Global Health

Abdalla Abdi Yusuf

3-1-2024
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CHAPTER 1
INTRODUCTION
What is Global Health?
 An area for study, research, and practice improving health and achieving equity in
health for all people worldwide.
Emphasizes transnational health issues, determinants, and solutions Involves many
disciplines within and beyond the health sciences and promotes interdisciplinary
collaboration A synthesis of population-based prevention with individual-level clinical
care.
 Health problems, issues, and concerns that transcend national boundaries, which
may be influenced by circumstances or experiences in other countries, and which
are best addressed by cooperative actions and solutions (Institute Of Medicine,
USA- 1997)
Global Health
Can be thought of as
 A notion (the current state of global health)
 An objective (a world of healthy people, a condition of global health)
 A mix of scholarship, research, and practice (with many questions, issues, skills,
and competencies)
Global Health Issues
 Refers to any health issue that concerns many countries or is affected by
transnational determinants such as:
• Climate change
• Urbanisation
• Malnutrition – under or over nutrition
Or solutions such as:
• Polio eradication
• Containment of avian influenza
• Approaches to tobacco control
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What is Public Health?

The science and art of
 Preventing disease
 Prolonging life
 Promoting physical health and efficacy
Through organized community efforts for
 Sanitation of the environment
 Control of communicable infections
 Education of the individual in personal hygiene
 Organization of medical and nursing services
 Development of social machinery
Historical Development of Term
Public Health
 Emerged in the mid 19th century The discipline on the basis of four factors:
1. Decision making based on data and evidence (vital statistics, surveillance and
outbreak investigations, laboratory science)
2. A focus on populations rather than individuals
3. a goal of social justice and equity
4. An emphasis on prevention rather than curative care. All these elements are
embedded in most definitions of public health.
What is International Health?
 Defined by Merson, Black, and Mills as “The application of the principles of public
health to problems and challenges that affect low and middle-income countries and
to the complex array of global and local forces that influences them”.
 Developed during past decades, came to be more concerned with
o the diseases (e.g. tropical diseases) and
o conditions (war, natural disasters) of middle and low income countries.
o Tended to denote a one way flow of ‘good ideas’.

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Global Health: More recent in its origin and emphasises a greater scope of health
problems and solutions
o that transcend national boundaries
o requiring greater inter-disciplinary approach

Comparison: Global Health

Geographical reach: Focuses on issues that directly or indirectly affect health but
that can transcend national boundaries
Level of cooperation: Development and implementation of solutions often
requires global cooperation
Individuals or populations: Embraces both prevention in populations and clinical
care of individuals
Access to health: Health equity among nations and for all people is a major
objective
Range of disciplines: Highly interdisciplinary and multidisciplinary within and
beyond health sciences
Comparison: International Health
Geographical reach: Focuses on health issues of countries other than one’s own,
especially those of low-income and middle-income
Level of cooperation: Development and implementation of solutions usually
requires binational cooperation
Individuals or populations: Embraces both prevention in populations and clinical
care of individuals
Access to health: Seeks to help people of other nations
Range of disciplines: Embraces a few disciplines but has not emphasized
multidisciplinary
Comparison: Public Health
Geographical reach: Focuses on issues that affect the health of the population of
a particular community or country
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Level of cooperation: Development and implementation of solutions does not

usually require global cooperation
Individuals or populations: Mainly focused on prevention programmers for
populations
Access to health: Health equity within a nation or community is a major objective
Range of disciplines: Encourages multidisciplinary approaches, particularly
within health sciences and with social sciences.
Disciplines involved in Global Health
 Social sciences
 Behavioural sciences
 Law
 Economics
 History
 Engineering
 Biomedical sciences
 Environmental sciences
What is Globalization?
• An extremely complex phenomenon It is the interactive co-evolution of multiple
technological, cultural, economic, institutional, social and environmental trends at
all conceivable spatiotemporal scales.
• Important features of the globalization process:
– Global governance structures
– Global markets
– Global communication and diffusion of information
– Global mobility, cross-cultural interaction
– Global environmental changes
Global Health Governance
 The interrelationships among globalization, disease and global health governance
cannot be overemphasized.
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 In order to provide a clear understanding of the concept of global health governance,

