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The World Federation of Public Health
Associations A NEW GLOBAL HEALTH RISKS AND
CHANCES Ulrich Laaser WFPHA, President
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FROM INTERNATIONALISATION TO GLOBALISATION I. TH
E INDUSTRIALISATION OF EUROPE JAPAN IN THE
18TH AND 19TH CENTURY II. THE GREAT PANDEMICS
esp. CHOLERA IN THE 2ND HALF OF THE 19TH
CENTURY III. MANDATING OF LARGE INTERNATIONAL
ORGANISATIONS (WHO, WB, IMF) gt WW II IV. THE
GROWING INFLUENCE OF NGOs IN THE 21ST CENTURY
(e.g. MSF, WFPHA)
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GLOBAL FAILURES THREATENING OUR SPACESHIP
EARTH I. GLOBAL WARMING floods deserts
II. GLOBAL DIVIDES poverty hunger III.
GLOBAL SECURITY war terrorism IV. GLOBAL
INSTABILITY financial crises V. GLOBAL HEALTH
a human right for all
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GLOBAL DIVIDES
Inequalities in Health (D.R. Gwatkin et al. 2003) Inequalities in Health (D.R. Gwatkin et al. 2003) Inequalities in Health (D.R. Gwatkin et al. 2003) Inequalities in Health (D.R. Gwatkin et al. 2003) Inequalities in Health (D.R. Gwatkin et al. 2003)
Country Fertility Fertility Infant Mortality Infant Mortality
Poor Wealthy Poor Wealthy
Egypt 4.0 2.9 76 30
Mali 7.3 5.3 137 90
Nepal 5.3 2.3 86 53
Nicarag. 5.6 2.1 50 16
Peru 5.5 1.6 64 14
Uganda 8.5 4.1 106 60
Zambia 7.3 3.6 115 57
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YLL, YLD, and DALYs by Region, 2001 (Mathers CD
et al. 2006)
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Distribution of health workers by level of health
expenditure and burden of disease
Source Mullen F
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Migration
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Rural Urban Migration Alleviates e.g.
overpopulation, land shortages etc. of the rural
areas. But costs through increased poverty, the
rise of slum and squatter areas, extremely
unequal distribution of resources, overburdening
of the urban infrastructure and difficulties to
supply mega-cities with the necessary resources
such as air and water. Indeed, the urban poor
are the main group affected by an unequal
distribution of resources, and they have to live
in quarters characterized by the worst
environmental conditions like overcrowded slums
and squatter settlements close to polluting
industries or congested roads. Cornelius-Taylor
B, 2001
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GLOBAL SECURITY The modern concept of public
health, the New Public Health (Frenk J, 1993)
carries a great potential for healthy and
therefore less aggressive societies. Development
of the health systems has to contribute to peace,
since aggression, violence and warfare are among
the greatest risks for health and economic
welfare (Laaser et al. 2002).
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Estimated average annual military deaths in wars,
worldwide, by century (Garfield Neugut 2000)
Century Average Annual Military Deaths Average Annual Military Deaths per Million Population
17th century 9,500 19.0
18th century 15,000 18.8
19th century 13,000 10.8
20th century 458,000 183.2
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Military Spending Global military spending in
2008 came close to 1500 billion USD the largest
contributors being the United States with 48.5
and the European Union with 21.2, followed next
by China with 4.8. Neither does the ranking of
the top three US, EU, China changes if the
calculation is based on purchasing power parity
USD. However, expressed as of GDP the US were
at rank 27 in 2005 and China at rank 96 (2009),
whereas the highest ranks were occupied by oil
producing Arab countries and countries near
conflict zones (e.g. Oman with 11.4 or Armenia
with 6.5). The growth rate of global military
spending was 8.4 in 2007 and is forecasted to
reach 33.9 since 2007 in 2012
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Public expenditures per capita for selected
countries (USD, 1990)
COUNTRY For military (a) For health (b) Ratio a/b
Sudan 25 1 25.0
Ethiopia 16 1 16.0
Angola 114 8 14.3
Chad 10 1 10.0
Mozambique 9 2 4.5
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Comparative average US monthly spending for
military operations and ODA for social services
(As of 2003)

• Sources of basic data US Congressional Research
  Services OECD-DAC
• www.realityofaid.org

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The Skopje Declaration on Public Health, Peace
Human Rights In the fall of 2001 the
representatives of public health of South Eastern
Europe gathered a in Skopje, capital of
Macedonia, after a decade of civil war and ethnic
cleansing in the wake of the dissolution of
Yugoslavia, to engage the good offices of public
health in promoting peace, preventing violence
and contribute to the building of a more equal,
stable and democratic world. The declaration of
Skopje was later i.e. in 2003 adopted by the
World Federation of Public Health
Associations. http//www.wfpha.org/Archives/
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• The Skopje Declaration (continued)
• Beyond their immediate professional domains
  public health professionals can contribute by
• Analyzing the causal interrelationships of
  violent phenomena
• Curbing the determinants of armed conflicts and
  violence
• Training health professionals in analytical,
  preventive and interventive skills
• (Lever N, 2000)

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GLOBAL INSTABILITY (Resetting Global Aid) The
steep global gradient between rich Highly
Developed Countries (HDL) and the poor Least
Developed Countries (LDC) is well known. With a
few exceptions the low GDP per capita goes hand
in hand with limited access to food and water,
low housing standards, incomplete educational
coverage, high levels of (hidden) unemployment
and high emigration. Not surprisingly also
limited access to and low quality of health care
services and population health measured as
(healthy) life expectancy are running in
parallel.
