News Flash 429: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 429

Weekly Snapshot of Public Health Challenges


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News Flash 428: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 428

Weekly Snapshot of Public Health Challenges


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Global Health Inequity 1960-2020

Health is the most cherished human aspiration across cultures and time. The only global health objective agreed by all countries is the constitution of the World Health Organization, which aims at the “best feasible level of health for all”. With international data - from 1960-2020- we identified such “best feasible level of health” and selected countries with good health (life expectancy above world average) and also economic and ecologic conditions that are replicable for all, including coming generations. The identified models question the prevailing concepts of development and poverty thresholds. Using healthy, replicable and sustainable (HRS) models, we are able to adjust mortality rates by age and sex published by the UN Population Division every five years. The excess mortality above that from the HRS models is the burden of health inequity, a powerful indicator for socioeconomic justice. It also allows setting the “dignity threshold” (below which no country has achieved that best feasible health) and the equity curve, between such minimum and the maximum “excess level” above which global equity and sustainability is not feasible, and wellbeing  neither improves for those in that hoarding end. Accumulation above that threshold and carbon emissions above the “ethical threshold” above which we are bound to irreversible global warming > 1.5 degrees, has a price on life years lost in others, which we factored in an “equitable and sustainable wellbeing” index. The world could save 16 million lives lost every year to inequity with only half the GDP present levels and preserve the lives of coming generations, including by investing the unnecessary surplus into global public goods. Such shift to equity requires a change in values and a redistribution of some 7% of GDP, only 10% of the GDP above the unnecessary and unethical excess threshold.

“Enough is enough and more is too much”

Mahatma Gandhi 

credit: WHO

Global Health Inequity 1960-2020 



By Juan Garay*, Nefer Kelley**, David Chiriboga***, Adam Garay****

*Professor of Bioethics, Chiapas University, Mexico

**Bay area Community Resources, Berkeley, California

***University of Massachusetts, USA

****Sustainable Health Equity Movement

The views in this study and document do not necessarily reflect the positions of the organizations related to its authors


Scene setting

When the world was recovering from the major wars stemmed in Europe, it resolved to create system where all countries would preserve peace and respect human rights. Until then, just a handful of countries had taken the German Von Bismarck XIX century health care model from workers to the general population through universal health care systems. Norway and Sri Lanka[i] in the 30s and Costa Rica[ii] in the early 40s had committed to universal free health care. In the mid-40s, the Universal Declaration of Human Rights[iii] brought hope and a sense of brotherhood in a world ravaged by cruel massive wars, including its final blow of the nuclear bombs. Its article 25 declared the right of health and wellbeing, including through social protection. In parallel, the World Health Organization (hereafter WHO) defined health as a state of physical, psychological and wellbeing and its article 1 committed all member countries to strive for the “best feasible level of health for all peoples[iv]. The 60s witnessed the wave of African independence broke the last colonial chains that had lasted four centuries while the WHO managed to coordinate the efforts to eradicate smallpox. The 70s brought the international covenants on human rights and although they were legally binding, the states were meant to protect and promote human rights in a “progressive” way[v], that is, according to their means. It was by the end of the 70s that the declaration of Primary Health Care in Alma Ata[vi] renewed hopes and a sense of partnership for the right to health through civil society, the United Nations and countries throughout the world. However, little did it last. The oil crisis brought another dimension to the cold war, the dollar delinked with gold reserves; the Washington consensus hand in hand with the Bretton Wood institutions -created to rebuild from the wars- influenced countries to “structural adjustments” and reduce the size of the state and let the major capital powers, multinational and financial banks, to expand their businesses globally. The World Bank gradually “took over”[vii] the influence of health policies through loans subject to social spending cuts and tax exemptions to major economic powers, which from the 90s, hold most governments in their grips. Twenty years after the hopes of health for all from Alma Ata, Primary Health Care became “selective”[viii], health services became restricted to “cost-utility” (measured through the burden of disease tool of the World Bank) interventions (WB, Investing in health)[ix] and health financing was set at some meagre levels for low income countries by the commission on macroeconomics for health[x] . All were recipes of bankers for the poor countries to survive and lift from extreme poverty of under-one-dollar-a-day[xi] yet under much lower life expectancies than those feasible for all. The last decade of the century was further shadowed with the AIDS pandemic[xii] and the even less visible health impact of the collapse of the Soviet Union[xiii]. Globally life expectancy continued to slowly increase thanks to the counterbalance effect of the health gains of the most populous country in the world, China[xiv]. By the turn of the century, the Millennium declaration focused three out of their eight Millennium Development Goals  on health but, not surprisingly after two decades or restricted and selective health care, they focused on either population groups (maternal and under 5 mortality) or diseases (tuberculosis, malaria and HIV/AIDS). In parallel almost on one payed attention to the upgrade of the right to health in the international covenant of economic, social and cultural rights[xv]. The Global Fund to fight those diseases, responsible for some 20% of the global burden of disease, gathered more funding than the WHO itself, whose funding became gradually tailored to those and other vertical interventions[xvi] financed by Western development agencies, the Pharma foundations and philanthro-capitalism, in close connection with the former[xvii]. The following decade claimed advances in rolling back those diseases but it soon became clear that health systems, after three decades of de-funding and brain drain, were unable to sustain the donor-funded vertical cooperation programmes. By the end of the first decade of this century the Commission on Social determinants for Health[xviii] exposed the deep connections of socioeconomic inequities and the right to health, while the Rio+20[xix] in Brazil revealed the grim horizon of climate change. However, the massive economic powers, held in fewer hands playing financial speculation globally, fuelled a global economy based on scale production and blind consumption. Countries’ and their citizens’ debts were managed by the same financial powers that ruled over the interest rates of treasury bonds, vital for all countries to keep their services running. Health was not an exception and it was progressively fragmented and privatised[xx]. The world clearly entered its second decade of the present century with growing inequalities and global warming, hijacking the future of coming generations. The cold war had changed to a torrid stage, “a war with no guns”, with far more damaging impacts[xxi]. The 2015 MDG target date arrived while the world reinvented its goals in the 2030 agenda including the objectives of equity (“leave no one behind”)[xxii] and preserving nature (most urgently limiting carbon emissions). That very year the world met in Paris and agreed on Humanity’s main challenge: rolling back climate change and avoiding the 1.5-degree/increase from preindustrial levels[xxiii], a point-of-no-return that would, and most probably will, trigger feedback loops of nature degradation and human and all-life suffering in our ill-treated planet. However, the goals of greater intra-generational (socioeconomic justice) and inter-generational (environmental justice) equity were far from ambitious[xxiv]. Equity in SDG 10 merely aimed at a greater growth (even 0.0001 %?) in the lowest 40% income group than the average (allowing for the exponential wealth capture of the 1% and the 1% of them)[xxv]. Carbon emissions in the Paris initial commitments targeted low reduction levels that would not prevent irreversible and catastrophic global warming before mid-century. The last five years saw further rupture of multilateral commitments to preserve life in our planet, including ours, with US President Trump’s denial of climate change, growing carbon emissions and global warming, loss of biodiversity and progressive stress on other planetary boundaries as surface water, forestland, sea pH, phosphorus and nitrogen cycles[xxvi]. The stress on nature and the high levels of human mobility and trade related to globalization, led to the present Covid-19 pandemic[xxvii] and revealed the dominance of the global market.  The present framework shows the absence of global solidarity and frameworks to collectively share knowledge, produce and distribute global public goods[xxviii] that may equitably preserve human life and roll back this and most likely coming pandemics.

Elusive health equity

Ten years ago, the World Health Assembly welcomed the Report on social determinants and health, and countries committed to measure their levels of health inequity[xxix]. The WHO developed an online health equity monitor[xxx]. Equity became a term used widely and in all languages, even at a higher rate than equality. In the last ten years, though the use of the term seemed to decrease –see figure 1 on n-gram viewer counts screening over 8 million books -.

