This issue of Equinet is dedicated to covering some of the recent research and comment on the complex issue of globalisation and equity in health. Recent events signal that health has gained some profile as a global issue, whether in relation to the deliberations and campaigns around World Trade Organisation provisions on intellectual property rights and access to essential drugs, or in relation to the United Nations launch up of the Global Health Fund.
There are many questions about the impact of such initiatives in dealing with the real impact of globalisation on health, and its potential – or otherwise - to deliver greater equity in health. The conflict over TRIPS has highlighted contradictions between free trade provisions and access to existing technologies for health. Questions exist of how far a Global Health Fund addresses or diverts attention from the economic policies that generate the debt, poverty and marginalisation that produces a major share of the global burden of disease. As Fran Baum has written recently in the Journal of Epidemiology and Community Health "Can you imagine a world in which the spread of globalisation meant the world becoming a more just and equitable place? This seems like an impossible dream. All the indications are that the current forms of globalisation are making the world a safe place for unfettered market liberalism and the consequent growth of inequities. This economic globalisation is posing severe threats to both people's health and the health of the planet” (1).
There is debate on the health impacts of globalisation: David Dollar, in a recent World Health Organisation Bulletin on health and globalisation argues that economic globalisation has raised the incomes of poor countries, and that this has generally benefited poor people. Others argue that while globalisation has brought economic growth-promoting potential, these benefits have been restricted to a small number of countries, and have left the majority of developing countries excluded or even negatively effected by such growth potential. (2).
There is perhaps more wide consensus that changes are required to ensure that health outcomes are factored more centrally within globalisation processes. This means providing for measures to promote and protect health in globalisation as global public goods, and not as market or aid. It also means not waiting to act on those areas where health burdens are already accumulating under global economic and trade processes - such as in transfer of tobacco risks to youth in developing countries, or in the shift towards more casual jobs that lack adequate social protection. Nick Drager and Robert Beaglehole point out in the editorial of a special World Health Organisation Bulletin on globalisation and health:
“Public health scientists are still in the early stages of gathering concrete evidence on the effects of globalisation on population health. This evidence is required to inform policies and actions to protect and promote the health of the poor. The productivity of this research would be improved if there was an agreed framework for considering the various mechanisms by which economic globalisation affects population health status… It is already evident, however, that policy measures are required to rectify the adverse effects of globalisation on health and strengthen the positive ones. Policy should be guided by the following principles:(i) growth needs to be inclusive, equitable and sustainable, and this requires policy coherence between economic, social and environment sectors; (ii) opening up of borders should be gradual and preceded by appropriate protective conditions; (iii) international rules and institutions should promote the production of global public goods and the control of global public ‘‘bads’’; (iv) special attention is needed to increase the transfer of financial and technical resources to those left behind in the development process; (v) strong national health policies, institutions, regulations and programmes are essential; (vi) the public health workforce must be equipped with the knowledge and skills to engage with partners across sectors and across borders to achieve health and other social goals.” (3)
In the EQUINET September 2000 conference it was noted that during several decades of structural adjustment in southern Africa health scientists argued about the extent of negative impacts while populations became poorer, hungrier, more at risk of disease and less able to afford or access basic health services. By the time the negative impacts were acknowledged structural adjustment had been replaced by the much wider and more sweeping liberalisation and privatisation of the current phase of globalisation. Globalisation has increased the visibility and evidence of the global resources and opportunities available for health. This makes the contrast with the deprivation of such resources where they are most needed extremely stark.
1. Health, equity, justice and globalisation: some lessons from the People's Health Assembly. F Baum - J Epidemiol Community Health 2001;55:613-6. <a href=http://www.jech.com/cgi/content/full/55/9/613>http://www.jech.com/cgi/content/full/55/9/613</a>
2. Is globalization good for your health? David Dollar; Globalization and health: results and options; Giovanni Andrea Cornia. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>
3. Editorial: Globalization: changing the public health landscape. Nick Drager & Robert Beaglehole. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>
1. Editorial
2. Equity in Health
Technology is not delivering healthcare services to a large number of lowincome groups covered by medical aid, says Robert Dale, marketing director of Telg Africa.
