If we want more evidence-based practice, we need more practice-based evidence.*

Chapter 18
World and National Context of Community Health Services

Table of Contents





This first chapter in Part 5 sets the stage for an understanding of the delivery of community and population health services, including personal medical care, by presenting first the broader national policy and global context of health services. Our objective is to clarify how community and population health services are influenced by national and international contexts and resources.



Chapter 18 introduces the global underpinnings of community and population health services. The emphasis is on the historical, philosophical, political and economic context of community and population health relative to national and international health policies. The chapter begins with a discussion of the constitutional authority and responsibilities of the federal government in regard to the nation's health. A detailed description of official health agencies in the United States follows, contributing to an understanding of the purpose and function of each of these agencies. The remainder of the chapter acquaints you with professional health organizations, health foundations, and various international health organizations including the World Health Organization (WHO). 


Isolated Bangladeshi Area Proves an Ideal Lab.  (The New York Times, March 23, 2003) - Matlab, Bangladesh has been the location of many studies that have contributed to public health knowledge and serves as the basis of inexpensive, simple solutions to problems within the developing world.

Congressional Negotiators Reach Agreement on FY 2003 Omnibus Spending Bill.  Feb. 13, 2003

U.S. Hospitals Increasingly Recruiting Nurses from India to Fill Shortage.  Feb. 11, 2003

Bush Releases FY 2004 Budget Proposal; Plan Lacks Specific Details for Medicare Reform.  Feb. 4, 2003

Drug Companies in Accelerating Access Initiative Say They Will Increase HIV/AIDS Drug Supply to African Nations Jan. 15, 2003       

WHO Targets Health, Poverty (Washington Times, June 22, 1999) World Health Organization Director Gro Harlem Brundtland promoted a worldwide effort to reduce poverty in developing nations and improve global health. According to Brundtland, four key issues the WHO will confront in the coming decade are (1) lowering mortality from disease, (2) establishing systems to identify health threats, (3) creating more effective health systems, and (4) increasing the knowledge basis and research efforts. She noted that "infectious diseases are a neglected concern within the social and economic development sector," with about $800 million provided by WHO partners in 1990 to aid developing nations' control efforts--or less than 2 percent of overall donated funds. A WHO report released last week identified six diseases--AIDS, malaria, tuberculosis, measles, diarrheal diseases, and respiratory diseases--as the cause of every second death among young working adults and children throughout the world.
   For more information

World Health Organization Launches New Directions for Health Into the 21st Century - Global. (WHO Press Release, May 26, 1999) -The World Health Organization (WHO) today unveils new directions for health into the 21st century that could save millions of lives and have a major impact on global well-being and poverty reduction within a decade. The main aim is to increase healthy life expectancy for all - while ensuring a better deal for the world's poorest people. http://www.who.int/whr/1999/en/press_release.htm

World Health Assembly Paves Way for Framework Convention on Tobacco Control - (WHO Press release, May 1999). The World Health Assembly (WHA), the governing body of the World Health Organization (WHO), (yesterday) paved the way for multilateral negotiations to begin on a set of rules and regulations that will govern the global rise and spread of tobacco and tobacco products in the next century. The 191-member WHA unanimously backed a resolution calling for work to begin on the Framework Convention on Tobacco Control (FCTC) - a new legal instrument that will address issues as diverse as tobacco advertising and promotion, agricultural diversification, smuggling, taxes and subsidies. WHO hopes to reframe the tobacco issues in a such a way as to show that far from, and in addition to, being a debilitating personal habit, tobacco contributes to a public health disaster exacerbated by tobacco industry practices that seek new markets and newer victims for a product that addicts before it kills. TFI officials say they hope their work will contribute to increased popular understanding and demands for comprehensive government regulation of tobacco... For the full press release, go to:
http://www.who.int/inf-pr-1999/en/pr99-wha14.html . The full text of the WHO Executive Board resolution (EB103.R11) is available at the following link: http://www.who.org/gb/eb103/eer11.pdf

Liberia: Unicef Provides Latrines to Camp (UNICEF, Feb. 24, 1999). UNICEF and British charity Concern World-Wide have built 56 latrines for the Siaka Stevens Stadium in Freetown, which hosts some 50,000 internally displaced people following the rebel incursion in January 1999. The latrines have been handed over to the Freetown health authorities. Contact: UNICEF Liberia, fax: +231-226136, mailto:emcon02@unicef.org. Star Radio: Liberian Daily News Bulletin, 24 February 1999, http://www.africanews.org/west/liberia/stories/19990224_feat2.html

