Globalization and Health

At a time when a highly contagious pandemic and global political and economic turmoil are intertwined, worldwide cooperation under the leadership of an international organization has become increasingly important. This study aimed to estimate the effect of COVID-19 on public confidence in the World Health Organization (WHO), which will serve as a reference for other international organizations regarding the maintenance of their credibility in crisis management and ability to play a greater role in global health governance. We obtained individual data from the World Values Survey (WVS). A total of 44,775 participants aged 16 and older from 40 countries in six WHO regions were included in this study. The COVID-19 pandemic was used as a natural experiment. We obtained difference-in-differences (DID) estimates of the pandemic’s effects by exploiting temporal variation in the timing of COVID-19 exposure across participants interviewed from 2017 to 2020 together with the geographical variation in COVID-19 severity at the country level. Public confidence in the WHO was self-reported by the respondents. Among the participants, 28,087 (62.73%) reported having confidence in the WHO. The DID estimates showed that the COVID-19 pandemic could significantly decrease the likelihood of people reporting confidence in the WHO after controlling for multiple covariates (adjusted OR 0.54, 95% CI: 0.49–0.61), especially during the global outbreak (0.35, 0.24–0.50). The effect was found in both younger individuals (0.58, 0.51–0.66) and older adults (0.49, 0.38–0.63) and in both males (0.47, 0.40–0.55) and females (0.62, 0.53–0.72), with a vulnerability in males (adjusted P for interaction = 0.008). Our findings are relevant regarding the impact of COVID-19 on people’s beliefs about social institutions of global standing, highlighting the need for the WHO and other international organizations to shoulder the responsibility of global development for the establishment and maintenance of public credibility in the face of emergencies, as well as the prevention of confidence crises.

In much of the world, President George W. Bush was not admired for his foreign policy and diplomacy. It is therefore ironic that Bush’s single most uncontested foreign policy triumph was an instance of what has now become known as “health diplomacy”. In 2003 Bush launched the President’s Emergency Plan for AIDS Relief, a five-year $15 billion initiative to fight HIV/AIDS, mostly in Africa. The president’s pragmatic health diplomacy may well save his foreign policy legacy. This article argues that a middle power such as South Africa should consider a similar instrumental AIDS diplomatic strategy, to rehabilitate its public health as well as foreign policy images. This article reflects on the emergence and contemporary practice of health diplomacy. In particular, it explores the potential of niche areas within health diplomacy to become constructive focal points of emerging middle powers’ foreign policies. Middle powers often apply niche diplomacy to maximise their foreign policy impact, particularly by pursuing a multilateral agenda. The literature on middle powers indicates that such foreign policy ambitions and concomitant diplomacy mostly act to affirm the global status quo. Instead, this paper argues that there may well be niches within health diplomacy in particular that can be used to actually challenge the existing global order. Emerging middle powers in particular can use niche areas within health diplomacy in a critical theoretical manner, so that foreign policy and diplomacy become a project of emancipation and transformation, rather than an affirmation of the world as it is. The article first describes the emergence and contemporary practice of health diplomacy; this is followed by a discussion of niche diplomacy, in particular as it applies to the foreign policy agendas of emerging middle powers. It then reviews South African foreign policy and diplomacy, before situating these policies within the context of emerging mechanisms of south-south multilateralism. The article concludes by synthesizing these elements and advocating for a South African AIDS diplomacy, emphasizing its potential to galvanize a global project of emancipation.

The resolution adopted in 2006 by the World Health Organization on international trade and health urges Member States to understand the implications of international trade and trade agreements for health and to address any challenges arising through policies and regulations. The government of Maldives is an importer of health services (with outgoing medical travelers), through offering a comprehensive universal health care package for its people that includes subsidized treatment abroad for services unavailable in the country. By the end of the first year of the scheme approximately US$11.6 m had been spent by the government of Maldives to treat patients abroad. In this study, affordability, continuity and quality of this care were assessed from the perspective of the medical traveler to provide recommendations for safer and more cost effective medical travel policy. Despite universal health care, a substantial proportion of Maldivian travelers have not accessed the government subsidy, and a third reported not having sufficient funds for the treatment episode abroad. Among the five most visited hospitals in this study, none were JCI accredited at the time of the study period and only three from India had undergone the National Accreditation Board for Hospitals (NABH) in India. Satisfaction with treatment received was high amongst travelers but concern for the continuity of care was very high, and more than a third of the patients had experienced complications arising from the treatment overseas. Source countries can use their bargaining power in the trade of health services to offer a more comprehensive package for medical travelers. Source countries with largely public funded health systems need to ensure that medical travel is truly affordable and universal, with measures for quality control such as the use of accredited foreign hospitals to make it safer and to impose measures that ensure the continuity of care for travelers.

