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JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
JUAN GARAY: Salud Global: tendencias y desafíos
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JUAN GARAY: Salud Global: tendencias y desafíos

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Presentación hecha en el Taller Salud Global y Diplomacia de la Salud, en mayo. Lea más en http://bit.ly/XW38OY

Presentación hecha en el Taller Salud Global y Diplomacia de la Salud, en mayo. Lea más en http://bit.ly/XW38OY

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  • the International Covenant on Economic, Social and Cultural Rights (CESCR), which is monitored by the Committee on Economic, Social and Cultural Rights; the International Covenant on Civil and Political Rights (CCPR), which is monitored by the Human Rights Committee;the Optional Protocol to the International Covenant on Civil and Political Rights (CCPR-OP1), which is administered by the Human Rights Committee; the Second Optional Protocol to the International Covenant on Civil and Political Rights, aimed at the abolition of the death penalty (CCPR-OP2-DP);the International Convention on the Elimination of All Forms of Racial Discrimination (CERD), which is monitored by the Committee on the Elimination of Racial Discrimination;the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), which is monitored by the Committee on the Elimination of Discrimination against Women;the Optional Protocol to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW-OP);the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT), which is monitored by the Committee against Torture; the Convention on the Rights of the Child (CRC), which is monitored by the Committee on the Rights of the Child;the Optional Protocol to the Convention on the Rights of the Child (CRC-OP-AC) on the involvement of children in armed conflict;the Optional Protocol to the Convention on the Rights of the Child (CRC-OP-SC) on the sale of children, child prostitution and child pornography.the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (MWC).UN Convention on the Rights of Persons with Disabilities
  • In the field of health, health strategies and services need to be measured not just in their average impact but also on their effect on equity and sustainability (trans-generational equity). The main strategies which have a greater effect on impact, equity and sustainability are those related to agro-ecology as a sustainable strategy of food and water sovereignty (reducing for instance food miles) and security in a equilibrium with natural resources, and with lifestyles that have co-benefits in reducing carbon emissions while increasing health safety and fulfillment needs : these relate to increase the levels of physical activity to the adequate human potential levels (decreasing sedentary lifestyles) while decreasing the use of energy (e.g. through physical means of energy sources for daily needs), as well as increasing the psychosocial activities aimed at the social fulfillment while reducing also the abuse of energy and natural resources (e.g. through community gardening, social solidarity and community health, agricultural and social programmes, while reducing dependency on virtual means of communication).
  • Transcript

    1. Global health?
    2. GH principles
    3. Health needs Physical and psycho-Social potential developed and fulfiled If unmet : physicalhandicaps, chronic stress, lonelyness, anxiety,depre ssion Safety needs : from infections, toxic agents, unhealthy diets and sendentarism, accidents and violence If unmet : infectious diseases, intoxications, cardiovascular and metabolic disorders, cancer, trauma. Basic physical needs : water, air, nutrition. If un met : malnutrition, dehydration, respiratory conditions.J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 5
    4. Basic needs : enough water and food100 50 45 90 40 80 35 30 70 25 60 20 50 15 10 40 5 30 0 1990 2010 1990 2010 1990 2010 20 Developed Developing Total countries countries 10 Underweight 1.9 1.4 28.7 15.8 25.4 16.2 0 Stunted LIC L-MIC H-MIC HIC All 6 6 44 29.2 39.7 26.7 1990 Wasted 0.9 0.7 10 9.6 9 8.6 57 71 89 99 77 Obese 7.9 12.9 3.7 7.2 4.2 9.1 2008 67 86 95 100 87 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 6
    5. Safety needs % DALYs and health potential lost, by unmet safety needs 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% air/wat air- water- vector- air temper er bioche illicit Unsafe borne borne borne total trauma total pollutio fat diet tobacco alcohol total ature particle m drugs sex infectio infectio disease n s ns ns s tortal safety Physical chemical biological unmet needs%DALY 17.5% 2.5% 12.0% 3.0% 20.9% 4.0% 1.0% 7.0% 4.1% 4.0% 0.8% 10.0% 5.1% 0.7% 4.0% 0.3% 48.4%% Potential health lost 3.7% 0.5% 2.5% 0.6% 4.4% 0.8% 0.2% 1.5% 0.9% 0.8% 0.2% 2.1% 1.1% 0.2% 0.8% 0.1% 10.2% J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 7