Figure 1 : N-gram viewer counts of equity vs equality

The use of the term “equity” is also subject to interpretations. Interestingly, while the Latin original word relates to fairness its use in economy has been associated to the individual shares of profits through financial speculation, one of the main dynamics leading to inequities. In health, both the WHO, most countries, civil society and academia, have measured equity through inequalities in exposure to risks, access to services or health outcomes leaving the open question of what is fair or not, to interpretation or even political visions, interests or marketing. That is how the MDGs set arbitrary targets of under-five or maternal mortality reductions, or the present SDGs opted for addressing inequalities –and in a very marginal way as above mentioned- rather than inequities. So the main question remains: what is fair and what is unfair?[xxxi]. While it is subject to cultural norms, moral references and ideologies, from the ethical point of view “a collective goal which is feasible for all can set a minimum threshold of fairness”. In health, the only internationally agreed common goal is the WHO constitution, which article 1 states that all countries will strive to “the best feasible level of health for all peoples”, that is, health equity. However, the “best feasible level of health” has not been identified and, hence, the level of health equity or inequity has never been measured. As mentioned above, the World Bank developed the metrics of burden of ill health[xxxii] and did so by comparing the effects of risk factors and diseases on premature deaths and disability with the best levels of health in terms of healthy life expectancy (enjoyed by Japan in the last two decades). However, is that “best” “feasible for all”? Certainly not in terms of the use of economic means and natural resources. This applies as well to all high-income countries and the OECD group of “developed economies” championing “development” models and “development aid”[xxxiii]. In the same line, the United Nations way of assessing progress by the “human development index” (HDI)[xxxiv] puts a significant weight on income and monetary flows (measured by GDP pc). As a consequence, it grants the highest scores to countries, which use economic means far above the world´s average (hence not replicable) and through production (even if gradually externalized), and consumption patterns incompatible with preserving natural cycles for coming generations. Had the whole world “enjoyed” the wellbeing of countries with highest HDI with their levels of carbon emissions, just to name one of the planetary boundaries under human stress, global warming would be today almost incompatible with human life. So, how can we aim at defining “best feasible level of health”?

Health equity metrics

Selection of healthy, replicable and sustainable models

Since 2011 we have been trying to define the best levels of health which are feasible today and will remain so, that is, sustainable, for coming generations. Overall, people and their forms of associations, organize their collective lives through laws, knowledge and means. While knowledge and laws aim at constant advancement and universal rights, means are limited in natural sources and economic flows, inter-related between them. We looked for healthy and feasible (and sustainable) country references. We tried to avoid the arbitrary thresholds or goals as previously set with international poverty thresholds, MDGs, SDGs and others. We then chose health, economic and ecological indicators available at national averages since 1960 from World Bank, UN and WHO sources. To select “healthy” models we chose those with constant levels of life expectancy above world average. Among them, we looked for those constantly using economic means in a globally replicable way, measured in GDP pc below world average. Within that group, we identified countries with carbon emissions pc below the “ethical threshold” which would lead to 2 degrees of global warming during the XXIst century. The analysis then found 14 countries which met the above-mentioned three criteria (Healthy, economically Replicable, ecologically Sustainable: HRS)[xxxv] constantly from 1960 to 2010 : Albania, Armenia, Belize, Colombia, Costa Rica, Cuba, Grenada, Saint Lucia, Saint Vincent, Georgia, Paraguay, Sri Lanka, Tonga and Vietnam. Five years later, we refined our selection of healthy references introducing sex disaggregation in life expectancy and the burden of disability through the healthy life expectancy indicator. To select economically replicable models we looked not just at GDP pc but also GNI pc and not only in constant value but also in purchasing power parity (PPP).  By that time, the International Panel on Climate Change (IPCC) updated the threshold of global warming “point of no return” at 1.5 degrees over pre-industrial levels, and so we adjusted the “ethical threshold”. As a result, our selection of “HRS” countries in 2016 ruled out half of the 2011 HRS models, remaining only seven countries, which met the updated HRS criteria: Armenia, Colombia, Costa Rica, Paraguay, Sri- Lanka and Tonga[xxxvi]. Most of the countries dropped off the previous list did so due to carbon emissions above the ethical threshold. In our latest analysis hereby presented, we again looked at constant HRS models introducing three new indicators: wealth pc in economic replicable models (R), bio capacity pc, and ecological footprint consumption pc below world’s bio capacity average selecting ecologically sustainable (S) models beyond the carbon emissions. The trend of the previous list of countries (trespassing the carbon emission threshold in most cases and in others, as Costa Rica, the GDP pc) led to the selection of only one HRS country. In fact, that only HRS country 1960-2020 was also the only one to meet all criteria, including the latest introduced on bio capacity and ecological footprint, during the last 2010-2020 decade. That country is Sri Lanka.

Figure 2 : Sri Lanka life expectancies vs thresholds (world averages)

Figure 3: Sri Lanka GDP and GNI pc (CV and PPP) vs. thresholds (world averages)

Figure 4 : Sri Lanka carbon emissions and ecological footprint pc vs. thresholds (world bio capacity pc average)

Obviously international data have many limitations: the reliability of those statistics varies widely between countries and the average does not reflect the subnational often-heterogeneous reality, especially in large countries. We looked at subnational data -where available- and identified subnational regions, which met HRS criteria. Data are more limited across countries and time- periods on health and economic indicators. We found no official data on carbon emissions pc at subnational levels and we used the international correlation between GDP pc and carbon emissions. Using only those three indicators and often only available for less than a decade, we found large subnational regions in China (Shanxi, Guangxi, Anhui, Sichuan and Henan), India (Kerala), Russia (Ingushetia and Chechnya) and Brazil (Alagoas, Praiba, Ceara, Para, Bahia and Rio Grande). None of the EU, USA and Japanese subnational regions were ecologically sustainable. Ideally, the analysis of HRS indicators at subnational and sub-regional levels would increase the sensitivity in finding more HRS populations with healthier, more economically efficient, and ecologically sustainable features.

The burden of health inequity

Following the ethical argument of equity stated above (feasible common goal = moral imperative) in coherence with the WHO foundational objective (best feasible health for all) and the identification of such feasible and sustainable health models (for now at national level), we could calculate the burden of health inequity, that is, the unfair and preventable (in relation to feasible and sustainable models) loss of human life. The HRS models served as the reference mortality rates and so we could estimate the expected mortality in all countries if they enjoyed such –feasible and sustainable- rates (adjusted mortality rates). The net burden of health inequity excess of observed mortality in relation with the HRS-expected on.  As the UN Population Division publishes data on population and deaths by country, sex, age (5-year age groups) and country as 5-year annual averages, we have been estimating the burden of health inequity for the last decade for the periods 1960-2010, 1960-2015[xxxvii] and –hereby- 1960-2020. Using the first set of HRS –simplified- criteria (3 by 50 years and 198 countries : some 30,000 data) and 14 HRS reference countries till 2010 and the population and mortality data by 5-year periods and country/sex/age groups (some 80,000 data), the annual net burden of health inequity (nBHiE) evolved from some 23 million in 1960 to some 16 million in 1970 and was stable thereafter at that level –with some increase in the 90s (due to the AIDS pandemic and the collapse of the Soviet Union)- till 2010[xxxviii]. When we applied updated and refined HRS reference data in 2015 we found similar results with slightly lower nBHiE in the 60s and higher (around annual 17 million) in the last decade. At that point, we looked at sub-regional (European Union) and sub-national (China, India, USA, Russia and Brazil) data to identify –as mentioned above- HRS states and provinces, even counties in some cases, and estimate national nBHiE. When applying lower level/size and larger sample units in the analysis, we found enhanced sensitivity in detecting nBHiE in the regions and countries with life expectancy above world average. For instance, with the caveat that no NUTS region in the EU were ecologically sustainable, the ratio of nBHiE ref global HRS vs. nBHiE ref. sub-regional HR(S) was > 0.11. In the analysis of the data adjusted to refined HRS criteria and references (Sri Lanka) and updated until 2020, the nBHiE in the last five years remained at some annual 16 million. Figure 5 shows the different estimates of the nBHiE by the evolving HRS criteria and updates by the 5-year period UN Population data. The divergence of the most recent HRS methodology in the 1996-2000 period relates to the peak of victims of the Sri Lanka war, which in total meant some 100,000 casualties, mainly adult men. Hence, the under-estimate of the global burden of health inequity by the end of the century compared with the previous methodologies and results where a larger group of countries diluted individual circumstances in each of them.

Figure 5: nBHiE by the evolving HRS criteria and country references

As population size and demographic structure conditions the nBHiE and disables its comparison between countries, periods of time sex and age groups, we estimated the proportion of deaths, which were due to health inequity by dividing the nBHiE by the total number of deaths. We called it the relative burden of health inequity (rBHiE). As Figure 6 shows, such proportion of unfair/preventable deaths has decreased slightly in the last 5 years but remains close to one third of all deaths, a level with only minor variations since the 70s. The rBHiE is higher in women than men and such gap has increased since the turn of the century.

