The Challenges in Global Health/Public Health
In the past two centuries, global public health has witnessed enormous achievements in control of infectious diseases because previously, the leading cause of death in large measure has been reduced due to improved sanitation and food safety, vaccines, antibiotics and improved nutrition. This has led people to put their faith in the notion that medical science would succeed in overcoming the obstacles of diseases.
Furthermore, new knowledge of the microbiological origins of cancers such as that of the cervix, stomach and liver have strengthened primary prevention and brought hope that new cures will be found for other chronic diseases of infectious origin (CDC 1999, Dowdle 1999).
However, new diseases such as HIV and new forms of influenza have taken both professional and popular opinion by surprise and have renewed the challenges before the world public health community (Fauci 2005). More so, the emergence of antibiotic-resistant strains of common organisms due to overuse of antibiotics and lack of vaccines for many dangerous microorganisms poses problems to humanity. This stresses the need for new vaccines, effective antibiotics and strengthened environmental control measures.
Though gains are being made in control of many tropical diseases, but malaria, tuberculosis and other infectious diseases remain enormous global problems especially for developing African countries (Fauci 2005, Ursula 2009). Tragically long delays in adopting “new” and cost effective vaccines cause hundreds of thousands of preventable deaths each year in developing and mid-level developed countries (Antonie 2009).
However, in the face of the enormous challenges faced by global public health, some of the most critical issues in global health are; lack of resources available to combat the multiple scourges ravaging the world’s poor, lifestyle and the sick, unskilled public health workers, approach of global health initiative, bureaucracy within the health sector, the distance between the systems and the financial streams, leadership, the complexity of the modern social, economic and political determinants of health and most importantly is the explosion of actors working in health and development.
On the issue of financial, there has been recent extraordinary and unprecedented rise from world leaders, public and private givers, now more money is being directed toward pressing health challenges than ever before (World Bank, 1994, WHO 2000, Than 2002). In recent times, tackling the developing world’s diseases has become a key feature of many nations’ foreign policies over the last decade for a variety of reasons. For instance, African countries are battling with issues of infant and maternal mortality rates, curbing the spread of HIV/AIDS, tuberculosis (TB), malaria, avian influenza, some other opportunistic infections and other major killers as a moral duty. Also because of lifestyle and urbanization, especially in high and middle-income countries, the burden of illness has shifted from acute childhood infections to chronic non-communicable diseases.
The poor health status in these subpopulations can be attributed to problems such as poverty, malnutrition, illiteracy, and unsafe drinking water, lack of access to health services, social discrimination, and political conflict (Sanders, 2001, Kiskbusch 2010). However, the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases rather than at public health in general. Also, there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground.
Secondly, global public health is faced with the challenge of unskilled public health workers because the public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about its composition, training or performance (Kiskbusch 2010, Jain Sc 2000). Another challenge of global health is the focus or approach of global health initiative which according to Kickbusch, she argues that global health is not just about disease based initiatives rather it’s about strengthening systems and institutions for delivering health and this doesn’t just only refer to strengthening health systems but rather also on understanding of global health, global health governance which takes responsibility for the determinants of health.
This she further argued that the approach of health initiatives should not only be “vertical approach” which focuses more on treating and preventing a single disease, but rather consider “horizontal approach” which would help to build health systems, prevent disease and provide a range of other services (McMicheal 2000, Kiskbusch 2010). In their study, they concluded by advocating for a holistic approaches that incorporate vertical and horizontal projects that looks outward from the health sector to other policy fields such as trade, agriculture, transport, environment, rule of law and social justice where many of the determinants of health lie. This means that efforts much stretch beyond building institutions to deliver health care, to institutions and mechanism that can build coherence within health and between health and other sectors.
Furthermore, in doing the health sector must change its own mind-set. This is because, most active players in the health sector see health mainly as a national issue, and also see global health as a special niche of public health that is focused on addressing the diseases of poverty. This mind-set approach makes global public health as narrow, in contract, global public health issues need to be seen in a regional and global context otherwise policies and actions to address these issues will be ineffective.
The third challenge is the gap that exists between the systems and the financial streams which have been established between sphere of development cooperation and the sphere of the provision of global public goods (Kiskbusch 2010). For instance at country level, practically all the money for international health is with development agencies. This situation makes funding of some sectors to actually be active in relation to governing interdependence while creating laws, norms and standards, ensuring the implementation of international agreements difficult. In such situations, we see countries coming together to accept binding international treaties for health protection of populations worldwide, such as the International Health Regulations, but there is no money to help poor countries to establish the infrastructures to actually fulfill their obligations.
