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Global Scenario
The gaps in the health structure are widening fast. In 2002, the life expectancy for females
reached 78 years at birth in developed countries, it dropped to less than 46 years for men in SubSaharan Africa, mainly because of HIV/AIDS epidemic. Communicable diseases continue to
impact the global health scenario along with a simultaneous increase in the non-communicable
diseases which adds to the daunting challenge already facing the developing countries.
World today is like a global village, owing to rising concentrations of people in big cities, social
or economic factors leading to mass migrations, growing commerce and travel. Around 1.8
million people cross international borders daily through airlines, through routes by which
radiation of human infections happens around the world within hours. The crates and containers
in which goods are shipped worldwide provide safe passage for disease vectors and animal
Today, infectious diseases are a major cause of ill health and death. Mortality from infectious
diseases is highest in Africa, with both the highest number of deaths in absolute terms and the
highest mortality rate for infectious and parasitic diseases (837 deaths per 100 000 population).
The proportion of all deaths due to infectious diseases is also highest in Africa, where more than
60% of all deaths are due to infectious or parasitic diseases (compared with only 5% in Europe).
The global face of infectious diseases is changing in terms of magnitude, geographic scope, and
the inability of science to provide all the answers, but also for other reasons. There are new
diseases, most notably HIV/AIDS, SARS and variant Creutzfeldt - Jakob disease (vCJD) (and its
associated form bovine spongiform encephalopathy (BSE)), resulting from apparently new
pathogens, while ancient diseases such as TB and diphtheria are re-emerging as serious threats
to public health. Novel agents are being implicated in the causation of a number of clinical
syndromes, for example, parvovirus, human T-cell lymphotropic viruses I and II (retroviruses),
human papilloma virus and a number of human herpes viruses. With advances in scientific
investigation, causative agents are also being better defined examples include Legionella
pneumophila in Legionnaires disease, Borellia burgderfori in Lyme disease, and Helicobacter

pylori in stomach and duodenal ulcers, all age-old diseases where the causative organisms have
only been defined in recent years.
The economic costs of communicable disease outbreaks are increasingly becoming a global
concern. The epidemic of BSE, which decimated the British beef industry, is estimated to have
cost approximately 30 billion. Estimates of the cost of the SARS outbreak range from 8 billion to
24 billion, mostly due to behavioral changes from a perceived risk of SARS and loss of
economic confidence in countries where SARS emerged; direct health care costs were marginal.
This can be compared to the locally contained outbreak of plague in Surat, India, in 1994,
estimated to have cost approximately 1.5 billion and the 1997 avian influenza outbreak in Hong
Kong, estimated to have cost hundreds of millions of euros in lost poultry production, commerce
and tourism.
1. Child Mortality rate
Across the world, children have a higher risk of dying if their economic conditions are
weak. The most striking decline in child mortality have occurred in developed countries,
and in those developing countries where the mortality rate is low and their economic
condition has improved. In contrast, in developed countries with higher mortality rate, the
decline have occurred at a slower rate, stagnated or even reversed. Owing to the overall
development in developing nations, the mortality gap between the developing and
developed nations has narrowed since 1970. However, the disparity between the different
developing regions is widening because of the different rates of development in these
Global contrasts: A baby born in Sierra Leone is three and a half times more likely to
die before its fifth birthday than a child born in India, and more than a hundred times
more likely to die than a child born in Iceland or Singapore.
Causes of child mortality: Parasitic and infectious diseases remain the major causes of
deaths in children. Although developments have been made in eradicating some diseases
like polio, but communicable diseases still remain 7 out of 10 causes of child deaths.
Many countries of the Eastern Mediterranean Region and in Latin America and Asia have
partly shifted towards cause of deaths which are observed in developed countries. Here,

conditions arising in the perinatal period, including birth asphyxia, birth trauma and low
birth weight, have replaced infectious diseases as the main cause of death and are now
responsible for one-fifth to one-third of deaths. However, in Sub-Saharan region, under
nutrition, malaria, lower respiratory tract infections and diarrhoeal diseases remain to be
among the leading causes of death in children.
2. Adult mortality rates
In developed countries, communicable diseases and maternal, perinatal and nutritional
conditions contribute only 5% to the total number diseases, while in high-mortality
developing regions this figure increases to 40%. In African regions where the HIV/AIDS
epidemic has confounded the pattern of health transition during the past decade, these
conditions can contribute as much as 50--60% of the overall disease burden.