Figure 6 : World's rBHiE 1960-2020

We applied the same analysis to age groups and found, as Figure 7 shows, that the relative burden was higher in younger age groups and women had their higher share of inequity than men in the reproductive age groups.

Figure 7: World's rBHiE 1960-2020 by sex and age groups

The former analysis emerges from interactive pivot tables and maps of all countries and main geographic and economic regions based on algorithms calculating nBHiE and rBHiE data by 5-year period (1960-2020), sex, 5-year age groups. They form a set of close to 500,000 data which will be shortly on line and interactive to search and compare the burden of health inequity across countries, time and demographic variables.

Health and economic inequity

Another dimension of our analysis is the link between the burden of health inequity and the unfair distribution of economic inequality (“equinomics”). By the very concept and methodology of the selection of HRS models, those countries with lower levels than the HRS GDP pc have a lower life expectancy and the highest burden of health inequity. We therefore called the HRS GDP/GNI pc (CV or PPP) the “dignity threshold”. In contrast with the poverty threshold set by the World Bank (at present daily $1.9 pc) the dignity threshold enabling feasible and sustainable life expectancy stands now at daily $10.8 pc, 5.7 times higher. We then looked at the level of GDP pc above which no country has had -along the study period- levels of sustainable ecological indicators (carbon emissions and ecological footprint), which was almost symmetrical with the dignity threshold above the world average GDP pc and we called “excess threshold”. Interestingly, just four countries of over one million inhabitants (Japan, Switzerland, Italy and Spain) had life expectancy above Greece, with GDP pc below the mentioned excess threshold. Moreover, when exploring the sub-national regions’ life expectancies we found regions in Greece, Cyprus, Italy and Spain, with GDP pc lower than the excess threshold and life expectancies higher than the country with highest levels (Japan), notably Ipeiros, in Greece (GDP pc 14,600, life expectancy 84 years). Hence, GDP pc above the mentioned excess threshold of some daily $50 pc is not required for better health. In fact, most countries with higher GDP pc have lower life expectancies than Greece and the mentioned regions. Furthermore, higher levels of GDP pc accumulates resources in detriment of the deficit areas disabled to the right to health, and is unsustainable with the sustainability of natural resources, hence the health of coming generations.

The dignity and the excess thresholds above described set three “equity zones”: deficit, equity and excess. The majority (84%) of the nBHiE takes place in countries in the deficit zone, home –see below- to almost half of the world’s population. Countries with average GDP pc higher than the HRS reference have a degree of burden of health inequity revealing health inefficiencies or internal inequities in comparison with the HRS standard. Three fourths of the nBHiE in the equity zone takes place in China, Russia, South Africa, Brazil and Mexico.

Figures 8 and 9 show the contrast of the distribution of the world’s population and GDP according to the deficit, equity and excess zones. While only some 15% of the world’s population lives in countries in the excess zone, they accumulate almost 70% of the GDP. We also looked at wealth and the distribution was even more skewed, with the excess 15% population owning over 80% of the world’s estate, goods and capital.

Figure 8: World population by countries' equity zones

Figure 9: World GDP by countries' equity zones

The redistribution required to enable the entire world’s population to have at least the dignity threshold’s spending capacity would be 7.75% of the world’s GDP (vs. the OECD DAC 0.7% commitment) which is just 10.6% of the excess GDP (unnecessarily) above the excess threshold.

Health inequity and the ecology

The world’s national borders already pose a major inequity in terms of access to natural resources.  Figure 10 shows how in fact the countries with lower access to economic flows (GDP pc), in the deficit zone, also have a low bio capacity pc. We are, therefore, born already with skewed opportunities to enjoy the universal right to health.

Figure 10 : Bio capacity pc by populations in countries' equity zones

As figures 11 and 12 show, all countries in the excess zone have ecological footprint and carbon emissions pc, which are, if generalized, unsustainable with the turnover of natural resources. Even in the equity zone, the average of ecological footprint pc surpassed the ethical threshold in the last decade while the one for carbon emissions did so already in the 90s. In the case of carbon emissions, the level of cumulative carbon emissions pc of excess zone countries, from the industrial revolution until present days, would have already meant over 5 degrees of global warming and render unliveable most of the world, especially the tropical zones colonized by those polluting powers and decimated from their natural resources.

Figure 11: Ecological footprint by equity zones vs. ethical threshold

Figure 12: Average carbon emissions by countries' equity zones vs. ethical threshold

According to our analysis, the present level and trend of carbon emissions will lead to the 1.5-degree warming above pre-industrial levels before 2050. If that trend prevails, increased temperatures will mean an excess mortality of 220 million. The distribution of such excess mortality, more than three times the suffering by the world wars in the XXth century reveals the most perverse inequity : it will take place mainly in the second half of the century, in those over 60 years of age (millennials born after 1990) and in the less polluting countries in tropical regions.

HDI vs. Health holistic index

When we measure development indicators, we look at individual wellbeing, based on the western philosophy, which grants to each human life the highest value and so has championed universal human rights, including the right to health. As we have seen in the analysis of the burden of health inequity of the last 60 years, large inequities in natural and economic resources result in high levels of burden of health inequity within pour generation and between ours and the coming generation (due to global warming). We therefore looked into the negative impact on others of excess accumulation of resources (preventing equitable distribution and maintaining half the world in the deficit zone incompatible with the right to health) and of excess carbon emissions (leading to growing excess mortality in the coming generations). We estimated the life years lost due to the burden of health inequity in countries in the deficit zone (with unmet basic condition of the dignity threshold of resources). We then calculated the excess GDP above the excess threshold (above which health and wellbeing does not improve). The relation between both resulted in around one week life lost per annual GDP pc 1000$ above the excess threshold. We did a similar analysis for the life years to be lost due to global warming and the relation with excess carbon emissions above the ethical threshold. The result was of two life days lost per annual excess CO2 ton above the ethical threshold. We deducted from the individual life expectancy at birth in each country the annual negative impacts of excess GDP pc and excess carbon emissions pc, to calculate what we call “equitable and sustainable wellbeing(ESW) (including individual wellbeing void of negative impact on others).

The countries with highest ESW were Costa Rica (the highest, with 77.7 years) followed by Cuba, Greece, Albania and Uruguay. None of them is fully economically replicable and/or ecologically sustainable but falls within the equity curve and has committed to reduce carbon emissions below the ethical threshold. We compared our assessment with the UN Human Development Index (HDI). The HDI grants, besides life expectancy and education years (which correlates with the former), high value to GDP pc with no limit (and calls it “a decent standard of living”), mimicking the dominating concept and dynamics of capitalism (constant growth and accumulation). Consequently the countries with highest ESW rank moderate in the HDI rank while those with the highest HDI rank among the lowest in the ESW due to their negative impact through excess GDP pc and excess carbon emissions.

Country HLI 2018 HLI rank HDI 2018 HDI rank
Costa Rica 77.72 1 0.81 62
Cuba 76.83 2 0.78 70
Greece 76.29 3 0.89 32
Albania 76.12 4 0.80 69
Uruguay 75.94 5 0.82 55
Chile 75.94 6 0.85 43
Panama 75.69 7 0.82 57
Lebanon 75.41 8 0.74 92
Croatia 74.95 9 0.85 43
Montenegro 74.81 10 0.83 48
Table 1: Top countries in Equitable and Sustainable Wellbeing (ESW) vs. HDI and rank
Country HLI 2018 HLI rank HDI 2018 HDI rank
Norway -1.30 183 0.96 1
Ireland 3.43 182 0.96 2
Switzerland -7.24 184 0.96 2
Hong Kong 40.29 167 0.95 4
Iceland 8.47 180 0.95 4
Germany 39.75 169 0.95 6
Sweden 31.69 175 0.95 7
Netherlands 33.59 174 0.94 8
Australia 25.44 176 0.94 8
Denmark 23.17 177 0.94 10
Table 2 : Top countries in Human development Index vs. ESW value and rank

Our analysis of global health equity has been challenging for a decade the prevailing concepts of development, poverty threshold and health equity, and their related metrics.

