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Global health: time for radical change?

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?

The latest report from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 201
9 raises uncomfortable questions about the direction global health has taken in the 21st century. On the one hand, the news seems good. The health of the world population is steadily improving. Global life expectancy at birth increased from 67 · 2 years in 2000 to 73 · 5 years in 2019. Healthy life expectancy has increased in 202 of 204 countries and territories. In 21 countries, the healthy life expectancy at birth increased by more than 10 years between 1990 and 2019 with gains of up to 19 · 1 years. The estimated number of deaths in children under 5 fell from 9 · 6 million in 2000 to 5 million in 2019. In fact, the decline in age-standardized disability-adjusted life years since 1990 has been the largest for communicable, maternal, neonatal and nutritional diseases – and progress has been fastest in the last decade.

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.

This conclusion is immediately relevant to national strategies for resolving COVID-19. Although attention should be paid to controlling the transmission in communities of severe acute respiratory syndrome coronavirus 2 and protecting those most vulnerable to its consequences, success will require a more inclusive strategy. COVID-19 is a syndrome of coronavirus infection combined with an epidemic of non-communicable diseases that both interact on a social substrate of poverty and inequality. The message from the GBD is that unless deeply embedded structural inequalities in society are tackled, and unless a more liberal approach to immigration policies is adopted, societies will not be protected from future infectious outbreaks and the health of the population will not achieve the benefits that global health advocates seek. . It is time for the global health community to change direction.
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