The Swaziland government has announced a five-year sex ban for young women in a bid to combat the spread of HIV/AIDS in the country. The ban was announced on Sunday evening by the leader of Swaziland's young women, Lungile Ndlovu, who said the elders of the nation had deemed it fitting, AFP reported.
Christopher J L Murray, executive director. Evidence and Information for Policy, World Health Organization, 1211 Geneva 27, Switzerland
Braveman et al criticise the World Health Organiztion's approach of measuring the full spectrum of health inequalities in a population. They argue for a selective approach in which only health inequalities correlated with factors such as income, social class, or race should matter. Such a selective approach runs counter to the literature on inequality in other disciplines and runs the risk of discouraging scientific inquiry into the causes of inequality.
Paula Braveman, professor of family and community medicine, University of California, San Francisco, CA, USA; Barbara Starfield, university distinguished professor, Johns Hopkins Medical Institutions, Baltimore, MA, USA; H Jack Geiger, Logan professor of community medicine, emeritus c., City University of New York Medical School, Department of Community Health and Social Medicine, New York, NY, USA. BMJ September 22, 2001;323 678-681.
The World Health Organization’s World Health Report 2000 deserves praise for recommending that national health systems be assessed not only by the average health status of a country’s population but also by the extent to which health varies within the population. We are concerned, however, that the report’s approach to measuring health inequalities does not support -- and actually undermines -- efforts to achieve greater equity in health within nations, according to any meaningful definition of equity. We believe that the report’s measure of health inequalities lacks practical utility in general for guiding national policy because it provides no information to guide resource allocation or to target policies. In addition, it does not measure socioeconomic or other social disparities in health within countries. It therefore -- when used, as its authors implicitly and explicitly recommend, as a substitute for monitoring social inequalities in health -- removes consideration of equity and human rights from the routine measurement and reporting of health disparities within nations.
Over the next few decades, one of the most pressing issues, at both the national and international levels, will be the undeniable ageing of the world's richest peoples. Last month, at a Tokyo conference entitled Aging and the Global Economy, the Washington-based Center for Strategic and International Studies warned us that the world's wealthiest countries are ageing too quickly.
Pages
3. Human Resources
Rene Loewenson. Bulletin of the World Health Organization Volume 79, Number 9, September 2001
Increased world trade has generally benefited industrialized or strong economies and marginalized those that are weak. This paper examines the impact of globalization on employment trends and occupational health, drawing on examples from southern Africa. While the share of world trade to the world’s poorest countries has decreased, workers in these countries increasingly find themselves in insecure, poor-quality jobs, sometimes involving technologies which are obsolete or banned in industrialized countries. The occupational illness which results is generally less visible and not adequately recognized as a problem in low income countries. Those outside the workplace can also be affected through, for example, work related environmental pollution and poor living conditions. In order to reduce the adverse effects of global trade reforms on occupational health, stronger social protection measures must be built into production and trade activities, including improved recognition, prevention, and management of work-related ill-health. Furthermore, the success of production and trade systems should be judged on how well they satisfy both economic growth and population health.
4. Public-Private Mix
David P. Fidler. Bulletin of the World Health Organization Volume 79, Number 9, September 2001
Global threats to public health in the 19th century sparked the development of international health diplomacy. Many international regimes on public health issues were created between the mid 19th and mid-20th centuries. The present article analyses the global risks in this field and the international legal responses to them between 1851 and 1951, and explores the lessons from the first century of international health diplomacy of relevance to contemporary efforts to deal with the globalization of public health.
