Global Health from a donor’s point of view
By Kirsten Havemann, MD, MPH, PhD

As a health professional I have worked at many different levels of the health system and for many different organisations. This includes community, district, provincial, national and global level health institutions and organisations and as well for NGOs, multi – and bilateral donors, and finally UN organisations including WHO and the World Bank.  I have decided to end my professional life with a bilateral donor, namely DANIDA, and I am currently Counsellor for Development facilitating Danish support to health and nutrition in Mozambique.

The above self-introduction has the purpose of colouring my comments below on global Health.

What is Global Health and is it different from all the rest?

First of all I was happy to learn that you refer to Health and not the Health Sector as there is a huge difference. This is not about semantic but about concept, and these can be misleading and confusing. While Health is holistic, the Health Sector is narrow. Although a sector was primarily defined holistic it soon became evident that what we thought was ‘sector wide’ became ‘sector narrow’ as funding streams has restricted multi/intersectoral approaches. So much for the ‘Sector Wide’. Furthermore as the donor funding modalities took over the health sectors in many developing countries, ownership became important and innovation got lost in declaration such as Paris, Accra, Busan etc. which finally resulted in ‘ownership of ignorance’, innovation got lost!

How can Global Health be implemented? Health is an output/outcome of some input, meaning a result. How do we then achieve result? Results can only be achieved if we are specific about WHAT we want to achieve, WHERE, WHEN, HOW and by WHOM. When I read the Global Health article I ask myself, “and what would I then do, and what could we fund that could contribute to better Global Health”? and I really cannot answer. What I read now about Global Health is all and nothing, because it is unspecific. Global Health is maybe more of an approach – like the social determinants of health agenda – than it is a result. Global Health further embraces complexity, e.g finding the most appropriate entry point for change in a certain context at a certain time using some guiding principles rather than the ‘one size fit all’ approach, that we have seen too much of in the past. Complexity means that we can get huge results with relatively little input if we get it right.

Who is implementing Global Health? A plethora of implementers mushroomed since the 1990’ties in the health sector, from weak government officers to partners, donors and civil society organisations, all with their own agenda but pretending to subscribe to the politics of the day of good intentions. The blurring lines of accountability: e.g. is UN a donor or a partner? Do donors provide both insight and oversight? Can donors be accountable to their own constituency at home when the impact of their funding – for good and for bad – is more than five thousand kilometres away and will only be visible to people that cannot hold politicians and donors accountable. Many of these organisations therefore become ‘employment schemes’ for their own survival.

Why is a need for yet another definition? I cannot answer this question but have decided to ground this in politics, and politics is about power and control. Global Health has an inherent amount of problem in its own right and implementation. Too often we ‘technicians’ – usually health sector specialist – try to solve these problems with evidence, technical evidence. We have still not understood that Global Health is mainly a political problem and it can and will never be solved with a technical solution, even if the best data is presented.

Maputo 17 March 2014
Kirsten Havemann, MD, MPH, PhD
Counsellor Development, Health and Nutrition, Danish Embassy, Maputo, Mozambique

Kirsten Havemann is a public health physician with special interest and expertise in health and social sector analysis, design and systems development.  She has extensive knowledge and skills in participatory and action oriented approaches and has applied these skills both in operations and research settings. Kirsten has more than 25 years of experience in Africa and Asia and has held substantive posts, such as Senior Adviser for the Danish Government, and more recently worked as short-term consultant for NGOs, bilateral donors, the World Bank, WHO and lately as a counsellor development (Health and Nutrition) for the Danish Government in Mozambique.

By Guest Blogger David Musoke-Muweke, PhD, Clinical Pharmacologist, Postdoc at Gulu University, Uganda.

The presence of counterfeit or substandard drugs in Africa is a threat that cannot be under estimated as it has been widely reported worldwide. Indeed, sub-standard formulations of antimalarials and antibiotics have been reported in the East African region.^{1, 2, 3} These drugs are majorly procured from manufacturers in Asian countries. Manufacturing of drugs in African countries by local entrepreneurs is also on the increase. There is therefore need to develop local capacity to counter this problem as it has a direct bearing on morbidity, mortality and the overall confidence in the health services at all levels.

