As the purview of global health’s mission, goals, priorities, and responsibilities is constantly being defined and redefined, we can no longer allow politics, disjointed interdisciplinary efforts, and ill-informed practices set the standards for the future global health agenda. Millions of patients’ lives in both the developing and developed world depend on the agenda-setting decisions that are often based on outdated ideologies and pressure from insincere stakeholders. In order for the future generation of global health leaders to approach global health commitments through an ethical and evidence-based lens, I have listed below what I believe to be the most necessary and yet neglected global health priorities that should define the future global health agenda.
Priority I: Global health inequities must be approached through a human rights framework that becomes fully integrated with public health ideology and practice.
Dr. Paul Farmer, MD, PhD, one of the world’s most committed prophets of social justice, argues that while the emerging global health and human rights movement has reduces many inequities that plague the disease landscape of the developing world, the orthodox lens through which we view both public health and human rights approaches are essentially flawed (2008). Today, global health policies are popularly constructed around cost-effectiveness and sustainability, which possess genuine motives, but are devoid of the commitment required to not only cease epidemics, but address social and economic inequities, such as poverty, in impoverished countries (Farmer, 2008). In terms of human rights ideology, only civil, legal, and political rights are prioritized, and the much more dire issues of food, health, and education are regarded as an after-thought (Farmer, 2008). Dr. Farmer argues that both these theoretical approaches serve a neoliberal political and economic agenda set by domineering governments and international financial institutions, rather than the public health needs of the world’s most neglected communities (Farmer, 2008). Chidi Anselm Odinkalu, one of Africa’s leading human rights lawyers, astutely proclaims, “In Africa, the realization of human rights is a very serious business indeed. In many cases it is a life and death matter. From the child soldier, the rural dweller deprived of basic health care, the mother unaware that the next pregnancy is not an inexorable fate…and the activist organizing against bad government…people are acutely aware of the injustices inflicted upon them. Knowledge of the contents of the Universal Declaration will hardly advance their condition. What they need is a movement that channels these frustrations into articulate demands that evoke responses from the political process. This the human rights movement is unwilling or unable to provide. In consequence, the real-life struggles for social justice are waged despite human rights groups, not by or because of them, by people who feel that their realities and aspirations are not adequately captured by human rights organizations and their language” (Farmer, 2008).
One of the most telling examples of the salience of prioritizing an evidence-based human rights approach to the global health agenda is that of financing AIDS treatment in the developing world. The health and human rights community has successfully framed access to life-saving medications as a public good rather than a commodity (Farmer, 2008). This has compelled public health experts to rethink their traditional funding strategies that are adopted from international financial entities, such as capping health expenditures and prioritizing cost recovery in resource-poor countries (Farmer, 2008). After it was discovered that implementing user fees and selling AIDS therapy to poor African patients who could not afford treatment, diagnosis and care transformed from commodities with a market value to rights, driven by a framework of ethics and dignity (Farmer, 2008). It is promising to note that human rights and social justice were once the roots of public health action, and now are reemerging as priorities in the future global health agenda (Farmer, 2008). G8 countries must build on these recent encouraging responses and “move toward explicit endorsement of a rights based approach, backed up by firm long-term commitments to the redistribution of resources across national borders” (Labonte et al., 2005).
Priority II: Human, information, and material resources must be responsibly delivered and monitored to developing countries whose primary health care systems are experiencing crippling shortages of both health professionals and medical supplies.
As the brain drain of health professionals and dearth of medical supplies, ranging from gloves to HIV medications, threatens the delivery of care to millions of patients in the developing world, the long-term strengthening of human and material resources seems to fall at the bottom of the global health agenda each year. In sub-Sahara Africa alone, one million more health workers are needed just to provide basic primary care to its citizens (Labonte et al., 2005). The most unacceptable tragedy is that under-resourced health systems in most developing countries are unable to retain the nurses and physicians trained by their own professional schools (Labonte et al., 2005). The medical training of these health professionals is supported not only by private financing, which includes tuition, but by the local impoverished communities, who are taxed indirectly (Labonte et al., 2005). In order to reverse the brain drain, investments must be made medical universities and hospitals, health professionals must receive sufficient salaries and benefits that will incentives them to stay in their home country, such that they not only serve as clinicians, but public health leaders as well (Labonte et al., 2005). However, salaries alone cannot convince health professionals in the developing world to commit their professional lives to communities plagued by war, genocide, and social injustice. One study found that young physicians in urban Kenya were mostly unsatisfied with their working conditions simply due to the lack of diagnostic tools and medications needed in order to treat their patients (Labonte et al., 2005). Dr. Farmer once questioned, “How long can African doctors and nurses tolerate being little more than spectators to the grisly parade of suffering and premature death within the walls of that continent’s public hospitals?” (Farmer, 2008). In addition, the training and integration of community health workers is the most promising means by which to deliver care to the most neglected and isolated patient communities who possess the smallest chance of ever seeing a health professional in their lifetime.
It has been agreed upon by the global health community that since the most affluent countries benefit the most from this brain drain, these countries should begin negotiations on the multilateral agreement on migration of health professionals (Labonte et al., 2005). In addition to holding wealthy nations accountable for their intake of health professionals from the developing world, private foundations and donors must be encouraged to prioritize health information and human-resource development in their funding considerations (Labonte et al., 2005). The enhancement of health information systems can enable developing countries to “quantify health problems, set spending priorities, improve health care delivery, and measure the effects of interventions” (Okie, 2006).
Priority III: The funding decisions made by international institutions, national governments, non-profit organizations, and private foundations must follow standards of accountability, transparency, need, and sustainability.
