Vertical versus Horizontal delivery of health services: The never ending debate!

Written by: Amrita Sankaranarayanan

Edited by: Helen Myrr & Sinéad O’Ferrall


The delivery of pharmaceutical products or services is usually levered by either a horizontal function or a vertical function. A horizontal function refers to the interventions provided by a country’s government through a public health system, while vertical functions are typically donor driven,disease specific and not always well integrated into the health system. Horizontal functions are an outcome of the WHO/UNICEF Alma Ata Declaration in 1978 which stated the importance of health systems strengthening through participation of the community-:

Primary health care ... relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

Vertical functions on the other hand, are health intervention programs which focus and deal with one particular disease and the nuances surrounding it. They are a more recent trend,  with the rise of and increase focus on communicable diseases like HIV, malaria and TB and a rise in donor and public-private agencies like the Global Fund, GAVI, BMGF to name some. Political economics, donor interests and the emergence of newer diseases over recent decades have resulted in vertical programs gaining tremendous momentum, but also gaining much criticism. Increases in vertical programmes in the area of communicable diseases have been claimed to be responsible for a fragmentation of the health system and a disruption of services. An impact of the vertical program for HIV in the WHO European Region has been studied and found to be responsible for the highest number of rapidly increasing HIV and multidrug resistant TB species.[1],[2]

There has been an evidence based notion over the focus of the international community towards providing finances for a particular disease, resulting in dwarfed resources for other diseases which may have the country’s highest disease burden. Vertical programs for HIV and AIDS have been studied as donor prioritized diseases which may have mitigated the risk for displacement of resources (both in terms of funds and human resources) for other diseases. [3],[4],[5]

Let’s discuss the case of pneumonia. Pneumonia is a number one killer of children under the age of five. The mortality caused by pneumonia in children under five is greater than deaths caused by malaria and measles combined. In 2011, the overall assistance targeting pneumonia was 663 million dollars which was only 2% of the entire 30.6 billion dollars spent on overall global health financing. This is however an increase from 2008 figures which was about 308 million dollars. [6] One reason for this surge was the introduction of resources from GAVI Alliance – an international public private organization involved in vaccine coverage and vaccine supply chains. Pneumococcal vaccines were rolled out by the GAVI Alliance in specific resource limited countries which have a high burden of childhood pneumonia. [7]It is claimed that this vaccine introduction in Ethiopia was the reason for the significant decline in under five child mortality and achieving the MDG 4 much ahead of time. [8]

Some studies have questioned the rationale behind the decision by Government of Ethiopia to introduce the pneumonia vaccine PCV 10. The reasons that contributed to this decision were found to be political prioritization, availability of the GAVI funding and “the desire to address the burden of disease and seize the GAVI funding“. [9] This is an example of how advocacy and financing around an intervention can result in increased coverage of a pharmaceutical product and become the center of focus for country governments. What if there wasn’t any GAVI funding? Would the childhood pneumonia death still be lowered in Ethiopia? Debatable!

Studies of vertical programmes have not necessarily found them to be effective in terms of results, and have been blamed to have a largely single focus, ignoring the actual needs of the patients and to be largely bureaucratic in nature. [10],[11] It must however, also be kept in mind that some of the most successful interventions like polio eradication or family planning initiatives, all had a vertical component to them. [12]

Horizontal programs are reported to strengthen the health system and have a greater impact in terms of cost effectiveness and sustainability, much more so than vertical programs. Community based interventions are components of a horizontal program which provide a more patient centered approach and have shown to address the problems of a system as a whole rather than diversifying them into programs. There has been quite a lot of debate about the merits and demerits of both types of programs and no consensus has been made as to which approach is the best in what circumstances. With regards to this, WHO states that

The available evidence on the relative benefits of vertical versus integrated delivery of health services is limited and too weak to allow for clear conclusions about when vertical approaches are desirable.

In a generation where most of us expect a magic pill to resolve most issues, the reality is pretty farfetched. Donors and international agencies come with stipulated funding for certain diseases and begin implementation, often overlooking the structural challenges that the health system faces especially in developing countries. So the vertical program can be used as a short term strategy alongside the efforts to strengthen the health care system with a more integrated approach. There is no evidence on why a vertical and horizontal program cannot co-exist.  Studies have shown that it’s not necessary all the time for a program to be completely vertical or completely horizontal.

A mixed method approach could be used, making use of the policies from vertical programs under the leadership and management of horizontal programs for a more sustainable outcome. There is no standard golden rule to the application of a particular program for a disease intervention. In the absence of evidence on which are the most effective models, countries could have their own tailored and custom made models incorporating the administrative expertise of a horizontal model and operational expertise of a vertical program. There needs to be a system in place that can combine and utilize the expertise of both the programs. This system also should have a mechanism such that the donors also help in building a stronger yet sustainable health system saving a maximum number of lives.


[1] Tkatchenko-Schmidt E, Renton A, Gevorgyan R, Davydenko L, Atun R. Prevention of HIV/AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes. Health Policy. 2008 Feb 1;85(2):162–71.

[2] Tkatchenko-Schmidt E, Atun R, Wall M, Tobi P, Schmidt J, Renton A. Why do health systems matter? Exploring links between health systems and HIV response: a case study from Russia. Health Policy Plan. 2010 Jul 1;25(4):283–91.

[3] Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008 Mar 1;23(2):95–100.

[4] Berer M. HIV/AIDS, sexual and reproductive health: intersections and implications for national programmes. Health Policy Plan. 2004 Oct 1;19(suppl 1):i62–70.

