This document outlines the learning objectives of a module on global health and service development. It aims to define key concepts in global health and international development. It discusses determinants of health and factors contributing to health and disease globally. It also examines the roles of governments, organizations and communities in health provision. The module will analyze global health systems and inequalities in health. It identifies how different disciplines contribute to health service development and delivery globally.

1. Global Health and
Service Development

2. Learning Objectives
At the end of this module, the student is able to:
• Define the concepts of global health and international development
• Describe and discuss determinants of health
• Identify the factors that contribute to health and disease in a global context
• Discuss the relationship between health, environment and sustainable
development
• Discuss the incidence and prevalence of diseases affecting developed and
developing countries
• Describe the principal factors that result in premature death and excess
mortality in disadvantaged communities around the world

3. • Evaluate the role of governments, international agencies, NGOs and community
based organisations in health provision in developed and developing countries
• Analyse the inter-dependence of global health systems
• Summarise the historical evolution of public health and its influence on modern public
health
• Identify and discuss the factors associated with inequalities in health
• Describe the basic functions of health services and reasons why services develop
• Explain how different disciplines contribute to health service developments and
delivery
• Analyse key problems in providing health services globally
• Identify the distinct contribution of different disciplines to global health

4. Global Health – Definition
• An area for study, research, and practice that places a priority on
improving health and achieving equity in health for all people
worldwide.
• Emphasises transnational health issues, determinants, and solutions
• Involves many disciplines within and beyond the health sciences and
promotes interdisciplinary collaboration
• Involves both population-based prevention and individual-level clinical
care.
Koplan et al. Lancet 2009; 373: 1993–9

5. “Global public health is the collective action we take worldwide for
improving health and health equity, aiming to bring the best available
cost-effective and feasible interventions to all populations and selected
high-risk groups. Essential collective actions for health improvement
include disease prevention, health promotion, health protection, and the
provision of health care.”
Beaglehole & Bonita. Lancet 2008; 372: 1988–96

6. Definitions
• International health = health in low-income areas
• Infectious disease
• Nutrition
• Child health
• Reproductive (maternal) health
• Water & sanitation
• Aging, mental health, culture, and other global issues
• Global health = health concerns that cross borders
• Sometimes global health = international health
Jacobsen. Introduction to Global Health, 2008: 1-2

7. Global
Health
Epidemiology
Economics
Demography
SociologyPsychology
Law
Engineering

8. Global Health Issues
- New challenges
- Unfinished agenda
- Health priorities
- Effects of globalization Health Policy and Systems
- Provisioning
- Funding
- Stewardship
Non-communicable Diseases
Communicable Diseases
Injuries
Service Development
- Needs analysis, building business case
- Planning – staffing, location, logistics
- Establishing structure, process and outcomes
- Setting targets and indicators
- Delivery
- Monitoring and Evaluation

9. Basic Concepts of Public Health

10. WHO Definition of Health – since 1948
Health is “a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity.”
World Health Organization (WHO) – United Nations
(UN) agency that specializes in health, 1948

11. WHO Constitution on ‘Standard of Health’
WHO Constitution
• Areas with poor health standards
put everyone at risk of pandemic
outbreaks of infectious disease
• Health is linked with peace
• Health is a human right
• “The enjoyment of the highest
attainable standard of health is
one of the fundamental rights of
every human being.”
What is a “standard of health”?
• This means that the “standard” of
health should be raised so that
everyone has access to at least
basic medical and psychological
care, especially at-risk populations.
• This does not mean that everyone
has the right to advanced medical
therapies.
• What is the “standard of care” that
should be available to everyone?

12. Medicine and Public Health
• Public health cares about the health
of groups of people (populations)
• Medicine cares about the health of
individuals
Individual
Household
Community
State/Province
Nation
World Region
World
Domain of
Medicine
Domain of
Public Health
Jacobsen. Introduction to Global Health, 2008: 4

13. Population Health
Kindig, D. A. (2007). Understanding population health terminology. Milbank Quarterly, 85(1), 139-161.

14. Improving the health of population – 5th wave
Davies, S. C., Winpenny, E., Ball, S., Fowler, T., Rubin, J., & Nolte, E. (2014). For debate: a new wave in public health improvement. The
Lancet, 384(9957), 1889-1895.

