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Globalization and health viewed from threeparts of the world Direct health effectsPerhaps the most important direct effect of globaliza- tion on health in Thailand is unequal access to medical Chitr Sitthi-amorn,1 Ratana Somrongthong,2 care by different social groups. The rise in imported sophisticated technologies has increased costs andnecessitated new training. An analysis made in 1996 In recent years Thailand’s economy has become found that the average cost of medical care per increasingly dependent on international forces (1).
admission was 1558 bahts for health cardholders With this exposure have come advances in health care (rural) and 9981 bahts for civil servants (privileged), a technology and improvements in living standards, as sixfold difference (10). If these facilities were treating well as increasing disparities between social groups similar diseases, explanations are needed for the huge (2) and exposure to health risks from other parts of variation. The economic gap might create demand unrelated to need and distort market competition. The Prior to 1997, when the economy was strong, organization of health service delivery was obscure, there was intense competition for a share of the and there were no rules governing the payment of health market. Resources were invested in specu- providers. Unequal access to care was reflected by lative markets with potential for large expansion.
unequal health status (2). Infant mortality in the Private hospital beds increased from 8066 in 1982 poorest regions was twice as high as in the richest ones.
to 21 297 in 1992 and 34 973 in 1996. The number of specialized doctors in private hospitals increased, environmental pollution. These include inadequate leading to shortages in the public sector (5). The treatment of raw sewage (for instance, in tourist areas), culture of free enterprise brought with it an and the notorious air pollution in Bangkok and other enlarged middle class, insurance coverage for big cities (11). Environmental degradation and disrup- hospitalization, tax incentives for private health tion of the ecosystem have led to frequent floods and care, heavy investment in advanced health technol- changes in disease vector behaviour. The construction ogy for private sector use, and an internal ‘‘brain of a dam in the North-eastern region, financed by a drain’’, at the expense of public health (5, 6).
loan from a development bank, has caused natural Aggressive promotion increased the demand for disasters affecting food production (12).
expensive imported medicines and procedures (7, Third, concerns about new infections and the 8). The cost of medical care for civil servants and resurgence of old ones have been on the rise.
state employees has quadrupled in the last seven International trade and travel are shaping the patterns years, reflecting the lack of adequate governance in of epidemics. The plague scare in India had world- the health care business sector (5, 9). Meanwhile wide reverberations. The nipah virus outbreak in the share of the underprivileged in the country’s Malaysia caused concerns in Thailand (13). Cholera overall wealth was decreasing (4). The slump of epidemics can inflict enormous costs on a country 1997, followed by devaluation of the baht, and and this results in attempts to hide them by calling the recession with its concomitant negative health disease ‘‘severe diarrhoea’’. The costs associated with impact, reflects the country’s overdependence on controlling HIV infection continue to rise. Fears of cheap labour and foreign investment, and conse- foot and mouth disease have affected meat con- quent inability to control and protect its own sumption. The control of new dangers of this kind will require global cooperation but many aspects ofcontrol have to be country-specific.
Fourth, globalization has brought with it 1 Dean, College of Public Health, Chulalongkorn University, 10th floor, unhealthy lifestyles. Health has been damaged by Institute Building 3, Soi Chulalongkorn 62, Phyathai Road, Patumwan, the promotion of fashionable drugs, foods and other Bangkok 10330, Thailand. Correspondence should be addressed tothis author.
consumer products such as tobacco, alcohol, 2 Academic staff, College of Public Health, Chulalongkorn University, melatonin and Viagra. Fifth and finally, globalization brings with it many concerns about health ethics. For 3 Associate Dean, College of Public Health, Chulalongkorn University, instance, the options for genetic manipulation and the patenting of the technologies will have direct and far-reaching effects on health and social well-being.
Bulletin of the World Health Organization, 2001, 79 (9) 3. Health research for development: the continuing challenge.
These direct effects are complemented by indirect Discussion paper for International Conference on Health Researchfor Development, Bangkok, 10–13 October 2000.
ones, which include the economic crisis in Asia.
4. Regional consultative process, Asia. Disscussion paper for Among many other things, it led to a rise in suicides, International Conference on Health Research for Development, malnutrition, abandoned children, low birth weight, and a rise in deaths from preventable diseases such as 5. Bureau of Policy and Plan, Ministry of Health. Health in acute respiratory infections, diphtheria and measles Thailand 1995–96. Bangkok, Veterans Press, 1997.
(14, 15). These adverse effects were partly due to 6. Chaudhary V. Chile’s economic boom fails to improve health decreased use of the health services (14). Increased care. British Medical Journal, 1992, 305: 1113.