[5] Crossette B. Reproductive Health and the Millennium Development Goals: The Missing Link. Stud Fam Plann. 2005 Mar 1;36(1):71–9

[6] Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia [Internet]. [cited 2015 Oct 6]. Available from: http://www.healthdata.org/policy-report/pushing-pace-progress-and-challenges-fighting-childhood-pneumonia

[7] Vaccines to prevent pneumonia deaths reaching poor countries in record time – Gavi, the Vaccine Alliance [Internet]. [cited 2015 Oct 11]. Available from: http://www.gavi.org/Library/News/Press-releases/2012/Vaccines-to-prevent-pneumonia-deaths-reaching-poor-countries-in-record-time/

[8] GAVI Alliance partners to tackle childhood killer in Ethiopia – Gavi, the Vaccine Alliance [Internet]. [cited 2015 Oct 11]. Available from: http://www.gavi.org/Library/News/Press-releases/2011/GAVI-Alliance-partners-to-tackle-childhood-killer-in-Ethiopia/

[9] LSHTM. New vaccine introductions: decision‐making & impact on health systems [Internet]. Health Systems. 2013 [cited 2015 Oct 11]. Available from: http://blogs.lshtm.ac.uk/healthsystems

[10] Unger J-P, De Paepe P, Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries. Int J Health Plann Manage. 2003 Dec;18 Suppl 1:S27–39.

[11] De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N. Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br J Gen Pract. 2008 Jan 1;58(546):3–4.

[12] Levine R. Should All Vertical Programs Just Lie Down? [Internet]. Center For Global Development. 2007 [cited 2015 Sep 30]. Available from: http://www.cgdev.org/blog/should-all-vertical-programs-just-lie-down

How Health Is Political

Written by: D.I. Sotomayor-Irizarry

Edited by: Line Bayer (@lbager87)


GW6 Social Determinants
GW6 Social Determinants. Credit: Drawing Change

Topics such as poverty, education, work conditions and infrastructure, among others are roots of multiple social inequalities. These issues are highly political because they can be changed and are the base of everyday political discussions at national and global levels.  I find it both interesting and concerning that political stakeholders rarely link the issues that cause social inequities with health inequities, despite the fact that the correlation between both is well acknowledged and understood. Public health evidence has been disregarded in many political contexts and health has been simplified and depoliticized erroneously. I believe it is time that we politicize health to collectively recognize it as a human right obstructed by complex global forces that we should all strive to attain through a global good-governance and stewardship oriented approach.

Bambra et al provide three arguments on why health is political:

  1.     Health is distributed unevenly among and within societies
  2.     Health determinants are dependent on political action (or inaction)
  3.     Health is a critical dimension of human rights

The key message of the first Alternative World Health Report in 2005 supported these arguments and highlighted the need to increase political action on poverty and global health. Later on in 2008, the WHO’s Commission on Social Determinants of Health concluded that health is shaped by “the distribution of money, power and resources at global, national and local levels”, issues that are all tackled from non-health, political sectors. Most recently, the 2014 publication of the Commission on Global Governance for Health emphasized how health inequities between and within countries required global political solutions that transcended national health sectors.  

We know very well that our global health field is based on the principle that the social determinants of health play a major role in shaping health outcomes and health inequities and that these patterns of disease are not randomly spread across the population but rather clustered around the most disadvantaged (1). Social inequities lead to unequal experiences and resources, leaving some groups of people more or less vulnerable to poor health. Some of these include schooling, employment and income, working and living conditions, type of housing, sanitary systems and access to clean water, and food, among many others. Ultimately, we know that this social stratification within and among countries defines the access and use of health care and has implications in the inequitable promotion of health and well-being, disease prevention, illness recovery and survival. All in all, the access and distribution of resources that promote or impede health is inherently political.

The launching of the Sustainable Development Goals (SDG’s) last year demonstrates that the world needs a more integrated approach between health, development, economic growth, urbanization, gender equality, and climate action, among others. However, I have the impression that although the majority of the world’s leaders adopted these SDG’s, many governments are still not prioritizing an integrated health agenda that incorporates other seemingly non-health-related political topics. Health and its societal, economic and development implications continue to be very much depoliticized at national and global political contexts. Moreover, discussions on health issues continue to be reduced to technical health care services and systems controlled by physicians, pharmaceutical and insurance companies. Health continues to be a commodity that is produced and delivered by either the market or the health service.

Some authors have suggested that the depolitization of health has occurred as a result of the perception that politics is government, which ultimately creates a divide between individuals with and without political roles and power. However, it is fundamental to recognize that politics does not just take place in government through elite politicians in a top-down approach. Politics it is ubiquitous in society and it encompasses “all the processes of conflict, cooperation and negotiation in taking decisions about how resources are to be owned, used, produced and distributed”.  At a broader scale, the transnational activities that globalization has triggered and that involve multiple actors with different interests and degrees of power are also politics and have turned health inequities into a global and political challenge. Whether at national or global levels, all issues are political and everyone can and should engage in a political act.

I believe that this perceived elitism of politics has not only disengaged people from taking part in political processes but has also disengaged and frustrated public health professionals from the advocacy processes regarding the topics in which they are experts. In fact, authors such as Mackenbach are highly critical to public health professionals and their little involvement in politics. He argues that researchers often cite “lack of political will” to explain the failing to deal with factors that affect health; they urge health to be placed higher in the political agenda and continuously emphasize that health policies need to be evidence based without having an understanding the political arena (6).  He highlights that it is precisely because of this lack of training in politics, policy making processes and how their complexities function that the work and efforts of public health professionals can sometimes be fragmented or ignored.

I agree with Mackenbach up to some extent because I believe that as professionals that study and tackle social and health issues that are in essence and in practice very much political, we should be more educated and involved in the political processes from which these issues can be changed. Nonetheless, I understand that there are many ways of being politically active and that not everyone has to be in the frontlines of debate and policy creation in order to be an agent of change. I also recognize how time and energy consuming is research, especially when it requires doing fieldwork in countries around the world and that the high quality of evidence that we have today is the result of these investments.  However, I do believe that as global health professionals, working for a more equitable society, we should acknowledge and be proud of the variety of our politically charged efforts. By situating global health work within a political context and recognizing that what we do and what we want is political, we would be taking a step forward in pressuring national and global stakeholders to engage in the multiple levels of social change in a way that they connect health with the macro political causes of the major economic, social and health inequalities, such as macroeconomic policy, trade policy, defense policy, foreign policy and international development.