15. Population Health Improvement
• 1st wave – public health works, such as clean and safe water and sanitation.
• 2nd wave – discovery of antibiotics, vaccines and treating/preventing
infections.
• 3rd wave – development of welfare state and the NHS, tackling the
Beveridge Report’s “five giants”, viz., disease, squalor, ignorance, want and
idleness (unemployment).
• 4th wave – addressing lifestyle-related non-communicable diseases
• 5th wave – looking behind inequalities and increasing understanding of
social determinants of health, adopting a ‘culture of health’
Davies, S. C., Winpenny, E., Ball, S., Fowler, T., Rubin, J., & Nolte, E. (2014). For debate: a new wave in public health improvement. The
Lancet, 384(9957), 1889-1895.

16. Washington, A. E., Coye, M. J., & Boulware, L. E. (2016). Academic health
systems’ third curve: population health improvement. JAMA, 315(5), 459-460.
Population Health
Improvement is
academic health
systems’ 3rd curve.

17. Key Epidemiological Definitions
• Incidence: the number of new occurrences of a condition (or disease) in a
population over a period of time.
New cases over a period
Population at risk
• Prevalence: the measure of a condition in a population at a given point in
time (point prevalence) or period of time (period prevalence).
Number of cases at a point/period of time
Population at risk

18. Interview Question Type of Measure
"Do you currently have
asthma?"
Point prevalence
"Have you had asthma during
the last [n] years?"
Period prevalence
"Have you ever had asthma?" Cumulative incidence
Examples of Point and Period Prevalence and
Cumulative Incidence in Interview Studies of
Asthma
Gordis. Epidemiology, 4th ed, 2009; Saunders Elsevier.

19. Gordis. Epidemiology, 4th ed, 2009; Saunders Elsevier.

20. Summary:
Relationship
between
Incidence and
Prevalence
Incidence
Prevalence
Cured, deaths,
lost to follow-
up, etc
Duration

21. Burden of Disease
Refer also to: http://www.who.int/healthinfo/global_burden_disease/gbd/en/

22. Disability-Adjusted Life-Years (DALYs)
DALY = Years of Life Lost (YLL) + Years of Life Lived due to
Disability (YLD)
where:
YLL = Number of deaths x Life Expectancy
YLD = Incidence x Disability Weight x Disease Duration

23. Example: Lung cancer, 1,000 cases per year among
men (LEo=65 yo), onset at 50 yo, 1 year of survival,
disability weight = 0.6
• DALY = Years of Life Lost (YLL) + Years of Life Lived due to Disability (YLD)
• YLL = 1,000 * (65 – 51) = 14,000
YLD = 1,000 * 0.6 * 1 = 600
DALY = 14,600
• Usually expressed as percentage of overall DALYs.

24. Key Health Status Indicators
• Infant mortality rate – the number of deaths of infants under the age 1
per 1,000 live births in a given year
• Under-5 mortality rate (child mortality rate) – the probability that a
newborn baby will die before reaching age 5, expressed as a number per
1,000 live births
• Life expectancy at birth – the average number of years a newborn baby
could expect to live if current mortality trends were to continue for the rest
of the newborn’s life

25. United Nations, Department of Economic and Social Affairs, Population Division (2012). Changing Levels and Trends in
Mortality: the role of patterns of death by cause (UN, ST/ESA/SER.A/318).

27. • Maternal mortality ratio – the number of women who die as a result of
pregnancy and childbirth complications per 100,000 live births in a given
year
• Neonatal mortality rate – the number of deaths to infants under 28 days
of age in a given year per 1,000 live births in that year

28. Exercise
• Visit the WHO website -> http://www.who.int/gho/en/
• Navigate to GHO Data repository -> By category
-> Mortality and global health estimates
-> Maternal mortality
• What are the maternal mortality ratios (per 100,000 live births) for
Democratic Republic of the Congo, Ireland, Singapore, Switzerland and
United States of America for the yea 2015?
• What do you think is contributing to the differences? [note: you may wish
to re-visit these numbers after Global Health Systems studies]

29. What Are the Key Global Health Issues Today?

30. What Are Current Global Health Issues?
• Globalization and health
• Double burden of disease
• Challenges to access to health
services
• Poverty and health
• Politics and health
• Social determinants of health
• Climate change and health
• Environment and health
• Global health systems
• Sustainable development goals
• Primary health care
• Cancer and non-communicable
diseases
• Obesity Crisis

31. Globalization – the ‘flat world’
“… Doctors wanted it so that an X-ray taken in
Bangor could be read in a hospital in
Bangalore, without the doctor in Maine ever
having to wonder what computers that Indian
hospital had.” – Friedman, p. 82-83.