7. Tangcharoensathien V, Supachutikul A. Compulsory health poverty and unemployment also led to rising rates of insurance development in Thailand. Paper presented at the crime, prostitution, migration and drug trafficking (16).
International Conference on Economics of Health Insurance in Lowand Middle-Income Countries, Antwerp, Belgium, January 1997.
8. Barnett A, Creese AL, Ayivor ECK. The economics of pharmaceutical policies in Ghana. International Journal of Health These brief notes may be enough to indicate the need for an active response to globalization, rather than 9. Barraclough S. The growth of corporate private hospitals in mere observation and speculation. In the first place, Malaysia: policy contradictions in health system pluralism.
the world needs a clearly recognized moral authority International Journal of Health Services, 1997, 27: 643–659.
to uphold the principle of equity in health and social 10. Supachutikul A. Situation analysis on health insurance and justice (17). This authority has to be translated into future development. Bangkok, Thailand Health Research norms and standards, accountability, measures for 11. Chretnut GL, Ostro BO, Vichit-Vadakan N. Transferability resolving conflicts and responding to emergencies, of air pollution control health benefits estimates from the United and a mandate to implement them. It needs to focus States to developing countries: evidence from the Bangkok on key aspects of globalization which have implica- Study. American Journal of Agricultural Economics, 1997, tions for health. These include international capital volatility, drug trafficking, migration, protection of 12. Pak Moon Dam: Pak Moon has a lot to teach the state.
the environment, disease surveillance, and the indifference of market forces to marginalization, 13. Nipah virus in Malaysia. Communicable Disease Control Network, Ministry of Public Health, Thailand, 10 April 2001 (http://www.cdcnet.moph.go.th/cdcweb/nipa.htm).
Next, the existing international institutions 14. Tae-Arruk P. Impact of economic crisis on health of the have to be reoriented. They have to re-examine their Thai people. Bangkok, Health System Research Institute, 2001.
specific contributions to the overall well-being of the 15. Choprapawon C, ed. Health situation of the Thai people.
world. To do this they need to give full recognition to Bangkok, Health System Research Institute, 2000.
the changing context in which they are now working, 16. Woodward A, Kawachi I. Why reduce health inequalities? Journal of Epidemiology and Community Health, 2000, and to the other actors involved. They must clearly define the roles of all concerned, and establish true 17. Berlinguer G. Health and equity as a primary global goal.
partnerships for equitable cooperation, free from the domination of particular countries and companies.
Finally, national institutions have to be reor- iented. They have to work out new partnershipsbetween civil society, industry, government and other actors. An important goal here is to empower thepublic and specific groups in society to make rational choices and to demand accountability from those entrusted with implementing them. Thailand hasbeen through a political transformation highlighted The British Prime Minister in his introduction to a by the drafting of a new constitution. Its current recent government White Paper said, ‘‘Globalization health reform effort focuses on harmonization of creates unprecedented new opportunities and risk’’ living standards, rights, environmental protection, and the White Paper goes on to state that ‘‘making globalization work for the world’s poor is a moralimperative and a first-order priority for the British Government’’ (1). At the highest level of govern- The document was written with partial support from ment, then, globalization, including its impact on health, is seen as a policy imperative, albeit outward-focused, helping to eliminate world poverty.
1. Sitthi-amorn K. Thailand economic crisis and challenges related to economic structure, politics and governance. Bangkok,Infinity Press, 1998.
2. Sitthi-amorn C, Janjaroen W. The bubble in Thailand’s health 1 Secretary, The Nuffield Trust, 59 New Cavendish Street, London care system; need for reform and major issues. In: Hung PM et al., eds. Efficient, equity-oriented strategies for health: internationalperspectives. Melbourne, McKellar Renown Press, 2000.
Bulletin of the World Health Organization, 2001, 79 (9) The Nuffield Trust, an independent charitable fellowships, seminars and conferences, has played a foundation established in 1940, was one of the leading role in bringing this about. Alongside others, organizations in the United Kingdom to ask at an it has raised the awareness of senior ministers, policy early stage — in the context of its programme on ‘‘the officials, community leaders, researchers and the changing role of the state and the machinery of Royal Colleges about these issues. It will continue government for health policy’’ — whether globaliza- with further research and policy analysis in areas such tion was extending to health and health care. In 1997 as those listed in the box. The Nuffield Trust and the the Secretary of the Trust addressed the Annual UK Partnership for Global Health are also keen to Meeting of the Association of Academic Health pursue the notion of an international award for Centers in Palm Springs on this subject, and in 1998 responsible globality by international public and the Trust supported a delegation drawn from theRoyal Colleges, the National Health Service, uni-versities, senior policy-makers, key opinion-leaders and mass media to attend a trilateral conference (UK,USA and Canada) in Washington DC. At the . The impact of globalization on the determinants of health conclusion of the meeting the UK participants sawthe need to stimulate UK and international action on . The impact of the UK (its trade, industries, academic and globalization and health because of the moral and research resources) on global health.
