The Covid-19 Pandemic as Tipping Point (Part 1)

PEAH is pleased to publish the first half of a two-part blog post with remarkable insights by professor Theodore Schrecker as a renowned political scientist specializing in the political economy of health and health inequalities. Click here to see all relevant reflections by him published on PEAH over recent years 

By Ted Schrecker

Emeritus Professor of Global Health Policy, Newcastle University

The Covid-19 Pandemic as Tipping Point (Part 1)


I began a (pessimistic) 2022 book chapter on the prospects for ‘building back better’ after the Covid-19 pandemic by quoting the first sentences of J.G. Ballard’s magnificent dystopian novel High-Rise:

Later, as he sat on his balcony eating the dog, Dr Robert Laing reflected on the unusual events that had taken place within this huge apartment building during the previous three months.  Now that everything had returned to normal, he was surprised that there had been no obvious beginning, no point beyond which their lives had moved into a clearly more sinister dimension.

The giveaway word here is “normal,” and the new normal to which Laing’s world has returned is one in which a deadly class war between the affluent and even more affluent residents of a 40-story tower block has completely destroyed the interior of the building and most of its vital systems, and survivors are reduced to killing and eating the pets of their less fortunate neighbours.  In a scene near the end of the novel, surviving children play with human bones in the tower block’s rooftop sculpture garden.

This rather dramatic introduction was designed not to suggest that post-pandemic societies will literally regress to that extent, although that could happen in some contexts, but rather that conditions of life that come to be regarded as normal in the post-pandemic world will probably look very, very different from those of late 2019, and for most of us more insecure and threatening.  I am more convinced of this now than I was when I wrote the chapter.

In a recent conference paper, I argued that the pandemic should be understood as a tipping point, initiating processes that magnify and accelerate existing trends, in particular those involving rising inequality and its direct and indirect effects on health.  The concept of a tipping point is used in several, slightly different ways depending on context, but it is now most familiar from research on climate change.  Leading climate researcher Timothy Lenton explains: tipping points “occur when there is strongly self-amplifying (mathematically positive) feedback within a system such that a small perturbation can trigger a large response from the system, sending it into a qualitatively different future state.”  Stated more colloquially, “sometimes little things can make a big difference,” or at least a disproportionate difference, “to the state and/or fate of a system.”

Figure 1.  Schematic representation of cascading effects in the vegetation–rainfall system

(a) Vegetation–atmosphere system in equilibrium. (b) Initial forest loss triggered by decreasing oceanic moisture inflow. This reduces local evapotranspiration and the resulting downwind moisture transport. (c) As a result, the rainfall regime is altered in another location, leading to further forest loss and reduced moisture transport.  Reproduced without change from Zemp, D. C., Schleussner, C. F., Barbosa, H. M. J., Hirota, M., Montade, V., Sampaio, G. et al. (2017). Self-amplified Amazon forest loss due to vegetation-atmosphere feedbacks. Nature Communications, 8, 14681 under a Creative Commons Attribution 4.0 International Licence.

An especially striking example is provided by deforestation in large tropical rain forests (Figure 1).  As much as half of the precipitation that falls on such forests originates from evapotranspiration within the forest itself.   The concern is that deforestation resulting from human activity (forest clearance) will combine with reduced oceanic moisture inflows to lead to a tipping point in which reduced rainfall accelerates forest dieback, and the rain forest transitions to savannah or steppe.  This will itself accelerate climate change, as the forest no longer provides a carbon sink.  Researchers write that findings about multiple processes of this kind “imply that shifts in Earth ecosystems occur over ‘human’ timescales of years and decades, meaning the collapse of large vulnerable ecosystems, such as the Amazon rainforest and Caribbean coral reefs, may take only a few decades once triggered.”  This is a long time in the context of such phenomena as election cycles, but an eyeblink in geological time.  Whatever the time scale, once a tipping point has been reached, the pace of changes that were already under way accelerates rapidly, and entirely new changes may begin.

My pre-retirement colleague Clare Bambra and colleagues have provided an especially compelling account of how distribution of health outcomes during the pandemic reflected and magnified economic inequalities (open access, and essential reading).  Looking ahead, here are a few of the patterns (far from an exhaustive list) that suggest the value of considering the pandemic as tipping point:

  • Concentration of wealth at the very top of national and global economic distributions: The number of US dollar millionaires worldwide increased from 46.8 million in mid-2019, the last pre-pandemic year, to 62.5 million in 2021. This growth was fuelled by rising share prices, but also by
  • Soaring property prices in much of the world. US homeowners saw their wealth increase by more than US$6 trillion between the start of the pandemic and the third quarter of 2022; average house prices across Canada’s 15 major metropolitan areas rose by as much as 45 percent between 2019 and 2021, depending on distance from the city centre.  The ‘flip side’ of this pattern, which began before the pandemic but was accelerated by it and is repeated in many European centres, is
  • A growing pattern of unaffordable housing and semi-permanent housing insecurity, underpinned by the financialization of housing, which also predates the pandemic and led one group of Australian researchers to conclude that: “sustained inflation of property values … has fundamentally shifted the social class structure, from a logic that was structured around employment towards one that is organized around participation in asset ownership and appreciation.”
  • Housing prices are an important part of a larger cost-of-living crisis, originating in supply chain disruptions associated with the pandemic and worsened by Russia’s invasion of Ukraine and its weaponization of energy exports. Interest rate increases – a conventional central bank inflation-fighting tactic – cannot address these impacts because they have no effect on supply, and in fact are likely to magnify inequality, as they raise the cost of consumer debt and are passed through to consumers by producer firms.
  • In a global frame of reference, countries differed in the fiscal capacity they were able to deploy in initial responses to the pandemic, which will probably lead to increased inter-country inequality. Further issues arise from what could be
  • An impending sovereign debt crisis for many countries; before the pandemic the sovereign debt load of countries in sub-Saharan Africa, the world’s poorest region, was more than twice its nominal value in 2009, the year after the financial crisis. In early 2023 the American Public Health Association called on the International Monetary Fund, World Bank and G20 “to eliminate debt for the poorest countries and expand fiscal space for public financing of health services and public health programs.”
  • Finally, of course, there are the effects of climate change on various social determinants of health, including food security.

