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Article

Colin Binns and Mi Kyung Lee

Breastfeeding is one of the best public health “buys” available for countries at all levels of development. In the first year of life, appropriate infant nutrition (exclusive breastfeeding to around 6 months) reduces infant mortality and hospital admissions by 50% or more. Early life nutrition has important influences, including on childhood illnesses, obesity, cognitive development, hospitalizations, and later chronic disease. Breastfeeding is consistent with the historical cultural practices of all societies, and its benefits of breastfeeding last a lifetime. While the development of infant formula has been of benefit to some infants, its inappropriate promotion has resulted in a decline of breastfeeding, and, as a result, health gains in many countries have not been as great as they could have been. The health benefits of breastfeeding will provide some protection against the effects of climate change, which will cause a decline in potable water supplies and increases in the incidence of some infections. Infant formula production has very high environmental costs, while breastfeeding as well as being the best infant feeding intervention also has very low environmental impact. An important part of the sustainable development agenda must be to promote breastfeeding and its benefits and to reverse the inappropriate promotion and use of infant formula.

Article

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.

Article

Ravi Narayan, Claudio Schuftan, Brendan Donegan, Thelma Narayan, and Rajeev B. R.

The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM. Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.

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

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

David Sanders and Louis Reynolds

The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development. The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order. The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation. Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation. Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation. However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.

Article

Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.

Article

In different countries and regions of the world—particularly in Latin America and the Caribbean—the term “workers’ health” may have different meanings. From a more traditional perspective, defined on economic and demographic bases, this term introduces a delimitation characterized by economically active people, usually over 10 years of age, of both sexes, and who are working, have worked at some point in their life, or are in search of work. This condition usually ceases in case of retirement or disability. Such a criterion, as can be imagined, is extremely imprecise, particularly in regions such as the ones analyzed here, since it includes great variability of situations, including work considered informal; the work of children and adolescents (prohibited or restricted in accordance with international labor standards); clandestine and illegal work; domestic work (sometimes not formally recognized); and slave and forced labor. It is not clear, either, when work activity actually ceases, especially when there are no social protection systems for elderly and disabled people. But even if this definition is adopted, it is already possible to foresee the complexity of the theme, both in the conceptual perspective and in the scope of health programs, as well as in the health and illness problems of this population. However, in some countries, the term “workers’ health” (or “worker’s health”) goes beyond the economic or demographic delimitation, and includes a paradigm shift about the role of workers in the struggle for their health. This perspective, political and ideological, originates in the concepts and experience of the “Italian Labor Model”; brings in elements of the Marxist discourses and Liberation Theology; takes advantage of and improves the perspective of “Social Epidemiology” or “Social Medicine”; and, in our continent, can be considered as an unfolding of “Latin American Social Epidemiology.” This understanding of workers’ health also depends on social movements—such as unions and other forms of organizing workers—as well as on political leaders committed to the struggle of workers against precarious work, unemployment and the destruction of already established social rights, especially in the context of neoliberalism. Therefore, workers’ health is a polysemic and complex concept, and its discussion is a living, dynamic, and extremely rich agenda.

Article

Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.

Article

Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis. Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.

Article

Maria Cecília de Souza Minayo and Saul Franco

Violence is a problem that accompanies the trajectory of humanity, but it presents itself in different ways in each society and throughout its historical development. Despite having different meanings according to the field of knowledge from which it is addressed and the institutions that tackle it, there are some common elements in the definition of this phenomenon. It is acknowledged as the intentional use of force and power by individuals, groups, classes, or countries to impose themselves on others, causing harm and limiting or denying rights. Its most frequent and visible forms include homicides, suicides, war, and terrorism, but violence is also articulated and manifested in less visible forms, such as gender violence, domestic violence, and enforced disappearances. Although attention to the consequences of different forms of violence has always been part of health services, its formal and global inclusion in health sector policies and guidelines is very recent. It was only in 1996 that the World Health Organization acknowledged it as a priority in the health programs of all countries. Violence affects individual and collective health; causes deaths, injuries, and physical and mental trauma; decreases the quality of life; and impairs the well-being of people, communities, and nations. At the same time, violence poses problems for health researchers trying to understand the complexity of its causes, its dynamics, and the different ways of dealing with it. It also poses serious challenges to health systems and services for the care of victims and perpetrators and the formulation of interdisciplinary, multi-professional, inter-sectoral, and socially articulated confrontation and prevention policies and programs.