Most African countries lack the financial and human resources to setup well equipped state of the art laboratories country wide across the various regions and provinces.⁴ The development of field tests is a prerequisite to enhance drug quality monitoring as these field tests should be robust, inexpensive, simple to conduct, rapid and reliable quality control methods.

The support of drug regulatory authorities by way of building and developing specialized human resources and physical infrastructure should be enhanced. Human resource includes chemists, pharmacists and laboratory technicians among others. The physical infrastructure should be decentralized to the regions/provinces so that these services are as close as possible to where the drugs are being utilized.

Availability of inexpensive essential medicines that treat the common ailments at all times in an efficient public health service at all levels would reduce the temptation of unscrupulous drug companies and pharmacies to fill the void by providing substandard or counterfeit drugs. The failure to access genuine medicines in public facilities is probably the main factor why patients will seek medicines from the private sector where the propensity to supply counterfeit or substandard drugs is high due to poor law enforcement.⁵

Public health campaigns in the society on how to make decisions on where to obtain good quality drugs and hence make the right choices when seeking medical care are essential. This could be by way of posters, mass media i.e. radio and newspapers and health educators in the community.⁶ The information provided could include information on appropriate packaging, proper storage conditions, shelve-life and the reliable brands and manufacturers. The public awareness ought to be coupled with vigorous enforcement of laws and regulations governing the procurement and supply of medicines must be strengthened.

By Guest Blogger David Musoke-Muweke, Postdoc at Gulu University, Uganda.

References

1. Anon. Fake malaria drugs in Tanzania. Marketletter Feb 20, 2001
2. Kayumba PC, Risha PG, Shewiyo D, et al. The quality of essential antimicrobial and antimalarial drugs marketed in Rwanda and Tanzania: influence of tropical conditions on in vitro dissolution. J Clin Pharm Ther 2004; 29: 331-38.
3. Amin AA, Snow RW, Kokwaro GO. The quality of sulphadoxine-pyrimethamine and amodiaquine products in the Kenyan retail sector. J Clin Pharm Ther 2005; 30: 559-65
4. WHO. What encourages counterfeiting of drugs? http://www.who.int/medicines/services/counterfeits/faqs/16/en/index.html
5. Pecoul B, Chirac P, Trouiller P, Pinel J. Access to essential drugs in poor countries. A lost battle? JAMA 1999; 281: 361-67.
6. Rozendaal J. Fake antimalarials circulating in Cambodia. Mekong Malaria Forum 2000; 7: 62-69.

Dear Minister for Trade and Development Cooperation,

I have just returned from Northern Uganda where I had organized a PhD and masters course in basic research methods at a small public university with which we have a collaborative DFC funded research project on Primary health care, mental health and chronic diseases.

We have been present at this particular university since 2007 when we started an ENRECA (ENhancing REsearch CApacity) project with a cross disciplinary research consisting of researchers from KU, AU and SDU. Luckily we managed to obtain funding for a further 5 years in 2013 from DFC, now for two separate projects: one in health and one in land and trust issues.

I have been conducting these masters and PhD courses 7 times now and each course was ended by a new invention: “speed supervision” where we gave each student 30 minutes supervision on their individual concept paper or study issues. A uniform picture of the reality at African universities is beginning to emerge from these speed supervision sessions and the dialogues during the courses. I find them interesting in the light of the present developments in the Building Stronger Universities (BSU) plan and the decision to skip the planned phase 2 and replace it by a weak and inappropriate south driven approach. I would like to share with you, minister, just how far away from reality the BSU plan has moved with this decision. And I would like to suggest a cheap and simple solution to bring back BSU to reality and to the needs of universities and students in Africa.

Let me start with four illustrative cases:

Case A.

A young medical student asked the obvious research question his senior colleagues had overlooked: how many pregnant women contract HIV after their first negative HIV test during pregnancy? He managed to persuade the ENRECA project to fund his research. He carried out the study without help and found that 2 out of 100 pregnant women contracted HIV and suggested that pregnant women be tested for HIV at least twice during pregnancy. We urged him to write an abstract for the most prestigious international HIV congress and his abstract was accepted. At the same time he starting working in an obstetric department and the hospital management immediately made him head of department with a heavy workload and responsibility. Neither the hospital nor his university would help him obtain a passport or a visa for his travel abroad and there was no available funding for his travel expenses. Disappointed, he then chose to leave both university and hospital to work for an international humanitarian organization in a neighboring country.

CASE B.

A master student of business and management had finished and defended his master thesis with supervision by seniors from two different universities. When he wanted to publish part of his thesis as a scientific paper he was met by silence from his supervisors. We advised him to contact them in person, which he did, and he was told by one of the supervisors that his function as supervisor was over and any further assistance would require a payment. The student was unable to write the paper without the assistance of his supervisors as they were co-authors and the student had never written a paper for a journal before. The paper was never written.

CASE C.

A master student brought a concept paper for speed supervision that addressed a clear research question: do female students feel more stressed during exams than male students? However, his concept paper had been turned down by the ethical committee at his university with a simple conclusion: this is not research. He failed to get a more detailed explanation from the committee. He later learned that the head of the committee had wanted some sort of payment for an approval. His supervisor was not particularly helpful and the student subsequently gave up his efforts to obtain a master’s degree.

CASE D.

A senior employee at a university administration office presented a well-developed concept paper on retention of human capital at universities in Northern Uganda. He had worked on it for several years without finding suitable supervisors or interest in funding his PhD. The observations he had made prior to his proposal were plenty and quite clear:

1. Most teachers at universities were at masters or candidate level while very very few had a PhD.
2. Most master programmes were either non-functional or non-existing in reality.
3. A number of masters programmes had failed to seek and obtain national accreditation from the National Council for Higher Education (NCHE) and were in essence illegal. The general lack of resources in the academic departments in the faculties have engendered very low morale and negative attitudes on the part of the heads of department, hindering the review of academic programmes, and threatening the closure or shelving of programmes whose lapse of time is clicking the mandatory cycle acceptable by NCHE. Some private universities had been shut down for the same reason but no public universities had yet been asked to close down their non-accredited master programmes. The probable reason, the student indicated, was that most members of the NCHE were vice chancellors of public universities.
4. Master students most often pay for their master programme themselves out of their own pocket and universities see the tuition fees as a welcome income generation.
5. Most PhD’s leave their university shortly after they obtained the degree because of lack of career opportunities, heavy teaching loads, low pay and no funding of research.
6. Finally, the student behind the proposal had observed that the institutional brain was lost and system memory impaired because management colleagues don’t share knowledge and because deans and vice-chancellors leaving their position take everything with them, including knowledge, history and experience, leaving a completely blank desk, and institution,  to the successor. In accordance with the provisions of the law of Uganda, faculty deans and institute directors in Uganda’s public universities are elected after every four to five years or so.

Ghost masters

When we started the former ENRECA project at the university in Northern Uganda we were given the impression by university management that the university had over 15 Masters programmes running or planned. When it came to reality only one was near functional programme and two were more or less at a conceptual development stage with no actual content. There were no PhD schools.

Stunned students

During the speed supervision sessions we have had over the years at this particular university we have listened to the reports of over 150 PhD and master students. The majority have been working on their concept papers for more than 3 years, some for over 5 years, without relevant supervision or even basic guidance as to relevance and methodology. Students lament lack of clear administrative procedures, lack of knowledgeable seniors, lack of supervisors, lack of transparency in the academic processes and failure to maintain steady contact with supervisors during their PhD/Master studies.

Most students only had internet if they paid for it themselves and only through the mobile EDGE/3G telephone net. Surprisingly few students had received practical training in basic research skills like conceptual development, literature search, data handling, ethics or basic methodology. Students from larger universities also complained that they were “kept” in their position as PhDs for far longer than necessary because having PhDs was a source for supervisors to obtain extra funding and the students were forced to take over the supervisors teaching obligations at university for years. Some students were either lost in administrative or bureaucratic delays or missing documents while other students were told that they should collect more data.

BSU phase 2

With the proposed structure for BSU phase 2 DANIDA has decided that universities in Africa are capable of formulating research projects, developing curricula and they have fully functional university administration with transparent routine procedures for obtaining a master or PhD degree. DANIDA also seems to imagine that lecturers all have a PhD degree and that the programmes for obtaining masters and PhD degrees are functional and accredited according to national guidelines and international standards.

Why and how DANIDA has managed to create this picture of current state of affairs at universities in Africa is a mystery. I still receive emails from desperate PhD students at various universities in Ghana enrolled and funder under the BSU phase 1 project. They have failed to get local support for supervision and they have not been guided in making research relations with research teams at Danish Universities. Their funding will be withdrawn without a Danish partner so now they are forced to send desperate emails to Danish universities.

BSU

DANIDA has with the plans for the next BSU phase decided to move directly from basic research and administrative capacity building to research funding at (selected) universities in (selected) African countries.

There are no indications that universities in Africa have suddenly developed a fully functional masters and PhD environment nor have they yet got the administrative set-up or human teaching capital required to carry out independent research. Universities in Africa lack much more than money – they lack human capital, curricula and long term collaborative research capacity building programmes where senior lecturers from the North assist in lifting the huge teaching obligations while the young researcher obtain their masters and PhDs. That was what the former ENRECA programme did: trained researchers and university teachers. The ENRECA programme was praised in the HERA report for its construction and achievements, yet, for no sensible reason,  it was discarded by DANIDA and replaced by the current BSU programme that has failed completely in lifting the heir from the ENRECA era.

Furthermore DANIDA has decided to stop a phase 2 of BSU focusing on the administrative capacity building of universities and, for no obvious reason, suddenly assume the administrative capacity is in place. Furthermore, we have just learnt that the excellent idea with administrative PhDs has been dropped at the same time. Thereby the student in case C will never be able to fund his PhD that could actually have produced an evidence base for decisions on where to put our donor money in university settings. DANIDA has effectively put an end to South based relevant research supported by researchers from the North.

The new BSU project is termed phase 2, but as a Danish filmmaker once said when he wanted to make a follow up movie to his first movie success: we named the movie as number three, skipping the obvious no. 2 because no. 2 movies are always a failure, as he said. As it turned out the “third” movie was a complete failure.

Professional stunting

DANIDA has, once again, changed their policy for research development and as a senior University management person told us: they have changed their plans so often that we can no longer trust that their intentions are to support capacity building at our university. We are probably better off without their false promises, he concluded.

In Uganda, the state of university education went up from the point where there was only one university in 1987 with just about 10,000 students to a point where there were 28 universities with over 65,000 students by 2008 (ibid.). By 2011, the number of universities had reached 32, with an enrolment of 140,096 students. Nobody has tried to plan for the explosion in need of associate professors with PhDs to teach and supervise.

Research is not underwear you change every day, picking a color of your liking. By changing strategy once a year DANIDA is contributing to, maybe even speeding up, a rapid professional stunting at African universities. Building stronger universities is not about building because the BSU 2 is based on the assumption that there is a foundation to construct a building on. The capacity to engage in research collaboration the way that BSU 2 requires is not present in African universities. The South based DANIDA funded projects in Tanzania and Vietnam have proven this.  There is no foundation for the BSU 2 building and the BSU 2 model will bomb universities and students 25 years back to the time before ENRECA programmes. African universities are threatened by a huge gap in the human teaching capital that will initiate a process of professional stunting – they don’t need charity or short lived research funds with a new focus every year. African universities need close research collaboration and administrative capacity building in a long term commitment before they are forced to jump into the “free research market”, that the BSU 2 represents.

I strongly suggest that DANIDA takes a time out, and behaves as a responsible global donor seeking maximum evidence and impact. DANIDA should use the time out to consult the Danish research teams that have actually had decades of collaborative research and teaching with African universities and research groups. The present “quick and dirty” consultation with south partners is not sufficient and does not include all stakeholders. It is recommended that DANIDA seriously considers to re-introduce the excellent and popular ENRECA model where everybody was working according to a long term transparent plan both in Denmark and at African partner institutions. Now, that is building stronger universities and even on a foundation of solid, sound evidence.

By Mette Holm

Global health is much more than the two words that make up the term; it is the highly interdisciplinary intersection of epidemiology, policy and politics, law, environment, economics, demographics, climate change and sociology – to name but a few factors. Global health knows no national borders; it covers complex issues that are interdependent and often unfold far from their causes. Natural disaster, man-made conflict, climate change and unequal distribution all contribute negatively to global health.