The World Economic Forum’s 2023 Global Risks Report devoted an entire chapter to the concept of “‘polycrisis’ – a cluster of related global risks with compounding effects, such that the overall impact exceeds the sum of each part.”  This is a useful way of capturing the interactions discussed here, yet at the same time we must acknowledge that many trends in question will present as crises for many, and opportunities for others.  (Housing price escalation is a case in point.)

Perhaps my view of the future is excessively bleak.  After all, high-income countries were able to buffer many of the pandemic’s economic effects, and the US improbably experienced a substantial, if temporary, drop in poverty.  The situation outside the high-income world was, and is, considerably more grim, like the “vaccine apartheid” that has now largely faded from public consciousness reflecting the multiple dimensions of global inequality and the relative invisibility of the global majority.  Numerous blueprints, some quite detailed, exist for ‘building back better’.  The second part of this posting will direct readers to a few of these; assess some of the formidable political obstacles to their realization against the background of rising inequality; and offer a few conjectures about health in the post-pandemic new normal.





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‘See What Matters’ Campaign

PEAH is pleased to publish a piece by AFEW partner organization. AFEW is dedicated to improving the health of key populations in society. With a focus on Eastern Europe and Central Asia, AFEW strives to promote health and increase access to prevention, treatment and care for major public health concerns including - though not limited to - HIV, TB, viral hepatitis, and sexual and reproductive health 

By Olga Shelevakho 

Communications Officer, AFEW International

‘See What Matters’ Campaign

Combating Stigma to End HIV/AIDS in Eastern Europe and Central Asia (EECA)


AFEW Partnership has launched a social impact campaign «See What Matters» as a part of the project “Combating stigma to end HIV/AIDS in Eastern Europe and Central Asia (EECA)”.



Stigma and discrimination against people living with HIV continue to exist and affect various areas of human life, thereby creating barriers and obstacles to HIV prevention and treatment and seriously reducing the overall quality of life of those affected.

Self-stigma of PLHIV remains the most pressing issue for EECA countries. Findings from studies conducted in Kazakhstan, Kyrgyzstan, Russia and Ukraine showed a high level of self stigma among people living with HIV: 81.3%-91.2% of PLHIV surveyed conceal their HIV-positive status from others, half of respondents feel guilt and shame about their HIV status.

HIV infection is still associated with “inappropriate sexual behavior” and belonging to marginalized populations. Women are the most susceptible to HIV-related stigma.  HIV stigma in women is associated with rejection by family and friends, society, feelings of insecurity and loss, low self-esteem, fear, anxiety, depression, suicidal thoughts and even suicide attempts

To reduce the self-stigma of women living with HIV and affected by HIV and to change societal attitudes towards them through reducing social stigma, AFEW Partnership developed the project “Combating stigma to end HIV/AIDS in Eastern Europe and Central Asia (EECA)”.

Media campaign 

In 2022, we conducted a survey among women living with HIV, most vulnerable to HIV and affected by HIV (including the mothers of children with HIV), showing the challenges they face in their daily lives. Based on these responses, we created a media campaign in the “animadoc” style, which allowed us to combine artistic elements with realistic ones. Here we use direct quotes of the women involved, photographs of their eyes, and their real voices in national languages as a voiceover.

The campaign materials are freely available in English/Russian, as well as Kazakh, Kyrgyz, Uzbek, and Ukrainian languages, and include videos and other materials that can be used for online and offline promotion. You can find them on the official website of the campaign.

The “See What Matters” campaign was developed in the scope of the project “Combatting stigma to end HIV/AIDS in EECA”, implemented by the AFEW Partnership with financial support from Gilead. We would like to thank local organisations and communities of women living with HIV in the region for our collaboration – “Positive Women” in Ukraine, Public fund “Country Network of Women Affected by HIV” in Kyrgyzstan and “ISHONCH VA HAYOT” in Uzbekistan.


Official website of the campaign WWW.STOPSTIGMA.HIV

The report “Results of assessing the level of stigma and discrimination of women living with HIV in the EECA Region” -

Links for the videos -

Official news item -

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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

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Balochistan Primary Healthcare: What Has Been Done and What Needs to Improve?  by Muhammad Noman

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Balochistan Primary Healthcare: What Has Been Done and What Needs to Improve?

Balochistan, one of the four provinces of Pakistan, faces numerous challenges in terms of its primary healthcare system, including issues related to service delivery, quality, accessibility, and financing. This paper presents an overview of the primary healthcare system in Balochistan, highlights the achievements and challenges of the system, and suggests potential policy interventions that can improve the health outcomes of the population

By Muhammad Noman

Healthcare System, CHIP Training and Consulting

Quetta, Balochistan Pakistan

Balochistan Primary Healthcare 

What Has Been Done and What Needs to Improve?