the term “health governance” has to be appropriately defined.
 Health governance refers to strategies through which the health of a population is
promoted and protected, and it can exist at the local, national, regional, international
or global levels.
 Globalization has four major effects on health governance:
1) Increased globalization has brought about, or aggravated, transborder human
health risks, the origin and impact of which transcend national borders.
2) A unique effect of globalization on health governance is the steady increase in the
number, and influence of, non-state actors
3) Globalization, in its current form, more often than not, worsens existing
environmental, political and socio-economic problems.
4) Globalization is partly responsible for the decrease in the ability of national
governments to deal with challenges related to global health According to
literature,
 Global Health Governance (GHG) can be defined as strategies through which local,
national and international public and private entities strive to manage, regulate and
mitigate disease on a global scale.
 In this regard, the need for global health governance arises due to the fact that health
determinants are increasingly being destabilized by globalizing forces, not within the
scope of the health sector.
 Some of these forces include:
o climate or environmental change
o criminal activities and conflict
o as well as investment and trade.
 Therefore, to ensure human health is given a higher priority in public health policies,
GHG has increasingly garnered popularity as a vital concept in international debates.
 According to research, there is a relationship between global health and the global
system of disease; one which has not been adequately addressed. By and large, the
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global system of disease is often characterized by health indicators and disease

burden.

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CHAPTER 2
SOCIAL DETERMINANTS OF HEALTH AND HEALTHCARE DELIVERY

Framework of Social Determinants of Health

 Social determinants of health are the “conditions in the environments in which

people are born, live, learn, work, play, worship, and age that affect a wide range
of health, functioning, and quality-of-life outcomes and risks”.
 Furthermore, using a “place-based” framework, Social Determinants of Health
(SDOH) can be divided into five major parts, and these are presented in Figure 5.
Sub-divisions of these five parts are presented in Table 1.

Figure 2.1: Social determinants of health (Healthy People, 2017)

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Table 2.1: Social determinants of health and their sub-divisions (Healthy People,
2017; Heiman and Artiga, 2015)

S/N Social determinants of health Sub-division

(SDOH)

1 Economic stability • Employment

• Income
• Debt
• Support
• Poverty

2 Education • Early childhood education and development

• Enrolment in higher education •
Vocational training
• Language and literacy

3 Social and community context • Civic participation

• Discrimination
• Engagement in the community • Social
connection

4 Neighbourhood and built • Access to foods that support healthy

environment eating patterns
• Safety
• Environmental conditions
• Quality of housing
• Transportation

5 Health and healthcare • Access to healthcare

• Access to primary care

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• Health literacy
• Quality of healthcare

 Health impact assessments are increasingly being carried out to address the social
determinants of health as well as strategies which seek to close health gaps and
provide health services to more people.

Global Health and Healthcare Delivery

 First and foremost, to have a good grasp of the importance of global healthcare
delivery, it is important to understand what global healthcare means.
 According to literature, global healthcare is the subvention or supply of health
services to resource-deficit areas worldwide, which are provided with no or
inadequate health services.
 In their report on the global healthcare sector outlook, Deloitte projected that the
global healthcare expenditure ouldreach 8.7 trillion U.S. dollars by 2020. Besides,
the percentage of Gross Domestic Product (GDP) spent on healthcare was
projected to increase to 10.5 percent in 2020, a 0.1 percent increase from 2015.
Hence, low-income and emerging countries are expected to drive this growth.
 Some of the top issues in healthcare are:

 healthcare delivery
 operations,
 cost
 innovation
 and regulatory compliance.

 Global healthcare delivery can be defined as the conveyance of health services to

people with diseases for which a proven treatment is available.

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 In addition, it refers to the conscious effort to provide high-quality health services

to areas previously considered too remote or poor to utilize them. Health policies,
equity and justice also play a large role in expanding the reach of health services.
 Research suggests that one of the greatest problems being experienced by the global
health community is an “implementation bottleneck”.
 An implementation bottleneck means there exists a lack of appropriate delivery or
implementation methods for the healthcare resources injected into global health.
 In essence, availability of interventional health services is not the primary
constraint, but the delivery of these services to areas where they are needed the
most; mostly in developing countries.
 One of the evident reasons for this breakdown in health services provision when it
comes to delivery is the lack of appropriate infrastructure in areas where global
healthcare services are most needed.
 Three strategies have been identified as having the potential to alleviate the
problem posed by the implementation bottleneck and these are:

 Implementation research. This refers to studying successful implementation

models using the methods of global health research and building new
healthcare delivery system around them.
 The synergy between health systems and Global Health Initiatives (GHIs). This
entails the close monitoring of GHIs and existing health systems to ensure
health services delivery is cost-effective and efficient.
 Learning from successful business models. By doing this, those in charge of
global health delivery programming can understudy management strategies
used by companies in the private sector to successfully implement their
delivery

Core Competencies of Global Health

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 The essential skills in global health are a set of primary skills which professionals
should possess before indulging in the “practice, education and research of public
health”.
 these essential skills serve as a framework to improve health practitioners
professionally and better serve their communities.
 In essence, these core competencies or essential skills are needed by health
professionals for the adequate and appropriate delivery of healthcare services.
 The core competencies are divided into eight skill areas which address different
sections of global health. These eight essential skill areas are:

1. analytical skills

2. programme planning or policy development skills

3. management and financial planning skills

4. systematic thinking and leadership skills

5. public health sciences skills

6. cultural awareness or competency skills

7. communication skills

8. community health, oriented skills

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CHAPTER 3

PROMOTING HEALTHY BEHAVIOR

Behavior and Global Health

“Health is a state of complete physical, psychological, and social well-being and not
merely the absence of disease or infirmity.” (World Health Organization, 1948)

 Physical good health eludes billions of people

 Death and disease from preventable causes remain high

 Behavior is a key factor in determining health

Ten Leading Risk Factors for Preventable Disease

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1. High cholesterol
2. Indoor smoke from solid fuels
3. Iron deficiency
4. High body mass index or overweight
5. Maternal and child underweight
6. Unsafe sex
7. High blood pressure
8. Tobacco
9. Alcohol
10. Unsafe water, poor sanitation, and hygiene

Whose Behavior is Responsible for…?

• Maternal and child underweight

• Smoking and alcohol abuse

• Unsafe sex

• Unsafe water and lack of adequate sanitation

Maternal and Child Underweight

Maternal health
Health of women during pregnancy, childbirth and the postpartum period
Motherhood, for too many women it is associated with suffering, ill-health and death
Haemorrhage, infection, HBP, unsafe abortion and obstructed labour still are major direct
causes of maternal morbidity and mortality.
Maternal health care
Is a concept that encompasses family planning, preconception, prenatal, and postnatal
care.

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Goals of preconception care can include providing education, health promotion,

screening and interventions for women of reproductive age to reduce risk factors that
might affect future pregnancies.
Maternal health and developing countries.
Most women do not have a good Access to the health care and sexual health education
services.

A woman in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth,

compared to a 1 in 4,000 risk in a developing country – the largest difference between
poor and rich countries of any health indicator.

Maternal & child health

There are birth-related disabilities that affect many more women and go untreated like
injuries to pelvic muscles, organs or the spinal cord at least 20% of the burden of disease
in children below the age of 5 is related to poor maternal health and nutrition, as well as
quality of care at delivery and during the newborn period, yearly 8 million babies die
before or during delivery or in the first week of life Further, many children are tragically
left motherless each year. These children are 10 times more likely to die within two years
of their mothers' death.

Maternal and child health and disease

Maternal and child health and disease has multi-factor origin and can exist of sequential
and continuous form, bad Maternal conditions account for the fourth leading cause of
death for women after HIV/AIDS, malaria, and tuberculoses

Maternal death

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, Burden of maternal mortality is an important input to health decision-making.
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Burden of morbidity and mortality in maternal period.

• Global burden of disease in pregnancy woman (GBDPW) analysis provides a

comprehensive and comparable assessment of mortality and loss of health due to
pregnancy and its risk factors in all regions.

• Is assessed using the disability-adjusted life year (DALY), that combines years of
life lost due to premature mortality.

Smoking and Alcohol Abuse

 Individuals (choice)

• 75% of smokers live in low or middle income countries

• 1 billion smokers

• 5 million people die every year

Effective government policy

• Bans on tobacco advertising and sponsorship

• Regular price rises

• Stronger public health warning labels

• Smoking bans in all public places

Risk associated with smoking

• Lung cancer

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• Bronchitis

• Emphysema

• mouth cancer

• throat cancer

• bladder cancer

• esophageal cancer

• pancreas cancer

• kidney disease

• heart disease

• peptic ulcer disease

• allergies

• decreased immune system

• Alzheimer's disease

• decreased sperm count

• erectile dysfunction

• increase miscarriage and still born births

Unsafe Sex

 Unsafe or unprotected sex is sexual activity engaged in without precautions,

especially forgoing condom use.
 Safe sex is sexual activity engaged in by people who have taken precautions to
protect themselves against sexually transmitted infections (STIs) such as HIV.