It is unfortunate that social and health inequities continue to be addressed independently and therefore, redundantly. This is especially in light of the fact that the evidence relating the two as well as the know-how to address them in a more effective and sustainable way, already exist and is well documented. The recent adoption of the SDG’s has marked the initiation of the long-due conversation of the interrelatedness and relevance of health with all of the other social, development, economic and political aspects of the global agenda as well as the diversification of the stakeholders involved in the process. Thus, I believe that as global health professionals we have the responsibility of creating political pressure to achieve the SDG’s by 2030 through multi-sectorial civil society, national and transnational initiatives.  To achieve this, we need to embrace the politics of health and do a better job in communicating what we study, work and research in our academic circles and institutions to the multiplicity of sectors that can and should foster sustainable change. Let’s recognize how political our work is and let’s voice it for what it is.

The clock is ticking!


1. Merson M, Black R, Mills A. Global Health: Diseases, Programs, Systems and Policies. 3rd edn. Jones & Bartlett Learning ; 2012

Did you notice the one billion people?

Written by:  Thomas Hilberg Rahbek (@hilberger90)

Edited by Sinéad O’Ferrall (@sineadOFGH) & Line bager (@lbager87)


Did you notice two weeks ago, when it was UN’s World Toilet Day??

WTD15-2-2
Props from Poop Quiz Evening! (Photo Credit: UNYA.dk)

Some people did. Some people thought it was a joke. But most people just didn’t notice. Why is it then important that people notice? Well, as stated by the UN, 1 billion people still defecate in the open, endangering both themselves and others.  The substantial amount of people affected raises the question – why it is not a higher priority? Poor sanitation is a killer. It’s implications, especially for children under 5 with over 300.000 diarrheal related deaths per year, can not be ignored. Thus the purpose of the day was to “make sanitation for all a global development priority and urge changes in both behaviour and policy on issues ranging from improving water management to ending open defecation.” 

It may be difficult for people in high-income countries to grasp the importance of World Toilet Day. In these countries, talking about toilets is something for children to snigger at and the rest might feel uncomfortable talking about the subject. Our thoughts about what goes on in the toilet in an everyday context are more often connected to their use of creating a laugh than in their sanitational value. Due to the ease of access to toilets that exist for everyone in these countries, we don’t experience the problems first hand. Sometimes you do not notice the importance of something until you don’t have it anymore. That would definitely be the case with a toilet.  

Toilet_tunisia
Toilets! (Photo Credit: Thomas Hilberg Rahbek)

This is why a few Global Health students, who work as part of the United Nations Youth Association, concerning global health, took the initiative to set up an event on World Toilet Day, promoting awareness about the significant challenges we are facing in this field. At the event we introduced the concept of World Toilet Day and had inspiring talks by NGO’s and Director of COPE, Peter Kjær Mackie Jensen on the importance of sanitation in low-income settings and how work is carried out in the field.

The challenge we faced in promoting the event, is the same that the world community is faced with, as how to take sanitation seriously in countries that don’t experience particular sanitation issues. Communication is key. We tried to use people’s lightly humorous feel about toilets and put it to good use, by making a Poop Quiz incorporating important facts about sanitation, but keeping it easy by mixing fun with academics. Still the challenge is to raise awareness without this coming out as just another prepubescent joke or something that people won’t talk about. As social entrepreneur, Joe Madiath, explains in his 2014 TED TALK, food is a great conversation topic, but after it goes through the digestive system, the interest fades away.

The challenge is, walking the fine line between entertaining and educating. When the topic is filled with taboo, and a laugh not far away, how do we get the topic higher on the global agenda? Global Citizen tried to use an interesting approach in getting attention, empathy and a deeper understanding of how the problem is experienced in the local context. They set up a see-through toilet in a public space, so people could get a sense of the lack of privacy that open defecation creates. Check out how it looked here

This is the feeling of 1 billion people, defecating in the open, that we haven’t noticed. Let’s think about whether we can live with the knowledge that so many people lack such a basic amenity. The problem is not just limited to the bottom billion, but up to 2.4 billion don’t have access to improved sanitation. The inhuman conditions violating human rights and dignity should never be accepted when we have the possibilities to do something about it. This is not rocket science. We need to go back to basics, because this is something you can’t live without, something you should not live without.

Lack of good sanitation is a major risk factor for developing a ton of diseases, that are all preventable. We need to stress the importance of better sanitation for improving health and wellbeing of people. It’s a human right of equal importance as the right to food, shelter and security.

The lack of sanitation and its consequences inhibits the potential of the people affected. Children that are exposed to poor sanitation have higher risks of acquiring helminths which drains them of energy so crucial for their ability to learn in school, stunts their growth and physical development and can lead to chronic health complications for their entire life. It also endangers the safety of women, who often wait until the cover of darkness as a way of getting privacy, but also making them more vulnerable to assault and rape.

An effective sanitation system would help prevent situations like these, but it can’t go without emphasising the importance of actually using it.

Because toilets are lifesavers and the implications of not having or using them are enormous and of urgent need of a resolution. Breaking the silence and spreading the message means overcoming the taboo. So start talking about the untalkable, start talking shit. Smiles are allowed, then it will be remembered. But let’s not forget that we should smile because the solution is not impossible. The answer is not hidden, and prevention of disease is possible for the bottom billion. One third of the world doesn’t have access to improved sanitation and the challenge will only be increasing with other simultaneously occurring processes like population growth and climate change. 
So next up is the World Water Day on the 22nd of march. I hope you notice.


Why COP21 matters for Global Health

Written by Kina Hiller

Edited by Line Bager (@lbager87) & Sinéad O’Ferrall (@sineadOFGH)


From 30 November to 11 December 2015, more than 40,000 delegates from 195 countries meet to assess the progress in dealing with climate change, negotiate agreements and set goals for reducing greenhouse gas emissions. COP21 is a crucial conference, as its primary goal is to achieve a legally binding agreement to keep global warming at the critical threshold of 2°C. Now you can ask; why is this meeting important to Global Health?
The human population has flourished through the unsustainable exploitation of Earth’s resources but faces substantial future health risks from degradation. Environmental changes pose serious threats to human health, including climate change, ocean acidification, water scarcity, land degradation, and biodiversity loss. These effects are becoming increasingly apparent from the second half of the century. As shown in Figure 1, health impacts can be direct (e.g. heat stress, floods), secondary (due to change of natural systems) or indirect (e.g. population displacement).The concept of planetary health [p. 1973], defined as “the health of human civilization and the state of the natural systems on which it depends”, detects mechanisms and thus offers an opportunity for advocacy of reforms.

fig 1 kina
Figure 1: Mechanism potentially affecting human health by harmful changes of the ecosystem. Source: Whitmee et al. (2015; p.1978)

How are ecosystems affected by environmental degradation?

