course reflection 1-2 paragraphs
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COH601Week3Lecture.pptx
COH601 Global Public Health
Voice-over: Welcome to Week Three of COH601 “Global Public Health.”
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Week Three Navigation Menu
Reproductive Health
Environmental Determinants
Global Health Systems
VO: To get started, click on the session that you want to begin.
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Module 1: Reproductive Health
VO: Module 1: Reproductive Health.
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Selected Definitions on Women’s Health
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VO: This table displays selected definitions in women’s health.
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Sex-Selective Abortion
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VO: Skewed ratios of males to females in some countries, including China, India, Taiwan, Singapore, and South Korea. Rising incomes and levels of education have led to more sex-selective abortion in these countries.
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Female Genital Mutilation (FGM)
| Type | Details |
| Clitoridectomy | Partial or total removal of clitoris Very rare cases: only prepuce |
| Excision | Partial or total removal of clitoris & labia minora With or without excision of labia majora |
| Infibulation | Narrowing of vaginal opening through creation of covering seal Formed by cutting/repositioning inner or outer labia With or without removal of clitoris |
| Other | Harmful procedures to genitalia for non-medical purposes e.g., Pricking, piercing, incising, scraping & cauterizing |
VO: Female genital mutilation is classified into four major types: 1. Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). 2. Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are "the lips" that surround the vagina). 3. Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. 4. Other: all other harmful procedures to the female genitalia for non-medical purposes (e.g., pricking, piercing, incising, scraping, and cauterizing the genital area).
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FGM
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VO: Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. The procedure has no health benefits for girls and women. Procedures can cause severe bleeding and problems urinating, and later cysts, infections, infertility as well as complications in childbirth and increased risk of newborn deaths. More than 125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where FGM is concentrated. FGM is mostly carried out on young girls sometime between infancy and age 15. FGM is a violation of the human rights of girls and women. Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. However, more than 18% of all FGM is performed by health care providers, and the trend towards medicalization is increasing. FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.
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FGM Facts
100-140 million had performed
Appears to be diminishing
Can cause shock, infection or hemorrhaging
Long-term problems include retention of urine, infertility & obstructed labor
VO: Estimated 100-140 million women worldwide have had some form of genital cutting performed on them. Practice appears to be diminishing. Can initially cause shock, infection, or hemorrhaging. Long-term problems include retention of urine, infertility, and obstructed labor. Cultural, social, and religious causes include stopping “illicit” sexual intercourse, social norm (e.g., all virgin girls do it before marriage), and considered a way to stay “clean.”
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Cultural, Social & Religious Causes
Stopping “illicit” sex
Social norm
e.g., Virgins do before marriage
Considered way to stay “clean”
VO: Cultural, social, and religious causes include stopping “illicit” sexual intercourse, social norm (e.g., all virgin girls do it before marriage), and considered a way to stay “clean.”
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Where Does FGM Happen?
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VO: The prevalence of female genital mutilation in Africa.
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How FGM Affects Throughout Life
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VO: Women are biologically more susceptible. Risk factors for women are young age, sex with high-risk partners, and inability to use a condom. 1.9% of total DALYs lost to women aged 15-44 were due to STIs.
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FGM Instruments
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VO: Tools utilized for female genital mutilation, and a billboard with message against female genital mutilation located near a street in Uganda.
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Violence/Sexual Abuse Against Women
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VO: UNAIDS estimates 10-50% of women worldwide have been abused physically by a partner, which can lead to injuries, unwanted pregnancy, STIs, depression, disability, and death. Risk factors include low socioeconomic status, young age of the male partner, proximity to alcohol, and gender inequality.
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Violence Against Women (VAW)
Act that results in physical, sexual or mental harm/ suffering to women
Including threats of such acts, coercion, or arbitrary deprivation of liberty
Whether in public or private
VO: The United Nations defines violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.
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Forms of VAW
Sexual, physical, or emotional abuse by partner, family members or others
Sexual harassment/abuse by authority figures
Trafficking for forced labor or sex
Forced/child marriages or dowry-related violence
Honor killings
VO: There are many forms of violence against women, including sexual, physical, or emotional abuse by an intimate partner; physical or sexual abuse by family members or others; sexual harassment and abuse by authority figures (such as teachers, police officers or employers); trafficking for forced labor or sex; such traditional practices as forced or child marriages, or dowry-related violence; and honor killings when women are murdered in the name of family honor.
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WHO VAW Study
15-71% reported physical/sexual violence by partner
Many said 1st sexual experience not consensual
4-12% reported physically abused during pregnancy
~5,000 women murdered in name of honor annually
VO: In a 10-country study on women's health and domestic violence conducted by WHO: Between 15-71% of women reported physical or sexual violence by a husband or partner; many women said that their first sexual experience was not consensual 24% in rural Peru, 28% in Tanzania, 30% in rural Bangladesh, and 40% in South Africa); between 4-12% of women reported being physically abused during pregnancy; about 5,000 women are murdered by family members in the name of honor each year worldwide.
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Trafficking & Forced Marriages
Trafficking for forced labor/sex widespread
Affects most vulnerable
Forced/child marriages violate human rights
Widely practiced in Asia, Middle East & Africa
VO: Trafficking of women and girls for forced labor and sex is widespread and often affects the most vulnerable. Forced marriages and child marriages violate the human rights of women and girls, yet they are widely practiced in many countries in Asia, the Middle East and sub-Saharan Africa.
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Child Sexual Abuse
20% women/10% men report sexual abuse as children
Children subjected to sexual abuse much more likely to encounter other forms of abuse later in life8
Health professionals need to be attentive to subtle forms of violence against women & children
VO: Worldwide, up to one in five women and one in 10 men report experiencing sexual abuse as children. Children subjected to sexual abuse are much more likely to encounter other forms of abuse later in life. Health Professionals need to be attentive to subtle forms of violence against women and children worldwide.
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Rape as a Weapon of War
World War 2
Rwanda
Darfur holocaust
Libya9
VO: Examples include World War 2, Rwanda, Darfur holocaust, and Libya.
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Reproductive Health
VO: Reproductive Health.
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Reproductive Health Definition
State of complete physical mental/social well-being
Not merely absence of disease or infirmity
Relating to reproductive system & processes
VO: The 1994 International Conference on Population and Development (ICPD) defined reproductive health as “… a state of complete physical mental and social well being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its processes.”
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All Stages of Live
“Reproductive health addresses the reproductive processes, functions and system at all stages of life.”
VO: “Reproductive health addresses the reproductive processes, functions and system at all stages of life.”
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Reproductive Health Elements
Satisfying/safe sex life
Capability to reproduce
Freedom to decide if, when & how
Right to be informed
Access to safe, effective, affordable & acceptable family planning
Access to services enabling safe pregnancy/childbirth
Sexual health to enhance of life/personal relations
VO: Reproductive health elements include: A satisfying and safe sex life; A capability to reproduce and the freedom to decide if, when and how; The right for men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice; The right of access to appropriate health-care services that enable women to go safely through pregnancy and childbirth; And sexual health, the purpose of which is the enhancement of life and personal relations.
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Reproductive Health Questions
Matter of human rights?
Have right to control own reproduction?
Purpose of sexuality only to reproduce?
VO: Uniquely human desire when and how many times we become parents. Control of fertility recognized as a human right for women and couples. By 1997, family planning services were found in 155 countries. There is a growing gap between observed and desired fertility. What percentage of the time do you think people have sex for the purpose of having children?
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Maternal Mortality
VO: Maternal Mortality.