Globally, ischaemic





(cerebrovascular disease) are the leading causes of burden of disease in adult males.
HIV/AIDS is the leading cause for males and the second leading cause for females,
accounting for around 6% of the global burden of disease. For females, unipolar
depressive disorders are the leading cause, reflecting their higher prevalence in women.
Individual maternal conditions of haemorrhage, sepsis and obstructed labour also remain
one of the leading causes of the burden of disease for women globally, reflecting the
continuing high levels of maternal mortality in many developing countries, and also the
high levels of disability resulting from these conditions.
Mortality and disease among older adults: In developing countries, 42% of adult
deaths occur after 60 years of age, compared with 78% in developed countries. Globally,
60-year-olds have a 55% chance of dying before their 80th birthday. Regional variations
in risk of death at older ages are smaller, ranging from around 40% in the developed
countries of Western Europe to 60% in most developing regions and 70% in Africa.
The growing burden of non-communicable diseases: Nearly half of the global burden
of disease (all ages) is contributed by non-communicable diseases, a 10% increase from
estimated levels in 1990. While the proportion of burden from non-communicable
diseases in developed countries remains stable at over 80% in adults aged 15 years and

over, the proportion in middle-income countries has already exceeded 70%. Surprisingly,
almost 50% of the adult disease burden in the high-mortality regions of the world is now
attributable to non-communicable diseases. Other factors like Population ageing, mental
ill health, injuries, and non-fatal health outcomes have further augmented the epidemic of
non-communicable diseases in many developing countries.
Challenges enhancers
1) Weak health systems in major parts of the world
2) Drug resistant organisms which are unresponsive to antimicrobial agents, have become a
major public health challenge in the recent years
3) The constant microbial adaptation
Microorganisms are continually evolving. Resistant microbial agents and new strains of
viral agents are emerging by mutation, often as a response to inappropriate use of
antibiotics. In turn, immunological responses of hosts to these changes vary.
4) The changing host for the diseases
a) Population growth
i) The worlds population is growing at a rate of 1.1 % per annum. Moreover, the
demographic properties are different in different countries. Some western countries
have ageing population while many developing nations have relatively young
populations. These differences have many unforeseen consequences for disease
patterns and their corresponding control efforts. For example, while overcrowding is
likely to promote the spread of infectious diseases, population shrinkages (especially
when associated with an ageing population) may result in reduced economic growth,
increased pension obligations, higher demands on the health system and human
resource constraints on provision of care, with serious implications for the
sustainability of health systems.
ii) Movement of population
According to UNFPA report, 213 million people or 3.2% of the world population live
outside their country of birth. Majority of them cross borders in search of better social
and economic conditions. Others are forced to flee their country in case of crisis. The
increased movement of people and the speed with which they can now traverse the
globe mean that the potential for infectious microbes to be carried globally in a matter
of days is very real. The SARS epidemic, affecting within days countries separated by
thousands of miles graphically highlighted this potential.

b) Human behavior
Human behavior aspects like non-compliance to the expected set of actions by health care
workers, patients, pharmaceutical producers an health care systems has the potential to
promote drug resistance in human microorganisms. The collapse of health care systems in
the former Soviet Union and non-compliance with international norms of care for TB
resulted in high rates of MDR-TB.
c) Changing health systems
It was expected that the eradication of smallpox would presage the eradication of other
communicable diseases, thus heralding the dawn of a new era of public health. The global
smallpox campaign illustrated what could be achieved when a safe, effective, and
affordable vaccine was allied to a comprehensive public health and was directed at a
communicable disease with sufficiently favourable transmission dynamics. Importantly,
eradication (zero cases and zero risk) demands the sustainability of a public health system
only for the duration of the campaign. Whereas elimination (zero cases but continuing
risk), or sustained control demand more, including the ongoing maintenance of capacity
and performance, and long-term political and strategic focus and commitment. The
experience of eradicating or eliminating many communicable diseases since the 1980s
has been mixed. Leprosy elimination, for example, has been a relative success story. In
1991, it was resolved to eliminate leprosy by the year 2000. From approximately 10
million cases globally in 1985, a decade later it was estimated that this had fallen to only
one million cases. On the other hand, improving vaccine coverage for poliomyelitis has
been patchy.
Many countries, which have had limited success in addressing public health challenges,
have yet to undertake the structural reforms necessary for their health systems to improve
system responsiveness and address effectively the burden of communicable diseases.