Afganistan: Disease Outbreak. (WHO, Feb. 24, 1999). A disease outbreak, thought to be plague or cholera, in Darwaz, Badakhshan, near the Tajik border in Afghanistan, is killing dozens of people a day. Some 6,300 cases and 135 deaths have been reported so far. The World Health Organization (WHO) has sent emergency medical supplies and special team to the area to help local health authorities deal with the outbreak. WHO Outbreak News, 24 February 1999, http://www.who.int/emc/outbreak_news/n1999/feb/n24feb1999.html  

UN Seeks End to Avoidable Blindness. GENEVA (AP, Feb. 19, 1999) - The United Nations pledged Thursday to eliminate avoidable blindness by the year 2020. Cataracts, curable by surgery and accounting for almost half the world's blindness, are a prime target of the World Health Organization's "Vision 2020: The Right to Sight" initiative. Some 20 million people are blind from the condition. The plan identifies four other conditions, including trachoma and childhood blindness, as priorities. WHO will work with independent development organizations to redouble efforts against blindness, concentrating on disease prevention, training and transferring technology to developing countries.

Report on The Federal Budget The FY 1999 Omnibus Spending bill (H.R. 4328) was approved by Congress and signed by the President on October 21, 1998. Included in this bill were the amounts appropriated for programs at the Health Resources and Services Administration (HRSA, e.g., preventive medicine residencies), the Centers for Disease Control and Prevention (CDC), the Agency for Health Care Policy and Research (AHCPR), and the National Institutes of Health (NIH), among others. For more information, contact Suzy Leous, at sml@acpm.org   or 202-466-2044, ext. 106.

WHO Pinpoints Smoking as Huge Global Health Threat. COPENHAGEN (Reuters) - World Health Organization director-general Gro Harlem Brundtland t least 227 of them have died, health officials said Thursday. "The ratio is high, but it is still well below the international standard for an epidemic, which is 1%, or 100 deaths per 10,000 patients," Hardjotanogo said.

President's Committee on Health Care Quality Finished. (CNN 1998). A report critical of the US health-care system has been endorsed by and large by the President. It suggests a consumer bill of rights for the medical-care system.

Most Doctors Agree: French Health System Needs New Prescription. (Wall Street Journal April 25-26, 1996). A one-day walk out by French physicians was a flop with less that one quarter participating. The new reforms include caps on procedures and billing.

Why Canada's Single-Prayer Medicare is Worth Preserving (Globe and Mail June 10, 1996). Privatization is not the route Canadians want to follow. They do agree that the current system needs improvement but putting money into the hands of a few select doctors and insurance companies is not on the Canadian agenda.

World Climate: Experts Predict a Grim Future. (Sydney Morning Herald September 30, 1996). Australia will come under intense international pressure to reduce its greenhouse gas emissions after study says planet can't absorb any more.


For related news stories, please click here.


CARE, 660 First Avenue
New York, NY 10016
Phone: (212) 686-3110

Known best for its CARE relief packages, this non-profit organization serves developing countries in a variety of ways.

National Council for Int. Health, Suite 600
1701 K Street, NW
Washington, DC 20006
Phone: (202) 833-5900

Publishes International Health News monthly. Annual international health conference in June. Director lists U.S.-based agencies involved in international health assistance.

Physicians for Human Rights
100 Boylston Street, Suite 620
Boston, MA 02116-9442
Phone: (617) 695-0041

Publishes The PHR Record three times per year. Membership donations provide all PHR reports without charge. This organization is particularly active in trying to prevent torture.

Office of International Health
Department of Health and Human Services
Parklawn Building, Room 18-87
5600 Fishers Lane
Bethesda, MD 20857
Phone: (301) 443-1774

OIH serves as a policy office, and represents the DHHS with WHO. It does not distribute materials but will respond to questions on U.S. participation in international health agreements and programs.

Health Education Board Scotland. HEBS Research Centre
Country of Origin: United Kingdom - Scotland.

The HEBS Research Centre gives access to a range of published researchdocuments from HEBS, and provides the latest information about researchevents in HEBS and elsewhere. The website also contains links to research in other national and international organizations.

Office of Public Inquiries
Office of Public Inquiries
Bureau for External Affairs
U.S. Agency for International Development
Washington, DC 20523
Phone: (202) 647-1850

For information, catalogs and media on USAID's activities throughout the Third World.

Healthy People 2010


Information on the new initiative for the first decade of the new century, Healthy People 2010.