Global health encompasses more than international health; it includes a wealth of new researchers and decision makers beyond the fields of health, who along with the traditional health sector workers and researchers aim at equity in health and fair distribution of knowledge and technologies; thus global health also has a highly political aspect.

A Globalised world

The UK government defines it thus: “Global health refers to health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions. Global health is focused on people across the whole planet rather than the concerns of particular nations. Global health recognises that health is determined by problems, issues and concerns that transcend national boundaries.”

In a globalised world disease travels almost at the speed of light; diseases travel with people, cargo, migratory animals as well as with human life styles. Historically, peoples and nations have been separated by e.g. distance, geography, climate and perhaps religion or ideology. Over recent decades increased travel, trade and communication have increasingly bridged these factors of separation.

Hence the health of everyone and every nation can be affected, some to a large, some to a lesser extent as some have more resources and resilience and some less.

Poverty and disease in one country can affect the health status of people in other countries. Chronic disease like obesity, diabetes, mental disorder, traffic injury, and abuse of alcohol and tobacco that used to affect mainly the industrialised world are now truly global. While some factors relate strictly to health, others stem from social behaviour and circumstances, e.g. poverty and/or lack of education.

Professor of Global Public Health at University of Copenhagen Maximilian de Courten puts it this way: ”As the industrialised world directly or indirectly exports some of the key global health risk factors, it would be their responsibility to be concerned about the consequences no matter where they occur.” In other words industrialised nations carry a larger responsibility for as well as a larger capacity to improve global health.

Health is a human right

Professor Ib Bygbjerg of Copenhagen School of Global Health at University of Copenhagen points out that in accordance with the Universal Declaration of Human Rights everyone has the right to life, liberty and security of person; and he builds on prominent American ”disease detective” Jeffrey P Koplan’s definition of global health in his summary of what it is:

• an area for study, research, and practice, that
• places a priority on improving health,
• advancing equity in health for all worldwide, while respecting everyone’s right to life, liberty and security of person;
• emphasizes transnational health issues, determinants, and solutions;
• involves many disciplines within and beyond health-sciences;
• promotes interdisciplinary and international collaboration;
• a synthesis of population-based prevention, with individual-level clinical care.

Thus caring for and preserving health in a global perspective is not solely a matter for specialised health workers; it involves e.g. politicians, lawyers, economists, sociologists, anthropologists, community workers, civil society, schools and teachers as well. And, strange as it may seem, these collective efforts can be fiercely opposed by other actors on religious, political or other grounds.

Unsexy and overlooked issues, the Nordic Agenda

“We want to point out areas where we lack knowledge, ‘unsexy’ problems that tend to be overlooked, future risks that we should focus on; one example is social determinants of health, which is totally overlooked and badly in need of attention,” says professor Morten Sodemann of Odense University Hospital and University of Southern Denmark.

He refers to the “Nordic Agenda”, which covers issues often shunned by the big national and international donors; e.g. the deeper cause of conflict and its impact on health as well as religious influence on health. Also, “HIV resistance towards medicine in developing and poor countries is one disaster that no one wants to know about, let alone do research on. Another example is the effect of urbanisation and the introduction of user fees in the health sector in Africa,” says Morten Sodemann.

Adds Birte Holm Sørensen, Independent Consultant: “While governments do make an effort to address issues of maternal mortality and family planning, the more contentious issues of access to safe abortion, access to information on sexual and reproductive health and services for young people, child marriage and other gender based violence issues and access to family planning for marginalized people are not addressed.“

All this most sensible and very hard to disagree on, one might think; but the Nordic Agenda has many critics and even enemies amongst donors and recipient countries that are driven by religious, political or other agendas that prioritise these above the health of their peoples.

Double burden of disease

Low- and middle-income countries are badly affected by infectious diseases; this unfinished agenda has a nasty contender in a growing epidemic of non-communicable diseases (NCDs), which are driven aggressively by development, industrialisation, urbanisation, investment, and aging. Malnutrition and infection in early life increase the risk of chronic NCDs in later life, and in adult life, combinations of major NCDs and infections, such as diabetes and tuberculosis, can interact adversely, with one fuelling the other.

