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Access to health Intergovernmental Panel on Climate Change (IPCC) 38 concludes that climate change can result in significant ecosystem disruptions and threatens substantial damage to the earth’s natural systems. In addition, several authors have argued that maintaining a certain level of biodiversity is necessary for the proper provision of ecosystem goods and services 39-42 . The Millennium Ecosystem Assessment warns that the ongoing degradation of ecosystem functions poses a growing health risk 43 . Several ecosystem functions are important to sustain our physical health. First, ecosystems provide us with basic human needs like food, clean air, and clean water. Second, they prevent the spread of diseases through biological control. Finally, ecosystems provide us with medical and genetic resources, which are necessary to prevent or cure diseases 44 . Globalization and proximal health determinants Figure 2 shows that the impact of globalization on each proximal health determinant is mediated by the abovediscussed changes in distal factors. The most important relationships will be discussed in more detail below. Health services Health services are increasingly influenced by globalizationinduced changes in health care policy, economic development and trade, and knowledge, but also by migration. Although WHO aims to assist governments to strengthen health services, government involvement in health care policies has been decreasing and, subsequently, medical institutions are more and more confronted with the neo-liberal economic model. According to Collins 45 , populations of transitional economies are no longer protected by a centralized health sector that provides universal access to everyone and some groups are even denied the most basic medical services. The increasing trade in health services also has some profound implications. Although it is perceived as improving the consumer’s choice, some developments are believed to have long-term dangers, such as establishing a two-tier health system, movement of health professionals from the public sector to the private sector, inequitable access to health care and the undermining of national health systems 9,11 . The illegal trading of drugs and the provision of access to controlled drugs via the Internet are potential health risks 46 . In addition, the globalization process can also result in a “brain-drain” in the health sector as a result of labour migration from developing to developed regions 47 . However, increased economic growth is generally believed to enhance improvements in health care. Increased (technological) knowledge resulting from the diffusion of information can further improve the treatment and prevention of diseases. Social environment One central mechanism that links the social environment to health is “social support”, the transfer from one person to another of instrumental, emotional and informational assistance 48 . Social networks and social integration are closely related to social support 49 and, as a result, globalization-induced changes in social cohesion, integration and interaction can influence the degree of social support in a population. Another important factor in the social environment is violence, which often is the result of the complex interplay of many factors. WHO 50 argues that globalization gives rise to obstacles as well as benefits for violence prevention. It induces changes in protective factors like social cohesion, Economics Global markets Globalization process Socio-cultural Global communication & diffusion of information global mobility cross-cultural interaction Institutional structures Global governance Health policy health-related policy Economic development trade Health services – Socioenvironmental lifestyle Population health Knowledge social interactions Physical living environment food & water Ecosystem goods and services Global environmental change Environmental Contextual determinants Distal determinants Proximal determinants Figure 2: Conceptual framework for globalization and population health 2 070 ✜ Global Forum Update on Research for Health Volume 4
Access to health knowledge and education levels, and global prevention activities. On the other hand, it also influences important risk factors associated with violence such as income inequality, collective conflict, and trade in alcohol, drugs or firearms. Lifestyle Due to the widespread flow of people, information and ideas, lifestyles also spread throughout the world. It is already widely acknowledged that several modern behavioural factors such as an unhealthy diet, physical inactivity, smoking, alcohol misuse and the use of illicit drugs are having a profound impact on human health 51-54 . Individuals respond to the range of healthy as well as unhealthy lifestyle options and choices available in a community 55 , which are in turn determined by global trade, economic development and social interactions. Although the major chronic diseases are not transmittable via an infectious agent, the behaviours that predispose to these diseases can be communicated by advertising, product marketing and social interactions 56 . Global trade and marketing developments drive, for example, unhealthy developments in diet 53,55 , tobacco use 53,57 , and alcohol consumption 58 . However, health education can play a role in promoting healthy lifestyles by improving an individual’s knowledge about the health effects of different lifestyle options. Besides health education, (global) policies can also directly discourage unhealthy behaviour by means of economic incentives (e.g. charging excise on tobacco) or other legislation. An effective implementation of WHO Framework Convention on Tobacco Control (FCTC) 59 is expected to have profound implications on tobacco related-policies and, hopefully, tobacco use. Physical living environment: infectious disease pathogens The spread of infectious diseases is probably one of the most mentioned health effects of globalization and past disease outbreaks have been linked to factors that are related to the globalization process (e.g. Newcomb 60 ). The SARS outbreak demonstrated the potential of new infectious diseases to spread rapidly in today’s world. The combination of movement of goods and people, and profound changes affecting ecosystem goods and services all contribute to increased risk of disease spread. For example, the globalization of food production, trade and consumption has been associated with the increased spread and transmission of food born diseases 61 . The global spread of knowledge and technologies, however, can improve the outbreak surveillance and monitoring of antibiotic resistance 21 , increasing the speed of responses in some cases. Wilson 28 states that responding to disease emergence requires a global perspective. Hence, the policies and actions undertaken by WHO are becoming increasingly important in controlling infectious diseases at a global level. For instance, WHO played a critical role in controlling SARS by means of global alerts, geographically specific travel advisories and monitoring 62 . Food Food trade has become