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Maternal Mortality: Definition
Death while pregnant or within 42 days of termination
Irrespective of duration/site
From any cause related to pregnancy/management
But not from accidental or incidental causes
VO: The WHO defines “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
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Maternal Mortality & Poverty
| Category | Details |
| Rates | Every minute woman dies while pregnant/giving birth 100 die every 90 minutes 99 live in countries with high levels of poverty |
| Reasons | Bleed to death on way to ill-equipped hospital Acquire infection delivering in hut with dirt floor Blood pressure skyrockets without life-saving medicines Bodies weakened by malnutrition, malaria, HIV, tuberculosis or diabetes Abortions in secret by practitioners without training/sterile equipment Genitals cut in childhood Left with obstructed birth canals & scar tissue |
| Remedies | 500,000+ deaths in pregnancy & childbirth preventable Knowledge to prevent/treat for 100+ years Preventive measures & emergency obstetric care needed for progress |
VO: Every minute of every day somewhere in the world a woman dies while pregnant or while giving birth. One hundred women die every 90 minutes and 99 of these women live in countries with high levels of poverty. They die because they bleed to death on the way to an ill-equipped hospital or acquire an infection delivering their babies in a hut with a dirt floor. They die because their blood pressure skyrockets out of control without lifesaving medicines that were developed decades ago. They die because their bodies have been weakened by malnutrition, malaria, HIV, tuberculosis, or diabetes. They die having abortions in secret by practitioners without training or sterile equipment. They die because their genitals were cut in childhood as part of an ancient ritual that leaves them with obstructed birth canals and scar tissue. The more than half a million deaths of women in pregnancy and childbirth are preventable. Medical science has had the knowledge to prevent and treat these conditions for more than one hundred years. However, preventive measures and emergency obstetric care need to accessible, available, affordable, and acceptable to all of the women in need before progress is made.
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Maternal Mortality Estimates
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VO: Maternal mortality trend by region.
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Maternal Mortality Ratios (2)
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VO: Maternal mortality ratio globally and by WHO regions from 1990-2013.
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Maternal Mortality Statistics
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VO: 50% of all maternal deaths occur in six countries: Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo. 830 women die from pregnancy-related causes every day. In 2015, 302,700 women in the world died as a result of pregnancy or childbirth. The five countries with the highest number of maternal deaths in 2015 were: Nigeria (58,000); India (45,000); Democratic Republic of Congo (22,000); Ethiopia (11,000); and Pakistan (9,700). For many aspects in global development it is true that the world made a lot of progress in the past and we know that we can make a lot of progress still. In the visualization we see the latest maternal mortality rates across the world. What becomes clear from the map scale—spanning orders of magnitude—is the extent of cross-country inequality: the magnitude of the differences in mortality between countries are very large. In most high-income countries, maternal mortality is now very low. The average rate in the European Union is 8 maternal deaths per 100,000 live births. In some countries such as Poland, Greece, Finland and Sweden, the rate is even lower at 3 to 4 per 100,000. In Sierra Leone, a woman is 300 to 400 times more likely to die with each pregnancy. At an estimated rate of 1360 deaths per 100,000 live births, around 1-in-75 pregnancies ends in the death of the mother. The five countries where a woman is most likely to die in a given pregnancy are Sierra Leone, Central African Republic, Chad, Nigeria, and South Sudan.
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Maternal Mortality Causes
~75% of deaths caused by:
Hemorrhage (25%)
Infection (15%)
Unsafe abortion (13%)
Eclampsia (12%)
Obstructed labor (8%)12
VO: Almost 75% of maternal deaths are caused by direct complications as follows: hemorrhage (25%), infection (15%), unsafe abortion (13%), eclampsia (very high blood pressure leading to seizures) (12%), and obstructed labor (8%).
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Maternal Mortality Causes Globally
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VO: The direct causes of maternal mortality: Hemorrhage (35%); Hypertension (18%); Sepsis (8%); Abortion (9%); Other Direct (12%); Indirect (18%).
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Maternal Mortality: Risk & Prevention
| Type | Details |
| Risks | Poverty No medical facilities for labor/delivery No skilled providers during delivery |
| Primary Prevention | Hygienic practices Safe, legal abortions Access to family planning services Early prenatal care Education |
| Secondary Prevention | Blood transfusions Anesthesia Education of traditional birth attendants |
| Tertiary Prevention | Rehabilitation of women who suffered complication Prevention of further pregnancies |
VO: Risks: poverty; no medical facilities for labor and delivery; no skilled health care providers available during delivery. Primary Prevention: hygienic practices; safe, legal abortions; access to family planning services; early prenatal care; education. Secondary Prevention: blood transfusions; anesthesia; education of traditional birth attendants. Tertiary Prevention: rehabilitation of women who have suffered complication; prevention of further pregnancies.
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Fertility & Childbirth
VO: Fertility and Childbirth.
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Impact of Reproductive Patterns
Impacts on children & risks for maternal mortality:
Parity
Maternal age
Short birth intervals
Unwanted pregnancy/birth
Poverty & nutrition
Cigarettes, alcohol & drugs
VO: Impact of reproductive patterns on the health of children and potential risks for maternal mortality as well: parity, maternal age, short birth intervals, unwanted pregnancy and birth, poverty, nutrition, cigarettes, alcohol, and drugs.
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Parity
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VO: Definition: “The condition of having carried pregnancy to a point of viability.” First births are more dangerous. Higher-orders births may suffer due to poor maternal health as a result of cumulative exposure to previous pregnancies.
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Maternal Age
Children born to:
Teen mothers die at higher rates than born to 25-35
Older mothers may suffer because of poorer health
VO: Children born to teenage mothers die at higher rates than children born to mothers aged 25-35. Children born to older mothers may suffer because of poorer maternal health.
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Short Birth Intervals
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VO: There is excess mortality risk of children born less than 24 months after the preceding birth. Why? First, maternal depletion. Premature cessation of breastfeeding. Competition from limited family resources. Transmission of infectious diseases, such as diarrhea and measles due to overcrowding. Emotional stress and depression.
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Unintended Fertility Consequences
| Type | Details |
| Abortions | “Safe” abortion performed by trained provider Proper equipment, technique & sanitary standards 70,000 women die from unsafe abortions annually Rates vary among regions |
| Infant health | Unintended pregnancies riskier for infant |
VO: Unintended pregnancies increase the lifetime risk of maternal mortality. Abortions (in particular unsafe abortion). A “safe” abortion is one performed by a trained healthcare provider, with proper equipment, technique, and sanitary standards. Estimates suggest that 70,000 women die from unsafe abortions every year. Rates of unsafe abortion vary among regions. Consequences for infant health: unintended pregnancies are riskier for infant.
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Human Capital Investment
Correlation between family size & health/ educational status
Older children suffer disproportionately:
Lower educational attainment
Health status
VO: There is an inverse correlation between family size and health status, as well as educational status. Older children, especially girls, suffer disproportionately in terms of lower educational attainment and health status as family size increases.
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Unsafe Abortion
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VO: Unsafe abortions, by region.
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Family Planning & Fertility
VO: Family Planning and Fertility.
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Total Fertility Rate (TFR)
# of children women bear if lived to end of reproductive period
Estimate of births a woman would have over lifetime
If adhere to age-specific fertility rates in population
2.1 referred as replacement fertility
e.g., Europe = TFR below 1.9
VO: Definition: “The number of children women would bear, on average, if they lived to the end of the reproductive period (the childbearing period). … It is an estimate of the number of births a woman in a particular society would have over her lifetime if she were to adhere to the current age-specific fertility rates in that population.” 2.1 usually referred as replacement fertility. For example, Europe equals TFR below 1.9.
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Total Fertility Rates Comparisons
| Country | TFR |
| Italy | 1.1 |
| Spain | 1.2 |
| Greece | 1.3 |
| Austria | 1.4 |
| Germany | 1.5 |
| Denmark | 1.6 |
| France | 1.7 |
| Britain | 1.7 |
| Ireland | 1.8 |
| Australia | 1.8 |
| Canada | 1.8 |
| USA | 2.1 |
| Brazil | 2.5 |
| Mexico | 2.7 |
| Philippines | 3.6 |
| Egypt | 3.8 |
| Iran | 5.9 |
| Saudi Arabia | 6.2 |
| Nigeria | 6.3 |
VO: A TFR or birth rate of 2.1 rate is needed for replacement. Below 2.1 means that, without immigration, the population of those countries will decline. Italy 1.1; Spain 1.2; Greece 1.3; Austria 1.4; Germany 1.5; Denmark 1.6; France 1.7; Britain 1.7; Ireland 1.8; Australia 1.8; Canada 1.8; USA 2.1; Brazil 2.5; Mexico 2.7; Philippines 3.6; Egypt 3.8; Iran 5.9; Saudi Arabia 6.2; Nigeria 6.3.