Developed and underdeveloped world

The health challenges, as can be said, vary highly between developed and developing countries.
Income levels, health care policies by the governments, infrastructure for basic amenities etc.

influence largely the health levels in any nation. Either absence or reduced stress on development
of any of the aforementioned areas would lead to poor public health levels.
High-income countries represent 15% of the world population, middle-income countries about
47% and low-income countries about 37%. The distribution of deaths is similar to that of
population across the country income groups, despite the comparatively young populations in the
middle-income countries, and the even younger populations in the low-income countries. The
risk factors or rather the health challenges across countries are listed in WHOs Global Health
Risks Report as follows:
Table 1. Health challenges: Low, middle and high income nations
Childhood Underweight
Unsafe Sex
Alcohol Use
Unsafe hygiene & Water
High BP
Tobacco Use
Suboptimal breastfeeding
High blood glucose
Indoor smoke from solid fuels
10 Overweight and Obesity
Middle Income Nations
Alcohol Use
High BP
Tobacco use
Overweight and obesity
High blood glucose
Unsafe sex
Physical Inactivity
High Cholesterol
Occupational Risks
10 Unsafe hygiene & Water

Low Income Nations

Childhood Underweight
Unsafe hygiene & Water
Unsafe Sex
Suboptimal breastfeeding
Indoor smoke from solid fuels
Vitamin A deficiency
High BP
Alcohol Use
High blood glucose
10 Zinc deficiency
High Income Nations
Tobaccos use
Alcohol use
Overweight and obesity
High BP
High blood glucose
Physical Inactivity
High Cholesterol
Illicit drugs
Occupational Risks
10 Low fruit and vegetable intake

Health challenges: Contrasting developing economies & developed economies

As seen in the above table, the 20 challenges faced by developing economies encompass a wide
range than what the developed economies face. The risks range right from Vitamin A deficiency,

which is due to malnutrition, to Overweight and obesity, a characteristic of developed economys

health challenges.
A prime cause of a rise in these challenges over the years in the low income countries can be
attributed to the meagre spending on healthcare as shown in the chart below. The chart shows the
spending by the respective countries on healthcare as a percentage of their GDP. As can be seen,
low income nations over the years have spent below 6% of their GDP on public healthcare where
as the high income nations have spent up to 12% on their citizens.
Fig1. Healthcare spend across countries as a percentage of their GDP
Low income













High Income

















Low income nations have also been facing an increase in drug resistant parasites, case in point
being rise of MDR Tuberculosis in India, China and African nations.
According to public health report of Canada the following factors are the key determinants of a
nations health:

Employment and working conditions
Food security
Environment and housing
Early childhood development
Education and literacy
Social support and connectedness
Health behaviours
Access to health care

Now let us see how the developed and developing nations fare on few of these points:
The following graph shows the sanitation access in a country as a percentage of the population.
Lack of sanitation access results in pollution of water and land which then become breeding
grounds for Cholera and Dengue which are the disease with the highest incident rate in the low
income countries.
Fig2. Sanitation access as a percentage of population
Low income

High Income


























The following graph is from Food and Agricultural Organization showing the regions with
malnutrition as a percentage of the population. Food security has been at the forefront of
Millennium Development Goals formulated by the UN.
Fig3: Region of malnutrition as a percentage of population

Low Income

High Income










For all the above we have seen how low income countries have been faring against the developed
nations and the World average as such. These conditions discussed above are heavily dependent
on the external surroundings and policy making i.e. the health risks in the Low income nations
are heavily influenced by external factors. In contrast to this situation, the other part of the world
i.e. the developed nations face a health risk that is internal to the population: lack of activity and
obesity. High income levels and fast moving routines have taken a toll on the health of the
wealthy nations population. The following map by WHO signifies the obese population
distribution across the World nations.

