Global Health Governance

Original Editor - Laura Ritchie with tremendous gratitude to members of the Global Health Division of the Canadian Physiotherapy Association for assistance with content for this article.

Top Contributors - Naomi O'Reilly  

Introduction

Global Health refers to ‘those health issues, which transcend national boundaries and governments and call for actions on the global forces and global flows that determine the health of people’[1].

Since is establishment in 1948 the World Health Organisation (WHO) has been one of the primary actors in driving the health agenda globally and remains the only body able to create legally binding treaties (there are currently two; the Framework Convention on Tobacco Control (FCTC) and International Health Regulations (IHR)).

Kickbusch & Szabo [2] set out the transnational and cross-cutting nature of governance in the global health domain along three political spaces: Global Health Governance, Global Governance for Health, and Governance for Global Health.

  • Global Health Governance refers mainly to organisations and processes of global governance which have explicit health mandates, e.g. World Health Organization [2]
  • Global Governance for Health refers mainly to organisations and processes of global governance which have either a direct and/or indirect health impact, e.g. United Nations, and World Trade Organization [2]
  • Governance for Global Health refers to organisations and mechanisms established at National and/or Regional Level that contribute to Global Health Governance and/or to Governance for Global Health e.g. National and/or Regional Global Health Strategies or Initiatives [2]

They suggest that in order to keep global health firmly on the political agenda, and to strengthen action on the determinants of health, reform and strengthening of the governance institutions in all three of these political spheres as well as how they interface is critical.

Fig.1 Global Health Governance along Three Political Spheres[2]

Fig. 2 Linking within and between Dimensions[2]

Global health policy is now being influenced by an ever-increasing number of nonstate and non-intergovernmental actors to include influential foundations, multinational corporations, multi-sectoral partnerships, and civil society organizations. Kelley [3] examined the current architecture of global health governance including the World Health Organisation, various United Nations Agencies and the role of International Non-Governmental Organisations.  

Finally Kickbusch [4] examines the changing context for Global Health and with the advent of the agreement on the Sustainable Development Goals identifies some key questions in relation to Global Health Governance that still need answering. How will responsibility for our future be distributed as power is diffused? What political mechanisms will we have at our disposal? Can the commitment to the SDGs help build a new UN?

Organisations

United Nations Organisations

World Health Organization 

World Health Organisation building from south.jpg

"When diplomats met to form the United Nations in 1945, one of the things they discussed was setting up a Global Health Organization, which had been proposed by Brazil and China. WHO’s Constitution came into force on 7 April 1948 - a date we now celebrate every year as World Health Day [5] and contains several key principles, including [5]

  • Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
  • The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
  • The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. 

According to Kelly the broad mandate of the World Health Organisation has 6 Core Functions: [5] [3]

  1. Provision of collective health leadership,
  2. Shaping of research as well as the generation and dissemination of knowledge
  3. Setting of norms and standards and the promotion and monitoring of their implementation
  4. Production of ethical and evidence-based policy options
  5. Provision of technical support and capacity-building
  6. Monitoring of health situations and trends.

The organization also has a 6-Point Agenda: [5] [3]

  1. Promote Development
  2. Foster Health Security
  3. Strengthen Health Systems
  4. Harness Research, Information, and Evidence
  5. Enhance Partnerships
  6. Improve Performance

For more information, please visit http://www.who.int/en/

United Nations General Assembly

The United Nations General Assembly (UNGA, GA, or French: Assemblée Générale "AG") is one of the principal organs of the United Nations and the only one in which all member nations have equal representation. The General Assembly is the main deliberative, policymaking and representative organ of the United Nations. Decisions on important questions require a two-thirds majority, which can include those on peace and security, admission of new members and budgetary matters, while decisions on other questions are by simple majority. Each country has one vote. [6]

In September 2000, building upon a decade of major United Nations conferences and summits, world leaders came together at United Nations Headquarters in New York to adopt the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets, with a deadline of 2015, known as the Millennium Development Goals. According to Kelley [3] the 3 Health-related Goals of the Millenium Development Goals, highlighted below, have directly provided high-level, consensus to global health policy direction and played a key role in moving Global Health forward.