According to a recent publication by the Rockefeller Foundation-Lancet Commission on planetary health, effects of climate change will become evident by 2100 through increased melting of ice sheets; a projected mean sea level rise of 0.52-0.98m; a surface temperature rise between 2.6-4.8°C; changes in rainfall patterns; and a higher prevalence of extreme weather events. Ocean acidity has already increased by about 26% since the industrial revolution, and will continue to rise up to 170% by 2100, leading to losses of marine animals and coral reefs and therefore negatively impacting the livelihoods of millions of people.

With population growth, water demand is projected to increase by 55% between 2000 and 2050. Renewable surface water and groundwater resources will be reduced, some areas will basically dry off. Food security and biodiversity will be additional negatively impacted by soil degradation, which is driven by land clearance and intensive farming to meet the growing demand for animal products and non-food crops for biofuel and cosmetics (oil palm cultivation is increasing by 9% annually). Toxic chemical pollution (>140,000 chemicals are estimated to be sold in the EU) and agricultural fertilizer (nitrogen and phosphorus) have furthermore been key drivers of ecosystems change, leading to biodiversity losses and unpredictable consequences.

What are the health effects?

According to WHO, “vulnerable groups are disproportionately at risk and climate change is expected to widen existing health inequalities, both between and within populations”. Human health will be negatively affected mainly by heat stress and fires; increased malnutrition and stunting due to lower agricultural productivity and loss of pollinators; higher rates of respiratory diseases due to air pollution; endocrine disruptions due to toxic chemical exposure; productivity loss of vulnerable populations; physical and mental impacts of extreme weather events; and a higher prevalence food-, water- and vector-borne diseases. For example, diarrhoeal diseases are expected to increase by 8-11% globally by 2040s, and additional people will be at risk of malaria, schistosomiasis and zoonotic diseases.

Uncertain but more severe threats include a breakdown in food supplies, conflict due to resource scarcity and migration, the vanishing of some states, and an exacerbation of poverty, impeding the realization of the SDGs. It has been estimated by the WHO that 250,000 additional deaths per year will already occur by the 2030s.

What can we do about it?

Temperature has risen by 0.85°C since 1880, and the gasses emitted so far will probably result in an unavoidable rise of around 2°C of warming. Significant reductions in emissions in the near future and sustainable development are therefore needed, with financial support of high income countries. We need legally binding agreements on the one side, and changes in consumer behavior on the other. Suggestions for more sustainable behaviors of individuals include eating less animal-products (500g beef = 100km driving on the highway); buying local, organic and packaging-free food items; using green methods of transport; buying less but sharing instead; simply being aware and communicating concerns.

Also, we as practitioners in the health sector should set good examples and aim to build up resilient and sustainable systems. In developed countries, health services account for 5-15% of the carbon emissions. We should therefore strive for energy efficiency, renewable, and greener supply and delivery chains. Adaptation strategies should include investments in surveillance and response systems, improving social and environmental determinants of health (nutrition, water, sanitation), and ensuring equal access to health services.

Climate change can be seen as the biggest threat of the century but also as the greatest opportunity to rethink and alter our behaviour. This is a call for global action before the planet strikes back!

cop21 kina
COP21 meets in Paris to discuss Climate Change and how we can reduce the damage to our planet. Photo Credit: https://www.tagesschau.de/ausland/klimakonferenz-121~magnifier_pos-1.html

Swedish Network for International Health Conference, 20th-21st November 2015.

Writers: Line Bager (@lbager87) & Sinéad O’Ferrall (@sineadOFGH)

Editor: Helen Myrr

As heads of the Global Health blog, Line and Sinéad were invited to Swedish Network of International Health (SNIH) 2nd Annual Conference looking at “Health Equity in an Unequal World”. But who are SNIH and what was the weekend all about?

SNIH was set up just over a year ago in Sweden for global and public health students and alumni, to create a network of students and young professionals. The network aims to facilitate interaction between members and provide tools for personal and professional development, to the benefit of the profession. SNIH also stresses the need to bridge the gap between student and professional life, as they are doing through one of their initiatives, the mentorship programme Global Health Me. You can find more about the SNIH and their activities here.

The conference was held over two days in Karolinska Institutet in Stockholm, striking a satisfying balance between panel discussions, talks and networking sessions. There were many interesting points made and discussions throughout the two days but here we will share three keys themes that came up:

The first major theme that emerged was best highlighted in Hans Rosling’s talk. As always, he was an animated and captivating speaker, looking at data and how it is often misinterpreted or not challenged enough. He highlighted the concept of “factfulness”, first introduced by his son a few years back, as a concept the world needs more of.

Factfulness
Hans Rosling talk about factfulness at SNIH conference. Photo credit: Line Bager

When we are discussing important issues such as health differences between and within parts of the world, grounding what we say with facts and knowledge is crucial – otherwise they are simple statements of opinions. Unfortunately, opinions are too often presented as facts. 

If you have not yet had a chance to see Hans Rosling talk yet, we highly recommend a number of excellent talks available on TED.

The emphasis on evidence was also highlighted in other talks. Dr. Helena Nordenstedt, assistant professor and researcher at Karolinska Institutet, spoke about international efforts to address the recent Ebola outbreak. In 2012, Dr Nordenstedt started working for Médecins sans Frontières and has been to the Democratic Republic of Congo, Guinea and Liberia, where she worked in an Ebola Treatment Centre. Dr. Nordenstedt emphasised the need to continually expand our knowledge of this disease and many neglected disease. It is our lack of true understanding that left us vulnerable as demonstrated by the new cases of Ebola in Liberia even after the country was declared Ebola free, as well as the discovery that the Ebola virus can remain dormant for a long time in human tissue.

me panel
Panel: Young Leadership in Health – Our very own Editor and writer Sinéad O’Ferrall was invited to sit on this panel at SNIH Conference. Photo Credit: Line Bager

Putting Global Mental Health on the Agenda

Written by Christian Ulrich Eriksen, MScGH, & Jane Brandt Sørensen, PhD Fellow

Edited by Sinéad O’Ferrall & Helen Myrr


The University of Copenhagen’s School of Global Health is conducting a one-day seminar: “Who works on Global Mental Health in Denmark – an exploratory stakeholder seminar” on Wednesday, 21 October 2015 at Center for Sundhed og Samfund (Health and Society). While focus and resources remain scarce for mental health in the international development agenda, international or transnational coordinated efforts are even scarcer.

