Was the diet appropriate, what changes to the food intake would you make if your client is to continue following a vegan diet?

2000 words
This assessment asks you to consider a practical case where you have a client who is currently happy with their weight but wants to follow a vegan diet. How will you approach this to ensure your client does so in a healthy way? (Please note your client is you!). The specific aim is therefore to design and carry out an assessment to evaluate the current energy balance status of a vegan client using methods taught on this and on previous modules.
Writing up the Report

The report should be written using the following guidelines –
Please ensure your work is anonymous and the name of the client is confidential.
2000 words

Introduction;
Describe the reasons for nutrition assessment including the importance of measuring body composition, energy intake, energy expenditure and energy balance.

Aim;
Nutritional assessment of a healthy person (you) who wants to follow a vegan diet.

Methods;
Give a detailed and concise description of the methods you used and if necessary the instructions provided to the client.

Results;
Present your findings from the body composition, energy expenditure, and energy intake measurements using text and tables as necessary.
Raw data can be put in an appendix.

Discussion
Points to consider:
Did the body composition assessment provide useful information?
Was the diet appropriate, what changes to the food intake would you make if your client is to continue following a vegan diet?
Did you measure BMR or RMR or total energy expenditure?
Is your participant in energy balance, what are the long term implications for this?
Does your participant need to be referred to another health professional e.g. a GP or a physio
How could your assessment be improved for greater accuracy?

Conclusion;
Summarise your findings and put them in into the vegan context, what was the overall outcome?

References;
Association for Nutrition (2020) http://www.associationfornutrition.org/. Accessed 8 Jan 2020.
British Dietetic Association (2019) Plant based Diets. https://www.bda.uk.com/food-health/food-facts.html. Accessed 17.1.20
Elia M, Ljungqvist O, Stratton RJ, Lanham-New S (2012) Clinical Nutrition. Wiley Blackwell: London.
FAO/WHO/UNU (1985). Energy and Protein Requirements. WHO
Gibson RS (2005) Principles of Nutritional Assessment, OUP: Oxford.
Weir, J.B. d. V. (1949). New methods for calculating metabolic rate with special references to protein metabolism. Journal of Physiology 109, 1-9.

Instructions if you are measuring BMR or energy expenditure;
Prepare the participant by ensuring they are in thermoneutral conditions, rested and are familiar with the mouthpiece. After approx. 5 mins of acclimatisation to the mouthpiece, the measurement may begin.

Analyse the contents of the Douglas bag using the Servomex Gas Analysers to measure O2 and CO2 content. And the Harvard Dry gas meter to measure the volume of air the Douglas bag contains.

At the end of the measurements, the data can be used to determine energy expenditure using the following equation by Weir (1949).

21 – r CF
BMR (kJ/min) = V * * *20
100 t

Where:
V = Volume of expired air (l) CF = correction factor (to account for temperature and pressure)

r = O2 content of expired air (%) 20 = energy equivalence of O2 (kJ/l)

21 = O2 in inspired air (%) t = time (min)
If calculating BMR state which specific equation (Schofield, Mifflin St Jeor or Oxford)

Identify the fitness requirements of the clients through and interview and needs analysis.

For this activity you will need to plan and implement five fitness programs for clients in the age group of 13 to 17 years of age.

For each of the fitness programs you will need to:

1. Identify the fitness requirements of the clients through and interview and needs analysis.
2. Undertake a health appraisal.
3. Make referral to AHP for 2 clients where indicated in templates.
4. Develop plans for the exercise sessions.
5. Instruct the exercise sessions.
6. Review the exercise sessions.

These assessment activities may be undertaken using real clients in an actual fitness setting, or where that is not possible or practical, they may be undertaken in a simulated environment and/or using volunteers who will role-play the clients.

Where any simulation occurs the conditions must be consistent with the fitness setting, which means the available resources and conditions must be the same as in the commercial fitness setting.

Use the templates provided in the Answer Assist below to assist in the planning of the sessions, and in recording the details.

Identify and discuss two strengths and two weaknesses of this policy specifically related to this situation (not her initial hospitalization).

Paper 1 Health Policy Examination

Obtain a copy of your own health insurance policy (also referred to as the Schedule of Benefits) through your family or a copy of your B.U. Aetna Insurance Co. policy, if you carry that insurance.

Using your health care policy, write a paper to answer the questions below.

Scenario: Sara, a 21 year-old B.U. undergraduate student suffered a head injury over break. Sara is on the crew team. She has a part time job off campus as a waitress. After the injury, she has short- term memory problems, loss of appetite, and is feeling depressed. She has decreased coordination, mild left-sided weakness and mild expressive aphasia (word finding ability). Sara is determined to get back into full participation at school, and with her doctor’s agreement, begin the semester. She is home after spending one night in the hospital. Her physician clears her to return to school but recommends that she see several different health professionals as an outpatient when she returns to Boston to begin school again.

Write in the third person as if you are a professional explaining the policy coverage to someone else. You are role playing as “Sara” using your own policy.
Your paper will address all of the following questions:

  1. 1-  How much does the subscriber (you or your parents) pay annually? Briefly explain what type of policy this is (e.g. HMO,PPO, IPA, POS model). (Note: The true cost of insurance is often shielded from the consumer. The purpose of this information is to enlighten you as to the cost of insurance). You will need to get this information in most cases directly from your parent/guardian.
  1. 2-  How much will Sara pay for medications, (including in and out of network costs, co-payments, generic drugs, drug tiers, and mail order)?
  2. 3-  Sara’s physician recommends counseling, at least weekly for the next two months. What does the policy cover (including in and out of network costs)? How much will Sara pay out-of-pocket for counseling? Whom specifically can she see (i.e. a psychologist, psychiatrist, social worker, etc)

4- Sara needs to see a nutritionist, and an occupational therapist, physical therapy, and speech and language health professional and she may need ongoing treatment from each of these practitioners. Which of these services does her policy cover (including in and out of network costs) and how much will she pay for out of pocket for visits?

5- Identify and discuss two strengths and two weaknesses of this policy specifically related to this situation (not her initial hospitalization).

Paper Requirements:
§ See formatting requirements under Common Understandings.
§ 3-4 pages in length (not including title or reference page). Nothing beyond 4 pages will be read or graded.
§ In the text, reference the page numbers from your policy relevant to each question.
§ Follow APA style for referencing. See Quick reference for APA style
§ Highlight (in color) all pertinent information on the insurance policy
§ Attach the relevant plan information to your paper. You will receive this information back with your graded paper. § See grading criteria below.
§ Insurance Paper Grading Criteria Student Name__________________________________

  Max Pts.   Comments
    Ideas  
  4 Clearly discusses the type of policy and all costs to the subscriber.  
  5 Clearly and completely discusses cost of medications (including co- payments, generic drugs, drug tiers, and mail order).  
  5 Clearly and completely discusses coverage (3pt) and out of pocket cost (2 pt) of counseling (including in and out of network costs) and the providers (i.e. psychiatrist, social worker, psychologist, etc) that the subscriber can see under the policy.  
  8 Clearly and completely discusses coverage (including in and out of network costs) and out of pocket cost for nutrition (2pt), occupational therapy (2pt), physical therapy (2pt), and speech and language (2pt).  
  8 Clearly and thoughtfully discusses two strengths and two weaknesses (2 pts each) of the policy related to the situation (separate from the concluding paragraph).  
    Structure  
  3 Begins with a separate introductory paragraph, including a brief summary of the context for the paper.  

12

  3 Ends with a separate concluding paragraph, including a review of the key points of the paper.  
  3 Develops a logical, well-organized discussion of the material.  
    Mechanics  
  3 Follows APA style guidelines with regards to both format and citations.  
  2 Identifies policy page numbers next to cited text (1 pt); highlights pertinent information within the policy (1 pt).  
  3 Maintains a sophisticated and engaging academic tone.  
  3 Presents a college-level (relatively error-free) use of grammar.  
50 TOTAL SCORE (____) x2 = _____  

 

Discuss a specific epidemiological study which measured the association between pregnant women’s exposure to the teratogen and adverse effects on the offspring (don’t forget to cite the study).

Assignment on Teratogens

Teratogens are exogenous agents, such as certain chemicals, drugs, or viruses, that disrupt the normal processes of development.  For this assignment you will choose a teratogen, which is known to cross the placental barrier, and cause damage or long-lasting adverse effects to the developing embryo or fetus.  You will do some research on the teratogen and then answer questions below.

Here are some examples of teratogens which cross the placental barrier:

Class of Teratogen Some Potential Choices*
Recreational Drugs Alcohol, Cocaine, Methamphetamine, Nicotine
Infectious Agents Toxoplasma Gondii, Rubella, Cytomegalovirus, Varicella Zoster Virus (chicken pox), Treponema pallidum (Syphilis), Herpes Simplex viruses, Zika virus, others
Prescription Drugs Retinoic Acid (Accutane), Anti-convulsants, Others
Environmental contaminants Mercury, Lead, Others

 

*Before you get too attached to a specific teratogen, be sure that there is sufficient literature on the effects of the teratogen.  To answer question 1, there have to be epidemiological studies that demonstrate an association between exposure of pregnant women to the teratogen and adverse outcomes in their children.  To answer question 2 on the underlying biological mechanisms, there should also be animal studies on the effects of the teratogen.  For example, I do not recommend choosing thalidomide since this was a drug mostly prescribed in Europe (Germany) in the 1940s, thus there would be few epidemiological studies and they would be fairly old and mostly in German.

You must do some research on your teratogen choice in order to answer the following questions.  Here are the parameters for the types of resources you are required to use.  You must actually cite these resources in your answers to the questions below using in-text citations and include them in your reference list at the end. citations should follow APA format:

  • At least 1 review article from published peer-reviewed literature. For example, the following is a review article published in the Journal Nature Reviews Neuroscience on the effects of prenatal exposure to drugs:

Thompson, B. L., Levitt, P., & Stanwood, G. D. (2009). Prenatal exposure to drugs: effects on brain development and implications for policy and education. Nature Reviews Neuroscience10(4), 303.  doi: 10.1038/nrn2598

  • At least 1 primary research article from published peer-reviewed literature: For example, you could find an article that is an epidemiological cohort study which measured the relative risk of infants being born with birth defects or having a developmental delay when the mother was using a specific prescription drug during her pregnancy. You could also find an experimental study that looks at the biological mechanisms for the effects of the teratogen using animals.  The references at the end of your review article (or on some websites) are a good starting point for finding primary research articles.
  • At least 1 Reputable Website (such as government websites (.gov), The Teratology Society, hospital websites, charitable organizations, etc.)
  • Charitable organizations that support Child and Maternal Health, such as the March of Dimes.

https://www.marchofdimes.org/complications/pregnancy-complications.aspx

 

  • You may also cite chapters in books if you wish. For example, the Teratology Primer (https://birthdefectsresearch.org/primer/) has chapters on teratogens such as Alcohol, Prescription drugs like Anti-depressant medications, Environmental Toxins, and Infectious Diseases.

 

You MUST answer the following questions in your own wordsDo NOT quote directly from your sources.  You must paraphrase instead.

  • If you copy from sources, you have committed plagiarism. Turn-it-in software will be used to detect plagiarism.
  • You must cite every new idea you discuss that is not your own (e.g. that came from other sources or is not general knowledge) using in-text citations and include a list of references at the end (in APA format).
  • You must submit a Word document (not pdf) with a title page and your answers to the questions to the LEARN Dropbox for Assignment 2
  • Do not include the actual questions in your Word document, just the question number and subpart (i.e. 1b, 2a, etc).
  • Use a title page for your Assignment with the following:
    • HLTH/KIN/GERON310 Assignment 2 – Winter 2020
    • Title that includes name of Teratogen
    • Your name and Student ID number
  • Use 1.0 spacing and 10 pt Times New Roman Font.

Questions to Answer

1) Epidemiology of the teratogen and risks to development. Vulnerable populations.

1-a) Discuss a specific epidemiological study which measured the association between pregnant women’s exposure to the teratogen and adverse effects on the offspring (don’t forget to cite the study). What type of study was it, how was the study carried out (e.g. describe study design and methods), and what were the main results of the study?  Report on specific statistics to help indicate the risk, such as the odds ratio or relative risk, or prevalence of adverse outcomes in the offspring that were exposed in utero.  You may have to give different statistics for different types of deficits associated with the same teratogen. (18-20 sentences)

Rubric: (5 points)              

Excellent and thorough description of an epidemiological study that measured association between teratogen exposure and adverse effects in the offspring. Your description clearly included the following:

–  thoroughly described study design and methods, including: the type of epidemiological study design; characteristics of the recruited participants, inclusion and exclusion criteria; description of what was measured and at what time points

– Thoroughly described the main results of the study.

– You included statistics to indicate the risk of deficits with exposure to the teratogen. (at least two different statistics to be Excellent)

– You cited the study and/or other relevant sources throughout in your description.

1-b. Which particular populations of pregnant women or regions of the world are most vulnerable or have higher prevalence of exposure to this teratogen?  Explain and cite your sources. (9-10 sentences)

Rubric: (2 points)

– Excellent description of particular populations or regions of the world with higher prevalence of exposure to the teratogen.  Must describe at least 2 vulnerable populations or regions to be excellent.

-You cited relevant sources.

2 Biological aspects of the teratogen effects:

2-a Describe the congenital defects, disorders, or neurobehavioral deficits associated with prenatal exposure to the teratogen.  What organs or tissues are mostly affected?  What are the most sensitive periods of prenatal development for the types of defects described above? (9-10 sentences)

Rubric: (3 points)

Excellent description that includes:

  1. a) Thorough description of the congenital defects, disorders, and/or neurobehavioral deficits.
  2. b) organs and organ systems most affected
  3. c) the most sensitive periods of prenatal development for exposure to the teratogen (note that the sensitive periods may differ for different defects/outcomes)

– You also cited relevant sources.

2-b. For one of the defects described above, describe a potential underlying biological mechanism for the teratogenic effects during development (usually these data come from animal studies).  Be specific in your description of the biological mechanism (e.g. death of cells in a certain part of the brain leading to severe mental retardation, decrease in nutrient transport across the placenta leading to very low birth weight).  (5-6 sentences)

Rubric: (2 points)

Excellent description of a potential underlying biological mechanism for one of the defects/disorders/deficits that is specific and cites a relevant source (such as an animal study).

3) Take on the role of a public health educator.  You need to get the word out to the public on the potential harmful effects of this teratogen.  Come up with a strategy to disseminate the information (public service announcement on TV? infographic signs in certain places?).  In your strategy, discuss how you will target those who are more likely to be exposed to the teratogen or the most vulnerable segments of society (i.e. from part 1b).  What are the most salient points to make about the harmful effects of the teratogen, based on your answers to the above questions?  Keep in mind that you can’t be too technical in your wording or you will confuse or lose the interest of your audience.  Be creative and describe your strategy in at least 13 sentences (but no longer than 15 sentences).

Rubric: (4 points)

Uses excellent strategy to disseminate information to the public that is thorough, clear, and logical.

Strategy efficiently targets the people most likely to be exposed or most vulnerable populations/regions (eg focus on 1 of the regions or populations discussed in Q1b).

Emphasizes the most salient points on the harmful effects of the teratogen

Presents information in an engaging and simplified manner to hold the attention of the public.

Research, references, and citations (be sure to use proper APA format).

Rubric: (3 points)

Excellent use of sources, citations, and proper formatting of references.

Used the three required types of sources (Review article, primary research article, and reputable website).