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The Monterrey Consensus of 2002
We urge developed countries that have not done
so to make concrete efforts towards the target
of 0.7 of their GNP) as ODA to developing
countries (art. 42).
Donor country 2008 USD (billion) GNP
United States 26,0 0,2
Germany 13,9 0,4
Britain 11,4 0,4
France 11,0 0,4
In addition there are serious imbalances between
DAH and BoD (Ravishankar et al., 2009)
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The Fragmentation of global aid One of the
obvious reasons for imbalances is the extreme
fragmentation and therefore ineffectiveness of
international aid. East Timor 1 study/1000 as
compared to 1 physician/10.000 Vietnam 2 donor
visits/Working Day Tansania 1500 projects with
separate reporting oversight Globally 280
agencies, 242 multilateral funds, 24 Development
Banks, 40 UN Organisations, and 1000ds of NGOs
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The value of international aid The temptation
to accept international aid without conditions on
the side of the beneficiary often disrupts
national priorities. Loans e.g. of the World
Bank though at low interest rates put often an
underestimated burden on later years. Loans have
two sides Money is available now but has to be
repaid later. In addition the money goes via
expert fees and purchase of equipment mainly back
to the crediting countries.
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Funding channels of DAH ( share)
DONOR CATEGORY Last Decade (2000/1) ( 1990) Recent (2006/7)
UN Agencies 32.3 (1990) 14.0 (2007)
World Bank and regional banks 21.7 (2000) 07.2 (2007)
Aid through bilateral channels 27.1 (2001) 34.0 (2007)
Global Fund 08.3 (2007)
GAVI 04.2 (2007)
Bill Melinda Gates 03.9 (2007)
Funds channeled through NGOs 13.1 (1990) 24.9 (2006)
Ravishankar et al. 2009
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National coordination As has been outlined
already, specially in developing and transitional
societies coordinative capacities and competences
are limited vis a vis a complicated and time
consuming process of implementing international
and bilateral aid efficiently. In addition
international and even more bilateral aid very
often is disrupting coherent national development
plans and priorities.
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The Sector Wide Approach (SWAp) The national
coordination deficit became more known in the
nineties and proposals to cope with were
developed. One of the most promising - however
rarely implemented - concepts is the Sector-Wide
Approach. (Cassels 1997)
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THE MILLENIUM DEVELOPMENT GOALS We have been
moving too slowly to meet our goals The numbers
of people going hungry and living in extreme
poverty are much larger than they would have
been had progress continued uninterrupted (Ban
Ki-Moon 2009). In fact it is unlikely that the
other seven goals can be achieved sustainably if
poverty remains as widespread as it is today. A
closer look reveals in addition that the
improvements up to 2005 are grossly different
between continents.