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Family Planning Programs
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VO: Control of fertility. By 1997, family planning services were found in 155 countries. Ideally it should include exams, pregnancy tests, discussions on alternative methods of contraception (with couples, families), logistics for clinic or home visits, and follow up.
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Family Planning Questions
Why need family planning?
Factors that affect family planning?
China one child policy: Possible in democratic society?
How does patriarchal ideology affect issues of family planning?
How has technology affected family planning?
How deal with abortion from a global perspective? What happens when abortion illegal in many countries?
VO: 1. To reduce maternal mortality and control population growth. 2. Cultural, religious, socio-economic, political issues. 3. Coercive: was it necessary. 4. The preference for boys. The desire to control women’s sexuality and reproduction. FGM, honor killings, and many other practices. Women are denied the right to contraceptives, to have a tubal ligation, etc. 5. Has made it possible for families to select babies by gender or other characteristics. Many have been able to postpone having kids, use in vitro fertilization, carry children for others, carry others’ children. 6. Do countries that do not believe in abortion have a right to tell other countries or coerce them into not having legal abortion?
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Breastfeeding
VO: Breastfeeding.
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UNICEF Estimate
1.5 million babies die each year worldwide because not breastfed
More effective way of improving maternal/infant health & lowering fertility than breastfeeding
VO: UNICEF estimates that 1.5 million babies die each year worldwide because they are not breastfed. There is no cheaper or more effective way of improving maternal and infant health and lowering fertility than the promotion of breastfeeding.
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Breastfeeding: Benefits for Child
| Benefits |
| Get: Sick less often Illnesses less severe |
| Hospitalized less often Lower rate of mortality |
| Lower risk: Diarrheal disease Urinary tract infections |
| Lower incidence: Gastrointestinal illness Allergies Respiratory disease SIDS Ear infections |
| Lower rates: Obesity Pneumonia, neonatal sepsis & giardia |
| Fewer learning/behavior difficulties |
VO: Breastfed babies: Get sick less often and get illnesses that are less severe; Are hospitalized less often and have a lower rate of mortality; Have a lower risk of diarrheal disease and urinary tract infections; Have a lower incidence of gastrointestinal illness, allergies, respiratory disease, sudden infant death syndrome (SIDS) and otitis media (ear infections); Have lower rates of obesity, and pneumonia, neonatal sepsis, and giardia; have fewer learning and behavior difficulties.
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Breastfeeding: Benefits for Mother
| Benefits |
| Bonds mother & child |
| Provides hormone-induced contentment |
| Encourages efficient uterine contractions after childbirth |
| Allows lose pregnancy weight/size faster |
| Is: Convenient Cost-effective/saves money Protective against cancer |
| Contributes to: Natural family planning Household food security |
| Fosters confidence/promotes self-esteem |
| Reduces: Urinary tract infections Osteoporosis |
| Lowers chronic hepatitis |
VO: Benefits for mother: Bonds mother and child; Provides the mother with a hormone-induced contentment; Encourages efficient uterine contractions after childbirth; Allows mothers to lose pregnancy weight and size faster; Is convenient (the milk is pre-warmed, clean and always available), cost-effective and saves families money, and protective against cancer (breast, ovarian, cervical); Contributes to natural family planning and household food security; Fosters confidence and promotes self-esteem; Reduces the incidence of urinary tract infections and the risk of osteoporosis; Lowers the incidence of chronic hepatitis.
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Breastfeeding: Benefits for Community
Results in less environmental waste/pollution
Frees up health resources
Saves money for hospitals/health clinics
May decrease spending on imports
VO: Benefits for community include results in less environmental waste and pollution, frees up health resources, saves money for hospitals and health clinics, and may decrease spending on imports.
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Health of Men vs. Women
Greater focus put on extent which gender discrimination affects women
19 conditions disproportionately affect women
Some:
Specific to women
Related to women’s higher life expectancy
Result of gender discrimination
VO: Greater focus has recently been put on the extent to which gender discrimination affects women’s health. 19 conditions disproportionately affect women: some are specific to women, some are related to women’s higher life expectancy, and some are a result of gender discrimination.
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Breastfeeding Questions
Why reproductive health focus primarily on women/children?
Issues of men’s reproductive health be included?
Reproductive health be more inclusive? Approached from family perspective?
Disparities of maternal mortality between developing vs. developed world? Factors that affect differences?
Need to have medical doctors attend all births?
Some barriers to prenatal care/assistance with birth in some cultures?
VO: 1. Physiologically speaking the burden is for women. From an outcome point of view, women and infants bear the burden of pregnancy much more directly than men. 2. Men also reproduce and when they are involved and know what to expect, they embrace the process more and the outcomes are better? 3. The entire family is affected by reproductive issues. For example, when a woman gets pregnant too close to another pregnancy, both the “outside baby” and the fetus are affected. Limited resources for the family. The more children the family has, the less likely they are to educate all of them or climb out of poverty. 4. Women die from pregnancy-related complications at much higher rates in developing questions from poverty-related issues. Malnutrition, lack of prenatal care, trained birth attendants, lack of blood transfusions, antibiotics, etc. In the West, women are waiting longer and longer to have children, many are overweight or obese when they do get pregnant. Some smoke, or drink alcohol during pregnancy which jeopardizes the health of the fetus. 5. No. Midwives, or even trained-birth attendants are quite effective in reducing maternal mortality?
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Module 2: Environmental Determinants
VO: Module 2: Environmental Determinants of Health Major Global Environmental Issues.
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World Health Organization (WHO)
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VO: Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations.
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Why Environmental Heath?
Water, sanitation & air pollution critically affect health
Environmental health issues major risk factors in global burden of disease
Reducing environmental risk factors critical to meeting SDGs
VO: Water, sanitation, and air pollution critically affect a population’s health. Environmental health issues are major risk factors in the global burden of disease. Reducing environmental risk factors is critical to meeting SDGs.
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How Environment Impacts Health
19
VO: How the environment impacts our health.
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Environmental Risk Transition (ERT)
Changes in environmental risks that happen as economic development in less developed regions
VO: The term Environmental Risk Transition characterizes changes in environmental risks that happen because of economic development in the less developed regions of the world.
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ERT: Before Transition
Struggles with inadequate food, air & water quality
Diarrhea: poor water, sanitation & hygiene
Asthma: poor housing & indoor air pollution
Malaria: poor housing quality
Malnutrition
VO: During development, societies tend to push off environmental problems from local to global scales. Household hazards dominate in the poorest parts of the world as those countries struggles with inadequate food, poor air and water quality leading to widespread diarrhea, asthma, malaria, and malnutrition. During the transition, as countries reach middle income status through industrialization, environmental risks shifts towards industrial and vehicular pollution.
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ERT: After Transition
Household risks brought under control
Society more developed causing new set of problems:
Acid rain precursors
Ozone-depleting chemicals
Greenhouse gases
VO: After the transition, problems of household risks are brought under control and community risks from industrial and vehicular pollution starts to diminish, but then a new type of risk emerge at the global level in the form of increasing level of greenhouse gas. Such global risks are shared by all countries since of its global nature.
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ERT Curve
20
VO: The environmental risk transition curves shown here should not be considered fixed in the sense that today’s developing nations will be forced to go through them in the same way that today’s industrialized countries have done in the past to reach where they are. Rather, the curves should be viewed as a management framework by which to judge the progress of development policy. The task in developing countries is to avoid the excesses of the past, to continue to push down the household curve, and to not let the community curve rise out of hand. This might be considered a kind of “tunneling” through the curves to avoid climbing over the peaks by applying cleaner, more efficient energy supply and use technologies earlier in the development process than has occurred to date.
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Reduced Mortality
Historical causes:
Improved:
Sanitation
Nutrition
Work environments
Less number of children
VO: Historical causes of reduced mortality: improved sanitation, improved nutrition, improved work environments, and lower number of children.
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U.S. Life Expectancy
Since 1900:
Increased from 47 to 78.9
Due to reduced mortality from infectious diseases
VO: Since the year 1900, average U.S. life expectancy increased from 47 to 78.9 years mostly due to the greatly reduce mortality from infectious diseases.
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Module 2 Question 1
Developing countries suffer more problems associated with environmental degradation than developed countries?
VO: Why do developing countries suffer far more problems associated with environmental degradation than do developed countries?
