The Oxford Research Encyclopedia of Global Public Health has moved behind the paywall. For information on how to continue to view articles visit the how to subscribe page.
Dismiss

 41-60 of 137 Results

Article

Sarka Lisonkova and K. S. Joseph

Fetal death refers to the death of a post-embryonic product of conception while in utero or during childbirth, and it is one of the most distressing events faced by women and families. Birth following spontaneous fetal death is termed “miscarriage” if it occurs early in gestation, and “stillbirth,” if it occurs beyond the point of viability. There are substantial between-country differences in the criteria used for reporting stillbirths and these differences compromise international comparisons of stillbirth rates. In high-income countries, a majority of fetal deaths occur due to genetic causes, fetal infection, or other pregnancy complications. Congenital anomalies, placental insufficiency, and/or intrauterine growth restriction are frequent antecedents of fetal death. Maternal risk factors include advanced maternal age, high body mass index, smoking and substance use during pregnancy, prior stillbirth, chronic morbidity, and multifetal pregnancy. Disparities in education and socioeconomic status and other factors influencing maternal health also contribute to elevated rates of stillbirth among vulnerable women.

Article

Linda Dahlberg, Alexander Butchart, James Mercy, and Thomas Simon

An important function of public health is to prevent injuries or to lessen their impact when they occur. An estimated 251,000 people worldwide die each year from a firearm-related death and many more suffer nonfatal injuries with consequences that can last a lifetime. Firearm injuries, which include those that are intentionally self-inflicted, unintentional, or from an act of interpersonal violence, are heavily concentrated in the Americas, driven largely by firearm homicides. Firearm-related deaths and injuries disproportionately impact males and younger populations and are associated with factors such as access, substance use, adverse childhood experiences, involvement in high-risk social networks, drug trafficking, density of alcohol outlets, and neighborhood and social disadvantage. While progress is being made to understand firearm injuries and how to effectively prevent them, much more needs to be done to improve the availability and timeliness of data; apply the knowledge that is generated to effectively reduce firearm-related injuries, deaths, and costs; strengthen the scientific infrastructure; and move countries closer to achieving the violence-related targets in the 2030 Sustainable Development Goals.

Article

Suzanne O. Bell, Mridula Shankar, and Caroline Moreau

Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.

Article

Since the 1970s, global goal setting to increase access to safe drinking water has taken a number of different approaches to whether water should be primarily understood as a “human right” or a “human need.” In the Mar del Plata declaration of 1977, states both recognized a human right to water and committed themselves to achieving universal access by 1990. By the 1990 New Delhi Statement, with universal access still out of reach, the goal was renewed with a new deadline of 2000, but water was described as a human need rather than a human right. This approach was coupled with an emphasis on water’s economic values and the need for increased cost recovery, which in turn increased the focus on, and uptake of, private-sector participation in the delivery of water and sanitation services across the Global South. A similar needs-based approach was adopted at the start of the new millennium in Target 7 of the Millennium Development Goals (MDGs), but during this decade a consensus on the recognition of the human right to water also emerged in international law. As the normative status and content of this right came to be better articulated and understood, it began to influence the practice of providing water and sanitation services, and by the end of the MDG process a rights-based approach featured more prominently in the Sustainable Development Goals (SDGs) of 2015. While the provision of water and sanitation services is multifaceted, the evidence of global achievements from the 1970s onward indicates that a rights-based approach increases the priority given to the social values of such services and focuses attention on the need to go beyond technical solutions to address the structural issues at the heart of water inequality. Going forward, approaches to the provision of water and sanitation services and the human right to water will need to continue to adapt to new challenges and to changing conceptualizations of water, including the growing recognition that all living things have a right to water and that water itself can have rights.

Article

The end of the Cold War brought far-reaching world changes in many areas, including the health field. A number of “new” terms emerged (such as global health, global governance, and global health governance or global governance for health), among them global health diplomacy (or health diplomacy). There is no single, consensual definition of this term, and still less are there theoretical and analytical frameworks or empirical data to help understand its meaning and practice more clearly. Global health diplomacy is a sociopolitical practice involving the global health policy community, which promotes the interrelationship between health and foreign policy both at the national level, through cooperation projects or international actions and, in international arenas, by acting in global political space in the widest range of spheres, whether health-sector-related or otherwise.