Goal 4: Reduce Child Mortality Rate [3]

  • Target 4A: Reduce the under-5 mortality rate by two-thirds, between 1990 and 2015

Goal 5: Improve Maternal Health [3]

  • Target 5A: Reduce the maternal mortality ratio by three-quarters, between 1990 and 2015 Target 5B: Achieve universal access to reproductive health by 2015

Goal 6: Combat HIV/AIDS, Malaria, and other Diseases [3]

  • Target 6A: Have halted and begun to reverse the spread of HIV/AIDS by 2015
  • Target 6B: Achieve universal access to treatment for HIV/AIDS for all those who need it by 2010
  • Target 6C: Have halted and begun to reverse the incidence of malaria and other major diseases by 2015

In September 2015, the Assembly agreed on a further set of 17 Sustainable Development Goals, contained in the outcome document of the United Nations summit for the adoption of the post-2015 Development Agenda (resolution 70/1), which are key goals to guide a coordinated approach to Global Health.

Goal 3: Good Health & Wellbeing [7]

Ensure healthy lives and promote well-being for all at all ages

  • Target 3.1: Reduce the global maternal mortality ratio to less than 70 per 100,000 live births
  • Target 3.2: End preventable deaths of newborns and children under 5 years of age, to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
  • Target 3.3: End the epidemics of AIDS, Tuberculosis, Malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases
  • Terget 3.4: Reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
  • Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
  • Target 3.6: Halve the number of global deaths and injuries from road traffic accidents
  • Target 3.7: Ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
  • Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
  • Target 3.9: Substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

For more information, please visit http://www.un.org/en/ga/

Non-Governmental Organisations

Handicap International

Handicap International is an independent international aid organisation working in situations of poverty and exclusion, conflict and disaster. Since Handicap International was founded in 1982, their work has benefitted several million people in more than 60 countries worldwide.

Handicap International was a co-recipient of the 1997 Nobel Peace Prize as a founding member of the International Campaign to Ban Landmines which led to the signing of the Mine Ban Treaty. In 2011 theyr were awarded the Hilton Humanitarian Prize in recognition of almost 30 years of humanitarian action. Handicap International also received the 1996 Nansen Refugee Award for their work with refugees and victims of landmines. Instituted in 1954, the Nansen Refugee Award is given annually to an individual or an organization in recognition of extraordinary and dedicated service to refugees and is the most prestigious honour conferred by UNHCR.

Handicap International is a Federation of eight National Associations: Belgium, Canada, France, Germany, Luxembourg, Switzerland, UK and USA. Together, they mobilise resources and manage projects around the world to support disabled and vulnerable people.

CURE International 

"A non-profit organization that operates charitable hospitals and programs in 30 countries worldwide where patients experience the life-changing message of God’s love for them, receiving surgical treatment regardless of gender, religion, or ethnicity." [8]

For more information, please visit https://cure.org/

Canadian Association for Medical Relief

"The Canadian Association for Medical Relief (CAMR), founded in 2002 by Dr. Rand Askalan, is a non-for-profit organization that provides medical services in developing countries. These services may be in the form of:

  • Offering financial and social support to patients coming to Canada for medical treatment *Improving quality of care by sending medical equipment and supplies
  • Sponsoring Canadian physicians to offer free medical care
  • Supporting students during their medical training in Canada
  • Organizing educational seminars for local community physicians"[9]

For more information, please visit: http://camr.ca/

Medical Ministry International 

"Each year, over half a million people benefit from the compassionate and quality care of our Health Centers, Project Teams, and Residency Training Programs. Founded in 1968, MMI works in over 23 countries around the world. In 2014 we provided health care services worth US$177,519,522 to 668,475 people throughout the world who typically would have had limited or no access to medical services. Our business model is unique in that we utilize volunteers both medical and non-medical to bring life-changing services to the poor. We seek to eliminate a “welfare” mentality by asking that the patients contribute to their services. This contribution may be a little, but we have found over time that if someone has invested in their care, they will follow the doctors direction and get healthy. Gone are the days of people just throwing money a problem and then those who receive the gift tossing it aside because they think its not worth something."[10]