Fig4: Obese population distribution across world

Source: WHO Research

Summing up there is a huge variation between Low income countries and High income
countries health challenges in the fact that one is facing contagious drug resistant diseases,
undernourished population, lack of healthcare etc. while the other is suffering from noncontagious health issues due to lack of physical inactivity.

Making Humankind Healthier

Communication Diseases
Majority of deaths across the world are due to communicable diseases like HIV/AIDS,
tuberculosis, malaria and respiratory infections. Although in developing countries significant
amount of steps have been taken to eradicate infectious diseases like measles and polio.
However, there is still a lot to do to make the world healthy by stopping and reversing the spread
of communicable diseases which are spread by viruses, bacteria, and other parasites. These
diseases can be prevented by active interventions at various stages.
In order to develop new diagnostics, drugs and vaccines, health education, promotion, prevention
and intervention is required to combat diseases and ultimately improve global health.
Human Immunodeficiency Virus (HIV): In order to beat the HIV epidemic, programs related
to HIV prevention, treatment and education must be run globally which would require a
countrys health and education system to be sufficiently developed. Also most important step in
winning the fight against AIDS is to remove the HIV-related stigma and discrimination. Because
this fear of getting discriminated creates resistance among people from getting tested, treatment
and admitting publically to the HIV status. This discrimination and fear needs to be removed at
both society and national levels.
Fighting to HIV is a long-term task and it would require an effective planning. First and foremost
step in fighting against HIV would be to stop new HIV infections. HIV prevention campaigns
need to be run on a major scale, in addition to scaling up of treatment education and programs to
eradicate HIV worldwide.
Tuberculosis (TB): Despite the fact that nations have made a lot of efforts to treat the rising tide
of TB cases, they are as yet being outpaced by the epidemic. Eradication of TB requires
community participation in TB control activities, there is a need to improve case detection and
treatment success rates. A variety of TB has grown over the past few years and the bacteria has
become resistant to cheap and commonly used drugs. There is a need to do a lot of research in
the development of drugs to combat TB which currently is very slow. Hence complete TB
control requires work in education, diagnosis, treatment, and case-holding to ensure the
worldwide removal of this disease.

Non-communicable diseases
While the burden of communicable diseases is immense, we cannot overlook non-communicable
diseases which also has a major contribution to the disease burden worldwide. These diseases are
more prevalent in the urban and rural areas, primarily among the poor population and the deaths
due to them is increasing at a considerable rate especially in developing part of the world. Major
diseases involves heart disease, diabetes, lung diseases, and cancer. Hence it is very critical to
reduce the mortality due to non-communicable diseases.
Cancer: No of patients dying due to the cancer already surpasses deaths due to HIV/AIDS,
tuberculosis and malaria. Many of the cancers like cervical, breast and prostate can be prevented
if detected early enough. Limit to early screening, diagnosis or treatment can be attributed to
insufficient resources and inadequate infrastructure. Major causes of cancer are viral infection,
poor nutrition, obesity, pollution and widespread tobacco use. Governments in developing
countries are very ill-prepared to address the growing cancer burden. Governments, international
organizations, and specialists ought to work on the whole to improve awareness, education, and
counteractive action and treatment projects to help delivery of complete cancer care.
Diabetes: Diabetes is a silent, lethal and the most dangerous disease prevalent across the globe.
Major causes to the spread of this disease is urbanization and lifestyle changes. Majority of
people with diabetes remains undiagnosed due to the inadequate awareness and attention.
Majority of people, especially in the poor countries die or suffer debilitating consequences of
diabetes prior to diagnosis. Diabetes is not fully curable but its complications are largely
preventable. The low cost strategies includes changes in diet, increase physical activity and
modify lifestyle that can reduce the impact of diabetes. These steps also generates health gains in
other related non-communicable diseases. There is a dire need to increase community awareness
about diabetes through the combined efforts of individuals, community, organizations and
governments. This is the most optimal time to take such actions before it reaches to an epidemic
Cardiovascular Disease (CVD): Burden of CVD across the globe is huge and it is growing at a
rapid pace in developing countries. Difficulties in combating CVD includes lack of awareness
and education of the disease, early diagnosis and absence of access to viable interventions.