ethical imperatives for action rather than for primarily . Health as a foreign policy imperative in the UK. The likely effect of the UK 2001 budget announcement of the On returning to the UK, the group became the government’s intention to establish a Global Health Fund Steering Group for the ‘‘Global Health A Local Issue’’ with WHO and to introduce a new and special tax credit to policy review — an analysis with a view to action — help companies contribute to the relief of disease aroundthe world and provide an incentive to accelerate research which culminated in a national conference funded by on the killer diseases in the poorest countries. This was the Trust and held jointly with the Royal College of discussed at the G8 meeting in Genoa (July 2000) and Physicians on 31 January 2000. The framework incorporated in the communique´ (5), announcing the adopted was based on the work of Dr Kelley Lee. It establishment of a new global fund to fight HIV, AIDS and describes globalization as a process that is changing the nature of human interaction across many spheres, . Further integration of domestic and development policy particularly those of politics and institutions, econom- objectives for health. The formulation of a UK Global ics and trade, social and cultural life, and the Health Strategy, building on the government’s practice of environment and technology. It is changing the temporal, spatial and conceptual boundaries thatseparate individuals in society. During the programme private sector organizations through responsibility 14 seminars and workshops were held and 18 papers were presented (2), covering: health and the environ- Peter Hain, in his book The end of foreign policy (6) ment; economy, trade and aid; social and cultural sketches out a vision for new diplomacy to reflect factors; institutional and political issues; uncertainty interconnectedness and the new global interests that and global health risks; local perspectives of global have taken shape alongside more traditional national health; working with industry for global health; and ones. ‘‘Perhaps foreign ministries will be named development of a framework, including a practical Departments of Global Affairs as the concept of model for UK action on global health.
‘foreign’ becomes ever harder to define.’’ The task requires the specialized skills of all government following which a number of significant events have departments and the committed and innovative taken place: a UK Partnership for Global Health was involvement of nongovernment actors in business established; a web site and network contact was and civil society. ‘‘In the process we will see an end to established for those interested in the field to traditional foreign policy and the evolution of a new exchange contributions (3); members of the Partner- foreign policy based upon global linkages recognizing ship contributed to the UK Foresight Report, natural limits and embracing global responsibility: a particularly on trade and health (4); members of the foreign policy for a world in which there is no longer Partnership did the research for the UK White Paper on the implications of globalization for the health ofthe poor, women’s health and the caring professions; 1. Eliminating world poverty: making globalisation work for the poor.
and a Centre for Health, Environment and Climate London, Stationery Office, 2000 (White Paper on International Change was established at the London School of 2. www.nuffieldtrust.org.uk/health2/global.htm3. www.ukglobalhealth.org 4. www.foresight.gov.uk5. www.g8itali.it/_en/docs/XGKPT170.htm Globalization and health is now a priority area for 6. Hain P. The end of foreign policy. British interests, global government in the UK. The Nuffield Trust, through linkages and natural limits. London, Fabian Society, Green Alliance its network of influence and its programme of grants, and Royal Institute of International Affairs, 2001.
Bulletin of the World Health Organization, 2001, 79 (9) Taking advantage of this situation, the unregulatedprivate sector in Kerala opened many hospitals with high-tech equipment, thereby increasing the cost of health care. For example, in 1995, 22 out of the26 computerized tomography scan centres in the The Indian State of Kerala with a per capita income of state were in the private sector (6) and even the small around 1% of that of the wealthiest countries, has remainder in the public sector is decreasing now. The achieved good health comparable to theirs. For introduction of user charges in the public hospitals as example the infant mortality rate for Kerala in 2000 part of the reform process increased the out-of- was 14/1000 live births (1) compared with 7/1000 pocket expenses of those using public health for the USA (2). Life expectancy at birth was 76 years for women and 70 for men in Kerala; in the United Household health expenditure in Kerala has States these figures were 80 and 74 respectively (2).