For more information, please visit: https://medicalministrytrips.org/

Terre Sans Frontières - Physiothérapie Sans Frontières 

"Terre Sans Frontières is an international cooperation organization that supports and strengthens its southern education and community development partners; it matches Canadians—in particular specific segments of the population—with initiatives fostering the wellbeing of underprivileged individuals both in Canada and farther south. Founded by the Brothers of Christian Instruction, Terre Sans Frontières has always had a close relationship with Canadian religious communities." [11]

For more information, please visit: http://terresansfrontieres.ca/en/

Work the World 

"Work the World provides highly tailored clinical internships across the developing world. Every intern's aim is different, so we tailor each and every aspect of your placement to your own individual needs. Whether you're interested in paediatric physical therapy in Sri Lanka, or geriatric rehabilitation in Kathmandu, we'll be able to create the perfect placement for you."[12]

For more information, please visit http://www.worktheworld.com/

Physiotherapy Organisations

International

World Confederation of Physical Therapists 

"Founded in 1951, the World Confederation for Physical Therapy (WCPT) is the sole international voice for physical therapy, representing more than 350,000 physical therapists worldwide through its 112 member organisations. The confederation operates as a non-profit organisation and is registered as a charity in the UK."[13]

"WCPT believes that every individual is entitled to the highest possible standard of culturally appropriate healthcare delivered in an atmosphere of trust and respect for human dignity, and underpinned by sound clinical reasoning and scientific evidence. It is committed to furthering the physical therapy profession and improving global health through: 

  • encouraging high standards of physical therapy research, education and practice 
  • supporting the exchange of information between WCPT regions and member organisations 
  • collaborating with national and international organisations" [13]

For more information, please visit: http://www.wcpt.org/

National

ADAPT

ADAPT (Chartered Physiotherapists in International Health and Development) is a Clinical Interest Group recognised by the Chartered Society of Physiotherapy in the United Kingdom of Great Britain and Northern Ireland. ADAPT will support members and facilitate information exchange in order to contribute to the development of culturally appropriate effective physiotherapy services world-wide. They work to do this in a way that promotes an understanding of healthcare in all cultures and belief systems and which is socially and economically appropriate. ADAPT members have worked or are currently working in many of the world's low and middle income countries, and have been involved in many Global Health Initiaitives in a wide variety of settings [14].

For more information, please visit http://adapt.csp.org.uk/about-us

Global Health Division of the Canadian Physiotherapy Association

[15]

The Global Health Division (GHD) was created in 2004 as a result of the growing interest in International Health by Canadian physiotherapists. The vision of the GHD is to be a reliable and influential resource and a strong advocate group for the importance of physical therapists in the area of global health. Focusing on countries with developing and transitional economies, the GHD facilitates access to a broad range of information ranging from global health and disability issues to volunteer opportunities. The GHD harnesses the passion, interests and energy of its members from across Canada and works in collaboration with colleagues from around the world. The mission of the GHD of the CPA is to educate, advocate and motivate physical therapists from across Canada regarding Global Health.[16]

Canadian physiotherapists have been actively engaged in global health initiatives in a variety of settings on many of the world's continents. Some examples of these initiatives include the International Centre for the Advancement of Community Based Rehabilitation (ICACBR) at Queen's University supporting work in the Balkans among other countries, as well as at Dalhousie University whose physiotherapists have worked in Kuwait for a number of years. These are only a few examples of Canadian Physical Therapy organizations and universities, who have made an impact at the global level. These institutional examples are of course in addition to the numerous individual physiotherapists who have independently contributed to international health in various capacities.

For more information, please visit http://physioghd.com

Global Health Special Interest Group of the American Physical Therapy Association

"Promoting Social Responsibility & Community Engagement at Home & Abroad"[17]

"Mission: To provide resources, information, and support to SIG, Section, and APTA members regarding global health, health disparities, cultural competency, disability, and service-learning in resource-limited settings."[17]

"History: Ronnie Leavitt and Karin Schumacher co-founded the Cross-cultural and International Physical Therapy Interest Group in 1986. The group was officially recognized as a special interest group within the Health Policy and Administration Section in 1996. To reflect member interests in health equity, cultural determinants of health, and service-learning both in the United States and abroad, the group changed its name to the Global Health SIG."[17]