    6. Health fulfillment needs : physical, psychosocial 70.0% 60.0% 50.0% 16.00% 40.0% 30.0% 14.00% 20.0% 10.0% 12.00% 0.0% 10.00% world HC UMIC LMIC LIC % DALYs 26.3% 51.4% 44.2% 36.1% 15.6% 8.00% %deaths 53.3% 66.3% 64.6% 56.6% 41.1% 6.00% 4.00% 7.00 6.00 5.00 4.00 2.00% 3.00 2.00 1.00 0.00 0.00% WORLD HIC UMIC LMIC LIC world HC UMIC LMIC LIC Physical inactivity 0.50 0.64 0.91 0.44 0.44 % DALYs 9.00% 14.00% 10.00% 9.00% 7.00% Overweight and obesity 0.44 0.70 1.12 0.40 0.40 % health potential lost 1.89% 2.94% 2.10% 1.89% 1.47% High blood pressure 1.17 1.40 2.19 1.18 1.18 High cholesterol 0.41 0.48 0.81 0.32 0.32 High blood glucose 0.53 0.58 0.77 0.44 0.44 Low fruit and vegetable 0.26 0.21 0.46 0.28 0.28 intakeTotal sedentary effects 3.30 4.01 6.26 3.06 3.06 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 8
    7. Risk combinations of ill health Unmet basic needs 10% of ill -health Unmet fulfillment Unmet safety needs needs 48% of ill-health (59,3% if safe delivery added) 35% of ill-health J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 9
    8. Present and potential health capacity 85 years LE 2 % health potential? Healthier lifestyles lost/year Best country (Japan)83 years LE 5 % health potential? lost/year HIC (average HICs) 80 LE 12% health potential World average lost/year (average HICs) 62 LE LICs 21 % health potential lost/year 57 years LE 30,3% health Lowest health potential lost/year state Zimbabwe 42 years LE 82% health potential lost/year J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 10
    9. J Garay, Challenges for EU and US policies in Global health : Global Health is Global 11 Justice
    10. Global Health Equity• Most consistent stratifying variable : income• Best standards at country level : Upper quintile• Best standards at global level : High income region.• Narrow disparities, improve global averages and best standards. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 12
    11. Health disparities 90dispersion of life expectancy 11.000 80 10.500 Life expectancy 70 10.000 men women 60 9.500 all y = 6.3959Ln(x) + 12.433 R2 = 0.7041 50 9.000 40 8.500 1990 2000 2008 30 0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 years GDP pc PPP 2008 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 13
    12. Different risks and forms of ill health30.00%25.00%20.00% Injuries Neuropsychiatric disorders + self injuries NCDs -MH/Injuries15.00% Infectious diseases Nutritional deficiencies10.00% Perinatal conditions Maternal conditions 5.00% 0.00% WORLD LICs LMICs UMICs HICs J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 14
    13. Excess ill-health vs. best regional standards 1800000 1600000 1400000 1200000 1000000 800000 600000 400000 Injuries 200000 mental health 0 -200000 NCDs -MH/Injuries -400000 LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE INCOME Infectious diseasesInjuries 214203 549165 130480 Nutritional deficienciesmental health -23750 -119174 2064 Perinatal conditionsNCDs -MH/Injuries 63441 385607 167824 Maternal conditionsInfectious diseases 696672 382814 259105Nutritional deficiencies 54884 61483 15694Perinatal conditions 260550 231043 29470Maternal conditions 55229 43802 6810 Injuries Maternal conditions 25% 3% Perinatal conditions 14% Nutritional deficiencies 4% NCDs -MH/Injuries 17% Infectious diseases 37% J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 15
    14. Excess burden of disease vs. HICs 100% 90% 80% 70% 60% 50% rest of burden 40% Excess burden 30% 20% 10% 0% LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE INCOME TOTAL EXCESS BURDEN OF DISEASErest of burden 1184034 4577872 1158219 6920125Excess burden 1321229 1534741 611446 3467415 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 16
    15. Distribution and trend of life expectancyJ Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 17
    16. Distribution of child and adult mortality J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 18
    17. Excess deaths due to health inequity 25000000 25000000 20000000 20000000 15000000 15000000 10000000 10000000 5000000 5000000 0 1990 2000 2008 Upper middle 1549017 1912015 1792779 0 income 1990 2000 2008 Lower middle 11180365 11759717 10716957Avoidable 15-60 7209077 9007941 8921937 incomeAvoidable <5 10859818 11251207 10408335 Low income 5339512 6587417 6820535 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 19
    18. Proportion of deaths due to inequity = injustice? 60000 90.0% 80.0% 50000 70.0% 60.0% 40000 50.0% 30000 40.0% 30.0% 20000 20.0% 10000 10.0% 0.0% Lower middle Upper middle 0 Low income year 1990 year 2000 year 2008 income income % inequity deaths 1990 81.1% 65.5% 49.6% 35.51% 36.34% 34.13% rest of deaths 2000 84.0% 68.4% 57.3% 32887 33846 36586 2008 83.8% 66.8% 57.1% inequity detahs 18110 19320 18960 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 20