Cited sources extensively where appropriate in the answers to the questions.

Provided a complete list of references at the end with proper APA formatting.

How can the sources of biases be reduced in observational studies for managing diabetes and obesity?

1) Proposed Research Title:

Reducing Bias in Observational (non-interventional) Studies for Obesity and Diabetes Management.

2) Introduction:

While in experimental trials a direct intervention can be made, observational studies only allow passive observation of the occurring events, making them susceptible to a high degree of bias. The high risk of bias associated with observational studies makes it difficult to establish a causal inference and may lead to inaccurate interpretation of results.

There is a need to reduce associated bias in observational studies being undertaken.

The reduction of bias should first identify the possible sources and types of bias that may be associated with a particular context [1].

The three main types of biases in observational studies include selection bias, confounding bias and information bias. A selection bias leads to the lack of inclusion of some participants into the study, therefore reducing the representativeness of the research. Confounding bias results when the statistical analysis does not consider all the relevant effects. Information bias arises from factors such as misclassification and false reporting of the findings [2].

 

3) Research Questions and Objectives: 

This research aims to identify ways that can be used to reduce the level of bias in observational studies, on the effectiveness of the lifestyle changes, in particular exercise, for the management of obesity in patients with type 2 diabetes.

  • How is the quality of research achieved in observational studies?
  • What are some sources of biases in observational studies relating to the management of diabetes and obesity?
  • How can the sources of biases be reduced in observational studies for managing diabetes and obesity?

The objectives that are pursued in the research questions include:

  • To determine ways for ensuring quality in observational studies.
  • To explore the sources of biases in observational studies relating to the management of diabetes and obesity.
  • To recommend measures that can be used in the reduction of the identified biases of the selected studies.

 

Justification and Rationale:

Regardless of the existence of numerous observational studies on the management and prevention of obesity and diabetes, the data presented may be biased due to the subjective nature of observational studies [3]. For instance, selection bias can occur when the researcher fails to include some participants in the research, therefore reducing the representativeness of the process.

Since obesity and diabetes are significantly affected by environmental and social factors, the biases from an observational study may lead to unreliable conclusions regarding the management measures adopted. This study is therefore justified in the identification of the errors in such studies. The findings of this study will contribute towards the improvement of the methodological processes in obesity and diabetes studies.

 

4) Short Literature Review:

According to the WHO the prevalence of obesity and diabetes has increased dramatically in the past three decades in all countries regardless of their income levels. The number of individuals with diabetes increased from 108 million in 1980 to 422 million in 2014. Similarly, the prevalence of diabetes in adults rose from 4.7% in 1980 to 8.5% in 2014. The prevalence of obesity has also increased in the past 50 years to pandemic levels globally [4]. Obesity presents a major health challenge leading to a substantial increase in the risk of diseases like type 2 diabetes, obstructive sleep apnoea, myocardial infarction and stroke.

Accordingly, the management of the two conditions is of the utmost importance in the global health sector. The reduction of obesity and diabetes burden is based on the combination of individual interventions and changes in the environment and society [5].

Therefore, an understanding of the influence of the personal behaviours on the management of the two conditions is critical in establishing the relative effectiveness of the appropriate strategies. Some of the lifestyle strategies that are used in the prevention and treatment for both diabetes and obesity include the maintenance of a healthy diet, regular physical activities, and avoiding tobacco and alcohol use.

5) Data Collection& Analysis by Systematic Review:

The proposed study involves a comparison of observational studies against randomised control trial (RCTs) regarding the measures of managing obesity via exercise and type 2 diabetes. Following a systematic review all relevant observational studies will be compared against  RCTs.

The inclusion and exclusion criteria will be based on factors such as year of publication (to be published within the last 5 years) and relevance to the topic of discussion.  Therefore the studies excluded will be those published more than five years ago and do not address the management of obesity and diabetes through changes in lifestyle.

Additionally, studies that focus on the changes in lifestyle habits towards the management of other diseases other than obesity and diabetes are excluded.

The study population is represented by adults over 35 years. The data collection is quantitative and qualitative, including questionnaires and statistical diagrams to represent the results of the study.

The main databases that will used for the search are Clintrials.gov, MEDLINE and PubMed with the search restricted to studies published in the last five years. The search strategy retrieves the studies that are then assessed for eligibility and inclusion.

The search terms used in the study include ‘observational studies’, ‘non-interventional studies’, ‘random clinical trials’, ‘interventional studies’, ‘diabetes’, ‘obesity’, ‘management’, ‘exercise’ and ‘lifestyle changes’.

6) Project Management Timetable:

Month Activity Completion
Mar 2020 Database Search, Systematic Review and Final Selection of Studies for Analyses
Mar 2020 Analyse Studies
Mar 2020 Draft Dissertation
Apr 2020 Finalise Dissertation
May 2020 Submit Final Draft for comment
Jun 2020 Revise and Submit Dissertation Project

 

7) Management of Risks to Project:

The main risk to this systematic review project is the risk of bias assessment of the validity of the included studies. The risk of bias entails the overestimation and underestimation of the effect of the intervention in the included studies.

The risk of bias will be ensured by enhancing the validity of the included studies through the adoption of the inclusion and exclusion criteria to enhance the quality of the evidence.

 

8) Ethical considerations:

No ethics submission is needed

The main ethical factors in the project relate to the considerations undertaken in the selected studies as the randomised control trials involve human subjects. Consequently, the included studies are those with ethical approvals.

9) Financial costs: NONE

10) Key References:

  1. Roglic G. WHO Global report on diabetes: A summary. International Journal of Non communicable Diseases. 2016 Apr 1; 1(1):3.
  2. Sharma M, Nazareth I, Petersen I. Observational studies of treatment effectiveness: worthwhile or worthless?. Clinical epidemiology. 2019; 11:35.
  3. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Jama. 2003 Jan 1; 289(1):76-9.
  4. Dietz WH, Baur LA, Hall K, Puhl RM, Taveras EM, Uauy R, Kopelman P. Management of obesity: improvement of health-care training and systems for prevention and care. The Lancet. 2015 Jun 20; 385(9986):2521-33.
  5. Naimi TS, Stockwell T, Zhao J, Xuan Z, Dangardt F, Saitz R, Liang W, Chikritzhs T. Selection biases in observational studies affect associations between ‘moderate’ alcohol consumption and mortality. Addiction. 2017 Feb; 112(2):207-14.

Comments received from reviewer: –

I think this is a very reasonable project. This sort of thing has been done before though (John Ioannidis had a paper in JAMA a few years ago comparing trials vs observational studies – I recommend the student look at that)

http://www.ncbi.nlm.nih.gov/pubmed/11497536

My main criticism is that the method for selection of the trials and observational studies is too vague. Why 5 trials? That is completely arbitrary. It would be better to select a defined (sub)area of the subject and then select all observational and all trials in that area.

Then the most logical thing to do is to determine how the outcomes (trials vs Obs) compared as per the Ioannidis paper using methods like meta-analysis.

What were the major epidemics of the Middle Ages? Why were they so feared? What factors contributed to their spread? What were some strategies people used to prevent these diseases?

1.What were the major epidemics of the Middle Ages? Why were they so feared? What factors contributed to their spread? What were some strategies people used to prevent these diseases?
2.Discuss the Renaissance and why it is important to the history of health and health care.
6.Identify at least five major groups or events that forwarded school health programs.
8.What are national health objectives? Where can they be found? Why are they so important?

Assist the CEO in scheduling business meeting, conference call and corporate presentation Xcelom Limited.

EDUCATION
2016 – Present The Hong Kong University of Science and Technology § Bachelor of Science in Biotechnology (Anticipated Graduation: June 2020)

Business Development Assistant
Sanomics is a pioneering genomics technology company based in Hong Kong. Using a new generation of proprietary technologies, Sanomics offers blood-based genomics testing for cancer patients. It is backed by US$10 million in funding from investors including Chow Tai Fook Enterprises and Shenzhen-listed non-invasive DNA prenatal testing firm Berry Genomics Co.
§ Set up Sanomics Thailand branches
§ Performed as a major role in the cooperation with KPMG(Thailand) and CBRE(Thailand) to
facilitate the operation of Thailand branches
§ Assist in preparing corporate and geographical development materials (e.g. IPO pitch PowerPoint,
videos and posts on social media)
§ Assist the CEO in scheduling business meeting, conference call and corporate presentation Xcelom Limited.
Feb2018 – May2018
Sales and Marketing Intern
Xcelom has been exclusive licensed by CUHK to provide an Non-Invasive Prenatal
Technology (NIPT) service called “safeT21express”.
§ Assist in preparing marketing materials (e.g. product brochure, presentation PowerPoint)
§ Performed as a major role in cooperation with video production house to produce an interview with Dr. Leung Kwong Chuen Agnus
Ace Printing Group Ltd
Jul2016 – Jan2018
Personal Assistant
Ace Printing Group Ltd is a garment manufacturing print house established in 2015 with its Head Quarters in Hong Kong, and factory in Cambodia. It is supported by Kwan Tat Group with more than 30 years’ experiences in the industry and modern management concepts.
§ Perform quality control in chemical and testing requirements
§ Assist in general accounting works (e.g. monitoring of account receivables and documentaries, monthly closing and billing to clients and travel planning purchases) § Prepare company’s marketing material.

Intern
Urban Spring is a company which aimed to raise awareness regarding plastic waste impact by innovating the design of water dispensers and providing a sustainable solution to minimize the use of single-use bottle.
§ Assist in events like Wow and Flutter presents THE WEEKEND and Eco Expo
§ Assist in animation video making to feature the Well water dispenser of the company
§ Conduct research on plastic waste problems and environmental service companies (e.g. Elkay, Smart Bottle, etc.)
§ Facilitated the design of Operation & Maintenance Manual of the water dispenser.
LEADERSHIP

Member
By cooperating with 30 members in the team, I learnt the importance of teamwork and hardwork, also tend to bounce back quickly after setbacks.
MAGNET Peer Mentoring
Program
Sep2017 – Aug2018
Peer Mentor
A peer mentoring program at HKUST, aims to help new students to transit smoothly to university life by providing 10 mentees a support network, opportunities to meet friends and benefit from the knowledge and experience of senior student.
MenTernship Program
Nov2016 – Aug2017
Mentee
This is a mentorship cum internship program for students to match with social dignitaries as mentors. I had Barbara Fu as my mentor, part-time Lecturer in HKBU School of Communication and an advertising veteran, inspired me in planning skills include positioning and build brand image.
The Model LegCo
2014 – 2016
Vice Chairperson
Model LegCo by HKYLDA organises different activities for 70 secondary students to experience both internal and external work of the Legislative Council in order to deepen students understanding on vary topics of current affairs, by providing workshops – Advanced political knowledge, meeting with Legislative Councillors and visit to the Legislative Council.
SKILLS
Languages: Native – Cantonese; Fluent – English (IELTS Overall Score: 7.0), Mandarin, Fukien
Computing: Proficient in English, Chinese word processing, Microsoft Office (Word, PowerPoint, Excel) and Adobe Creative Suite (Photoshop and Illustrator); Skilled knowledge of Excel VBA and WIX.

Multiple sclerosis progression and the eye. What can OCT studies tell us about disease progression?

Dissertation
Title: Multiple sclerosis progression and the eye. What can OCT studies tell us about disease progression?
The use of OCT is ever increasing in daily optometric practice, but can these instruments be used to inform the clinician about neurological conditions? This study will review the literature to examine how OCT imaging of the retinal nerve fibre layer can provide clinical information about progression of the systemic disease.
Literature review in a CET style article. 5,000 words and 500 words for the overview statement.
Maximum 20 references- mostly peer reviewed journal articles- using APA referencing style.

Structure:

• Abstract (250 words max)
• Introduction
• Main body- includes: data analysis, statistical approach using tables, graphs and figures
• Discussion
• Conclusion
• Overview statement (500 words max that’s not included in the 5,000 words)- includes: why the topic was chosen, how the search on the topic was conducted, summary of the principal findings and how its implicated and relevant in high street optometry practice.

Systematically collect data appropriate to the project and critically analyse and report this information.

8000 words Literature Review on a Diagnostic Radiography question :

IS THERE A CASE FOR NON-SMALL CELL LUNG CANCER SCREENING USING LOW DOSE SPIRAL CT?

COMPARISON OF CHEST XRAY AND LOW DOSE SPIRAL CT  IN CONSIDERATION TO SPCIFICITY  AND SENSITIVITY IN TERMS OF RADIATION DOSE.

8000 words Literature Review on a Diagnostic Radiography question: IS THERE A CASE FOR NON-SMALL CELL LUNG CANCER SCREENING USING LOW DOSE SPIRAL CT?

For  Literature Review instructions, please follow and read the handbook thoroughly.

The making criteria is also provided  in the handbook.

 

Aims of the Handbook

The handbook is a guide for students in the Department of Allied Health.  The information in the handbook can also be found in a number of other electronic or paper sources and the document provides links to the definitive data sources wherever possible.

Note that the electronic version of the handbook will be kept up to date and you will be notified of any significant changes.  If you have taken a hard copy of any information please remember to refer back to the electronic version to ensure that you are working with the most up to date information.

 

1. Module specific information

On successful completion of this module students will be able to:

  1. Critically evaluate the research evidence base with respect to chosen research topic.
  2. Systematically collect data appropriate to the project and critically analyse and report this information.
  3. Apply a critical understanding of the research process relevant to professional practice.
  4. Produce a cohesive and concise report of the research process.
  5. Assignment Brief

By the end of the module you will produce an 8000 word report. The following information will help you to achieve this goal.

 

Writing the Report

The project report should be prepared progressively throughout the project.  It is advisable to undertake the literature review at an early stage, ideally before designing data collection.  The supervisor will give consideration to the organisation, timeliness and progression of the project when allocating the final mark.

Draft Report

The draft will take the form on one main chapter of your choice and an annotated plan with subheadings plus a full reference list of literature collected to date.

To expand on the annotated plan idea what we expect is a series of headings with a few sentences of explanation so the supervisor can assess that your argument is covering the correct areas.

The full chapter will allow the supervisor to assess your style of writing to ensure it is of the correct level 3 standard .It is strongly recommended that you submit  a draft  as this will give your supervisor a chance to offer in depth constructive criticism on content, layout and the overall format of the final report. You may negotiate a slight extension to the suggested deadline but please remember that the later you submit the draft then the time you will have to act on the outcome will be reduced. Supervisors will feedback within 7-10 days if drafts are submitted on time but are under no obligation to feed back within that period if the project is poorly managed. You should not make your deadlines become your supervisor’s as this is a busy time for all of us! Your supervisor will only look at each section once.

Once you have received feedback you can meet with your supervisor to discuss and then you are on your own and the supervisor will not be able to provide any further assistance

 

GENERAL REQUIREMENTS

Word Count: up to 8000 words. This means 8000 is a maximum and you will be penalised if the final count is significantly over this figure. There is no penalty for work which is under 8,000 words but a significant number of words below the limit would tend to indicate that some areas may lack depth of analysis.

Reference citations within the body of your text, are to be included within the word count.

Presentation: Typed/word processed, on A4 paper, size 12 font, 1- 1.5 line spacing.  All pages must be numbered.  The total word count must be presented on the abstract page.

 Margins: A minimum of 4.0 cm for the left (if you decide you want to bind a copy but usual margin if just electronically submitting), 1.5 cm for the right, and 2.5 cm for the top and bottom margins.

Abstract: Approximately 250 words, single spacing- should contain key words.