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Climate Change: Health Impacts
VO: Health Impacts of Climate Change.
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Climate Change Threatens Public Health
One serious public health threats of 21st century
VO: Climate change is one of the most serious public health threats of the 21st century.
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Public Health Professionals
Advocating for action
Engaging in prevention/preparedness efforts
Conducting surveillance/research on climate change & health
Educating public health professionals
Control/prevention of diseases
VO: Public health professionals will be involved in such aspects as advocating for action, engaging in health prevention and preparedness efforts, conducting surveillance and research on climate change and health, educating public health professionals, and control and prevention of diseases.
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A Warming World: Ten Indicators
21
VO: After observing and making lots of measurements, using lots of satellites and special instruments, scientists see some alarming changes. These changes are happening fast—much faster than these kinds of changes have happened in Earth's long past.
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Climate Change Evidence
| Observations | Details |
| Global temperature | Increasing |
| Glaciers | Retreating Sea ice (Northern Hemisphere) shrinking Freezing seasons of lake/river ice shorter |
| Sea level | Rising |
| Extreme rainfall | Leading to more floods Eastern North/South America Northern Europe Northern/central Asia |
| Droughts | Increasing Sahel, Mediterranean, southern Africa & parts of southern Asia |
| Heat waves | Increasing |
| Wildfire | Increasing |
VO: Observations over recent decades show: Global temperature is increasing; Glaciers are retreating, sea ice (in the Northern Hemisphere) is shrinking, freezing seasons of lake and river ice are shorter; Sea level is rising; More extreme rainfall events leading to more floods (eastern part of North and South America, northern Europe, northern and central Asia); Droughts are also increasing (Sahel, Mediterranean, southern Africa, and parts of southern Asia); Heat waves are increasing; and wildfires are increasing.
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Sea Level Rise: Threatens Costal Areas/Low-Lying Islands
VO: Sea Level Rise: Threatens Costal Areas/Low-Lying Islands.
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Sea Level Rise
Increase in global mean sea level
Increase in volume of water in oceans
VO: A sea level rise is an increase in global mean sea level as a result of an increase in the volume of water in the world’s oceans.
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A Warming World
Sea Gauge Records
Satellite Data
22
VO: 1993-2020 ≈ 95 mm = 3.3 mm/year (satellite data source). As compared to 1910-1990 = 1.5±0.5 mm/year (sea gauge records).
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Current Sea Level Rise
23
VO: Contribution by source to global mean sea level rise (expressed in month/year). This chart is from the IPCC.
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Projected Sea Level Rise
24
VO: Figure from IPCC illustrating global mean sea level rise projected until year 2100 by utilizing different IPPCC scenarios (RCP2.6 to RCP 8.5).
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Potential Sea Level Rise
25
VO: The potential sea level rise from various components of the cryosphere under the scenario of 100% melting of ice.
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Cryosphere
Ice mass & heat capacity
2nd largest component of climate system after oceans
Due to reduced mortality from infectious diseases
VO: In terms of ice mass and heat capacity, cryosphere (snow, river and lake ice, sea ice, glaciers and ice caps, ice shelves, ice sheets, and frozen ground) is the second largest component of the climate system after oceans.
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Cryosphere Storage
Land: stores 75% of freshwater
Ice sheets melt:
Greenland (7 m)
Antarctic (58 m)
VO: Cryosphere on land stores 75% of the world’s freshwater. Greenland Ice sheets melt: 7 meters sea level rise. Antarctic Ice sheets melt: 58 meters sea level rise.
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Global Temperature Rise
VO: Global Temperature Rise.
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Global Temperature Increase
26
VO: Global temperature increase since pre-industrial time (1884) until 2017.
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Warming Trend
27
VO: The warming trend has been continuing with 2016 the hottest year in the 125-year instrumental record. The last 50 years appear to have been the warmest half century in 6,000 years (ice cores).
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Global Estimates (Land/Ocean)
28
VO: 1880-2018: global annual mean temperature increase averaged over land and ocean.
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Surface Temperature Projection
29
VO: Global average surface temperature to 2100.
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Global Temperature Change Impacts
30
VO: The possible changes would be many negative impacts on the earth system. There would be potential risk of abrupt and major irreversible changes of large-scale shifts in the earth climate system. Extreme weather events such as rising intensity of storms, forest fires, droughts, flooding, and heat waves could potentially impact many regions around the globe. The whole earth ecosystem would face a rising number of all kinds of species extinction. As the land-based ice melting and ocean thermal expansion occur, sea level rises. The flooding and disappearance of ice alone could impact many species and habitats, but these are the two of many potential, negative impacts on the earth system that we could potentially face with the global temperature increase between 2-3 degrees Celsius from pre-industrial time. Small mountain glaciers disappear, and water supplies threatened in several areas. Significant decreases in water availability in many areas, including Mediterranean and Southern Africa. Sea level rise threatens major cities. In a hypothetical scenario sea level will rise to 64 meter and New York City would be literally halfway under that depth of the ocean. The global food production would be impacted. Some high latitude regions could have high yields, and there would be falling crop yields in many areas, especially in developing regions.
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Climate Change: Impacts on Health
31
VO: The pathways by which climate change and other drivers can affect human health. Climate change will act through regional weather changes to affect health directly (temperature-related illness and death; and extreme weather-related health effects) and indirectly (air pollution-related health effects; water- and food-borne diseases; vector- and rodent-borne diseases; and mental, nutritional, infectious, and other health effects). The extent to which health impacts will be realized depends on the effectiveness of adaptation measures and on modulating influences (other drivers of health outcomes, such as population density in regions vulnerable to flooding). So, what does that mean? Increases in temperature, changes in disease vectors, reduced crop yields, etc. are the proximate “downstream” causes of the adverse health effects of climate change, which include heat related illness, the effects of extreme weather events, respiratory and other air pollution-related disease, increases in vector, water and food-borne diseases, malnutrition, and physical and mental trauma due to civil conflicts and displacement. The upstream cause of these adverse health outcomes is largely our propensity to pump greenhouse gas emissions into the environment. That means that if we want to focus on primary prevention and the upstream determinants of adverse health effects of climate change,, we need to be looking at the role of public health in advancing the implementation of climate change mitigation strategies. Mitigation policies for reduction of greenhouse gas emissions include energy efficiency, use of renewable energy sources, and forest preservation. As professor emphasizes in our one of our class lecture slides, “the upstream cause of these adverse health outcomes is largely our propensity to pump greenhouse gas emissions into the environment.” He further stated: “that means that if we want to focus on primary prevention and the upstream determinants of adverse health effects of climate change, we need to be looking at the role of public health in advancing the implementation of climate change mitigation strategies.” In one of the few studies to examine the sectoral effects of mitigation policies across countries, Meyer and Lutz (2002), using the COMPASS model, carried out a simulation of the effects of carbon taxes or the G7 countries, which include some of the biggest energy users. The authors assumed the introduction of a carbon tax of $1 per ton of CO2 in 2001 in all of these countries, rising linearly to $10 in 2010, with revenues used to lower social security contributions. […] Moderating influences. Moderating influences include non-climate factors that affect climate related health outcomes, such as population growth and demographic change, standards of living, access to health care, and public health infrastructure. Population density and growth need to be in balance. This is easier said than done, but any actions for positive influences would be better than the status quo. Technological development could be used to improve health and environment in many ways. Adaptation measures. Adaption measures include actions to reduce risks of adverse health outcomes, such as vaccination programs, disease surveillance, monitoring, use of protective technologies, such as air conditioning, pesticides, water filtration and treatment, use of climate forecasts and development of weather warning systems, emergency management and disaster preparedness programs, and public education.
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Climate Change & Health
32
VO: Climate change and health: pathway from driving forces, through exposures to potential health impacts.
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Developing Countries Most Vulnerable
More flood/drought prone
Large share of economy in climate sensitive sectors
Lower capacity to adapt—lack of:
Financial, institutional & technological capacity
Access to knowledge
VO: Climate impacts are worse in developing countries: already more flood and drought prone; a large share of the economy is in climate sensitive sectors. Lower capacity to adapt because of a lack of financial, institutional, and technological capacity and access to knowledge.
