1221, 1222

2902 Maternal nutrition, 2078 Maternal obesity, 964 Maternal sepsis, 84 Maternal undernutrition, 2078 Maternity homes project, 303 Mechanical ventilation, 446 Médecins sans Frontières (MSF), 2798 Medical anthropology, 1128 Medical (health) volunteerism, 2557 Medical pluralism, 123 Medical plurality, 113 Medical robots, 1856 challenges, 1854–1856 clinical considerations, 1852–1854 Medical technology, 1395–1396 Medication management, 1752 Medicines, 2015–2016, 2687–2688 Meeting of Parties (MOP), 642 α-Melanocyte stimulating hormone (α-MSH), 756 Menopause, 1014–1021, 1023, 1024, 1027, 1029, 1031, 1034, 1036 Mental disorders environment role in health services, 606 human resources and treatment gap, 606–610 human rights framework, 602–605 impact of COVID-19 on burden, 592–596 person-centered and recovery approach, 598–602 role of person with lived experience with, 597–598 stigma as contributing factor, 596–597 Mental health, 980–982, 2190–2191 men, 1167–1168 and psychosocial disorders, 2419 women, 1168–1169 Mental health and psychosocial support (MHPSS), 2448, 2449 Mental Health Gap Action Programme (mhGAP), 608 Mental health hazard job satisfaction, 2588–2589 quality of life, 2589 stress, 2587–2588 suicide, 2589 Mercury, 2242–2244 Metagenomic analysis, 2382 Methicillin-resistant-Staph. aureus (MRSA), 2382 Mexico, 1426 burden of illness, 1427

Index cultural characteristics, 1426 demograpics, 1427 economy and government, 1426 environmental hazards, 1427 healthcare delivery system processes, 1428–1429 quality of healthcare, 1429–1430 mHealth, 1737, 1749 Micronutrients deficiencies, 766, 979, 2066, 2067, 2077, 2086 supplementation, 2066, 2083, 2084 Middle East respiratory syndrome coronavirus (MERS-CoV), 2317 Midlife cancer, 1024 cardiovascular health, 1022–1024 contraception in, 1020 definition, 1014 depression, 1015, 1033 disability in, 1025 eating disorder, 1034 lifestyle factors, 1026–1027 menopausal women, 1015 menopause-related changes, 1018–1019 midlife crisis, 1031 ovarian/reproductive aging and menopause, 1016–1018 physical health problems, 1016 posttraumatic stress and anxiety disorders, 1032 psychological issues, 1030 reproductive healthcare, 1018 rheumatoid arthritis and pain, 1021 schizophrenia and psychosis, 1033 sexuality, 1020 sleep, 1028–1029 stress, 1030 urinary problems and sexual health, 1025 violence, 1035 vulvar pain, 1019 Migrant health, 1196–1197 climate change, 1209 concepts and definitions, 1196–1197 global and regional migration networks, societies and alliances, 1211 hypothesis and myths, 1202–1206 phases in development of interest in, 1202 soft policy instruments on, 1208–1209 Migrant populations, 390 Migrant workers, 412, 2277 Migration, 374–375, 1194, 1195, 1201, 1202 age profile measures, 377

Index age standardized migration intensities, 376–377 and migrant health (see Migrant health) CMIs, 375–376 and education, 1069–1070 and employment, 1070 on family stability and wellbeing, 1071–1072 globalization, 379–382 GMR, 377 migration expectancies, 377–378 movement rates, 375 policies, 1205 population growth, in cities, 378–379 transition probabilities, 375 trends in young adulthood, 1065–1066 Millennium development goals (MDGs), 11, 172, 267, 950–953, 1216, 2536, 2627, 2660, 2661, 2813–2814 criticisms, 1893 education targets and indicators, 1894 empowerment and rights, 1896 issues, 1905 Millennium Declaration, 1891 principles in design process, 1894 and targets, 1892–1893 Millennium ecosystem assessment, 2172 Million Deaths Study, 1003 Minimally invasive techniques, 758 Ministry of Health, 762 miPlan, 146 Mixed methods, global health research data collection tools and techniques, 254, 255 definition, 244, 245 designing, 245–250 planning, 245 public health, 240 qualitative research approach, 240 research analysis, 255, 256 research methodology, 240–242 research traditions, 258 sampling, 250–253 scientific traditions, 242–244 typological approach, 250 writing-up research, 256–258 Mixed-methods approach, 307 Mobile phone ownership, 153 Mobile source air toxics (MSATs), 727 Mobility, 49, 1951, 1954, 1955, 1957, 1961 urban, 61 Moderate consumers, 1298 Modern global migration, 390–394

2903 Modified Medical Research Council (mMRC), 451 MomConnect programme, 145–146 Morbidity, 1081, 2198, 2201, 2202 compression, 1093, 1094 expansion, 1093, 1094 Mortality, 343, 346–366, 368, 370–374, 376–378, 382, 383, 1047–1057, 1060, 1063, 1072, 1081, 1093–1099, 1101, 1103, 1104, 1107, 1110, 1113, 1118, 1122, 2198, 2199, 2201, 2202 indicators, 995 rate, 182 Motherhood, 891, 892, 903 Mother-to-child transmission (MTCT), 553, 566 Motivational interviewing techniques, 809 Motorcycle helmets, 831 MOXi robot, 1825, 1826 mPesa, 147 MPOWER package, 646–652, 657 Multi-cluster/sector initial rapid assessment (MIRA), 2406 Multi-component approach (MCA), 2045 Multi-morbidity, 454 Multi-phase mixed method designs, 248, 249 Multiple micronutrient supplementation, 965 Multi-stakeholder approach, 2730 Multivariate testing, 1797 Municipal solid waste (MSW), 728 Muthuswamy healing temple, 126 Mycobacteria, 448

N Naltrexone, 755, 756 Namaste method, 2743 Nanoparticles, 2231, 2234 Nanotechnology, 2387 National Appropriate Mitigation Action (NAMA), 1961 National communicable disease surveillance systems, 319 National Diabetes Prevention Program (NDPP), 524 National essential medicines lists (NEMLs), 1474 National Health and Nutrition Examination Survey (NHANES), 204 National health insurance (NHI) model, 1375 National institutes of health (NIH), 1317, 2691 National systems innovation, 334 Native American medicine, 110