The international community’s health focus is shifting from achieving disease-specific targets towards aiming for universal health coverage. Integrating the global HIV/AIDS response into universal health coverage may be inevitable to secure its achievements in the long run, and for expanding these achievements beyond addressing a single disease. However, this integration comes at a time when international financial support for the global HIV/AIDS response is declining, while political support for universal health coverage is not translated into financial support. To assess the risks, challenges and opportunities of the integration of the global HIV/AIDS response into national universal health coverage plans, we carried out assessments in Indonesia, Kenya, Uganda and Ukraine, based on key informant interviews with civil society, policy-makers and development partners, as well as on a review of grey and academic literature. In the absence of international financial support, governments are turning towards national health insurance schemes to finance universal health coverage, making access to healthcare contingent on regular financial contributions. It is not clear how AIDS treatment will be fit in. While the global HIV/AIDS response accords special attention to exclusion due to sexual orientation and gender identity, sex work or drug use, efforts to achieve universal health coverage focus on exclusion due to poverty, gender and geographical inequalities. Policies aiming for universal health coverage try to include private healthcare providers in the health system, which could create a sustainable framework for civil society organisations providing HIV/AIDS-related services. While the global HIV/AIDS response insisted on the inclusion of civil society in decision-making policies, that is not (yet) the case for policies aiming for universal health coverage. While there are many obstacles to successful integration of the global HIV/AIDS response into universal health coverage policies, integration seems inevitable and is happening. Successful integration will require expanding the principle of ‘shared responsibility’ which emerged with the global HIV/AIDS response to universal health coverage, rather than relying solely on domestic efforts for universal health coverage. The preference for national health insurance as the best way to achieve universal health coverage should be reconsidered. An alliance between HIV/AIDS advocates and proponents of universal health coverage requires mutual condemnation of discrimination based on sexual orientation and gender identity, sex work or drug use, as well as addressing of exclusion based on poverty and other factors. The fulfilment of the promise to include civil society in decision-making processes about universal health coverage is long overdue.

The potentially destructive polarisation between 'vertical' financing (aiming for disease-specific results) and 'horizontal' financing (aiming for improved health systems) of health services in developing countries has found its way to the pages of Foreign Affairs and the Financial Times. The opportunity offered by 'diagonal' financing (aiming for disease-specific results through improved health systems) seems to be obscured in this polarisation. In April 2007, the board of the Global Fund to fight AIDS, Tuberculosis and Malaria agreed to consider comprehensive country health programmes for financing. The new International Health Partnership Plus, launched in September 2007, will help low-income countries to develop such programmes. The combination could lead the Global Fund to fight AIDS, Tuberculosis and Malaria to a much broader financing scope. This evolution might be critical for the future of AIDS treatment in low-income countries, yet it is proposed at a time when the Global Fund to fight AIDS, Tuberculosis and Malaria is starved for resources. It might be unable to meet the needs of much broader and more expensive proposals. Furthermore, it might lose some of its exceptional features in the process: its aim for international sustainability, rather than in-country sustainability, and its capacity to circumvent spending restrictions imposed by the International Monetary Fund. The authors believe that a transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund is feasible, but only if accompanied by a substantial increase of donor commitments to the Global Fund. The transformation of the Global Fund into a 'diagonal' and ultimately perhaps 'horizontal' financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features.

The objective of this article is to describe the state of North, Central, South American and Caribbean (Pan-American) indigenous health. The second objective is to identify recommendations for optimal healthcare and research strategies to achieve indigenous health equity. Current health disparities continue to present between indigenous populations and general populations. Research foci of Pan-American indigenous health center on health outcomes for chronic and acute disease as well as presence of indigenous in data sets. Research is both qualitative and quantitative. Recommendations to improve indigenous health in effort of health equity are variable yet feasible. Stronger epidemiology, continued cohesive Pan-American global strategies, better research alignment with emphasis to quality and comprehensive metric analyses in healthcare delivery are all avenues to improve the health of the indigenous. Research and healthcare delivery on the Pan-American indigenous must be maximized for optimal results, must be representative of the indigenous communities, must be implemented in best practice and must introduce sustainable healthcare delivery for Pan-American indigenous health equity.