Productions NSP Inc.
C. P. 993, Succ. Snowdon,
Montreal, Quebec, Canada H3X 3Y1
Phone: (514) 487-8869
e-mail: r.martin#nsp-healthcom

The New Public Health Video Conversation Series presents 6 videos to be released in 1998. It brings together the top researchers in Public Health and Health Promotion to discuss key issues in public health. 

World Health Organization
Avenue Appia
1211 Geneva  Switzerland

Catalogue of World Health Organization Publications. Lists publications of the WHO. Publications are grouped by subject area.. Lists publications of the WHO. Publications are grouped by subject area.

Canadian International Development
Agency (CIDA)

Provides international assistance to developing countries.


U.S. Department of Health and Human Services

Updated Strategic Plan FY 2001-2006 http://aspe.hhs.gov/hhsplan/

The Department of Health and Human Services (HHS) is one of the largest federal Departments, the nation’s largest health insurer, and the largest grant-making agency in the federal government. The Department promotes and protects the health and well- being of all Americans and provides world leadership in biomedical and public health sciences.

Course on Ethical Issues on International Health Research


Media Beat


This web site covers selected articles from news media coverage of communication, development and change trends, programs and policies, especially in developing countries. Articles compiled by The Communication Initiative in their summarised, full and archived forms can be found at their website. Media Beat is produced through The Communication Initiative Partnership. Examples of new items about the media and development in developing countries on the "Media Beat" web site: Click here

Government and the Market: Lesson Plans


Central Bank Teaching Resources
Fundamentals of Representative Democracy
Federal Government News and Analysis
Understanding Government Systems Around the World
International Relations Lesson Plans
EducatorLabs is comprised of school librarians and media specialists who volunteer as curators and conservators of the scholastic web. Their mission is to assist educators in discovering valuable resources of substance for classroom use


Arai, Y & Ikegami, N. Health Care Systems In Transition II. Japan, Part I. An Overview Of The Japanese Health Care Systems, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 29-33.

Bardsley, M., Jenkins, M., & Jacobson, B. For Debate. Local Health And Lifestyle Surveys - Do The Results Justify The Costs?, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 52-57.

Beck, E.J. & May, N. Editorial. Health Care Systems In Transition II: East Asia - The Roaring Tigers, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 3-4.

Chung-Tung, L. Health Care Systems In Transition II. Taiwan, Part I. A General Overview Of The Health Care System In Taiwan, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 5-10.

Ferrinho, P., van Lerberghe, P., Julien, M.R., Fresta, E., Gomes, A. & Dias, F. Research Report. How And Why Public Sector Doctors Engage In Private Practice In Portuguese-Speaking African Countries.  Health Policy & Planning, 1998, 13(3):332-338.

Fiedler, J.L.,Schmidt, R.M., & Wight, J.B.. Public Hospital Resource Allocations In El Salvador: Accounting For The Case Mix Of Patients. Health Policy & Planning, 1998, 13(3):296-310.

Forsythe, S., HasbunJ., & Butler de Lister, M. Protecting Paradise: Tourism And AIDS In The Dominican Republic. Health Policy & Planning, 1998,13(3):277-286.

Global Distribution of Transfusion-Transmitted Virus. The New England Journal Of Medicine.   SEP 10 1998, v 339 n 11:776.

Gochfeld, M., & Goldstein, B. D. (1999). Lessons in Environmental Health in the Twentieth Century. ANNUAL REVIEW OF PUBLIC HEALTH 20: 35-54.
    ABSTRACT/Full-Text: Abstract.

Goldacre, M.J., Lambert, T.W., & Parkhouse, J. Views Of Doctors In The United Kingdom About Their Own Professional Position And The National Health Service Reforms, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 86-92.

Hanson, K., & Berman, P. Review article. Private Health Care Provision In Developing Countries: A Preliminary Analysis Of Levels And Composition, Health Policy and Planning, 13(3):195-211. 

Heath, JA.  The Financing And Provisioning Of Education And Health Services In Developing Countries: Review Article, Economics of Education Review. 17(3), 359-362.

Jha,P., Bangoura, O., & Ranson, K. The Cost-Effectiveness Of Forty Health Interventions In Guinea. Health Policy & Planning, 1998, 13(3):249-262.


Klein, Rudolf (1998).  Why Britain Is Reorganizing Its National Health Service--Yet Again.Health Affairs.  JUL 01 1998 v 17 n 4, 111.  
As brand-new reforms by Britain's Labour government supersede the 1991 Conservative reforms, new insights emerge on "collaboration" versus "competition" in health care.