32. Globalization
Lee. Globalisation: what is it and how does it affect health? The Medical Journal of Australia. 2004;180:156-8.
Smith. Globalization: the key challenge facing health economics in the 21st century. Health Economics. 2008;17:1-3.
Spatial
• Cross-border
movement of
people, goods,
services, etc
Time
• Temporal
compression via
telecomms
technologies
Cognitive
• Flow or spread of
ideas, lifestyle or
values

33. Global Health and Globalization
• Spread of health risks and diseases across the world linked with trade or
attempted conquest
• Plague spread across Europe/Asia in the middle ages
• Smallpox and measles introduced to the New World by European
invaders in 16th century
• European explorers took tobacco from the Americas to Europe and
beyond
• Opium was sold to China in the 18th/19th centuries as a product of
trade and subjugation by imperial western powers
Koplan et al. Lancet 2009; 373: 1993–9

34. Double Burden of Diseases in Developing Countries
• Unfinished Agenda
• Communicable diseases
• Emerging Epidemics
• Non-communicable diseases
• Injuries

35. Butler. Nature 2012, 20 December; 492: 322,
doi:10.1038/492322a

36. ‘Triple Whammy’
Clockwise: Tsunami, Sri Lanka, 2004;
Post-cyclone Myanmar, 2008; flood
waters Pakistan, 2010; earthquake
Southern Sumatra, Indonesia, 2009

37. Challenges to global health services
Video: Polio Spreads, Resistance Grows. From PBS’s Rx for Survival: A Global Health Challenge Program 1 Disease Warriors. Refer also to: http://www.pbs.org/wgbh/rxforsurvival/series/video/

38. http://www.telegraph.co.uk/news/worldnews/northamerica/usa/11363703/Disneyland
-measles-outbreak-spreads-amid-anti-childhood-vaccination-row.html
September 18th, 2018 – The Minnesota Department of Health (MDH)
officials have confirmed the 3rd case of measles in the last 6 weeks.
This new measles case was a child who had been partially vaccinated for
measles, mumps and rubella (MMR), and was likely infectious between
September 6 and 14, 2018.
The most recent measles case was a 2-year-old Ramsey County child
who recently returned from a trip to the Middle East, according to the
MDH.
Uptake of the jab fell for the fourth year in a row as parents become
“complacent” about the threat of deadly diseases.
Leading nurses warned that Britain is “turning back the clock and
leaving thousands of children unprotected”.
Experts urged the NHS to do more to reach children as longer GP
waits get in the way of vaccinations.
Professor Jonathan Ball, of the University of Nottingham, said: “If
uptake continues to decline we will see increasing numbers of
outbreaks and, inevitably, illness and possible death.”Is the self-styled “happiest place on earth”. But Disneyland is also now the source
of a measles outbreak that has spread beyond California as health experts express
alarm about the impact of the anti-childhood vaccination movement.
At least 59 cases have been diagnosed in California, with eight related infections in
other western US states and Mexico as people infected at the theme park have
passed the disease to others far from the park.
With 16 million visitors from around the world to Disneyland last year, public health
officials warned that the measles virus could spread among unvaccinated
communities across the US and internationally.
https://www.dailystar.co.uk/news/latest-news/730919/measles-
mumps-jab-decrease-health-crisis-disease
https://www.precisionvaccinations.com/most-international-travelers-
lack-vaccine-immunization-infectious-diseases
"All 3 cases have been associated with travel," said Cynthia Kenyon, the
supervisor for the vaccine-preventable disease surveillance unit, at
MDH.
"I think it's important for people to remember if they are going to be
traveling to make sure they are up to date on their vaccines.”
“Especially with young children, especially those children under the
age of 1, to talk to their health care providers because they might
actually recommend an early dose of the MMR to make sure that those
children are protected," Kenyon told MPR News.