References: Harvard style (see the Faculty Undergraduate Modular Programme Student Handbook).

Secondary referencing should be kept to a minimum and only used in exceptional cases where it is difficult to obtain the original article (eg translations of foreign texts, historical articles).

 

Appendices: Inclusion of an appendix /appendices is optional and may contain consent forms, subject information sheets, raw data collected by you during your research (eg complete raw data, summaries of raw data, examples of raw data) or copies of any validated measurement or search tools that you have used for literature reviews. You must feel able to defend the attachment of appendices as ADDING something useful to your work. Don’t be tempted to just add them in just “for good measure”!!! Appendices which have not been thought through carefully and selectively will detract from the quality of your work, although they will not be marked, as such. Appendices are not included in the word count.

SPECIFIC GUIDELINES FOR WRITING A LITERATURE REVIEW

Acknowledgements   Acknowledge those who have helped you in your study but keep it brief and professional in style.

 Abstract:  Written in single line spacing on a separate page.  Write your research title again above the abstract. It should not exceed 250 words. This is in many ways the most important part of your literature review.  It determines whether or not people interested in your area of inquiry learn about your work, and it gives the reader a framework on which to hang the details.  It should briefly convey the reason for the review, the overall approach (method), the main findings and conclusions.  The abstract is not the place for a great deal of detail.  Do not append references to the abstract.  Declare the word count of your full work at the end of your abstract.

 Table of contents  A page number reference should be given for each section. An index is not required.  If you have them, a numbered list of figures and tables, each with a title that describes them and the page on which they are situated, should be provided at the end of the table of contents.

 Introduction This should explain your hypothesis, or the question/s you are trying to answer, and  the aim/s you are trying to fulfil by your review of the literature. It “sets the scene” and logically and progressively focuses in on the gap in understanding that you are trying to fill by your orderly and methodical review of the literature. The introduction should contain three clearly identifiable and logically presented elements:-

  1. The reason for the investigation. This sets the scene and justifies your research question/s or aim/s and provides a background
  2. The contribution of others in the field and current schools of thought

iii. The lead in to the main body of the review.  Establish the need for your study and for your method (i.e. systematic literature review).  What relevance does it have and to whom?  Explain how you will proceed with your argument in this review i.e. outline how you have reviewed the literature in a systematic way & how the work is organised.

Conclude this section with your main aim or main research question and identify any secondary aims.

Strategy for reviewing the literature   This section describes how you systematically reviewed the literature and explains why you selected this approach.  What were your criteria for reviewing the literature and why did you choose these?  What was your search strategy? Which databases did you use?   Did you hand-search for literature? Did you refer to “grey” literature?  What key words or word combinations did you use? etc.  Has this topic been reviewed before?  If so, how was it reviewed and why did you choose to review it again and, perhaps, in a different way?  You may decide to use tables or flow-charts to illustrate your search strategy. Essentially this section is your method and should be explicit such that a reader could reproduce what you did exactly. You may find that some of the key points and headings from the lecture on Searching the Literature Systematically will help you organise this section of your work.         

Findings /Review of the selected literature/ Results   This is a critical and systematic (i.e. orderly and methodical) review of the important literature available to date that is relevant to your hypothesis, question/s or aim/s as outlined in your introduction.  Present your findings succinctly.

Discussion

Subheadings may be used.

Each section of the discussion is expected to progress from the factual (this is what was found) via detailed argument to a more theoretical or generalized conclusion (this is what it could mean).  The following issues should be addressed:

What did you find?

Are there any problems or limitations associated with the literature when trying to address the research question/s or aim/s explained in your introduction?  E.g. was the published research valid, reliable, were there gaps in the literature etc?

Identify any questions/key issues that arise in trying to address your research question/s or aim/s.

What are the findings (results) of your review and how do they relate to your research question/s or aim/s.

So what? What are the practical/clinical implications of your      review findings? How might they influence practice?

Discuss suggestions for further research.  Where do we go from here?

Methodological/approach considerations relating to your search strategy should also be discussed here, i.e. was your search strategy appropriate for the research question or aim/s of your study? Critically evaluate your approach to reviewing the literature.    Would alternative strategies be more appropriate?  How has your chosen strategy influenced your findings?

Your review and discussion of the literature must demonstrate your ability to think critically.  Critical thinking involves a combination of different skills. Make sure you have demonstrated the following:

Analysis – the ability to breakdown material and examine its component parts.

Synthesis – the ability to combine separate elements and make a new coherent whole.  This involves the discovery of new patterns, structures and meanings.

Evaluation – The ability to judge the value of material, based on definite criteria.

Conclusions A short account of your main conclusions. It should encapsulate the key findings, meanings and implications of your literature review.  Make sure that your conclusions relate to the research question or aim/s you stated in your introduction!    Do not introduce any new material here!

References Harvard style (see Faculty Undergraduate Modular Programme Student Handbook). Remember that it is the quality of the references (scope, depth, relevance, up-to-date etc.) that is important, not the quantity.  You should have read everything that you cite. Only include secondary references where absolutely necessary.

A bibliography is not required.

Appendices: Appendices are optional. They are not marked.  If you decide to include appendices they should contain material such as copies of any validated measurement or search tools that you used/discussed in your literature review or perhaps raw data.   For example you may have an appendix containing either complete raw data, summaries of raw data or samples of raw data that you have collected as part of the literature review process.  This may occur if you have chosen to include a quantitative or qualitative analysis of the literature. This raw data may be presented as words (eg. raw data derived from a thematic analysis of the literature) or as numbers (eg. frequency analysis of the literature or meta-analysis).

You should feel able to defend the inclusion of all appendices as adding something to the work and not just placed there “for good measure”! Appendices which have not been thought through carefully and selectively will detract from the quality of your work.

Recommended Word Limits for the Report

for a lit review

Chapter Recommended Minimum Recommended Maximum

 

Introduction 500 500

 

Methodology 750 1,250

 

Literature review 5250 5500
Conclusions 500 750

 

Totals 7,000 8,000

 

 

Plagiarism

A Warning about Plagiarism:

All students are warned that unacknowledged use of source material in any assignment submitted as part of their work for the Degree may be held to constitute the offence of plagiarism.  Plagiarism is the counterpart of cheating under examination conditions.  Any suspected case of plagiarism will be investigated and where it is established that a student has committee the offence, the penalties are severe.  They include the automatic forfeiture of the award of the degree, as well as disciplinary action by the University.

Cheating, Collusion and Plagiarism:

Assessment

What are markers looking for in your dissertation?

Markers will be checking for evidence that you have followed your proposal outline.

In the case of research involving human participants markers will need evidence that Ethical approval was granted.

DESCRIPTORS

To achieve a pass your work MUST meet the specific descriptors set out below. 

 Markers will be looking for the extent to which your work satisfies specified descriptors as shown below: 

 Knowledge & understanding

  1. i) Knowledge-base
  • An appropriately comprehensive, detailed and in-depth knowledge base and understanding is evident.
  • You demonstrate knowledge and understanding of relevant research methods and methodological issues appropriate to your specialized area of study.
  • You have undertaken personal responsibility for the development of your own knowledge of relevant research methodology.
  • Your work shows an awareness of the provisional nature of knowledge.
  1. ii) Ethical issues
  • Your work shows evidence that professional and ethical codes of conduct frame your thinking and a critical ethical dimension is incorporated into your writing.
  • Where primary data collection has involved the participation of human subjects, the relevant ethical issues are clearly and fully presented in a manner which shows depth of understanding.
  • Literature reviews reveal, where relevant, that ethical issues have pervaded your thinking as you have explored the literature.

Intellectual skills

  1. i) Analysis
  • There is persuasive evidence of analysis (the ability to breakdown and organise material and examine its component parts) within your literature review or primary data collection project.
  • Your work shows how you have analysed material from the literature in a detailed and comprehensive way, and how you have been able to deal with complexities and contradictions.
  • Where primary data has been collected, you show analysis of your findings appropriate to the nature of the data, and using relevant methods/techniques.
  • Where literature has been reviewed you have systematically analysed your findings.
  1. ii) Synthesis
  • There is clear evidence of synthesis/creativity. Synthesis/creativity involves the formulation of new patterns and meanings to the topic of investigation and your own interpretation should be evident.
  • Your work shows how, with minimum guidance, you have transformed concepts, constructs, evidence from the literature (including abstract material) towards meeting the aim of your study.
  • Literature reviews show how you have synthesized material towards generating and then answering your research question or problem.
  • Primary data collection studies show how you have synthesized existing material to generate your research question and devise your method/s and then how you have synthesized possible meaning from your findings (your interpretation).

 

iii)       Evaluation

  • Evaluation is demonstrated by a comprehensive and critical review of the literature relevant to your area of investigation and the method/s you have chosen.
  • Your work convincingly shows that you can appraise and evaluate evidence critically to support your conclusions/recommendations, reviewing its reliability, validity and significance.
  • There is evidence of your ability to deal with contradictory information and identify possible reasons for contradictions.
  1. iv) Application
  • Your work shows clearly how you have defined complex problem/s and have applied appropriate knowledge towards finding its/their solution.
  • You show evidence, as appropriate, of flexibility and creativity in ways of solving the problems arising while undertaking your research.
  • You indicate, where appropriate, how your results can be applied to professional practice and/or further investigation. The significance of your findings (statistical, if relevant, and clinical/practical) should be identified and applied to context. (You have considered the “so what? factor”!!).

Transferable skills

  1. i) Communication
  • Your work is presented professionally, scientifically, formally and with appropriate attention to detail.
  • Your writing employs an articulate and coherent academic style, is well organised and shows a clear line of argument.
  • Your work is appropriately concise.
  • You present your ideas, discussions and debates eloquently and fluently.
  • The work is properly referenced and contains no typographical, grammatical or spelling errors.
  • Your work is presented in a format which follows given guidelines, and which, with appropriate editing, may be of a suitable style and standard to submit for publication.

 

  1. ii) Learning resources and management of information
  • A full range of relevant learning resources has been used and information searching has been achieved with minimum guidance.
  • Your work shows how you have selected and managed material to accomplish your research and produce your results.
  • Within your report there is evidence of group working in the management and implementation of your research.
  • There is evidence that your criteria of judgement have been applied appropriately and criticality is demonstrated.
Level 3/FHEQ Level 6 Indicative Qualities
100 – 90% Exceptional Exceptional scholarship for the subject. Creative and original insight into theoretical issues. Exemplary.
89 – 80% Outstanding Outstanding knowledge and sustained argument and critical evaluation. Mature analysis. Clear evidence of independent thought. Convincing synthesis of a range of appropriate sources. Excellent referencing. Evidence of use of new sources and approaches.
79 – 70% Excellent Knowledge and understanding is comprehensive in both breadth and depth. Strong ability to critically appreciate concepts. Evidence of independent thought. Presentation is fluent and focussed; use of a wide range of evidence. Clear and well-presented discussion. Excellent referencing.
69 – 60% Very Good Comprehensive in content and well-organized argument but evaluation and analysis of ideas could be further developed. Clear evidence of appropriate reading with evidence of having drawn on reading from beyond the course material. Good accurate referencing. Ability to relate theory and concepts to discussion. Content always relevant and well focussed.
59 – 50% Good Sound comprehension of knowledge base. Reasoning and argument generally relevant but could be further developed. Critical evaluation is apparent but ability to conceptualize and/or apply theory could be strengthened with greater focus and more in-depth analysis. Good evidence of reading. Appropriately referenced.
49 – 40% Pass Meets the relevant learning outcomes but mostly descriptive and/or lacks clarity. Some basic evaluation but analysis is not very well developed and could be strengthened. Some misunderstanding of key principles and concepts.  Evidence of appropriate structure but not always well sequenced. Evidence of some reading but limited. Presentation and focus may need improving.
39 – 35% Marginal Fail Little evidence of understanding and overall not reaching the minimum pass standard due to some key omissions in presentation, argument or structure. Argument needs further development. Content not always relevant. Limited evidence of reading.
34 – 30% A Limited Piece of Work Some evidence of effort but missing some essential aspects. May be lacking in evidence of understanding, focus and structure. Likely to have limited discussion with some lack of relevance. Presentation may need to be improved. Likely to show insufficient evidence of reading.
29 – 20% A Limited Piece of Work Some material presented but generally unsatisfactory with some irrelevant or incorrect material. Lack of discussion. Likely to show insufficient evidence of reading. Likely to be incomplete.
19 – 10% A Very Limited Piece of Work Significant deficiencies. Likely to have insufficient, irrelevant or incorrect material. Likely to have very poor structure and no discussion.
9 – 0% Exceptionally Limited Work Insufficient material presented. No evidence of sufficient preparation.

Zero is reserved for failure to attempt an answer but where a submission has been made.

 

QAA descriptor for a higher education qualification at Level 3 (6)

  • a systematic understanding of key aspects of their field of study, including acquisition of coherent and detailed knowledge, at least some of which is at, or informed by, the forefront of defined aspects of a discipline
  • an ability to deploy accurately established techniques of analysis and enquiry within a discipline
  • conceptual understanding that enables the student:

– to devise and sustain arguments, and/or to solve problems, using ideas and techniques, some of which are at the forefront of a discipline

– to describe and comment upon particular aspects of current research, or equivalent advanced scholarship, in the discipline

  • an appreciation of the uncertainty, ambiguity and limits of knowledge
  • the ability to manage their own learning, and to make use of scholarly reviews and primary sources (for example, refereed research articles and/or original materials appropriate to the discipline).

Appreciate the common and unique health challenges in an international context, and explore emerging and intensifying global health issues.

CHAPTER 7

INTERNATIONAL HEALTH POLICY ISSUES

Letting a hundred flowers blossom and a hundred schools of thought contend is the policy for promoting the progress of the arts and the sciences and a flourishing culture in our land.

—Mao Zedong

Protecting Health, Saving Lives—Millions at a Time.

—Johns Hopkins Bloomberg School of Public Health

LEARNING OBJECTIVES

After completing this chapter, you should be able to

  • describe the critical health policy issues in developed countries,
  • discuss the critical health policy issues in developing countries,
  • understand how various countries address their health challenges,
  • appreciate the common and unique health challenges in an international context, and
  • explore emerging and intensifying global health issues.

CASE STUDY 1

CLIMATE CHANGE AND PUBLIC HEALTH

The natural environment has a profound impact on human health, as reflected in the United Nations (UN) Framework Convention on Climate Change (Singh et al. 2011). Climate scientists predict that the world will warm 4°C by 2100, yet the relationship between rising global temperatures and human health is not fully understood. Severe weather events, such as heat waves, earthquakes, floods, hurricanes, and cyclones, pose direct threats to human life and health. Some argue that changing weather patterns have already indirectly affected food yields, water flows, patterns of infectious disease (e.g., the increasing reach of tropical diseases beyond the typical geographic areas of occurrence, changes in the seasonality of certain diseases), and population displacement (Chowdhury, Dey, and Smith 2018; Hundessa et al. 2018; McMichael et al. 2003).

Public health experts are calling for climate change policy interventions that have an immediate, positive impact on population health. For example, policies to encourage reduced meat consumption mitigate the excess intake of saturated fats and remove some methane (a greenhouse gas) from cattle-producing regions (McMichael and Lindgren 2011). Examples such as these and findings from other emerging research show that a public health discussion must be incorporated into the larger climate change discourse.