Article

Emily Q. Ahonen, Sherry L. Baron, Lisa M. Brosseau, and Alejandra Vives

Standard employment arrangements—where the relationship between employers and employees is clear and employment is full-time, understood to be lasting, and with full protections—coexist with nonstandard employment (NSE) relationships. A variety of terms have been used to describe specific types of NSE including temporary, contingent, contract, freelance, on-call, gig, and app-based employment. These forms of employment, in combination with larger social and economic forces, structural power dynamics, and advances in technology, can work together to limit the ways in which employment supports health, and undermine workplace health protections. Nonstandard employment brings with it particular concerns for health and safety related to work, and in a broader public health sense. Health can be protected in NSE through intervention at national, state and province, and local levels to proactively shape the quality of employment arrangements.

Article

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.

Article

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).

Article

José Gomes Temporão and Carlos Augusto Grabois Gadelha

The health economic-industrial complex concept was developed in Brazil in the early 2000s, integrating a structuralist view of the political economy with a public health vision. This perspective advances, in relation to sectoral approaches in health industries and services, toward a systemic approach to the productive environment, focusing on the dimensions of innovation and universal access to health. Health production is seen in an interdependent way, recognizing that the different industrial and service sectors have strong articulations that need to be integrated. The shift toward a universal care model that focuses on human and social needs requires a productive knowledge base that favors promotion, prevention, and local and permanent healthcare, requiring new productive patterns of goods and services and innovation. Therefore, these dimensions are not conceptually apart from each other, considering an analytical and political point of view. The production, care, and sustainability of universal health systems are understood in an integrated and systemic way. Within this vision, a cognitive leap is presented in relation to the traditional health economics, linked to the allocation of scarce resources, to a vision of health political economy that favors the development, expansion, and transformation of the health system and its economic and industrial base. Health is conceived as a moral right of citizenship and a vital space for the development of countries (and for global health), generating social inclusion, equity, innovation, and a possibility for the cooperation between countries and peoples. The Brazilian experience is an exemplary case of association between the development of theoretical conception and its implementation in the national health policy that led to the link between economic development policies and social policies. It was possible to advance both conceptually in terms of a vision of health and social well-being and in contributing to a new paradigm of public policies. This perspective allowed the guidance of guide industrial development and services toward the human needs and universal health systems, considering the challenges brought by the context of an ongoing fourth technological revolution.

Article

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.

Article

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.

Article

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.

Article

Inequities in the United States have gained renewed attention as a result of social movements such as Black Lives Matter (racism), Me Too (sexual abuse and gender), and immigrant rights. Yet despite the growing awareness of inequality across major social categories, there has been little or no public attention paid to the persistent inequities facing older adults. The news media in the 2020 presidential elections uncritically reported charges that one, or both, candidates were “too old” for the job or had some other liability tied primarily to their age. There is a whole field of “anti-aging” medicine that claims to slow the biological process of senescence (distinct from fighting specific diseases), even as the greatest challenges of growing older are rooted in social and political processes. This reflects the ageism in society that results in undervaluing older adults’ lives and often marginalizes them. In addition, there are serious inequities within the older population based on class, race, gender, and citizenship status. Health inequities involve conditions that are avoidable, are not the result of informed choice (e.g., injuries among extreme sports participants), and which differ by membership in groups that hold different levels of power and resources. As such, inequities also include an element of “unfairness” such that the disadvantage is in groups with less power and resources than others.

Article

Louise Biddle, Kayvan Bozorgmehr, and Rosa Jahn

Ensuring the health of migrants and access to appropriate health services presents a challenge to health systems in the age of global migration. Reliable and timely information is key to decision-making in all sectors of the health system to ensure that health system goals are met. Such information is even more important among a mobile, sometimes rapidly changing, dynamic and heterogeneous migrant population. While health information systems (HIS) are crucial for effective functioning of other health system blocks as well as for evidence-informed decision-making, they are often sidelined in health system policy and development. Looking across the World Health Organization (WHO) European Region, HIS for migrants are deficient both in their overall availability and their integration into regular monitoring structures. Less than half of the 53 member states routinely report health data for refugees and migrants. Most of the routinely collected data on migrant and refugee health can be identified in countries with strong population-based records, with some good practice examples of well-integrated and high-quality health monitoring surveys, disease-specific registries, and “parallel” HIS in migrant-specific settings. Overall, however, HIS in the WHO European Region are not able to provide data of sufficient quality and comparability to be well integrated into regular health monitoring structures. The reasons for this can be highlighted by five key barriers to improved information systems for migrant health: barriers in recording data, standardizing data collection, harmonizing migrant indicators, producing high-quality data, and sharing information. Better integration can be achieved through increased multilateral collaboration for the harmonization of indicators, strengthening of governance frameworks for data-sharing and protection measures, and the increased use of currently underutilized data collection mechanisms, including health monitoring surveys and medical records from refugee reception facilities. These steps will remain essential for the adequate planning and provision of needs-based care for refugees and migrants.

