Globalization and Health Equity:

Investigating the Connections

Ted Schrecker, Ronald Labonté

Basic Science Departments presentation to
Dean of Medicine, University of Ottawa

January 23, 2007

Globalization
„ “A process of greater integration within the world
economy through movements of goods and
services, capital, technology and (to a lesser
extent) labour, which lead increasingly to
economic decisions being influenced by global
conditions” (Jenkins, 2004)

Health Equity
ƒ The absence of disparities in health that are
avoidable, unfair, and systematically related to
social disadvantage
 Globalization’s challenges for
population health include:
„ Increased economic inequality and insecurity
„ New forms of social exclusion and polarization
„ Speeds up diffusion of unhealthy lifestyles
„ Limits governments’ ability to protect and enhance
health
„ Increases ‘brain drain’ of health professionals from
developing countries
 Pathways from globalization
to (ill) health include:
„ Lack of material resources for health, often leading
to or worsening effects of
„ Exposure to hazards (unsafe drinking water,
pollution, road accidents)
„ Psychosocial stress, both acute and chronic
„ Unhealthy lifestyles (smoking, drinking, bad diet)
„ Inadequate access to health care

Adapted in part from work by Giovanni Andrea Cornia and colleagues for Globalization
Knowledge Network, WHO Commission on Social Determinants of Health
 Multiple entry points for policies to
address the effects of globalization
SOCIAL AND POLITICAL CONTEXT

DIFFERENTIAL
CONSEQUENCES

DIFFERENTIAL
EXPOSURE HEALTH
OUTCOMES:
SOCIAL HEALTH
STRATIFICATION SYSTEM
ILLNESS
CHARACTER-
DIFFERENTIAL HEALTH ISTICS
VULNERABILITY DISPARITIES

GLOBALIZATION

Source: Modified from Diderichsen, Evans & Whitehead, 2001

The G8 and global health:
An ongoing report card (2001 - )

„ Work began in advance of 2002 (Canadian) G8

Summit
„ Initial publications led to development of health
equity agendas, collaboration with civil society
organizations → contributions to Global Health
Watch
„ Funding: International Development Research
Centre, CIHR, Nuffield Trust
 Key research questions

„ How do commitments made by the world’s richest

and most powerful nations at their annual Summits
affecting population health?
„ Are the G8 fulfilling their Summit commitments?
„ Are the commitments adequate?
„ Are the commitments appropriate?
The G8 and global health:
An ongoing report card (2001 - )

„ Sample products
Globalization Knowledge Network,
WHO Commission on Social
Determinants of Health (2005 - 2007)

„ Based at Institute of Population Health (Network

leader R. Labonté; coordinator T. Schrecker)
„ One of nine Knowledge Networks that are the
Commission’s main knowledge gathering mechanism
„ 29 participants from all regions of the world
„ 13 commissioned research synthesis papers
(nearing completion)
„ Two Network meetings (completed)
„ Canadian “reference group” for Commission
Social Determinants of Health

„ Conditions in which people live and work that

affect their opportunities to live healthy lives
„ ‘Upstream’ as
distinct from
‘downstream’
influences
„ Closely related
to poverty,
inequality,
discrimination
 Key research questions

„ What does the best available evidence tell us about

how globalization is affecting social determinants of
health and health outcomes?
„ How are the gains and losses from globalization
distributed, and what are the health implications?
„ What policies will mitigate the actual and potential
harmful effects of globalization on health?
Globalization Knowledge Network,
WHO Commission on Social
Determinants of Health (2005 - 2007)

„ Final report of Network: March/June, 2007

„ Final report of Commission: May, 2008
„ Early product: T. Schrecker and R. Labonte,
“Globalization and Social Determinants of Health: A
Diagnostic Overview and Agenda for Action,” WIDER
Conference on Health Equity, Helsinki, September
2006 (now under journal review)
Globalization Knowledge Network,
WHO Commission on Social
Determinants of Health (2005 - 2007)

„ Anticipated products: Monograph series based on

commissioned papers; edited book (University of
Ottawa Press?); journal articles; teaching materials
„ Funding: International Affairs Directorate, Health
Canada
Health in an Unequal World:
Global Ethics and Policy Choices
(2006 - 2009)

„ Co-PIs R. Labonté, T. Schrecker, M. Johri (Université

de Montréal); research network of 14 investigators at
eight universities launched November 2006
„ Methodology: multidisciplinary “working
conversation” in such forums as
„ Pre-conference on global health ethics at Cana-dian
Bioethics Society annual meeting (May 2007)
„ Funding: CIHR (Ethical, Legal and Social Issues
Strategic Initiative)
 Key research questions