With the preliminary findings of our third analysis hereby outlined, we have fine-tuned criteria of wellbeing-health, economic feasibility-replicability and ecologic sustainability and updated to the period 1960-2020 demographic data. The results, in the midst of the Covid-19 pandemic, adding more global inequity[xxxix], lead us to reaffirm our challenge to the above-mentioned mainstream concepts, in our opinion, detrimental to the universal right to health and health equity.

The main findings from the latest global analysis of health equity are as follows:

1.-the concept of equity, that is, fair inequality, requires the definition of feasible levels of the agreed common goal (health). The 73-year old (same as world average life expectancy now) constitution of the World Health Organization states this concept (best feasible levels for all) in its founding constitution. While best health levels are identified to estimate the burden of ill health and economic indicators as cost-utility, often guiding major decisions on priorities and strategies, best feasible (and sustainable) levels have not been identified and used at national nor international levels. WHO continues to monitor health equity, ten years after the resolution on social determinants for health, by estimating health inequalities (by stratifying variables of income, education or rural/urban settings) and only in certain age groups (children and pregnant women) and some countries, (low and some middle income countries) based on household surveys with limited representability and time-frequency. Through our studies during the last decade, we continue to propose the definition of best feasible (and sustainable) health levels which enables the estimates of net and relative burden of health inequity. We propose this methodology, improved and developed at national and subnational levels, as a critical indicator of the realization of the universal right to health and a powerful barometer of international and national justice.

2.-the number of countries meeting the evolving (fine-tuned with health sex disaggregation, economic and ecologic dimensions) criteria of replicable and sustainable health-wellbeing from 1960 has been decreasing from fourteen till 2010, to seven till 2015 and only one till 2020, possibly the last year when we may identify countries that have steadily met the mentioned criteria.

  1. – for the last forty years, the net-burden of health inequity (nBHiE) has been fluctuating between 18 and 16 million deaths and the relative burden of health inequity (rBHiE) remained almost stagnant around 30% with a slight reduction since the turn of the century. Such reduction rate has been lower for girls and women and they suffer significantly higher levels health inequity, especially in the reproductive age groups. Children and youth have higher rBHiE although older age groups have gradually increased their rBHiE with time. Our interactive database (updated with the recent data hereby outlined) allows the comparison of the net and relative burden of inequity between periods, countries, sex and age groups. When such analysis is done at subnational level, as we have attempted in the last years in a number of countries, the mapping of the burden of health inequity and demographic features may guide economic, social, fiscal and territorial cohesion/equity targets and strategies.

4.-the HRS reference models define a “dignity threshold” below which no country has, now for sixty years, been able to enjoy a level of life expectancy at birth, for women and men, feasible and sustainable for all. Such dignity threshold, presently at some 10$/day, is more than five times higher the “poverty threshold”. One third of the world’s population lives between the poverty and the dignity threshold, has no chance to enjoy the right to health and remains neglected by economic and cooperation approaches led by the concept and threshold of poverty.

  1. – The prevailing development concepts and references are deeply intertwined with the mainstream economic dynamics ruling the international and national policies and lifestyles. It avoids setting any limit to economic flows, growth and accumulation. In fact, it grants the highest human development index to the countries with highest GDP pc called (the higher the better) “decent (?) standard of living” which, if generalized, would require several planets in terms of natural resources to be replicable and sustainable. Contrary to this dominant paradigm, excess accumulation of economic flows and wealth is one of the main root causes of health inequity as it prevents equitable distribution of resources while it is ecologically unsustainable and, above the excess threshold, does not improve individual and collective health. We therefore propose an equitable and sustainable wellbeing index, which takes into account the individual conditions counterbalanced with the negative impact on others through excess accumulation and nature degradation. The countries with highest HDI rankings are among the lowest in the ESW index and this fact merits a debate around the concepts and metrics guiding development.

6.-We define the “equity curve” as the distribution of the human population according to their GDP pc capacity, between the above-mentioned dignity threshold a centre around the average and a symmetric “excess threshold”. It allows best subnational levels of life expectancy within the equity curve, economically replicable models to gradually improve its efficiency in translating shared knowledge and resources into wellbeing and a sustainable use and recycling of natural resources to allow intergenerational health equity.

Figure 13: Equity curve and thresholds



HRS : healthy replicable and sustainable

BHiE : Burden of health inequity

nBHiE : net burden of health inequity

rBHiE : Relative burden of health inequity

WES : Wellbeing in equity and sustainability











































A Global Health Crisis To Shape a New Globalisation

After major crises and wars, the world tends to recompose itself. One such crisis is Covid-19. The pandemic is exposing deep inequalities within and between countries that question the current model of globalisation. 

This piece argues that the pandemic is so widespread and disruptive that it is bound to bring significant changes in the world order. Covid-19 is already altering the balance of powers in global health, provoking a rethinking of a new legal and policy framework to prepare and respond to future global health threats, and inspiring a popular movement to treat global health as a global public good. 

A critical question is whether these changes will combine to address economic, environmental, and social inequalities rendering globalisation more legitimate, transparent and accountable; or whether the new order in global health will perpetuate inequality

By Enrique Restoy, PhD

Head Evidence: Frontline AIDS

Associate Researcher: University of Sussex, UK 

A Global Health Crisis To Shape a New Globalisation


Ironically, the biggest global health threat since AIDS might have certified the demise of globalisation as we know it.

We have witnessed a fragmented, disorganised and unequal response to the Covid-19 pandemic.

Can you recall any special session or resolution by the UN Security Council or the G-20 on the pandemic? Do you know what the World Bank or the International Monetary Fund did over the first months to help countries prevent the epidemic from becoming a pandemic with massive economic impact?

As the pandemic broke out, essential supplies such as ventilators and PPE were sold to the biggest bidder, with supplies turning last minute to whatever country paid the highest price. Big pharmaceutical companies rushed to develop vaccines with public funding from Western states that pre-ordered the vast majority of doses. It took months to set up the global initiative on vaccines (COVAX). The initiative will only deliver widespread distribution of vaccines to most low-income countries well after they have reached most people in the rich ones.

Governments constantly undermined World Health Organisation’s guidelines, imposing their own versions of what measures needed to take place. For months, Sweden allowed near normal life, while the rest of Europe was confined. For a few days, the US banned travel from Europe, but not from the UK, apparently because the UK government was a friend.

The coronavirus also provided the perfect canvas for nationalists and populist to show their true colours.

Brazilian president Jail Bolsonaro, first denied out rightly that there was even a pandemic killing hundreds of thousands of Brazilians. Then he told his people to ‘toughen up’. Late Tanzanian president, John Magufuli, rejected vaccines and invited the population to pray instead.

Some countries expelled migrant workers who had lost their jobs due to the pandemic thus fuelling discrimination against returnees in their country of origin.

This pandemic has indeed erased any belief that our globalised world was equipped to deal with a major planetary crisis.

Globalisation as we knew it

Since the end of WWII, globalisation has increasingly opened international borders to the exchange of goods, services, finance, people and ideas. It created institutions and policies at global and national levels to facilitate such movement.

Both neo-liberals and conservatives on one hand, and progressive thinkers on the other, loved to hate globalisation. But loved it somehow.

For the neo-liberals, globalisation broke down trade barriers, expanded the power of multinational corporations, and protected the global financial sector during economic crises, bringing the biggest global economic growth in GDP terms in history.

Any young graduate from a middle-class background in the rich West could choose in which country to work, where to go the next weekend on a city break abroad, what new gadget to buy that would be home in a matter of hours. A life of opportunity and open doors. Alas, not for all.

For the progressive proponents representing the interests of the most marginalised, globalisation brought about a strong human rights system underpinning its universal values, epitomised by the Human Rights Council, which since 1989 has periodically scrutinised the human rights record of almost all countries on the planet.

Globalisation made possible an unprecedented global health response to HIV and AIDS with its own global governance facilitating the access to affordable lifesaving treatment to now over 24 million people living with HIV across the world.

Globalisation framed the Millennium Development goals (MDGs), a set of state commitments that have led to a drastic reduction in maternal and child mortality and severe poverty, and a dramatic increase in girls’ access to education and among other huge advances in human development over the past few decades.

The Sustainable Development Goals (SDGs) which replaced the MDGs went further to underpin the respect for human rights in the pursuit of development; and the Paris Agreement represents a legally-binding recognition by many states that they need to take decisive action against climate change.

There were therefore positives in globalisation from all perspectives of the development debate.

