Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
Yudit Namer and Oliver Razum
For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations.
Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health.
It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.
Irena Gorski and Brian S. Schwartz
Unconventional natural gas development (UNGD), which includes the processes of horizontal drilling and hydraulic fracturing to extract natural gas from unconventional reservoirs such as shale, has dramatically expanded since 2000. In parallel, concern over environmental and community impacts has increased along with the threats they pose for health. Shale gas reservoirs are present on all continents, but only a small proportion of global reserves has been extracted through 2016. Natural gas production from UNGD is highest in the United States in Pennsylvania, Texas, Louisiana, Oklahoma, and Arkansas. But unconventional production is also in practice elsewhere, including in eighteen other U.S. states, Canada, and China. Given the rapid development of the industry coupled with its likelihood of further growth and public concern about potential cumulative and long-term environmental and health impacts, it is important to review what is currently known about these topics.
The environmental impacts from UNGD include chemical, physical, and psychosocial hazards as well as more general community impacts. Chemical hazards commonly include detection of chemical odors; volatile organic compounds (including BTEX chemicals [benzene, toluene, ethylbenzene, and xylene], and several that have been implicated in endocrine disruption) in air, soil, and surface and groundwater; particulate matter, ozone, and oxides of nitrogen (NOx) in air; and inorganic compounds, including heavy metals, in soil and water, particularly near wastewater disposal sites. Physical hazards include noise, light, vibration, and ionizing radiation (including technologically enhanced naturally occurring radioactive materials [TENORMs] in air and water), which can affect health directly or through stress pathways. Psychosocial hazards can also operate through stress pathways and include exposure to increases in traffic accidents, heavy truck traffic, transient workforces, rapid industrialization of previously rural areas, increased crime rates, and changes in employment opportunities as well as land and home values. In addition, the deep-well injection of wastewater from UNGD has been associated with increased seismic activity.
These environmental and community impacts have generated considerable concern about potential health effects and corresponding political debate over whether UNGD should be promoted, regulated, or banned. For several years after the expansion of the industry, there were no well-designed, population-based studies that objectively measured UNGD activity or associated exposures in relation to health outcomes. This delay is inherent after the introduction of new industries, but hundreds of thousands of wells were drilled before any health studies were completed. By 2017, there were a number of important, peer-reviewed studies published in the scientific literature that raised concern about potential ongoing health impacts. These studies have reported associations between proximity to UNGD and pregnancy and birth outcomes; migraine headache, chronic rhinosinusitis, severe fatigue, and other symptoms; asthma exacerbations; and psychological and stress-related concerns. Beyond its direct health impacts, UNGD may be substantially contributing to climate change (due to fugitive emissions of methane, a powerful greenhouse gas), which has further health impacts. Certain health outcomes, such as cancer and neurodegenerative diseases, cannot yet be studied because insufficient time has passed in most regions since the expansion of UNGD to allow for latency considerations. With the potential for tens of thousands of additional wells across large geographic areas, these early health studies should give pause about whether and how UNGD should proceed. Citing health concerns, several U.S. states and nations in Europe have already decided to not allow UNGD.
Catherine A. O'Donnell
Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.
Paulo Buss and Sebastián Tobar
The construction of the concepts of diplomacy and health diplomacy must consider their conceptions and practices, at both the global and regional levels. Health diplomacy is vitally important in a global context, where health problems cross national borders and more new stakeholders appear every day, both within and outside the health sector. On the other hand, regional integration processes provide excellent opportunities for collective actions and solutions to many of the health challenges at the global level. In the current global context, the best conditions for dealing with many health challenges are found at the global level, but the regional and subregional spheres also play essential roles.
The region of Latin America and the Caribbean (LAC) consists of 26 countries or territories that occupy a territory of 7,412,000 square miles—almost 13% of the Earth’s land surface area; it extends from Mexico to Patagonia, where about 621 million people live (as of 2015), distributed among different ethnic groups. Geographically, it is divided into Mexico and Central America, the Caribbean, and South America, but it presents subregions with populations and cultures that are a little more homogenous, like the subregions of the Andes and the English Caribbean. By its characteristics, LAC has acquired increasing global political and economic importance.
In the 1960s, integration processes began in the region, including the creation of the Union of South American Nations (UNASUR), Mercosur, the Andean Community, the Caribbean Community (CARICOM), the Central American System, the Bolivarian Alliance for the Peoples of Our America (ALBA), the Amazon Cooperation Treaty Organization (ACTO), the Sistema Económico Latinoamericano y del Caribe (SELA), the Asociación Latinoamericana de Integración (ALADI), and finally, since 2010, the Community of Latin American and Caribbean States (Comunidad de Estados Latinoamericanos y Caribeños, or CELAC), which is the most comprehensive integrative organization.
While originally a mechanism for political and economic integration, health is now an important component of all the abovementioned integration processes, with growing social, political, and economic importance in each country and in the region, currently integrating the most important regional and global negotiations.
Joint protection against endemic diseases and epidemics, as well as noncommunicable diseases, coordination of border health care, joint action on the international scene (particularly in multilateral organizations such as the United Nations and its main agencies), and the sectoral economic importance of health are among the main situations and initiatives related to health diplomacy in these integration processes.
The effectiveness of integration actions—and health within those actions—varies according to the political orientations of the national governments in each conjuncture, amplifying or reducing the spectrum of activities performed. The complexity of both the present and future of this rich political process of regional health diplomacy is also very important for global health governance (GHG).
Juan Garay, David Chiriboga, Nefer Kelley, and Adam Garay
There is one common health objective among all nations, as stated in the constitution of the World Health Organization in 1947: progress towards the best feasible level of health for all people. This goal captures the concept of health equity: fair distribution of unequal health. However, 70 years later, this common global objective has never been measured. Most of the available literature focuses on measuring health inequalities, not inequities, and compare health indicators (mainly access to health services) among population subgroups.