    19. Trend , burden and share of ill health 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% world HIC UMIC LMIC LIC 2002 22.8% 12.5% 17.3% 17.5% 32.0% 2008 21.8% 12.3% 19.9% 17.2% 30.3%0.250 70.0%0.200 60.0% 50.0%0.150 40.0%0.100 30.0% 20.0%0.050 10.0% 0.0%0.000 LIC LMIC UMIC world LIC LMIC UMIC world 2002 60.8% 28.3% 27.5% 45.1% 2002 0.195 0.050 0.047 0.103 2008 59.4% 28.4% 38.2% 43.5% 2008 0.180 0.049 0.076 0.095 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 21
    20. And national health inequities?100%90%80%70%60%50%40%30%20%10% 0% LIC (n=29) LMIC (n=23) UMIC (n=6) Rest 5.9% 11.1% 30.4% GHiE 67.5% 66.7% 37.8% NHiE 26.6% 22.2% 31.7% J Garay, Challenges for EU and US policies in Global health : Global Health is Global 22 Justice
    21. Conclusion GH situation and equity• Unprecedented average increase in life expectancy (one day every three days)• GH Inequity remained stagnant last 20 years• GH inequity translates in some 20 m premature deaths per year, one in three and half of the burden of ill health• NH inequity contributes to one third of the global health gap on average (more in LMICs) J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 23
    22. The equity approach …
    23. Vs. The inequity principle
    24. Annual death toll by…• Non equity and progress : 20 m• Non progress (since 1990) and equity : 12 m
    25. The response of health systemsDynamics : Situation analysis Definition of Costing and Monitoring BHCP/organization budgeting scenarios HIS/applied of services/health research system pillarsHealth priorities Reproductive health Child health care & Endemic Prevalent non-covered services nutrition communicable communicable diseases /emerging diseases vs. chronic threats* vs. Acute conditions. conditions.Health pillars Human resources for Infrastructures and Access to medicines Health fair financing health * logistics and fungible health schemes products*Health system Inclusive leadership Universal Coverage Patient centered Health in allprinciples(WHA 62.12) J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 27
    26. Gaps in health system resources 100.0 5 000 90.0 4 500 80.0 4 000 3 500 70.0 3 000 60.0 2 500 50.0 2 000 40.0 1 500 30.0 1 000 20.0 500 10.0 0 0.0 Low income 27 11 Lower middleLow income 5.3 41.9 58.1 8.7 83.1 3.7 80 34 incomeLower middle income 4.3 42.4 57.6 7.8 90.5 5.3 Upper middle 488 269Upper middle income 6.4 55.2 44.8 9.4 69.0 26.4 incomeHigh income 11.2 61.3 38.7 17.2 36.1 51.4 High income 4 405 2 699 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 28
    27. Gaps in health system capacities and performance 120 90 80 100 70 80 60 60 50 40 40 30 20 20 0 10 Births Immunizat attended Births by ion Contracep Antiretrovi 0 by skilled caesarean coverage tive ral therapy health sectionb among 1- prevalenc coverageLow income 4 10 15 personnel (%) year-oldsd eg (%) (%) b (%) (%)Lower middle 10 14 18 Low income 43 3.3 75 39.6 40 income Lower middle income 65 13.0 82 65.8 42Upper middle 24 40 39 Upper middle income 95 28.6 92 67.5 49 incomeHigh income 28 81 58 High income 99 26.8 95 70.1 90 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 29
    28. Threshold effect? Govt fin x H pc vs U5MR300250 Angola 105/22020015010050 0 Vietnam 72, 14 0 20 40 60 80 100 120 140 160 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 30
    29. Best efficient use of resources for healthCountry Life expectancy U5MR AMRMaximum CI GHStandards(HIRegion) 69 20 186Georgia 72 30 157Paraguay 74 28 139Guatemala 69 34 228Sri Lanka 69 17 209Syrian Arab Republic 72 16 150Morocco 72 36 118Fiji 70 18 204Vanuatu 69 33 182Philippines 70 32 174Tonga 71 19 188Honduras 70 31 179Cape Verde 71 29 185Republic of Moldova 69 17 227Micronesia (Federated States of) 69 39 172Viet Nam 73 14 150Nicaragua 74 27 165Solomon Islands 70 36 160total/average 71 27 176 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 31
    30. Potential gap per Potential total Potential gap per Potential totalCountry capita gap Country capita gapSomalia 95 847970000 India 47 55105902498 Lao Peoples Democratic Republic 46 286798203 Kenya 44 1698006238Myanmar 93 4626706050 Mozambique 42 935340804DemocraticRepublic of the ComorosCongo 93 5975509500 39 25851135Eritrea 85 417639395 Ethiopia 38 3092508752Sierra Leone 82 453570055 Kyrgyzstan 37 200772776Sudan 79 3270406535 Haiti 37 364009205Yemen 79 1799622530 Malawi 37 545483742Guinea-Bissau 78 122255000 Nigeria 36 5417034889Central African ZambiaRepublic 77 332053657 35 439600712Burundi 75 604989306 Chad 34 369766320Niger 73 1068860495 Cameroon 32 610679289Guinea 71 700888267 Burkina Faso 29 443019463Afghanistan 70 1912466881 Madagascar 26 502115027Mauritania 69 223183130 Uzbekistan 23 617853199Togo 69 445505071 Zimbabwe 19 238120773Uganda 64 2039481887 Congo 18 63589840Nepal 59 1708625067 Philippines 17 1517190241Tajikistan 58 396884638 Bangladesh 15 2355532468Liberia 56 213656772 Benin 11 94888745Ghana 55 1290703174 Senegal 8 98176440Pakistan 53 9406922191 Gambia 5 8144072Iraq 53 1580040000 TOTAL J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 114468324431 32