2904 Natural disasters EM-DAT, 2344 and global health, 2341–2343 global trends in, 2339–2340 mortality or morbidities pattern, 2344 types of, 2337–2338 Natural environment, 54 Natural livestock farming (NLF) network, 2179 Navajo medicine, 110 NCD, see Noncommunicable diseases (NCDs) NCD Risk Factor Collaboration (NCD-RisC) Group, 2073 NCE, see New chemical entities (NCE) Neglected tropical diseases (NTDs), 1557–1559, 2101, 2218, 2527, 2703–2706 Neighborhood Change Agents (NCA), 2001 Neighborhood Strategies Work Group (NSWG), 1991 Neither employed nor in education or training (NEET), 1063 Neoliberalism, 31 Neonatal health, 957 antenatal care, 958 intra-partum related events, 958 neonatal sepsis, 959–960 preterm/small for gestational age infants, 958–959 Neonatal mortality, 2416 Neonatal mortality rate (NNMR), 1221, 1222 Neonatal oxygen therapy, 446 Neonatal sepsis, 959–960 Nepali female community health worker programme, 1186 Net reproduction rate (NRR), 373 Newborn survival, 933 New chemical entities (NCE), 2701 NGOs, 2351, 2356, 2358 Nicotine, 628, 629, 631, 632, 635, 664, 666, 667, 671, 672 replacement therapy, 451 Nigeria, 148 NIH, see National institutes of health (NIH) Noise-induced hearing loss (NIHL), 2271 Noncommunicable diseases (NCDs), 38–41, 89–90, 172, 424, 432, 440, 619–620, 628, 642–644, 659, 741, 777, 788, 801, 802, 1222, 1296, 1829, 2065, 2067, 2071, 2234, 2421, 2439, 2457, 2528, 2664, 2675 during early recovery and rehabilitation phase, 2422

Index during emergency response phase, 2422 in humanitarian settings, 2446–2449 LMICs, 2445–2446 during preparedness phase, 2422 prevalence, 2439 risk factors, 2018–2021 trauma and injuries, 2422 Non-governmental organizations charitable (secular) organizations, 2791 consulting and contracting organizations, 2792 faith-based organizations, 2792 global health, 2795 global health diplomacy, 2797–2798 global health research, 2798–2799 in globalization, 2795–2796 goals and strategies, 2790 non profit, 2794 philanthropic foundations, 2793 in primary health care, 2796–2797 Schools of Public Health, 2798 Non-health digital data, 328 Non-methane volatile organic compounds (NMVOC), 722 Non-motorized transport (NMT), 733 Non-nucleoside reverse transcriptase inhibitors (NNRTIs), 576 Non-probability sampling techniques, 311–312 Non-profit NGOs, 2794 Non-random sampling, 201 Non-state actors, 2866 Norm entrepreneurship, 2616–2617 Novel coronavirus (2019-nCoV), 2317 NTDs, see Neglected tropical diseases (NTDs) Nutrient profiling, 1302 Nutrition, 1407 essential nutrition actions in (see Essential nutrition actions) health promoting role of, 2064–2065 in the life course, 2074–2090 nutritional status assessment, 2065–2066 population-level nutrition monitoring, 2066 Nutritional deficiencies, 2090 Nutritional disorders, 964 iron deficiency, 967 obesity, prevention of, 966–967 severe acute malnutrition, management of, 965–966 wasting and stunting, prevention of, 965 Nutritional rehabilitation, 2068 Nutrition education, 1298

Index O Obesity, 728, 1312 agricultural subsidies, 742 bariatric surgery, 757, 758 behaviour modification, 749, 750 biologic challenges, 743, 744 BMI, 747, 748 body fat mass, 744, 745 childhood, 741 chronic care model of disease, 748 diets for weight loss, 750–752 disease, 745 domains, 743 food intake, 744 genetic predisposition, 741 healthcare systems, 758–770 lifestyle intervention, 749 LMICs, 749 medical therapies, 742 medications, 752–757 methodological heterogeneity, 743 physical activity, 752 prevalence, 742 prevention of, 966–967 shared decision making, 747 stepped care treatment approaches, 748 stigma, 742 weight gain, 747 weight loss benefits, 746 weight loss maintenance, 752 Obesogenic environment, 743, 744, 751, 759 Occupational asthma, 2265 Occupational hazards, 2264 exposure to, 2268 hierarchy of controls, 2269 types of, 2267–2268 Occupational health aims, 2258 in cancer prevention, 2259 definition, 2259 disaster response and emergency management, 2286–2289 employer responsibility, 2272 and environment, 2274–2275 global, 2280–2281 global burden of work-related disease and injuries, 2262–2266 and globalization, 2273–2278 government responsibility, 2272 health surveillance, 2271–2272 hierarchy of controls approach, 2268–2270

2905 importance for global and public health, 2260–2261 prevention of, 2267–2273 services, 2281–2282 and social protection, 2274 and sustainability, 2278–2280 with community-oriented public health, 2260 work ability, 2285–2286 worker’s participation, 2273 Occupational health hazard definition, 2583 mental health (see Mental health hazard) people at risk, 2591–2594 physical health, 2584–2586 prevention (see Health hazard prevention) risks, 2584 workplace risk, 2589–2590 Occupational safety, 2283, 2285, 2287 Occupational segregation, 1181–1182 Office of Neighborhood Safety (ONS), 2001 Old zoonoses, 2112 On-demand information ervices, 1750 One Health, 2171, 2174, 2178–2179 concept, 1979 human, animal, environment interface, 2127–2132 operationalizing and validating, 2138–2143 social-ecological systems framework, 2132–2138 One patient one record approach, 1713 Online evaluation, 1796 OpenEpi, 202 Operation Sukuma Sake, 2092 Opioid overdose, 846 Oral rehydration, 1110 Oral rehydration solution (ORS), 2850 Organics, 2244 Organisation for Economic Co-operation and Development (OECD), 1279 Organization for Animal Health (OIE) Performance, 2323 Organization for Economic Cooperation and Development (OECD), 271 Orlistat, 755, 756 Osteoporosis, 1155 Outcome evaluations, 298 Out-of-pocket (OOPs), 1572 Outreach and enrollment agent model, 2566 Overweight micronutrient deficiencies, 763 and obesity, 2070–2071 (see also Obesity)