In this situation, there seem to be a conflict of interest because the financial resources for investing in such infrastructures are with the development agencies whose interests are not in provision of public goods at the global level but rather on ameliorating the suffering of populations at the local level (Mills A, 2000, Chen et al, 1999, Smith et al, 2003). This they argued that though such action is undeniably necessary, it also needs to be complimented by building institutions and mechanisms to fund and provide public goods at the global level; otherwise we are in many cases treating the disease while ignoring its causes.
The fourth challenge is that of the question of who actually takes leadership for global health, which is actually close to challenge three and where financial resources for global health lie. Taking leadership for global health can be helpful, but it can also be difficult this is because it answers the questions of who speaks for whom, who has taken the leadership, who has the power, money or the technical knowledge (Kiskbusch 2010, Than S 2002 and Wall S 2002). In many cases as seen from developing countries that it is mostly the development agencies that take the leadership.
This is because they have the money and the result is that, technical people in health are not involved or left behind because they have neither the power nor the money. These opinion leaders, stakeholders and researchers say that it should be addressed at global governance level. Another issues closely linked to this is that of managing the complexity of the modern social, economic and political determinants of health (Bertrand 1999). This is because there is absolutely no use talking about global health governance if we haven’t got our act together at home to address some of the leadership challenges. Good global health governance begins at home, and that means we need strategies, policies and mechanisms to bring together various sectors and stakeholders.
Just as the challenges countries faced can no longer be addressed from behind the nation-state’s sovereign borders, the same is true for traditional policy fields (Cardenas et al, 2002). This gap that exist in global health governance is even seen in our modern government were institutions are ministries are created to address a single category of issues. For instance, Tobacco regulation provides several examples where Ministries are caught between public health interests and industry interests which both have legitimate claims over government action.
The fifth challenge is one that reflects two sides of the same coin. In recent times, there has been an explosion of actors working in health and development in the last two decades, some actors are old, new and others are only newly engaging in heath. A side of the coin refers to the implication of this at national level, and specifically in developing countries which are often on the receiving end of these actors (WHO 2000, Mills A, 2000 and Kiskbusch 2010).
In fact, this is indeed a challenge generally to the field of foreign affairs and development cooperation which poses a challenge of “How can a country at national level create coherence among all these well-doers who come into your country and don’t only give you money but also take up your time and create vertical programmes rather than help you build a health system?” Though some organizations that have country office and working within some of these countries have had positive results but still, it doesn’t address a plethora of some other actors who organize projects and send delegations for country governments to receive.
This rapid increase in the number of actors is also a challenge at the global level. Though there have been initiatives to promote coherence, coordination and complimentarity such at the International Health Partnership (IHP), the Health 8 (H8) at the global level, however, these activities are mainly coordinated within the area of the vertical global health initiatives which are not in the area of global public goods. In view of this, Kickbusch suggest that coordination for global public goods is also needed. She also suggested that we need to see how this can be done and in what ways these coordination mechanisms can also be more accountable sighting Treaty processes as a coherence mechanism. Also, we need to think in what ways existing treaty processes can be moved forward in new ways and this coherence process should be linked again to the World Health Assembly.
In summary, from a developing and developed country perspective, global public health has various political, regional, socio-economical and religious challenges and limitation which includes the traditional approaches to public health training, the emphasis on epidemiology, biostatistics, communicable diseases, health protection, the relative neglect of other public health sciences and the lack of attention to emerging public health problems, the isolation of other health providers- local communities and other scientific disciplines from the ministries of health, the emphasis on institution based teaching, didactic training and the lack of direct field experience, the lack of experienced field based senior public health practitioners as role models and the absence of apprenticeship experience, also the view that public health is a medical specialty, funding and the slow realization that the leadership of public health programmes, leadership of medical training programmes, challenges of global health governance, and the uncoordinated philanthropy of recent years which has led to what some call market multilateralism
About the author: Emmanuel Kidochukwu Uzum is the Lead Consultant, Public Health and Social Development at EM & PH Consult, Ltd., Nigeria and is focused on health advocacy, monitoring and evaluation, project management, operational research and fund raising for youths, women and other vulnerable populations especially in the areas of Health, Education and Community Development. The author can be reached at: [email protected]
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