A method is hereby proposed to identify standards for the best feasible levels of health through criteria of healthy, replicable, and sustainable (HRS) models. Once the HRS model countries were identified, adjusted mortality rates were applied to age- and sex-specific populations from 1950 to 2015, by calculating the net difference between the observed and expected mortality, using the HRS countries as the standard. This difference in mortality represents the net burden of health inequity (NBHiE), measured in avoidable deaths. This burden is due to global health inequity, that is, unfair inequality, due to social injustice. We then calculated the relative burden of health inequity (RBHiE), which is the proportion of NBHiE compared with all deaths. The analysis identified some 17 million avoidable deaths annually, representing around one-third of all deaths during the 2010–2015 period. This avoidable death toll (NBHiE) and proportion (RBHiE) have not changed much since the 1970s. Younger age groups and women are affected the most. When data were analyzed using smaller sample units (such as provinces, states, counties, or municipalities) in some countries, the sensitivity was increased and could detect higher levels of burden of health inequity.
Most of the burden of health inequity takes place in countries with levels of income per capita below the average of the HRS countries, which we call the “dignity threshold.” Based on this threshold, a distribution of the world’s resources compatible with the universal right to health—the “equity curve”—is estimated. The equity curve would hypothetically be between this dignity threshold and a symmetric upper threshold around the world’s average per capita GDP. Such excess income prevents equitable distribution is correlated with a carbon footprint leading to >1.5º global warming (thus undermining the health of coming generations), and does not translate to better health or well-being. This upper threshold is defined as the “excess accumulation threshold.”
The international redistribution required to enable all nations to have at least an average per capita income above the dignity threshold would be around 8% of the global GDP, much higher than the present levels of international cooperation. At subnational levels, the burden of health inequity can be the most sensitive barometer of socioeconomic justice between territories and their populations, informing and directing fiscal and territorial equity schemes and enabling all people within and between nations to enjoy the universal right to health.
HRS models can also inspire lifestyles, and political and economic frameworks of ethical well-being, without undermining the rights of others in present and future generations.
Health for All and Primary Health Care, 1978–2018: A Historical Perspective on Policies and Programs Over 40 Years
Susan B. Rifkin
In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning.
Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.
Kira Fortune, Francisco Becerra, Paulo Buss, Orielle Solar, Patricia Ribeiro, and Gabriela E. Keahon
There is a broad consensus that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. The recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors has led to the emergence of a comprehensive policy perspective known as Health in All Policies (HiAP). Building on earlier concepts and principles outlined in the Alma-Ata Declaration (1978) and the Ottawa Charter for Health Promotion (1986), HiAP is a collaborative 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. Health in All Policies has become particularly relevant in light of the adoption of the 2030 Agenda for Sustainable Development and the 17 Sustainable Development Goals (SDGs), as achieving the goals of the agenda requires policy coherence and collaboration across sectors. Given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, the implementation of HiAP at the local level is seen as a powerful approach to advancing health and achieving the SDGs through scaled-up initiatives. As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success in order to identify best practices. The Region of the Americas has made much progress in advancing the HiAP approach, and as such much can be learned from analyzing implementation at country level thus far. Specific initiatives of the Americas may highlight key examples of local action for HiAP and should be taken into consideration for future implementation. Moving forward, it will be important to consider bottom up approaches that directly address the wider determinants of health and health equity.
Asa Cristina Laurell and Ligia Giovanella
Since the early 1990s, health policy in Latin America has focused on reform in most countries with the explicit purpose to increase access, decrease inequity, and provide financial protection. Basically, two different and opposed models of reform have been implemented: the Universal Health Coverage (UHC) model and the Single Universal Health System model. The essential characteristics of Latin American UHC are that health care is commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market that is particularly important in the Latin American region, the most unequal in the world. The Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model is a model inspired by the principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independent of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State.
Given that health system reform occurs in specific historical contexts, these models have had different results in each country. In order to highlight the concrete reform outcomes, the following issues need be addressed: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public institutions or insurance, public or private; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions. An analysis is needed of the UHC reforms in Chile, Colombia, and Mexico, on the one hand; and the Single Universal Health System in Brazil, Venezuela, and Cuba on the other.
The UHC model in practice tends to increase inequity in access, create new bureaucratic barriers to timely care, fail to provide financial protection, and leads to deteriorated public health measures. It has also created new powerful private sector stakeholders, particularly in Chile and Colombia, while in Mexico the predominance of a strong public sector has “crowed-out” the private one. The Single Universal Health System has significantly increased access for millions that before reform had almost no access and has also strengthened public health actions. However, the strong preexisting private sector providers have profited from the public-sector purchases of complex medical services. Private health insurance has also increased among the upper middle class and workers belonging to strong labor unions.
Rachel Humphris and Hannah Bradby
The health status of refugees and asylum seekers varies significantly across the European region. Differences are attributed to the political nature of the legal categories of “asylum seeker” and “refugee”; the wide disparities in national health services; and the diversity in individual characteristics of this population including age, gender, socioeconomic background, country of origin, ethnicity, language proficiency, migration trajectory, and legal status. Refugees are considered to be at risk of being or becoming relatively “unhealthy migrants” compared to those migrating on the basis of economic motives, who are characterized by the “healthy migrant effect.” Refugees and asylum seekers are at risk to the drivers of declining health associated with settlement such as poor diet and housing. Restricted access to health care whether from legal, economic, cultural, or language barriers is another likely cause of declining health status. There is also evidence to suggest that the “embodiment” of the experience of exclusion and marginalization that refugee and asylum seekers face in countries of resettlement significantly drives decrements in the health status of this population.