2906 Overweight (cont.) prevalence, 766 and underweight, 766 Ownership, 268, 270 Oxygen therapy, 961 P Package of Essential Noncommunicable disease (PEN) intervention program, 2160 Pan American Health Organization (PAHO), 2840, 2845, 2847, 2863 Pandemic, 2100–2103, 2114, 2120, 2122– 2124, 2143, 2449, 2451, 2452 COVID-19, 2731 (see also Coronavirus disease 2019 (COVID-19)) definition, 2730 influenza, 2730 zoonoses, 2112–2114 Paradigm shift, 241 Paris Agreement, 2191–2192 Paris declaration, 268, 270–271 PAR, see Participatory action research (PAR) Participant’s management, 180 Participatory action research (PAR), 224, 245 Particulate matter, 447, 1952 Partnership, 2658, 2662, 2664–2666, 2676 Partnership for Maternal, Newborn & Child Health (PMNCH), 2662 Patent Cooperation Treaty (PCT), 2691 Patient-centered care, 1793 PCT, see Patent Cooperation Treaty (PCT) Pearson correlation coefficient, 1114 Pediatric early warning signs (PEWS), 970 Pediatric triage systems, 970–971 Peer support work, 601 Penicillin, 2382 People at risk, 2591 People-centred approach, 1653–1657 system change, 1655–1657 People-centredness, 1652 Period analysis, 352 Period life expectancy, 363–364 Peripheral artery disease (PAD), 1847 Persistent organic pollutants (POPs), 2247–2248 Personal health records, 1736 Personal health tracking, 1750 Personal protective equipment (PPE), 2270, 2370, 2597 Person-centeredness, 599 Pesticides, 2228, 2244, 2246 DDT, 2246

Index Pharmaceuticals patent, 2689–2692 Phenotyping, 442 Phentermine, 755, 756 Philanthropic, 2792, 2793 Philip Morris vs. Australia, 2019–2020 Photovoice method, 227 Physical/economic environment, 2442 Physical accessibility, 2542 Physical activity, 1160–1161, 1298 and all-cause mortality, 780 and cancer, 782 and cardiovascular disease, 782 in children and youth, 785–786 data gaps in population surveillance, 799–800 device-based assessment of, 793 disseminating guidelines, 791–792 future challenges and opportunities, 813–816 Global Action Plan on Physical Activity, 803–804 global guidelines on, 790–791 global levels and trends in adult, 794–797 guidelines history, 789–790 health benefits of, 780 historical developments in policy, 800–803 levels and trends in adolescent, 798–799 origin of surveillance, 792–793 participation, 2495 population surveillance, 792–793 potential health risks, 787 promotion in primary health care, 808 public education and behavior change campaigns, 807–808 and quality of life, 787 sedentary behaviour, mortality and, 783–784 sedentary behaviour guidelines, 791 sports, 812 systems approach, 804–806 Physical environment, health system, 1398 Physical hazards, 2267 Physical health risks, 2585 Physically-assistive robots, 1845–1847 Pierre Bourdieu, 1351 Plague, 2318 Planetary crisis, 2495 Planetary health, 1232, 1544, 2171, 2173, 2185, 2193 future, 2298 Planetary Health Alliance case study, 2307 treatment and care, 2300–2306 Planning decisions, 2490

Index Planning phase, quantitative research case-control study, 198 cohort study, 199 conceptual framework, 194–196 cross-sectional study, 198 data dictionary, 204–205 data management, 207 electronic data collection form, 205 experimental study, 200 online vs. offline data collection, 206 phrasing research objectives, 194 sample size, 201–204 statistical analysis, 208–209 Pneumococcal vaccination, 450 Pneumoconioses, 2265 Pneumocystis jirovecii pneumonia, 546 Point of care (POC) data, 324 Poisoning, 844–849, 978–979 Policy harmonization, 769 Policy-relevant indicators, 53 Polio eradication, 2853 Political economy, 2483 of globalisation, 1276, 1289 Political libertarians, 1299 Polycyclic aromatic hydrocarbons (PAH), 722 Population/health system resilience, 2442 Population, 2131 health, 31 health index, 1240 Population ageing, 1510 assistive technology, 97–98 dementia, 95 demographic dividend, 92 demographic evolution (see Demographic transition) early childhood survival, 75 European commission, 85–86 expenditure dynamics, 93–95 fertility, 96–97 health policy, 81–84 industry 4.0, 92 life expectancy, 76 long term medical care, 87 maternal morbidity/mortality, 84 modern mortality evolution, 91 morbidity hypothesis, 90 musculoskeletal disorders, 95 noncommunicable disease, 89–90 poor dietary, 91–92 proportion in elderly population, 97 role of women, 76 third demographic transition, 87 transnational comparability, 88–89

2907 Population balance equation (PBE), 341 Population dynamics, 340, 342 calendar, 352, 353 cohort life expectancy, 362–363 cohort vs. period life tables, 359–360 crude birth rate, 368 crude death rate, 356–357 definition, 341 events, 348–349 fertility levels and parity progression, 372–373 intensity, 352, 353 life table, 358–359 migration, 374–382 mortality structure, by age, sex and cause of death, 357–358 natality, fertility and infertility, 366–368 period indices, 352 period life expectancy, 363–364 population doubling and halving time estimates, 373–374 quotients, 351–352 rate of population change, 373 rates, 349–351 ratios and proportions, 349 specific fertility rates, 369–370 standard phenomenon schedule, 355–356 standard population approach, 354–355 synthetic indices of fertility, 369–370 Positivism, 242 Post-conflict health system recovery, 2426 principles, 2426 steps, 2426 Post-crisis, 2443 Post-emergency health situation analysis and needs assessment, 2428 Post-graduate training, 2513 Poverty, 955 Power commodifying knowledge, 1287 dominant narrative, 1287 human and financial resources, 1286 piggyback oral rehydration solution, 1286 political, social and economic rights, 1287 rule setting, 1287 socio-political environment, 1286 transnational corporations, 1286 Power distancing, 115 Power generation, 728 PPE, see Personal protective equipment (PPE) Practice, patient and clinical management systems, 1738