Background and Context

Balochistan, the largest province of Pakistan, is home to approximately 13 million people, many of whom live in rural and remote areas with limited access to healthcare services.

Balochistan map - Google credit

The primary healthcare system in the province faces multiple challenges, such as inadequate infrastructure, inadequate human resources, lack of essential medicines, low funding, and poor quality of care. These challenges have contributed to a high burden of communicable and non-communicable diseases, poor maternal and child health outcomes, and low life expectancy.

Research Problem and Question

The primary healthcare system in Balochistan is in dire need of improvement. The research problem is to identify the factors that have contributed to the poor performance of the system and to suggest policy interventions that can enhance its effectiveness. The research question is: What has been done to improve the primary healthcare system in Balochistan, and what needs to be done to make it more responsive, efficient, and equitable?

Significance and Purpose of the Study

The study is significant because it provides a critical analysis of the primary healthcare system in Balochistan, which is essential for understanding the health needs and priorities of the population. The purpose of the study is to identify the strengths and weaknesses of the primary healthcare system in Balochistan and recommend policy interventions that can address the existing gaps and challenges.

Objectives and Hypothesis

The objectives of the study are to: (1) Review the existing primary healthcare system in Balochistan, (2) Identify the strengths and weaknesses of the system, (3) Analyze the factors that have contributed to the poor performance of the system, and (4) Recommend policy interventions that can improve the health outcomes of the population. The hypothesis is that policy interventions, such as strengthening the health system governance, enhancing primary healthcare services delivery, ensuring quality and accessible primary healthcare, addressing the financing gap, and promoting public-private partnerships, can improve the performance of the primary healthcare system in Balochistan.

Literature Review

Overview of Primary Healthcare in Balochistan

The primary healthcare system in Balochistan is characterized by a three-tiered structure, consisting of Basic Health Units (BHUs), Rural Health Centers (RHCs), and Tehsil Headquarter Hospitals (THQs). BHUs are the first point of contact for patients and provide a range of services, including maternal and child health, immunization, family planning, and basic laboratory tests. RHCs and THQs provide more specialized services, such as surgery, diagnostic tests, and inpatient care. The primary healthcare system in Balochistan is funded by the provincial government, the federal government, and development partners.

Achievements of the Primary Healthcare System

The primary healthcare system in Balochistan has achieved some significant milestones over the years. For example, the Government of Balochistan has established a network of basic health units (BHUs), rural health centers (RHCs), and maternal and child health centers (MCHs) across the province, which have significantly increased access to healthcare services, particularly in remote and rural areas.

Balochistan  has increased the number of BHUs from 649 in 2011 to 1,135 in 2019, and the number of RHCs from 153 in 2011 to 299 in 2019. The province has also made progress in reducing the prevalence of communicable diseases, such as tuberculosis, malaria, and polio, through targeted vaccination campaigns and disease surveillance. Moreover, the introduction of community-based programs, such as Lady Health Workers (LHWs) and Community Health Workers (CHWs), has improved access to basic healthcare services, particularly in hard-to-reach areas.

Challenges of the Primary Healthcare System

Despite the achievements, the primary healthcare system in Balochistan faces numerous challenges that impede its effectiveness. First, the system suffers from inadequate infrastructure, including dilapidated health facilities, insufficient equipment and supplies, and a shortage of safe water and sanitation facilities. Second, the system lacks sufficient human resources, including doctors, nurses, and other health professionals, especially in rural and remote areas. Third, the system is plagued by a shortage of essential medicines, medical supplies, and diagnostic tools, which hampers the delivery of quality care. Fourth, the financing of the primary healthcare system is inadequate and unstable, with limited resources allocated for preventive and primary care services. Fifth, the quality of care in the primary healthcare system is low, with inadequate supervision and monitoring of health workers, poor management of health facilities, and weak health information systems. Finally, the primary healthcare system in Balochistan is characterized by limited accessibility, with many people unable to access basic healthcare services due to geographical, financial, cultural, and social barriers.

Some of the specific achievements of the primary healthcare system in Balochistan include:

Improved access to healthcare services: The establishment of BHUs and RHCs has significantly increased the accessibility of healthcare services in Balochistan, particularly in remote and rural areas. This has enabled more people, particularly women and children, to access basic healthcare services.

Maternal and child health: The primary healthcare system has contributed to improving maternal and child health indicators in Balochistan. The establishment of MCHs has helped reduce maternal and infant mortality rates, while immunization programs have helped increase vaccination coverage among children.

Control of communicable diseases: The primary healthcare system has played a crucial role in controlling communicable diseases in Balochistan. Through the implementation of disease control programs, such as the tuberculosis control program and the malaria control program, the prevalence of these diseases has been significantly reduced.

Health education and promotion: The primary healthcare system has facilitated health education and promotion activities in Balochistan. Health workers at BHUs and RHCs have conducted awareness campaigns and health education sessions, promoting healthy lifestyles and disease prevention.

Human resource development: The primary healthcare system has contributed to the development of human resources in the healthcare sector in Balochistan. The training and capacity-building of healthcare workers, particularly those working in BHUs and RHCs, has improved the quality of healthcare services in the province.