an increasingly important factor with regard to food security worldwide. At present, however, the developed countries still subsidize their agricultural sectors, and tariffs for agricultural products remain relatively high. Economic liberalization policies are expected to have profound implications on food trade and, subsequently food security 63 . Some argue that free trade will create access to better and cheaper food supplies via food imports and can stimulate more efficient use of the world’s resources, as well as the production of food in regions that are more suitable to do so. Accelerated economic growth can also contribute to food security 63, 64 . According to The State Of Food Insecurity in the World 2005 65 , accelerating the progress towards an open and more equitable trading system is one of the key elements in the worldwide reduction in hunger. On the other hand, trade could also endanger food security (e.g. Lang 66 ). For many countries the increasing dependence increases their vulnerability to shocks arising in global markets, which can affect import capacity and access to food imports 63 . Many food insecure countries are not able to earn enough with exporting goods in order to pay for the needed food imports 67 . At the global level, there are increasing international efforts to achieve widespread food security. In 1996, the World Food Summit, for example, stressed the right of everyone to have access to safe and nutritious food. Globalization can also enhance the knowledge of foreign nations about the usefulness of food aid. Additionally, the globalization process can facilitate the worldwide implementation of better technologies and improved knowledge. At the same time, however, the natural resource base for food production is increasingly threatened by compromised ecosystem functioning due to global environmental change. Water Globalization also raises concerns over water security. The globalization process is accompanied by privatization policies affecting the provision of water. Governments and international financial institutions promote privatization, as they believe it will promote market competition and efficiency. Others are less optimistic about the effects of privatization. In fact, some cases show that prices and inequalities in access even rise 68 . The virtual trade of water is also believed to be of increasing importance, The water that is used in the production process of a commodity is called the “virtual water” contained in that commodity. Therefore, the increasing global trade of commodities is accompanied by an increasing trade in virtual water 69 . In addition, the globalization process can increase water security by facilitating the worldwide implementation of better technologies and improved knowledge. At the same time, the natural resource base is increasingly threatened as, for example, global climate change and deforestation profoundly affect our ecosystems’ ability to provide us with sufficient and adequate fresh water. On a global scale, there are increasing efforts to set up global guidelines or policies with regard to fresh water, however, none of the international declarations Global Forum Update on Research for Health Volume 4 ✜ 071
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Global Forum Update on Research for
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Editorial Advisory Board: Luis Gabr
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Contents 096 Child immunization: ac
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Introduction Research contributions
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Introduction Type I Type II Type II
Page 11 and 12: Introduction making), takes account
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Page 15 and 16: Access to health raising public awa
Page 17 and 18: Access to health Recent trends in r
Page 19 and 20: Access to health districts with a p
Page 21 and 22: Access to health Understanding heal
Page 23 and 24: Access to health This study investi
Page 25 and 26: Access to health References continu
Page 27 and 28: Access to health combining particip
Page 29 and 30: Access to health 2002 2005 Diff. SU
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Page 33 and 34: Access to health Americans think th
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Page 39 and 40: Access to health Open access to res
Page 41 and 42: Access to health References 1. Rose
Page 43 and 44: Access to health national and globa
Page 45 and 46: Access to health Senior Research Fe
Page 47 and 48: Access to health ✜ Rights alone a
Page 49 and 50: Access to health meaningful communi
Page 51 and 52: Access to health Inequality, margin
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Page 67 and 68: Innovation 076 Towards the developm
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Page 75 and 76: Innovation The changes in internati
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Research resources investigated the
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Research resources A new landscape
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Research resources 13 + 1*- HIV/AID
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Research resources international le
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Research resources Partnership dyna
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Research resources that many public
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Research resources compounds from m
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Research resources References 1. So
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Decision-making Delivering evidence
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Decision-making Equitable access: g
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Decision-making years’ experience
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Decision-making Policy-makers Compl
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Decision-making interview studies),
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Decision-making References 1. Haine
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Decision-making reviews in this fie
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Decision-making Inequities in healt
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Decision-making Deaths Crude death
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Decision-making Group I Group II Gr
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Decision-making Low- and middle-inc
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Decision-making Europe and Central
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Decision-making Europe and Central
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Decision-making References 1. Banni
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Decision-making irresponsible-to be
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Decision-making Several strategies
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To achieve better health, particula
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