2908 Practice, 2506, 2508, 2509, 2512, 2513, 2516, 2517, 2519–2521 Preceed-proceed model, 250 Precision global health definition, 1670–1672 ethics and policy, 1685–1687 impact of, 1683–1685 Pre-exposure prophylaxis (PrEP) contraindications, 574 cost and social benefits, 574 effectiveness, 570 eligibility criteria, 570 investigations and interventions, 573 screening, 572 Preferential trade agreements (PTAs), 2013 Pre-mature labour, 930 Prescription, 1752 Prescriptive analytics, 1792 Preston curve, 1097, 1103, 1118 Prevention, 1072, 1077, 1081 Prevention and public health fund (PPHF), 524 Prevention of maternal-to-child transmission (PMTCT), 567 Primary health care (PHC), 2532, 2537, 2549, 2662, 2810–2813 Primary School Nutrition Programme (PSNP), 2085 PRIME project, 126 Private health insurance (PHI) systems, 1382 Probability sampling techniques, 310 Problem orientation, 2141 Process-centered approach, 1653–1657 Productivity-adjusted life years (PALY), 516 Productivity commission, 2767, 2768 Programme, Budget and Administration Committee (PBAC), 2837 Progressive universalism, 1638 Pro-innovation culture, 1357 Project monitoring and evaluation, 296–297 budget, 312 data collection plan, 307 engaging stakeholders, 298–301 evaluation designs, 302–306 formative evaluations, 297 indicators for measurement, 307 intervention, 301–304 outcome evaluations, 298 process evaluations, 298 sampling strategies, 308–311 used by implementers, 306–307 Project Prabhat, 2744 Project-program-system, 274 Prostate cancer, 485–486

Index Protease inhibitors (PIs), 576 ProtoPolicy project, 59 Provider payment mechanisms (PPMs), 1591 Psychoactive drugs, 830 Psychological beliefs, 1319, 1323 Psychosocial hazards, 2268 Psychosocial intervention study, 247 Psychosocial stimulation, 966 Public budgets, 1227 Public education and behavior change campaigns, 807–808 Public financial management (PFM) systems, 1584, 1600 Public health, 1951 event notification, 1754 guidelines, 789 professionals, 1303 programs, 2119 surveillance, 319 road safety, 1955 Public Health Emergencies of International Concern (PHEIC), 11, 2316, 2650 Public Health Emergency Operations center and Incident Management System, 2405 Public policy, 2491 strategy, 37 Public-private partnerships (PPPs), 2658, 2663, 2664, 2756 definition, 2760 financial needs, 2759 in global health, 2761–2779 payment mechanism, 2761 sustainability and development agendas, 2759 Public transportation, 1964 Pulmonary rehabilitation, 450 Purchasing power parity, 1097

Q Qualitative data analysis, 229 Qualitative inquiry, 214, 216 evidence-based practice in global health (see Evidence-based practice) global health, 216–218 Qualitative research design of clinical trials, 216 empirical example (see Breast cancer) evidence-based practice in healthcare, 216 global health interpretation, 217 in-depth interviewing method, 224 inductive reasoning, 222 interpretive information, 215

Index meanings of people’s actions and behaviors, 214 methodological framework, 222–223 researchers, 230–231 source of data, 227–228 theory generation, 222 trustworthiness, 229–230 Quality, 1489 Quality-adjusted life year (QALYs), 184, 185, 2198, 2201 Quality-driven health systems, 1561–1562 Quality of hospital care, 968–970 Quality of life (QoL), 515–516 Quantitative research, 192 aims, 192 data analysis, 209–210 intellectual property, 210 reporting and sharing, 210 Quasi-experimental designs, 305 R Racism and discrimination, 117–118 Randomised controlled trials, 180, 181, 188 Randomized controlled studies (RCTs), 972 Rational-legal authority, 1135 Ready-to-use therapeutic foods (RUTF), 966 Realism, 243 Real time sequence data, 327 Real world data (RWD) applications, 1867 benefits, 1862 definition, 1865 financial RWD, 1862 sources, 1869–1873 stakeholder agencies in, 1866–1867 use cases, 1877–1880 Real world evidence (RWE), 1868 analysis, 1876 definition, 1865 Recovery model in mental health, 600–602 Rectangularisation of the survival curve, 1094 Referral coordination, 1752 Refugees, 391, 401, 410, 413 Regional Forums on Sustainable Development (RFSD), 1907 Rehabilitation, 1829, 1845 Reinforcement learning, 1783 Relative risk (RR), 2202 Reliance Industries Limited, 2744 Religion beliefs and practices, 1265 Buddhism and Taoism, 1258 resiliency factors, 1266

2909 Religiosity adaptive/maladaptive health outcomes, 1325 body sanctification beliefs, 1324 divine intervention, 1325 god-mediated control, 1325 health behaviors, 1324 health contexts, 1315 health locus of control, 1324 religious fatalism, 1325 socio-structural factor, 1323 Religious beliefs, 1315, 1324–1326 Religious fatalism, 1325 Remote monitoring services, 1736 Reproduction, 896, 901, 1020 Reproductive, maternal, neonatal and child health (RMNCH) interventions, 983 Reproductive, maternal, newborn, child and adolescent health (RMNCAH), 2415 during adolescence and before pregnancy, 2415 continuum of care, 2415 pregnancy, delivery and post-natal period, 2415 Reservoir, 2121 Resilience, 2135 Resilient health systems, 2443 Resilient system, 2137 Resource functions, 1446–1447 Responsiveness, 1381 Retrospective analysis, 2124 Retrospective cohort study, 177 Return migration, 2733 Revenue generation potential, 1580 Richmond Healthy Equity Partnership (RHEP), 1992 Rift valley fever, 2317 Rio+20 Summit, 1897–1902 Risk communication, 2424 Risk factors, 619, 620, 623, 628, 643–645, 658, 659, 672, 673, 826–828, 830–838, 840, 841, 842, 844, 845, 847, 849, 850 Road safety, 1955–1957 Road traffic accidents (RTA), 1223 Road traffic collisions age and gender, 828 decade of action for road safety, 827 infrastructure, 831 risk factors, 826, 827 safe system approach, 827 trauma care, 832 vehicle-related risk factors, 831 Robot-assisted therapy (RAT), 1830, 1840