A public health perspective can unite all actors from disparate sectors behind the common cause of public health and wellness in families, communities, and nations. Reducing inequities not only within but also between countries is crucial to greater climate change resilience and better global health. Neither can be achieved without sustainable development to address fundamental determinants of health such as access to safe water and clean air, food security, strong health systems with good access, and reduced social and economic inequity. Any focus on global health must therefore prioritize sustainable development and climate change (Watts et al. 2015).

By itself, a top-down approach—creating an international agreement, followed by establishing national legislation for individuals and businesses to follow—to addressing climate change is no longer adequate. Organizations and individuals are already taking their own steps to reduce emissions. At the same time, climate change is only one of many factors considered by decision makers, and rarely the one given the highest priority. Adaptation to climate change is clearly also an inadequate response, and current trends in energy production and consumption are driving the world toward a future of great climatic risk.

The most powerful strategy to protect human health from the risks of climate change would be a government mandate of carbon pricing, in ways that strengthen over time until the problem is under control (Boyle 2015). Like tobacco taxation, the policy of carbon pricing would send clear signals to all actors in the system—from producers to users—that the world’s economies must shift away from the use of fossil fuels, such as coal—the worst offender in terms of carbon intensity and damage. In addition to direct incentives, the revenues generated from carbon pricing could go toward wide-ranging measures including adaptation; the development of renewable, low-carbon energy sources; and the global diffusion of improved technologies and practices. Carbon pricing thus holds great potential, particularly when carried out as part of a comprehensive policy package. This potential solution, however, still faces political obstacles. The current drivers of economic growth force communities into patterns of energy use that no reframing can change without coordinated realignment of these drivers. And the idea that “others” are to blame and should be the ones to address climate change remains a potent excuse for inadequate action (Vignola, McDaniels, and Scholz 2013). The ideal international agreement would support stronger efforts at all levels in every country. To be effective, any agreement will need not only to set goals but also to identify needs at international and national levels to achieve the goals. Such an agreement may also require a motivation mechanism, such as a “feedback loop,” that strengthens national ambitions over time (Marteau, Hollands, and Fletcher 2012).

CASE STUDY 2

PRIMARY CARE AROUND THE WORLD

In 1978, the International Conference on Primary Health Care created the Declaration of Alma-Ata, which underscored not only the necessity of a robust primary healthcare system to sustain a comprehensive national health system but also the importance of establishing healthcare as an essential human right (WHO 1978). Globalization has continued to put pressure on health systems that are under strain to provide services that are high quality, universally accessible, and affordable. There is clear evidence that primary healthcare leads to better health for all and better-functioning healthcare systems.

While global health has improved on aggregate, a number of political, demographic, and epidemiological transitions have increased inequalities in progress within and between countries. These transitions have put a strain on existing healthcare systems, and a focus on primary care as an essential part of healthcare reform is necessary. The World Health Organization (WHO) considers universal healthcare a critical aspect of a move toward reform based on primary care. Since the adoption of the Sustainable Development Goals (SDGs), WHO has framed its advocacy for universal healthcare around Target 3.8 of SDG 3, which focuses on service coverage and financial protection (WHO 2018d, 2018e).

With rising healthcare costs and disorganized systems for financial protection, personal health expenditures now force more than 100 million people into poverty each year. Vast differences in health occur between and within countries and even within individual cities. In reemphasizing primary healthcare, WHO argues that its core principles and approaches are more relevant than ever, a conclusion which several findings support (Van Lerberghe 2008).

Using existing preventive measures more efficiently may reduce the global burden of disease by as much as 70 percent (Van Lerberghe 2008). Tasks performed by specialists may be better managed by general practitioners, family doctors, or nurses. Specialist-oriented care contributes to inefficiency, restricted access to care, and deficiencies in comprehensive care. When healthcare is skewed toward specialist care, a range of protective and preventive care interventions may be lost (WHO 2006). Unequal access to care and disparities in health outcomes are usually worst when health is regarded as a commodity and care is profit driven. Workforce shortages in primary care also pose a significant challenge (as described in Case Study 2, “Primary Care Workforce Around the World,” in chapter 4).

An effective primary healthcare approach protects against many of these problems, emphasizing a holistic view of health in which prevention is as important as cure in a care continuum that extends over the human life span. The primary healthcare approach targets key health determinants in multiple nonhealth sectors, in effect launching an “upstream attack” on threats to health (Van Lerberghe 2008). The main strategy for addressing disparities in healthcare is to shift toward universal health coverage with an emphasis on the values of equity, social justice, and solidarity and the overarching goals of fairness and efficiency in service delivery.

 

This chapter provides examples of important health policy issues from the international community, using selected countries—both developed and developing—to demonstrate their impact. Students’ exposure to these issues not only helps them understand international health policy applications but also introduces them to global health (as defined by Koplan et al. 2009) as a field and globalization (as defined by Shi and Singh 2017) as a reality.

The advent of globalization, technological advances, and shifting global demographics brings challenges in achieving equitable global health. Although globalization brings conformity in some areas of people’s lives, differences in economic policies, political and legal structures, social and cultural norms, and religious beliefs remain from country to country and region to region, creating additional barriers to the equitable delivery of healthcare (see the For Your Consideration box titled “Worldwide Access to Care”).

The greater ease of travel and communications has not only diminished barriers between countries but has also ushered in new concerns of disease transmission and other global health threats. Recently considered a problem predominantly afflicting the developing world, infectious diseases have become a concern for all countries as global trade, tourism, international relations, and migration facilitate the spread of disease. Another issue of global concern is injury prevention, particularly when injuries are the result of violence in the country (see the For Your Consideration box titled “Injury Prevention”). The United Nations (UN) works with several constituent organizations on global health initiatives; in addition, WHO coordinates some health activities between countries and surveillance of global health concerns. These organizations, and policymakers around the world, face varied problems and tough decisions regarding global health.

This chapter begins by discussing issues shared by many industrialized countries. Japan, Denmark, Canada, and South Korea are profiled in terms of their major health issues and the solutions they have proposed to address these issues. Next, the chapter discusses both common and unique challenges faced by developing nations. The variety of unique issues confronted by emerging economies is demonstrated in discussions of China, Ukraine, Nigeria, and Colombia. The chapter also includes several Global Health Impact boxes to illustrate issues that could affect global health in the future, challenging policymakers to rethink their approaches to public health (see, for example, the one titled “Migration”).

FOR YOUR CONSIDERATION
Worldwide Access to Care

According to a 2017 global monitoring report, more than 50 percent of the world’s population does not have access to essential healthcare services, more than 800 million people spend in excess of 10 percent of their household budget on healthcare, and nearly 100 million people experience extreme poverty due to healthcare costs (WHO and World Bank 2017). In today’s world, countries face a fast-growing need for equitable, inclusive, and fair primary healthcare systems.

FOR YOUR CONSIDERATION
Injury Prevention

Several governments around the world have developed national injury-prevention policies, strategies, or plans of action (WHO 2018f). Although these instruments vary in nature and scope, they help guide a country’s efforts to prevent injury-related death and disability. WHO suggests that responsibility be assigned for all stages of implementation and that these injury-prevention policies or action plans be developed in a collaborative way, involving both government and nongovernment participants. Some policies are developed by and for a single sector (such as health, transport, justice, or education), but ideally they should be developed across multiple sectors. WHO also recommends that policymakers and planners take into account at an early stage the human and financial requirements that will be necessary for their policies’ implementation.

GLOBAL HEALTH IMPACT
Migration

The UN Department of Economic and Social Affairs estimates that 3.1 percent of the world’s people live outside of their country of origin (International Organization for Migration 2017). In addition, many people are internally displaced, meaning that they have been forced from their homes but remain within the country’s boundaries.

People migrate for a variety of reasons, including to take advantage of economic opportunities, in reaction to political instability, and to avoid conflict. Two aspects of migrant health must be addressed. The first is the public health threat inherent in the migratory movement of people. Infectious disease concerns exist in all phases of such a journey, and the ease with which people and products can move around the world directly corresponds to the rapidity with which a disease threat may spread.

The second issue concerns the health needs of individual migrants after they reach their destination. In many countries, the health system restricts migrants’ access to healthcare or does not provide culturally appropriate care, leading to poor health outcomes (International Organization for Migration 2017).

Australia, in which one-fourth of the population was born elsewhere, has a well-developed system of healthcare delivery for migrants (Bulletin of the World Health Organization 2008). In contrast, Spain has only just begun to consider the health concerns and integration issues of migrants (International Organization for Migration 2017). Migrant health issues will grow as people continue to move around the world to find work or to escape undesirable conditions.

HEALTH POLICY ISSUES IN DEVELOPED COUNTRIES

Some health policy issues are unique to advanced economies. Most developed nations have controlled the spread of communicable diseases through well-established public health infrastructures and effective sanitation services (although the threat of importation of communicable disease from uncontrolled regions is a concern caused by globalization and increased travel and trade). However, their health systems are strained by an aging population and widespread chronic diseases.

COMMON POLICY ISSUES

All industrialized nations with established healthcare systems struggle to adapt these systems to meet changing needs. They must maintain an adequate, well-trained workforce and integrate new technologies while keeping costs at a manageable level.

Researchers first found that healthcare spending was rising among the Organisation for Economic Co-operation and Development (OECD) countries in the 1970s; a 2009 study confirmed the continuation of this trend by showing that OECD countries spent an average of 9.5 percent of their gross domestic product (GDP) on health, compared with an average of 5.3 percent in the 1970s (OECD 2011).

Policymakers in industrialized countries constantly seek ways to achieve sustainable growth and allocate adequate funding to ensure fiscal and population health. To meet the challenge of cost control, many countries have experimented with alternative methods of paying for and delivering health services. For example:

  • The Australian healthcare system provides universal access to a comprehensive range of services, largely publicly funded through general taxation. Australia has a federal system of government, with a national (Commonwealth) government and six states and two territories. At the time of federation, health remained the responsibility of the states. However, the Commonwealth government holds the greatest power to raise revenue, so states rely on financial transfers from the Commonwealth to support their health systems. This setup makes the Australian healthcare system a complex division of responsibilities and roles across levels of government (Duckett and Willcox 2015).
  • The Canadian provinces and territories have primary responsibility for organizing and delivering health services and educating, accrediting, and licensing healthcare providers. Generally, these regional health authorities are responsible for the funding and delivery of hospital, community, and long-term care, and mental and public health services. Some jurisdictions have consolidated a number of these authorities. Healthcare providers are almost entirely private (Hutchison et al. 2011).
  • The Danish government consolidated health services administration, decision making, and services provision (Andersen and Jensen 2010).
  • Israel placed its health system budget under the jurisdiction of the Ministry of Finance rather than the health ministry as in most other countries (Ministry of Finance, State of Israel 2017). The relationship is intended to help control spending: The Ministry of Finance sets the level at which it will fund the national health insurance after estimating the amount that will be collected from cost-sharing provisions (Ministry of Finance, State of Israel 2016).
  • Italy decentralized the authority of the Servizio Sanitaris Nazionale as a way to control federal health spending (Tediosi, Gabriele, and Longo 2009).
  • The Japanese government regulates almost all aspects of the universal public health insurance system. The national government sets the fee schedule by developing consensus among stakeholders; gives subsidies to local governments, insurers, and providers to implement its policies; and establishes and enforces detailed regulations for insurers and providers (Ikeda 2004).
  • New Zealand replaced its former healthcare model with one called the Primary Health Care Strategy, which increased public funding of preventive and public health activities, encouraged general practitioners to form nongovernmental primary health organizations, and changed payments from fee-for-service to capitated fees paid to primary health organizations (Cumming and Mays 2011).
  • In the United Kingdom, the National Health Service (NHS) provides healthcare, including hospital and physician services and prescription drugs, to all of its residents. Under the terms of the NHS Health and Social Care Act 2012, the day-to-day responsibility for running the NHS rests with NHS England, formerly known as the NHS Commissioning Board (Bevan and Hood 2006; Department of Health and Social Care 2012).

Each of these countries faced similar problems and shared the goals of providing low-cost healthcare while achieving positive health outcomes. Yet, they developed different solutions, each of which took into account the particular country’s level of political will and societal values.

In addition to experimenting with health system structure, some countries have developed mechanisms for determining suitable treatment methods in the hope of reducing pharmaceutical expenditures without negatively affecting health outcomes (Clement et al. 2009). Australia, the United Kingdom, Canada, and other countries have governmental agencies that evaluate the cost-effectiveness of certain pharmaceutical products by analyzing cost and comparative effectiveness evidence to make national coverage decisions. Australia has taken this measure a step further by often delaying the recommendation of drugs for use until the price is negotiated to a level low enough to be deemed cost-effective (Clement et al. 2009).

Some cost-reduction policies aim to directly improve health outcomes. For example, the United Kingdom has set up a physician payment model called pay for performance, under which physicians treat patients following disease-based clinical practice guidelines. The guidelines are drawn from evidence-based medicine and are designed to reflect the best path to achieving high-quality healthcare and strong patient outcomes. Not all experts agree that evidence-based care is the best mode of service delivery. Researchers assert that because patients experience diseases differently, treatment should be patient centered rather than disease centered (Prey et al. 2014; Starfield and Mangin 2010). Still, this example illustrates that most governments struggle to ensure that the money allocated for health systems is used to deliver the best possible health outcomes and high-quality care. In fact, France codified quality assurance—a medical practice supported by the government—in its creation of the National Agency for the Development of Medical Evaluation in 1990 and the Hospital Act in 1991, which made quality-of-care assessment mandatory. In 2004, a newer agency called the Agency for Accreditation and Evaluation of Health Care was given responsibility for these activities (Legido-Quigley et al. 2008).

Other countries have imposed varying levels of cost sharing, the amount of which depends on income, on their residents in an attempt to reduce government expenditures while ensuring adequate care for society’s poorest inhabitants. Ireland introduced a three-tiered payment system to address health equity issues. Those in the bottom tier (corresponding to the lowest-income residents) receive free health services, the middle-tier population shares some costs, and those in the highest tier overwhelmingly opt out of public insurance and buy private health insurance. Rather than providing equitable access to health services, however, this system created increased inequality in access (Smith and Normand 2011).

These examples illustrate that an individual’s income and sociodemographic status are among the most important predictors of unmet healthcare needs; that is, disparity is a multifaceted issue that extends far beyond the health system (Bryant, Leaver, and Dunn 2009; Chen et al. 2018). To determine the best solutions to meet these challenges, each country’s government must clarify its values and priorities with regard to health equity and cost sharing. As the burden of chronic disease increases in industrialized countries, disease prevention is promoted as a way to improve public health and reduce healthcare costs. Obesity is a preventable risk factor associated with many chronic diseases, such as cardiovascular disease, diabetes, cancer, and premature death. The treatment, management, and health complications associated with these chronic diseases generate high healthcare expenditures (Guy et al. 2017; Sassi 2010). Therefore, some countries are taking a public health approach to addressing obesity by encouraging lifestyle changes. Nordic countries have placed taxes on unhealthy foods in the hope of steering consumers to healthier choices. However, the obesity epidemic is not merely a result of an individual’s food choices; it also reflects broad changes that have occurred in the everyday lives of people in the modern world compared with preindustrial times. As such, some governments are considering new transportation and urban planning policies, among other programs, to improve health and decrease obesity rates.

UNDERLYING FACTORS

Several factors affect healthcare costs in developed countries, including the impact of aging populations and technological progress, as previously discussed. Country GDP, the participation of women in the labor force, and public budgetary values are also important variables that influence cost trends (Lavigne, Brown, and Matzke 2017; Pammolli, Riccaboni, and Magazzini 2012). For instance:

  • As a country’s total income rises, so do healthcare expenditures.
  • As an increasing number of women enter the workforce, caregiver responsibilities shift from the private sphere to the public sphere.
  • Countries tend to spend more money on those social goods most valued by society, which may be related to healthcare or its associated products and services.