Covid-19: globalisation as it really is

Anti-globalisation sentiment however, has been strong and mounting in the past few years. Although it traditionally came from the left side of the argument, it has also been highly criticised by the right.

The coronavirus and its inadequate response across the globe has exposed most brutally and to most people two critical problems globalisation has exacerbated to perhaps, a point of no return: inequality in treatment and opportunities, and an insatiable pursuit of economic growth to the detriment of the Earth’s limited resources.

These two problems are interdependent. Without strong social protection systems and measures to address inequalities in society, economic growth tends to multiply such inequalities while destroying the environment. And vice versa, societies with large inequalities need much greater economic growth to reduce poverty, thus decimating the Planet even further. Inequality hurts economic growth and the Earth.

However, across the globe, the quest for economic growth has meant weaker policies to ensure a more equitable distribution of wealth, and inadequate measures to reduce the environmental impact of such growth. Globalisation contestation has failed to stop this self-destructive trend.

But Covid-19 has had an unprecedented impact on the entire notion of globalisation. It has brutally exposed the underlying inequalities of globalisation both in the more economically developed countries and in the less economically powerful ones.

Inequality within countries is fuelling the pandemic and putting those left behind and everybody else around the world at higher risk.

People from all layers of society in the most unequal countries (whether rich or poor), with inadequate public health services for less affluent people, have suffered the most. Middle class people have descended into situations of near destitution and poverty. This is happening in countries with large GDPs (the great pursuit of globalisation as we now it), such as the UK, as well as countries with low GDPs.

Covid-19 has also exacerbated inequality between countries as illustrated by the huge concentration of vaccines in richer economies while the rest of the world watches on.

Yet, this is a global health crisis involving an air-borne virus that travels the world around thanks to globalisation. In this case, the cliché is real and resonates among people the world over: nobody will be safe from the coronavirus until all people in all countries are.

Globalisation has gone so far that the question might not be whether it will survive, but rather, what will make it work for all. According to Joseph Stiglitz, globalisation could promote equality provided it was transparent, legitimate and accountable.

The challenge is to make globalisation favour full employment, social protection policies to protect living standards against economic shocks, universal quality health coverage, and perhaps most important of all, policies that reduce inequalities within and between countries.

Global health is so embedded into the engine of globalisation that it will be at the core of any reform of the economic order that might ensue from the pandemic.

I see three critical areas of positive change if global health was to reform because of Covid-19: a new global health balance of powers, a change in the laws and practices of international cooperation on health, and a popular movement for equality in the access to vaccines and equitable access to health in all countries.

  1. A new balance of powers in global health

According to WHO and UNAIDS, global health should be treated as a public universal good, with global governance structures which should not be dominated by the richer, more powerful countries. Yet, these very agencies are indeed at the mercy of the biggest economies that fund them. The dependency is even greater in the case of the Bretton Woods institutions: the IMF, the World Bank, and the World Trade Organisation (WTO). In global health, there is the additional dependency on multinational pharmaceutical companies, who control key global health supplies with patents largely protected under Intellectual Property regulations, a regime set out by WTO.

These dependencies contradict all the principles of change that would render globalisation a framework of equality. They do not favour transparency and these institutions are mostly only fully legitimate for and accountable to rich countries.

I wouldn’t hold my breath that powerful countries would want to give away their power in global health decisions. However, the balance of powers in global health may be changing. For example, the vaccine diplomacy of China (Sinovac vaccine) and Russia (Sputnik V vaccine) is making their Covid-19 vaccines available to lower income countries faster than vaccine-producing countries in the West. This diplomacy is increasing the popularity of these no longer emerging superpowers across many regions. Yet, as of early 2021, most countries were still negotiating with very little bargaining power their access to Vaxzevria (formerly AstraZeneca), Pfizer-BionTech, Moderna, and Johnson & Johnson Janssen, all of which were produced by Western multinationals with heavy public investment from European countries and the USA governments.

The new vaccine diplomacy might simply signal a change in who is dominating global health rather than a more equal distribution of powers across the board. But Mike O’Sullivan also sees a new multilateralism bringing countries together around shared values or interests. This has led to interesting initiatives such as Nordic countries and Southern Hemisphere countries acting together against climate change. These initiatives could be more transparent and accountable for more people living outside rich countries.

This trend could facilitate the creation of alliances among countries for which public health is a true public good and these countries could establish new global, albeit not universal, agreements and frameworks that advance global health as a public good in a good number of countries. Could there be room for an improbable alliance for health as a public good involving Cuba, the UK and Japan, for example?

  1. Changing laws and practices in global health cooperation

Reforming the laws and practices of international cooperation on health seems more straightforward given how abysmal such cooperation, or lack of, has been when confronting the Covid-19 pandemic. However, this might prove tricky. Global health legal and policy instruments are riddled with red lines set by states and corporations. In the end, big pharmaceutical companies’ interests, border control, and geopolitics often have the upper hand over public health needs, let alone the human right to health.

There is already a battery of legal instruments to regulate global health and foster collaboration to address health risks with the potential to threaten global security. These are mostly encapsulated in the WHO health regulations (IHR) introduced in 2005 and currently under review.

The IHR include requirements for the development of States Parties’ capacity to rapidly identify, report, and respond to potential public health emergencies of international concern. They also state that the responses must avoid unnecessary interference with human rights (although the IHR contemplate temporary derogation of human rights under some public health imperatives).

The IHR have not really worked well to respond to the Covid-19 pandemic.

It is therefore tempting to advocate for the current overhaul of IHR or the establishment of a new legal framework on pandemic suppression to radically change how the world responds to global health threats. For that, this instrument  would have to uphold the principle of health as a global common good, embracing the right to equality as the key paradigm for the prevention of pandemics.

For this to work, there needs to be wide political consensus across countries and have teeth: to be legally binding, to come with considerable funding to help countries collaborate and prepare for future pandemics and distribute the medical response to them equitably; and to set up strong accountability mechanisms to ensure monitoring and compliance.

If such new mechanism underpins the principles of health as a public good, and the human right to development, not just to health, it could help frame a response to the economic, social and environmental inequalities within and among countries that are the root cause of health inequality. With that framing, the mechanism could be particularly ambitious in the medical preparedness and response to pandemics, for example, with the suspension of vaccine patents in times of pandemic crisis and fair pre-established vaccine production and distribution schemes and economic recovery stimulus. If the mechanism is clear in its definitions, principles and enforcement measures, it has the potential of bringing levels of transparency and accountability that have not existed to date in global health.

Some countries are already calling for a Pandemics Treaty for preparedness and response. They demand an instrument that ensures “universal and equitable access to safe, efficacious and affordable vaccines, medicines and diagnostics for this and future pandemics”. This is a good starting point to make things change. But it sticks to the idea of promoting just health equality. Yet again, advancing a medicalised response to pandemics that falls short in addressing the root causes of health inequality: social, environmental and economic inequality within and between countries.

  1. A people’s movement to change priorities in global health

The problem with the two first areas of positive change I just mentioned is that they both very much depend on governments’ will. In the international arena, bold ideas often end up watered down by conflict of priorities, corporate interests, internal public opinion and diplomatic disputes.

Here is where the example of HIV and AIDS is most compelling. It was a global human rights campaign initiated in the US and Europe, but followed suit soon after in South Africa, India and many other countries that sparked the biggest global respond to a health threat ever to be seen. Herein lied a great deal of the legitimacy of the global HIV movement.

The argument that won this response was an outcry for the human right to live. Hundreds of thousands of people filling the streets and demanding access to treatment for those living with AIDS. A case for AIDS as a global security risk made at the UN Security Council and as a major public health threat warning by WHO came when the movement was well underway.

However, even though the HIV movement created its own global governance and has mobilised billions of dollars to safe millions of lives, it has not ended health inequality, and stigma, discrimination and human rights violations against marginalised populations affected by HIV: people who use drugs, the LGBT community, sex workers, young women and adolescent girls, among others.

This time, it will take a much bigger social movement to make the profound shift to bring about global equality in health. It will need to be an overwhelming force demanding accountability at all levels of the global health architecture. A truly global movement with legitimacy the word over, not a campaign dominated by civil society in the global north.

Will it be the #Peoplesvaccine campaign? It is early to say. In favour of this initiative, this pandemic is affecting every single person around the World. That was not the case with HIV. The campaign message is also compelling:  ‘pharmaceutical corporations must allow the Covid-19 vaccines to be produced as widely as possible by sharing their knowledge free from patents. Governments must facilitate such transfer of knowledge so that, when safe and effective vaccines are developed, they are produced rapidly at scale and made available for all people, in all countries, free of charge.’

