Global Tobacco Control: An integrated approach to global health policy

Unproven stem cell interventions: A global public health problem requiring global deliberation

The unproven stem cell intervention (SCI) industry is a global health problem. Despite efforts of some nations, the industry continues to flourish. In this paper, we call for a global approach and the establishment of a World Health Organization (WHO) Expert Advisory Committee on Regenerative Medicine to tackle this issue and provide guidance. The WHO committee can harmonize national regulations; promote regulatory approaches responsive to unmet patient needs; and formulate an education campaign against misinformation. Fostering an international dialog and developing recommendations that can be adopted by member states would effectively address the global market of unproven SCIs.

Balancing science and political economy: Tobacco control and global health

Background: Global tobacco control is a major public health issue, as smoking-related disease burden remains high worldwide. The World Bank and the World Health Organization (WHO) are the driving forces in global tobacco control. However, little research has focused on their development, financing, decision-making, and accountability structures. Methods: We used two strategies to identify the development and structure of global tobacco control initiatives. First, we reviewed the published literature through electronic databases. Second, we conducted grey literature searching. Results: We identified four periods in the Bank's involvement in global tobacco control, from creation of the evidence base in the 1990s to the implementation of tax reforms. We identified three phases in the WHO's efforts, from its early recognition of the link between tobacco and health risks in the 1970s to its implementation of the Framework Convention on Tobacco Control. Both organisations are financed by a handful of private philanthropies, and face similar risks for effective tobacco control: reduced accountability and resource mobilisation, poor decision-making authority due to specific donor influence, and difficulty in monitoring and evaluation. Conclusions: Continued attention should be paid not only to the primary health-related outcomes of tobacco use, but also to the decision-making and financing structures to promote tobacco control activities.

Global Health Governance at a Crossroads

This review takes stock of the global health governance (GHG) literature. We address the transition from international health governance (IHG) to global health governance, identify major actors, and explain some challenges and successes in GHG. We analyze the framing of health as national security, human security, human rights, and global public good, and the implications of these various frames. We also establish and examine from the literature GHG's major themes and issues, which include: 1) persistent GHG problems; 2) different approaches to tackling health challenges (vertical, horizontal, and diagonal); 3) health's multisectoral connections; 4) neoliberalism and the global economy; 5) the framing of health (e.g. as a security issue, as a foreign policy issue, as a human rights issue, and as a global public good); 6) global health inequalities; 7) local and country ownership and capacity; 8) international law in GHG; and 9) research gaps in GHG. We find that decades-old challenges in GHG persist and GHG needs a new way forward. A framework called shared health governance offers promise.

The Global Role of the World Health Organization

The 21^st century global health landscape requires effective global action in the face of globalization of trade, travel, information, human rights, ideas, and disease. The new global health era is more plural, comprising a number of key actors, and requiring more coordination of effort, priorities and investments. The World Health Organization (WHO) plays an essential role in the global governance of health and disease; due to its core global functions of establishing, monitoring and enforcing international norms and standards, and coordinating multiple actors toward common goals. Global health governance requires WHO leadership and effective implementation of WHO's core global functions to ensure better effectiveness of all health actors, but achieving this global mission could be hampered by narrowing activities and budget reallocations from core global functions.

Global health inequalities: an international comparison

OBJECTIVE

To study cross-national inequalities in mortality of adults and of children aged <5 years using a novel approach, with clustering techniques to stratify countries into mortality groups (better-off, worse-off, mid-level) and to examine risk factors associated with inequality.

DESIGN, SETTING AND PARTICIPANTS

Analysis of data from the World Development Indicators 2003 database, compiled by the World Bank.

MAIN OUTCOME MEASURES

Adult and child mortality among countries placed into distinct mortality categories by cluster analysis.

RESULTS

29 countries had a high adult mortality (mean 584/1000; range 460/1000 to 725/1000) and 23 had a high child mortality (mean 207/1000, range 160/1000 to 316/1000). All these countries were in western and sub-Saharan Africa and Afghanistan. Bivariate analyses showed that relative to countries with low child mortality, those with high child mortality had significantly higher rates of extreme poverty (p<0.001), populations living in rural areas (p<0.001) and female illiteracy (p<0.001), significantly lower per capita expenditure on healthcare (p<0.001), outpatient visits, hospital beds and doctors, and lower rates of access to improved water (p<0.001), sanitation (p<0.001) and immunisations. In multivariate analyses, countries with high adult mortality had a higher prevalence of HIV infection (odds ratio per 1% increase 18.6; 95% CI 0.3 to 1135.5). Between 1960 and 2000, adult male mortality in countries with high mortality increased at >4 times the rate in countries with low mortality. For child mortality, the worse-off group made slower progress in reducing <5 mortality than the better-off group.

CONCLUSIONS

Inequalities in child and adult mortality are large, are growing, and are related to several economic, social and health sector variables. Global efforts to deal with this problem require attention to the worse-off countries, geographic concentrations, and adopt a multidimensional approach [corrected] to development.

Ethics and governance of global health inequalities

BACKGROUND

A world divided by health inequalities poses ethical challenges for global health. International and national responses to health disparities must be rooted in ethical values about health and its distribution; this is because ethical claims have the power to motivate, delineate principles, duties and responsibilities, and hold global and national actors morally responsible for achieving common goals. Theories of justice are necessary to define duties and obligations of institutions and actors in reducing inequalities. The problem is the lack of a moral framework for solving problems of global health justice.

AIM

To study why global health inequalities are morally troubling, why efforts to reduce them are morally justified, how they should be measured and evaluated; how much priority disadvantaged groups should receive; and to delineate roles and responsibilities of national and international actors and institutions.

DISCUSSION AND CONCLUSIONS

Duties and obligations of international and state actors in reducing global health inequalities are outlined. The ethical principles endorsed include the intrinsic value of health to well-being and equal respect for all human life, the importance of health for individual and collective agency, the concept of a shortfall from the health status of a reference group, and the need for a disproportionate effort to help disadvantaged groups. This approach does not seek to find ways in which global and national actors address global health inequalities by virtue of their self-interest, national interest, collective security or humanitarian assistance. It endorses the more robust concept of "human flourishing" and the desire to live in a world where all people have the capability to be healthy. Unlike cosmopolitan theory, this approach places the role of the nation-state in the forefront with primary, though not sole, moral responsibility. Rather shared health governance is essential for delivering health equity on a global scale.