UNIQUE POLICY ISSUES, BY SELECTED COUNTRY

Maintaining a healthy population should be a high priority for any nation, just as cost control should be. Taking these two priorities into consideration, countries have approached the creation and implementation of health system administration, quality, and access policies in different ways. We discuss Japan, Denmark, Canada, and South Korea to illustrate unique health policy issues addressed by developed nations.

Japan

Japan adopted universal health insurance coverage in 1961. Since that time, its model has served as a blueprint for other counties to build a successful low-cost, high-quality, and highly equitable health system. However, the Japanese system is reaching a critical crossroads. The population has been rapidly aging since the late twentieth century (currently, more than 20 percent of the population is aged 65 or older), which has enormous implications for the cost of healthcare. At the same time, the government cannot rely on increasing tax revenues to pay for the health system because population growth and, consequently, economic growth are stagnant (Shibuya et al. 2011). In response to these challenges, the Japanese government has introduced innovative ways to slow spending.

In 2000, the government instituted its Long-Term Care Insurance (LTCI) program to care for the country’s aging population. The goal of LTCI is to provide long-term care services to adults aged 66 or older at the institutional and community levels and to ease financial and emotional burdens for both the patient and the patient’s caregivers (Tsutsui and Maramatsu 2007). To pay for LTCI, Japan set aside a portion of general tax revenues and levied a new tax on adults aged 41 or older.

Compared with other industrialized countries, Japan has made few formal efforts to ensure healthcare quality. While healthcare payment is under tight control, healthcare delivery is not; providers within the system are free to deliver care as they see fit. They are reimbursed on the basis of diagnosis–procedure combination categorization, thus diluting healthcare quality data that would be available under a fee-for-service payment system; monitoring fee-for-service data is the primary way providers can be held accountable. Although its health outcomes are comparable to those of other countries, Japan has no accountability mechanism in place, such as the pay-for-performance model in the United Kingdom and the quality assurance law in France. As Japan’s health system continues to undergo reform, structural measures of quality assurance might eventually be considered (Hashimoto et al. 2011).

Out of total health expenditures, 80.5 percent were financed through the public sector through the universal Statutory Health Insurance System in 2009 (Matsuda 2018; OECD 2011). Insurance premiums accounted for about half of the total health expenditure and are determined on a per capita, per-household, income-related, and asset-related basis. Employer-based insurers levy premiums on employee wages, and employers pay half of these employee premiums. The rates of such plans vary from 3 percent to 10 percent of wages, while rates are about 10 percent of income for employees of small- and medium-sized employers, who are insured by the Japan Health Insurance Association (Matsuda 2018; OECD 2011). Rates also vary among municipalities, albeit to a lesser degree. Government employees are covered by their own system of insurers (known as Mutual Aid Societies), as are some groups of professionals (e.g., physicians in private practice). Government subsidies, funded from the general budget, are provided mainly to Citizens Health Insurance insurers, Health Insurance for the Old-Old (a federal program) insurers, and, to a lesser extent, small-business employer-based insurers. There are also cross-subsidies from Citizens Health Insurance and employer-based insurance to Health Insurance for the Old-Old, and between Citizens Health Insurance and employer-based insurance (Ikegami and Anderson 2012).

In 2012, the federal government revised its health promotion objectives, known as Health Japan 21, and made reduction of health disparities a general goal. Its objectives include a target for reducing disparities in healthy life expectancies and cancer treatment delivery between prefectures; the government gives subsidies to prefectures to develop cancer care centers (Ueno 2013).

One emerging trend has been to promote evidence-based policymaking. For example, the current process through which the Central Social Insurance Medical Council revises the national fee schedule has been criticized for a lack of transparency and for vulnerability to potential abuses and conflicts of interest. Introduction of economic evaluation methods into health technology assessments, although highly controversial, has been increasingly discussed. Policymakers have also stressed the importance of prevention and wellness in reducing healthcare costs. Current priorities in prevention include reducing smoking and reducing the incidence of cardiovascular disease, diabetes mellitus, and hyperlipidemia. Since 2008, statutory health insurers have been responsible for delivering annual health checks to beneficiaries aged 40–74 (Matsuda 2018). Policy tools for improving quality and efficiency, such as comparable quality indicators, are being developed. As an early victim of bioterrorism, Japan also has had to consider security threats posed by the deliberate release of infectious diseases and address this issue in its policies and laws (Sugishima 2003; see also the Global Health Impact box titled “Bioterrorism, Global Health Security, and Surveillance”).

Despite a lack of quality standards, Japan’s long-standing health system has achieved successes that other developed countries are still striving toward. All of the measures described here were adopted to maintain good health outcomes and quality of life at low cost to both consumers and the government, making it a model worthy of consideration by other developed nations.

GLOBAL HEALTH IMPACT
Bioterrorism, Global Health Security, and Surveillance

A notorious example of bioterrorism is the 1995 attack in a Tokyo subway, where a domestic terrorist group released a chemical weapon called sarin. Sarin is a nerve agent that can paralyze muscles needed for breathing; in the Tokyo subway attack, 13 people were killed and 50 were severely injured. Also in the twentieth century, Iraq and the former Soviet Union were found to have military bioweapons programs (Khan et al. 2000). Scientists in the United States and the Netherlands exposed the possibility of disease-related bioterrorism when they created a highly contagious strain of avian flu in late 2011 (Novossiolova, Minehata, and Dando 2012).

The 2014 Ebola virus outbreak in West Africa was of unprecedented scale and impact and brought attention to global health security—its definition and role in programs and policy. For example, the government sought to strengthen its core public health capacities to meet the International Health Regulations, and experts sought to define global health security concerns. The lessons learned from the Ebola outbreak can serve to inform better global health governance. Once viewed merely as a protection from the pandemic spread of infectious diseases, health security demands greater collective action to ensure “access to safe and effective health services, products, and technologies” for the health security of all individuals (Heymann et al. 2015). This more inclusive definition recognizes that collective health security derives from individual health security, and it compels an adequate global response to provide all people worldwide with access to essential healthcare services (Heymann et al. 2015).

Health policy to counter bioterrorism should focus on preparedness efforts, as with natural disasters and pandemics, and plans that are put in place must be carefully and thoroughly executed. Local jurisdictions can also take measures to reduce their vulnerability to bioterrorism by assessing their infrastructures and environment, health system capacity, and emergency response teams and procedures. International cooperation is required on a far larger scale to establish better disease surveillance systems, laws and policies that strengthen health systems, and preventive measures against violent conflicts to make the world a healthier and safer place for all people.

Denmark

The Danish parliament passed major legislation in 2007 to reorganize and consolidate the country’s governmental structure; 215 local municipalities were condensed to 98, and 13 counties were reduced to 5 regions. The health system underwent a similar recentralization. Key areas in need of improvement had been identified in hospital future planning and current efficiency, primary care coordination, and public health prevention (Andersen and Jensen 2010). Denmark has one of the lowest life expectancies and highest cancer mortality rates in the European Union (Economist Intelligence Unit 2011; OECD 2016). The population is also getting older, and as a result, the chronic disease burden is increasingly cumbersome (OECD 2016).

Denmark’s 2007 health reform legislation, called the Health Act, included several measures to address the country’s pressing health policy concerns. To improve coordination of care, Danish officials put into effect a series of regulations (Andersen and Jensen 2010):

  • Regional health authorities were charged with creating patient rehabilitation plans for hospital discharge.
  • General practitioners were asked to participate in coordination-of-care strategies by reporting patient data in a shared database.
  • The newly formed regions were required to plan hospital systems whereby all hospitals are expected to provide an array of basic, frequently needed services, accounting for about 90 percent of hospital services; one hospital per region is to provide specialized services; and a few hospitals in the country will perform a limited number of highly specialized services.

These initiatives are meant to work together to provide coordinated and high-quality care for all Danish patients, whether they have an acute condition or a chronic disease.

The 2007 reform aimed to centralize hospital care administration to enhance the coordination of delivery and improve quality and efficiency. The five regions established under the reform are reorganizing their hospital systems, closing or merging small hospitals, and building new hospital infrastructure, at a total cost of 40 billion Danish kroner, or about US$7.2 billion (Rigsrevisionen 2013). Reorganization of acute care with stronger prehospital services and larger specialized emergency departments is an important aspect of this new structure. The Danish Health and Medicines Authority has also issued new guidelines for the localization of specialized treatments and departments; generally, these guidelines support centralization. The structural reform also introduced municipal cost sharing (about 20 percent of the cost of treatment) for hospital services to encourage municipalities to emphasize disease prevention and health promotion. Mandatory agreements between municipalities and regions are also intended to promote collaboration. These agreements are formalized at least once during each four-year election term for municipal and regional councils, and they must be approved by the Danish Health and Medicines Authority (Rigsrevisionen 2013).

Apart from the government, semi-independent organizations also play a governance role. The Danish Healthcare Quality Program (known by its Danish abbreviation, DDKM) consists primarily of medical professionals and works to develop extensive accreditation standards to improve quality across all healthcare sectors. The DKKM is developed, planned, and managed by the Danish Institute for Quality and Accreditation in Healthcare (known by its Danish abbreviation, IKAS), a board that comprises representatives from the Danish Health and Medicines Authority, the Danish regions, and the Ministry of Health. The International Society for Quality in Healthcare, in turn, oversees both the DDKM and the IKAS. The DDKM has now been implemented in all hospitals and is being introduced in primary care and pharmacies. It aims to include all healthcare delivery organizations, and it applies both organizational and clinical standards. The core of the program is a system of accreditation based on annual self-assessment and external evaluation (every third year) by a professional accreditation body. The self-assessment involves reporting of performance against national input, process, and outcome standards, which allows comparison over time and between organizations. The external evaluation considers the self-assessment when determining the status of providers’ overall quality improvement activities and opportunities. Quality data for a number of treatment areas are captured in clinical databases and published online. The data are used for a variety of purposes, including patients’ choice of hospitals and the management of hospital quality (EU 2011).

The implementation of Danish health reform is well under way, but it is progressing at a sluggish pace. Successful implementation seems to depend on the goals of the dominant political party in each region. Yet to be seen is how political and ideological tensions—such as those present in most countries—will affect the end result of the Danish health reform (Andersen and Jensen 2010).

Canada

Canada’s health policy issues are different from those of Japan and Denmark. Its population is not aging as rapidly as Japan’s, and, unlike Denmark, its provincial decentralization of the healthcare system has been stable since the late twentieth century. However, Canada faces problems related to paying for healthcare and an increasing public health burden from preventable diseases.

Based on OECD (2011) data, Canada spends a greater percentage of its GDP, and more per capita, on healthcare than many industrialized countries do (but less than Germany, Denmark, and the United States spend). In the twenty-first century, the country has taken steps to control healthcare spending at all levels of government. For example, the Common Drug Review process was introduced in 2003 to assess the safety, clinical effectiveness, and cost-effectiveness of new drugs presented by pharmaceutical companies and to provide recommendations regarding eligibility for public reimbursement to all participating drug plans (CADTH 2018). In this way, Canada seeks to promote the use of the most effective and least expensive pharmaceuticals.

Canada’s drug plans, which are administered separately from general health services plans, attempt to use cost-sharing mechanisms to control public expenditures. For example, the province of British Columbia implemented the policy Fair PharmaCare in May 2003. It is an income-based benefits program with three main goals: (1) to keep government spending low while (2) providing access to all necessary medication (3) in a way that is equitable for people of all income levels. Analyses show that decreases in public pharmaceutical funding would work against stated policy goals and that federal money infused into the states is key to access and equity (Morgan et al. 2006).

Canada’s struggle to achieve equity in medication access and affordability reflects its larger struggle with health disparities. The life expectancy at birth of an aboriginal man living on a reserve (67 years) is nine years less than that of a man in the general population (76 years); aboriginal status and socioeconomic status are the biggest contributors to health inequities in Canada, with disadvantaged populations having increased infant mortality rates, risky health behaviors (e.g., smoking), infectious disease, and chronic disease (Health Council of Canada 2011). These disparities are primarily attributable to differences in access to resources and opportunities (Farmer, Peressini, and Lawrence 2017; Frohlich, Ross, and Richmond 2006; Rocheleau et al. 2017). As with the public health agencies of other countries grappling with similar issues, research findings about Canadian health issues are slowly being translated into programs and policies designed to reduce health disparities.

According to the Canadian Institute for Health Information (CIHI 2012a), private health insurance covers about two-thirds of the 23 million people who make up the Canadian population. In 2010, it accounted for approximately 12 percent of total health spending (CIHI 2012a). Private health insurance covers services such as vision and dental care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals (which are not covered by public programs). Out-of-pocket payments made by private households accounted for about 15 percent of total health expenditures in 2010 (OECD 2011). According to CIHI (2012a), the main services sought with out-of-pocket spending in 2010 were dental care (20 percent), nonhospital institutions (mainly long-term care homes) (20 percent), prescription drugs (17 percent), vision care (12 percent), and over-the-counter medications (10 percent). In 2011, approximately 85 percent of premiums for private health plans were paid through group contracts with employers, unions, or other organizations (CLHIA 2018). Supplementary private insurance to provide faster access to publicly funded physician and hospital services was not available. Providers set their own fees for services covered by private insurance, and each insurer sets its own reimbursement level (e.g., based on the lowest fee among representative providers in a particular geographic area).

In 2010, of the 69,699 total doctors in Canada, about half were family doctors and half were specialists (CIHI 2011). Primary care physicians largely act as gatekeepers for further care. Most physicians are in private practices and are remunerated on a fee-for-service basis, although an increasing number of family doctors receive alternative forms of public payment such as capitation, salary, and blended funding. For 2010–2011, fee-for-service payments made up 50 percent of payments to family physicians in Ontario, compared with 70 percent in Quebec and 86 percent in British Columbia (CIHI 2012b).

South Korea

South Korea adopted universal health insurance coverage in 1989. Since then, it has worked to improve the health system, but with minimal success. Although the country has achieved admirable gains in health outcomes (e.g., increased life expectancies), the health system is plagued with several problems, including the following:

  • The healthcare benefits that citizens enjoy are still limited compared with those of other developed countries.
  • The public sector has little involvement in healthcare delivery.
  • Costs are rapidly rising.
  • Some insurance plans are in financial distress.

These problems are caused by a diverse set of factors and will likely take significant effort over many years to resolve (Moon and Shin 2007).

From 1989 to 2000, South Koreans were covered under a multi-insurance fund that included about 370 insurers. The National Health Insurance Act, enacted in 2000, integrated these multiple insurers into a single insurer and established the Health Insurance Review and Assessment Service (HIRA) to review medical fees and assess the quality of healthcare services provided to those who are insured (HIRA 2018a, 2018b). The government instituted the National Health Insurance Corporation (NHIC) in 2000 under the Ministry of Health, Welfare, and Family Affairs (MIHWAF). South Korea is currently working to increase health insurance benefits, which is particularly difficult because of the variety of sources that fund the NHIC, including the public sector, out-of-pocket payments, private financing, and voluntary and charitable contributions (Ahn et al. 2015; Chun et al. 2009).