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Climate Change: Disproportionate Impact
Impact poorest countries/ persons
Exacerbating inequities—health status
Access to adequate food, water & other resources
VO: Climate change is likely to impact disproportionately upon the poorest countries and the poorest persons within countries, exacerbating inequities in health status and access to adequate food, clean water, and other resources.
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Climate Impact: Human Health
33
VO: Specific examples of how climate change can affect human health, now and in the future. These effects could occur at local, regional, or national scales.
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Climate Impact: Human Health (2)
34
VO: Climate change impacts a wide-range of health outcomes. This slide illustrates the most significant climate change impacts (rising temperatures, more extreme weather, rising sea levels, and increasing carbon dioxide levels), their effect on exposures, and the subsequent health outcomes that can result from these changes in exposures.
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Climate Mitigation & Adaptation
35
VO: “In general, there are two different strategies when it comes to dealing with climate change. We can try to stop future warming (mitigation of climate change) or we can find ways to live in our warming world (adaptation to climate change). Adaptation involves developing ways to protect people and places by reducing their vulnerability to climate impacts. For example, to protect against sea level rise and increased flooding, communities might build seawalls or relocate buildings to higher ground. Mitigation involves attempts to slow the process of global climate change, usually by lowering the level of greenhouse gases in the atmosphere. Planting trees that absorb CO2 from the air and store it is an example of one such strategy. Of course, there is a third option: to do nothing. The triangle diagram … sums these options. It is from the IPCC Fourth Assessment Report (Chapter 18). The corners of the triangle represent 100% of each of these three options. Areas in the middle of the triangle represent a combination of approaches. There are costs associated with mitigation and adaptation. However, notice that with no action, we are facing a high cost associated with climate impacts because we will be ill prepared to deal with impacts. It’s quite unlikely that we will be able to clean up the extra greenhouse gases and halt climate change entirely through mitigation efforts. Thus, some adaptation will be necessary. Both adaptation and mitigation are essential to reduce the impacts of climate change. Strategies to mitigate and adapt to climate change range from an individual, to local, national, and global efforts. Adaptation happens in a variety of ways. Some adaptations are fueled by changes in government policies. Other adaptations occur because of technological advances. (And there are, of course, ways that we individually adapt (insulating the attic to keep cool during summer heat waves or raising and reinforcing a house in a hurricane-prone area). There are limits to how much we can adapt. There are often technological and financial limits that prevent the scale of adaptation that we would need. And often people are unwilling to change their behaviors. Plus, while humans may have the ability to adapt to climate change, many other species may not.”
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Paris Agreement
| Highlights | Details |
| Adoption | 2015 2016: Signed November 4, 2016: in force |
| Temperature/emission goals | Pathway to limit temperature rise below 20 Comparison with pre-industrial level Ultimate goal: -1.50 GHG emissions peaking soon as possible 2050: balanced by removals by sinks Net-zero goal Explicit role of forests Development of “negative emissions” technologies |
| Mitigation & adaptation | Now of equal importance |
| Adaptation | Establishes global goal: Enhancing adaptive capacity Strengthening resilience Reducing vulnerability |
VO: Adopted in 2015, signed in 2016, entered into force November 4, 2016. Temperature and emission goals: Provides a pathway forward to limit the temperature rise “well below 20” in comparison with the pre-industrial level, the ultimate goal -1.50. GHG emissions peaking “as soon as possible”, after 2050 should be balanced by removals by sinks (net-zero goal). Explicit role of forests and hopes for development of “negative emissions” technologies. Mitigation and adaptation are now of equal importance. Adaptation: Paris Agreement establishes a “global goal” on adaptation of “enhancing adaptive capacity, strengthening resilience and reducing vulnerability to climate change.”
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Water Sanitation & Hygiene (WaSH)
VO: Water Sanitation and Hygiene (WaSH).
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Unsafe Water
| Categories | Details |
| Drinking water services | 2.1 billion lacked access |
| Sanitation facility | 4.5 billion people lacked 800+ children die daily from diarrhea: Poor sanitation & hygiene Unsafe drinking water |
| WaSH | Water, Sanitation and Hygiene |
VO: According to WHO and UNICEF, by 2017, 2.1 billion people lacked access to safely managed drinking water services and 4.5 billion people lacked safely managed sanitation services. Unsafe hygiene practices are widespread, compounding the effects on people’s health. The impact on child mortality rates is devastating with more than 340,000 children under five who die annually from diarrheal diseases due to poor sanitation, poor hygiene, or unsafe drinking water—that is more than 800 deaths per day. WaSH is the acronym for “Water, Sanitation, and Hygiene.” Due to their interdependent nature, these three core issues are grouped together to represent a growing sector. While each a separate field of work, each is dependent on the presence of the other. For example, without toilets, water sources become contaminated; without clean water, basic hygiene practices are not possible.
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Drinking Water/Sanitation Facilities
36
VO: This table shows the various classification of Improved and Unimproved facility types. You want to make sure you can identify which ones are improved and which are unimproved sources. Water: A person without access to improved drinking water (for example: from a protected borehole well or municipal piped supply) is forced to rely on sources, such as surface water, unprotected and possibly contaminated wells, or vendors selling water of unverifiable source and quality. For many communities, water sources are usually far from their homes, and it typically falls to women and girls to spend much of their time and energy fetching water, a task which often exposes them to attack from men and even wild animals. Sanitation: Without improved sanitation—a facility that safely separates human waste from human contact—people have no choice but to use inadequate communal latrines or to practice open defecation. In the immediate environment, exposed fecal matter will be transferred back into people’s food and water resources, helping to spread serious diseases, such as, cholera. Beyond the community, the lack of effective waste disposal or sewage systems can contaminate ecosystems and contribute to disease pandemics. Hygiene: In some parts of the world there is little or no awareness of good hygiene practices and their role in reducing the spread of disease. However, it is often the case that even when people do have knowledge of good hygiene behavior, they lack the soap, safe water and washing facilities they need to make positive changes to protect themselves and their community.
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Improved vs. Unimproved Latrine
37
VO: The image on the left shows an improved latrine and the image on the right shows an unimproved hanging latrine.
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Water/Sanitation Facilities Classification
38
VO: This table provides definitions of the various classification of drinking water facilities.
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Safely Managed Drinking Water Services
39
VO: This chart depicts the proportion of population using safely managed drinking water sources in percentages all over the world in 2017. Improved drinking water is defined as a type of water source that, by nature of its construction or through active intervention, is likely to be protected from outside contamination, in particular from contamination with fecal matter. Based on the chart we can see that most of the world is already using improved drinking water sources. However, there is a large portion of Africa where the proportion is much lower. Drinking water supply and water safety: Globally, the inequalities between those having access to water living in an urban area or rural areas have decreased but large gaps remain. Eight out of ten people without access to safe drinking water live in rural areas and nearly half of them live in sub-Saharan Africa. The most deprived are still using untreated surface waters like lakes and rivers. Many of those deprived communities are located in remote hard to reach areas. Therefore, rural water supply will remain a challenge for many national governments and their development partners in the coming decade. Safety of drinking water is a growing concern in many parts of the world. Drinking water sources are increasingly under threat from contamination, which impacts on not only on the human health, but also on the economic, environmental, and social development of communities and nations. Threats to drinking water quality include unsafe handling and storage at the household: water drawn from safe sources may be contaminated by the time it reaches and is ultimately consumed in households. In addition to this, is the threat of contamination of water sources—both naturally occurring and from pollution. Water contaminated with arsenic and fluoride threaten the health of millions in certain countries; water that has been in contact with human feces is a major cause of disease, including diarrhea, which kills over 800 children a day. In some areas of the world, the availability of water is scarce. Poor governance, environmental degradation, over-extraction, and climate change are further diminishing already scarce freshwater resources. Using safe drinking water. The best way to address contamination of drinking water is by preventing it from happening in the first place. Water safety planning is an approach that helps communities and service providers understand and manage contamination risks, and it is increasingly being applied to new and rehabilitated water points. Water safety planning also helps to identify the necessary control measures communities can take to protect their water from becoming contaminated from such things as poorly constructed or located toilets. Well-constructed toilets help prevent the contamination of water supplies. Regular handwashing after defecation and before handling water minimizes the risk that dirty hands contaminate water used in the home. For these reasons, UNICEF stresses sanitation and hygiene promotion as an important line of defense for protecting drinking water from fecal contamination. Household water treatment (for example chlorination or filtration), along with improved water storage and handling, is another control measure to ensures safe water use inside the household and is supported by UNICEF.
