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Global health: time for radical change?

What strategies should governments use to improve the health of their citizens? At the heart of the COVID-19 syndemic it is easy to focus on global health security – on a minimum, robust health and health care system. WHO is based on the global approach to health in three pillars: overall health coverage, health emergencies, and better health and well-being. The indispensable elements of stable public health and health care are well-known and endlessly practiced – a capable health worker; efficient, secure, and high quality delivery service; health information systems; access to essential medicines; adequate financing; and good governance. But does health care around the world seem too narrow? Are leaders and health advocates missing the most important determinants of human health?

The latest report of the Global Burden of Diseases, Injuries, and the Study of Risk Factors (GBD) 201
9 raises uncomfortable questions about the direction global health has taken in the 21st century. On the one hand, the news looks good. The health of the world’s population continues to improve. Worldwide birth rate rose from 67 · 2 years in 2000 to 73 · 5 years in 2019. Healthy life expectancy rose to 202 by 204 countries and territories. In 21 countries, healthy life expectancy at birth increased by more than 10 years between 1990 and 2019, with gains up to 19 · 1 year. The estimated number of deaths in children under 5 years of age has decreased from 9 · 6 million in 2000 to 5 million in 2019. In fact, the fall in the standardized age rates has changed the disability since 1990 was the biggest for communicative, maternal, neonatal, and nutritional disorders — and growth was the fastest in the last decade.

But GBD also revealed, once again, that health depends more on health systems. The strong correlation between health and the socio-demographic index – a summary measure of a country’s overall development based on average per capita income, educational attainment, and overall fertility rates – is suggests that the health sector should consider redefining the scope of concern.

GBD 2019 also offers a modified theory of demographic transition, which refers to seven separate stages. One particular change is the idea of ​​late-transition and post-transition stages, separated for transition status. 35 countries, mainly in sub-Saharan Africa and the Middle East, are in the middle of the transition, with falling birth and death rates (until 2019, no countries in the pre-transition stage). Countries such as Brazil, China, and the USA are in the final stages of transition, with the death rate plateau, while birth rates continue to fall. The final stage of the transition is when the birth rate is lower than the mortality rate and the natural population growth is negative – as seen in Japan, Italy, and Russia. An important and unnoticed influence on these demographic stages is the transition. The 17 countries, including Spain, Greece, and many countries in eastern Europe, are in “a dangerous state” – in the transition phase, including net transfers. Here, policies are needed to minimize the social and economic impacts of an increasingly inverted pyramid of population – encouraging immigration can be a way to help.

None of these arguments should suggest that the overall scope of health and global health security is unrelated to health. As the authors of GBD 2019 argue, some countries have longer life expectancy than their developmental stage predicts. These underdeveloped countries – such as Niger, Ethiopia, Portugal, and Spain – probably have superior public health and health care policies. GBD 2019 suggests that the global health community needs to rethink its vision. An exclusive focus on health care is a mistake. Health is created from a broader prospectus that includes quality education (primary to tertiary), economic growth, gender equality, and migration policy.

This conclusion is immediately related to the national strategy to address COVID-19. Although attention should be paid to controlling the transmission of the community to severe chronic respiratory syndrome coronavirus 2 and protecting the most vulnerable to its consequences, success will require a healthier approach. COVID-19 is a coronavirus infection syndicate accompanied by an epidemic of non-communicable diseases, both in contact with a social substrate of poverty and inequality. The GBD message is that unless the deeply embedded structural inequalities in society are recognized and unless a more liberal approach to immigration policies is adopted, communities will not be protected from future infectious outbreaks and the health of the population do not achieve the achievements sought by health advocates around the world. It is time for the global health community to change direction.
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