Therefore we need education, prevention and intervention to reduce the burden of cardiovascular
diseases and hence decrease the number deaths caused to it.
Diarrhea: Faecal-oral pathogens is the major cause of diarrheal diseases. These are transferred
to sewage system through flush toilets which subsequently contaminate surface waters and
groundwater. Interventions at various points has proved to be efficient in interrupting the
pathogen transmission cycle. Majority of cases of diarrhea globally were attributable to water,
sanitation and hygiene which also play a role in malnutrition. It is high time that the governments
need to spend resources on these factors to reduce and prevent burden of diarrhea.
Malaria: Malaria is caused by one of four parasite species in the genus Plasmodium. The bite of
an infected female mosquito (Anopheles) transmits the parasite. This mosquito prefers clean,
stagnant or slowly moving fresh water habitat. To reduce the burden of malaria we should
modify or manipulate human habitation/behavior or the environment. Environmental
modifications include installing wastewater management, vegetation management and the
maintenance of sanitation and water supply.
Community Engagement for health improvement
Community engagement is a capable vehicle for realizing environmental and behavioral changes
for reducing the burden of diseases and improving the health of mankind. Community
engagement includes community participation, community mobilization, constituency building,
community psychology and cultural influences. The most productive approach to accomplish
general wellbeing objectives is to effectively draw in those experiencing the problems in aspects
of addressing them. It will be more beneficial to mobilize a whole group to get more impactful
results as opposed to engaging them on individual basis. Change is more prone to be effective
and perpetual when the individuals it influences are included in starting and advancing it. This
will also assure long-term program viability. Projects to build participation, impact and add to a
mutual association among group individuals can serve as impetuses for change and for
connecting with people and the group in health improving activities.
A generic framework which might help in providing solution for any of the diseases are formed
which includes:
1. Hygiene improvement

2. Behavior central programming

Generic framework for hygiene improvement

Hygiene is one of the most prevalent reason for diseases, Most of the diseases spread because of
bad practices used by people. Better hygiene will reduce around 35% of diseases. So we are
trying to make generic framework which will help to improve hygiene factor related to any
Hygiene Improvement Framework is basically focused on three main componentsHardware This section include all the external factors which will result in spreading of

Example Access to water, chlorination system

Promotion In this section major focus is on promoting common hygiene behaviors which will
help in stopping the growth of spreading of disease

Example Safe water storage, Hand washing

Environment Enabling environment for revising and strengthen the environment or try to
make improvement in key technologies and behaviors. This can be provided with the help of
advocacy, training, institutional strengthening and other appropriate support mechanisms.
Health sector will play a crucial role for empowering these changes. Lets take an example of
diarrheal diseases.
The role of health sector in curing diarrhea

Partner with sanitation and improvement in water supplies effort in communities

They Can provide promotion and training by selecting volunteers from community

Providing support material for private and public clinic and health related institute
Partnership with local NGOs for conducting programs which will result in the

improvement of hygiene factor

Health sector can advocate national health ministry for allocating and implementation of
resources and programs which will spread awareness in the communities

If we see the context of developed and developing nations, there is a huge difference in terms of
awareness and government spending for the promotion activity and facilities provided to the
common people.

In most of the developed countries government is giving health related services for free in
contrast developing countries people are paying good amount of taxes but still there are

unavailability and insufficient resources

Free Primary education and good amount of money allocated for health related promotion

and awareness programs which is not there in the developing countries

High number of uneducated Population and less awareness of effect of pollution on the

Corruption is one of the biggest challenge and responsible for declined growth in almost
all the sectors

Generic framework for hygiene improvement


Sanitation facilities
Water Supply
Household technology
and material


Programs for involvement


Example soap container,

hand wash

Diseases prevention

Hygiene Improvement


Government aided
financial and cost recovery
Improvement in policy
Cross domain public
private partnership
Community organization