“Because intervention against either health problem will affect the other, intervening jointly against non-communicable and infectious diseases, rather than competing for limited funds, is an important policy consideration requiring new thinking and approaches,” says Ib Bygbjerg.

The vicious circle of poverty

Morten Sodemann points out that most diseases are caused by poverty and cause poverty. Disease leads to reduction in farm production and increases school- and education dropout. HIV leads to a 50 per cent reduction in farm production in families where one adult is infected. Diseases like HIV and diabetes boost the effect of poverty. Every year, disease reduces 100 million people to live in extreme poverty due to the formal as well as the informal fees they have to pay for medical examination, treatment and medicine.

What to do?

Maximilian de Courten stresses the need for multidisciplinary cooperation with a particular focus on turning the effects of trans-national determinants of health into solutions; easier said than done …: ”Collaborations for this type of research are critical to address all health issues and especially global issues which have a multiplicity of determinants and involve a complex array of institutions dedicated to finding solutions,” says Maximilian de Courten.

Most can agree on solutions such as education, prevention, meaningful health budgets (economy permitting) and intervention.

Morten Sodemann suggests starting with ”school for all, gender equality in all fields, educate teachers, pay them a decent salary, strengthen the universities, strengthen the hospitals, go ahead with simple interventions like vaccine against measles, impregnated mosquito nets, malaria combination treatment for children and expecting women; also, donors should coordinate their efforts so as to make best use of resources, agree on who does what, do research on how the health sector contributes to inequality in order to secure equal benefit for all.”

Research, experience and knowledge must be coordinated in order to extract useful data to build on: “We need to rewind the process to where it all began and then set up a system that is immune to fashion, politics and religion. We have failed to setup a monitoring system so we could have learnt how and why we actually managed to reduce child mortality in the majority of the world’s countries,” says Morten Sodemann.

Maximilian de Courten points out that “healthy” policies need to be implemented; nationally and globally, by donors as well as recipients. Tobacco control is a case in point – as well as a prime example of how politics and health can be fiercely at odds.

New development goals; SDGs

The United Nations’ eight globally agreed Millennium Development Goals were set in 2000 to be achieved by 2015; they were poverty alleviation, education, gender equality and empowerment of women, child and maternal health, environmental sustainability, reducing HIV/AIDS and communicable diseases, and building a global partnership for development, all of which, if and when realised, contribute positively to the improvement of global health. Some have been achieved, to a varying degree in different parts; e.g. Brazil, China and Vietnam have done well. Sub-Saharan Africa has not.

In 2012 in Rio de Janeiro at the Rio+20 summit 192 UN member states decided to continue the process by designing a new set of Sustainable Development Goals, SDGs which are “action-oriented, concise and easy to communicate, limited in number, aspirational, global in nature and universally applicable to all countries while taking into account different national realities, capacities and levels of development and respecting national policies and priorities.”

One such simple goal from the point of view of global health: Improvement of life expectancy in terms of healthy years lived.

This requires in-depth analysis of successes and failures of the development goal process in order to continue along the lines of what went well – and change course where nothing or little was achieved. Experience, best practise and general knowledge needs to be pooled and made easily accessible for both experts and lay-people.

And further to all the above efforts, it takes courage and political will from governments and decision makers to seriously combat backwardness, ignorance and ill will.

So, this is one – distinctly lay – version of global health pieced together from many sources, and also with the help of wise answers from some of the founder-members of Global Health Minders. Hopefully, it will inspire further input and reflection from other stakeholders in the realm of social sciences, the law, politics, education and more … (and thus: to be continued)

Mette Holm is a free lance journalist; www.metteholm.com

Photo: IRIN (www.irinnews.org)

Read the summary of Morten Sodemann’s contribution to the An Open World – Niels Bohr Conference.

Global health should be studied the same way we study peacekeeping, global governance and defense management.

Pandemic flu won the First World War – there were too many unplanned casualties following the attack from an unexpected enemy for which no sides of the war had effective defense mechanisms. Health has always been a part of ‘high politics’ – but while the flu didn’t get much attention for its role in the First World War, HIV, SARS and the recent flu pandemics have wiped away any doubts about the importance of global health in shaping foreign policy, international relations and human security.