Study Design

This study uses a qualitative research design, based on a review of the existing literature on the primary healthcare system in Balochistan, including government reports, academic articles, and international health organization publications. The study also draws on secondary data from national and provincial health surveys, such as the Pakistan Demographic and Health Survey and the Balochistan Health Survey.

Data Collection and Analysis

The data collection for this study involves a comprehensive review of the literature on the primary healthcare system in Balochistan, focusing on the period from 2010 to 2020. The data are analyzed using a thematic approach, which involves identifying common themes and patterns across the literature, and summarizing the findings in a narrative format. The analysis is guided by the objectives and research question of the study.

Results and Discussion

Strengths and Weaknesses of the Primary Healthcare System

The review of the literature indicates that the primary healthcare system in Balochistan has several strengths, including the expansion of the BHUs and RHCs, the introduction of community-based programs, and the reduction of communicable diseases. However, the system also has several weaknesses, including inadequate infrastructure, insufficient human resources, inadequate financing, poor quality of care, and limited accessibility.

Policy Interventions to Improve the Primary Healthcare System

Based on the strengths and weaknesses identified in the literature review, the study recommends several policy interventions that can improve the performance of the primary healthcare system in Balochistan. These interventions include: (1) Strengthening the health system governance by improving policy and planning, promoting inter-sectoral collaboration, and enhancing accountability; (2) Enhancing primary healthcare services delivery by improving the quality of care, introducing innovative service delivery models, and expanding the scope of services; (3) Ensuring quality and accessible primary healthcare by strengthening the health information system, promoting patient-centered care, and addressing social determinants of health; (4) Addressing the financing gap by increasing the budget allocation for primary healthcare, exploring alternative financing mechanisms, and enhancing resource mobilization; and (5) Addressing human resource gaps by improving recruitment and retention, enhancing training and capacity-building, and promoting community engagement.

Implications for Practice and Policy

The findings of this study have several implications for practice and policy in Balochistan. First, the study highlights the need for a more comprehensive and integrated approach to primary healthcare, which includes the promotion of preventive and curative services, as well as the management of non-communicable diseases. Second, the study emphasizes the importance of community engagement and empowerment in improving access to and utilization of primary healthcare services. Third, the study underscores the need for a more sustained and stable financing mechanism for the primary healthcare system, which includes both public and private sources. Finally, the study emphasizes the importance of evidence-based policymaking, which takes into account the local context and the needs of the population.


The primary healthcare system in Balochistan has made progress in expanding access to basic healthcare services, reducing communicable diseases, and introducing community-based programs. However, the system still faces numerous challenges, including inadequate infrastructure, insufficient human resources, inadequate financing, poor quality of care, and limited accessibility. To address these challenges, the study recommends several policy interventions that can improve the performance of the primary healthcare system, including strengthening health system governance, enhancing primary healthcare service delivery, ensuring quality and accessible primary healthcare, addressing the financing gap, and addressing human resource gaps. These interventions have several implications for practice and policy, including the need for a more comprehensive and integrated approach to primary healthcare, the importance of community engagement and empowerment, the need for sustained and stable financing, and evidence-based policymaking.


  1. Ahmad K, Jafri W, Ali A, et al. Health status of the people of Balochistan, Pakistan: an overview. Journal of Ayub Medical College Abbottabad. 2012;24(3-4):4-9.
  2. Balochistan Health Department. Annual Development Program (ADP) 2021-22. Accessed on February 22, 2023.
  3. Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A. Health systems in Pakistan: challenges and opportunities. The Lancet. 2013;381(9885):1193-1207.
  4. Government of Pakistan. Pakistan National Health Vision 2016–2025. Ministry of National Health Services, Regulations and Coordination; 2016.
  5. Jafri W, Bhatti N. Healthcare system in Pakistan: a critical review. Journal of Rawalpindi Medical College (JRMC). 2015;19(1):91-94.
  6. National Institute of Population Studies (NIPS) [Pakistan] and ICF International. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF; 2019.
  7. World Health Organization. Health Systems Strengthening Glossary. World Health Organization; 2011.
  8. World Health Organization. Primary health care. World Health Organization; 2022. Accessed on February 22, 2023.
  9. World Health Organization. World Health Statistics 2021: Monitoring Health for the SDGs. World Health Organization; 2021.
  10. Zaman S, Sahito A. Current status and future prospects of health policy and systems research in Pakistan. Health Research Policy and Systems. 2021;19(1):49.


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Decision Makers’ Perception of the Performance and Salary of UC Polio Officers in Pakistan

Union Council (UC) polio officers are responsible for implementing and monitoring polio vaccination campaigns at the grassroots level in Pakistan. Semi-structured interviews were conducted with policymakers, program managers, and other relevant stakeholders at the federal and provincial levels to explore their perception of the performance and salary of UC polio officers. Several themes related to their perception were identified, including the importance of the role of UC polio officers in the program's success and the low salary as a major factor in their motivation and retention

By Muhammad Noman

Healthcare System, CHIP Training and Consulting

Quetta, Balochistan Pakistan

Decision Makers’ Perception of the Performance and Salary of UC Polio Officers in Pakistan



Pakistan is one of the two remaining countries in the world where polio is still endemic, and the government has been running a polio eradication program with the support of international organizations, including the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO). The program employs thousands of workers, including Union Council (UC) polio officers, who are responsible for implementing and monitoring polio vaccination campaigns at the grassroots level. However, the program has faced many challenges, including security threats, vaccine refusals, Gray houses, un registered children, low routine immunisation and social mobilization issues. In this study, we aim to explore the decision-makers’ perception of the performance and salary of UC polio officers in Pakistan.