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Safely Managed Sanitation Services
40
VO: What is sanitation? Sanitation is a comprehensive term, and it means more than just toilets. Sanitation can be understood as interventions that reduce human exposure to diseases by providing a clean environment in which to live. It involves both behaviors and facilities, which work together to form a hygienic environment. The chart above depicts the proportion of population using safely managed sanitation facilities in percentages all over the world in 2017. Improved sanitation includes connection to public sewers or septic systems, pour-flush latrines, pit latrines, and ventilated improved pit latrines which are an improved sanitation compared to unimproved facilities such as bucket latrines, public latrines, and open pit latrines (WHO). Based on the chart, we can see that most of North America, Europe, Australia, western parts of South America, and northern parts of Africa are using improved sanitation. On the other hand, we can see that most of sub-Saharan Africa and parts of South Asia still have less than 50% of the population living without improved sanitation facilities.
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Open Defecation
41
VO: Open defecation is when people go out in fields, forests, open bodies of water, or other open spaces rather than using a toilet. It is incredibly dangerous, as contact with human waste can cause diseases such as cholera, typhoid, hepatitis, polio, diarrhea, worm infestation and under nutrition. Every day, over 800 children under five die from diarrhea-related diseases. Currently, 1 in 7 people, or 946 million people, practice open defecation. Of those who do, 9 out of 10 live in rural areas. Globally, India has the largest number of people still defecating in the open: more than 564 million. One of the biggest challenges to ending open defecation is not just providing clean and safe toilets but changing the behavior of entire communities. In order to end open defecation, it is important to generate awareness, share information and to spur behavior change in an effort to bridge the gap between building toilets and their proper use.
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Progress by UN-Water
42
VO: UN-Water is the United Nations inter-agency coordination mechanism for freshwater related issues, including sanitation. The Sustainable Development Goals, a set of goals to guide global development to 2030, include a specific goal to “ensure the availability and sustainable management of water and sanitation for all.” References: World Water Development Report (WWDR) is the reference publication of the UN system on the status of the freshwater resources. This report is released annually to provide the most up to date and factual information of how water-related challenges are addressed around the world. The progress report of the WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation, and Hygiene presents the results of the global monitoring of progress towards access to safe drinking-water, and adequate sanitation and hygiene.
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Indoor & Outdoor Air Pollution
VO: Indoor and Outdoor Air Pollution.
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Global Air Pollution
43
VO: The research is an extension of the Global Burden of Disease study, an international collaboration led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington that systematically measured health and its risk factors, including air pollution levels, for 188 countries between 1990 and 2013. World Health Organization (WHO) air quality guidelines set daily particulate matter at 25 micrograms per cubic meter. While air pollution has decreased in most high-income countries in the past 20 years, global levels are up largely because of South Asia, Southeast Asia, and China. More than 85 per cent of the world’s population now lives in areas where the World Health Organization Air Quality Guideline is exceeded. Cardiovascular disease accounts for the majority of deaths from air pollution with additional impacts from lung cancer, chronic obstructive pulmonary disease (COPD) and respiratory infections. New research shows that more than 5.5 million people die prematurely every year due to household and outdoor air pollution. More than half of deaths occur in two of the world’s fastest growing economies, China and India. Power plants, industrial manufacturing, vehicle exhaust and burning coal and wood all release small particles into the air that are dangerous to a person’s health. Two countries account for 55% of the deaths caused by air pollution worldwide. About 1.6 million people died of air pollution in China and 1.4 million died in India in 2013. In China, burning coal is the biggest contributor to poor air quality. In India, a major contributor to poor air quality is the practice of burning wood, dung, and similar sources of biomass for cooking and heating. Millions of families, among the poorest in India, are regularly exposed to high levels of particulate matter in their own homes.
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Risk Factors for All-Cause Deaths
44
VO: According to the State of Global Air 2019 (3rd Edition) from Health Effects Institute, Air pollution (example: PM2.5, ozone, and household air pollution) is the fifth leading risk factor for mortality worldwide. Contributes to ~5 million deaths yearly; nearly 1 in every 10 deaths.
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Deaths by Socio-Demographics
45
VO: This graph compares the percentages of deaths attributable to household air pollution, ambient PM2.5, and ozone by socio-demographic index.
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Global Deaths Attributable to Air Pollution
46
VO: According to the 2017 global burden of disease study, reducing exposure to just ambient particulate matter air pollution can avert 60 million years of life lost (YLLs).
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Energy Ladder
47
VO: This diagram shows the concept of Energy Ladder.
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Clean Fuels vs. GDP per Capita
48
VO: Access to clean fuels for cooking versus GDP per capita (2000-2016).
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Unimproved Stoves Examples
49
VO: Stoves without chimneys. Three-stone stoves, mud stoves, etc. Poor combustion. Increased fuel use. Increased air pollution.
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Outdoor Air Quality
| Categories | Details |
| Coal burning | Major cause of air pollution 1952 London: Daily mortality 2x during 2-week period by burning China: Morbidity/mortality increasing India: Extra 15-205 mortality within urban population |
| Asthma | Increasing in industrialized countries for three decades |
| Air pollution | National/international in scope U.S. lives in urban areas Air pollution crosses local/state lines Even borders with Canada & Mexico Dusts from Asia in northeastern U.S. |
VO: Coal burning a major cause of air pollution. 1952: London daily mortality was doubled during a two-week period caused mainly by the industrial and household burning of coal. China where coal is still used, morbidity and mortality from coal use is increasing. India also relies on dirty coal. Indian average exposure may cause an extra 15-205 mortality within the urban population. Asthma has been increasing industrialized countries for three decades. Air pollution crosses borders. The problem of air pollution is national—even international—in scope. Most of the U.S. population lives in expanding urban areas where air pollution crosses local and state lines and, in some cases, crosses U.S. borders with Canada and Mexico. Dusts from Asia can end up in the northeastern part of the U.S.
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Reducing Burden of Disease
| Categories | Details |
| Air pollution | Outdoor: replace coal with alternative fuels Indoor: Improve stoves Switch to kerosene |
| Sanitation | Implement low-cost sanitation/behavior change |
| Water supply | Promote better hygiene Implement appropriate water systems |
| Hygiene | Enhance knowledge/practice of: Hygiene Hand washing |
VO: Outdoor air pollution: replace coal as a source of fuel with alternative fuels. Indoor air pollution: improve stoves and switch to kerosene. Sanitation: implement low-cost sanitation and behavior change. Water supply: promote better hygiene and implement appropriate water systems. Hygiene: enhance knowledge and practice of hygiene and hand washing.
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Module 3: Global Health Systems
VO: Module 3: An Introduction to Global Health Systems.
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Why Study Health Systems?
Health service provided through
Countries spend share of national income on
Individuals spend share of family income on
Many do not function as planned
Outcomes improved if improved
VO: Health services are provided to people through health systems. Countries spend an important share of national income on health systems. Individuals often spend a considerable share of family income on health. Many health systems do not function as planned. Health outcomes can be improved if effectiveness and efficiency of the health system is improved.
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What is a Health System?
Activities to promote, restore or maintain health
Organizations, institutions & resources to improve health
VO: A health system includes all the activities whose primary purpose is to promote, restore or maintain health (WHO, 2001). It is the sum total of all the organizations, institutions, and resources whose primary purpose is to improve health.
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Health System Needs
Staff, funds, information, supplies, transport, communications & overall guidance
Provide services responsive/financially fair
Treating people decently
VO: A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently.
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Range of Factors
Health system product of complex range of factors:
Historical patterns of development
Power of different interest groups
VO: Each country’s health system is the product of a complex range of factors, including historical patterns of development and the power of different interest groups.
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WHO on Health System
“A good health system delivers quality services to all people, when and where they need them.”
VO: “A good health system delivers quality services to all people, when and where they need them.”