Conclusion: time to make globalisation promote global health equality

Covid-19 and globalisation are inextricably linked. The virus has travelled all around the world at lightening speed facilitated by the free flow of people, a trait of globalisation. The pandemic has become a global health threat of utmost concern for the institutions governing globalisation, especially the Bretton Woods organisations, WHO and other UN agencies, and multilateral governmental fora, such as G-20.

Yet, Covid-19 is having a devastating impact on the lives of billions of people in both high and low-income countries. The pandemic has exacerbated deep economic, social, environmental and health inequalities within and between countries. It has also brutally exposed deep weaknesses in the current globalisation model and its instructions.

Critical changes are already underway in three key areas of global health with the combined potential of revolutionising globalisation as we know it. The balance of power in global health is changing with a new vaccine diplomacy; a growing number of governments are calling for a review of laws and policies framing preparedness and responses to global health threats, and a mounting mobilisation of civil society for a reconsideration of global health as a global good.

We have a historic opportunity to ensure these changes combine with the long-term objective of eliminating global economic, social, health and environmental inequalities. For that, the new globalisation institutions and legal and policy frameworks must be transparent, legitimate and accountable.

However, if governments, civil society, private actors and other key stakeholders take a short term, narrow vision, these changes are bound to perpetuate the inequalities that the current globalisation model has created. That will be the case if the new balance of power simply replaces exiting dominant governments and corporations for new ones, if the new legal and policy framework for pandemic preparedness just focuses on medical aspects ignoring economic, environmental and social inequality, and if the peoples’ vaccine campaign fizzles out once Covid-19 is under control in most countries.







News Flash 427: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 427

Weekly Snapshot of Public Health Challenges



World Health Day 2021: did I miss something?

Policy Cures Research: webinar registration G-FINDER Launch Apr 15, 2021 01:00 PM in London

Webinar registration: “How do the 3Gs coordinate their efforts to strengthen health systems? From Policy to Practice” Apr 19, 2021 02:00 PM in Amsterdam

Regional Security in Times of Health Crisis – A Look at the East African Community by Becky Adiele 

Coronavirus disease (COVID-19) Weekly Update

A WHO senior official is under investigation in Italy

Chile and Uruguay, from model to emergency 

AstraZeneca’s COVID-19 vaccine: EMA to provide further context on risk of very rare blood clots with low blood platelets 

COVID-19 Vaccine Janssen: assessment of very rare cases of unusual blood clots with low platelets continues 

South Africa halts J&J vaccine jabs; Europe rollout delayed 

Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination 

Changes in symptomatology, reinfection, and transmissibility associated with the SARS-CoV-2 variant B.1.1.7: an ecological study

2021 Public Forum (28 to 30 September) theme to be “Trade beyond COVID-19: Building Resilience”

Previous COVID-19 Infection Reduces Reinfection By 84%, Finds Lancet Study

Meeting highlights from the Pharmacovigilance Risk Assessment Committee (PRAC) 6-9 April 2021

Chinese vaccines’ effectiveness low, official admits

Battling ‘supply constraints’, COVAX May Only Deliver 20% Of Vaccine Target By June

COVAX: A global multistakeholder group that poses political and health risks to developing countries and multilateralism 

COVAX reaches over 100 economies, 42 days after first international delivery 

In Brief: Lift export barriers to boost global vaccine supply, Moderna says

Access to Covid 19 vaccination only for the rich 

Online event: Big pharma: Your profits, our lives Wed, Apr 21, 2021, 6:00 PM –Thu, Apr 22, 2021, 7:00 PM CEST 

COVID-19 vaccine hesitancy and resistance: Correlates in a nationally representative longitudinal survey of the Australian population 

Africa Plots Ambitious Vaccine Targets at Manufacturing Conference

HIV and TB Patients Face New Barriers To Accessing Services In COVID-19 Era

New WHO Global Compact to speed up action to tackle diabetes

MSF calls on WHO to prioritise supply of more quality-assured sources of insulin

Diabetes: Three dangerous myths that are hurting patients

Mali’s failure to ban FGM challenged in West Africa’s top court

Lo Stigma della siringa 

Shielding Corporate Interests, Europe Leaves NGOs Working in China by the Wayside 

Barilla Foundation Brings Health and Climate Together in New Double Pyramid 

NZ to launch world-first climate change rules

US envoy John Kerry woos China over climate

From 22-25 April 2021, the COP26 Coalition will host From the Ground Up: Taking Action, our second global gathering for climate justice






News Flash 426: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 426

Weekly Snapshot of Public Health Challenges




Webinar registration: “How do the 3Gs coordinate their efforts to strengthen health systems? From Policy to Practice”

Investing In Evidence To Inform Practice: Reimagining The US Public Health System

Rwanda Global Healthcare Summit: 9th to 11th August 2021 by Memory Usaman

Bundle of Joy or Cause for Shame? Just What Mothers in the Kenyan Informal Settlements Face. A Tale of Inequalities in Maternal Health Service Delivery by Reagun Andera Odhiambo 

Rohingyas, human rights and raising our voice

Promoting Women’s Economic Empowerment in the COVID-19 Context

Lessons for effective COVID-19 policy responses: a call for papers

How will COVID-19 transform global health post-pandemic? Defining research and investment opportunities and priorities

COVID-19, lies and statistics: corruption and the pandemic

Coronavirus disease (COVID-19) Weekly Update

AstraZeneca’s COVID-19 vaccine: EMA finds possible link to very rare cases of unusual blood clots with low blood platelets

Interim statement of the COVID-19 subcommittee of the WHO Global Advisory Committee on Vaccine Safety on AstraZeneca COVID-19 vaccine

Strong Link Between COVID-19 Infection & Mental Health Diagnoses – New Lancet Study

Brazil’s Supreme Court decision to amend national patent law could break lengthy monopolies on lifesaving medicines

WHO urges countries to build a fairer, healthier world post-COVID-19

U.S. puts J&J in charge of plant that botched COVID vaccine, removes AstraZeneca

Webinar registration: Conversation Series 2- Pandemics and Public Health: Learnings from the Past and Present April 16, 2021 Time: 06:30 PM – 08:30 PM IST 9:00 AM – 11:00 PM EDT

Vax-Covid. A passo di gambero

Haiti has no Covid vaccine doses as violence looms larger than pandemic

Uganda Green Lights Private Imports Of COVID-19 Vaccines – Kenya Nixes Similar Initiative

Kenya, expressing concern about counterfeit vaccines, blocks private imports of doses

Control of sexually transmitted infections and global elimination targets, South-East Asia Region

Eliminating mother-to-child transmission of human immunodeficiency virus, syphilis and hepatitis B in sub-Saharan Africa

The need for a new strategy for Ebola vaccination

Environmental burden of disease from unsafe and substandard housing, New Zealand, 2010–2017

The world report on hearing, 2021

A Healthy Indian Ocean Feeds, Protects, and Connects all South Asians

Indonesia’s Climate Villages Where Communities Work Together to Mitigate Climate Change

Impact of elevated air temperature and drought on pollen characteristics of major agricultural grass species

Ecological restoration of agricultural land can improve its contribution to economic development

‘Staggering’ scale of acute hunger in the Democratic Republic of the Congo










Rwanda Global Healthcare Summit: 9th to 11th August 2021

As per Memory Usaman (CEO at Be Still Investments)’ words “…The Rwanda Global Health Summit 2021 is perfectly launched at the start of a new decade during an unprecedented and uncertain time in global healthcare. This edition of the Summit will serve to highlight some of the most pressing contemporary global health challenges such as the coronavirus pandemic, Covid-19 national strategy, mental health ecosystems, and other pertinent topics in healthcare that are currently taking the back stage such as nutritional health, heart disease, diabetes, cancer, etc. The summit will also address topics such as healthcare quality, role of digital health in crisis management, Clinical trials in the New Health Economy, workforce shortages in healthcare, technological disruptions etc…”

By Memory Usaman

Founder & Chief Executive Officer at Be Still Investments-BSI organisers for Rwanda Global Healthcare Summit

Rwanda Global Healthcare 2021 Summit 

Theme: Global Health Delivery, Introduction Of New Ideas And Digital Innovation



About the event

Rwanda Global Healthcare Summit is an international three day event taking place in the beautiful & vibrant city of Kigali, Rwanda from 9th to 11th August 2021. The upcoming event is enriched with the combination of both realism in global healthcare delivery of today’s world & the opportunities the rapidly-evolving technologies bring to healthcare. Currently, the event is featuring more than 40 speakers from around the globe including Government delegates, healthcare industry experts, digital health experts, medical experts, pharma delegates & cultural icons who will address more than 1200 delegates in real time during the summit. There is a huge participation taking place from African sub-continent & from around the globe, where International hospitals, pharmaceutical companies, medical device companies, startups, NGOs’ to the biggest healthcare agencies are partnering so far from all over the world. We are committed to make it the biggest healthcare event in Africa for 2021.