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Unsafe sex is ranked second among the top ten risk factors to health in terms of
the burden of disease they cause. HIV/AIDS is the reason unsafe sex ranks so
high. Despite falling prevalence rates in some countries and advances made in
treatment and care, the global HIV/AIDS epidemic continues.

• Unsafe Water and Lack of Adequate Sanitation

A child’s well-being is highly dependent on both the quality and the availability of water,
and on how well this precious resource is managed.

Around the world or global, both biological disease agents and chemical pollutants are
compromising drinking-water quality. Contaminated water causes a range of diseases
which are often life-threatening. Of the waterborne diseases affecting children, the most
deadly are diarrhea infections. Childhood diarrhoea is closely associated with insufficient
water supply, inadequate sanitation, water contaminated with communicable disease
agents, and poor hygiene practices.

Risky behaviors translate to diseases

Global Causes of Death

1. No communicable diseases 60%

2. Communicable disease maternal and prenatal condition and nutritional
deficiencies 31%
3. Injuries 9%

Behavior change reduces risky behaviors

Behavior change is a central objective in public health interventions, with an increased

focus on prevention prior to onset of disease, This is particularly important in low and
middle income countries, where efficiency of health spending and costs and benefits of
health interventions has come under increased scrutiny in recent decades. Behavior

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change in public health is also known as Social and Behavior Change Communication
(SBCC).

Behavior change communication (BCC)

Behavior change communication, or BCC, is an approach to behavior change focused on

communication. It is also known as Social and Behavior Change Communication, or
SBCC. The assumptions is that through communication of some kind, individuals and
communities can somehow be persuaded to behave in ways that will make their lives
safer and healthier. BCC was first employed in HIV and TB prevention projects

Stages of change model

a. Pre contemplation
b. Maintenance
c. Action
d. Decision

Community Mobilization

Encompasses wider social and political contexts

Community members assess health risks, take action.

Encourages empowerment, building on cultural strengths and involving disenfranchised

groups

Organizational Stage Theory

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Define problem

Identify solutions

Initiate action

Allocate resources

Implement

Institutionalize
Organizational Development Theory

Organizational structures

Worker behavior and motivation

Communication channels

• Mass media (enhanced by listening groups, call-in opportunities, and face-to-face

approaches)

• Peers

• Respected leaders

Health Promotion
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Health Promotion Tools

 Mass media

 Social marketing

 Community mobilization

 Health education

 Client-provider interactions

 Policy communication

Behavior Change Successes

• Reducing malnutrition (micronutrient initiatives)

• Preventing malaria (insecticide-treated bednets)

• Helping children survive (breastfeeding)

• Improving maternal health (safe motherhood movement, emergency obstetric care)

• Making family planning a norm (worldwide efforts)

• Combating HIV/AIDS (Uganda program)

CHAPTER 4

GLOBAL HEALTH RISK

Introduction

Global Health problems, issues, and concerns that transcend national boundaries, which
may be influenced by circumstances or experiences in other countries, and which are best
addressed by cooperative actions and solutions (Institute Of Medicine, USA- 1997)
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Global Health Issues

 Refers to any health issue that concerns many countries or is affected by

transnational determinants such as:
 Climate change
 Urbanisation
 Malnutrition – under or over nutrition

Or solutions such as:

 Polio eradication
 Containment of avian influenza
 Approaches to tobacco control

Historical Development of Term

Public Health: Developed as a discipline in the mid 19th century in UK, Europe and US.
Concerned more with national issues.

 Data and evidence to support action, focus on populations, social justice and
equity, emphasis on preventions vs. cure.

Global Health: More recent in its origin and emphasises a greater scope of health
problems and solutions

 that transcend national boundaries

 requiring greater inter-disciplinary approach

International Health: Developed during past decades, came to be more concerned with

 the diseases (e.g. tropical diseases) and

 Conditions (war, natural disasters) of middle and low income countries.
 Umuqato Tended to denote a one way flow of ‘good ideas’.