increased over five times (517%) during a 10-year However, Kerala’s per capita expenditure on health period of 1987–96. This increase was significantly was only US$ 28 whereas that of the USA was higher (768%) among the poorest people than among US$ 3925 (3). The most important reasons for this the richest (254%). Even after adjusting for inflation good health in Kerala are probably the following: its the increase in health expenditure was about 4 times high level of female literacy (87%); access to health higher than the increase in consumer price index (7).
care (e.g. 97% institutional deliveries); a good public The major reasons for this increase in health care distribution system (PDS), which provides essential costs are the increasing privatization of health care in food items at subsidized rates (the system covers the state, the increasing and often unnecessary use of 96% of the population); political commitment (40% technology, and a rise in drug prices. For example, of the state budget went to the social sector till Kerala has one of the highest rates of caesarean recently — 15% to health, and 25% to education); deliveries in the world now. Caesarean rates were good communication and transport (newspapers, reported to be 22% of all deliveries in rural areas and telephones, rural roads); land reforms (land distrib- 34.5% in urban areas (8). The extra cost of caesarean uted to the poorest and the landless) which helped deliveries in the state was estimated to be Rs reducing inequality in land and income; and Christian 25 million (US$ 540 000) in the year 2000. Around missionaries who started schools and hospitals, 75% of the pregnant mothers had at least one mostly in rural areas (4). Overall, the achievements ultrasonography test without any notable change in of Kerala seem to result from a relatively fair the management or outcome of pregnancy (9).
distribution of wealth and resources across nearly Another aspect of globalization is migration.
the entire population of the state (5).
Although there had been small-scale migration from Globalization as promoted by the World Trade Kerala to other Indian states and neighbouring Organization (WTO), the World Bank, the Interna- countries since India’s independence in 1947, large- tional Monetary Fund and the transnational corpora- scale migration started after the oil boom of the tions has created a new world order. One of its major 1970s. The Kerala economy started to stagnate in the impacts is increasing inequality, which is detrimental early 1970s owing to many factors, including high to Kerala’s health achievements. The Indian govern- wage levels compared to those in other states, and ment initiated a major economic reform in June 1991 well-organized and militant workers creating a less to increase economic growth. Social sector expendi- investor-friendly environment. The investors could ture declined considerably during the first few years easily start industries in other states, using cheap of this reform, resulting in stagnation in the labour. Slow growth of the economy and the development of public sector facilities.
consequent high unemployment rate (3 times the In spite of the high demand for health care, the Indian average) were the push factors for large-scale Kerala government could not increase its hospital beds substantially, for lack of resources for the health International migration has been increasing sector. During the 10 years from 1986 to 1996, public over the years. In 1998 there were 1.4 million sector hospital beds in Kerala increased by only 5.5%, Keralites residing in other countries and another from 36 000 to 38 000, while in the private sector 0.7 million in other states of India. In addition there there was a 40% increase, from 49 000 to 67 500.
were 1.65 million Keralites who came back to the Furthermore, the quality of the public health sector state after residing in other countries or other states decreased because the financial restrictions affected of India. There were an estimated 6.35 million supplies, including drugs, more than the salaries of households in Kerala in 1998, and 40% of them had the well-organized and militant employees (6).
at least one migrant (10). One of the majorconsequences of migration was the flow of remit-tances into Kerala, estimated at Rs 4717 million (US$ 876 million) or 10.7% of the domestic product Associate Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences & Technology, of Kerala in 1998. The total amount of remittances Thiruvananthapuram, Kerala, India 695 011 was nearly 3 times the budget support to the state from the government of India (10). Better housing and commodities were some of the advantages the Bulletin of the World Health Organization, 2001, 79 (9) families of migrants enjoyed compared to those of The potential for additional resource mobilization non-migrants. For example 54% of migrant house- from the local community and from the migrants holds had a television set compared with 34% of non- could be realized in the decentralized planning migrant households. The respective percentages for process. Transparency in programme implementa- refrigerators were 40 and 13 (10). Migration also tion, together with the democratization of planning helped to reduce inequality in the state because a large processes, will enhance people’s participation.
proportion of migrants were from the poorer classes There is enormous potential for further growth (11). Although the remittances could not be in the service sector in a well-educated society like effectively used to promote industries in Kerala that of Kerala. However there is a need to devise there is some evidence of revived growth in the specific measures to make Kerala more investor- Kerala economy since 1991, mainly in the service friendly and attract investment from within and sector. The annual growth rate of net domestic outside the state including foreign investment for product in Kerala for 1991–97 was reported to be accelerated growth of income. This should be done 6.05% compared to 2.88% during 1971–90 (12).
without sacrificing the welfare gains of the past, and Kerala has always been a food-deficit state.
without a market takeover of health, education and This deficit has been corrected by an efficient PDS welfare, which could price out the poor. n through a widespread network of ration shops in thestate. The ration shops, school lunches and agricul- 1. Registrar General of India. Sample registration system. Sample tural labour pensions were reported to benefit Registration System Bulletin, 2001, 35: 1 (available from Registrar female-supported households more than male- General of India, 2-A Mansingh Road, New Delhi 110 011).