2910 Robot prostheses, 1847–1851 Roll Back Malaria partnership, 2638–2640 Routine immunization (RI), 2411 Rural health economic benefits, 2544 effective service coverage, 2540–2543 health workers, importance of, 2543–2545 health workforce availability, 2539–2543 policy, role for, 2545–2548

S Safe Motherhood Promotion Project (SMPP), 2670 Safe system approach, 827 Sample registration system (SRS), 998 Sampling concurrent strategy, 253 databases, 252 in-depth interviews, 251 multiphase, 253 QUAL and QUAN component, 250 sample size, 251 sequential strategy, 252 typology, 251 Satellite data, hospital attendance, 330 Saturation, 228 School feeding program, 768 Scientific traditions constructivist/interpretivist, 242 critical realist approach, 243 dialectics, 243 dynamic mechanical theory, 242 inquisitive minds, 242 positivism, 242 public health, 243 substantive theories, 243 Scorecard, 2142 Seasonal epidemic zoonoses, 2113 Seat belts, 830 Second-hand-smoke (SHS), 641 Sedentary behaviour definition, 783 guidelines, 791 physical activity and mortality, 783–784 Seizure disorders, 754 Self-prescription, 2596 Self-regulation, 1299 Semi-structured interviews, 759 Semi-supervised learning, 1783 Sepsis, 962–964 Sequential mixed methods design, 246, 247 Sero-surveillance, 325–326

Index Service delivery, 1394 Severe acute malnutrition, 965–966 Severe acute respiratory syndrome (SARS), 2122, 2855 Severe pneumonia, 960 Sex biological, 1148 and communicable diseases, 1156–1158 definition, 1147 intersex health, 1158 and non-communicable diseases, 1150–1155 Sexual and reproductive health, 980 Sexual and reproductive health and rights, 1175–1176 adolescent girls to, 1176 Sexual harassment, 1060 Sexually transmitted infection (STI), 549, 564 Shame, 112 Shared delivery infrastructure, 1563 Shelter, 2421 Short-lived climate pollutants (SLCPs), 1952 Sickness funds, 1374 Sickness presenteeism, 2595 Silver Tsunami, see Population ageing Simple random sampling., 200 Single-payer national health insurance, 1375 Skin disorders, 2265 Small for gestational age (SGA), 958 Small island developing states (SIDS), 2627 Smallpox eradication, 2851 Smart cities, 52 Smith, Adam, 632 Smoking cessation, 443, 452 Social capital, 1351 Social cognition, 1315, 1317, 1322, 1323, 1326, 1327 Social construction, 1130, 1131, 1136, 1138 Social determinants, 1250 of health, 1400–1409, 1652, 1657, 1661, 1987, 1989, 1999, 2021–2023, 2189–2190, 2420, 2491, 2494 Social entrepreneurship-supporting program, 2677 Social environments, 55 healthcare system, 1398–1399 Social exclusion, 1096 Social health insurance model, 1374 Social inequalities, 1095, 1337 health inequality and technology model, 1360 innovation adoption, 1359 public health, 1361

Index rates of diffusion, 1359 SES-based variations, 1360 state sponsorship, 1362 Social justice, 1687 Socially assistive therapy robots, 1841–1844 Social media data, 329 Social resistance, 2362 Social robots, 1830, 1836, 1841–1843, 1852 Social sciences, life course developments, 864 Social stratification, 1096 Social theory, of global health biosocial analysis, 1129 governmentality and biopower, 1136–1139 social suffering and structural violence, 1139–1141 sociology of knowledge, 1130–1131 unanticipated consequences, causes of, 1131–1133 Social transitions, 1045, 1046, 1081 and health determinants, 1057–1063 Social values, 187 Social vs. individual responsibility free choice, 1282 harmful products and capacitous consumers, 1282 moral hazard, 1282 national and cultural values, 1281 negative externalities, 1281 public health, 1280 smoking cessation, 1280 utilitarianism, 1281 Socio-demographic variables absolute level/population-level ranking, 1319 colorectal cancer screening, 1320 discrimination, 1320 education level/income, 1319 ethnicity and minority status, 1319 psychological cognitions and beliefs, 1320 race and ethnicity, 1320 Socio-ecological systems, 2172 Socio-economic determinants of health, 913, 935, 940, 1234 Socioeconomic development, 723 Socio-economic status (SES), 767, 1092, 1095, 1096, 1107, 1108, 1110, 1111, 1113, 1121, 1337 Sociology, 1130 Socio-structural variables behavioral interventions, 1317, 1318 ethnicity, 1318 health belief model, 1317 health disparities, 1315

2911 indirect effects, 1316 process model, 1318 psychological determinants of health, 1317 psychological mediators, 1319 residual effects, 1316 social cognition theories, 1315 theory-based determinants, 1318 theory-based modifiable behavioural determinants, 1317 Solid fuel use (SFU) adverse health effects, 724 geographical distribution, 722 health impacts, 723 Solid waste burning health impacts, 724 state of, 723 Solid waste management services, 723 South African School Health Policy, 2043 South-Central Regional Transit District (SCRTD), 1964, 1966 Spanish flu, 2730 Speculative design, 59, 60 Speed, 830 Spillover, 2121 Spiritual Health Locus of Control, 1326 Sports, 812 Spring loaded model, 745 Stakeholders, 298, 1898, 1899, 1902, 1907, 1911 identification, 299 intervention, 301–302 management plan, 300 and modes of dissemination, 301 Stakeholder theory, 2729 Standard life expectancy, 2199 State Disaster Relief Fund (SDRF), 2735 State of Food and Nutrition Security, 2089 Statistical analysis, 208–209 Stereotactic radiosurgery (SRS), 1821 Stereotyping, 116 Stigma, 1258 Stockholm Convention, 2246 Stomach cancer, 486–487 Stopping Tobacco Organizations and Products (STOP), 655 Stop TB Partnership, 2639–2640 Store-and-forward services, 1736 Stranded Workers Action Network (SWAN), 2736 Strategic Partnership for Health Security (SPH), 2650