In terms of sustainable financing, it has been estimated that most developing nations will not be able to achieve the Millennium Development Goals by 2015 that were set by G8 countries, unless these G8 countries increase their long-term funding commitments to these countries (Labonte et al., 2005). The G8 countries account for almost half the world’s economic output and govern the agenda-setting processes of the World Bank and International Monetary Fund, and yet only provided one-third of the estimated minimum health care needs of developing countries (Labonte et al., 2005). G8 countries must also specify mechanisms to ensure the affordability and availability of any vaccines, essential medicines, and diagnostic tools developed, as well as commit to ensuring access to and reduced prices of treatments (Labonte et al., 2005).In addition, the funding of research for diseases that afflict the wealthiest populations the most, disproportionately outweigh the many more millions of people who are dying of neglected and tropical diseases in impoverished countries due to the lack of market value incentives for researchers (Labonte et al., 2005). In order to reconstruct the funding agenda for global health, development aid must not undermine equity, such that health and education expenditures are capped or user fees are required for cost recovery (Labonte et al., 2005). Patients in the developing world do not wish for “cost-effective” solutions to their problems; they simply desire effective solutions (Farmer, 2008). Shirin Ebadi, a Nobel Peace Prize winner and human rights lawyer in the Middle East, recently encouraged the United Nations to cut off its funding to all nations who spent more on their military than on health and education for their people.
Private foundations, most notably the Bill & Melinda Gates Foundation, have arguably “energized research and forged partnerships among academia, governments, and industry much more effectively than most other institutions have” (Okie, 2006). The world’s largest charitable foundation, the Bill & Melinda Gates Foundation provides approximately $3 billion, or approximately one dollar per year for every person in the poorer half of the world’s population, solely to global health innovations, projects, and campaigns (Okie, 2006). “I think people watch what the Gateses do and assume that if they’re doing it, it’s not only a smart humanitarian move, but a smart business move,” said Helene Gayle, a former official at the Centers for Disease Control and Prevention (Okie, 2006). While the size of the foundation’s grants have largely shaped the current global health agenda, critics have argued that such monopolizing power instills long-term threats to global health needs (Okie, 2006). “The foundation’s grant making may not always reflect the priorities of recipients in developing countries, and its choices may influence the decisions of other funding agencies, potentially steering money away from basic science and toward product development” (Okie, 2006). Thus, Gates Foundation advisors must become more fully integrated into the communities they serve so that funding is responsibly distributed to the issues and patients who need it the most.
Priority IV: We must resurrect the priority public health once placed on primary health care infrastructure and we must ensure that our current disease-specific approach does not undermine the sustainability of these health systems
Due to the detrimental impact infectious diseases have had on impoverished patient communities throughout the world, disease-specific initiatives have institutionalized a vertical, “stovepipe” approach to the global health agenda. This has partly been due to the relative ease of raising media attention, garnering resources, and securing financing for disease-specific actions, as opposed to the less glamorous public health issue of broad health system strengthening (Smith & MacKellar, 2007). For instance, the world’s two most largely endowed funding sources, the Global Fund and PEPFAR, are allotted specifically for HIV/AIDS, tuberculosis, and malaria. However, the impacts that funding and attention for infectious diseases are belittled by widespread health system weaknesses, such shortages of skilled personnel and insufficient resources for operating hospital vehicles (Smith & MacKellar, 2007). “Although disease-specific interventions are important, assuring real change will require attention to environmental, political, and social actions that target the root causes of disease as envisaged at Alma Ata” (Magnussen et al., 2004). As a result, the seemingly short-fix solutions to our current global health crises pose as our largest threat, as it steals the spotlight away from the long-term systemic issues that need the attention the most.
Our future global health agenda can easily prioritize primary health system strengthening alongside current disease-specific programming in such a way that the two do not cancel each other our. First, the Ministry of Health of each country must work intimately alongside leaders from their fellow departments of agriculture, housing, sanitation, education, and food distribution (Magnussen et al., 2004). Second, health care system strengthening can no longer be placed in the hands of distant policymakers and top-down officials. The Alma Ata Declaration of 1948 requires that interventions are derived from the needs of the community, and are expressed and led by community members themselves (Magnussen et al., 2004). Furthermore, it is implied from this notion that programs need to be founded and researched in the locality in which they will be applied, rather than in universities and think tanks halfway across the world (Magnussen et al., 2004). Finally, accessibility to health services and resources to rural populations in both the developing and developed world must be ensured through the creation of community clinic networks, rather than on building acute, tertiary hospitals in booming urban centers (Magnussen et al., 2004).
Works Cited
Farmer, P. (2008). Challenging Orthodoxies: The Road Ahead for Health & Human Rights. Health and Human Rights, 10 (1): 5-19. Retrieved April 19, 2009, from < class="Apple-tab-span" style="white-space:pre"> article/viewFile/33/102>.
Magnussen, L., Ehiri, J., & Jolly, P. (2004). Comprehensive Versus Selective Primary Health Care: Lessons for Global Health Policy. Health Affairs, 23 (3): 167-176.
Okie, S. (2006). Global Health- The Gates-Buffet Effect. New England Journal of Medicine, 355 (11): 1084-1088.
Ollila, E. (2005). Global health priorities- priorities of the wealthy? Globalization and Health, 1(6): 1-5.
Smith, R.D., & MacKellar, L. (2007). Global public goods and the global health agenda, problems, priorities, and potential. Globalization and Health, 3(9): 1-7. Retrieved April 19, 2009, from
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