An introduction to key challenges and concepts important to understanding the current status and determinants of global health.
Who are the Key Actors in Global Health, Part 1
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来自 Duke University 的课程
全球健康的挑战
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从本节课中
Actors & Action: Finding Global Health Solutions
This module explores the main global health actors, how they work, and what strategies they use to improve global health outcomes and to solve global health problems.
与讲师见面
Dr. David BoydAssociate Professor of the Practice of Global Health
Duke Global Health Institute
Good morning, class.
This photograph of the Old Arusha Clinic in the heart of Arusha,
Tanzania leads us to our question for today.
Who exactly are the actors who work in global health?
In other words, who are the individuals and
organizations that strive to make the world a better place.
Before I talk about that however, I think it's incrucial, crucial for
you to understand a little bit about the global health system.
I have students here, at Duke,
asking me all the time what the global health, what is the global health system?
And my answer is, well, honestly there isn't really a system per se,
in a formalized sense.
I think we could say that there's more of a landscape.
And by that I mean that there are a collection of global health actors.
Who all have the common goal of improving health outcomes whether that's locally,
nationally, regionally, or internationally.
Now many times these actors work together on solving problems.
Sometimes they work independently.
Once in a while, unfortunately, they work antagonistically to each other.
As happens, with, with, with any time you're dealing with many organizations.
And these actors work within, really, an ever evolving set of norms, laws,
strategies, relationships and even power dynamics.
And dynamics, that is, always depend on levels of funding for health.
But actors have goals and
challenges, as you can imagine from what I said in our former slide.
Now obviously the goal of global health actors is to
increase health as a public good.
To not only mobilize people, and organizations, and countries to
work in ways to improve health, but also mobilize other types of action as well.
Whether that is a political action for a health cause.
Actors strive for health sustainability, and they also strive to be good stewards.
Funds and good stewards of, of the trust that they have from people.
And also the the stewardship to be governments well, to govern themselves.
And to work again, going back to the public goods for the public good.
Obviously there are many challenges that global health actors face.
One is sovereignty.
The fact is that when an actor is working in a country or
an area in which they do not have sovereignty that can lead to issues.
Sometimes there are the issues of sectorality and cooperation.
In other words, global health actors might be or
actors might be trying to achieve the same global health goal.
But they might be doing in different sectors.
One might be working in providing building health care clinics,
the other in economic development.
So making certain that,
that those sectors cooperate, creating a multi-satural approach.
Becomes quite important.
Accountability, how do we maintain accountability especially during
global health crisis?
How do we create structures that are sustainable?
How do we improve health structures and
increase global health outcomes without encouraging dependence on future actions?
Right, we want to encourage as much agency and
independence among populations is possible.
And finally how do we avoid the, inexorable, I should al,
I hate to say inexorable.
But the inexorable, fact that,
frequently in every enterprise around the world, there can be leakage.
Loss of money, waste of money and corruption.
So one of the things that these actors ne, have to do,
is they have to try to meet their goals and overcome challenges.
By working together, as necessary in a multisectoral fashion.
Now, I think actors work at different focal points.
And I think the easiest way to describe them is to look at geography, level,
strategy and health impact, right?
From geographical perspectives, actors can work from they can be local actors,
national, regional or global.
Some of them work at the level of primary prevention.
And what I mean by primary prevention is that they focus on preventing disease or
improving structures so that disease will never come about.
Some work at the secondary prevention level.
That is the level of both detecting and treating
disease in its early stages or detecting disease in people who are at risk.
There are also actors who work at the tertiary level.
And that is actually working on ,, mitigating the impact of disease or
disaster that have all ready taken place.
Some actors work at all three levels at the same time.
It just depends.
Actors have a variety of strategies.
Some actors focus on horizontal interventions.
In other words, they focus on creating or
working within structures that improve health systems or health outcomes overall.
Other actors focus vertically.
That is, they focus on one disease or one focal point.
That might be malaria, HIV AIDS, tuberculosis.
There are also approaches that we call diagonal.
And those are approaches that might use a vertical approach such as
malaria treatment.
As a way of then building up health system in general, diagonal.
Finally, the health impact.