Literature Review

Previous research on the polio eradication program in Pakistan has identified several challenges, including security threats, vaccine refusals, Gray houses, unregistered children, low routine immunisation social mobilization, and monitoring and evaluation issues. Some studies have also highlighted the importance of the role of polio workers, including UC polio officers, in the success of the program. For example, a study conducted in 2017 found that the performance of UC polio officers was positively associated with the vaccination coverage in their respective areas. Another study conducted in 2019 found that the salary and working conditions of polio workers, including UC polio officers, were important factors in their motivation and retention.


To explore the decision-makers’ perception of the performance and salary of UC polio officers in Pakistan, we conducted semi-structured interviews with policymakers, program managers, and other relevant stakeholders at the federal and provincial levels. We used purposive sampling to select participants with different levels of authority and experience in the polio eradication program. We conducted 20 interviews between June and August 2022, and the interviews were audio-recorded and transcribed verbatim.


Our analysis of the interview data identified several themes related to the decision-makers’ perception of the performance and salary of UC polio officers. One theme was the importance of the UC polio officers’ role in the program’s success, and many participants acknowledged their hard work and dedication. However, several participants also expressed concerns about the quality of their work, including issues related to supervision and monitoring. Another theme was the low salary of UC polio officers, which was identified as a major factor in their motivation and retention. Many participants suggested that increasing their salary could improve their performance and retention.


The decision-makers’ perception of the performance and salary of UC polio officers in Pakistan is crucial for the success of the polio eradication program. Our study identified several themes related to their perception, including the importance of their role in the program’s success and the low salary as a major factor in their motivation and retention. These findings have important implications for policy and programmatic interventions aimed at improving the performance and retention of UC polio officers in Pakistan.

The study suggests that the low salary of UC polio officers is a significant factor in their motivation and retention. The decision-makers interviewed for the study acknowledged that the salary of UC polio officers was not sufficient to meet their basic needs and that it was an issue that needed to be addressed.

The study recommends that the relevant stakeholders should consider increasing the salary of UC polio officers to improve their motivation and retention, which in turn, can help improve the performance and success of the polio eradication program in Pakistan.



  1. Azizullah, A., Khattak, M. N. K., & Ahmad, S. (2017). Performance of polio workers and their perceptions about the reasons for missed children during polio campaigns in Peshawar, Pakistan. Journal of epidemiology and global health, 7(1), 27-34.
  2. Janjua, N. Z., Razaq, M., Chandir, S., Rozi, S., Mahmood, B., & Mullen, S. (2019). Exploring the reasons for low polio vaccination coverage in Karachi, Pakistan. BMC public health, 19(1), 174.
  3. Pakistan Polio Eradication Program (2021). Retrieved from
  4. United Nations Children’s Fund (UNICEF). (2021). Pakistan. Retrieved from
  5. World Health Organization (WHO). (2021). Poliomyelitis. Retrieved from
  6. Khan, M. U., Ahmad, A., Ur-Rehman, N., & Alkhathami, M. A. (2020). Challenges and solutions to eradication of polio from Pakistan. International journal of environmental research and public health, 17(13), 4876.
  7. Khan, M. U., Ahmad, A., & Khan, A. U. (2018). Polio eradication in Pakistan: the challenges and the way forward. Journal of epidemiology and global health, 8(1-2), 1-3.
  8. Shaukat, S., Riaz, A., Alam, M. M., Khurshid, A., Sharif, S., Rana, M. S., … & Zaidi, S. S. Z. (2019). Environmental surveillance of poliovirus in sewage samples from selected sites in Pakistan. Journal of clinical microbiology


By the same Author on PEAH

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Webinar registration: What are policy options for effectively tackling medical deserts? Wednesday March 15, 2023

Webinar registration: Promoting Health and Rights: Prioritising People in Detention in the COVID-19 Pandemic and Beyond Mar 8, 2023 03:00 PM in London

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A Renewed International Cooperation/Partnership Framework in the XXIst Century

This reflection piece calls for a debate to discuss whether the present trend of “business-based” partnerships (from former solidarity based cooperation) is pertinent with the evolving global challenges and coherent with the ethical principles inherent to the human and environmental global agreements related to global wellbeing in sustainable (CO2 emissions below 1,8 mT per person and year –ppy-) equity (international and subnational inequality GINI [i] < 0,2). It concludes that in order to progress to lower global inequities and achieve a carbon neutral world by the mid of the century and so prevent a climate disaster for the next generation, a greater focus is required on rural vs local, collaboration vs. competition, justice vs. market access to right-based universal social services and a shift from military spending to exhaust all peace agreements and fund a meaningful collaboration according to capacities and needs

By Juan Garay

Professor of Global Health Equity in Chiapas, Mexico, ELAN and UCLV, Cuba and National School of Health, Spain

A Renewed International Cooperation/Partnership Framework in the XXIst Century


Development co-operation (let us define it as a relation of mutual benefit) has been the Cinderella of international relations, and it seems now to be “lost in translation”

Historically, interactions between larger groups, tribes or countries, translated in benefiting those with greater power by poaching minerals, crops and/or slaves. It often came with taking over the governance through colonization in different shapes and in the name of “civilization” or “conversion”. Europe was most often in that power side throughout history.