2. World Bank. World development report 2000/2001– attacking supported ones, reducing one aspect of gender poverty. Washington DC, The World Bank, 2000.
inequality in the state (5). During 1986–87, 37% of 3. Hypertension Study Group. Prevalence, awareness, treatment the rural Keralites depended on PDS for their and control of hypertension among the elderly in Bangladesh purchase of rice, the staple diet (13). The PDS also and India: a multicentre study. Bulletin of the World Health worked as a price check in the open market. From 1997, however, as a consequence of the change in the 4. Thankappan KR, Valiathan MS. Health at low cost, the Kerala model. Lancet 1998, 351: 1274–1275.
policy of the government of India, arising out of the 5. Franke RW, Chasin BH. Is the Kerala model sustainable? process of economic reform, it was decided to limit Lessons from the past, prospects for the future. In: Parayil G, ed.
the PDS subsidy to those below the poverty line.
Kerala – the development experience. Reflections Moreover, the hike in prices for PDS announced by on sustainability and replicability. London, Zed Books, 2000: the Union Finance Minister of India in his budget speech in February 2000 was described as ‘‘a severe 6. Kutty VR. Historical analysis of the development of health care blow to the PDS in Kerala threatening its very facilities in Kerala State, India. Health Policy and Planning, 2000,15: 103–109.
7. Aravindan KP, Kunhikannan TP, eds. Health transition in rural Since rice cultivation in Kerala was not profit- Kerala, 1987–96. Kerala, Sastra Sahitya Parishad, Kozhikodu, able compared to cash crops like rubber and coconut, farmers converted paddy fields into coconut and 8. Thankappan KR. Cesarean section deliveries on the rise in rubber plantations. As a result of international trade Kerala. The National Medical Journal of India,1999, 8: 297.
agreements the importation of edible oil, coconut and 9. Hemachandran K. Burden cause and cost of cesarean sections in rubber has been unrestricted since 1994. Although three city corporations of Kerala (unpublished MPH dissertation2001, available on request from Achutha Menon Centre for some import restrictions are still there, India’s Health Science Studies, Sree Chitra Tirunal Institute for Medical agreement to the WTO calls for the removal of all Sciences and Technology, Thiruvananthapuram, May 2001).
the remaining restrictions by 2005. Kerala is the state 10. Zechariah KC, Mathew ET, Rajan SI. Impact of migration most affected by this liberalization because its major on Kerala’s economy and society. International Migration: agricultural products are coconut and rubber. The Quarterly Review, 2001, 39: 63–85.
price of 100 kg of rubber plummeted from Rs 5204 in 11. Prakash BA. The economic impact of migration to the gulf. In: Prakash BA, ed. Kerala’s economic development; issues and 1995–96 to Rs 2994 (a 42.5% reduction) in 1998–99 problems. New Delhi, Sage, 1999: 134–149.
(15). Rubber provides the livelihood of over 12. Subramanian KK, Abdul Azeez E. Industrial growth in Kerala: 750 000 families in the state. The fall in prices of trends and explanations. Working paper No. 310 (available rubber and coconut has severely affected the on request from the Centre for Development Studies, economy of the state, which will have serious implications for the health of Keralites, especially 13. Nair KN. Food security and the public distribution system in Kerala. In: Krishnaji N, Krishnan TN, eds. Public support for foodsecurity: the public distribution system in India. New Delhi, In conclusion, globalization challenges the foundations of the Kerala model of low cost health 14. Kannan KP. Food security in a regional perspective. A view care, which is built on distributive justice. How can from ‘Food Deficit Kerala’. Working paper No. 304, 2000 the people of the state face the challenges of (unpublished paper available on request from Centre for globalization? The decentralization process, which Development Studies, Thiruvananthapuram).
the Kerala government started in 1996 by transfer- 15. Government of Kerala. Economic Review 1999.
ring power and money (40% of the state budget) to Thiruvananthapuram, State Planning Board, 1999.
the local authorities presents a good opportunity totackle at least some of the challenges of globalization.
Bulletin of the World Health Organization, 2001, 79 (9)

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