Disciplines involved in Global Health

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 Social sciences

 Behavioural sciences

 Law

 Economics

 History

 Engineering

 Biomedical sciences

 Environmental sciences

Communicable Diseases and Risk Factors

 Infectious diseases are communicable

But...

 so are elements of western lifestyles:

 Dietary changes

 Lack of physical activity

 Ku tiirsan Reliance on automobile transport

 Smoking

 Stress

Key Concepts in Relation to Global Health

1. The determinants of health

2. The measurement of health status

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3. The importance of culture to health

4. The global burden of disease

5. The key risk factors for various health problems

6. The organisation and function of health systems

1. Determinants of Health

Genetic make up

Age

Gender

Lifestyle choices

Community influences

Income status

Geographical location

Culture

Environmental factors

Work conditions

Education

Access to health services

Determinants of Health

Plus more general factors such as:

 Political stability

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 Civil rights
 Environmental degradation
 Population growth/pressure
 Urbanisation
 Development of country of residence

Multi-sectoral Dimension of the Determinants of Health

 Malnutrition –
 more susceptible to disease and less likely to recover
 Cooking with wood and coal –
 lung diseases
 Poor sanitation –
 more intestinal infections
 Poor life circumstances –
 commercial sex work and STIs, HIV/AIDS
 Advertising tobacco and alcohol –
 addiction and related diseases
 Rapid growth in vehicular traffic often with untrained drivers on unsafe roads-
 road traffic accidents
2. The global burden of disease

 Predicted changes in burden of disease from communicable to non-communicable

between 2004 and 2030

 Reductions in malaria, diarrhoeal diseases, TB and HIV/AIDS

 Increase in cardiovascular deaths, COPD is a chronic inflammatory lung disease
that causes obstructed airflow from the lungs., road traffic accidents and diabetes
mellitus
 Ageing populations in middle and low income countries

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 Socioeconomic growth with increased car ownership

 Based on a ‘business as usual’ assumption malo

3. Key Risk Factors for Various Health Conditions

 Tobacco use –

 related to the top ten causes of mortality world wide

 Poor sanitation and access to clean water-

 related to high levels of diarrhoeal/water borne diseases

 Low condom use –

 HIV/AIDS, sexually transmitted infections

 Malnutrition –

 Under-nutrition (increased susceptibility to infectious diseases) and over-nutrition

responsible for cardiovascular diseases angina myocardial infraction stroke
hypertensive disease heart Failure rheumatic Heart disease cardiomyopathy
congenital heart disease, cancers, obesity etc.
4. The Organisation and Function of Health Systems

 A health system

 comprises all organizations, institutions and resources devoted to producing

actions whose primary intent is to improve health (WHO)

 Most national health systems consist:

 public, private,
 traditional and informal sectors:

Health patterns

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Genetic factors

Environmental factors

Lifestyle factors

Communicable vs. Non-communicable diseases

Health patterns in resource poor countries

 Infectious/communicable diseases prevalent:

 vaccine preventable diseases, e.g. Measles

 acute respiratory infections (ARI)

 diarrhoeal diseases (cholera)

 malaria

 Tuberculosis

 hepatitis

 HIV/AIDS

Plus:

 Malnutrition related conditions:

 Calorie deficiencies
 Micro-nutrient deficiencies

 Trauma/accidents

 Many of these diseases are treatable

Health patterns in resource rich countries

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NON-COMMUNICABLE DISEASES PREVALENT:

Causes of death (all ages):

 40% Circulatory diseases, e.g. heart disease, strokes, etc.

 25% Cancers
 16% Respiratory diseases
 5% Injuries and Poisonings
 0.6% Infectious disease
 Premature mortality (<65):
 25% Circulatory diseases
 33% Cancers
 16% Injuries (RTAs/Suicides) and Poisonings
 1% Infectious diseases

Factors affecting physical and mental health:

 Smoking – one third of cancer deaths related to smoking

 Drinking
 Healthy eating/nutrition
 Physical activity
 Substance abuse.