In South Korea, under the Medical Law, only authorized healthcare professionals—doctors, dentists, nurses, oriental medicine doctors, and midwives who are licensed by MIHWAF—can provide health services. Nurse’s aides, acupuncturists, and massage therapists are considered “quasi-medical professionals.” Based on OECD health data, there were 91,400 physicians, 23,114 dentists, 16,663 traditional oriental medicine doctors, 57,176 pharmacists, 8,587 midwives, and 235,687 nurses in South Korea in 2007 (Moon and Shin 2007). To address the high utilization of physician and medical technology services, South Korea piloted a diagnosis-related group financing mechanism with promising results (Moon and Shin 2007).

A major problem concerning healthcare resources in South Korea is regional disparities in medical services. Due to medical profit maximization strategies, most private medical facilities are located in urban areas, as are 92.1 percent of physicians, 90.8 percent of hospital beds, and 79.7 percent of the population (National Health Insurance Corporation 2018).

South Korea is becoming an aging society faster than any other country in the world. Along with the increase in the elderly population, there has been a rise in medical expenditures for chronic degenerative diseases, which has become a great social burden. The South Korean government is trying to reduce the financial burden, especially for younger people, with comprehensive healthcare reform. The MIHWAF is also taking various measures to care for the elderly, such as expanding healthcare facilities and introducing Long-Term Care Insurance Program (National Health Insurance Corporation 2018).

HEALTH POLICY ISSUES IN DEVELOPING COUNTRIES

The health policy issues of developing countries are, in many ways, fundamentally distinct from those of developed countries. Developing countries face a range of health problems, from communicable, highly contagious diseases to incipient, invisible problems that manifest from exposure to polluted environments. These nations must address the drivers of preventable morbidity and mortality to improve health outcomes and, relatedly, increase economic growth and development.

In this section, we discuss the policy issues shared by developing countries, including the communicable and noncommunicable diseases that cause the highest burden of disease. Because developing nations rely heavily on international governing bodies to provide assistance regarding health concerns, we also outline the types of policy actions these international agencies take to address these concerns. Finally, as with the selected developed countries, we delve into the particular problems faced by selected developing countries—China, Ukraine, Nigeria, and Colombia.

COMMON POLICY ISSUES

Distinct policy issues and risk factors related to both communicable diseases and noncommunicable diseases are common problems in developing countries. Communicable diseases include acute diarrheal disease, sexually transmitted diseases, HIV/AIDS, tuberculosis (TB), malaria and other tropical diseases, and other infectious diseases, particularly when they spread quickly and become a worldwide threat (see the Global Health Impact box titled “Pandemics: SARS, H1N1, Avian Flu, and Zika”). Noncommunicable diseases—illnesses not traditionally seen in abundance in developing nations, such as cancer, cardiovascular disease, diabetes, chronic pulmonary disease, and mental illness—are becoming increasingly common in developing countries and come with a different set of health policy considerations (George et al. 2017; Walker et al. 2018).

A common theme among these diseases is the economic depression that accompanies the high incidence of disease and the paradoxical need for large economic inputs (capital, labor, and innovation) to prevent the transmission and onset of disease, which places low-income, developing countries at a particular disadvantage in solving these public health problems.

The way to address health policy issues in developing countries is increasingly envisioned as a stewardship of trust and legitimacy between a government and its people for improving the welfare of a population. Health policy today involves multiple actors and increasingly involved global and international agencies. Increased investment in the context of the Millennium Development Goals (a UN effort to improve health and healthcare around the world) is also placing greater attention on good national and international governance (WHO 2008). This approach has demonstrated benefits for the specific diseases being addressed, yet it threatens other programs and the capacity of local authorities to meet broad health needs. National governments in developing countries should set clear priorities on the basis of health needs and infrastructure capacity as well as on sound ethical guidance that will help achieve maximum improvement in health for minimum expenditure.

Comprehensive national health accounting is an important policy tool to track health spending from all sources. Performance assessment can support policymaking in monitoring and evaluating progress toward critical outcomes and the efficiency of the health system in a way that allows comparison over time and across systems. Particular attention is being given to financing healthcare for the more than 1.3 billion people in rural poverty and workers in the informal sector in developing countries who have no financial protection against catastrophic costs of healthcare (González-Block et al. 2009).

Success with these and other efforts will depend on solving the multiple challenges facing the health workforce. Relying on a public–private mix of services to address health infrastructure raises the question of the capacity of government to develop contracts, set prices, and monitor and supervise private providers. It is not always easy to reconcile efficiency with equity in health policy. Equity should be a primary concern for sustainable policymaking, and tools are available to measure how greatly national investments benefit the poor and needy. In many respects, health policy in developing countries is all about the encouragement of innovation and the scaling up of lifesaving technologies and systems (see the Global Health Impact box titled “Technology and Innovation”). Access to knowledge and technology has accounted for a high proportion of the decline in mortality rates. New strategies for organizing health research systems can contribute to making evidence-based policy a reality in developing countries (González-Block et al. 2009).

The term universal health coverage is gaining popularity among countries that have not yet attained it. A majority of the world’s developing countries plan to implement universal health coverage to protect vulnerable citizens who cannot afford healthcare services and thus may incur catastrophic expenses as individuals and families. If a nation can provide universal health coverage, it can bring all of its citizens under the provision of equal and high-quality care. However, implementation of universal health coverage is not an easy task. Good governance and a sustainable health financing system are fundamental to establishing universal health coverage in developing countries (Zaman and Hossain 2017).

GLOBAL HEALTH IMPACT
Pandemics: SARS, H1N1, Avian Flu, and Zika

A single businessman traveling from the Guangdong province of China through Hong Kong and on to Hanoi, Vietnam, brought severe acute respiratory syndrome (SARS) to global attention. He, and the doctor who diagnosed him, died of the disease while it was spreading rapidly throughout Asia, and later to 24 other countries worldwide (A.D.A.M. Medical Encyclopedia 2018). The story of SARS illustrates the negative impact of globalization and migration and the ease with which a highly contagious disease can spread worldwide and cause a pandemic (Shi and Singh 2017).

Threats of widespread illness from H1N1 (swine) influenza and West Nile virus evolved in similar fashion, and avian flu is the next major infectious disease to watch, according to observers (CDC 2017b; Pompe et al. 2005). Typically, only people who had worked in close contact with infected birds are known to have been infected with avian flu. However, it is a highly deadly influenza virus, and if it were to mutate and become easily transmitted from human to human, serious consequences would follow.

The Zika virus is a growing public health concern. As documented by Flahault and colleagues (2016), the Zika virus is found in parts of Africa, was reported in Southeast Asia, and is rising in the Americas and Caribbean. Since it was first detected in Brazil in 2015, it has become a major public health challenge in the Americas. Although the virus can cause mild illness (characterized by conjunctivitis, fever, rash, and joint pain), many affected countries also reported neurological and autoimmune complications potentially related to the Zika virus, including more cases of Guillain-Barré syndrome and birth defects such as microcephaly. Aware of the growing body of evidence suggesting an association between infection by the Zika virus and the development of neurological disorders, including adverse pregnancy outcomes, WHO established a framework to systematically assess for a causal relationship based on three types of clinical outcomes: (1) autoimmune disorders, including Guillain-Barré syndrome; (2) acute central nervous system disorders, including myelitis; and (3) congenital anomalies, including microcephaly (Flahault et al. 2016).

In efforts to thwart pandemics, worldwide reporting and surveillance systems have been developed and are improving, but many countries lack critical laboratory infrastructure and access to vaccines and antiviral medications. Any country that has not already done so should establish emergency preparedness plans that account for social distancing, travel, health system processes, and mass vaccination procedures.

GLOBAL HEALTH IMPACT
Technology and Innovation

The advancement of information technology, and of clinical technology in particular, has greatly altered how healthcare is delivered. Examples of these technological innovations in healthcare include health informatics, mHealth, electronic medical records, telemedicine, and virtual physician visits. Medical innovations have also brought safer surgical and imaging procedures; genetic testing and gene therapy; and therapeutic uses for vaccines to treat diseases such as cancer and HIV/AIDS.

As with any area of technological innovation, the positive aspects of clinical technology are accompanied by a number of challenges. The development of useful medical technologies often comes at a very high cost, which may make it difficult for poorer countries to bring technological innovations to their populations. In addition, technological advances in processes can threaten the privacy of individuals and patient confidentiality because of increased access to medical records.

The US Department of Health and Human Services, in its Global Health Initiatives statements, has described the need for the government to strengthen regulatory systems and to monitor the safety of the medical products, food, and feed that enter the United States through global manufacturing and supply chains (HHS 2013). Another approach to addressing the challenges brought by technology is for the health department of a country to assess community needs and ensure that appropriate medical devices and technologies reach people in need in a cost-effective manner.

Communicable Diseases

Acute diarrheal disease and other diseases attributable to poor water sanitation (e.g., acute respiratory disease, some tropical diseases) account for about 10 percent of the global burden of disease. Nearly 1.7 million deaths each year are attributable to acute diarrheal disease; about 95 percent of these deaths occur in children aged four or younger in developing countries (Van Minh and Hung 2011). Worldwide, at least 2 billion people lack access to a clean water supply—one of the most important preventive measures that can be taken to lower mortality rates (WHO 2018b).

The UN has recognized this type of disease as a global public health problem. In its Millennium Development Goal (MDG) 7.C, the UN stated that it aims to “halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation” toward ensuring environmental sustainability (UN 2010). Cost–benefit analyses suggest that achieving this MDG could result in a total worldwide economic benefit of $38 billion annually (Van Minh and Hung 2011). Some countries have accepted the challenge, but, as the UN has noted, “disparities in urban and rural sanitation remain daunting” (UN 2010). These challenges were illustrated by the cholera epidemic in Haiti following the devastating earthquake there in 2010, which showed that poor sanitation and resulting diseases can shut down entire industries (Haiti Libre 2010). By 2018, at least 2 billion people worldwide still were using a drinking water source contaminated with feces (WHO 2018b).

The MDG also addresses HIV/AIDS, TB (which often accompanies AIDS), malaria, and other major diseases in MDG 6 (UN 2010), as the burden of these diseases is felt more strongly in developing countries. At the same time, some global health experts argue that the attention given to HIV/AIDS prevention and treatment diverts resources from more basic public health and health system needs (Wu, Roychowdhury, and Khan 2017; Yu et al. 2008).

Noncommunicable Diseases

Much has been written about the devastating effects of communicable diseases, as well as their prevention and treatment modalities (on HIV/AIDS, see, e.g., Bongaarts and Over 2010; Potts et al. 2008; Sambo and Kirigia 2011; Stanecki et al. 2010; UN 2010; Weiss et al. 2008; and on TB and other infectious diseases, see Avert 2018b; Kirwan 2009; WHO 2018a). However, noncommunicable diseases are beginning to have an equally disruptive impact on developing countries (Islam et al. 2014; see also the Global Health Impact box titled “Noncommunicable Diseases”). In these nations, 80 percent of deaths related to noncommunicable diseases occur before the age of 60—the age at which people tend to reach their peak economic productivity, therefore reducing economic growth and progress in the country.

Mental illnesses are a group of noncommunicable diseases responsible for about 13 percent of the global burden of disease. Mental illnesses in particular do not generally attract international health policy attention. Neuropsychiatric disorders that affect people in developing countries include unipolar depressive disorder, bipolar disorder, schizophrenia, epilepsy, substance abuse disorders, dementia, anxiety disorders, mental retardation, and some neurological disorders (Patel 2007). Those who experience mental illness often endure many years of living with a disability. In addition, the societal costs of mental disorders, such as the impact on families, social services, and the criminal justice system, are significant and essentially immeasurable.

Globally, most people in need of mental health care lack access to high-quality mental health services. Stigma, insufficient human resources, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the mental health treatment gap. The global mental health landscape has transformed since 1990 with the raised visibility of the disease burden of mental health and substance-use disorders. Mental health disorders comprise 7.4 percent of disability-adjusted life years and 22.7 percent of years lived with disability worldwide (Baingana et al. 2015). The main contributors are depression and dysthymia, which account for 9.6 percent of all mental health disorders; anxiety, which accounts for 3.5 percent; and schizophrenia, substance-use disorders, and bipolar disorder, which together account for about 2.0 percent (Baingana et al. 2015). According to Baingana and colleagues (2015), alcohol and substance-use disorders are the second-leading cause of mental health disorders in most of the developing world, especially for southern Africa (drug use) and Eastern Europe (alcohol). The global prevalence of mental health and substance-use disorders is predicted to rise in coming years, with the most dramatic increase expected in low- and middle-income countries as a result of longer life expectancy, population growth, and underresourced healthcare. For example, the associated health burden of alcohol and substance misuse is predicted to increase by 130 percent in sub-Saharan Africa by 2050 as a result of population growth and aging (Baingana et al. 2015). Untreated mental health disorders are associated with a high burden on the economy. Yet commonly used health metrics do not reflect the additional social burdens of living with mental illness. Pervasive stigma and human rights violations increase the suffering associated with these disorders and exacerbate the social vulnerabilities of people with mental illnesses (Baingana et al. 2015).

People who are poor, less educated, or experiencing acute financial strain are at a greater risk for mental illness than are those who are financially secure and educated. In turn, those who suffer from mental illness are likely to remain impoverished due to lost wages or the cost of medical care. Mental health disorders can be effectively treated, but policymakers in developing nations face enormous challenges in legislating and financing effective interventions; the average government mental health spending (in US currency) in 2016 was a mere two cents per person per year in low-income countries and $1.05 per person per year in lower-middle-income countries, as compared with $2.62 per person per year in upper-middle-income countries and a whopping $80.24 per person per year in high-income countries (WHO 2018c). People in developing countries experience similarly huge disparities in their access to mental health professionals (including psychiatrists, other medical doctors, psychologists, social workers, nurses, and other paid workers working in mental health). In 2016, low-income countries had an average workforce of 1.6 mental health professionals for every 100,000 people, and lower-middle-income countries had an average workforce of 6.2, as compared with 20.6 in upper-middle-income countries and 71.7 in high-income countries (WHO 2018c).

To help countries identify gaps in their existing mental health system and address any deficiencies with system-level policy changes, WHO developed the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), which evaluates countries across several domains (e.g., policy/legislative framework, existing mental health services) to present a broad picture of their mental health provision capabilities (WHO 2009). Nearly 40 low-income and lower-middle-income countries have used WHO-AIMS, and the resulting data reports are available through WHO (2009, 2018g). As additional countries implement WHO-AIMS, policymakers can comprehend the state of their country’s mental health services and policy as a whole, which will enable them to make better policy decisions that can lead to improvement.

GLOBAL HEALTH IMPACT
Noncommunicable Diseases

The global rise in noncommunicable and chronic diseases is one of the greatest current challenges faced by all countries, whether they are developed, emerging, or developing. In September 2011, WHO Director-General Dr. Margaret Chan discussed noncommunicable disease in her address to the General Assembly (UN 2010):

The worldwide increase of non-communicable diseases is a slow-motion disaster, as most of these diseases develop over time, but unhealthy lifestyles that feed these diseases are spreading with a stunning speed and sweep. I can understand why some developing countries are being taken by surprise by the onslaught of these diseases. Their initial burden was greatest in affluent societies.

Noncommunicable diseases were once considered to be confined to wealthy people and wealthy nations. That paradigm is shifting as the burden of noncommunicable and chronic diseases, and associated risk factors, is now being felt worldwide. A fundamental shift is also being seen in the United States and other developed countries as community wellness and preventive care are increasingly viewed as a vital part of controlling and reducing chronic disease prevalence in their populations (Bauer et al. 2014; Navarro et al. 2007). In general, noncommunicable diseases are quickly becoming the leading cause of death worldwide and have been associated with nearly 70 percent of all global mortalities (Bauer et al. 2014; Navarro et al. 2007). Although not currently the largest cause of mortality in sub-Saharan Africa, deaths from noncommunicable diseases in the region are projected to surpass deaths from maternal, perinatal, and nutrition-related diseases by 2030 (Bauer et al. 2014; Navarro et al. 2007).