The summit has already been endorsed by the Honorable Minister of Health in Rwanda, Dr. Daniel Ngamije and he will also inaugurate the summit which is supported by Rwanda Biomedical Centre, Rwanda Convention Bureau, FDA Rwanda and Rwanda Development board 

Be Still Investments Rwanda, the organisers of the Rwanda Global Healthcare Summit assures their respectable coming partners & sponsors, exhibitors, delegates and speakers to accept the assurance of the Ministry of Health’s highest consideration for the event. Our mission is to spark a global conversation on the healthcare of today, our pandemic preparedness and to raise the social consciousness of global health in 2021 and beyond. The summit will feature a range of pertinent topics that seek to empower and enable stakeholders to address the sustainable development goal of Health and Wellbeing for all.

Why This Is A Must-Attend Event of the Year in the African Sub-continent

  • Three-day conference aims to focus on the leadership challenges nations are facing in healthcare today.
  • A forum to widen and enrich the healthcare delivery and discuss the latest innovations in the sector.
  • Create opportunities for health experts from a range of disciplines and geographies to share their research ideas.
  • Engage with specialists in the domain of Pharmaceutical Sciences and Drug Manufacturing.
  • Increase knowledge by exploring the presentations of new techniques, novel approaches, unpublished data under one platform.
  • Advocate for areas of action in healthcare to achieve better outcomes and plan for future changes.
  • Develop tangible outcomes (e.g., strategic direction, policy papers, blueprint for action) to improve health care systems, delivery and digital technologies.
  • Creating great networking and business opportunities for the delegates, sponsors & participants.
  • Attracting hundreds of diverse exhibitors, from established fortune 500 companies to start-ups.

Why Rwanda

Rwanda has proven itself to be an extraordinary African success story & a pioneer in digital health in Africa. Emerged as East Africa’s investment gateway, it’s a market of over 12 million people with a rapidly growing middle class. Rwanda is a hub for rapidly integrating Africa, located centrally in the region and is part of East African Community (EAC) Common Market and Customers Union with a market potential of over 132 million people. It is also signatory to the 2018 Kigali African Continental Free Trade Area Agreement (ACFTA) currently being implemented under the African Union. Rwanda is showing the world how they can sustainably tackle the challenges in healthcare, and make it accessible and affordable for all at the same time.” The nation has made significant strides to enhance healthcare delivery to its population of 12 million people as it keeps demonstrating its appetite to undertake ambitious new approaches to addressing its challenges. Rwanda is internationally recognized for its success in offering universal access to healthcare. With over 84% of Rwandans insured by the mutuelle de santé, Rwanda has ensured that her citizens have access to primary health care. Rwanda plans to expand the provision of better health care and develop medical tourism through the attraction of state-of-the-art and specialized medical facilities. Technology is a big focus for Rwanda, so let’s come together to support & advance the progress towards the country’s long-term development goals.

The Rwanda Global Healthcare Summit is divided into:

The Conference

The conference is open for the abstracts for oral, poster presentations and symposia with the theme “Global health delivery, introduction of new ideas and digital Innovations”. All the original research abstracts and innovations are invited.

The Exhibition

With over 1,200 delegates this event is a perfect platform for all the companies to gain visibility in the growing African Healthcare, ICT Service Solution Providers, Pharmaceutical & Supplements, Medical Equipment & Devices, Surgical Sundries, Instruments, Reagents etc. market.

We are conducting Business to Business sessions, where Business owners & Decision Makers get time to give short presentations on what their esteemed organisations are doing or have achieved. Sponsorships will make your brand accessible & visible to the opinion makers, potential buyers & customers. It’s the best place for product launch, networking, workable business deals & winning more customers, all under one roof. We have more than 100 booths for the exhibitors in the Kigali Convention Center for three days to showcase the products & services.

What are we covering

The Rwanda Global Health Summit 2021 is perfectly launched at the start of a new decade during an unprecedented and uncertain time in global healthcare. This edition of the Summit will serve to highlight some of the most pressing contemporary global health challenges such as the coronavirus pandemic, Covid-19 national strategy, mental health ecosystems, and other pertinent topics in healthcare that are currently taking the back stage such as nutritional health, heart disease, diabetes, cancer, etc. The summit will also address topics such as healthcare quality, role of digital health in crisis management, Clinical trials in the New Health Economy, workforce shortages in healthcare, technological disruptions etc.

The power packed 3 days event consists of 11 featured tracks & 52 sub-tracks:

  1. Covid-19
  2. Clinical
  3. Public Health
  4. Digital Health
  5. Lifestyle
  6. Social determinants of Health
  7. Nursing and Midwifery Care
  8. Communicable Diseases
  9. Healthcare Quality & Patient safety
  10. Healthcare as Entrepreneurship
  11. Pharma & Life Sciences

Who should attend

The Rwanda global Healthcare Summit provides an excellent forum for entire healthcare fraternity, National & International Healthcare & social agencies, Private & Public healthcare providers, Medical Doctors, Nursing, Other Healthcare Frontlines,  Regulatory Bodies, Policy makers, Government Heads & Officials, Directors & Deans, Academia, Paramedics, Medical Devices Manufacturers, Suppliers, Entrepreneurs, R&D, Midwives, NGOs, Medical University students, Health Experts, Health Informaticians, Computer scientists, Public health experts, Epidemic intelligence systems providers, IT/SM industry, Pharmaceutical manufacturers & suppliers, Block-chain Specialists, Big Data Scientists, Bio-Medical Technologists, Bioinformatics, Sports medicine, Physiotherapists, Environmentalists, Health Insurance companies, Training Institutes, Healthcare quality professionals, Patient safety expert, Design thinking experts, Human Factors Expert, Patient Advocates, Technologists, Pharma Distributors, Economists, Biotech, Med-tech, Life-sciences, Diagnostics, Digital Health Specialists, AI Companies, Startups & more.

Some of our esteemed partners so far

Rwanda Ministry of Health, Rwanda Biomenidal Centre, Rwanda Convention Bureau, FDA Rwanda, Rwanda Developments Board, WHO, WaterAid, UNICEF USAID, SAFAIDS, Partners In Health, Nuralogix, MedAditus, Healthinnovationtoolbox, Zipline, Babyl Rwanda, Kipharma, Cedars Sinai, Rwanda Youth Impact, Sanitas Hospitals, Digital Machina, Turkey Green Crescent, Rwandair, Kenya Airways, THC, Africa Medical Suppliers, Novartis, Pyramid Pharma, Manorama SMAC, Legacy Speciality Clinic & many more.

Our invite

Rwanda Global Healthcare Summit 2021, Conference & Exhibition is the most distinct & can not-miss healthcare event of the year in the Africa Sub-continent, where healthcare stakeholders from around the global healthcare ecosystem are going to connect for addressing complex health and social issues, digital innovations & cross ecosystem collaboration. With a bid to become an international investment hub for the budding East African Community as well as International investors, we invite every healthcare stakeholder globally to partner in this event as we collaboratively focus on building agreement around the barriers in healthcare and discussing solutions to overcome them through cross-sector panels, action-oriented discussion, and networking opportunities. By shedding light on the strengths and challenges of different groups, we believe we can make real progress together to achieve our vision to improve healthcare globally.


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Bundle of Joy or Cause for Shame? Just What Mothers in Kenyan Informal Settlements Face

Informal settlement areas with their numerous challenges (high insecurity, insufficient clean water supplies, food shortages, poor maternity services, poor housing and poor waste disposal/ hygiene etc.) remain to be homes for many underprivileged women in Kenya. It is however more disturbing to realize that most of these women live with other serious conditions and risks which further makes them vulnerable by diminishing their control over their health and that of their newborns

By Reagun Andera Odhiambo

Population & Reproductive Health Expert

Nairobi, Kenya

Bundle of Joy or Cause for Shame?