CHAPTER 5

GLOBAL BURDEN OF DISEASE

Health Indicators and Burden of Disease

 In general, health indicators can be defined as directly or indirectly measurable health
phenomena related to individuals or members of a defined population at the local,

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subregional, regional, continental or global scale, which can be used to report and
expantiate upon the quality and quantity of their health over time.
 According to literature, global health indicators which measure health phenomena,
directly and indirectly, can also be referred to as proximal and distal indicators,
respectively.
 The World Health Organization (WHO) grouped health indicators into four major
groups, each of which belongs to the communicable or non-communicable diseases
subdomain.
 The four health indicators groups are those relating to;
 health status
 risk factors
 service coverage
 and health systems.
Figure 1.1 to 1.4 provide more subdomains information of these groups.

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Figure 1.1: Health status indicators (World Health Organization, 2015)

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Figure 1.2: Risk factors indicators (World Health Organization, 2015)

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Figure 1.3: Service coverage indicators (World Health Organization, 2015)

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Figure 1.4: Health systems indicators (World Health Organization, 2015)

 Apart from health indicators, health can also be measured in terms of:
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 the incidence
 prevalence
 occurrence
 and disease burden.
 The proportion of the population that has a disease at a point in time (prevalence) and
the rate of occurrence of new disease during a period of time (incidence) are closely
related.
 The ubiquitous way through which the burden of disease can be measured is by
estimating the years ’lost’ as a result of poor health. This loss is referred to as
“Disability Adjusted Life Years (DALYs)”, and is the addition of years of “potential
life lost as a result of premature mortality and the years of productive life lost due to
disability”.

There are some 7 billion people in the world and hundreds of millions experience disease
or injury each year. Taken as a whole, the combined pain, suffering, loss of productivity
and unrealized hopes and dreams are our world’s burden of disease.

The burden of disease approach is a systematic, scientific effort to quantify the

comparative magnitude of health loss due to diseases, injuries, and risk factors by age,
sex, and geography for specific points in time.

The burden of disease can be thought of as a measurement of the gap between current
health status and an ideal situation where everyone lives into old age, free of disease and
disability.

“The purpose of the research into the global burden of disease was not only to
measure and describe the health of the world but also, and more important in many ways,
to explain why these events and phenomena have occurred.”

The Global Burden of Disease study, begun in 1992, involved 100 collaborators in
more than 20 countries. It attempted to quantify disease and injury burden of over 100
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conditions and make projections out 30 years for 500 consequences or results of these
conditions.

The Global Burden of Disease Study 2010 (GBD 2010) has three related but distinct
uses:

1. to provide a coherent picture of which diseases, injuries, and risk factors

contribute the most to health loss in a given population;

2. to compare population health across communities and over time;

3. and to help guide an assessment of where health information systems are

strong or weak by identifying which data sources are missing, are of low
quality, or are highly uncertain

Global Burden of Disease Surprises-2020

1. Rapid rise of chronic disease

 73% of GBD by 2020

2. High level mental illness

 3.7% of GBD – depression

3. Violence, war, injuries

 12% deaths worldwide

 41% deaths < 20 years, USA

4. Alcohol and Tobacco

 Tobacco #1 instigator
 Fastest gain, underdeveloped nations

5. Significant increase in cancer

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 Number 1 killer in many countries

Reasons to measure burden of disease

 Assign priorities between different public health problems.

 Compare strategies on a single public health problem in terms of impact.
 Choose health interventions that target different health problems with different
strategies.

Health risks

Although there are many possible definitions of “health risk”, it is defined here as “a
factor that raises the probability of adverse health outcomes”. The number of such factors
is countless.

Burden of disease and global risk factors

Five leading risk factors identified in this report (childhood underweight, unsafe sex,
alcohol use, unsafe water and sanitation, and high blood pressure) are responsible for one
quarter of all deaths in the world, and one fifth of all DALYs.

Burden of disease and global risk factors

The leading global risks for mortality in the world are:

 High blood pressure (responsible for 13% of deaths globally),

 Tobacco use (9%),
 High blood glucose (6%),
 Physical inactivity (6%), and
 Overweight and obesity (5%).

These risks are responsible for raising the risk of chronic diseases such as heart disease,
diabetes and cancers. They affect countries across all income groups: high, middle and
low.

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The leading global risks for burden of disease as measured in disability-adjusted life
years (DALYs) are:

 Underweight (6% of global DALYs) and

 Unsafe sex (5%), followed by
 Alcohol use (5%) and
 Unsafe water, sanitation and hygiene (4%).

