• Disparities of outcome in and between countries are now the major challenges in medicine… What branch of medicine is not forced to confront the growing outcome gap that promises to shield the privileged while the world’s bottom billion continue to die from readily preventable and treatable diseases?
  
• Paul Farmer

For many years, the global public health community viewed hospital-level health care delivery to be an inefficient drain on the health systems of low-income countries. The Primary Health Care Movement of the late 1970s sought to bolster community-level primary preventive health care services in low-income countries, oftentimes at the expense of hospital-level services. At that time, urban referral hospitals in many low and middle-income countries consumed large portions of national health budgets (often in the range of 40–60%) while providing little of the overall health care service delivery (often less than 5%). Furthermore these hospitals were not accessible to the large rural populations of these countries and were seen as preferentially benefiting the wealthier members of these societies.

In the mid-1990s, many global health leaders began to reexamine this view and to recognize that hospitals, especially district or primary-level hospitals that provide more accessible services at lower costs than referral hospitals, could be important drivers of improved health care delivery at all levels of the health system. Shortly after this, in the early 2000s, the creation of the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) led to massive increases in health sector funding in many low-income countries and a concomitant expansion of health care service delivery. As the global health community struggles to use this money effectively and equitably to improve the health of the poorest and sickest populations, the role of hospital-level services in global public health strategy is being closely examined.

This chapter provides an overview of the role of hospital-level health services in global public health programs and explores the link between Hospital Medicine and global health. It briefly describes global health and the global burden of disease, discusses the global disparities in health and in access to health care services, examines the role of district and referral hospitals in the health systems of low-income countries, describes how these hospitals function in the strategies to combat the leading public health problems facing these countries, and discusses the human resource crisis facing many countries. The chapter provides an example of how global public health programs can strengthen access to hospital-level services by examining a program in Haiti that one of the authors (DW) helps to lead. The conclusion reflects on common themes in global health and Hospital Medicine and how U.S.-based hospitalists can become involved in global health efforts.

The term global health refers to the study and practice that is concerned with improving health and achieving health equity for all people worldwide, with an emphasis on addressing those problems that are transnational. As the World Health Organization defines it, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. This chapter focuses on the health of populations that have limited resources, since it is these populations whose well-being is the most at risk.

There are many ways one can try to measure the health of a population. Some indicators attempt to assess the well-being of populations, whereas others assess impediments to health, such as the burden of disease. Because the vast majority of hospitals focus on providing health services to those suffering from disease, we will briefly review how disease burden is measured. (The World Health Organization regularly publishes reports on the global burden of disease. The following information comes from The Global Burden of Disease: 2004 Update, WHO, Geneva, 2008.)

Mortality is one method of assessing the burden of disease (see Table 2-1 for a list of leading causes of death worldwide). Using this measure a few facts are worth highlighting:

• Of every 10 deaths, 6 are due to noncommunicable conditions; 3 to communicable, reproductive, or nutritional conditions; and 1 to injuries.
  
• Cardiovascular disease are the leading cause of death worldwide, accounting for 32% of all deaths in women and 27% of all deaths in men.
  
• 9.5 million children under the age of five die each year; 99% of these children die in low and middle-income countries. The vast majority of these are preventable deaths. Undernutrition is an underlying cause of about a third of these deaths.
  
• Almost one in five deaths worldwide are of children under 5 years of age.
  
• 500,000 women die of pregnancy-related complications each year, accounting for 15% of deaths of women of child-bearing age worldwide.
  
• There are great differences in life expectancy and cause of death between high and low-income countries. In high income countries more than two-thirds of all people live beyond the age of 70 and predominantly die of chronic diseases. In low-income countries less than a quarter of all people reach the age of 70, and people predominantly die of infectious diseases. Over a third of all deaths are among children.

By only accounting for death and not years of life lost, mortality data alone do not give a full picture of the global burden of disease. Over the past decade, the concept of the disability-adjusted life-year (DALY) has become the widely accepted measure of the global burden of disease. The DALY is based on years of life lost from premature death and years of life lived in less than full health. By accounting for years of healthy life lost to illness, it has replaced cruder estimates of disease burden such as total mortality and disease incidence and prevalence. DALYs for a disease or injury are calculated as the sum of the years of life lost due to premature mortality in the population and the years lost due to disability for incident cases of the disease or injury. Years of life lost are calculated from the number of deaths at each age multiplied by a global standard life expectancy for each age. (See Table 2-2 for a ranking of global disease burden by DALY). Following are some important points to consider: