Modern Global Health Challenges

Global health today faces many unique challenges.  In an increasingly globalized world, global health currently exists as a collection of interconnected and systemic problems.  From lack of best practices to increasing rates of drug resistance, global health must move toward an integrated, transparent, and holistic movement in order to effectively tackle modern challenges.  As shown throughout this course, understanding the successes and failures of the past can inform future efforts.

Best Practices and the Knowledge-Action Gap

Rather than a coordinated movement, efforts to improve global health are diverse in their activities and impact. The lack of a clear conception regarding global problems and the lack of coordination means that the results of global health and development work can be unpredictable.  When NGOs, microfinance organizations, and global partnerships fail to set their standards high, unintended consequences abound.  Such consequences include unsustainable programs, lack of local integration, and poor mechanisms for assessment, transparency, and accountability.  In a world with limited resources, these pitfalls cause waste and often present new problems.

These concerns highlight the need for best practices to be established and spread.  While the fields of health care and public health have many evidence-based innovations, knowledge disseminates slowly, if at all. The failure to implement health interventions that have been demonstrated to be cost-effective by high-quality research affects both high-income and low-income countries.“Low-income countries face additional challenges to disseminating research evidence such as the weakness of their health systems, the lack of professional regulation and a lack of access to evidence.”(1)

Best practices and innovations can take years, if not decades, to become standard practices.  A pressing question in global health today is how to facilitate the spread of best practices.  There is a need to strengthen institutions and mechanisms that can systematically promote interactions between researchers, policy-makers, and health workers who are positioned to influence the uptake of research findings.

Health Care Delivery

The global health community today is facing what some have called an “implementation bottleneck”.   There are vast amounts of resources being funneled into global health work, such as vaccines, primary health care, drug therapies, maternal and child health care, and basic surgery.  However, despite vast amounts of money, tools and interventions, the successful delivery and implementation of these resources remain elusive.  

In other words, the greatest constraint is not the availability of interventional tools, but rather their delivery to those who need them most.(2) For example, full use of existing interventions would cut the 10 million annual child deaths that occur globally by more than 60%.(3)  In addition, a high proportion of the half-million maternal deaths that occur globally every year could be prevented by promoting access to interventions and services of known efficacy.(4)

In the rest of the economy, huge gains have been made by better integrating and coordinating all activities required to serve customers. Seamlessly coordinated networks and partnerships have replaced adversarial or arms-length relationships in delivering value for end users. Health care is long overdue for such a transformation.” (5)

Part of the reason for this delivery failure is due to the lack of health infrastructure in much of the developing world.  Because of this reality, global health programs must transfer vast amounts of resources to individuals, often in rural and remote locations, with little-to-no infrastructure to work through.  Several steps exist in the process of achieving successful health outcomes: the discovery of a drug or intervention, its development and production, and lastly, its delivery. This final link in the chain poses a formidable challenge to the success of global health endeavors.  

Metrics

As noted, unprecedented amounts of resources are invested in public health and healthcare worldwide.(6)   Data from 2000 to 2004 found a continuation of this trend, with donor funding for global health approaching $14 billion in 2004.(7)  Because of the vast amounts of resources funneled into global health, funders are beginning to demand performance data in return for their financial assistance.(8)  Donors want to know results regarding health and health-system performance in the countries in which they are investing and they want to set goals and standards for those countries to meet. Thus, it is in the mutual interest of the developing and industrial worlds to invest in strengthening systems for the collection of health information.(9)

“Sound information on financial and human resources invested in health, health interventions delivered to people in need, and the impact of these efforts on people's health is critical for planning health systems, implementing programs, epidemic response, allocating budgets for research and development, monitoring progress, and evaluating what works and what does not.”(10)

The availability of health information to inform decisions can ensure funding and improve the efficacy of global health interventions.  Information on outputs and outcomes is essential for action as it is the foundation for policy-making, planning, programming, and accountability. Unfortunately, high quality health information is not widely available in developing countries.  In order to overcome this challenge, health metrics are needed to ensure accountability and achieve best practice standards.

Drug Resistance

Years of poor compliance rates for drugs regimens targeted at tuberculosis, malaria, and HIV have led to the emergence of wide-spread resistance.  For example, while the prevalence of malaria infections has declined in the developed world, incidences have been increasing in already endemic regions.  In fact, forty-one % of the world's population now lives in areas where malaria is transmitted.(11)  These alarming figures continue despite over a century of malaria control efforts and large resources spent toward such efforts.  Drug resistance poses a major challenge to global health efforts as it makes drugs ineffective and can lead to highly virulent parasites.