DOUGLAS W BETTCHER and HEATHER WIPFLI - J Epidemiol Community Health 2001;55:617-8
In her article Fran Baum is correct in pointing out that the political complexities of our globalised world must be taken into account by public health professionals. Global health futures are directly or indirectly associated with the transnational economic, social, and technological changes taking place in the world. Issues such as poverty, equity, and justice must be firmly rooted in any discussions aimed at improving global public health. However, globalisation is a "janus faced" creature: the double face of globalisation, one promising and the other threatening, is a fact of life as humanity is being catapulted into a more interdependent future.
5. Resource allocation and health financing
Inge Kaul & Michael Faust. Bulletin of the World Health Organization Volume 79, Number 9, September 2001
We examined recent special health initiatives to control HIV/AIDS, malaria, and tuberculosis, and make four policy recommendations for improving the sustainability of such initiatives. First, international cooperation on health should be seen as an issue of global public goods that concerns both poor and rich countries. Second, national health and other sector budgets should be tapped to ensure that global health concerns are fully and reliably funded; industrialized countries should lead the way. Third, a global research council should be established to foster more efficient health-related knowledge management. Fourth, managers for specific disease issues should be appointed, to facilitate policy partnerships. Policy changes in these areas have already begun and can provide a basis for further reform.
Adam Wagstaff. Development Research Group and Human Development Network World Bank
In its latest World Health Report, the World Health Organization argues that a key dimension of a health system's performance is the fairness of its financing system. In addition to discussing the ways policymakers can improve this aspect of performance, the report proposes an index of fairness, discusses how it should be operationalized, and presents a league table of countries ranked by the fairness with which their health services are financed. This paper provides a critical assessment of the WHO index. It shows that the index cannot discriminate between health financing systems that are regressive and those that are progressive, and cannot discriminate between horizontal inequity and progressivity/regressivity. The paper compares the WHO index to an alternative and more illuminating approach developed in the income redistribution literature in the early 1990s and used in the late 1990s to study the fairness of various OECD countries’ health financing systems.
Gerald Bloom and Hilary Standing. ISBN 1 85864 361 9 - IDS Working Papers - 136, Institute of Development Studies, University of Sussex, 2001
This paper is part of a broader attempt to identify the key producers of social goods and how social policy interventions can support them. This paper is focused on the health sector. It
examines the changing roles of health care providers and the management of health expertise in the context of pluralism and increasing marketisation of health goods and services; explores how pluralism of provisioning and increasing markets for health goods have affected the ways households meet their health needs; stimulates a reassessment of what governments should or could do to enable delivery of competent health care under conditions of pluralism and marketisation.
6. Governance and participation in health
Is tobacco control a development issue? How will the WHO's Framework Convention on Tobacco Control (FCTC) affect developing countries? What new research is needed to explore these issues? What do YOU think? id21 Health's email discussion aims to bring a broader development perspective to the tobacco control debate. Participants will include international and national policy-makers, health professionals, tobacco control agencies, NGOs and researchers from diverse academic disciplines. A summary of the discussion will be distributed to participants at the next round of negotiations on the FCTC in late November. To join the discussion, send an email to lyris@lyris.ids.ac.uk, with the message: ''subscribe tobacco Firstname Lastname", e.g. "subscribe tobacco Emily Smith".
This Worldview International project is a youth Internet forum on global issues. Every fortnight, they cover pertinent issues, chosen by youth themselves through an offline and online poll. Recent discussions have included Sexuality Education: If Not Now, Then When?
7. Monitoring equity and research policy
This report summarizes the findings of an assessment conducted for the United States Agency for International Development’s "Corridors of Hope" Initiative, a regional HIV/AIDS prevention project focusing on key sites along the Durban-Lusaka highway in southern Africa. Conducted in November 1999 in Messina, South Africa, Chirundu, Zambia, and Beitbridge and Chirundu in Zimbabwe, the assessment sought to develop, test, refine and package a standard participatory methodology for evaluating HIV risk, identifying prevention opportunities and designing grounded, coordinated regional prevention initiatives.