Other relations aimed at counter-balancing those power relations and focus on the benefit those in the “losing side”. Those intentions were often related to religious groups and came with other interests, as evangelization, and a “vertical” approach (from those knowing better or having more than those in the receiving end) under different shapes of “charity”.

After the world wars in the XXth century, the cry for peace led to the foundation of the United Nations and the adoption of the Universal Declaration of Human Rights. Such new spirit, together with the impact of the war in the colonial powers, led to the wave of independence of most of the African, Caribbean and Pacific countries, while the European Union (EU) was born. Soon after, the former EU colonial and colonized countries gathered in the Youndee, Lome, Cotonou Agreement. As the Breton Woods institutions progressed with the post war reconstruction of Europe, they started to offer finance to lower income countries in return for opening up their economies to investments of former metropolia and introduce “adjustment programmes” which often meant lower government spending (especially for public services), a move called by some as neo-colonization.

Development cooperation bid to respect national priorities and governance, which led in 2000, in parallel to the Millennium Development Goals (MDGs), to the Paris principles on Aid Effectiveness (meant to respect country’s priorities and sovereign processes). Ten years later, and aware and alarmed by the threat of global warming and the responsibility of the “developed” countries, the world agreed in Busan 2011 on a more horizontal approach where all countries shared challenges and all could learn from each other. In Addis Ababa 2015, as total Overseas Development Assistance (ODA) was less than 0,2% of the world’s Gross Domestic Product /GDP- (0,4% in the EU), the global consensus on financing for development called to increase aid and domestic revenues, remittances and foreign investment towards sustainable development.

Limited ODA, appropriation and weak links with additional financing for development undermined compliance with the MDG targets which were swiftly replaced by the Sustainable Development Goals (SDG) 2030 agenda relevant to all countries and called on enhanced global collaboration beyond former vertical north-south dynamics.

Soon after, in 2020, just after Brexit, the Covid pandemic hit the world and greed to hoard vaccines ruled over solidarity. When the pandemic seemed to vanish, Russia’s invasion of Ukraine further confronted the countries with greater military power (members of the United Nations’ Security Council) and the world increased spending in arms and in burning coal. The EU embraced more clearly than ever security under United States of America (USA)-led North Atlantic Treaty Organization, sided -without the cracks of the Iraq war- with the USA and confronted Russia’s military invasion and China’s leading world trade. So it was that the EU remained allied with the biggest army while confronting as enemies its main energy (Russia) and manufactured import sources (China).

The EU’s (claimed) leading roles on peace, human rights, equity and ecology were blurred by providing arms, rejecting refugees, eroding its social model, burning coal and dismissing the imports’ factor in carbon emissions.

The world’s leading economies gradually shifted the focus of international cooperation to Foreign Direct Investment, eight-times higher than annual ODA, some 1,6% of the world’s GDP, which, if adjusted to SDG needs, could meet the estimated SDG gap in ten years.

In reaction to China’s 2013 Belt and Road Initiative (BRI) one-trillion initiative signed with 151 countries, the USA launched with G7 in 2021 the B3W (build back better world) as a “values-driven, high-standard, and transparent infrastructure partnership led by major democracies” aimed to narrow the $40 trillion (Tn) world estimated (by McKinsey) investment gap  (60% by emerging economies) infrastructure ( power, roads, telecom, water, rail, airports, ports) required by 2035[ii]. As part of it and claiming its own leading role as still the world’s main investing, trading and ODA partner in the world, the EU launched its Global Gateway (GG) aimed to mobilize €300 billion (Bn) in investments focused on quality and transparent connectivity as the way of “showing political presence and ambition”[iii]. However, the financial muscle of EU’s GG is a third of China’s BRI and 0,7% of the G7 B3W gap.

Besides the limited funds in relation to the estimated gap, the EU’s GG is uncertain as it is engineered to attract or direct EU investments towards development, a call that has frequently fallen short to expectations in the last decades. Besides, offering public subsidies, often to profitable multinationals (and dropping past principles as untied aid) may echo the recent public uproar at governments rescuing banks after the 2008 crisis.

While China, the US and the EU and other G7 members add up 70% of the world’s GDP what is their legitimacy to promote “Sustainable Equity”?

In terms of sustainability, the EU’s carbon footprint per capita is 6 metric Tonnes (mT), four times above the ethical threshold (above which we’re bound to catastrophic global warming) compared to 7.6 of China and 14.6 of the USA. They together mean 80% green-house emissions, close to 90% if carbon emissions of imports were factored in. Their production-trade-consumption pattern are unsustainable. Despite many waves of global strategies as the MDG and SDG agendas and the recurrent G7 and Chinese initiatives in the name of development inequities have widened and CO2 emissions have increased or remained far from the ethical threshold mentioned above. The world’s growing inequity means 16 million excess (from feasible levels for all) deaths per year[iv] (one in four of all deaths) and the progress towards the 1.5° warming (“point of no return”[v]) predicted over 200 million excess deaths in the remains of the century[vi], the worst-ever intergenerational legacy in human history.

With such a record of low legitimacy in terms of their own carbon emissions, it is unclear how China, the USA and the EU will bring about the change the world needs towards sustainable equity. As per the EU’s GG, it is unclear its added value on digital connectivity (most chips are produced in Taiwan and the majority of communication satellites are from the US), clean transport (green hydrogen will still be a high-cost fuel and e China controls most key minerals for energy storage) or renewable energy sources (with China’s lead in solar panels scale production and decreasing prices).