39. An outbreak of measles in Japan and Taiwan has put thousands of people in quarantine and forced tourists to put off visits to southern
Japan, media reports said.
More than 3,500 people in the southern Taiwanese city of Kaohsiung have been quarantined and are being monitored by the island's
health authorities after coming into contact with infected crew of budget carrier Tigerair Taiwan, Taiwanese media reported.
Another 980 are being monitored following the discovery of an infection cluster at a major hospital in Taoyuan, just outside Taipei.
The outbreak has been traced to a 30-year-old male flight attendant with Tigerair Taiwan, said the semi-official Central News Agency.
He caught the highly contagious disease in Thailand in March and was confirmed to be infected on March 29. But by then he had infected
two other cabin crew during a Tigerair Taiwan flight to the southern Japanese prefecture of Okinawa.
The latter two - a 34-year-old man and a 28-year-old woman - continued working until they fell seriously ill and were diagnosed with
measles in early April, Central News Agency said.
So far, at least 22 people in Taiwan have been confirmed to have the highly contagious disease, which causes high fever and rashes.
It can be fatal for infants and toddlers, and may result in miscarriage.
The disease has since spread in Okinawa, which is a popular tourism destination among Taiwanese, and appeared to be heading north,
with cases confirmed in Nagoya.
The source of the outbreak is the same person as in Taiwan - the male Tigerair Taiwan flight attendant who caught the virus in Thailand,
reported Taiwanese media.
The man had flown to the prefecture for a holiday between March 17 and 19.
As of April 20, a total of 67 patients in Okinawa were confirmed to have contracted the disease, reported Japanese media. They included
people who had come in contact with the tourist, as well as their family members and colleagues, the Asahi Shimbun said.
Some schools in Okinawa have cancelled classes.
The outbreak couldn't have happened at a worse time for local tourism: More than 170 people have cancelled trips to Okinawa ahead of
the spring holiday season, according to public broadcaster NHK.
The prefectural government is receiving about 30 inquiries a day from people and travel agencies about where infections are rampant and
how to protect against the virus, it added. The government plans to hold an emergency meeting of all its division chiefs on Monday, NHK
said.
The disease has also been detected in the central city of Nagoya, where a resident who had visited Okinawa was diagnosed on April 11. A
nurse at a local hospital was confirmed to be infected 10 days later.
Japan's Health Ministry is urging the public to get vaccinated ahead of the country's Golden Week travel peak next week.
In Hong Kong, the government’s Centre for Health Protection said it was closely monitoring the situation, South China Morning Post
reported. It urged travellers to remain vigilant, and noted that vaccination was the most effective way of preventing the disease, which has
a 21-day incubation period.

40. SINGAPORE - The recent measles outbreaks in Japan and Taiwan have raised concerns that the disease could flare up here as well.
Here are the answers to some questions you may have about measles and the possibility of an outbreak in Singapore.
Q. What is measles?
A. Measles is a highly infectious disease caused by a virus in the paramyxovirus family. Symptoms include high fever, a runny nose,
coughing, red and watery eyes and a rash. On average, rashes occur 14 days after exposure to the virus.
Serious complications associated with measles can result in blindness, ear infections, severe diarrhoea and even death.
Q. How does measles spread?
A. The disease is usually passed by direct contact or through the air.
Q. Are Singaporeans safe from contracting measles?
A. Most Singaporeans have developed immunity towards measles either by vaccination or through contracting the disease naturally.
Under the Infectious Diseases Act, children here must undergo two doses of the combined measles, mumps, and rubella (MMR) vaccine
during their lifetime - the first dose at 12 months of age and a second dose at 15 to 18 months. Two doses of the MMR vaccine grant life-
long protection against measles.
Q. How can Singaporeans protect themselves from measles if they have not been vaccinated?
A. Vaccination is the best way to prevent measles. If you have not been vaccinated (and do not want to be), good hygiene and
cleanliness should be maintained.
Q. Will a measles outbreak occur in Singapore?
A. It is unlikely that an outbreak will happen here as a large proportion of Singaporeans have been vaccinated. This not only provides
immunity to those vaccinated, but also decreases the likelihood of measles within the unvaccinated population. This is herd immunity:
This occurs when the vaccination of a significant proportion of a population can provide a measure of protection towards unvaccinated
and non-immune individuals.

41. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the
Commission on Social Determinants of Health. Geneva, World Health Organization.
• Children from the poorest 20% of households
are nearly twice as likely to die before their
fifth birthday as children in the richest 20%.
• Children in sub-Saharan Africa are about 16.5
times more likely to die before the age of five
than children in developed regions.
http://www.who.int/features/factfiles/health_inequities/facts/en/

42. Chang MC. FieldNotes: S. Korea’s
growing problem of elderly poor. The
Straits Times. December 19, 2015
Saturday. A45.

43. Poverty and Health
• More susceptible to injury and illness
• Poor diet
• Existing infections
• Dangerous work and home environments
• Less able to prevent illness
• Less screening (to diagnose disease early)
• Less access to health care
• Limited money / insurance
• Cannot take off work or find transportation
• Less health education
Jacobson. Introduction to global health, 2008
See also a shorter version:
Sachs JD. The end of
poverty. Times magazine,
Sunday, Mar. 06, 2005

44. Image source: https://sites.google.com/site/apusgovernmentpoliticskaras/home/political-ideology

46. Three millennia ago in ancient Greece, a plant called
autumn crocus was used to treat gout. A pill form of the
active ingredient, colchicine, has been used to treat the
illness in the United States since the 19th century.
But six years ago, a clinical trial showed the drug's safety
and efficacy and URL Pharma was granted the exclusive
marketing rights for a drug that had previously sold for 9
cents a tablet. The price shot up to $4.85 -- a more than
5,000 percent increase.
Sound familiar?
[A defining moment in modern health care.]
This week, a roiling controversy was ignited after Turing
Pharmaceuticals chief executive Martin Shkreli hiked the
price for his drug Daraprim by a mind-boggling 4,000
percent. The major pharmaceutical and biotech industry
groups have portrayed Shkreli's actions as totally repugnant
and the work of just one company, acting alone, with a
flippant young chief executive who doesn't reflect the
broader values, practices, or trends of other companies.
Daraprim (a drug that treats
toxoplasmosis) cost USD13.50 until
Shkreli took over the drug company
Turing Pharmaceuticals that
manufactured the drug. He raised it
to USD750 … since there was no
competitor.
https://www.washingtonpost.com/news/wonk/wp/2015/09/25/the-drug-industry-wants-us-to-think-
martin-shkreli-is-a-rogue-ceo-he-isnt/
September 2015

47. http://www.chinesemedicalnews.com/2014/04/hospital
-ticket-scalpers-fight-outside.html
https://beijingtoday.com.cn/2015/05/health-and-mobility-in-the-hands-of-the-huangniu/
“Seeing a doctor at a hospital requires purchasing a
number. Patients must buy a number for a doctor in a
relevant department, and doctors are priced according to
their experience. Most will only see 30 patients per day.
Huangniu often arrive at the hospitals early in the
morning and buy out all the numbers for the most
experienced doctors. Incoming patients are left with no
choice other than to buy a number from a huangniu.”

48. http://www.md2.com/

49. McDonough, S. (2013). Paying for an open medical door. CMAJ : Canadian Medical
Association Journal, 185(2), E105–E106.
“… a small but fast-growing segment of American health care, paying US$1500 a year to
see a doctor who offers a “personalized” approach known as concierge medicine …”
“Concierge Medicine”
“… Now the waiting room he visits has two chairs,
one for him and another empty. Instead of seven
minutes with the doctor, he gets at least 30, plus
email consultations day and night, an annual
physical lasting 2.5 hours, appointments within 24
hours, follow-up when he’s referred to a specialist
and an intense focus on preventive care. ‘It’s like
old times,’ says Campagna, in his mid-60s, ‘when
the family knew the doctor and we had house
calls.... This allows a doctor to be a good doctor. It
unleashes the inner doctor.’”