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Health System Response to Population
Improving health
Defending against what threatens health
Providing equitable access to care
Possible to participate in decisions affecting health
VO: A well-functioning health system responds to population’s needs and expectations by: Improving health status of individuals, families, and communities; Defending the population against what threatens its health; Providing equitable access to people centered care; Making it possible for people to participate in decisions affecting their health and health system.
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Configuration of Services
Requires robust financing mechanism
Trained/adequately paid workforce
Reliable information to base decisions & policies
Facilities/logistics to deliver quality:
Medicines
Technologies59
VO: The exact configuration of services varies from country to country, but in all cases: Requires a robust financing mechanism; A well-trained and adequately paid workforce; Reliable information on which to base decisions and policies; Well-maintained facilities and logistics to deliver quality medicines and technologies.
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WHO: Health System Key Elements
Stewardship
Health Information Systems
Health Financing
Human Resources For Health
Essential Medical Products/Technologies
Service Delivery
VO: According to the WHO in 2010, key elements of a well-functioning health system include: 1/) Stewardship (Leadership and Governance); 2.) Health Information Systems; 3.) Health Financing; 4.) Human Resources for Health; 5.) Essential Medical Products and Technologies; and 6.) Service Delivery.
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1. Stewardship
| Categories | Details |
| Definition | Narrowly defined as governance Functions by governments to achieve policy objectives Strong sense of direction needed |
| Without leadership | Health systems not make efficient use of resources Subject to powerful forces/influences Poorly regulated systems become commercialized |
| Growing recognition | Governments must shape sound/efficient health systems Provide effective disease prevention/treatment to all No matter who/where live |
VO: Stewardship, sometimes more narrowly defined as governance, refers to the wide range of functions carried out by governments as they seek to achieve national health policy objectives. A strong sense of direction is needed. Without strong leadership, health systems do not make the most efficient use of their resources. Health systems are subject to powerful forces and influences. In poorly regulated systems, health care become commercialized. Overall, there is a growing recognition that to maintain and improve the health of the world’s people, governments. Must shape sound and efficient health systems that provide effective disease prevention and treatment to all women, men and children, no matter who they are or where they live.
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2. Health Information Systems
| Categories | Details |
| Challenges & performance information | Household surveys Civil registration systems Epidemiological surveillance Consumption/access to pharmaceuticals Cost of technology Quality of services provided |
| Institutional mechanisms | Monitoring/evaluation plan with core indicators/targets e.g., Healthy People 2020 Information accessible to all Communities, civil society, health professionals & politicians |
| Sound information | For accountability, resource allocation, program improvement & management decisions |
VO: Good information on health challenges and on performance of the health system are needed including household surveys, civil registration systems, epidemiological surveillance, consumption of and access to pharmaceuticals, cost of technology, and quality of services provided. Requires a variety of institutional mechanisms. National monitoring and evaluation plan that specifies core indicators with targets (e.g., Healthy People 2020). Information accessible to all involved, including communities, civil society, health professionals, and politicians. Accountability, resource allocation, program improvement and management decisions all rely on sound health information.
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3. Health Financing
| Categories | Details |
| Purpose | Ensure funding/financial incentives to guarantee all access to health care System to: Raise funds for health fairly Pool financial resources to share financial risks |
| Health Financing | Public: government administrated through taxes Indirect taxes e.g., Tobacco, beer & liquor Payroll taxes/social insurance premiums International financing e.g., World Bank Private: not government, for-profit or not-for-profit Direct household Employer Mixes of Financing Sources |
| World Bank | Largest international financier in low-/middle-income countries through two loans: Developing countries able to pay near-market interest rates Poorest countries (free of interest) |
VO: The purpose of health financing is to ensure that adequate funding is available, and the right financial incentives are in place to guarantee that all individuals have access to needed preventive and personal health care. A system to raise sufficient funds for health fairly. A system to pool financial resources across population groups to share financial risks. Health Financing. Public: government administrated and funded through taxes.
Indirect taxes, such as taxes on tobacco products, beer, and liquor. Payroll taxes or social insurance premiums. International financing: World Bank. Private: not government, for-profit or not-for-profit. Direct household. Employer. Mixes of Financing Sources. The largest single international financier of health services in low- and middle-income countries is the World Bank through two types of loans. First type for developing countries that are able to pay near-market interest rates. Second type for the poorest countries. These loans are free of interest.
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4. Human Resources For Health
| Categories | Details |
| Health workforce | Central to achieving health Improving recruitment, education & training Enhancing productivity/performance Improving retention |
| Requirements | Payment/incentives Regulatory mechanism Ensure system-wide deployment of workforce Work environments to foster success Mechanisms to ensure cooperation of stakeholders: Health worker Advisory groups Donor groups Private sector Professional associations Communities Consumers |
| Performance | Depends on knowledge, skills, motivation & distribution of people organizing/delivering services |
VO: Health workforce is central to achieving health: Improving recruitment, education, and training; Enhancing productivity and performance; And improving retention. Requires: Payment and incentives; Regulatory mechanism to ensure system-wide deployment of workforce in accordance with needs; Enabling work environments to foster success; Mechanisms to ensure cooperation of all stakeholders (health worker, advisory groups, donor groups, private sector, professional associations, communities, and consumers); The performance of health care systems depends on the knowledge, skills, motivation and distribution of the people responsible for organizing and delivering services.
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5. Essential Medical Products/Technologies
| Categories | Details |
| Medical products | 2nd largest component of most budgets After salaries Largest component: low- and middle-income countries |
| Needs | Affordable: Medicines Vaccines Diagnostics Health technologies Assured quality |
| Necessity | Availability, quality, efficacy, safety & rational use: Drugs Technology Effective health service delivery |
VO: Medical products are the second largest component of most health budgets (after salaries). The largest component in low- and middle-income countries. Need affordable essential medicines, vaccines, diagnostics, and health technologies of assured quality. The availability, quality, efficacy, safety and rational use of drugs and health technology are necessary for effective health service delivery.
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6. Service Delivery
| Categories | Details |
| Health services | Effective as services provide |
| Chief function | Deliver health services |
VO: Health systems are only as effective as the services they provide. Just as the principal objective of a health system is to improve people's health, the chief function the system needs to perform is to deliver health services.
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Other Elements
| Categories | Details |
| Knowledge | Fostering creation, sharing & effective application of knowledge vital |
| Research | How to develop/maintain systems towards universal coverage Research vital Access to healthcare/MDGs through research & use informing policies World Health Report 2012 first to discuss impact of health research60 Main point: Research helps decision-making processes within systems |
| Equity | Reducing health inequities important Human right Progressive realization will eliminate inequalities |
| Health & Development | Strengthening systems More equitable key strategies for: Fighting poverty Fostering development |
VO: Knowledge: Fostering environments that encourage creation, sharing, & effective application of knowledge is vital for a health system to function well. Research: There remain many unanswered questions about how to develop & maintain well-functioning health systems that progress towards universal coverage. Research in this area is vital. “The achievement of universal and equitable access to healthcare, of health-related Millennium Development Goals (MDGs), and of other health goals is more likely to be realized through research and the use of research in informing health policies. …The World Health Report 2012 is the first World Health Report to discuss the impact of health research.” Main point: Research helps with the decision-making processes within the health systems. Equity: Reducing health inequities is important because health is a fundamental human right, and its progressive realization will eliminate inequalities that result from differences in health status. Health and Development: Strengthening health systems and making them more equitable are key strategies for fighting poverty and fostering development.
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Classification Criteria
| Categories | Details |
| Financing methods | Tax Social or private insurance Out-of-pocket |
| Underlying political philosophies | Capitalist Socialist |
| Nature of state intervention | Cover whole population Or only poor |
| GNP levels | High Middle Low |
| Historical/cultural attributes | Industrialized Non-industrialized Transitional |
VO: Dominant methods of financing: Tax, social insurance, private insurance, out-of-pocket payment. Underlying political philosophies: Capitalist or socialist. The nature of state intervention: Cover the whole population or only the poor. The level of gross national product (GNP): High, middle, or low. Historical or cultural attributes: Industrialized, non-industrialized, transitional.
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Health Care Spending
50
VO: Health care spending as a percentage of GDP.
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Health Care System Performance
51
VO: Health care system performance compared to spending.