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MDG 1, Target 1 Halve, between 1990 and 2015,
the proportion () of people whose income is less
than USD 1 a day (here 1.25 USD is used)DR
Developing Regions SSA Sub-Saharan Africa
Southern Asia SEA South Eastern Asia EA Eastern
Asia LA Latin America SEE South Eastern Europe
Region 1990 1999 2005 Target 2015
DR (all) 42 31 25 21
SSA 57 58 51 29
SA 49 42 39 25
SEA 39 35 19 20
EA 60 36 16 30
LA 11 11 8 6
SEE 0 2 1 0
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MDG 4 Reduce by two-thirds, between 1990 and
2015, the under-five mortality rate. MDG 5,
target 1 Reduce by three quarters the maternal
mortality ratioDR Developing Regions SSA
Sub-Saharan Africa
Region 1990 2005 2007 Target 2015
MDG 4
DR (all) 103 74 34
SSA 183 145 61
MDG 5
DR (all) 480 450 120
SSA 920 900 230
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A dim outlook for the MDGs achievement In
summarizing it can be said, that the health
related MDG targets for Goals 1, 4, 5 and 6 are
unlikely to be achieved in spite of some
sluggish progress made. Also it is obvious that
the economic growth of 4 in the developing
regions between 2000 and 2007 did not translate
directly into better population health. The low
correlations between growth and MDG achievements
show that growth is necessary, but not sufficient
for a sustainable MDG strategy. It has to be
complemented with the appropriate sectoral
policies (Bourguignon et al. 2008).
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GOOD GOVERNANCE AND A NEW GLOBAL HEALTH Health
systems have a broader scope since they
incorporate the population dimension inherent to
public health and all relevant social and
political determining factors (i.e. incl. global
factors). (Council of Europe, 2009)
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Ethical governance The main health systems in
Europe variations of Bismarckian social
insurance and the Beveridgean national health
service models rely on administrative,
financial and professional accountability. It is
taken for granted that health services, despite
the diversity of systems, should be based on
principles of universality, equity and
solidarity. Health and healthcare are not
ordinary commodities. They are seen as
public/social goods. There are several principles
that are more generally applied to the whole
range of public services and administration.
These include transparency or openness,
accountability, public participation,
effectiveness and efficiency, and quality and
safety.
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CONCLUSIONS I. To improve global health will
not become possible without a strong involvement
of the civil society. Already by now about 25 of
the DAH is channelled through NGOs and is on the
increase. However NGOs are not only accountable
to their clientele but should be to an open
society in general. Therefore a code of conduct
for NGOs is a first main recommendation and
demand.
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II. Unchecked demographic growth, poverty, the
burden of disease, and violent conflicts are
interconnected. The demand for basic needs like
shelter, clothing, provision of safe food and
water, access to adequate (primary) health
services and to education, and last not least
security in daily life for all populations does
not seem to be an extraordinary or unjustified
one. A renewed major effort of the UN community
therefore is to be initiated to achieve the MDGs
as planned. To simply continue as so far will
certainly not be enough!
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III. Resetting global aid has to become part of
such a renewed effort towards the MDGs. As of
today aid is highly fragmented, bilateral and
donor dominated with enormous transaction costs,
and not given according to priorities in the
recipient countries. It also frequently lacks
planned integration and coordination. In fact
most of the financial support is channelled back
to the donating countries (via dept repayment,
purchase of technical equipment and international
expert charges). The concept of sector wide
approaches (SWAp) has to be further developed and
made practical to put the receiving governments
into the drivers seat on the condition of
improved governance.
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IV. The migration towards Highly Developed
Countries - especially of qualified professionals
- cannot simply be stopped without violation of
basic human rights. However, there should be an
agreed mechanism to compensate the "sending"
countries for basic investments into upbringing
and education.
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V. Military conflicts and violence in many forms
are a major cause of mortality and morbidity and
of excessive waste of scarce resources. The
developments towards regional peaceful
cooperation in Europe, the Pacific region,in the
Americas and elsewhere, is to be enhanced.
Public health professionals can contribute by
1) analyzing the causal interrelationships of
violent phenomena at all levels of society, 2)
curbing the determinants of armed conflicts and
violence, and 3) training health professionals in
analytical, preventive and interventive skills.
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VI. The deficit of all good will proposals and
actions is a mechanism of enforcement at the
global level. However, a good global government
is still behind our horizon. Nevertheless a
global awareness in the sense of a New Global
Health is a first and essential step on this path
and a participatory approach is the only way open
to us.
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The Istanbul Declaration 2009 www.wfpha.org NOW
IS THE TIME To revive human values To renew
political will To change direction To
acknowledge Public Health as the first public
good To achieve global cooperation on global
health To unite the public health workforce