Article

Ricardo Ventura Santos, James R. Welch, Ana Lucia Pontes, Luiza Garnelo, Andrey Moreira Cardoso, and Carlos E. A Coimbra Jr.

Victims of epidemics, slavery, genocide, and countless other episodes of violence during the colonial enterprise in Brazil, which continues decades into the 21st century in some regions, Indigenous peoples face health inequities resulting from a five-century history of social marginalization and vulnerability. Since the late 1990s, the health and well-being of Indigenous peoples in the country have benefited from progressive legislation that values sociocultural diversity within a public primary healthcare subsystem attending to Indigenous peoples living in federal Indigenous lands. However, these transcultural ideals remain elusive in practice. The Indigenous Healthcare Subsystem continues to suffer from numerous systemic problems, including low quality of local services, lack of health professional training for work in intercultural contexts, and unpreparedness for attending to health emergencies involving Indigenous peoples living in voluntary isolation. Being Indigenous in Brazil in the 2020s implies greater chances of higher infant mortality, lower life expectancy, suffering from undernutrition and anemia during childhood, living with a high burden of infectious and parasitic diseases, being exposed to a swift process of nutritional transition, and experiencing a surge in chronic violence. Community case studies have shown the importance of close patient follow-up over long periods of time, the heavy burden of disease due to nutrition transition since the mid-1980s, the relevance of international reference curves for evaluating Indigenous child undernutrition, and failures of primary healthcare provided to Indigenous populations. Improvements in national health information systems in Brazil beginning in the early 2000s have shown external causes, perinatal diseases, infectious and parasitic diseases, and respiratory diseases to be the leading causes of death among the country’s Indigenous population.

Article

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.

Article

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.

Article

Maria Helena Machado, Renato Penha de Oliveira Santos, Pedro Miguel dos Santos Neto, Vanessa Gabrielle Diniz Santana, and Francisco Eduardo de Campos

The greatest challenge in the development of universal health systems worldwide is to increase organization, training, and regulation of the health workforce (HWF). To accomplish this, the World Health Organization (WHO) has pointed out several strategies utilized since the beginning of the 2000s. One of the world regions with the greatest internal HWF disparities is the Americas, more specifically Latin America and the Caribbean. Brazil is another of the countries in this region that presents great inequities in its HWF distribution, although its Unified Health System (Sistema Único de Saúde, or SUS), created after 1988, is one of the largest universal health systems in the world. It is worth noting that Latin America, the Caribbean, and Brazil historically have high levels of social inequality and have recently become regions severely affected by the COVID-19 pandemic. Despite some advances in the formation and distribution of HWF in Latin America and the Caribbean in the last 10 years, structural problems persist in the health systems of several countries in this region, such as Brazil. The COVID-19 pandemic aggravated some problems such as the distribution of specialized health workers in intensive care units and the precarious working conditions in several public health services that were organized to face the pandemic.

Article

Marcos Cueto and Steven Palmer

From the late 19th to the late 20th century, Latin America was a developing region of the world in which public and private health discourses, practices, and a network of agencies were consolidated. Many organizations appeared as a response to pandemics, such as yellow fever, that attacked the main ports and cities, and they interacted with global agencies such as the Rockefeller Foundation. Frequently, single-disease-focused and technocratic approaches were promoted in a pattern that can be defined as the “culture of survival.” However, some practitioners believed in public health programs as a tool to improve the living conditions of the poor, the most important being comprehensive primary health care, which emerged in the late 1970s. Toward the end of the Cold War (ca. 1980s), neo-liberal reformers supported a restrictive idea of primary care health that overemphasized cost-effectiveness and efficiency.

Article

Ralph J. DiClemente and Nihari Patel

At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices. While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.