The objective of the seminar is to kick-start the debate on this lack of response and to hopefully gather concrete tools for advancing the agenda. As part of this exercise University of Copenhagen’s School of Global Health will map stakeholders in Denmark – NGOs, policy makers, academics, journalists, health professionals, students and others – with a Global Mental Health focus as (part of) their agenda. In doing so, we hope to provide a starting point for strengthening and establishing new avenues of collaboration and move forward in increasing awareness about the topic in Denmark and beyond.

In the run up to the seminar, we have gathered a collection of informative and inspirational resources on global mental health, which hopefully will instigate fruitful discussions and prove useful in understanding some of the dilemmas and opportunities in working on these issues.

Social determinants of mental health

The World Health Organization estimates that mental and substance use disorders directly account for around 7% of the global disease burden. Mental Health conditions bring grave implications on the quality of life for the affected and their surroundings, and especially in low- and middle-income countries they bring serious challenges to already strained healthcare systems. In these settings poor mental health is oftentimes exacerbated or triggered by already stressful and challenging life-situations, which can be due to poverty, physical health issues and disasters, making prevention and response highly complex and multifaceted. The following short film on pesticide self-poisoning in a rural area of Sri Lanka, clearly highlights the complex nature of mental illnesses.

NCDFREE Sri Lanka Video

The resource gap

The largest challenges faced by many low and middle income countries in dealing with the increasing burden of mental illnesses are the paucities of both mental health care professionals and services available to people with mental illnesses. Mental health services are, especially in low and middle income countries, not allocated the needed resources to cater to the need for treatment and prevention. Thus, new approaches need to be sought and attention drawn to the topic to combat the challenges faced. In the TED-talk below, the psychiatrist and mental health care advocate, Vikram Patel, shares his views on how to approach global mental health.

Vikram Patel’s Ted Talk 

Putting mental health on the agenda

Though the focus on mental health is increasing, it is still rarely brought up in the popular media, which further removes the issue from the political agenda. The following clip is an exception to this, and it showcases how mental health issues can be mediated to the general public in a nuanced and informative way.

John Oliver report on Mental Health 

Further readings

If you are inspired to do some more reading, we recommend this special section in the journal Transcultural Psychiatry, which has a specific focus on communities and mental health, as well as the Lancet series on Mental Health from 2007  and 2011.

A tale about smoking

Written by Laura Revsbech Winther

Edited by Sinéad O’Ferrall & Helen Myrr


Once upon a time there was a world in which the tobacco industry ruled. To secure a future generation of smokers (i.e. profit) the industry undertook research into what appealed to teenagers,and came up with products like menthol flavoured cigarettes or “light” versions. Children and adolescents would be told by the tobacco industry that ‘kids don’t smoke’, and that they should wait until they were of age to make the decision about smoking. However, that just made the products even more attractive to this age group. Some of the adolescents, who did not believe tobacco products could be very harmful, when they were legal to adults, managed to get hold of cigarettes and the contemporaries would gather around them drawn by the ‘dangerous’ products, the dream of appearing older and the wish to be a member of the popular group. The children would start taking puffs of the cigarettes and then progress to inhaling, and they would all feel boosted with energy by being part of this group ritual. They were popular, they appeared older and they sent a strong signal that they weren’t afraid of anything.

laura blog pic

However, when they turned 18, 19 or 20, when they had become mature adults and therefore no longer needed the cigarettes as a symbol of adulthood and risk taking behaviour, they could not stop smoking. It was as if their fingers were glued on to the cigarette packages, and their free will belonged to the tobacco industry. They now fully comprehended that the cigarettes they consumed every day killed 6 million people annually, and that they had a risk of 2 in 3 of dying from their habit, but no matter how hard they tried to quit, no matter how much they wanted not to be part of these statistics, most of them could not give up smoking once they had started. Almost as if the tobacco industry knew that the smokers someday would want to break off their relationship with the cigarettes, the industry had added addictive components to the cigarettes to ensure that they most likely would continue consuming until they died.

The global population of smokers and non-smokers at risk of taking up smoking all needed help. Help came in the year 2003, when countries all over the world signed the Framework Convention on Tobacco Control – an auspicious law designed with the aim of reducing demand and supply of cigarette products. However, despite the law’s effect in reducing cigarette consumption, it only seemed to have limited effect on smoking uptake in adolescents. Stronger measures were needed.

Tasmania had some of the highest smoking rates in Australia. 40% of young men smoked, a number which had not decreased significantly over the last decade. With alarmingly high rates of smoking among teenagers, rates that hadn’t declined from 2005-2011, a future generation of smokers seemed to be secured. Research had shown that 80% of all adult smokers started before age 18, so if t adolescents experimenting with cigarettes could be prevented, smoking as a behaviour could be almost eradicated in the long run.

The Australian Professor Jon Berrick and his team of researchers in Singapore developed exactly such a plan to save future generations from the damaging effects of tobacco with a tobacco endgame. Never before had anyone suggested to reach the aim of a tobacco free generation by preventing sales of tobacco products to people born in 2000 and beyond (generation 2000). Although the legal age of smoking remained to be 18, those born in 2000 and later would not be able to purchase the cigarettes even once they turn 18.

A group of people in Tasmania met with Jon Berrick,believing his bill could pave the way for a tobacco free generation in Tasmania. In August 2012, congress member Ivan Dean presented the bill to the Upper House of the Parliament in Tasmania and received strong support. The tobacco industry strongly opposed the bill, and some retailers feared they would lose profits. However, help came from unexpected quarters. The young Tasmanian adults age 18-29 were strong supporters of the bill, some of whom wished they had been protected from tobacco products before it was too late. Another, a Tasmanian retailer, publicly told her story about how she had stopped selling cigarettes after seeing how members of her community became sick and died from products purchased in her shop.