Some actors who I say, whom I say, I say, are global health actors focus directly on
improving health but others are more indirect.
So, for example, an organization that focusses on economic developement.
Or that focuses on, for example, education.
As you know, from both of those determinants.
Which have a huge impact on health outcomes,
I say that those are indirect global health actors.
As you can imagine from this,
this landscape of global health actors is quite complicated.
And I want to help you simplify it a bit by coming up with a way of
dividing them up to, I think, facilitate your memory.
But first let me make one point clear.
The bedrock of health outcomes arround the world,
the bedrock really is nation health systems.
But whether we are in China, the United States, the United Kingdom,
Australia, Swaziland, or Morocco.
We really focus on health systems as the unit
that provides the most care to the people within it's country.
Or should provide the most care, there are exceptions.
Health systems are composed of variety of building blocks.
They deliver services to populations.
They provide a health care work force.
They provide information.
They provide products, vaccines, technologies.
They have a financing system, and they are responsible for leadership and
governance when it comes to health.
As they report to their national authorities.
Their goals, of course,
are to improve health levels, to increase equity, to improve responsiveness.
To, provide social and
financial risk protection, such as types of insurance systems.
And to be as efficient as possible.
Now I say all of this, but
I want to make clear that not all health systems are the same.
Some health systems actually function
completely through government funding and subsidization.
Other health systems actually function through private actors, they may be
private, though there are levels of regulation always by, by the government.
Sometimes there are mixed models, it really depends system to system.
And one of your discussion board exercises this week,
I'm actually going to ask you to describe the healthcare system in your country.
And again, just as healthcare systems are the bedrock of global health,
the bedrock of the healthcare system should be primary care.
In our previous slide, I went over primary, secondary, and tertiary care.
Especially preventive care.
And I want you to understand that for
a health system to function well primary care should be the bedrock.
The secondary and tertiary care taking second and third place.
Now, let me give you an example of a national health system.
And I thought that I would choose China since it's one of
the worlds most populated countries.
This image is from Guangzhou hospital of
traditional Chinese medicine where I was visiting I visited several times.
The Chinese system is state based.
And it's really administered through an administry of health.
this.
Government of China spends 5% of its gross domestic product on health care.
It supports both biomedicine or
western medicine and also traditional Chinese medicine as well.
That includes modalities like acupuncture and herbal medicine.
[NOISE] There is universal coverage via
three insurance schemes that most of the population.
In which most of the population is included at this point.
Though there are insurance premiums and
copays that, that, that, that, for which individuals are responsible.
Now within this system patients can choose their own providers, and
they can choose bio medicine versus traditional Chinese medicine.
Based on their preferences, finances, and or their ability to access them.
Patients end up paying about 35% of cost out of pocket.
Sometimes for medicine, sometimes for, what we call a co-pay, right?
The amount that an individual has to pay above that which insurance will cover.
And sometimes there are certain tests.
In urban areas,
there are both hospitals, where people can go for outpatient care or inpatient care.
And there are also community health centers and
stations where people can visit every day if they need healthcare as well.
That's not as complicated as, say, surgery for gallstones.
In rural areas most townships have health centers,
and there are small village clinics.
But from more complicated care, people need to go to larger urban areas.
Now China has made great strides in
providing an increasing amount of healthcare.
And increasingly high quality health care to the population as a whole but
as an other middle income countries, there are still challenges.
Cost is still a factor for many people.
Especially in rural areas.
Even with the insurance schemes.
In rural areas in particular, access is more limited.
There might not be as much access to the types of physicians that you need.
Coverage is broad.
It is universal, as I said, but it's relatively shallow.
Again, maybe not all services are available to everyone.
And depending on whether you are in an urban or a rural area you might have a,
more or less access to highly qualified health care providers.
Particularly the case in rural areas.
And in some of the ethnic regions as well.
It can also be the case for migrant groups who, have moved from
rural China into one of the cities, where they do not necessarily have,.
What we call Hukou, which is permission or registration to live in that city.
So they might not have the same level of access to
health care unless they end up paying more money.
These are all issues that while the specifics maybe unique
to China sometimes, these are all issues that take place in almost every country.
>> Including my own country the United States as well
