the world federation of public health associations a new global health risks and chances

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1 The World Federation of Public Health The World Federation of Public Health Associations Associations A NEW GLOBAL HEALTH A NEW GLOBAL HEALTH RISKS AND CHANCES RISKS AND CHANCES Ulrich Laaser Ulrich Laaser WFPHA, President WFPHA, President

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The World Federation of Public Health Associations A NEW GLOBAL HEALTH RISKS AND CHANCES Ulrich Laaser WFPHA, President. FROM INTERNATIONALISATION TO GLOBALISATION I.THE INDUSTRIALISATION OF EUROPE & JAPAN IN THE 18 TH AND 19 TH CENTURY II.THE GREAT PANDEMICS esp. CHOLERA - PowerPoint PPT Presentation

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The World Federation of Public Health The World Federation of Public Health AssociationsAssociations

A NEW GLOBAL HEALTHA NEW GLOBAL HEALTHRISKS AND CHANCESRISKS AND CHANCES

Ulrich LaaserUlrich LaaserWFPHA, PresidentWFPHA, President

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FROM INTERNATIONALISATION TO FROM INTERNATIONALISATION TO GLOBALISATIONGLOBALISATION

I.I. THE INDUSTRIALISATION OF EUROPE & THE INDUSTRIALISATION OF EUROPE & JAPAN IN THE 18JAPAN IN THE 18THTH AND 19 AND 19THTH CENTURY CENTURY

II.II. THE GREAT PANDEMICS esp. CHOLERATHE GREAT PANDEMICS esp. CHOLERAIN THE 2IN THE 2NDND HALF OF THE 19 HALF OF THE 19THTH CENTURY CENTURY

III.III. MANDATING OF LARGE INTERNATIONAL MANDATING OF LARGE INTERNATIONAL ORGANISATIONS (WHO, WB, IMF) > WW IIORGANISATIONS (WHO, WB, IMF) > WW II

IV.IV. THE GROWING INFLUENCE OF NGO’s IN THE GROWING INFLUENCE OF NGO’s IN THE 21THE 21STST CENTURY (e.g. MSF, WFPHA) CENTURY (e.g. MSF, WFPHA)

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GLOBAL FAILURES THREATENINGGLOBAL FAILURES THREATENINGOUR “SPACESHIP EARTH”OUR “SPACESHIP EARTH”

I.I. GLOBAL WARMING GLOBAL WARMING – floods & – floods & desertsdeserts

II.II. GLOBAL DIVIDES GLOBAL DIVIDES – poverty & hunger– poverty & hunger

III.III. GLOBAL SECURITY GLOBAL SECURITY – war & – war & terrorismterrorism

IV.IV. GLOBAL INSTABILITY GLOBAL INSTABILITY – financial – financial crisescrises

V.V. GLOBAL HEALTHGLOBAL HEALTH – a human right for – a human right for allall

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GLOBAL DIVIDESGLOBAL DIVIDESInequalities in Health (Inequalities in Health (D.R. Gwatkin et alD.R. Gwatkin et al. 2003). 2003)

CountryCountry FertilityFertility Infant MortalityInfant Mortality

PoorPoor WealthyWealthy PoorPoor WealthyWealthy

EgyptEgypt 4.04.0 2.92.9 7676 3030MaliMali 7.37.3 5.35.3 137137 9090NepalNepal 5.35.3 2.32.3 8686 5353Nicarag.Nicarag. 5.65.6 2.12.1 5050 1616

PeruPeru 5.55.5 1.61.6 6464 1414UgandaUganda 8.58.5 4.14.1 106106 6060ZambiaZambia 7.37.3 3.63.6 115115 5757

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YLL, YLD, and DALYs by Region, 2001 YLL, YLD, and DALYs by Region, 2001 (Mathers CD et al. 2006)(Mathers CD et al. 2006)

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Distribution of health workers by Distribution of health workers by level of health expenditure and level of health expenditure and

burden of diseaseburden of disease

Source: Mullen F

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MigrationMigration

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Rural – Urban MigrationRural – Urban Migration

Alleviates e.g. overpopulation, land shortages etc. of the rural areas.

But costs through increased poverty, the rise of slum and squatter areas, extremely unequal distribution of resources, overburdening of the urban infrastructure and difficulties to supply mega-cities with the necessary resources such as air and water.