In March 2015 the bill was debated again in the Parliament with strong support, and within a couple of years the bill was enforced. Never again would Tasmania give up on its youth and smoking became within generations completely eradicated.

Syria’s Silent Voices: The Experience of Young Volunteers Working for a Better Generation

Written by: Benedetta Amici

Edited by: Sinead O’Ferrall


I am sure that everybody is now familiar with the image of the three years old Syrian boy drown on the Turkish coastline.  Aylan’s tragedy has been upsetting the newspapers’ front pages during the last week, raising indignation all around the world. When I heard about Aylan’s story, my thoughts immediately went back to the many Syrian children I have met while volunteering in Turkey, whose lives have been brutally distressed by the harsh conflict. As we already know, children are always the first victims of war.

My voluntary work took place in Gaziantep, an industrial city in the southeast part of Turkey, only 60 km far from the Syrian border. Although the registers report 220.000 refugees living in Gaziantep, in reality they are estimated to be more than 400.000 (1).  

Gaziantep

Here, the refugees’ crisis is now part of the ordinary life. During the Ramadan evenings, local citizens are used to sit in the park and enjoy their first meal of the day,  while for many other people that same park represents the only place they can call home. Moreover, the tension among the local population is becoming more and more visible: the massive arrival of refugees made the rent prices raise while the salaries have dramatically dropped, causing dissatisfaction and protests.

When the statistics overtake the individuals

As part of a local NGO’s who is dealing with vulnerable children, my job essentially consisted of providing orphans and refugee children with educational and material support. During these activities, I got in contact with many little kids and their touching stories, which we hope have helped turning to a better end.

Here I would like to share these narratives with you, just as a simple reminder that behind those “unprecedented numbers” (a term so loved by the media) there are real people with their individual experiences.  Perhaps, by letting their stories speak on my behalf, my message will go beyond the pure information and stimulate some empathy.  

Credit: Emily Troutman (aid.work)
Ahmed, 6 years old, lives in this single room with his mother, sister, father and baby brother. They burn trash to keep warm. Credit: Emily Troutman (aid.work)

Mohammed’s story:

Mohammed is a 4 year old boy living in an orphanage in Gaziantep. The staff members said that when he was brought there, he was covered with blood. We can still see the marks of the war on his little body, carved with scars from the bottom to the top. Just the sound of the word “Syria” is enough to upset him, he starts screaming and running everywhere and it takes a while to calm him down.

Hadija’s story:

When I first saw Hadija, her deep blue eyes and her beautiful smile immediately struck me.  But as I got close to her I realized that there was something different. She is deaf. While she was still in Syria, a bomb was dropped close to her, and since then she cannot hear anymore.  Her hearing is not the only thing she has lost; her sister and grandmother died in the same attack. A surgery intervention could give her hearing back and change her life, as she could learn how to speak and get an education.  The excessive cost of that is unfortunate , considering that her family struggles everyday to get the basic necessities to survive.

Farrah’s story:

I met Farrah during our pre-school activities specifically designed for Syrian kids. One of my colleagues tells me how naughty and hyperactive she used to be; then her family’s economic situation changed and she suddenly turned to by silent and introverted.he began to beg from us.

Marya, age 5, she is part of a gang of kids who often beg together. Credit: Emily Troutman (aid.work)
Marya, age 5, she is part of a gang of kids who often beg together. Credit: Emily Troutman (aid.work)

The story of thousand voiceless children:

Many other kids have crossed my life during my stay in Gaziantep, but unfortunately, I didn’t have the chance to get to know their stories. Many   children in dirty clothes, carrying huge bags, four times their size under the burning sun, foraging inside the trash containers and collecting plastic bottles that they can sell for a small bit of money; children begging on the street and sleeping in open parks, earning their life little by little, every day.  

Building a new generation

But unlike Aylan’s tragic destiny, these stories will hopefully turn towards a happy ending.  Despite the local community’s unrest, there is still an important number of motivated people that works hard to bring some relief to the refugee population. Many local NGOs are running different projects and initiatives in order to rescue and give a future to this generation, as the one I was working for.  Everyday, with its goodwill and enthusiasm, the local and international staff gives its contribution; thanks to its work and effort, they are bringing small changes in small lives.

Leila, age 7, isn't able to go to school in Turkey, though she enjoyed school in Syria Credit: Emily Troutman (aid.work)
Leila, age 7, isn’t able to go to school in Turkey, though she enjoyed school in Syria. Credit: Emily Troutman (aid.work)

Now Mohammed knows that there are people caring about him, people that come everyday to his orphanage to play and teach him English. He is also aware of his different nationality, but together with his mates, he has been educated about the fact that human beings are all the same and need to be treated equally, despite their Arab, Kurdish or Turkish origin.

Hadija’s family is now receiving constant economical support. They know that they are not alone, that there are people coming every week to bring them food and clothes and trying to get some contacts or funding for her operation.  Maybe in the future, Hadija will be able to get that surgical intervention that will change her life.

Farrah’s is surrounded by a group of volunteers that provides her with affection and psychological support. They encourage her to participate in all the activities and stimulate her toward a positive attitude, while working on a way to support her family with an economical contribution.

However, the short list of happy stories ends here. There is still so much to do for all those “voiceless children” left on the street and all the refugees living outside the camps. But as long as there are motivated volunteers willing to dedicate their own voice to Syria’s silent voices and use their time to bring a smile on people’s faces, all is not lost.

A special thanks goes to all my motivated local and international colleagues, which have inspired me with their work and dedication.


(1) ORSAM Report No: 195, Effects on the Syrian refugees on Turkey, January 2015

Summer School in Global Health Challenges 2015

Written by Amrita Sankaranarayanan

Edited by Sinéad O’Ferrall & Helen Myrr


The Copenhagen School of Global Health hosted the 2015 Summer School in Global Health Challenges, a two week summer course seeking participation from 85 students from 27 different nationalities. The atmosphere was as vibrant as it could get with experts and beginners from various different strata, with backgrounds in medicine, engineering, law and politics to name but a few. The Danish sun also decided to show up to justify “the summer” in “summer” school.