2912 Strategic Partnership Portal (SPP), 2650 Strategic tool for assessing risks (STAR), 2406 Stratified random sampling, 201 Strengths, weaknesses, opportunities and threats (SWOT), 1304 Stroke, 427 Structural adjustment programme (SAP), 2811 Structural adjustment programs, 1615 Structural racism, 1988, 1993 Structural violence, 1139–1141, 1545–1548 Stunting, 2067–2069, 2075 Sugar sweetened beverages (SSBs), 433 Sullivan method, 1100 Superbugs, 2384 Super-diversity, 104 Supervised learning, 1782 Supply chain, 764, 1295 management, 1754 Surgical robots commercial, 1819, 1820 computer-controlled, 1819–1822 definition, 1818 endoscopic, 1822–1823 safety, 1828 telerobotic surgical systems, 1819 Surveillance, 2271–2272 Survey of Health, Ageing and Retirement in Europe (SHARE), 1114 Survival, 995, 997–999, 1002, 1003, 1005 Sustainability, 54, 56, 67, 275, 280, 283, 2303, 2306, 2727, 2729, 2739 Sustainable development agenda (SDA), 1216 Sustainable development goals (SDGs), 12, 424, 527, 642–644, 720, 758, 912, 952, 953, 1195, 1216, 1672, 1932, 2212, 2319, 2439, 2487–2489, 2497, 2536, 2538, 2626, 2628, 2629, 2635, 2660, 2661, 2814–2816 challenges in cities, 48 and 2030 development agenda, 1910–1914 and environmental factors, 49 IAEG-SDGs inaugural meetings, 1916 monitoring, reporting and verification of, 1914–1918 SDG 3, 48, 49 SDG 5, 48, 62 SDG 6, 2213 SDG 11, 48, 49, 52–53 Symbolic capital, 1351 Symbolic violence, 1355 Symptomatic data, 326–327 Syndromic data, 328

Index Systematic international physical activity surveillance, 793 System inputs, 1409 processes, 1409–1411 knowledge, 2485 T Tailored client communication, 1750 Talaromycosis, 547 Tanahasi framework, 1450, 1451 Targeted education campaigns, 1290 Targeted service robots, 1827–1828 Target knowledge, 2485 Task shifting, 127, 559 Tata Consultancy Services, 2744 Taxes diets, 1302 discourage voluntary reformulation, 1301 employment and economy, 1301 evidence, 1301 health and revenue, 1300 Technical Advisory Committee (TAG), 1990, 1991 Technical Review Panel (TRP), 2663 Technological innovation, 1338, 1340 diffusion of innovations theory, 1346 diffusion of statins, 1348 diffusion rate, 1342 direct and indirect gatekeeper, 1343 disrupted social structures, 1353 economic value creation, 1354 educational gradient in mortality, 1347 false empowerment, 1358 fundamental cause theory, 1346 glucose monitoring device, 1340 grander theory, 1351 health and social stratification, 1350 health care, 1340 health enhancing services, 1361 hysteresis, 1353 insulin injection devices, 1344 insurance coverage, 1344 intermediary mechanisms, 1345 knowledge and economic resources, 1338 life expectancy, 1349 medicalization, 1356 mortality rate, 1349 natural social forces, 1355 personal genome sequencing, 1353 personalized medicine, 1358 public health, 1340 technology-dependent intervention, 1341

Index unnatural inequality, 1349 variations in use, 1342 Technologies and humanitarian health efforts, 2462–2464 in humanitarian settings, 2460–2462 Techno-medicalization, 1357 Telecare services, 1737 Telecommunications data, 329 Telemedicine, 147, 1736, 1752 Telepresence robots, 1825–1827 Telerobotic surgical systems, 1819 Tenofovir disoproxil fumarate (TDF), 572 Testimonial injustice, 1565 Thailand tobacco monopoly (TTM), 1293 The Future We Want, 1897, 1901 vs. Transforming Our World, 1919 The Healthy Cows Healthy Food program, 2179 Theil index, 1102, 1108, 1111, 1112 Theories of ill health, 1203 Theory of change, 2142 Theory of habitus, 1354 Therapy robots, 1830–1837 end-effector, 1838–1841 exoskeleton, 1832–1837 safety, 1851 socially assistive, 1841–1844 Tobacco, 1279, 1288 economic cost, of tobacco related disease, 630–631 economics of consumption, 631–632 farming, 634 harm reduction, 668 tobacco-related disease burden, 627–628 use, trends and disparities, 624–626, 1161–1162 Tobacco advertising, promotion and sponsorships (TAPS), 641 Tobacco control, 2854–2855 barriers, 652 fiscal measures, 632 global regulatory environment, 636–645 implementation, 646–653 intergovernmental organisations, 653–655 municipal governments, 657–659 non-price measures, 632 policy measures and public health interventions, 632 supply-reduction measures, 633 Tobacco Free Initiative (TFI), 638 Tobacco industry, 670 globalisation of, 620–621 interference, 633–636

2913 litigation, international obligations, 659–664 Tobacco plain packaging (TPP), 660, 662–664 Tobacco products and nicotine, 628–630, 666–669 regulation, 664–665 Topiramate, 755, 756 Total body surface area (TBSA), 977 Total burden (TB), 2204 Total fertility rate (TFR), 370, 371 Toxic stress, 1995 Toxoplasmosis, 546–547 Trade and investment access to medicines, 2015–2016 bilateral and regional deal expansion, 2012–2013 birth of global trading system, 2011 for health governance, 2015–2023 health-proofing trade policy, 2028–2029 health services, 2016–2018 international investment agreements, 2013–2015 noncommunicable disease risk factors, 2018–2021 for public health, 2026–2029 social determinants of health, 2021–2023 trade-proofing health policy, 2026–2027 World Trade Organization, 2012 Trade liberalisation, 1293 Trade-proofing health policy, 2026–2027 Trade-related aspects of intellectual property rights (TRIPS), 2695 limitations, 2700–2701 national patent laws, 2695–2697 plant and animal invention, 2697 subject matter exclusion, 2697–2700 test data protection, 2701–2702 trademarks, 2702 Traditional and complementary medicine (T&CM), 123, 1461 advantages and opportunities, 1466 availability, global landscape of, 1491–1493 benefits and challenges, 1463 cooperation channels, 1489 education and training, 1489 governance and leadership, 1468–1470 guidelines for regulation of, 1474 health service delivery systems, 1493–1494 human resources, 1489–1493 information and research, 1470–1472 integration of, 1466–1468 legal and regulatory frameworks, 1490

