Barbara Parfitt, Flora Cornish & Linda Ferguson
Introduction 3 Global priorities for health 3 Millennium Development Goals 4 Global Burden of Disease 5 Health systems and the health care workforce 7 International organizations and development aid 8 Voluntary organizations 9 Foundations 9 Private industry 10 Government and inter-government agencies 11 International nursing organizations 13 Conclusions 13 Notes and References 14
Health, illness, and health care are global issues requiring global solutions. 'Globalization' is more than a cliché describing abstract economic and political processes. It also has a concrete impact on health and the provision of health care, and suggests that people everywhere are connected. An outbreak of severe acute respiratory syndrome in China is of concern not only to China's neighbors, but also to governments around the world. When a nurse emigrates from Kenya to take up a better paying job caring for the aged in the UK, it affects the workforce and delivery of services in both countries.
This chapter introduces the global priorities for health and health care, and the international organizations particularly nursing organizations - that coordinate the world community's response to health challenges. Rapid changes in such challenges mean that current tools and mechanisms for health promotion and care will not always be sufficient. High-quality and continuous nursing research is necessary to determine the best ways to promote health and deliver care.
Global priorities for health
Because health problems and health services vary greatly, international organizations and governments have sought to establish common goals and priorities. Such goals ensure that efforts by a wide range of health agencies are appropriately targeted to areas where they can have the greatest impact and that these efforts are coordinated. While there are various ways to establish global priorities, the two approaches discussed here are the Millennium Development Goals and Global Burden of Disease statistics. Priorities concern specific health conditions and the means of addressing them - for example, developing a health care workforce and putting research findings into practice.
Millennium Development Goals
These goals set the agenda for global development efforts from 2000 to 2015. The eight Millennium Development Goals (MDGs) (Box 1.1) were a product of the United Nations' Millennium Summit, which convened in September 2000 to address the role of the UN in the 21st century. Their purpose is to provide a clear framework for all stakeholders involved in pursuing development in developing countries. The goals shape efforts in every setting. Governments and international organizations, including the World Bank, the Organization for Economic Co-operation and Development, and the International Monetary Fund, use them to guide their policies and programs.
All of the MDGs have major implications for health issues, given that economic, social, natural, and political environments are powerful determinants of a population's health. Three of the MDGs - to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, and other diseases - are specifically related to health and to the work of nurses and midwives. Each is associated with a set of quantitative, time-bound targets to provide clear aims and allow monitoring of progress (Table 1.1).
Nurses and midwives have much to contribute to achieving the targets. When children die in developing countries, it is usually from preventable or easily treated conditions such as measles, diarrheal diseases, or malaria (United Nations 2006; World Health Organization [WHO] 2003b). Children in poor rural households suffer disproportionately. Nurses have an important role in vaccination because they increase parents' ability to protect children's health, make referrals when necessary, and provide care. A key way to prevent maternal deaths during delivery is to have a skilled attendant, such as a nurse, on hand (United Nations 2006). Nurses' health promotion skills are also crucial in reducing the incidence of HIV/AIDS, malaria, tuberculosis, and other infectious diseases.
To achieve the MDGs, corrective measures focus on public health and primary health care - namely, using well-established methods to prevent health problems. These are not high-tech, crisis interventions; rather, they are simple, community-based services delivered by a skilled health care worker. An appropriate system for distributing medicines and equipment, and an appropriate team to receive referrals when necessary, support these efforts.
Research is needed to determine how best to deliver optimal prevention and health care services using the limited resources available in developing countries. To support the emphasis on primary care and public health, such research should include studies of behaviour change, community participation, and mobilization, and the appropriate configuration of health service teams and community-based models of service delivery.
The MDGs were designed to advance development, as it is broadly understood, in low- and middle-income countries; health is not their primary focus. The health-related goals - child and maternal health, and communicable diseases - target areas in which huge discrepancies exist between developing and developed countries. Other health issues emerge when the topic is the Global Burden of Disease.
Global Burden of Disease
This term describes the biggest health problems around the world. National statistics are used to identify the most common causes of death and the major causes of disability in low, middle, and high-income countries, and to produce a composite measure of disability-adjusted life years (DALYs). DALYs are a gauge of the number of years of healthy life lost because of premature death and disability (Mathers & Loncar 2006). The measure reveals which diseases and risks cause the most problems. Table 1.2 lists, in descending order, the 10 leading causes of the Global Burden of Disease in 2001, the most recent year for which data have been analyzed.
The 10 leading causes include the communicable diseases that have recently been associated with developing countries (for example, diarrheal diseases and malaria) and the non-communicable, chronic conditions (sometimes called 'diseases of modernity,' including depressive disorders, heart disease, and chronic obstructive pulmonary disease [COPD]) that are more typically associated with affluent and aging populations in developed countries.
In wealthy countries, chronic conditions have the highest health priority and often are related to an aging population and lifestyle. In the UK and the USA, for example, top priorities are regular exercise, healthy eating, reducing tobacco and alcohol use, and support for good mental health. Much can be done to prevent lifestyle-related illness and disability, although health care expenditures have traditionally focused on treatment rather than prevention. To support nurses' efforts in this regard, a priority should be high-quality research on developing sound and appropriate approaches to health promotion.
However, wealthy countries are not the only ones with aging populations. Between 2000 and 2050, the number of people in the world who are aged 60 years or older will more than triple to 2 billion from 600 million; most of this increase is occurring in developing countries (WHO 2007a). Demographic changes such as these, and improvements in dealing with communicable disease, will have major impacts on the global burden of disease everywhere. Table 1.3 shows what the 10 leading causes of DALYs are projected to be in 2030.