The risk factors associated with many noncommunicable diseases are well documented in the scientific literature. Risky behaviors such as tobacco use, alcohol abuse, unhealthy diet habits, and physical inactivity have been linked to cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes. Lifestyles in developing nations are changing to include these behaviors, sometimes as a consequence of development, such as the emergence in low- and middle-income countries of supermarkets—the largest providers of processed foods that are high in fat, sugar, and sodium and low in nutritional value (Vancampfort, Stubbs, and Koyanagi 2017; Wagner and Brath 2012). The health-related costs of development are stunning: In 2005, the estimated national economic losses from heart disease, stroke, and diabetes were (in US dollars) $18 billion in China, $11 billion in the Russian Federation, $9 billion in India, and $3 billion in Brazil (WHO 2006).

Researchers working in developing countries have produced a robust literature on the epidemiology of noncommunicable diseases in most regions of the world (except for sub-Saharan Africa, but see Dalal et al. [2011]). Evidence suggests that public health policymakers have several policy tools by which to address noncommunicable diseases and their risk factors. Yet such policies are not well defined at the national or global levels, even though science and medicine have enhanced our understanding of the determinants of chronic disease. Observers note that the most effective policies are long-term, collaborative approaches that engage both the public and private sectors. For example, WHO has deemed “best buy” interventions to be cost-effective in reducing disability-adjusted life years associated with noncommunicable diseases. Examples of such interventions include raising tobacco taxes, restricting access to alcohol, providing primary care diet counseling, promoting healthy living and physical activity in mass media, and offering vaccination programs (Dalal et al. 2011).

The consequences of failing to stem noncommunicable diseases are enormous. In developed countries, where clinical chronic care is currently available, the increasing burden of disease will place increasingly greater strains on the health financing system. In developing countries, where clinical chronic care is less available and more people go undiagnosed, primary prevention is essential to saving lives and improving life expectancies (Alaofè et al. 2017). Policymakers at all levels, as well as other stakeholders, have the power to reshape this intensifying public health issue.

Weak Health Infrastructure

The lack of a sound health system infrastructure affects care for all diseases and impedes access to essential health services. At the beginning of the twenty-first century, governments in developing countries generally spent about 5 percent of their total budget on health (Nambiar et al. 2007); in contrast, the average developed country spent more than 10 percent of its GDP on health, according to OECD data. Low government spending leads to extremely low quality of care and creates long waiting times, constant shortages of essential drugs and supplies, and inadequacy of staff training. In addition, out-of-pocket expenses can prohibit residents of developing countries from seeking care.

Modern Environmental Hazards

In the developing world, substances such as mercury, lead, pesticides, asbestos, air toxins, and hazardous waste are commonly released into the environment by unregulated mining operations (e.g., mining for gold ore), soap product and paint manufacturers, gasoline producers, agricultural operations, emissions from automobiles, and industrial waste disposal. Such toxins are associated with a host of complicated health problems, including nerve or nerve tissue damage, birth defects, and hormone dysfunction—problems that the health systems of many developing countries are ill equipped to handle.

These and other modern environmental health hazards are emerging in a health environment that is already overwhelmed by poverty, malnutrition, and communicable and chronic diseases. With the understanding that governments in developing nations must take swift preventive measures, the United Nations Environment Program has made headway with its Partnership for Clean Fuels and Vehicles initiative for removing lead from gasoline and sulfur from diesel fuel. Other initiatives aim to reduce or control stockpiles of harmful pesticides, introduce cleaner methods of gold mining (which is strongly associated with mercury poisoning), and initiate substance monitoring programs for manufacturing and other operations.

Most of this work has been performed by nongovernmental organizations, with less substantive action taken by national governments. Going forward, policymakers must take a population-level approach toward addressing modern environmental health hazards to reduce the burden of preventable ill health and premature mortalities (Nweke and Sanders 2009).

UNDERLYING FACTORS

These health-related challenges raise the question of how to use health policy to strengthen health systems and public health infrastructure in developing countries. Industrialized countries are seeking ways to provide aid to developing nations that will help their overwhelmed ministries of health. The sectorwide approach, which focuses on centralizing public health leadership, improving health sector management, and increasing coordination, is one such method that has had some success.

In recognition of the fact that good governance is essential for an effective health system and overall development, WHO devised a method for assessing health system governance. This framework allows researchers to assess public health problems with health system leadership and governance at the policy and operational levels and to suggest improvements. Using the WHO method allows motivated governments to effectively promote and protect population health (Siddiqi et al. 2009).

Addressing noncommunicable diseases requires that health policies be designed to work together at various levels of government. For example, one policy might impose taxes to deter people from smoking cigarettes, and other policies might ensure that people who need it can access care for chronic obstructive pulmonary disease.

UNIQUE POLICY ISSUES IN SELECTED COUNTRIES

Many blanket statements have been made about health issues in developing countries, but it is essential to recognize the great diversity between and within countries when considering health issues and health policies. China, for example, has a huge land mass and a diverse population of urban and rural dwellers. This situation poses health policy challenges that are unique to that country. Each country is dealing with a particular set of factors that largely determine what health issues are pertinent and what policy solutions are feasible in that particular country. In the following sections, we examine the unique situations of four developing countries: China, Ukraine, Nigeria, and Colombia. The small nation of Singapore is also highlighted; see the For Your Consideration box titled “Singapore’s Healthcare Delivery.”

FOR YOUR CONSIDERATION
Singapore’s Healthcare Delivery

Singapore has one of the most successful healthcare systems in the world, based on its efficiency in financing and the positive results it has achieved in community health outcomes. The Singaporean government combines the ideas of individual responsibility and government control in a financing system of federal subsidies for primary care, hospital services, pharmaceuticals, and individual savings accounts (Bai et al. 2018; Brookings Institution 2018). In 1983, the government established a National Health Plan, which detailed plans for the infrastructure for the next 20 years, together with the idea of individual savings accounts, called Medisave. The restructuring of public-sector hospitals in 1985 started merging the business and financial sectors into healthcare services to provide higher-quality services and more efficient financing. In 2002, the government promulgated the ElderShield plan to help the elderly and people with severe disabilities in particular.

Singapore provides all citizens with universal healthcare coverage, funded by a combination of federal subsidies, financing schemes, and individual savings, all administered nationally. Capital expenditures for healthcare are calculated at the national level in the federal budget. In the first tier of financial protection, the government subsidizes up to 80 percent of the total bill in public hospitals and primary care polyclinics. Subsidies of up to 80 percent are also provided for bills in government-funded intermediate and long-term care institutions. This coverage is funded by a network of savings and insurance programs known as the “3Ms” (Medisave, MediShield, and Medifund) to help individuals and families pay for their care. Together, these programs play a critical role in maintaining the health and welfare of all Singaporeans.

China

With more than 1.4 billion people, China has one of the largest populations in the world (Worldometers 2018). The country has experienced overwhelming transformations since the late twentieth century, which have dramatically affected population health.

Prior to 1978, the Chinese government headed up extensive public health improvements, leading to lower infant and maternal mortality rates, greater life expectancies, and improved quality of water and sanitation. The associated policy decisions emphasized disease prevention and community involvement, reflecting an approach to health rooted in basic public health principles (Gong, Walker, and Shi 2007).

A major change in China occurred in 1978, when it moved from a communism-based to a capitalism-based market economy. This shift brought many positive developments as well as a number of challenges to China’s health system:

  • Overall spending on healthcare has rapidly increased, while government funding for public health institutions has steadily fallen (Gong, Walker, and Shi 2007; Nofri 2015).
  • Rates of noncommunicable diseases and health disparities are on the rise (Hu, Liu, and Willett 2011; Zhu et al. 2017).
  • The cost of healthcare has become prohibitively expensive for many people, particularly those living in rural areas (Hu, Liu, and Willett 2011).

In response to these emerging issues and to create a solid health policy framework for the coming years, in 2008 the Chinese government passed the Healthy China 2020 act to address healthcare equity and accessibility through five mandates that correspond to major health problems identified by the Chinese Ministry of Health (Chen 2009; Hu et al. 2011; Ling et al. 2011):

  1. Health insurance must be expanded to cover 90 percent of the population.
  2. A national drug system must be established to meet basic pharmaceutical needs.
  3. Grassroots-level improvement of medical care and public health must occur.
  4. Basic public health services, including preventive health, must expand.
  5. Hospital reform must be instituted to abate the health system’s increasing tendency to commercialize.

The development of a “Healthy China” is central to the Chinese government’s agenda for health and development. President Xi Jinping has placed health at the center of the country’s entire policymaking operations, and China’s leaders have made health a national political priority with the approval of the Healthy China 2030 Planning Outline by the Central Party Committee and the State Council (Tan, Zhang, and Shao 2018).

Through advanced technologies and an improved health insurance system, China hopes to achieve health equity for its people by 2030. Significant steps have already been taken toward that end. In 2009, China embarked on a major national health system reform (Nofri 2015), aiming to extend care to those residing beyond its prosperous urban centers. At the beginning of the twenty-first century, less than one-third of the population had access to health insurance. Now nearly 100 percent do (Tan, Zhang, and Shao 2018). China has provided its huge population a healthcare safety net that protects its people from becoming impoverished by the costs of healthcare (Tan, Zhang, and Shao 2018).

Still, China faces many health challenges. They include increasing rates of cancer; higher incidence of cardiovascular disease linked to such lifestyle factors as smoking; and demographic trends such as an aging population (Nofri 2015; Tan, Zhang, and Shao 2018). These challenges cannot be met sustainably in a health system that relies solely on hospitals. Therefore, a key component of Healthy China is the promotion of healthy lifestyle behaviors and physical fitness, including through the development of the Healthy Cities program, to emphasize prevention over treatment. One of the most important steps toward a Healthy China is a national smoke-free law, which would have a significant impact on the prevention of many associated noncommunicable diseases.

According to Tan, Zhang, and Shao (2018), to better protect people’s basic right to health, a series of plans have been implemented, including the Healthy China 2030 Planning Outline, the National Fitness Program (2016–2020), the Thirteenth Five-Year Plan for Medical and Health Service Development, and the Plan for Deepening Reform of the Medical and Healthcare System During the Thirteenth Five-Year Plan Period (2016–2020). The Chinese government has set a “three-step” goal: (1) establishment of a sound basic medical and healthcare system with distinctly Chinese characteristics covering both urban and rural residents, such that its main health indicators would place China in the forefront of the rankings of high- and middle-income countries by 2020; (2) improvement of the health-promotion system such that its main health indicators would be in the ranks of those of high-income countries by 2030; and (3) existence of a healthy China that conforms to the requirements of a modern socialist country by 2050 (Tan, Zhang, and Shao 2018).

Ukraine

Over the five years following the fall of the former Soviet Union in 1991, Ukraine faced—and continues to battle—several debilitating public health issues. The population is plagued by epidemics of HIV and TB, which are interrelated: In 2015, 22 percent of tested TB patients were HIV-positive (CDC 2017a). In addition, cardiovascular disease, the leading cause of mortality in the country, is highly prevalent among the population, partly because of high rates of smoking and alcohol consumption.

Inconsistencies in public health legislation and implementation, resulting from an unstable parliament, create a difficult political environment in which to address these challenges and improve health (Lekhan, Rudiy, and Shevchenko 2015). For example, the Global Fund for AIDS, Tuberculosis, and Malaria initially granted $98 million to the Ukrainian government to respond to the combined AIDS/TB epidemic; however, the Global Fund switched its grantee to community organizations instead because the government was not transparent with the use of funds (Hurley 2010). As a result, local community organizations now provide most HIV/AIDS prevention and treatment services in Ukraine, with funding from the Global Fund (Hurley 2010).

Poor development and implementation of policies distinguish Ukraine’s TB control from that of the rest of Europe. For example, TB infections are often transmitted through the prison system, but postincarceration treatment plans are not coordinated before prisoners’ release. Furthermore, many ex-prisoners do not adhere to medication plans and transmit the disease to the public, as evidenced by higher-than-average TB infection rates in areas surrounding prisons. In addition, Ukraine lacks a centralized TB monitoring system, and most regional TB recording and reporting systems do not meet WHO recommended standards (Atun and Olynik 2008).

Policies aimed at reducing the burden of noncommunicable disease in Ukraine have been more successful—the tobacco excise tax is one example. Estimates from 2005 suggest that 66 percent of men and 20 percent of women smoked cigarettes (Ross, Stoklosa, and Krasovsky 2011). Following the lead of other countries that adopted tax policy reform in response to high rates of disease, premature death, and lost productivity, Ukraine implemented excise taxes on tobacco in 2009 and 2010. These taxes significantly reduced tobacco consumption, illustrating that tobacco use is price sensitive (Ross, Stoklosa, and Krasovsky 2011). By 2015, cigarette smoking rates had fallen to about 49 percent among men and 14 percent for women (Tobacco Atlas 2018).

From 2006 to 2012, the average life expectancy in Ukraine increased, even with little progress in policy implementation. During the 2010s, armed conflict created a new, large-scale humanitarian crisis in Ukraine, and the health system proved ill equipped to cope with it. Even before the turmoil that led to this crisis, the Ukrainian health system was weak and far from equitable. Pilot reforms initiated in 2010, which aimed to reorient the system toward a primary care focus, were still in early stages, and scale-up was delayed indefinitely (Lekhan, Rudiy, and Shevchenko 2015). In many respects, as Lekhan, Rudiy, and Shevchenko (2015) observed, the pilot reforms showed that change is possible in the system, although a lack of meaningful reform since independence from the Soviet Union meant that many inefficiencies were deeply entrenched. In October 2017, the Ukrainian Parliament approved a bill that made major changes to the country’s healthcare system effective January 1, 2018, including the establishment of a National Health Care Agency and a financing model similar to that of the United Kingdom (Raczkiewycz 2017). However, the country’s political instability made successful implementation of the approved changes uncertain.

As Lekhan, Rudiy, and Shevchenko (2015) contend, successful implementation of the health system reforms requires both political will and popular consensus, including community and health worker engagement in the reform and belief in its benefits. Perhaps most important, changes to a health system need policy windows. For example, although economic crises can spur focused efforts to make health systems more efficient, a policy environment of political, social, and economic turmoil can push health systems concerns far down the policy agenda. The successful implementation of health systems reform requires a certain degree of stability, but stabilizing such conditions is beyond the control of the health sector.

Nigeria

Nigeria’s health issues are all-encompassing, ranging from communicable diseases, such as HIV/AIDS, TB, rare tropical diseases, and even poliomyelitis (polio), to noncommunicable diseases, such as cardiovascular disease and the effects of modern environmental health hazards. Each of these health problems has been inefficiently managed by the Nigerian government and exacerbated by a weak health system, little health financing, and loss of health professionals through emigration (FMTalk360 2016; GPEI 2018).

Two key health issues set Nigeria apart from other sub-Saharan nations with otherwise similar health problems. First, Nigeria is the only African country (and one of only three countries in the world, the other two being Afghanistan and Pakistan) to have failed to ever eliminate polio (GPEI 2018). Efforts implemented by the Global Polio Eradication Initiative (GPEI) beginning in 2009 greatly reduced the total number of cases, to the point that the country went for two years with no new cases of polio detected. However, in July 2016, one type of wild poliomyelitis reemerged, triggering a GPEI response in which nearly 58 million children were vaccinated to help prevent further outbreaks (GPEI 2018; WHO 2016).