„ What international obligations exist to design

policies and institutions to secure access to health
for all and eliminate inequities in access?
„ What are the appropriate roles and limits of markets
in allocating resources necessary for access to
health?
„ What are the strengths and implications of rights-
based approaches to health, and the social
determinants of health, as a response to
globalization?
Canada and Migration of Health
Professionals from sub-Saharan Africa
(2005 - 2009)

„ PI R. Labonté; research involves three Canadian

universities and collaborators in the region
„ Phase One completed; sample product
 Key research questions

„ Are health worker flows from SSA to Canada

increasing, decreasing or remaining the same?
„ What are the financial costs (and, via remittances,
benefits) to source countries of health worker
migration? What are the financial benefits (in
avoided training costs) to Canada?
„ What is the level of health system support in
Canada for different policy options that minimize
push and pull factors and improve health equity in
both source countries and receiving (Canadian)
provinces?
Canada and Migration of Health
Professionals from sub-Saharan Africa
(2005 - 2009)

„ Methods: Semi-structured interviews, secondary

data analysis
„ Funding (Phase One): CIHR; (Phase Two): Social
Sciences and Humanities Research Council of
Canada
Globalization and the Health of Canadians
(2006 - 2011)

„ PI R. Labonté; research team of 20 investigators

from 10 universities
„ Launched February 2007 at conference co-
sponsored with Parkland Institute
 Key research questions

„ How will globalization affect health of children in

low-income metropolitan households (Montréal,
Toronto, Vancouver, Calgary, Edmonton)?
„ What are the distinctive impacts on women and on
recent immigrants?
„ What are the multiple dimensions of vulnerability
that are relevant to understanding globalization’s
impacts?
„ How does globalization affect the international
policy context within which Canada must respond?
 Key research questions (cont’d)

„ How effectively has Canadian public policy

responded to the challenges?
„ What best practices can be identified from the
experience of other countries?
„ What might the pattern of health disparities in major
Canadian metropolitan areas look like in 2025?
„ What are the most important policy entry points for
Canadian governments?
Globalization and the Health of Canadians
(2006 - 2011)

„ Multiple methods: generating and mapping a

neighbourhood-level Globalization-Relevant Index of
Disadvantage (GRID); systematic reviews of policy
interventions (for Cochrane/Campbell Health Equity
Field); qualitative research; multivariate national-
level statistical analyses; scenario construction
„ Funding: CIHR Reducing Health Disparities and
Improving Health Equity Strategic Initiative
Revitalizing Health for All: Learning from
Comprehensive Primary Health Care
Experiences (2007 - 2011)

„ Co-PIs R. Labonté and D. Sanders (University of the

Western Cape); 53 investigators in India, South
Africa, Tanzania, Zimbabwe, Guatemala, El
Salvador, Nicaragua, Bolivia, Brazil, Australia
„ Focus on comprehensive primary health care (CPHC)
 Comprehensive Primary Health Care:

A political philosophy and implementation strategy for

health systems that emphasizes equity in health
outcomes through universally accessible, affordable
and quality health care; actions on the social
determinants of health’; and citizen participation in
health system policy-making
 Key research questions

„ How effective is CPHC in terms of:

a. Equity in access to health care, other services essential to
health
b. Reduced vulnerabilities
c. Reduced exposure to risk through changes in social and
environmental determinants of health
d. Improved participatory mechanisms and opportunities
e. Increased community resilience to enable effective
responses to promote and protect health
f. Health equity as measured by population health outcomes?
 Key research questions (cont’d)

„ How can an international capacity building program

on research skills for CPHC contribute to
strengthening the evidence base for effectiveness?
„ What approaches to research, and what evaluation
tools and methods, are most useful in advancing
understanding and implementation of CHPC?
Revitalizing Health for All: Learning from
Comprehensive Primary Health Care
Experiences (2007 - 2011)

„ Multiple methods: systematic reviews; research

capacity training workshops; new field research in
four regions; regional network meetings and
development; international conference
„ Funding: CIHR/International Development Research
Centre Teasdale-Corti Initiative
Immediate future plans: Globalization and
health equity training program

„ CIHR Strategic Training Initiative for Health

Research (round 2): RFA for letters of intent to be
released July 2007
„ A multidisciplinary, multi-faculty University of
Ottawa graduate training program that will
„ Build on Labonté’s experience as PI of a program at
Universities of Regina and Saskatchewan funded in
round 1
 How much good does it do
to treat people's illnesses ...

only to send them back to the conditions

that made them sick?
 For further information

„ On the globalization and health equity research

program: rlabonte@uottawa.ca or
tschreck@uottawa.ca
„ On the WHO Commission on Social Determinants
of Health:
http://www.who.int/social_determinants/en