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Health System Comparisons
52
VO: Health system comparisons in OECD countries: per capita health expenditure and life expectancy.
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Life Expectancy
53
VO: A global comparison of countries: Life expectancy versus per capita health spending.
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Additional Updated Information on Health Expenditure
“National health accounts unit of the WHO recently launched a new website to disseminate selected data series and indicators on NHA along with related macroeconomic data it has gathered over 10 years on the Member States of the WHO.”65
VO: “National health accounts unit of the WHO recently launched a new website to disseminate selected data series and indicators on NHA along with related macroeconomic data it has gathered over 10 years on the Member States of the WHO.”
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Healthcare Models Summary
VO: This graphic illustrates Healthcare Models.
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Beveridge Model: “Socialized Medicine”
| Categories | Details |
| Creator | William H. Beveridge British economist Designed Britain’s health system |
| Countries | Britain Spain New Zealand Scandinavia Hong Kong Cuba |
| Characteristics | Provided by government through tax payments Government owns hospitals/clinics Most doctors government employees Low costs per capita since government controls covered benefits/payment |
VO: Named after William Beveridge, the daring social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge. Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.
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Bismarck Model
| Categories | Details |
| Creator | Prussian Chancellor Otto von Bismarck Invented welfare state 19th c.: unification of Germany |
| Characteristics | Uses insurance system Insurers: “sickness funds” Financed through payroll deduction Plans cover everybody/not make profit Doctors & hospitals tend to be private Tight regulation: government cost-control clout |
| Countries | France Germany Belgium Netherlands Japan Switzerland |
VO: Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system—the insurers are called “sickness funds”—usually financed jointly by employers and employees through payroll deduction. Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model—Germany has about 240 different funds—tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides. The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.
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National Health Insurance Model
| Categories | Details |
| Creator | Elements of Beveridge & Bismarck |
| Characteristics | Uses private-sector providers Payment: publicly run insurance program citizens pay into No marketing: No financial motive to deny claims No profit Single payer have market power to negotiate lower prices |
| Countries | Canada Taiwan South Korea |
VO: This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated. The classic NHI system is found in Canada, but some newly industrialized countries—Taiwan and South Korea, for example—have also adopted the NHI model.
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Out-of-Pocket Model
| Categories | Details |
| Characteristics | Developed/industrialized countries 40 of 200 countries have established systems Most too poor/disorganized to provide mass medical care Basic rule: rich get medical care, poor stay sick or die |
| Countries | Rural India Africa China South America |
VO: Only the developed, industrialized countries—perhaps 40 of the world’s 200 countries—have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die. In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease. In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat’s milk or childcare or whatever else they may have to give. If they have nothing, they don’t get medical care. These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we’re Britain or Cuba. For Americans over the age of 65 on Medicare, we’re Canada. For working Americans who get insurance on the job, we’re Germany. For the 15% of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital. The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.
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Patchwork Model
| Categories | Details |
| Creator | United States |
| Characteristics | Informal term Has elements of all four systems Treating veterans: Britain 65+ on Medicare: Canada Insurance on job: Germany Uninsured/underinsured: rural India |
| Recent systems | Affordable Care Act Obama Care |
VO: Country: United States. A little of this, a little of that. The patchwork model is an informal term, it is only for America, because the system has elements of all four systems in its fragmented national health care apparatus. When it comes to treating veterans, it’s Britain. For Americans over the age of 65 on Medicare, it’s Canada. For working Americans who get insurance on the job, it’s Germany. For the uninsured or underinsured, the U.S. is rural India with access to a doctor available if you can pay the bill out of pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital. Affordable Care Act or Obama Care.
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Public Funds Sources
Total: 45.5%
Medicare: 18.7%
Federal Medicaid: 8.8%
Other Federal: 5%
State Medicaid: 6%
Other state/local: 7%
VO: Public Funds: 45.5%; Medicare: 18.7%; Federal Medicaid: 8.8%; Other Federal: 5%; State Medicaid: 6%; Other State and Local: 7%.
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Private Funds Sources
Total: 54.5%
Private health insurance: 32.9%
Out-of-pocket payments: 17%
Other private payments: 4.6%
VO: Private Funds: 54.5%; Private health insurance: 32.9%; Out-of-pocket payments: 17%; Other private payments 4.6%.
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Sources
1Skolnik, R. (2012). Global Health 101 (2nd ed.). Burlington, MA: Jones & Bartlett Learning
2https://ourworldindata.org/gender-ratio
3https://www.psychologytoday.com/us/blog/how-we-do-it/201811/genital-mutilation-girls-and-women
4https://www.physiospot.com/wp-content/uploads/2015/02/fgm-infographic.jpeg
5https://wiki.ubc.ca/images/thumb/3/3d/FGM-infographic.jpg/450px-FGM-infographic.jpg
6https://www.worldvisionphilanthropy.org/hs-fs/hubfs/stories/21551-35.jpg_33312.jpg?width=350&name=21551-35.jpg_33312.jpg; https://upload.wikimedia.org/wikipedia/commons/thumb/c/c3/Campaign_road_sign_against_female_genital_mutilation_%28cropped%29_2.jpg/450px-Campaign_road_sign_against_female_genital_mutilation_%28cropped%29_2.jpg
7http://strive.lshtm.ac.uk/resources/global-and-regional-estimates-violence-against-women
8http://www.who.int/mediacentre/factsheets/fs239/en/
9http://www.bbc.co.uk/news/world-africa-13803556
10https://blogs.worldbank.org/sites/default/files/health/table1.png
12https://ourworldindata.org/maternal-mortality
13http://www.maternal-health.org/1/34/Causes_of_maternal_Mortality/
14http://news.bbc.co.uk/2/hi/health/213202.stm
15http://www.nzdl.org/gsdl/collect/fnl2.2/archives/HASH012f.dir/p015.gif
16Skolnik, R. (2012). Global Health 101 (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
17https://www.unfpa.org/news/three-things-you-need-know-about-contraceptives-and-covid-19
18https://www.who.int/about/who-we-are/publishing-policies/logo
20http://csud.ei.columbia.edu/files/2012/04/Week3_Health_McGranahan.pdf
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Sources (2)
21https://www.globalchange.gov/browse/multimedia/ten-indicators-warming-world
22https://climate.nasa.gov/vital-signs/sea-level/; https://climate.nasa.gov/vital-signs/sea-level/
23https://www.ipcc.ch/site/assets/uploads/2018/02/WG1AR5_Chapter13_FINAL.pdf
24https://www.ipcc.ch/site/assets/uploads/2018/02/WG1AR5_Chapter13_FINAL.pdf
25https://www.ipcc.ch/site/assets/uploads/2018/02/WG1AR5_Chapter04_FINAL.pdf
26https://climate.nasa.gov/news/2671/long-term-warming-trend-continued-in-2017-nasa-noaa/
27https://www.climatecentral.org/gallery/graphics/global-decades-of-warming
28https://data.giss.nasa.gov/gistemp/graphs_v3/
29https://ar5-syr.ipcc.ch/topic_summary.php
30https://public.wmo.int/en/resources/bulletin/water-security-changing-climate
31https://doi.org/10.1016/j.puhe.2006.01.002
32https://www.who.int/globalchange/summary/en/index12.html
33https://health2016.globalchange.gov/high/ClimateHealth2016_ExecSummary_Standalone.pdf
34https://www.cdc.gov/climateandhealth/effects/default.htm
35https://scied.ucar.edu/longcontent/climate-mitigation-and-adaptation
36https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
37https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
38https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
39https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
40https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
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Sources (3)
41https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
42https://www.who.int/water_sanitation_health/publications/jmp-2019-full-report.pdf
43http://www.healthdata.org/infographic/global-burden-air-pollution
44https://www.healtheffects.org/sites/default/files/SoGA-Figures-01.jpg
45https://www.stateofglobalair.org/resources?resource_category=archives#block-exposedformresources-all
46https://www.stateofglobalair.org/resources?resource_category=archives#block-exposedformresources-all
47Drawn by Professor Zohir Chowdhury.
49Photos by Professor Zohir Chowdhury.
52http://upload.wikimedia.org/wikipedia/commons/8/8b/Health_systems_comparison_OECD_2008.png
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