As developing countries make progress against communicable diseases, they will also have to reorient health services to meet the needs of their aging populations to prevent or delay the onset of age-related conditions, and offer supportive, continuous management of chronic diseases (WHO 2007a). The global changes in demographics and health profiles will necessitate relevant, practice-focused research to establish the most effective ways of dealing with new challenges, such as chronic disease management in resource-poor settings.
Health systems and the health care workforce
Perhaps more important than individual diseases are the health systems and health care workforces necessary to respond to them effectively. Addressing workforce shortages was the focus of the World Health Organization's 2006 World Health Report, which estimated that in order to provide the essential interventions necessary to meet the health-related MDGs, the world needs 2.4 million more doctors, nurses, and midwives. The largest proportional shortfalls are in sub-Saharan Africa and in South and South-East Asia (WHO 2006).
Given the aging of populations and the pressures on health budgets globally, governments are looking for ways to deliver health care more efficiently. They are seeking to reduce costly hospital stays and to deal with health issues in homes and communities as much as possible. Thus, the worldwide focus is moving toward public health and primary care, with an emphasis on family health care programs rather than acute care (Crisp 2007). The favored training approach is to give health care workers the particular skills ('know how') they will need in the community, in contrast to today's primary competency ('know all'). It encourages training in the practice setting, learning from role models, and using problem-solving techniques (WHO 2006). But this approach also poses a danger: producing health care workers who have received inexpensive, low-level training when the developing world needs highly competent professionals who can take responsibility for a broad range of practice and adapt to changing circumstances.
National and international programs have often strived to involve communities in their own health-related decisions, a central concept in the Declaration of Alma-Ata issued 30 years ago at the International Conference on Primary Health Care (WHO 1978). The response to and success of engaging communities with local health care providers have been mixed, although there is evidence that this approach does instill positive and sustainable health behaviours. However, the meaning of 'community' and whether a community is truly participating in health efforts are matters of debate (Midgley et al. 1986).
One key problem for nations is the migration of health care workers. The World Health Report concluded that migration is largely due to the perception among workers of better financial prospects elsewhere. Others fear violence in their home country or see little or no opportunity for career advancement, further education, or satisfactory working conditions (WHO 2006).
The positive and negative impacts of migration are extensive (Kingma 2006). On the positive side, money that workers abroad send home can benefit the local economy. The Philippines, for example, invests in nurse education with the expectation that an oversupply of nurses will venture overseas and send money back to their families. In addition, health care workers may gain skills and expertise in a foreign country that ultimately could benefit their home country when they return. On the negative side, a country loses its investment in the education and preparation of health professionals when they remain abroad, and its own health services may suffer if there is a shortage of qualified workers.
Efforts to manage migration are targeted to both source countries and recipient countries. The former are advised to adjust training so it meets internal workforce needs first and to improve local pay and opportunities for career advancement. Recipient countries are encouraged to foster fair treatment of migrant workers, adopt responsible recruitment policies, and partially compensate source countries for their investment in health professional education (WHO 2006).
Finally, developing an appropriately skilled workforce of professionals for global health requires not only high-quality research on how best to accomplish this, but also mechanisms for sharing expertise in effective health care delivery and bringing research findings into practice. The latter is critical because '[a]pplying what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade' (Pang et al. 2006, p. 284). Effective measles vaccines, bed nets to prevent malaria, and regular physical activity are well-established ways to improve health, but their impact may be limited because implementation is not universal. Research that investigates the best way to turn health knowledge into effective, patient-centered, feasible, and sustainable health care practice is crucial.
Nurses have a major role in delivering services, given that they constitute 80% of the global health care workforce. But they could also play a major research role in innovations and evaluating processes that put knowledge to work. Key areas warranting nursing-related research are the link between education and effective practice, and the practical skills nurses must have to meet the world's health care needs. This research focus requires qualitative research training, beyond quantitative methodologies, because complex health situations in the real world require a broader perspective.
Nurse researchers with sound qualitative skills have an opportunity to inform both the policy and practice of international health development. Lorenz (2007) believes that researchers' current view of global health issues is at risk of becoming detached from daily realities, and suggests that sharing practical experience and success stories by means of critical incident reporting may be a good way to confront health challenges on the national and international levels.
Participating in research aimed at international health issues calls for an understanding of how organizations around the world contribute to that effort and of nurses' important role.
International organizations and development aid
International organizations have never been so important. In addition to providing financial aid, they help integrate services, promote health, and, through research and evaluation, foster expansion of the evidence base for health care practice.
However, coordination of global aid is becoming increasingly complex, largely because of the many organizations now involved in overseas projects. The average number of donor organizations per country rose to 32 in the 20012005 period from 12 in the 1960s. This has caused fragmentation of donor funding and delivery of health services, which may make it difficult for a country receiving aid to use it effectively. Many projects focus vertically on a single health issue, excluding other related and important issues (International Development Association 2007), or on a particular geographic area, such that surrounding areas do not benefit.
Organizations realize they are less likely to achieve desired outcomes if they work alone. Success in education, research, and improved health requires partnerships between developed and developing nations, between donor agencies and the governments receiving their assistance, and between organizations.
The many types of international organizations that contribute to health-related projects are described below.
Private voluntary organizations that support health development date back hundreds of years. For many centuries, religious organizations of all faiths have provided medical and nursing care to the needy and destitute through charitable offerings. Many secular organizations, motivated by humanistic and social concerns, sponsor philanthropic care programs.
Excerpted from Improving Health through Nursing Research by William L. Holzemer Copyright © 2009 by John Wiley & Sons, Ltd. Excerpted by permission.
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