This paper assesses progress in the development of a global framework for responding to non-communicable diseases, as reflected in the policies and initiatives of the World Health Organization (WHO), World Bank and the UN: the institutions most capable of shaping a coherent global policy. Responding to the global burden of chronic disease requires a strategic assessment of the global processes that are likely to be most effective in generating commitment to policy change at country level, and in influencing industry behaviour. WHO has adopted a legal process with tobacco (the WHO Framework Convention on Tobacco Control), but a non-legal, advocacy-based approach with diet and physical activity (the Global Strategy on Diet, Physical Activity and Health). The paper assesses the merits of the Millennium Development Goals (MDGs) and the FCTC as distinct global processes for advancing health development, before considering what lessons might be learned for enhancing the implementation of the Global Strategy on Diet. While global partnerships, economic incentives, and international legal instruments could each contribute to a more effective global response to chronic diseases, the paper makes a special case for the development of international legal standards in select areas of diet and nutrition, as a strategy for ensuring that the health of future generations does not become dependent on corporate charity and voluntary commitments. A broader frame of reference for lifestyle-related chronic diseases is needed: one that draws together WHO's work in tobacco, nutrition and physical activity, and that envisages selective use of international legal obligations, non-binding recommendations, advocacy and policy advice as tools of choice for promoting different elements of the strategy.

The ripple effects of protracted armed conflicts include: significant gender-specific barriers to accessing essential services such as health, education, water and sanitation and broader macroeconomic challenges such as increased poverty rates, higher debt burdens, and deteriorating employment prospects. These factors influence the wider social and political determinants of health for women and a gendered analysis of the political economy of health in conflict may support strengthening health systems during conflict. This will in turn lead to equality and equity across not only health, but broader sectors and systems, that contribute to sustainable peace building. The methodology employed is a multidisciplinary narrative review of the published and grey literature on women and gender in the political economy of health in conflict. The existing literature that contributes to the emerging area on the political economy of health in conflict has overlooked gender and specifically the role of women as a critical component. Gender analysis is incorporated into existing post-conflict health systems research, but this does not extend to countries actively affected by armed conflict and humanitarian crises. The analysis also tends to ignore the socially constructed patriarchal systems, power relations and gender norms that often lead to vastly different health system needs, experiences and health outcomes. Detailed case studies on the gendered political economy of health in countries impacted by complex protracted conflict will support efforts to improve health equity and understanding of gender relations that support health systems strengthening.

The World Summit on Sustainable Development (WSSD) was held in Johannesburg in 2002 to review progress since the Rio conference in 1992, and to agree a new global deal on sustainable development. Unlike its predecessor, it was primarily concerned with implementation rather than with new treaties and targets, although a number of new targets were agreed, for example one on sanitation. Failure to agree a target on renewable energy was regarded as a major disappointment of the conference. While relatively modest in its achievements, and with difficulties in achieving consensus in key areas such as energy, trade, finance and globalisation, WSSD nevertheless succeeded in placing sustainable development back on the political agenda, giving new impetus, in particular to the environment and development needs of Africa, with a strong focus on local issues like household energy, water and sanitation. Health was singled out as one of five priority areas, along with water, energy, agriculture and biodiversity, and was devoted a separate chapter in the resulting Plan of Implementation, which highlighted a range of environmental health issues as well as issues relating to health services, communicable and non-communicable diseases. A number of new partnerships were formed at WSSD, including the Healthy Environments for Children Alliance (HECA) launched by WHO, which will form an important platform for implementation. The Commission on Sustainable Development has been designated main responsibility for monitoring and follow up, with its programme of work reorganised to focus on thematic clusters of issues. From the perspective of health, WSSD must be seen as a reaffirmation of the central place of health on the sustainable development agenda, and in the broader context of a process which began in Rio and was given added impetus with the Monterrey Financing for Development conference and the World Trade Organisation meeting held in Doha. Translating policies into action at all levels- global to local – remains the single biggest challenge in the years that lie ahead.