    31. Public financing gap for global health standards/equity 11.5 7.8 6.5 HDA to PFG 2.7 Add redistr Add ODA 0,7% Add HAD 15% Rest gap 89.5 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 33
    32. Ecological dimension : trans- generational equity12.811.2 9.6 8 6.4 4.8 3.2 1.6 0 SHE 30.0 40.0 50.0 60.0 70.0 80.0 90.0 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 34
    33. Countries with SHE Country Life expectancy Hectare use Indonesia 69.4 1.2 Sri Lanka 74.9 1.2 Morocco 72.2 1.2 Moldova 69.3 1.4 Viet Nam 75.2 1.4Dominican Republic 73.4 1.5Syrian Arab Republic 75.9 1.5 Peru 74 1.5 Nicaragua 74 1.6 Algeria 73.1 1.6 Egypt 73.2 1.7 Armenia 74.2 1.8 Guatemala 71.2 1.8 Georgia 73.7 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 1.8 35
    34. Countries with ëfficient”SHE”Country Hectare use Country Hectare useGeorgia 1.8 TongaParaguay 3.2 Honduras 1.8Guatemala 1.8 Cape VerdeSri Lanka 1.2 Republic of Moldova 1.4Syrian ArabRepublic 1.5 MicronesiaMorocco 1.2 Viet Nam 1.4Fiji Nicaragua 1.6Vanuatu Solomon IslandsPhilippines 1.3 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 36
    35. Ill health legal values governance resources frameworks Physical and psycho- Social potential developed and fulfiled If unmet : physicalhandicaps, chronic health system stress, lonelyness, anxiety,depression national social governance national legal Safety needs : from frameworks national infections, toxic economic Income levels agents, unhealthy diets and governance and distribution sendentarism, accidents and violence national Human ecological If unmet : infectioussolidarity and diseases, intoxications, cardi governance ecological equilibrium ovascular and metabolic global social disorders, cancer, trauma. governance Global legal global economic frameworks governance Basic physical needs : water, air, nutrition. Natural global ecological resources and If un met : governance conditions malnutrition, dehydration, respiratory conditions. J Garay, Challenges for EU and US policies in Global health : Global Health is Global 37 Justice
    36. The world’s response• Weak global rights framework• Weak global economic governance (regulation, tax redistribution)• Weak global social governance (global social security)• Weak global health governance (WHO democratic leadership)• Weak global ecological governance (commitments, compliance) J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 38
    37. Inequity deaths 1990 vs MDG targets2000000018000000160000001400000012000000 Non MDG Total MDG 610000000 MDG5 target8000000 Target MDG 4600000040000002000000 0 Low income Lower middle Upper middle Total income income J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 39
    38. Needs vs health ODA 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % LIC % DC % ODAInjuries 11. 18 12.79 1Mental health 10. 81 14.00 1Noncommunicable conditions 26. 52 34.96 1Comm Diseases 34. 53 25.12 54Nutritional deficiencies 2. 82 2.33 2Perinatal conditions (e) 11. 18 8.54 2Maternal conditions 2. 96 2.26 8 J Garay, Challenges for EU and US policies in Global health : Global Health is Global 40 Justice
    39. Health system fragmented• > 100 global initiatives• Advocacies by problems, isolated funding gap analysis (consolidated > 30 b!), vertical approaches, duplication and opportunity cost• The case of a safe delivery : basic service – Vs. divided into? : • MDG 4 : reducing neonatal death • MDG 5 : SRHRs : reducing maternal deaths • MDG 6 : – AIDS : PMTCT – Malaria : AN PrTx – Tb : BCG J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 41
    40. J Garay, Challenges for EU and US policies in Global health : Global Health is Global 42 Justice
    41. Mozambique Health Financing 2001-2008 350 300 250 Paris? Which 200 Paris?Budget 150 100 50 0 2001 2002 2003 2004 2005 2006 2007 2008 Year Government budget Common Funds Vertical Funds
    42. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice Aid effectiveness example: predictability and longevity of ODA must be improved Donor Commitments for Health as % of Total Health Donor Commitment for Health as % of Total Health Expenditure Expenditure100 60.0080 50.00 Mauritania Guinea 40.0060 Benin Tanzania 30.0040 Burundi Mali 20.00 Liberia20 10.00 Eritrea 0 0.00 1997 1998 1999 2000 2001 1997 1998 1999 2000 2001 44
    43. Ext Health aid vs Pot Fin Gap 600 Niue -1003/551 500 400 Palau 651/323 300 7,8 Bn Marshall, Mi cronesia, Na uru 200 11,5 Bn Israel - 100 1700/50 0-3500 -3000 -2500 -2000 -1500 -1000 -500 0 500 J Garay, Challenges for EU and US policies in Global health : Global Health is Global 45 Justice
    44. J Garay, Challenges for EU and US policies in Global health : Global Health is Global 46 Justice