Indeed, the urban poor are the main group affected by an unequal distribution of resources, and they have to live in quarters characterized by the worst environmental conditions like overcrowded slums and squatter settlements close to polluting industries or congested roads. Cornelius-Taylor B, 2001Cornelius-Taylor B, 2001

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GLOBAL SECURITYGLOBAL SECURITY

The modern concept of public health, the New Public Health (Frenk J, 1993) carries a great potential for healthy and therefore less aggressive societies. Development of the health systems has to contribute to peace, since aggression, violence and warfare are among the greatest risks for health and economic welfare (Laaser et al. 2002).

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Estimated average annual military Estimated average annual military deaths in wars, worldwide, by centurydeaths in wars, worldwide, by century

(Garfield & Neugut 2000)(Garfield & Neugut 2000)

CenturyCentury Average Average Annual Military Annual Military DeathsDeaths

Average Average Annual Military Annual Military Deaths per Deaths per Million Million PopulationPopulation

1717thth century century 9,5009,500 19.019.0

1818thth century century 15,00015,000 18.818.8

1919thth century century 13,00013,000 10.810.8

2020thth century century 458,000458,000 183.2183.2

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Military SpendingMilitary Spending

Global military spending in 2008 came close to 1500 billion USD the largest contributors being the United States with 48.5% and the European Union with 21.2%, followed next by China with 4.8%. Neither does the ranking of the top three US, EU, China changes if the calculation is based on purchasing power parity USD. However, expressed as % of GDP the US were at rank 27 in 2005 and China at rank 96 (2009), whereas the highest ranks were occupied by oil producing Arab countries and countries near conflict zones (e.g. Oman with 11.4 or Armenia with 6.5%). The growth rate of global military spending was 8.4% in 2007 and is forecasted to reach +33.9% since 2007 in 2012

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Public expenditures per capita for Public expenditures per capita for selected countries (USD, 1990)selected countries (USD, 1990)

COUNTRYCOUNTRY For military For military (a)(a)

For health For health

(b)(b)

Ratio a/bRatio a/b

SudanSudan 2525 11 25.025.0

EthiopiaEthiopia 1616 11 16.016.0

AngolaAngola 114114 88 14.314.3

ChadChad 1010 11 10.010.0

MozambiqueMozambique 99 22 4.54.5

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Comparative average US monthly spending Comparative average US monthly spending for military operations and ODA for social for military operations and ODA for social

services (As of 2003)services (As of 2003)

•Sources of basic data: US Congressional Research Services; OECD-DAC•www.realityofaid.org

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The Skopje Declaration on Public The Skopje Declaration on Public Health, Health,

Peace & Human RightsPeace & Human Rights

In the fall of 2001 the representatives of public health of South Eastern Europe gathered a in Skopje, capital of Macedonia, after a decade of civil war and ethnic cleansing in the wake of the dissolution of Yugoslavia, to engage the good offices of public health in promoting peace, preventing violence and contribute to the building of a more equal, stable and democratic world. The declaration of Skopje was later i.e. in 2003 adopted by the World Federation of Public Health Associations.

http://www.wfpha.org/Archives/

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The Skopje Declaration (continued)The Skopje Declaration (continued)

Beyond their immediate professional domains public health professionals can contribute by:

1) Analyzing the causal interrelationships of violent phenomena

2) Curbing the determinants of armed conflicts and violence

3) Training health professionals in analytical, preventive and interventive skills

(Lever N, 2000)

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GLOBAL INSTABILITYGLOBAL INSTABILITY

(Resetting Global Aid)(Resetting Global Aid)

The steep global gradient between rich Highly Developed Countries (HDL) and the poor Least Developed Countries (LDC) is well known. With a few exceptions the low GDP per capita goes hand in hand with limited access to food and water, low housing standards, incomplete educational coverage, high levels of (hidden) unemployment and high emigration. Not surprisingly also limited access to and low quality of health care services and population health measured as (healthy) life expectancy are running in parallel.

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The Monterrey Consensus of 2002The Monterrey Consensus of 2002

Donor countryDonor country

20082008USD (billion)USD (billion) % GNP% GNP

United StatesUnited States 26,026,0 0,2%0,2%GermanyGermany 13,913,9 0,4%0,4%BritainBritain 11,411,4 0,4%0,4%FranceFrance 11,011,0 0,4%0,4%

“We urge developed countries that have not done so to make concrete efforts towards the target of 0.7% of their GNP) as ODA to developing countries” (art. 42).