Just What Mothers in the Kenyan Informal Settlements Face

A Tale of Inequalities in Maternal Health Service Delivery



Motherhood in the African context

For most African cultures, motherhood remains the primary source of women’s self-esteem and public status leave alone personal fulfilment. Culturally, having children and nurturing them into responsible adults is the primary index of the worth of women. The inability of a woman to give birth to and raise children therefore deprives her of the pride that comes with being a mother and may imply that she does not meet her life-long purpose. This should not be the case especially bearing in mind that some factors leading to such outcomes are out of control of the woman.

Culture aside, having a healthy baby is one of the biggest joys of life. Ideally, babies should bring hope, happiness and purpose to parents. This is however not the case always owing to the fact that some parents lose their babies from preventable causes related to pregnancy and its management, diseases or accidental causes. The grief of losing a baby is a heartbreaking and immeasurable encounter. When your baby dies from a miscarriage, stillbirth or at/after birth, your hope of being a parent dies too. The dreams you had of holding your baby and watch them grow fade leaving an empty space inside you; this may take a long time to heal.

The death of a mother for reasons related to pregnancy and childbirth is not any better. This is because a mother’s love being irreplaceable, losing her to a preventable death is an extremely painful and unforgettable experience.

The Kenyan informal settlements situation

The risk of a woman dying from complications of pregnancy and childbirth over the cause of her lifetime in Sub-Saharan Africa stands at 1 in 160 See. The same risk stands at 1 in 3,700 in high income countries. Over the years, downward trends in childhood mortality in slums have been witnessed across Africa. This has been solely attributed to intra-urban disparities in health, environmental factors as well as social conditions.

In Kenya for instance, rapid growth of urban populations in a context marked by inadequate urban planning and limited service provision has led to mushrooming of shanty towns and slums (Mukuru, Kibera, Mathare, Kawangware, Lang’ata, Ngando etc.) See. Typically, such areas have poor housing conditions, inadequate water supplies and sanitation infrastructure, poor livelihood opportunities and limited education, health and other fundamental social services. Rapid slum population growth points to the likelihood that maternal and newborn health indicators in the Kenyan slums are likely to determine the respective national health indicators.

Often, health facility delivery is a proxy for skilled birth attendance; an important intervention in reducing maternal and neonatal mortality. Sadly though, most expectant women living in the Kenyan slum areas (Mathare, Mukuru, Kibera, Kawangware, Ngando etc.) still do not utilize facility based maternity services right from prenatal care. For most of them, lack of essential newborn care items such as baby clothes, soap, comfortable newborn beds etc. presents an immediate and more serious hurdle which blinds them from an even more serious impending danger presented by out of facility delivery.

Parenting for such women remains to be a challenging and painful experience which leaves them with depressive thoughts, stigma and feelings of being failures. On a broad spectrum, parenting involves taking responsibility in nurturing children and relating to them in a manner that prepares them to attain their full potential in life. Parenting makes great emotional demands and thus requires exceptional interpersonal skills. Supporting a child right from birth through to adulthood while looking into their physical, emotional, social and intellectual well-being is a demanding task which often goes unrewarded.

Majorities of women living in the Kenyan slums do not complete at least four of the recommended eight ANC visits during pregnancy. Worse even, a large proportion still delivers at home with the help of unqualified and unskilled birth attendants. The main reason for this high risk behavior is the fear of judgement, discrimination and stigmatization presented to underprivileged women in health facilities for reasons of lacking basic newborn care essentials (baby clothes, towels, blanket/shawl etc). These women shun from facility-based care for the fear of being tormented by nurses and birth attendants something which leaves deep scars of regrets, shame and guilt. The reality that such women cannot offer the recommended basic care to their newborns causes them to feel less important and failures in nurturing children. The truth of the matter is that such women live with bitterness and regret giving birth because it is the newborns that bring the unanticipated shame and hopelessness.

Special risk groups of women living in slums

Informal settlement areas with their numerous challenges (high insecurity, insufficient clean water supplies, food shortages, poor maternity services, poor housing and poor waste disposal/ hygiene etc.) remain to be homes for many underprivileged women in Kenya. It is however more disturbing to realize that most of these women live with other serious conditions and risks which further makes them vulnerable by diminishing their control over their health and that of their newborns.

Teen mothers

Teenage motherhood remains to be a serious problem in Kenya mostly rooted with urban slums and contributing significantly to the maternal and newborn mortality estimates. The problem manifests at teenage which is a crucial phase of growth and development during which young people make choices that define their health and well-being for life. In Kenya, the problem poses a significant obstacle to the attainment of a number of key SDGs, (goal 3 on healthy lives and well-being for all at all ages, goal 4 on equitable quality education for all and goal 5 on gender equality and empowering women and girls). This is because it denies the girls the right to enjoy quality life with the minimum possible health risks and vulnerabilities. The problem imposes huge costs on the lives of the young people and ultimately affects their future reproductive health life.

For slum dwelling teens, motherhood presents every possible pain and stress which to some can only be dealt with through abortion, suicide or abandoning the newborn- all of which are wrong and seriously detrimental choices. The lack of newborn care essentials, leave alone food and appropriate shelter is a serious burden which cannot be handled by a teen mom owing to her young age and limited knowledge.

Expectant women and mothers living with HIV/ AIDS

Living with HIV/AIDS as an expectant mother can be challenging and full of uncertainties. Living in a slum with all these uncertainties can be unbearable and a reason for hopelessness and desolation. Women living with HIV need specialized care, proper diet, protection as well as love and affection. These are often lacking in informal settlements which on the contrary are full of social crimes and insecurity, poor housing/ living conditions, poor sanitation and worse of all inaccessibility to quality healthcare including emergency obstetric care. Newborns to these infected women may be at an increased risk for infection and may lack proper nutrition right from birth. They may also lack affection, something that contributes greatly to their development.

Mothers living with chronic conditions/ Non-Communicable Diseases (NCDs)

With the current high incidences of Non-Communicable Diseases, many women living in slum areas are becoming victims of these life-long and detrimental conditions (cancers, high blood pressure, diabetes, chronic heart disease etc.). The management of such conditions requires huge sums of money and the adoption of healthy lifestyles all of which are almost impossible for slum dwellers owing to their low incomes and few health options. Being pregnant or a nursing mom only adds up to the devastation of such women causing them to feel inadequate and incapable of satisfying their societal and personal obligations.

Expectant women and mothers living with disability

Being disabled in one way or the other and living in a slum can be challenging. Expecting a newborn in such an environment only adds up to the many challenges and worries of a woman. A disabled mother needs care and support to carry out her normal activities, having a newborn increases this need and makes the mother and her newborn vulnerable to both individual and external factors.

Homeless expectant women/ mothers

Owing to many reasons (mostly economic), some women may find themselves without homes within informal settlements. They have no shelters/place to sleep and thus keep shifting positions within congested streets hoping for a better day. Having a baby for such a woman is a troubling encounter which cannot be described enough. The circumstances surrounding the lives of such women and their newborns can prompt life-long social and psychological effects which can be hard to rectify.

Why Facility-based care is a lesser option

For many slum dwellers, facility based maternal care is a lesser option – a reason for the high maternal and child mortalities in such areas. Among the reasons for the low uptake of available health services include; high costs and service fees which makes it unaffordable, fear of judgement and stigmatization for lack of birth preparedness, negative perception of the importance of ANC, fear of being diagnosed with other serious ailments (which would mean extra treatment costs) and view of pregnancy/ childbirth as a normal risk-free process.


Expectant women and newborns living in slums have various special needs ranging from safety and protection, need for clean water, sufficient food supplies, emergency obstetric services and quality maternity care, proper housing and most importantly male involvement and support. In addition to this, they require dignified care with zero tolerance to discrimination and stigmatization. All efforts should be geared towards mass education on the importance of ANC and facility delivery. Heath service delivery systems should be strengthened to ensure each individual has access to quality and affordable care tailored to their specific needs. Also, economic empowerment and poverty eradication strategies should be focused on informal settlements as this would curb the main underlying drivers of poor maternal and newborn health outcomes in such areas.

News Flash 425: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 425

Weekly Snapshot of Public Health Challenges


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