International relations have been invaded by a range of health subjects that previously were blind spots: globalization, human rights, social determinants, social media, migration and international law.

Women live lives more dangerous than soldiers at war just because they give birth. Every year 200 million people end in extreme poverty because of catastrophic health expenditure for their illness. Every day 4,500 children die from simple and preventable diseases such as diarrhea while sanitation still receives less than 0.5 % of what is spent on aid in low income countries.

All of these deaths and suffering are the result of local and international political decisions. Decisions made contrary to what history has learnt us and contrary to what science tells us.

Most people will agree that health as a human right is vital to good politics and human security, yet States have consistently refused or ignored to include health on the list of basic rights.

An open world has been created by globalization and social media, but politicians and large international donors need to open their minds to the history and science of global health. The 186 years between discovering the Smallpox immunization and until the disease was eradicated, is a lesson in global health: science, as health, does not exist in a vacuum and depends deeply on brave sensible politics based on facts and historical evidence.

Today we can control a car driving around on Mars and drones can deliver ordered books directly to you within an hour – why is it then that hand washing, sanitation, maternal-child health and respect for history and scientific evidence is so difficult?

Maybe we have complicated matters by allowing global health to be defined and governed by a chaotic group of private donors, large funds and NGOs without regard to what human beings really need to be able to live a normal healthy life.

Most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the ‘high politics’ of national security and economic material interests. Development, human rights and ethical/moral arguments for global health support, the traditional ‘low politics’ of foreign policy, are present in dialogue but do not appear to control practice. While political drive for health as a foreign policy goal persists, the framing of this goal remains a disputed issue.

Narrow minds in an open world are what prevent global health from releasing its full potential among the poorest populations of the world. Homer Simpson shows us just how embarrassing our narrow minds are: “How come you guys can go to the moon but you can’t make my shoes smell good?”

Maybe it is not so difficult after all if we start with the smelly feet problems instead of looking for a fix behind the moon?

Condoms were invented in 1564 but still fail to be in the right place at the right time. Global health in an open world requires an open mind… and brave sensible politicians dealing with earthly matters.

This is a summary of Morten Sodemann’s contribution to the An Open World – Niels Bohr Conference. Download the full-text speech here.

By Kåre Mølbak, Statens Serum Institut

The vast majority of this burden of illness lies in Africa and Asia. For example, it is estimated that about 800,000 children die of diarrheal diseases each year, and for those children who survive, repeated episodes of diarrhea may precipitate impaired growth, impaired intellectual development, and poor quality of life.

It is also thought provoking that about 47 percent of India’s 330 million households have toilet facilities while 63 percent of homes have phone connections — mostly mobiles.

The sanitary revolution in Europe came in the aftermath of the cholera epidemics in the second part of the 19th century, and by providing toilets, sewage, and water, engineers, plumbers and constructors probably did much more for human health than doctors did. Perhaps it was a naïve hope that the cholera pandemics that affected Africa in particular from the early 1960s and South America from the 1990s would have resulted in similar sanitary revolutions.

However, it seems to be a rather slow evolution more than a revolution! Perhaps donor agencies and international organizations have oversimplified international health by a massive focus on malaria, hiv and tuberculosis while disregarding the enormous burden of parasitic, bacterial and viral diseases that are consequences of poor sanitation and water supplies, and that has equal direct and indirect costs for health and development. Think about it.

Nonetheless, there is progress. For example, in Bhutan, 93 % of the population has access to basic sanitation and 91% to safe water supplies. This is one of the many factors that – together with primary health care and vaccinations – resulted in a remarkable decline in child mortality and morbidity as well as better nutritional indicators in a period of less than 50 years.

The issue is also about human dignity. Can you imagine not having a toilet? Can you imagine not having privacy when you need to relieve yourself? The harsh reality is that one in three people on this globe has no access to a toilet! Have you ever thought about this meaning of dignity?

World Toilet Day was created to pose these kind of questions and to raise global awareness of the daily struggle for proper sanitation that a staggering 2.5 billion people face. World Toilet Day brings together different groups, such as media, the private sector, development organizations and civil society in a global movement to advocate for safe toilets.