Meng-Kin, L. Health Care Systems In Transition II. Singapore, Part I. An Overview Of Health Care Systems In Singapore, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 16-22.

Olsen, I.T. Sustainability Of Health Care: A Framework For Analysis. Health Policy & Planning, 1998,13(3):287-295.

Pannarunothai, S. & Mills, A. Researching The Public/Private Mix In Health Care In A Thai Urban Area:Methodological Approaches. Health Policy & Planning, 1998,13(3):234-248.

Pollock, A.M., D Gaffney, D. & Dunnigan, M. Editorial. Public Health And The Private Finance Initiative, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 1-2.

Sims, P. The Heart Of Darkness - Does Public Health Medicine Offer Any Solutions For The Next Millennium In Africa?, The Journal of Public Health Medicine, Volume 20, Issue 1: March 1998, pp. 78-79.

Stuer, F. Enhancing Health Programme Efficiency: A Cambodian Case Study. Health Policy & Planning, 1998 13(3):263-276.

Yip, W.P. Wang, H., & Liu, Y. Determinants Of Patient Choice Of Medical Provider: A Case Study In Rural China. Health Policy & Planning, 1998,13(3):311-322.

Book Review

A summary of the World Bank Report, "Curbing the Epidemic – Governments and the Economics of tobacco control" was launched on May 18, 1999, by the WHO. The document marks a significant development in the co-operation and commitment of two major UN agencies to tobacco control worldwide. The report examines the economic consequences of tobacco and tobacco control and explains why raising tobacco taxes should play a key role in anti-tobacco strategies. The document is available on the ASH website at: http://www.globalink.org/tobacco/wb/

Other References

Global Progress Toward Laboratory Containment of Wild Polioviruses---July 2001-August 2002.  Morbidity and Mortality Weekly Report 51(44). November 8, 2002, pp. 993-995.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5144a2.htm.  Since the World Health Assembly launched the Global Poliomyelitis Eradication Initiative in 1998, the number of countries in which wild poliovirus is endemic has decreased from 125 to 10 in 2001.  Three of the six World Health Organization (WHO) regions (Americas, European, and Western Pacific) have been certified as free of wild poliovirus transmission.  The Global Commission for the Certification of the Eradication of Poliomyelitis will declare the world polio-free when all regions have documented the absence of wild poliovirus transmission for at least 3 consecutive years and when laboratories with wild poliovirus-containing materials have implemented appropriate containment conditions.  This report describes preparations for laboratory containment and the creation of a global inventory of laboratories and institutions retaining wild poliovirus and summarizes global progress since July 2001.  The data indicate that substantial progress has been made in identifying laboratories with wild poliovirus-containing materials and in conducting national wild poliovirus inventories.


1. Declaration of Alma-Ata, Summary. This box contains the essence of the influential declaration of the member states of WHO at the global health meeting in Alma-Ata, then still in the USSR. The emphasis on primary health care to reduce the inequities in health among and within populations is operationalized in the articles on participation and on the combination of health and social measures. Translate this understanding of health to your own community.

2. Immigrant health. Immigrant health is an important aspect of world and national community health services. Epidemiological investigations can provide information that may be used in the development of health planning for immigrants. Students preparing for careers in the health professions, and multicultural health services in particular, need to understand the culture of the community in question. Without an in-depth understanding of the community's culture, conflicts may develop which render health services, however well developed or intended, ineffective. Familiarize yourself with legislation regulating health care both locally and nationally or internationally. Identify immigrants to your communities, the health concerns of these populations, and the cultural implications for health.

3. Changing organizations. The review of official federal health agencies (see text) illustrates changes in the structure and function of these agencies over the years. Select either an executive department which offers health services or, a specific division within the Department of Health and Human Services. Write a report which documents the history and services of the department/division. What were the founding principles? How have these evolved or changed in response to new health care issues?

4. Community-based research. The National Heart, Lung, and Blood Institute, the National Cancer Institute and the National Institute for Dental Research have funded a number of community intervention studies. The Multiple Risk Factor Intervention Trial (MRFIT) and the Hypertension Detection and Follow-up Program (HDFP) are two examples. Select a NIH-funded community intervention study. Describe the research methods, sample, intervention and outcome of the study.

5. Working together. How did world and national health agencies cooperate in the eradication of smallpox? When did major initiatives to eradicate this disease begin? What agencies were involved? How were services delivered to individual communities? What kinds of barriers had to be overcome to achieve such cooperation?  

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