In addition there are serious imbalances between DAH and BoD (Ravishankar et al., 2009)

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The Fragmentation of global aidThe Fragmentation of global aid

One of the obvious reasons for imbalances is the extreme fragmentation and therefore ineffectiveness of international aid.

East Timor: 1 study/1000 as compared to 1 physician/10.000Vietnam: 2 donor visits/Working DayTansania: 1500 projects with separate reporting & oversight

Globally: 280 agencies, 242 multilateral funds, 24 Development Banks, 40 UN Organisations, and 1000ds of NGO’s

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The value of international aidThe value of international aid

The temptation to accept international aid without conditions on the side of the beneficiary often disrupts national priorities.

Loans – e.g. of the World Bank though at low interest rates – put often an underestimated burden on later years. Loans have two sides: Money is available now but has to be repaid later.

In addition the money goes via expert fees and purchase of equipment mainly back to the crediting countries.

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Funding channels of DAH (% Funding channels of DAH (% share)share)

DONOR CATEGORYDONOR CATEGORY Last DecadeLast Decade(2000/1); (* 1990)(2000/1); (* 1990)

Recent Recent (2006/7)(2006/7)

UN AgenciesUN Agencies 32.3 *(1990)32.3 *(1990) 14.0 (2007)14.0 (2007)

World Bank and regional banksWorld Bank and regional banks 21.7 (2000)21.7 (2000) 07.2 (2007)07.2 (2007)

Aid through bilateral channelsAid through bilateral channels 27.1 (2001)27.1 (2001) 34.0 (2007)34.0 (2007)

Global FundGlobal Fund 08.3 (2007)08.3 (2007)

GAVIGAVI 04.2 (2007)04.2 (2007)

Bill & Melinda GatesBill & Melinda Gates 03.9 (2007)03.9 (2007)

Funds channeled through NGO’sFunds channeled through NGO’s 13.1* (1990)13.1* (1990) 24.9 (2006)24.9 (2006)

Ravishankar et al. 2009

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National coordinationNational coordination

As has been outlined already, specially in developing and transitional societies coordinative capacities and competences are limited vis a vis a complicated and time consuming process of implementing international and bilateral aid efficiently. In addition international and even more bilateral aid very often is disrupting coherent national development plans and priorities.

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The Sector Wide Approach (SWAp)

The national coordination deficit became more known in the nineties and proposals to cope with were developed. One of the most promising - however rarely implemented - concepts is the Sector-Wide Approach.

(Cassels 1997)

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THE MILLENIUM DEVELOPMENT THE MILLENIUM DEVELOPMENT GOALSGOALS

We have been moving too slowly to meet our goals…The numbers of people going hungry and living in extreme poverty are much larger than they would have been had progress continued uninterrupted (Ban Ki-Moon 2009).

In fact it is unlikely that the other seven goals can be achieved sustainably if poverty remains as widespread as it is today. A closer look reveals in addition that the improvements up to 2005 are grossly different between continents.

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MDG 1, Target 1: Halve, between 1990 and MDG 1, Target 1: Halve, between 1990 and 2015, the proportion (%) of people whose 2015, the proportion (%) of people whose

income is less than income is less than USD 1 a day (here 1.25 USD is used)USD 1 a day (here 1.25 USD is used)

DR Developing Regions; SSA Sub-Saharan Africa; Southern Asia; SEA South Eastern DR Developing Regions; SSA Sub-Saharan Africa; Southern Asia; SEA South Eastern Asia; EA Eastern Asia; LA Latin America; SEE South Eastern EuropeAsia; EA Eastern Asia; LA Latin America; SEE South Eastern Europe

RegionRegion 1990 1990 19991999 20052005 Target 2015 Target 2015

DR (all)DR (all) 4242 3131 2525 2121SSASSA 5757 5858 5151 2929SASA 4949 4242 3939 2525SEASEA 3939 3535 1919 2020EAEA 6060 3636 1616 3030LALA 1111 1111 88 66SEESEE 00 22 11 00

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MDG 4: Reduce by two-thirds, between 1990 MDG 4: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. and 2015, the under-five mortality rate.