Three of these risks particularly affect populations in low-income countries, especially in

the regions of South-East Asia and sub-Saharan Africa. The fourth risk – alcohol use –
shows a unique geographic and sex pattern, with its burden highest for men in Africa, in
middle-income countries in the Americas and in some high-income countries.

Life span vs. Health Span

 Lifespan
 Number of years lived
 Health Span
 Number of healthy years lived

We increasingly appreciate that disease and disability can significantly limit an

individual's productivity and happiness and radically alter individual, family and
community well being.

Examining “Lifespan” and “Health Span”

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Impact on: “Lifespan” “Health Span”

Cause % Total % Total

Deaths Disability

Malnutrition 11.7 15.9

Malnutrition is responsible for approximately 12% of total deaths worldwide, radically

altering global “lifespan,” but affects “health span” to an even greater degree,
contributing nearly 16% of the world’s total disability.

Four Key Drivers of Rapid Changes in Global Health Patterns

 Demographic transition – increasing population size, substantial increase in the

average age in most regions and falling death rates.
 Cause of death transition – fraction of deaths or years of life lost shifting from
communicable, maternal, neonatal and nutritional to non-communicable diseases
and injuries despite the HIV epidemic.
 Disability transition – steady shift to burden of disease from diseases that cause
disability but not substantial mortality.
 Risk transition – shift from risks related to poverty to behavioral risks.

The risk transition

As a country develops, the types of diseases that affect a population shift from primarily
infectious, such as diarrhea and pneumonia, to primarily non-communicable, diseases
such as cardiovascular disease and cancers. This shift is caused by:

 Improvements in medical care, which mean that children no longer die from easily
curable conditions such as diarrhea

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 The ageing of the population, because non-communicable diseases affect older

adults at the highest rates
 Public health interventions such as vaccinations and the provision of clean water
and sanitation, which reduce the incidence of infectious diseases.

Major risk factors

Changing Disease Burden

Expected to Decrease

 Lower respiratory infections

 Diarrheal disease
 Perinatal conditions
 Measles
 Congenital anomalies
 Malaria
 Malnutrition
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 Anemia

Expected to Increase

 Depression
 Heart disease
 Traffic accidents
 Chronic obstructions/
pulmonary disease
 War, violence, suicide
 HIV
 Lung cancer

Change in 20 leading causes of daly at global level, 2000 to 2011

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The Global Burden of Disease

“The burden of disease is the great oppressor, perhaps the single greatest cause of loss of
personal freedom. Now, more than any other time in human history, we can influence
this great oppressor with our actions. We have it within our power to improve the health
of people on the earth.”

DALY

 The disability-adjusted life year (DALY) is a measure of overall disease burden,

expressed as the number of years lost due to ill-health, disability or early death.

 DALY "extends the concept of potential years of life lost due to premature
death...to include equivalent years of 'healthy' life lost by virtue of being in states
of poor health or disability. In so doing, mortality and morbidity are combined
into a single, common metric.

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One

Disability Adjusted Life Year

“One year lost to poor health.”

 A DALY is a health outcome measure with two main components

 Quality of life reduced due to a disability
 Lifetime lost due to premature mortality

It is essential to understand what the DALY-concept measures and how it is constructed.

Burden is measured along two dimensions: time lived with disability and time lost due to
premature mortality.

DALYS due to living with disability

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Some basic Definitions

 Impairment: loss or abnormality of psychological, physiological, or anatomical

structure or function

 Disability: any restriction or lack of ability to perform an activity in the manner or

within the range considered normal.

 Handicap: disadvantage resulting from impairment or disability that limits or

prevents the fulfillment of a role that is normal (depending on age, sex, social, and
cultural factors).

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Disease Impairment Disability Handicap

Polio Paralyzed legs Inability to walk Unemployed

Mild mental
Brain injury Difficulty learning Social isolation
retardation

Industrialization and Urbanization

Dietary changes lead to:

 Higher levels of obesity, diabetes and heart disease.

 Smoking, high fat diets and poor exercise habits accompany industrialization and
urbanization.

Developed Nations:

 Resources to challenge harmful changes

Developing Nations:

 No resources to cope

NB: Poor people are often sick because they are poor, and sometimes poor people
are poor because they are sick.”

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