50. Doctors in uproar over third party administrators'
charges
- See more at: http://business.asiaone.com/news/doctors-uproar-over-third-party-administrators-
charges#sthash.Qcujhg7e.dpuf

51. Financial Incentives for Weight Loss and Healthy
Behaviours
Ries, N. M. (2012). Financial Incentives for Weight Loss and Healthy Behaviours. Healthcare Policy, 7(3), 23–28.
“… use of direct incentives to promote healthier behaviours, including weight loss for
persons facing obesity-related health risks. Available evidence suggests that short-term
incentives will not sustain enduring outcomes, but targeted and longer-term incentive
programs may be more effective. A promising finding of some studies is that people who
receive incentives for weight loss shed pounds without additional assistance, such as
personalized fitness training and nutrition counselling. Incentive recipients report that they
achieved weight loss by modifying their diet (97%) and getting more exercise (86%) …
Sixty per cent made changes on their own, while 40% took additional steps such as joining
a gym or participating in a weight-loss group. This finding suggests that people know
what to do to lose weight; they just need an incentive to make changes.”

52. http://www.projectprevention.org/
“Project Prevention offers cash
incentives to women and men addicted
to drugs and/or alcohol to use long term
or permanent birth control…using your
donations to stop a problem before it
happens. We have paid addicts in 50
States and the District of Columbia.”

53. Sandel, M. J. (2012). What money can't
buy: the moral limits of markets. Farrar,
Straus and Giroux, New York.

54. Objectives of Health System
AccessCost
Quality
Kissick, W. L. (1994). Medicine's dilemmas: infinite needs versus finite resources. Yale University Press, New Haven, CT.
Kissick’s Iron Triangle

55. Murray & Frenk. Bulletin of the World Health Organization, 2000, 78 (6)

56. Image source: Leerapan B (2014); available from http://www.slideshare.net/borwornsom/creating-managing-new-models-of-care-in-thailand

57. Thomas, S., Burke, S., & Barry, S. (2014). The Irish
health-care system and austerity: sharing the pain. The
Lancet, 383(9928), 1545-1546.

58. Briggs, A. D. (2013). How changes to Irish healthcare financing are
affecting universal health coverage. Health Policy, 113(1), 45-49.

59. Determinants of Health
1. Income and social status
2. Social support
3. Education
4. Employment
5. Physical environments
6. Biology and genetics
7. Early life
8. Lifestyle habits
9. Health systems and services
Dahlgren G, Whitehead M. Policies and strategies to promote social equity in
health. Copenhagen: World Health Organization, 1992.

60. CSDH (2008). Closing the gap in a generation: health
equity through action on the social
determinants of health. Final Report of the
Commission on Social Determinants of Health.
Geneva, World Health Organization.

61. Climate Change and Health

62. http://time.com/4155365/china-red-alert-smog/

63. http://news.yahoo.com/tehrans-air-pollution-hits-worst-
level-months-131353184.html

64. Thurston GD, Ahn J, Cromar KR, Shao Y, Reynolds HR, Jerrett M, Lim CC, Shanley R, Park Y, Hayes RB. Ambient Particulate Matter Air Pollution
Exposure and Mortality in the NIH-AARP Diet and Health Cohort. Environ Health Perspect; 2015: http://dx.doi.org/10.1289/ehp.1509676.
Air Pollution Was Associated with Risk of CVD
Mortality

65. http://www.un.org/sustainabledevelopment/sustainable-development-goals/

66. The ultimate goal of primary health
care is better health for all.
WHO has identified five key elements
to achieving that goal:
 Reducing exclusion and social disparities
in health (universal coverage reforms);
 Organizing health services around
people's needs and expectations
(service delivery reforms);
 Integrating health into all sectors (public
policy reforms);
 Pursuing collaborative models of policy
dialogue (leadership reforms); and
 Increasing stakeholder participation.
World Health Report 2008

67. Pearce et al. The road to 25× 25: how can the five-target strategy reach its goal?. The Lancet
Global Health 2014; 2(3): e126-e128.
WHO’s War on NCDs

68. 25 x 25 Strategy To Reduce NCD Mortality
Relative reduction of 25% mortality due to NCD by 2025.
Beaglehole, R., Bonita, R., Ezzati, M., Alleyne, G., Dain, K., Kishore, S. P., & Horton, R. (2014). NCD Countdown 2025:
accountability for the 25× 25 NCD mortality reduction target. The Lancet, 384(9938), 105-107.

69. Lancet series on obesity February 18, 2015

70. Thank you