MDG 5, target 1: Reduce by three quarters MDG 5, target 1: Reduce by three quarters the maternal mortality ratiothe maternal mortality ratio

DR Developing Regions; SSA Sub-Saharan AfricaDR Developing Regions; SSA Sub-Saharan Africa

RegionRegion 1990 1990 20052005 20072007 Target 2015 Target 2015

MDG 4MDG 4

DR (all)DR (all) 103103 7474 3434SSASSA 183183 145145 6161MDG 5MDG 5

DR (all)DR (all) 480480 450450 120120SSASSA 920920 900900 230230

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A dim outlook for the MDG’s A dim outlook for the MDG’s achievementachievement

In summarizing it can be said, that the health related MDG targets for Goals 1, 4, 5 and 6 are unlikely to be achieved in spite of some sluggish progress made.

Also it is obvious that the economic growth of 4% in the developing regions between 2000 and 2007 did not translate directly into better population health.

The low correlations between growth and MDG achievements show that growth is necessary, but not sufficient for a sustainable MDG strategy. It has to be complemented with the appropriate sectoral policies (Bourguignon et al. 2008).

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GOOD GOVERNANCE AND GOOD GOVERNANCE AND A NEW GLOBAL HEALTHA NEW GLOBAL HEALTH

Health systems have a broader scope since they incorporate the population dimension inherent to public health and all relevant social and political determining factors (i.e. incl. global factors).

(Council of Europe, 2009)

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Ethical governanceEthical governance

The main health systems in Europe – variations of Bismarckian social insurance and the Beveridgean national health service models – rely on administrative, financial and professional accountability. It is taken for granted that health services, despite the diversity of systems, should be based on principles of universality, equity and solidarity. Health and healthcare are not ordinary commodities. They are seen as public/social goods. There are several principles that are more generally applied to the whole range of public services and administration. These include transparency or openness, accountability, public participation, effectiveness and efficiency, and quality and safety.

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CONCLUSIONSCONCLUSIONS

I.I.

To improve global health will not become possible without a strong involvement of the civil society. Already by now about 25% of the DAH is channelled through NGOs and is on the increase. However NGOs are not only accountable to their clientele but should be to an open society in general.

Therefore a code of conduct for NGOs is a first main recommendation and demand.

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II.II.

Unchecked demographic growth, poverty, the burden of disease, and violent conflicts are interconnected. The demand for basic needs like shelter, clothing, provision of safe food and water, access to adequate (primary) health services and to education, and last not least security in daily life for all populations does not seem to be an extraordinary or unjustified one.

A renewed major effort of the UN community therefore is to be initiated to achieve the MDGs as planned. To simply continue as so far will certainly not be enough!

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III.III.

Resetting global aid has to become part of such a renewed effort towards the MDGs. As of today aid is highly fragmented, bilateral and donor dominated with enormous transaction costs, and not given according to priorities in the recipient countries. It also frequently lacks planned integration and coordination. In fact most of the financial support is channelled back to the donating countries (via dept repayment, purchase of technical equipment and international expert charges).

The concept of sector wide approaches (SWAp) has to be further developed and made practical to put the receiving governments into the “drivers’ seat” on the condition of improved governance.

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IV.IV.

The migration towards Highly Developed Countries - especially of qualified professionals - cannot simply be stopped without violation of basic human rights.

However, there should be an agreed mechanism to compensate the "sending" countries for basic investments into upbringing and education.

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V.V.

Military conflicts and violence in many forms are a major cause of mortality and morbidity and of excessive waste of scarce resources. The developments towards regional peaceful cooperation in Europe, the Pacific region,in the Americas and elsewhere, is to be enhanced.

Public health professionals can contribute by 1) analyzing the causal interrelationships of violent phenomena at all levels of society, 2) curbing the determinants of armed conflicts and violence, and 3) training health professionals in analytical, preventive and interventive skills.

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VI.VI.

The deficit of all good will proposals and actions is a mechanism of enforcement at the global level. However, a good global government is still behind our horizon.

Nevertheless a global awareness in the sense of a New Global Health is a first and essential step on this path and a participatory approach is the only way open to us.

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The Istanbul Declaration 2009www.wfpha.org

NOW IS THE TIMETo revive human valuesTo renew political willTo change direction

To acknowledge Public Health as the first public good

To achieve global cooperation on global health

To unite the public health workforce