Focus on behavior
Behaviour of humankind affects its health to a large extent. The diseases that spread due to lack
of hygiene, emission of carbon, release of waste in water bodies, consumption of unhealthy food,
ignoring initial symptoms of diseases, ignorance etc. constitute a major portion of the diseases
that are prominent in todays world. So if we divert our attention and try to focus on behavioural
aspect then we can find and provide solutions to make humankind healthier. Behaviour-Centered
Programming (BCP) is a tool that we can take advantage of to contribute towards the goal of
improving health of people worldwide. BCP is a strategy process which is used for identification,
promotion, and facilitation of people who carry out behaviours that impart a positive impact of a
significant degree on a problem of interest, and are feasible to achieve. The pre-requisite for BCP
is that most of the people in the area of the program should be willing as well as able to make
changes. The Behaviour-Centered Programming process gives guidelines on the exploration of
the determinants of current behaviours of the area, then tests possible improved behaviours,
those which favour better health in order to produce a menu of feasible behaviours which will
have an impact on health. BCP will also give strategies that will motivate and facilitate those
behaviours. BCP actions to motivate and facilitate people may include strategic communication,
community (collective) action, training, improved service delivery, new or improved products,
technologies or infrastructure, and policy change. BCP is different from other health programs in
the way that it looks at the issues from the behaviour lens. Other programs generally introduce
new services and technologies to address a health problem. For e.g. public toilets have been built
or a public source of water has been established. But these things have been done hardly with
any effort to encourage appropriate use. In such cases educating people on the use of those
technologies is required but this also doesnt work all the time towards solving the issue.
The first step in BCP is to examine the epidemiology of the health problem which is the science
that studies the causes, patterns, conditions and effects of health problems. The next step is to
identify the behaviours that can solve or reduce the problem to a great extent. The strategy
should be such that it supports those feasible behaviours. A feasible behaviour is one which if a
family or community follows reduces the important barriers which stand between current and
improved health promoting behaviours. These barriers or restrictions can be

Internal: lack of awareness, motivation, superstitious beliefs, etc.

External: Lack of money, time, and access to technology or products, etc.

These behavior determinants can be explained in detail as below:

External Determinants
Socioeconomic status

Environmental constraints

Access to services and technologies

Cultural norms

Money: to buy essential products,

services, transportation
Literacy and education
Time to implement new behaviour
Lack of interest and encouragement
Quality of technology
Availability of appropriate hygiene

Physical access to reach services
Availability of medical experts,

medicines, vaccines, etc.

Taxes and charges of services
How well the new behaviour is
accepted in the existing cultural

Internal Determinants

Awareness of the problem and doing

Superstitious beliefs
Knowledge of what to do and how to

Perceived risks

Fear of criticism, wrong beliefs


about serious side effects of change

Level of confidence to bring out the

Practical knowledge

Both internal and external determinants that are mentioned above should be addressed to support
the behaviour change.

BCP does not entirely depends on what a particular team which is implementing it in an area
thinks what are right behaviours, but it relies on the inputs that are given by families,
communities and other participating groups. This program takes an open and learning attitude
towards solving health issues and promote hygiene behaviour change. The manifestation of this
attitude happens through regular consultations with the families and communities involved.
The process is as follows:

Assessment of current behaviours related to the concerned problems

Identification of barriers and enabling of factors required for improvements
Discovery of motivations
Identification of feasible behaviours that are required to bring change
Involving individuals, families, communities, institutions, and policymakers in
development and implementation of effective strategies

Steps which are used to develop program recommendations are written below along with the
strategies for supporting them.



program How to do each step

1. Select ideal behaviours

Decide which ideal behaviours to promote

2. List essential actions of each ideal Divide each ideal behaviour into essential

sub-behaviours (actions)

3. Identify constraints to carrying out Learn about current activities and which
the essential actions






practised and why

4. Test





the Use trials of new improved practices to gain

an insight on what people are willing to try
and how does it influences them negatively
and positively

5. Select solutions that will have a Review the results of last step as the basis
health impact and are feasible

for finalizing essential practices and subbehaviours

Through BCP only, we cannot expect everyone to practice the same behaviour precisely. There
are other restraints which brings differences in how people are practicing those behaviours. Some
would move towards the ideal way more than others, some wouldnt. To ensure that everyone
who was under the program is practicing the behaviours same way, technologies and economic
support should be facilitated by the program. With the help of mass media, a program can
promote the ideal practices and sub-behaviours that are feasible. Negotiation of the best subbehaviour should be done through individual counselling.