CSSGH 2015 class
CSSGH 2015 class

Week 1:

Dr Flemming Konradsen, Director of the Copenhagen School of Global Health, gave an introductory talk on various job opportunities within the field and how to achieve a career in global health. This talk was followed by Dr. Alessandro Demaio, who highlighted the density and enormity of global health challenges in the 21st century. He talked about the complex landscape of the influences of the actors, the unprecedented opportunities for a transformational change, and highlighted how 2015 is an important year in global health. He put a special focus on climate change’s relation to global health and the growing concern about NCDs.

Dr Fiona Lander led the day forward by discussing the major actors in global health today, laying special focus on the structure and working of The Global Fund, Bill and Melinda Gates Foundation, World Health Organization, PEPFAR and the World Bank, civil society organizations and national governments. She also discussed state and non state actors and private vs. public actors and the way they work in unison. The takeaway message from this session was that goal setting and funding of initiatives do not necessarily reflect the needs or priorities of the recipient country.

Fiona’s energy and positivity, continued as day 2 began with a more serious lecture on Human Rights and clarifying concepts related to it. There was an interactive session on what human rights actually meant to each participant with ranging answers such as right to life, right to play, right to health, right to education, right to a fair trial, freedom of speech and freedom from torture. The session also involved a more extensive discussion on women’s right to abortion.

Alessandro then continued with an eye opening talk on NCDs, ascertaining that NCDS are not just diseases of the lazy, not just  diseases of the rich, not just diseases of the aged and do not just affect men. There needs to be a focus and attitude shift for NCDs in terms of prevention strategies and early childhood education. He also gave quite an animated explanation for whose responsibility is it to  prevent NCDS, suggesting  the government, the individual, and consumer companies. He asserted that food literacy is fundamental to navigate a healthy lifestyle.

The advent of technology was indeed used to the fullest as the day proceeded with two lectures over Skype. The first one was by Dr Gauden Galea, (Director of division of Non Communicable Diseases, WHO-EURO), on transitions in health. He explained reports from WHO and World Bank from 1993 to 2015 and their (lack of) focus on NCDs. He raised important questions such as why is there a system which neglects  NCDs, why is there a lack of investment in NCDs and is it a zero sum gain on investing in NCDs?

This was followed by another e-lecture by Dirk Christiansen focusing on epigenetics  and NCDs explaining the double burden of under and overnutrition. He explained the effects of foetal malnutrition giving the examples of the Dutch famine, sub Saharan Africa, Ethiopia and Somalia. He also mentioned about the correlation of intrauterine nutrition and the development of Type II Diabetes. His catchy take home message was “Stay in your local environment and you will not get diabetes!”

‘Food for thought’ dinners with some of the key speakers were arranged where the participants got involved in more in-depth discussions in smaller groups around a dining table filled with delicious foods..

Day 3 began with lecture from the mighty Ib Bybjerg with a very detailed pathology and public health concern of infectious diseases – HIV, Malaria and Tuberculosis. This was followed by an inspiring interview session.

How do you keep the drive after so many years? With his charming smile, he just pointed out to us, and mentioned that it’s the students and patients that keep him going. He mentioned that his first trip to India in his 20s proved as turning point in his transition in career from a clinician to a global health practitioner. Although he continued his clinical practice, global health and in particular malaria always interested him.

The afternoon was a fun session  (periodically  in the bright sun!) by Dr. Genevieve Bios who shared her experiences on political advocacy and lobbying. We had a simulation session where the audience was divided into groups and given a case study of a particular country, with a focus on coming up with country plans to control smoking and obesity.  Each team seemed so very responsible for their own country and passionately designed a program.

Class working outside in the sun
Class working outside in the sun

Day 4 was opened by Siri Tellier on public health demographics, explaining the 6 megatrends affecting demography- fertility, mortality, migration, growth, age and sex.  This was preceded by a simulation exercise where the student had to find alarming figures in demography of six countries with data from 1950, 2010 and an “estimated” numbers in 2050. The afternoon session was a peppy talk by James Michiel on social media and m-health and exploring its creative uses as tools in public health. A simulation exercise was carried out where students figured out health campaigns using technology and came up with some interesting examples.

The last day of week 1 was a thought provoking lecture by Peter Furu on the impact of climate change on global health. Addressing climate change is the biggest global health threat of the 21st century. But also the greatest global opportunity! He explained the in detail consequences of climate change on health shedding focus on infectious diseases, NCDs and the effect of migration to vulnerable populations and regions. He summarised the main projected trends of health effects related to climate change as malnutrition and related diseases, injury in extreme weather events, malaria, diarrhoeal diseases, heart and lung mortality and morbidity, dengue and deaths from cold.

Peter Furu lecturing on climate change
Peter Furu lecturing on climate change

Siri Tellier continued the day explaining the impact of disasters on public health. She explained the consequences of both man-made and natural disasters in terms of demographics and disease trends.

Week 2:

With renewed energy and enthusiasm, week 2 began with Britt Tersbol’s lecture on women’s and child health. She began by asking questions asserting the importance of  women and child health. Are women more fragile? Do men not experience illness, or sexual abuse, forced prostitution, socio economic inequality, educational and nutritional neglect, lack of access to quality life and knowledge, poorer care seeking behaviour?

Jo Jowell then gave his insight on the threats and opportunities of globalization in health especially in food and nutrition. He acquainted us with terms such as “Coca-colonization” and “Mc-donaldization” which are major global drivers of our eating behaviour. He also gave an insight how the government can support healthy food preferences. The following day, Andreas Bjerrum discussed about Universal Health Coverage and its economic challenges in the globalized world. Alarming statistics was flashed to us that the developing countries have a disease burden of 90% but only contribute to 12% of all health spending.

We then had a great panel discussion on careers in global health where a lot of questions were answered for us young aspirants. Absolutely motivating and valuable advice given such as follow your heart, keep applying, grab the opportunity that gets your way and don’t be afraid to get your hands dirty in the field. At the end of the day Maureen Wilkinson touched the sensitive topic of mental health affected by migration and asked us situational questions which put up the whole audience in awe and high in emotions.