    45. A new global solidarity framework?• Resources for Minimum country dignity : 3300• Maximum to keep average : 19000
    46. 0- 1 10 15 20 25 30 0 5 30 000 0- 00 1 -4 200 000 400 000 600 000 800 000 1 000 000 1 200 000 1 400 000 1 600 000 1 800 000 0 30 000 00 60 00 0 -4 00 60 00 - 00 0 90 700 00 0 90 -70 - 00 0 0 12 100 00 012 -100 0- 0 00 00 15 13 0 0 00 015 -13 0- 0 00 00 16 0 0 1818 -16 00 000 00 00 0- 0 0 21 19 021 -19 00 0 00 00 0- 0 0 0 24 22 024 -22 00 0 00 00 0- 0 0 0 27 2527 -25 00 000 00 00 0 0 0- 30 28 030 -28 00 00 00 0 0 0 0- 033 -31 33 31 0 00 00 00 0 0 0 0- 0 GDP frequency/population GDP frequency/countries 36 3436 -34 00 00 00 000 0 0 0-39 -37 39 37 0 00 00 0 00 0 0 0- 042 -40 42 40 0 00 00 0 00 0 0 0- 045 -43 45 43 0 00 00 0 0 0 00 0- 048 -46 48 46 00 00 0- 0 00 000 49 0- 00 49 0 00 0 Countries and poulations under mDp
    47. GDP gap, public financing gap• 2,235 Trillion• 20% public financing gap : 447 Bn• GPGs (1,5 % GDP at global level?) : 700 Bn• 1,147 Bn• 75% direct GDP SS : 1,11% GDP• 25% indirect GlTr SS : 1,9% GlTr
    48. Global SS vs. ODA100%90%80%70%60% Gap50% ODA40%30%20%10% 0% Level Predictable Alligned Equitable Gap 1047 5 85 50 ODA 100 1 15 50
    49. US vs. EU on Global Health• Social values : – Internationalism (EU > US) • should deal with its own problems and let other countries deal with their problems as best they can… – Exceptionalism (US > EU) • their culture is superior to that of other nations – Role of the state (EU > US) • it is more important for everyone to be free to pursue their life’s goals without interference from the state J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 51
    50. US vs EU constitution• concept of rights : – the U.S. Bill of Rights is a list of individual rights AGAINST the interference of the state, – the EU Charter of Fundamental Rights (Part II of the Treaty) includes a long list of rights to services provided by the state, including education, paid maternity leave, social security benefits and social services, preventive health care and high levels of environmental and consumer protection. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 52
    51. Health ODA and equity in the last decade (for all?) Inequity deaths 1990 vs MDG targets• Focus on MDGs 20000000 18000000 16000000 14000000• Emphasis on Results 12000000 Non MDG Total MDG 6 10000000 MDG5 target 8000000 Target MDG 4 6000000• Boost of health ODA : 4 to 16 Bn $ 4000000 2000000 0 Low income Lower middle Upper middle Total income income• Progress : 4 m Tx AIDS Commitments 14.000,00• Distortion/restriction : 12.000,00 MDG 6 GH inequity remains 10.000,00 Other H ODA H systems remain weak +distorted by diseuse- 8.000,00 approaches? 6.000,00 4.000,00 2.000,00 J Garay, Challenges for EU and US policies in 0,00 2002 2003 2004 2005 2006 2007 Global health : Global Health is Global 53 Justice
    52. Federailsm 7 6 5 4 3 2 1 0 US EUFederal/EC 3.7 0.16States and local 3.1 6.3 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 54
    53. US vs EU economy and income equalityIndicator US EUGDP pc (PPP) 46970 30973Ratio US/EU GDP pc 1,4 GDP/employed 1,3 GDP/hour 1,09Employment (1970,  66  80 70  672005)Income distribution(top 20%/ low 20%, R : 45/4.8, R : 9.8 38,5/8,3, R : 4.7ratio)GINI index 52.5 40 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 55
    54. US vs. EU fiscal policies US EUTax revenue from GDP 24,8 39,6Tax on income and 9,8 11,4profitsTax on property 2,3 1,5Tax on goods and 4,5 11,8servicesContributions to social 6.6 11.8security J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 56
    55. US vs. EU healthy lifestyles?4035302520 United States of America15 European Union10 5 0 Adults aged ≥15 years who are obese Alcohol consumption among adults Prevalence of smoking any tobacco (%) aged ≥15 years product among adults aged ≥15 years (litres of pure alcohol per person per (%) year) J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 57
    56. US vs. EU child mortality Neonatal and under five mortality rate EU-US 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008 Male Female Both sexes Male Female Both sexes Neonatal mortality rate (per 1000 live births) Under-five mortality rateUnited States of America 11.0 8.0 7.0 8.0 7.0 6.0 10.0 7.0 7.0 13.0 9.0 9.0 10.0 8.0 7.0 11.0 9 8European Union 10.5 6.6 4.7 8.2 5.3 3.7 9.3 5.9 4.4 12.6 7.8 5.7 10.0 6.4 4.5 11.4 6.9 5.1 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 58
    57. US vs. EU adult mortality rates Adult health EU-US 500 450 400 350 300 250 200 150 100 50 0 1990 2000 2008 1990 2000 2008 1990 2000 2008 2004 2004 Male Female Both sexes CD NCD Injuries CD NCD Injuries Adult mortality rate (probability of dying between 15 and 60 years A-S mortality Life years lost per 1000 population)United States of America 172 144 135 91 83 79 132 114 107 36.0 450.0 50.0 9.0 73.0 18.0European Union 167.1 141.3 122.5 77.5 66.9 58.3 122.9 104.6 90.7 27.0 456.2 37.7 5.7 82.6 11.7 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 59
    58. US vs. EU health systems Health financing EU-US 80 70 60 50 40 30 20 10 0 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007 Social security General General Total Private expenditure on Out-of-pocket Private prepaid government government expenditure on expenditure on health as % of expenditure as % plans as % of expenditure on expenditure on health as % of health as % of general of private private health as % of health as % of gross domestic total expenditure government expenditure on expenditure on total expenditure total government product on healthb expenditure on health health on healthb expenditure healthUnited States of America 13.4 15.7 43.2 45.5 56.8 54.5 17.1 19.5 33.5 27.9 25.5 22.6 60.3 63.5European Union 8.1 8.8 74.9 76.2 25.1 23.8 13.8 15.1 50.6 51.2 70.7 68.1 21.3 21.4 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 60
    59. US vs. EU health spending Health spending per capita, EU-US 8000 7000 6000 5000 4000 3000 2000 1000 0 2000 2007 2000 2007 2000 2007 2000 2007 Per capita total expenditure Per capita total expenditure Per capita government Per capita government on health at average on health expenditure on health at expenditure on health exchange rate (US$) (PPP int. $) average exchange rate (US$) (PPP int. $)United States of America 4703 7285 4703 7285 2032 3317 2032 3317European Union 1518 3182 1864 2754 1164 2463 1419 2119 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 61
    60. Signed and ratified international treatiesInternational treaties US EU (all EU member states directly, by EU or “acquis”)CESCR NO YESCCPR YES YESCCPR-OP1 NO YESCCPR-OP2-DP NO YESCERD YES YESCEDAW NO YESCEDAW-OP YES YESCAT YES YESCRC NO YESCRC-OP-AC YES YESCRC-OP-SC YES YESMWC NO YESRPD NO EU and all 27 MSs J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 62
    61. US vs. EU development policies Common features US specificities EU specificitiesStructure Coordination across relevant Development Policy under Development Policy under sectors National Security: development foreign policy/partly as a central pillar of US national independent. Policy coherence security policy, equal to diplomacy and defense. Director of Development agency (USaid and Europaid) in Interagency Development Joint EU coordination and joint charge lf development policies Policy Committee aimed at programming. and reports to US Secretary of coherence across all State/EU Foreign Office chief. Government departments US Global Development Council for consultation with stakeholdersPrinciples Economic growth as main pull US leadership and effective Development aid is a priority effect for development partnership and a modern for EU external action in architecture that elevates support of EUs interests for a Country ownership development and harnesses stable and prosperous world. development capabilities (in support of “common Inclusive and sustainable objectives”). economic growth is crucial to long-term poverty reduction and USAID as the world’s leading growth patterns are as important development agency. as growth rates. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 63
    62. US vs. EU development prioritiesPriorities Good governance "Game-changing" initiatives Energy : Address price such as vaccines for neglected volatility and energy security. Public administration and diseases, weather-resistant seed Link to climate change, service delivery varieties, and clean energy including access to low carbon technologies, technologies. Access to secure, affordable, clean and Sector reforms Global Health Initiative : High sustainable energy services. priority given to targeted health FTT/sustainable agriculture challenges Social cohesion : share target (but see different approaches) for social inclusion and human development of at least 20% of Attention to climate change EU aid : Support sector reforms that increase access to quality health and education services, mainly through „sector reform contracts‟ with intensified policy dialogue.Different approaches on some Agriculture and food security: Comprehensive approach to food Agriculture and food security:priority areas security by accelerating economic Safeguarding of ecosystem growth and raising incomes services, priority to locally- through greater agricultural developed practices and focusing productivity, increasing incomes on smallholder agriculture and and market access for the rural rural livelihoods. Strengthen poor and enhancing nutrition. nutrition standards, food security Establishment of the Global governance and reducing food Agriculture and Food Security price volatility at international Program (GAFSP) based at the level. World Bank designed to help J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice poor farmers grow, market and 64 earn more.
    63. Agriculture, food security and aid modalitiesAid modalities Selective sectors and countries Renew the US leadership in the In line with the Operational multilateral development banks Framework on Aid Effectiveness. Ownership of country priorities and the G20 (seen as the premier forum for US international A new element is the increased economic cooperation) differentiation between Donor coordination Millennium Challenge developing countries as several Corporation –MCC- (aligned partner countries (notably the Leverage private funds support-sector budget support- BRICS) have become donors like), more connected to while others are facing increasing Aligned support to country infrastructures and water- fragility. systems : EU GBS, US MCC sanitation, based on governance and corruption assessments. General Budget Support (GBS): Leverage to private investments. aligned, untargeted and predictable support to Ministries Attention to fragile contexts of Finance. Now called through LRRD-like approaches. development contracts Strengthen key multilateral Blending instruments. capabilities. Sector reform contracts. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 65
    64. US vs. EU development aid levels EU and US development aid levels 90000 80000 70000Million dollars 60000 50000 40000 30000 20000 10000 0 2003 2004 2005 2006 2007 2008 2009 2010 EU DAC members 41427.53 47290.44 60063.5 64741.92 67560.25 76433.07 71098.44 73733.23 US 18257.49 20604.13 28750.32 24531.56 22690.52 27414.13 29659.18 31159.3 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 66
    65. EU and US ODA as % of GDP 0.0600 0.0500 0.0400ODA % of GDP 0.0300 0.0200 0.0100 0.0000 2003 2004 2005 2006 2007 2008 2009 2010 US ODA/GDP 0.0165 0.0175 0.0229 0.0184 0.0163 0.0193 0.0214 0.0216 EU(DAC) ODA/GDP 0.0356 0.0386 0.0468 0.0465 0.0457 0.0497 0.0472 0.0479 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 67
    66. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 68
    67. US vs. EU ODA distribution Ratio LDCs/all EU and US distribution by income regions 0.6100%90% 0.580%70% 0.460%50% UMICs 0.3 LMICs40% other LICs LDCs 0.230%20% 0.110% 0% US EU US EU US EU US EU US EU US EU US EU US EU 0 US EU US EU US EU US EU US EU US EU US EU US EU 2003 2004 2005 2006 2007 2008 2009 2010 2003 2004 2005 2006 2007 2008 2009 2010 Ratio LDCs/all 0.38 0.45 0.31 0.41 0.22 0.42 0.33 0.39 0.35 0.42 0.41 0.43 0.43 0.38 0.48 0.44 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 69
    68. Share bilateral/multilateral of EU and US ODA100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% US EU US EU US EU US EU US EU US EU US EU US EU 2003 2004 2005 2006 2007 2008 2009 2010Multilat 1671 1343 3466 1697 2363 1750 2380 1927 2895 2333 2992 2610 3667 2617 3775 2655Bilat 1658 2799 1713 3031 2638 4256 2215 4546 1979 4423 2442 5032 2599 4492 2738 4717 70 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice
    69. Compliance with aid effectiveness 2005 2007 2010 Average Target US EU US EU US EUInd 3 : disbursed/estimatedaid 66 58 73 62 64 61 41 85Ind 4 : TA coordinated withcountry programming 47 36 54 50 37 50 57 50Ind 5a : Use of countrysystems :PFM 10 41 3 40 4 56 48 55Ind 5 b : use of countrysystems : Procurement 12 42 5 36 4 55 44 55Ind 6 : Reduction ofprogramme Implementationunits (2005 baseline) 0 0 0 48 04 61 30 60Ind 7 : Aid Disbursementspredictable and captured bynational budgets 29 51 37 63 30 60 43 71Ind 8 : Untied aid 70 80 79 86 80 92 86 89Ind 9 : Programme-basedsupport 51 27 47 36 59 48 45 66Ind 10 : Donor missionscoordinated 28 34 9 37 6 25 19 40Ind 11 : Country analysiscoordinated 40 45 37 90 39 59 43 66 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 71
    70. US vs. EU policies on global healthFeatures EU-US GH policy US GH specificities EU GH specificities commonalitiesPrinciples Country ownership Gender focus. Equity Support to health systems Research and innovation Governance Monitoring frameworks CoherencePriority areas Special attention to MDG5 AIDS (80% of the Universal health coverage programmed support) through aligned support (50% Health system strengthenning use of country systems and Malaria 66% through programme based apporaches). Neglected tropical diseases Governance through increased core support to WHO (>50%). Mother and child care Coherence in trade, migration, Nutrition security, food security and climate change.Targets Inputs : Financial allocations. Process : aid affectiveness and governance. Impacts : Patients prevented or treated. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 72
    71. US vs. EU levels of HDA 8000 7000 6000 5000 4000 3000 2000 1000 0 EU USother 1207Nutrition 112 75SRHR 280 455Basic health care 602Mother and child care 495Malaria 60 382Tuberculosis 35 162HIV/AIDS 564 5509 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 73
    72. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 74
    73. US HAD equity Equity distribution of US GH pc 50 45 40 35 30 25 20 y = -0.003x + 4.887 R² = 0.025 15 10 5 0-2500 -2000 -1500 -1000 -500 0 500 J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 75
    74. EU HDA equity 20 18 16 14EU pc health aid 12 10 8 6 y = -0,0031x + 0,9267 2 4 R = 0,0078 2 0 -250,00 -200,00 -150,00 -100,00 -50,00 0,00 50,00 potential pc public health financing gap J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 76