2914 Traditional and complementary medicine (T&CM) (cont.) national health insurance reimbursement scheme, 1494–1497 national health systems, 1489 policy basis for promotion and development, 1463–1464 regulation of, 1475 research and development, 1475 research-derived evidence base, 1461 strengthen country capacities, 1498 utilization patterns, demand and needs, 1462–1463 WHO guidelines on, 1476 Traditional authority, 1134 Traditional Chinese medicine (TCM), 109 Traditional medicine (TM), 1460 Traditional software programming, 1780 Traffic-related trauma, 2266 Training, 2505–2508, 2510–2520 Transdisciplinary, 1671, 1672, 1684, 1688, 2102, 2105, 2133, 2138, 2139, 2142, 2144, 2145 ecosystem approach, 2141 research, 2102, 2142 Transformational knowledge, 2485 Trans health, 1158 Transnational corporations, 39, 40 Transnational tobacco corporations (TTCs), 619, 621, 623, 629, 631, 632, 634, 635, 637, 641, 653, 666 Transportation, 61, 1950, 1951, 1959, 1963 accessibility, 1957–1958 global air quality and health impacts, 1953 greenhouse gas emissions, 1953 noise levels, 1953 outdoor air pollution, 1952 physical activity, 1954–1955 road safety, 1955–1957 transport policies/interventions and health outcomes, 1959–1962 transport strategies, 1963 Trauma care, 832 Traumatic brain injury (TBI), 976–977 Travelling workers, 2278 Trilateral study, 2688–2689 Triple burden of malnutrition, 2066 TRIPS, see Trade-related aspects of intellectual property rights (TRIPS) Tropical medicine, 7

Index Trust, 2348–2350, 2352–2356, 2358–2364, 2366–2370, 2372, 2373 Tuberculosis (TB), 448, 545–546, 628, 1157, 2263 prevention and treatment, 2418 risk of, 2417 Type I diabetes, 498, 500 Type II diabetes, 498, 500, 753

U U.K. Prospective Diabetes Study (UKPDS), 514 Uber’s Greyball algorithm, 1805 Ultra-processed foods, 764, 765, 769, 1279, 1285, 1303 UN Convention on Biological Diversity, 2131 Under-five child mortality rate (U5MR), 950 Undernutrition, 2067, 2080, 2090 Underweight, 2069–2070 Unemployment, 1060–1062 protection schemes, 1077–1078 UNESCO Institute for Statistics, 1069 UNHCR, 2806 Unhealthy diets, 1159, 1302 UNICEF, 2805 Unified health system, 1614 Unintentional injuries, 824, 826, 849, 2266 United Nations achievements of, 2816–2821 challenges in global health protection, 2821–2824 Economic and Social Council, 2804 General Assembly, 2803 global health initiatives, 2809–2816 HIV/AIDS, tuberculosis and malaria, 2818–2820 millennium development goals, 2813–2814 noncommunicable disease prevention, 2820–2821 primary health care, 2810–2813 responsible use of antibiotics, 2816–2817 Security Council, 2803 smallpox and polio eradication, 2817–2818 specialised agencies and high-level panels, 2804–2806 sustainable development goals, 2814–2816 WHO’s role, 2807–2809 United Nations Children’s Fund (UNICEF), 2662 United Nations Cluster System, 2404

Index United Nations Development Programme (UNDP), 2662 United Nations Educational, Scientific and Cultural Organization (UNESCO), 2662 United Nations High Commissioner for Refugees (UNHCR), 2662 United Nations Millennium Declaration, 81 United Nations Office on Drugs and Crime (UNODC), 2662 United Nations Population Fund (UNFPA), 2662 United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), 2675 Univariate analysis, 208 Universal Declaration of Human Rights (UDGR), 266 Universal healthcare, 139–141 Universal health coverage (UHC), 140, 268, 645, 802, 982–983, 1463, 1556–1557, 1612, 1733, 2030, 2539, 2541, 2543, 2545, 2549, 2554, 2562, 2571, 2661, 2777 administrative costs, 1581 benefit design, 1596 budget priority for health, 1634–1636 collective negotiation, 1593 community mobilization, 1642–1643 conceptual framework, 1576 depth of costs covered, 1598 dimensions of, 1617–1624 donor funding, 1573, 1636 economics of health, 1576 efficiency in health spending, 1584 efficient use of resources, 1636–1637 emergence of goal, 1614 emergency preparedness and response, 1602 equitable financing (see Equitable financing) equity of tax instrument, 1581 financial protection, 1573 fragmentation of pools, 1585 global action for, 1615 governance and accountability, 1641–1642 government revenue constraints, 1634 health sector-specific grants and foreign aid, 1582 health sector-specific resources, 1580 history of, 1613–1617 individual negotiation, 1593 macroeconomic conditions, 1579, 1633