Ensuring that patients are adhering to drug regimes can prevent the further emergence of drug-resistant parasites.  In addition to stopping the spread of resistance, high adherence rates can prevent the transmission of disease. When patients fail to take appropriate doses at regular time intervals they increase the chance that they will remain infectious and thus spread the disease to their family and friends. “For individuals living in extreme poverty, adhering to antiretroviral medicine regimens helps them protect the relationships they rely upon to survive”.(12)
Lastly, non-adherence has detrimental effects on patient outcomes.  In fact, research data supports the importance of adherence in post-operative eye-health.(13)  For example, patients who faithfully instilled their non-steroidal anti-inflammatory eye drops after surgery were far less likely to develop Cystoid Macular Edema, a common cause of vision loss after cataract surgery.(14)

Vertical Programs and Horizontal Health Systems

A major critique of global health today is that it is primarily defined by multitudes of NGOs, programs, and global health initiatives (GHIs) that are focused on singular, discrete problems.  Global public health programs will have to move beyond a focus on building successful “projects” in order to become fully functioning health care delivery organizations.

The concept of positive synergies between health systems and GHIs is a strategy meant to address the problems that may occur when resources are supplied to a country’s health services through GHIs or NGOs.(15)  Some of these problems include fragmented infrastructures, multiple reporting, and uneven distribution lines.  Developing a positive synergy refers to actively and systematically managing the relationship between GHIs and already existing health systems to structure and coordinate the delivery of health care in an efficient and cost-effective manner.  Maximizing positive synergies between health systems and global health initiatives can contribute to the goal of developing a “science of delivery,” and address the proliferation of global health initiatives that operate in isolation.

Conclusion

Throughout this course we have briefly traced global health efforts from the colonial era to the modern day.  We have seen how various ideologies have dictated the path of global health and the role of bureaucracies in setting the international health agenda.  Furthermore, we have illuminated traditional tensions in global health and followed the ebb and flow of movements such as primary health care, selective primary health care, and the development phenomenon.  While the field of global health may never be devoid of new challenges, the key to progressive movement lies in unraveling the faults of the past with the goal of a better future.

Footnotes

(1) Sanders, David, and Andy Haines. (2006). "Implementation Research Is Needed to Achieve International Health Goals." PLoS Medicine. 3 e186, 1-4.

(2) Ibid.

(3) Jones G, Stekettee RW, Black RE, Bhutta ZA, Morris SS, et al. (2003). How many child deaths can we prevent this year? Lancet 362: 65–71.

(4) Wagstaff A, Claeson M (2004) The Millennium Development Goals for health: Rising to the challenges. Washington (D. C.): World Bank Publications.

(5) Porter, Michael and Elizabeth Teisberg. (2007).How Physicians Can Change the Future of Healthcare. JAMA. 297:1103-1111.

(6) CJL Murray. 2004. AD Lopez and S Wibulpolprasert, Monitoring global health: time for new solutions, BMJ 329 pp. 1096–1100.

(7) J Kates, JS Morrison and E Lief. 2006. Global health funding: a glass half full?, Lancet 368pp. 187–188.

(8) Horton R. 2005. The Ellison Institute: Monitoring health, challenging WHO. Lancet 366: 179–181.

(9) Stansfield, S. 2005. “Structuring Information Systems to Improve Health.” Bulletin of the World Health Organization 83 (8): 562.

(10) Ibid.

(11) Burattini, M. N., E. Massad, and F. A. B. Coutinho. 1993. Malaria transmission rates estimated from serological data. Epidemiology and Infection 111, (3) (Dec.): 503-23.

(12) Ware et al. Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study. PLoS Medicine, 2009; 6 (1): e11.

(13) Henderson, B.A., Kim, J.Y., Ament, C.S., Ferrufino-Ponce, Z.K., Grabowska, A., and Cremers, S.L. “Clinical pseydophakic cystoids macular edema: Risk factors for development and duration after treatment.” Journal of Cataract & Refractive Surgery. 33.9 (2007): 1550-1558.

(14) Lloyd, B. “The Power of Postoperative Eye drops.” September 2007. Eye On Vision. WebMD weblog. blogs.webmd.com.

(15) World Health Organization. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Geneva: World Health Organization, 2008.