    75. Challenges for EU and US on GHE• PERTINENCE• Health development aid (hereafter HDA) does not address the main root causes of the main challenge in global health: stagnant global health equity. These causes are related to high income disparities within and between countries.• HDA follows the MDG framework, which only targets 60% of the overall gap of global health equity, when under the main stratifying variable, that of income, the upper regional quintile (high income region) is considered the best standard.• Countries with lower public spending per capita should maximize their potential of fiscal revenue (to at least 20% of GDP) and the public budget allocation to health (to some 15% , as the OECD average and the Abuja commitments for Africa). The gap remaining after those increased domestic revenues are estimated, affects the 44 countries listed in annex 4, for a total of over 100 Bn a year, that is, some 6 times higher than the present levels of HDA.• Besides lower than required levels of HAD, the distribution is not equitable in relation to the mentioned public financing needs. Only 30,9% of ODA goes to countries that are under this financial gap. Both, the EU and the US show low HAD equity levels. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 77
    76. Challenges for EU and US on GHE• COHERENCE – overall development aid is poorly aligned and predictable, as committed in the aid effectiveness agenda and the Paris commitments, hence having very little effect on the required transformations or reforms of policies to meet people needs. – The same fragmentation and undermining effect of sovereignty takes place with the global governance role of the United Nations, especially in the case of health with the World Health Organization, suffering from weak, fragmented and biased governance. – The US has not ratified the Covenant on Economic, Scoial and Cultural Rights and its comment 14 in year 2000, which gives the right to health an operational nature acknowledging the duty of the state and the wide scope of services and basic and security needs for health to which all persons are right holders. – There are many concerns on how the EU and the US are approaching trade and migration agreements, among others, which may have a significant effect in the availability of vital resources for health care, such as qualified health professionals and essential medicines. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 78
    77. Economic frameworks:• The present economic order leads to growing income disparities within and between countries.• Such dynamic requires of regulations ensuring minimum income levels (that guarantee the minimum conditions of dignity of all human beings) and avoiding excess income levels (which, in a world with limited resources, result in deficit for others).• Beside regulations (ex-ante), the economic dynamics require of fiscal policies that have at least an effect on redistribution of resources that the market rules have in concentration of resources in privileged groups.• Fiscal policies require a minimum rate of fiscal revenue and an adequate distribution between indirect and direct taxes and the progressive nature from basic to luxury goods and speculative transactions, and from lower to higher salaries.• At global level, such direct taxes (on GPP) and indirect taxes (on international transactions) should also be established in a legal framework and with the objective of minimum levels of redistribution to avoid gaps and their effects in human lives.• This concept (of global justice) needs to gradually replace the present concept of “development aid”. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 79
    78. Social frameworks• :Social governance needs to guarantee basic services which enable equal basic opportunities for all (health, education, justice) in relation to social rights.• This concept is being slowly developed by the UN under the framework of the social protection floor.• It is in close relation with the fiscal policy outlined above and requires a definition of universal social security basic services, linked to a legal framework.• Such concept will also need to be translated at global level through a global social governance which may identify the minimum social services all human beings are entitled to for their basic dignity.• The UN agencies should work towards those definitions, which, in the case of health, should include a minimum basic health promotion and care package. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 80
    79. Ecological governance• At the present rate of use of resources, the EU and the US, as most OECD countries, have unsustainable models of development.• This challenges the very concept and definition of development.• The countries that use natural resources at a renewable rate (e.g. 1,8 hectares per person and year) and manage to have health and education standards (to be better defined and measurable, as in health-see above), should be the models of sustainable (and hence trans-generational equitable) development.• The progress of those economies with resources below the minimum levels required for decent living conditions and those others with abuse of global natural resources should find ways towards the equitable and sustainable development models. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 81
    80. J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 82
    81. Thank you! Y hasta muy pronto!J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 83

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