Day 3 was no less in action packed. Nicolai Lohse lectured us on how drug companies think, how they act and what should be their role in global health? Who is responsible for making quality treatment affordable, accessible and available to patients? We had mixed reactions from the audience on do Pharma companies really care about global health or are they only interested in making profits? The industry must not only stick to development and manufacturing of newer and better drugs but must also continue to influence policy making, advocate public health issues and collaborate on the ground with public health programs.

Taking a quick break between sessions
Taking a quick break between sessions

This was followed by a great panel discussion on access to medicines where critical questions such as do we need a new incentive system than patenting for Pharma companies? What are the new ways of risk sharing while developing a new drug?  Why should companies manufacture essential medicines which have no scope of profit making but are for the betterment of millions devoid of its access? Maja Pleic then gave a broad overview on the social determinants of health and presented us with case studies concerning policies in different situations.

The penultimate day (we couldn’t believe the amazing two weeks were almost coming to an end), Jeffrey Lazarus gave an energetic take on health systems in a global contexts and the challenges it faces as we move from MDGs to SDGs. He questioned the WHO framework of the health system and where is the common man in this health system? A great discussion followed, on the need for a people centered health system where the patient (and the healthy) must be kept in focus.

Mike Rowson continued the day ahead with a lecture on health and development and explained the Preston curve and its implications and making us understand concepts such as GDP. The last day was also led by Mike explaining health care in poor markets and global health dilemmas. The afternoon comprised of case studies on is it feasible for the Tanzanian government to invest in and undertake local production of pharmaceuticals followed by an important topic discussion on human resources in health.

CSSGH 2015 class
CSSGH 2015 class

The blasts of information and different perceptions of lecturers and participants from an array of different backgrounds and experiences was no lesser than a joy ride. Activities ranging from a swim at Islands Brygge, to exploring Christania, to movie night at Faelledparken kept the spirits high even during the evenings. When  the weekend arrived, most participants got around the beautiful city of Copenhagen, said a little hello to the Little Mermaid and visited the majestic castles! It was two weeks of fun.

For just the second round since its inception, the program was perfectly placed, well managed and had no eye closers. The group seemed very energetic and well-read to throw questions at speakers, and wouldn’t settle for anything less than a perfect explanation. Focus was laid on various country contexts, often with real life experiences which indeed helped to shed light on real time global health challenges. It also seemed quite a challenge to leave behind the bright sun and to stay indoors for lectures, but it was completely worth it! 

Great experience! Greater global challenges to address!

To give or not to give? That is the question.

Written by Sinéad O’Ferrall (@sineadOFGH)

Edited by Helen Jane Myrr and Line Bager (@lbager87)


In early May, 17 students on the Masters in Global Health set off to Moshi, Tanzania to experience a different health care system and to study some different perspectives and cultures. We all had expectations and ideas about how wonderful and rewarding this trip would be, both personally and academically. And to be sure, it has been. But also very ethically challenging and instead of giving a summary of our activities and lectures I want to present an ethical dilemma that we ourselves were faced with. To paraphrase the great Shakespeare, I want to ask the question “to give or not to give?”

Misquoted Shakespeare
Misquoted Shakespeare

Would you have given the money?

On a visit to a regional hospital as part of our academic schedule we were given a tour of the wards, including the female only ward where we encountered a family of three woman – a young mother, teenage daughter and her 5 year old daughter. All three had HIV and were severely malnourished.

We were informed, as we already knew, that their HIV medication was free due to local and international political support. The problem was they couldn’t afford to buy food. This not only meant they were slowly starving to death, but also they couldn’t take their HIV medications since they were too weak to swallow them.

The director of the hospital paraded us to these woman, or perhaps paraded the women in front of us – a huge group of mzungus* through a small ward with many patients all on looking. He passionately explained their circumstances and then implored us to give some money so food could be brought for this family.

Would you have given the money?

As a group of 17 Global Health students and two academic supervisor, some did, some didn’t.

Credit: Giuilia Perazzini Photos
Credit: Giulia Perazzini Photos

Why wouldn’t you give the money?

There were three concerns raised when it was discussed later in class.

It perpetrates the damaging expectation of the white people swooping in and fixing the problem. The concern was that it feeds into the “white saviour complex”. Also, did we really fix the problem? Sure they will get food for a week, maybe two or three. But then what? Maybe we just prolonged their suffering.

The way the request came across could have been perceived as extremely unfair. Some felt emotionally blackmailed into handing over money which we may not have had to give. But since we were white people, it was just assumed we did have the money.

The third issue raised was that – we were asked to help these three women in front of an entire ward of potentially equally deserving patients. No consideration was given to their needs which could have caused a rift between them and the women we did help.

So the ethical sensitivity of the director making this request was raised. Was it ethical to ask us, and to ask us in such a way?

Why would you give the money?

Again three main issues came up to support giving the money.

Firstly, when it comes down to life and death and when faced with human suffering so starkly, surely compassion rules out any other consideration. We were called to step up and help, regardless of our own ideas on ethics. Surely that is the business we have signed up to as Global Health students.

Secondly, the director’s responsibility is to the patients and he did what he had to do in order to protect and alleviate the suffering of three of his patients. Surely that is the most ethical thing a director of a hospital can do. He clearly cared for these people and had no more to give himself except to plead with these visitors to his hospital.

Finally, we didn’t have to give. Despite the pressure of expectation from such a request as we looked on at these emaciated woman, ultimately we had a choice. Perhaps if it was hard not to give, it was because giving was the right choice not because the request was unethical.

To save one now or many later?
To save one now or many later?

So to give or not to give?

There is no clear answer, certainly from the later discussion we had. Individually, we all made a choice to give or not to give and no one needs to declare if they did, or didn’t. But as a group we failed to reach a consensus about what was right. To me, this is not a failing on our part but an example of the difficulty of aid and development. There is the short term aid, of which giving money to a starving family falls under. There is a critical and immediate need, like that often seen after a disaster or war that needs an immediate response. But we also need people with a long- term view focused on fixing the system, so that one day there won’t be a starving family to ponder over.

So the only this left to say is “would you have given the money?”

Feel free to comment below letting us know your answer to the question.

*mzungos is the Swahili word for European/ white people