Is the present EU cooperation framework, under the GG investment lead, coherent with the challenge of a carbon neutral EU and the strength of promoting its social model?

Many studies question how FDI to developing countries may make them more reliant on the depletion of natural resources to keep their economies running[vii]. The link between ODA subsidizing private FDI and the impact on wellbeing in sustainable equity in lower income countries, embeds the following uncertainties: 1) will the level of ODA, still a very low share of global GDP and FDI, attract higher flows to low-income countries? 2) If so, will that flow be clearly linked to sustainable equity, often meaning lower profits (equities, the “s” meaning often the opposite)? 3) If flows increase and increase sustainable equity, will they increase countries’ debts and dependency? And, 4) if FDI, as often aims, boosts EU trade,
will it increase our already unsustainable and harmful ecological and carbon footprint and undermine the wellbeing of coming generations?

So, is it the right direction for the EU to bet, with unclear global lead, on connectivity, under the shadow of the US-led B3W, through the uncertain and questionable leverage on the private sector and aimed at gaining political ambition?

What is the primary responsibility of the EU in the context of global challenges?

The EU has reduced (21% lower) more than any other region of the world its carbon emissions since 1990. However, it needs to further reduce them by three fourths (and other green-house emissions and ecological footprint) by changing its production-trade-consumption patterns, a sine-qua-non which is, more often than not, ignored. Its contribution to excess mortality through excess emissions may be 15% of the global projected burden of mortality due to climate change during the XXIst, that is, over 30 million deaths.

In contrast, the EU’s positive impact in the world is uncertain through 65 years of EU ODA and through the questionable link of innovation improving global wellbeing given the evidence of market failures of the potential public goods as Covid vaccines have recently shown.

So, the first challenge of the EU to be good for the rest of Humanity, as the “primum non nocere” (first, do no harm) medical oath states, is to reduce carbon emissions including through imports.

The EU commitment to a carbon neutral economy by 2050 meets the ethical challenge but it may come too late and insufficient especially if such commitment does not include the carbon emissions attributed to others, mainly China, whose exports are consumed in the EU. A reduction by three-fourths of the EU emissions means less production, less trade (as with China) and less consumption. The innovation, technology and scale of investments required to shift completely to energy based on renewable energies and fuels (as green hydrogen), will not come in time to meet the ethical goal without changing, urgently, our unsustainable lifestyles.

Which is then the main singularity of the EU to contribute to a better world in sustainable equity based on universal rights and as the solid base for global peace and prosperity?

While the EU reduces the harm imposed on others through excess carbon emissions, mainly the less polluting tropical countries, the EU should preserve at home and promote globally its social model regulating the market towards equity by a strong social contract between institutions -duty bearers- and citizens -right holders- enabling fiscal space and universal right-based social services as health, education, justice and social protection of those in greater need.

The EU’s main difference with China and the USA is its rights-based social model, with the most advanced and equitable regulation and taxation (with a tax-to-GDP revenue rate of 41% compared to 26% in the USA and 12% in China) of the market so as to reduce inequalities (EU’s GINI stands at 0.3 vs China’s and USA around 0.4) and provide universal social protection. The EU social model translates in the highest regional average life expectancy (80 years vs. 78 in China and 77 in the USA). The other main global lead in equitable wellbeing is Japan, with GINI of 0,32 (yet with a tax revenue rate of only 13% of GDP) and world’s highest life expectancy at 84 years. Equity dynamics call for a GINI <0,2 which may limit inequalities to a fair distribution between dignity and excess thresholds[viii].

A global strategy to effectively progress towards human wellbeing in sustainable equity

If ODA did not reach the necessary scale and impact, and private FDI has many uncertainties to translate in global sustainable equity, where could the EU and global cooperation head to?

One approach to be considered, on which we have based upcoming EU cooperation in Cuba is to focus at the local rural level. This is based on two main reasons: on the one side, ecologically basic needs need to be met with local means if we really commit to a carbon neutral world by 2050 and escape the 1,5° point of no return. On the other side, it is by recovering local and rural dimensions, blurred by national and global dynamics, how we can increase empathy with the communities we live with and the nature which supports our lives.

Hence, local sustainable development should aim at sovereignty (self-sufficient based on local means and capacities) of basic living needs, that is, food through sustainable agriculture, clean energy through renewable sources, both linked to sustainable water supply and circular economy and collaborative innovation (including 3D manufacturing) of housing and basic “wellbeing technology”.

The regional level links local communities under a shared geographic, cultural or national or sub-national administration, where cooperation may promote fiscal and territorial cohesion strategies aimed at socioeconomic equity and universal coverage of rights-based services of education, health, justice and social protection, where the EU has a strong record and potential lead.

Cooperation should also aim at promoting global collaboration towards public goods, shifting from the present focus on global competitiveness for market-driven inequitable access to raw materials, manufactures and services, including global public goods as recently revealed with the Covid pandemic.

The above mentioned approach requires sharing information online (as travels for work, and less for tourism are most often non-essential and unsustainable in terms of carbon emissions) and contributing with means meant to reach every person as a public good, according to added values in each country and region of the world.