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

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

Gerard Bodeker and Kishan Kariippanon

An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens. Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world. For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable. The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.

Article

Evelyne de Leeuw, Jean Simos, and Julien Forbat

The authors of this article purport that for current understanding of Healthy Cities it is useful to appreciate other global networks of local governments and communities. In a context where the local level is increasingly acknowledged as decisive in designing and implementing policies capable of tackling global threats such as climate change and their health-related aspects, understanding how thousands of cities across the world have decided to respond to those challenges appears essential. Starting with the concept of “healthy cities” in the 1980s, the trend toward promoting better living conditions in urban settings has rapidly grown to encompass today countless “theme cities” networks. Each network tends to focus on more or less specific issues related to well-being and quality of life. These various networks are thus not limited to more or less competing labels (Healthy Cities, Smart Cities, or Inclusive Cities, for instance), but entail significant differences in their approaches to the promotion of health in the urban context. The aim of this article is to systematically typify these “theme cities.” A typology of “theme cities” networks has several objectives. First, it describes the health aspects that are considered by the networks. Are they adopting a systemic perspective on all health determinants, such as Healthy Cities, or are they focusing on “hardware” determinants like Smart Cities? Second, it highlights the key characteristics of the networks. For instance, are they pushing for technological solutions to health problems, like Smart Cities, or are they aiming at strengthening communities in order to mitigate their detrimental effects, like Creative Cities? Third, the typology has the potential to be used as an analytical tool, for example, in the comparison of the results obtained by different types of networks in urban health issues. Finally, the typology offers a tool to enhance both transparency and participation in the policymaking process taking place when selecting and engaging in a network. Indeed, by clarifying the terms of the debate, decisions can be made more explicit and achieve a greater level of congruence with the overall objectives of the city. Indeed, Healthy Cities today need to make alliances with other theme networks, and this typology gives the keys to find which networks are the “natural best allies,” avoiding mutually harmful antagonisms. In that sense, the typology developed should be of interest to any actor involved in health promotion at the city level, whether in an existing “theme cities” policy process or as willing to participate in such a program, and to scholars interested in better understanding the main drivers of “theme cities” networks, a rapidly growing field of study.

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

Non-governmental organizations (NGOs) working in developing countries are chiefly a post-World War II phenomenon. Though they have made important contributions to health and development among impoverished people throughout the world, the documentation of these contributions has been limited. Even though BRAC and the Jamkhed Comprehensive Rural Health Project (CRHP) are but two of 9.7 million NGOs registered around the world, they are unique. Established in 1972 in Bangladesh, BRAC is now the largest NGO in the world in terms of population served—now reaching 130 million people in 11 different countries. Its programs are multi-sectoral but focus on empowering women and improving the health of mothers and children. Through its unique scheme of generating income through its own social enterprises, BRAC is able to cover 85% of its $1 billion budget from self-generated funds. This innovative approach to funding has enabled BRAC to grow and to sustain that growth as its social enterprises have also prospered. The Jamkhed CRHP, founded in 1970 and located in the Indian state of Maharashtra, is notable for its remarkable national and global influence. It is one of the world’s early examples of empowering communities to address their health problems and the social determinants of those problems, in part by training illiterate women to serve as community health workers. The Jamkhed CRHP served as a major influence on the vision of primary health care that emerged at the 1978 International Conference on Primary Health Care at Alma-Ata, Kazakhstan. Its Institute for Training and Research in Community Health and Population has provided on-site training in community health for 45,000 people from 100 different countries. The book written by the founders entitled Jamkhed: A Comprehensive Rural Health Project, describing its pioneering approach, has been translated into five languages beyond English and is one of the most widely read books on global health. These two exemplary NGOs provide a glimpse of the breadth and depth of NGO contributions to improving the health and well-being of impoverished people throughout the world.

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

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.

Article

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.