For more information, please visit http://www.aptahpa.org/?page=GlobalHealthSIG

Global Health Initiaives

Barriers and Solutions

Many barriers can limit the effects of Global Health initiatives, with considerable regional variation. The following challenges were discussed at The First Physical Therapy Summit on Global Health in 2007; [18]

  • Lack of access to physiotherapists, particularly in rural areas
  • Lack of understanding of cultural differences
  • Logistical barriers such as bad roads, lack of clean water supply, lack of appropriate waste management, poor electricity supply
  • Insufficient research into population-specific health conditions and best practices
  • Insufficient or delayed knowledge translation of existing research
GHD photo nepalability4 (2).jpeg
  • Discrepancy between current entry-level curricula, research and the most prevalent and/or serious region-specific health conditions. o For example, there is much focus on musculoskeletal (MSK) conditions in university programs and in research circles, yet such conditions are not a leading cause of mortality. In the statistics shown at the 2007 Summit, Ischaemic Heart Disease and Cardiovascular Disease were the first and second causes of mortality in four of the five geographic regions. Only Africa did not follow this pattern. There, the primary cause of mortality is HIV/AIDs, with Ischaemic Heart Disease and Cardiovascular Disease ranking 5th and 7th in the top ten, respectively. Accidents (including Road Traffic Accidents) were ranked the 7th leading cause of mortality in the Asia Western Pacific region, the highest position calculated for that category. Although Accidents can obviously result in MSK injuries, the rankings presented at the Summit relate to mortality thus the types of MSK injuries that physiotherapists typically see would unlikely factor in to these figures. Therefore, the disproportionate dominance of MSK conditions in regards to research and physiotherapy education do not seem to be in the best interests of Global Health.
  • Insufficient recognition of and research into differences between health and health care of indigenous versus non-indigenous populations, rural versus urban populations as well as factors affecting immigrant populations [18]

The Summit also proposed the following recommendations;

  • Increase number of training institutions that offer the appropriate degree award
  • Allocate an appropriate proportion of university curricula for region-specific conditions
  • Accept internationally-trained physiotherapists for clinical shadowing experiences to promote exposure to facilities and therapeutic studies
  • Establish local Centres of Excellence through the World Health Organization and/or World Confederation for Physical Therapy,
  • Promote more research into Global Health issues, particularly where region-specific research is lacking
  • Expedite knowledge translation once research is performed
GHD photo nepalability16.jpeg

Others have proposed additional ways to enhance Global Health.

  • “Recognise chronic non-communicable diseases as a major impediment to development” [19] and provide sufficient leadership, advocacy, organizational cooperation, political backing, financial support, industrial change and research to counter these epidemics [19] [20]
  • International service-learning – “a structured learning experience that combines community service with explicit learning objectives, preparation and reflection….a philosophy of educations that ‘emphasizes active, engaged learning with the goal of social responsibility.’” [21]
  • Open online courses – For example, Physiopedia has run several accredited Massive Open Online Courses to provide free quality educational opportunities for physiotherapists who can then apply their new knowledge and skills in their own communities. “Perhaps the greatest value of MOOCs in the future will be for providing a means for tackling large global problems through community action” [22]

Potential Concerns / Issues

[23]

“Voluntourism” is a term that has taken on a negative connotation because of the often disingenuous, condescending and ultimately short-sighted and ineffectual work that volunteers often perform in the name of Global Health. [24] [25] Even with the best of intentions, there is a risk of a negative impact to on the very community that the volunteer is trying to help. Appropriate reasons to volunteer include trying to form global partnerships and to learn from the opportunity (e.g. about historical and sociopolitical impacts on health or the role of rehabilitation professionals working in the area of global health). Inappropriate reasons include using the experience as a vacation or to look impressive on a resume. As well, it is important to understand the cultural context in which a volunteer will be working to avoid the expectation that he/she will effect fast or sweeping changes by knowing a ‘better’ way to do things. [26] Following guideline or framework can help volunteers and organizations working in Global Health ensure the work they do is meaningful and socially responsible. An example of such guidelines can be found here

Recent Related Research (from Pubmed)

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References

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