What strategies should governments adopt to improve the health of their citizens? In the midst of the COVID-19 syndrome, it would be easy to turn our attention to global health security – at least strong public health and health systems. The WHO has based its global health strategy on three pillars: universal health coverage, health cases and better health and well-being. The indispensable elements of robust public health and health care are well known and endlessly practiced – a skilled health workforce; efficient, secure and high quality healthcare information systems; access to essential medicines adequate funding and good governance. But has the outlook for global health been too narrow? Have health leaders and lawyers lacked the key determinants of human health?
But GBD also reveals once again that health depends on more than health systems. The strong correlation between health and the socio-demographic index – a summary measure of a country’s overall development based on the average income per capita. Population, educational attainment and overall fertility – suggests that the health sector should consider redefining its level of concern.
GBD 2019 also offers a revised theory of the demographic transition and delimits seven separate phases. A particular innovation is the idea of late transition and post-transition phases, broken down by migration status. 35 countries, largely in sub-Saharan Africa and the Middle East, are in the middle transition with declining birth and death rates (as of 2019, no countries were in the pre-transition phase). Countries such as Brazil, China and the United States are in the late transition phase, where the number of deaths is plateau, while the birth rate continues to fall. The last phase after the transition is when the birth rate is lower than the death rate and the natural population growth is negative – as seen in Japan, Italy and Russia. An important and overlooked influence on these demographic phases is migration. 17 countries, including Spain, Greece and many Eastern European countries, are in “an uncertain state” – in the post-migration phase. Policies are needed here to reduce the social and economic impact of an increasingly inverted population pyramid – encouraging immigration can be a way to help.
None of these arguments suggest that universal health coverage and global health security are irrelevant to health. As the GBD 2019 authors claim, some countries have longer life expectancy than their stage of development would predict. These overperforming nations – such as Niger, Ethiopia, Portugal and Spain – are likely to have superior public health and health care policies. What GBD 2019 suggests is that the global healthcare community needs to radically rethink its vision. An exclusive focus on health care is a mistake. Health is created from a broader prospectus that includes the quality of education (primary to tertiary), economic growth, gender equality and migration policy.
Published: October 17, 2020
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