Second, Nigeria has encountered particular difficulty implementing key components of standard disease control protocol in combating HIV/AIDS. In 2016, only about 30 percent of the 3.2 million people living with HIV in Nigeria were receiving antiretroviral therapy, and the death rate from AIDS was about 148,000 people per year (Avert 2018a). The rate of mother-to-child transmission remains high—at 22 percent in 2016—and Nigeria accounts for nearly 27 percent of all the mother-to-child transmission cases in the world (Avert 2018a).

Several types of barriers impede Nigeria’s ability to effectively address the HIV/AIDS epidemic, including the following (Avert 2018a):

  • Cultural practices that increase HIV vulnerability among the general population (e.g., female genital mutilation, marriage of young girls to much older men, encouragement of men to have multiple female sexual partners, low levels of condom use) as well as the social stigma of being known as HIV-positive, which inhibits testing
  • Strict laws against homosexuality (punishable by up to 14 years in prison) that discourage men who have sex with men from seeking treatment; laws against sex work (punishable by two years in prison) that make sex workers reluctant to disclose their occupation to healthcare workers during provision of healthcare services
  • Lack of sites for HIV testing and treatment for those willing to seek it
  • Low levels of funding by the Nigerian government to address the epidemic, exacerbated by gender inequality, with less than 1 percent of government spending on HIV allocated for women despite the fact that 58 percent of the people living with HIV are women

Closely related to the challenges in addressing the HIV/AIDS epidemic is the dramatic rise in Nigeria of TB, which is a common coinfection that can develop in people living with HIV and has likewise reached an epidemic level (Avert 2018a, 2018b). Multidrug-resistant strains of TB in Nigeria increased by 30 percent between 2015 and 2016, making the disease even harder to treat effectively (Avert 2018a).

Unavailability of modern equipment and obsoleteness of existing equipment is a major issue with the Nigerian healthcare system. Lack of proper or properly functioning equipment has been identified as a root cause of incorrect diagnoses and is reportedly a key reason foreign medical trips remain the only option for affluent Nigerians or patients in dire need of a correct diagnosis (see the Global Health Impact box titled “Medical Tourism”). Stories of medical errors and how they have accounted for avoidable deaths in some Nigerian medical facilities have also been reported, further contributing to Nigerians’ discomfort with seeking medical care in their own country (FMTalk360 2016).

Despite these difficulties, the prospects for improving global health policies are promising. The 2011 presidential election in Nigeria was deemed by some experts as the most legitimate and transparent election the country ever held. The National Assembly passed the National Health Bill in May 2011, placing health at the top of the national agenda with an emphasis on ensuring basic access to health services for all citizens, retaining trained health professionals, and holding the government accountable for complete implementation of the bill’s mandates (Lancet 2011). With widespread support from health professionals and the general public as well as a demonstrated commitment to health by the Nigerian president, the bill was signed into law on October 31, 2014, and became known as the National Health Act (Enabulele and Enabulele 2016). A study in December 2015, however, found that although most health professionals were aware of the National Health Act and viewed it favorably, nearly 74 percent of them showed poor knowledge of it (Enabulele and Enabulele 2016), signaling a need for further education on the provisions of the act.

In 2016, the Nigerian Sovereign Investment Authority (NSIA), along with the country’s Ministry of Health, agreed to modernize and expand healthcare services with the involvement of the private sector. They aimed to build the capacity of specialist hospitals and diagnostic centers to ensure that they can provide advanced medical care. Ten memorandums of cooperation had already been signed between the NSIA, Ministry of Health, and various healthcare facilities in the country’s six geopolitical zones, with six of them in advanced stages. Although Nigeria’s National Health Insurance Scheme (NHIS), introduced in 1999, aims for universal coverage, penetration remains low. In 2016, less than 5 percent of the population was enrolled in the NHIS, and an estimated 120 million people lacked health insurance (Oxford Business Group 2018). Stakeholders in the insurance sector—such as the NHIS and health maintenance organizations—also called for legislators to make it mandatory for employers with more than ten employees to provide them with health insurance (Oxford Business Group 2018).

GLOBAL HEALTH IMPACT
Medical Tourism

Medical tourism is an international phenomenon by which people travel to another country for medical services. Travel often occurs on a regional level, and most procedures are elective (e.g., weight loss surgery, cosmetic surgery, dental care, fertility treatment). For example, Americans travel to Mexican border towns for dental procedures that are very expensive in the United States (IMTJ 2012) and seek affordable healthcare procedures, such as knee and hip replacements and cardiac surgery, outside of the country. Some countries are known to specialize in the provision of medical tourism procedures, including gender reassignment surgery in Thailand and cell transplants in China (Aizura 2010; Alleman et al. 2011; Song 2010).

Major US medical schools have partnered with other countries to set up tertiary and referral hospitals that provide higher-level care and procedures. These ventures can control costs for private insurers and improve the standards of care for those seeking care abroad. Joint Commission International has accredited more than 600 hospitals and certified hundreds of other specialty facilities and programs worldwide (JCI 2018). People also travel to the United States to receive healthcare at leading institutions, such as the University of Texas MD Andersen Cancer Center in Houston; Mayo Clinic in Rochester, Minnesota; and Jackson Memorial Hospital in Miami.

Since 2003, the government of Thailand has attempted to make its country a global center for medical tourism through the Center of Excellent Health Care of Asia initiative. It has held international road shows and allowed tax exemptions for investment in new health facilities to target medical tourists and recruit patients. In 2011, revenues from medical tourists generated the equivalent of an estimated 0.4 percent of Thailand’s GDP (Noree, Hanefeld, and Smith 2016). Despite such financial benefits, there is concern about the impact of medical tourism on equity in care, especially in areas with weak health systems and limited resources that may be diverted toward caring for patients from abroad (Noree, Hanefeld, and Smith 2016).

Facilitators of medical tourism have established an industry focused on connecting people with medical services abroad. However, several challenges have arisen with this emerging field. Reports have surfaced of complications after surgeries that could have been avoided if proper quality standards had been followed, underscoring the need for uniform standards of care across various settings, such as those used by Joint Commission International. Public health concerns also can be an issue for medical tourists, as they may become vectors (able to spread infectious agents) or victims of multidrug-resistant bacteria—a threat whenever physicians are unprincipled in their use of antimicrobial medications (Cusumano et al. 2017; Rogers, Aminzadeh, and Paterson 2011). Critics cite ethical issues regarding the use of the healthcare workforce and resources for medical tourism that takes away resources from the basic local medical needs of the country’s citizens. Another concern is the current lack of regulation and oversight of the providers of medical tourism; ethical issues have been raised concerning patients traveling after being given very limited information and foreign patients purchasing organs or surrogacy services from local populations in low- and middle-income countries (Noree, Hanefeld, and Smith 2016). As the medical tourism market continues to develop and become established, these and numerous other issues will need to be addressed.

Colombia

Colombia faces challenging public health issues that are deeply rooted in an ongoing conflict and urban–rural disparities.

Insurance Scheme

Colombia’s health disparities are evident in examinations of its universal health insurance system. Law 100 was approved in 1993, granting all citizens the right to health insurance with an essential benefits package, regardless of ability to pay. By 2009, about 80 percent of Colombians were covered under one of two health insurance schemes—the Contributory Regime (CR) or the Subsidized Regime (SR). The CR covers those who work and earn more than a set minimum level of pay, and the SR covers those who are considered poor, as determined by a means test. The SR offers a meager benefits package compared with that for the CR; for example, the SR offers only basic primary care services and coverage for catastrophic costs, whereas the CR offers comprehensive coverage. Critics say that the managed care model used by insurers covering both CR and SR limits access to care, restricts utilization, and has changed public providers’ behaviors to suit a competitive market scheme—all resulting in increased health disparities (Vargas et al. 2010). Meanwhile, proponents argue that this universal health insurance approach improved on the previous model covering SR subscribers by increasing access and reducing catastrophic health spending (Giedion and Uribe 2009). Although the government plans to implement policies to reach 100 percent insurance coverage of the population, no concurrent strategy is in place to address the great disparities inherent in this insurance scheme.

Vector-Borne Diseases

Colombia is also working to prevent and treat vector-borne communicable diseases, which are still prevalent and dangerous across about 20 percent of the country’s land area (Castillo-Riquelme et al. 2008). Vector-borne diseases include malaria, Chagas disease, and dengue fever, which are preventable with the proper insecticide treatment measures. However, prevention measures are not executed in a systematic, efficient way in Colombia (Castillo-Riquelme et al. 2008), and the bulk of the money allocated to vector-borne diseases is spent on treatment several years after contraction.

For example, sufferers of Chagas disease, which is typically transmitted by an insect, usually do not present with symptoms for at least a decade after exposure, and when symptoms do manifest, they often resemble other general cardiac illnesses (Cucunubá et al. 2017). Significant amounts of money, at levels that far surpass prevention efforts, are needlessly spent on diagnostic testing for and treatment of cardiomyopathy (deterioration of the heart muscle) and congestive heart failure (Castillo-Riquelme et al. 2008; Cucunubá et al. 2017). The government pays the majority of costs under Law 100, which grants universal health insurance coverage, but those with Chagas do not experience a positive health outcome (Castillo-Riquelme et al. 2008; Cucunubá et al. 2017). A comprehensive study by Cucunubá and colleagues (2017) concluded that a “a firm commitment from all levels of government and a coordinated, collaborative global response from international organizations and other stakeholders” are needed to successfully address the issues associated with Chagas disease in Colombia.

Colombia has had some success in its efforts to prevent vector-borne diseases, however. In 2013, it became the first country in the world to eliminate onchocirciassis (river blindness), an infection caused by a parasite, as verified by WHO (Cucunubá et al. 2017; Nicholls et al. 2018).

Violence

Colombia is among the leading Latin American countries in homicides, fueled by gang activity, civil strife, and general civil disobedience exacerbated by alcohol consumption. The murder rate in 2012 was 30.8 homicides per 100,000 people, compared with the US rate of 4.7 per 100,000 (UNODC 2013).

Law enforcement policies are in place to tackle gangs and paramilitary forces, and municipalities address the “culture of violence” through social outreach and restrictive policies that mitigate the effects of alcohol use (Ceaser 2007). For example, between 2004 and 2008, the government of Cali enacted three policies dictating the availability of alcohol. Studies showed that when alcohol sales were stopped earlier in the night, homicide rates dropped significantly (Sánchez et al. 2011). To further reduce the homicide rate, Colombia must address underlying social factors leading to multiple types of violence.

Overall, Colombia’s health policy issues reflect larger societal problems. Tropical diseases, health inequities, and violence must be curbed in conjunction with broader social and economic policies. The Colombian government under Alvaro Uribe, president from 2002 to 2010, began to address these issues (especially those related to violence), and his successor, Juan Manuel Santos, has followed suit.

Healthcare Reform

In 2015, Colombia underwent an economic recovery and transitioned toward an improved healthcare system, enacting important health-sector legislation, such as the Statutory Health Act (Act 1751) in basic welfare law and the National Development Plan (Act 1753), which builds on the General System of Social Security in Health and emphasizes key healthcare topics such as health system equity, access, quality, timeliness, trust, legitimacy, and sustainability. The revised health system includes features such as an integrated healthcare policy; an integrated healthcare model that comprises primary healthcare, a family and community healthcare focus, risk management, and a differential approach; further development of the Ten-Year Public Health Plan (2012–2021) in the country’s regions; creation of a unit to administer system resources; and strengthening of the pharmaceutical policy that was implemented in 2012. The Colombian government made peace with the armed rebel group Revolutionary Armed Forces of Colombia (known by its Spanish initials, FARC) in 2017 and in early 2018 was pursuing talks with another rebel group, the National Liberation Army (known by its Spanish initials, ELN), in a continuing effort to bring an end to Colombia’s ongoing civil strife (Charles 2018). As a result of the FARC talks, Colombia established a public health and postconflict policy jointly coordinated by the Ministry of Health and the Ministry for Post-Conflict. It also created a program for psychosocial and integrated care for victims of armed conflict, which guarantees the right to health and restoration of physical, mental, and psychosocial conditions according to relief and rehabilitation measures in the Victims Act (Charles 2018).

All Colombians have access to the same services as well as financial protection from excessive healthcare spending. Patient out-of-pocket expenses make up 14 percent of all health spending—one of the lowest proportions in Latin America and lower than the OECD average of 19 percent (OECD 2011).

In Colombia, the informality of the labor market presents a significant challenge to raising health system revenues. About half of the total health system funding comes from contributory sources (employer and employee payroll contributions). It has proven difficult to substantially increase this component of funding due to the size of the informal labor market: about 60 percent of the workforce. Informality narrows the contributory and tax bases and creates financial hurdles in all public sectors. These financial issues are exacerbated in the health sector, however, because of the Constitutional Court’s requirement to expand the range of services in the SR and make them equal to the CR.

Healthcare providers in Colombia tend to be largely concentrated in densely populated areas, with a notable increase in the number of private providers in those areas since the beginning of the twenty-first century. In contrast, people living in remote and rural provinces have very little choice of provider, even for simple outpatient care. Providers in these areas tend to be public providers and often struggle with issues such as high operational costs and difficulties in attracting and maintaining an adequate number of health professionals, which is likely to affect the quality of care provided.

Although unmet healthcare needs and visit waiting times have been significantly reduced, health insurers in Colombia have not yet transformed into effective, efficient purchasers of healthcare services. Payments to providers should reward quality of care and good health outcomes, rather than volume of services provided (Charles 2018).

KEY POINTS

  • Although most developed nations have controlled the spread of communicable diseases, their health systems are strained by an aging population and widespread chronic disease. They must maintain an adequate, well-trained workforce of health professionals and integrate innovative technologies while keeping healthcare costs at a manageable level.
  • Several factors affect rising healthcare costs in developed countries, including aging populations, rapid technological progress, the participation of women in the labor force, and public funding for healthcare.
  • Developing countries experience a range of public health problems, from communicable, contagious diseases to incipient, invisible health effects from exposure to pollution. These nations must address the drivers of preventable morbidity and mortality if they are to increase economic growth.
  • The lack of a sound health system infrastructure in most developing countries affects the spread of all diseases and impedes access to essential health services. Further, low government spending leads to low quality of care and creates long waiting times, constant shortages of essential drugs and supplies, and lack of trained staff.

CASE STUDY QUESTIONS

CASE STUDY 1

Based on your own research on climate change and its impact on public health, answer the following questions:

  1. Why is addressing climate change important for public health?
  2. What health policies and public health strategies could mitigate the effects of climate change?

CASE STUDY 2

Based on your own research of the global primary care workforce, answer the following questions:

  1. Why is there a shortage of primary care providers worldwide?
  2. What strategies might nation states adopt to expand their countries’ primary care workforce?

FOR DISCUSSION

  1. What are the primary health policy issues in developed countries? In developing countries?
  2. What are the specific health challenges in Japan?
  3. What has Denmark’s health reform accomplished?
  4. What is Canada’s health policy agenda?
  5. What are the public health challenges facing South Korea?
  6. What goals is China’s Healthy China 2020 attempting to accomplish?
  7. What are the public health challenges faced by Ukraine?
  8. What are the public health issues of Nigeria?
  9. What factors do Colombia’s health policies target?

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