David Woodward, Nick Drager, Robert Beaglehole,
& Debra Lipson. Bulletin of the World Health Organization Volume 79, Number 9, September 2001
Globalization is a key challenge to public health, especially in developing countries, but the linkages between globalization and health are complex. Although a growing amount of literature has appeared on the subject, it is piecemeal, and suffers from a lack of an agreed framework for assessing the direct and indirect health effects of different aspects of globalization. This paper presents a conceptual framework for the linkages between economic globalization and health, with the intention that it will serve as a basis for synthesizing existing relevant literature, identifying gaps in knowledge, and ultimately developing national and international policies more favourable to health. The framework encompasses both the indirect effects on health, operating through the national economy, household economies and health-related sectors such as water, sanitation and education, as well as more direct effects on population-level and individual risk factors for health and on the health care system. Proposed also is a set of broad objectives for a programme of action to optimize the health effects of economic globalization. The paper concludes by identifying priorities for research corresponding with the five linkages identified as critical to the effects of globalization on health.
8. Useful Resources
From 2002, Nature Publishing Group will publish Heredity, a journal of the Genetics Society. Focusing on eukaryotes, the journal publishes key papers on ecological, population and evolutionary
genetics, including human population genetics; genomics and post-genomics as applied to evolutionary questions; biometrical and statistical genetics; animal and plant breeding and cytogenetics. For submission and subscription enquiries e-mail us.
Hospital managers, policymakers and provincial health officers can use HOSPICAL to analyse current costs and revenue. It consists of a user's guide and an electronic spreadsheet file that allows managers to manage resources more effectively. It is available free of charge to institutions in Asia, Latin America, and Africa.
The Info Services page on the Environmental Health Project website has been changed to a mini-portal on environmental health to hopefully provide a more organized and convenient method for obtaining information on environmental health. Please check it out and contact Dan Campbell if you find it useful and if you have suggestions and other categories or resources to add.
9. Jobs and Announcements
The International Planned Parenthood Federation is looking for a Africa Regional Director. For more information Contact: Dick Irish -Ref: DB_09.
Catholic Relief Services (CRS) is looking for a Regional Technical Advisor for HIV/AIDS. The top priority for this post is to provide assistance to the South Africa HIV/AIDS Programme Office, which is responsible for programmes in Botswana, Lesotho, Namibia, South Africa and Swaziland. For more information contact: Dawn Sheckells. Include req. no. I 01 009 and source code DRUMBEAT.
CALL FOR PAPERS
Amidst a growing concern about increasing inequality, the spatial dimensions of inequality have begun to attract considerable policy interest. In China, Russia, India, Mexico and South Africa, as well as most other developing and transition economies, there is a sense that spatial and regional inequality, of economic activity, incomes and social indicators, is on the increase. Despite these important popular and policy concerns, there is remarkably little systematic and coherent documentation of the facts of what has happened to spatial and regional inequality over the past ten to twenty years. Correspondingly, there is insufficient understanding of the determinants of internal spatial inequality in a globalizing world. To meet this gap in knowledge, Cornell University, London School of Economics and WIDER are sponsoring a conference on "Spatial Inequality and Development," to be held at the London School of Economics on June 27-29, 2002. The conference seeks to attract contributions, which document and analyze the facts of within country spatial inequality, and its determinants, especially during the period of globalization of the last two decades. A broad view is taken of inequality, covering the distribution of such variables as economic activity, economic structure, population, income, social indicators, infrastructure and public expenditure. While the main focus of the conference is on empirical analysis of recent history, contributions which conceptualize the measurement of spatial inequality, or analyze its evolution in a longer historical frame, will also be considered. It is intended to collect the papers selected for and presented to the conference, in a volume to be edited by Professor Ravi Kanbur, Cornell University, and Professor Tony Venables, London School of Economics, and to be published by a leading academic press.