We all give a shit!

Guest Blogger Kåre Mølbak, Statens Serum Institut

While the ICPD Plan of Action  in 1994 emphasized women’s rights, a continuous point of contention has been sexual rights. Following up on ICPD at the Beijing Women’s Conference in 1995, women’s rights were specified to include their decision on own sexuality. Interestingly the term ‘Sexual and Reproductive Health and Rights (SRHR)’ did not appear in the adopted consensus texts prepared in Beijing, although several delegations, especially from the Nordic countries, were – and have continued to be – strong advocates.

In the development of the MDGs in 2000 we don’t see the inclusion of Reproductive Health. It was only in 2008 that international consensus on the idea that access to family planning must be part of the MDGs was reached and acted upon by including MDG 5b. This consensus is very significant, but also very recent, and it is not yet known what will happen in the post 2015 deliberations.

But is this at all important? Is it not only words in high level documents? What does it mean in real life?

UNFPA, the global agency charged with promoting sexual rights, refers to sexual and reproductive health and reproductive rights! WHO usually (but not consistently) refers to sexual and reproductive health! Large international NGOs such as IPPF use the inclusive health and rights term, SRHR, and so do a number of governments, including Denmark and Holland. Some African countries as well as some large donors (DFID, USAID) however use terms such as Sexual and Reproductive Health, Reproductive Health and Family Planning and do not mention ‘Rights’. While USAID is very generouns in their support to condoms for the purpose of preventing HIV transmission, they do not accept the use of the term ‘Reproductive Health Services’ from countries or global agencies they fund, as they see this as inclusion of family planning services and – even worse – safe abortion services.

In spite of serious challenges in global fora from conservative US based church groups – with substantial money to influence especially African governments – the High-Level Task Force for ICPD, a group of 26 leaders, still uses the term SRHR (ICDP Task Force 2013).

But again – does this ‘war on words’ matter?

We have recently in our news media learnt that Nigeria is likely to follow other African countries and introduce laws which will criminalize homosexuality and abortion. Likewise some weeks ago we read about young women in Uganda who have to leave school and thereby their opportunity for obtaining an education and future earning capacity because they have become pregnant. In a more recent article we learn that 7.3 million girls under the age of 18 become mothers every year – 2 million of them are under 14!!

So yes, it matters because these governments and donors fail to address the issues of sexual and reproductive rights on the ground. They may address and fund access to maternity services and to short term family planning services (condoms and pills) but they are not willing to address the more contentions – but equally important issues such as: provision of access to safe abortion (unsafe abortion is likely to cause 1/3 of all maternal death and disability); the persistently high unmet need for family planning, access to long acting or permanent family planning methods, access to reproductive and sexuality information and services to young people and sexual minorities, and actively addressing child marriage and teenage pregnancies.

So how about donor governments who in their own countries and in international meetings place high importance on the Rights aspect of SRHR and provide funding through multilateral and bilateral assistance?

Denmark provides about 1/2 of their funding through multilateral agencies such as UNFPA and WHO, both UN agencies which cannot support any activity at country level which may be seen as anti government. This means that in more conservative countries, such as a large number of African countries, where safe abortion and homosexuality is a criminal offence, these agencies cannot support local CSOs to undertake advocacy to change the law! Likewise, funding provided through general- or sector budget support will not be used to address reproductive and sexual rights unless the government is strongly in favor – in which case the external funding may not be required!

So what options are available for donors to support a ‘rights based’ ICPD agenda? 

In most of the western countries reproductive and sexual rights were initially introduced by local CSOs, professional groups such as Women’s Medical Associations and passionate individuals. Likewise most countries have individuals and local CSO’s which work to ensure that people know their rights and undertake advocacy to change restrictive laws. Recent studies have documented that funding for such activities is inadequate, ad-hoc and sporadic.

After several years of deliberations the Dutch and Danish Governments have very recently taken the first steps to set up a global mechanism to fund local CSO to undertake advocacy in the area of the Rights aspect of the ICPD agenda – which was agreed almost 20 years ago!! Let us hope this initiative takes off soon and that once it becomes operational, other funding agencies will step up and co-finance.