The main local basic needs include basic food, energy, water, housing, key appliances, local transport and access to internet needs -FEWHATI- . They require global investments in solar panels (1kw pc costing in China 220$/kw), basic agroecology technology at some 2000$/Ha (feeding 10p), basic water supply and sanitation networks (solar pumps for 1500$/kw pumping from 150 feet depth and serving 100 person needs), basic comfort appliances (clima, fridge, kitchen appliances, screen) at some 800$/4p, shared electric light vehicle (1000$/4p) –yet with the challenge of short-lived batteries- and access to internet (smart phone and modem 400$/4p), all around $1000/p, with circular economy dynamics linked to building materials and decent housing. Some 3Bn people in the world lack those basic sustainable needs, which means, besides the workforce, transport and some machinery as drilling and trillion-3Tn investment for the next decade. That may seem close to the 3,3 Tn annual investment estimates by McKinsey[ix] for G7[x] which led to the B3W gap estimate by 2035. But while the basic local needs’ investment aims al sustainable wellbeing, the McKinsey and G7 B3W is based on keeping up the present destructive model of growth, transport and trade (including estimates to upscale airports and roads’ capacities in high income countries…).

The mentioned 3Tn basic needs funds are 3,3% of global GDP, close to the world’s military spending and some 10% of the redundant GDP n high income countries[xi]. It could help prevent 16 million annual deaths and reduce some 3-5 Bn CO2 ton emissions per year.

Collaboration between education and research centres should promote open software, and additive manufacture capacities so as to promote local knowledge sovereignty, repairs, adjustments and progressive local design and production.

If ODA meets the (though arbitrary[xii]) 0.7% in high income countries, the cost of such basic local needs for almost half the planet would mean 10 years of global ODA void of unnecessary flights, hotels and experts’ fees now accounting to 40-50% of ODA. Such minimal economic redistribution, 20 times lower than the equitable tax rate of the top 10% in the EU, could be uploaded by financial markets so as to reduce carbon emissions and prevent excess mortality due to global inequity.

Such 3Tn gap aims at the basic needs which in Maslow’s scheme[xiii] is the base but should be complemented by protection (health and justice services), opportunities and sense of belonging (education and culture). While fiscal equiy and territorial cohesion should fund such human rights-based social services, the global competition for what-should-be global public goods (eg. essential vaccines and medicines) and for basic-services’ civil servants’ salaries (as health, education and justice professionals), means that the inequity (unfair distribution) of global salaries fuels brain drain and undermines access to those essential protection and belonging needs. The estimates of the basic salaries that would prevent such migration flows are in the range of another 1000 per person and year ppy which could be provided by a sort “universal social protection fund” to operationalize the International Covenant on economic, social and cultural rights. That would be part of the empirical evidence of minimum $4000 ppy CV –dignity threshold[xiv]– (in contrast with insufficient world bank set poverty thresholds) below which no country in 60 years has been able to achieve the best feasible and sustainable levels of wellbeing (by proxy of life expectancy). Such reality calls, after the local needs’ investment, for a gradual shift of the ODA present insufficient (from 0.7%) and vertical (from “aid”) flows to required levels (some 7% of global GDP towards equity of < 0,2 GINI cross and sub-national) and framework (international fund, as with the national social insurance schemes), if the world truly commits to universal rights as it did, though in a non/committal way- 74 years ago.

The above described approach guides global dynamics to rural vs. urban, local sovereignty vs. global trade, universal vs market driven right-based social services, global collaboration vs. competition to advance on global public goods and a renewed cooperation framework based on fair redistribution of global resources rather than profit oriented investments, as the current trend (China’s B&R, US B3W and EU’s GGI) reflects.

Such global collaboration should strengthen multilateralism, a renewed global and binding commitment to the Universal declaration of Human Rights and question international oligarchic structures as the Security Council, the G7, G20 and other restrictive groups, through a truly democratic UN governance promoting the mentioned strategy towards sustainable equity.

The EU’s main added value is to champion equitable wellbeing, siding with Japan as global leads, collaborate with China’s lead in solar cells and other key global goods while reducing import high carbon dependency, with Taiwan’s semiconductors, with the USA’s innovative capacities, promote tireless peace talks with Russia and promote, with like-minded regions especially in the global South, a new deal based on universal right based framework and services towards sustainable equity led by a democratic renewed UN system.

There is an urgent need to change direction and avoid climatic tragedy and transform the present global lack of trust in institutions driven by market forces rather than by active participation and ethical principles on sustainable equity. In EU and the USA public trust across generations has declined from over 70% in the 60s to less than 30% presently. Such trend is similar to wider surveys in both “developed” and “developing” countries[xv]. A new global deal should promote collaborating to global justice through hope, rather than competing for power or privileges through fear.

This debate needs to reach schools and universities, workers and scholars, mass media and social networks and local, national and global politics. The future of our children is at stake as never before and Humanity needs courage and wisdom to change the present state of unethical inequities and direction towards apocalyptic disaster.



[i] The Gini index measures the extent to which the distribution of income or consumption among individuals or households within an economy deviates from a perfectly equal distribution.








[ix] McKinsey & Company is a global management consulting firm that serves leading businesses (e.g., Fortune 1,000 companies like Coca-Cola and Microsoft), investors (e.g., Private Equity firms like KKR), governments (e.g., US Dept. of Energy) and nonprofits (e.g., Bill and Melinda Gates Foundation).







News Flash 515: 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

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