2915 passive to strategic purchasing, 1594 pay-for-performance (P4P), 1591 payment mechanisms and payment rates, 1589 payroll taxes, 1581 political cost, 1581 pooling of funds, 1577, 1585 population coverage, 1617–1619 price-setting, 1591 primary health care, 1620–1621 principle of, 1570 priority setting, 1598 progressive realization of, 1637–1641 provider payment mechanisms, 1589 public financing, 1600 re-prioritization of health, 1579 revenue mobilization, 1578 SDGs monitoring framework, 1575 service coverage & utilization, 1575, 1619–1620 socio-economic factors, 1587 spending by source, 1574 trends in global spending on health, 1572 unilateral price-setting, 1593 universal financial protection, 1621–1624 voluntary health insurance, 1588 Universality, 1906 Unsupervised learning, 1782 Untargeted client communication, 1750 Urban green spaces (UGS), 54 Urban health, 57, 1237 Urban health equity, HiAP economic development and education, 2000–2001 environmental health and justice, 2003–2004 full service and safe communities, 2001–2002 governance and leadership, 1999–2000 quality health care and services, 2004 residential and built environments, 2002–2003 Urban households, 723 Urbanis(z)ation, 47–51, 57, 58, 69, 345, 764 Urban liveability index (ULI), 53 Urban planning, 67 Urban settings and health, 2456–2458 urban humanitarian response, 2456–2458 Urinary bladder cancer, 487–488 Utilitarianism, 1281

2916 V Vaccine, 2686–2687 Vaccine preventable diseases (VPD), 2411 Validation method, 997 Validity, 304 Value-based healthcare, 1555, 1778, 1792–1795 Values, 1655 Vancomycin, 2382 Vector borne diseases, 2317, 2331 Vedanta, 2745 Vedantic philosophy, 2729 Vehicle ownership, 733 Vehicular emissions, 727 Verbal autopsies, 187 methods, 324 Very low-calorie diets (VLCD), 751 Very low-energy diets (VLED), 751 Village health services, 2559–2561 Virtual water trade, 1233 Vitamin A supplementation, 446 Voluntary contributions (VC), 2868, 2870 Voluntary health insurance (VHI), 1578, 1631–1632 Voluntary medical male circumcision (VMMC), 574–575 Volunteer health services characteristics of, 2563 and community volunteer services, 2569 cost, 2571 education, 2573 female, 2572 Vulnerability and risk assessment and mapping (VRAM), 2396 Vulnerable demographic groups, 47

W Waist-to-hip ratio (WHR), 499 Walking, 777, 799, 811 Water, sanitation and hygiene (WASH), 2084 city-wide services, 2220 continuum of care, 2218–2219 health and well-being, 2216–2218 and health sectors, 2216–2220 institutional settings, 2219 well-being classification, 2222 Water and sanitation, 2420 Water-related diseases, 2188 Weight management, 748 West County Indicators Project, 1991 WHO, see World Health Organization (WHO) WHO Alma-Ata Declaration, 1652

Index WHO Framework Convention on Tobacco Control (WHO FCTC), 450, 619, 622, 623, 639, 669, 670, 672–673, 2613 emergence of, 662 governance bodies, 641–642 illicit trade supply-reduction measures, 641 implementation, 655 institutionalisation of tobacco control, 641 origins of, 636–639 provisions, 639, 640 WHO framework model, 1234 WHO–ITU national eHealth toolkit, 1739 Whole medical systems (WMS), 124 Whole-of-government (WG) approach, 1934 Whole-of-system approaches, 814 WHO Secretariat, 637 WHO Tobacco Control Collaborating Centres (WHO TCCC), 656 WIPO, see World intellectual property organization (WIPO) Women’s Health Initiative, 1015 Women’s midlife health, see Midlife Work ability, 2285–2286 Work-exacerbated asthma, 2265 Workplace injury and illness, 2259 World Bank, 2629, 2662 World Bank Report, 632 World Economic Forum, 1687 World Health Assembly (WHA), 624, 637, 743, 2318, 2836, 2837, 2841, 2849, 2850, 2858, 2859, 2868, 2870 World Health Organization (WHO), 721, 741, 901, 967, 1217, 1250, 2107, 2205, 2354, 2529, 2586, 2662, 2807–2809, 2834, 2835 Article 19, 2613 Article 21, 2614 Article 23, 2614 Constitution, 2614, 2616, 2842–2845 conventional treaty-making authority, 2613 Director-General, 2848–2849 epidemics of 21st century, 2855–2856 ethics and societal norms, 2859 FENSA, 2867–2868 financing, 2868–2876 functions, 2862–2863 geopolitics and sovereignty, 2858 governing bodies, 2836–2837 headquarter location, 2841–2842 health and security, 2859 health for all, 2851 health promotion, 2852 HIV/AIDS, 2852–2853

Index horizontal and vertical health service delivery, 2860 intellectual leadership, 2861 legal and normative authority, 2613 low tech with high impact, 2850–2851 malaria eradication, failure of, 2850 maternal and child health, 2852 MDGs to SDGs, 2853–2854 media, 2867 medical approach, 2615 Member States, 2838–2839, 2865 non-legal approaches, 2615 norms and standards, impact of, 2856 partnerships and collaborative arrangements, 2866–2867 polio eradication, 2853 predecessors, 2839–2840 priority objectives, 2849 regional arrangements, 2845–2848 report, 2231 Secretariat, 2837–2838 smallpox eradication, 2851 special cases, 2867 technical/political focus, 2861 tobacco control, 2854–2855 trade and health, 2857–2858 World intellectual property organization (WIPO), 2691 World Obesity Federation, 743 World Trade Organization (WTO), 2012, 2695

Y Years lived with disability, 185, 2198–2201, 2204, 2205, 2208 Years lost due to disability, 1052–1057 Years of life lost (YLL), 185, 2198, 2199, 2201

2917 Yellow fever outbreak, 2317 Young adulthood, 1044, 1046, 1047 all-cause mortality, 1048–1049 cause-specific mortality, 1050–1052 education, 1058–1059, 1075–1076 employment, 1059–1061 family formation, 1066–1068 health insurance, 1075 health of young migrants, 1064–1065 health system interventions, 1072–1074 migration, 1065–1066 policies, young migrants, 1079–1080 social protection systems, for young women and families, 1078–1079 unemployment protection schemes, 1077–1078 years lost due to disability, 1052–1057

Z Zika epidemic, 1177 Zika virus, 2317 Zoonoses, 2106, 2108 adaptive governance of, 2104 emergence process, 2120 emerging zoonoses, 2114–2126 epidemiologic types of, 2112 global health burden, 2106–2114 prevention and control, 2106 transdisciplinary research, 2105