Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

Sir Michael Marmot, internationally renowned Principal Investigator of the Whitehall Studies of British civil servants (investigating explanations for the striking inverse social gradient in morbidity and mortality), spoke about research on the social determinants of health and taking action to promote policy change. Pointing out the extreme disparities in life expectancy for peoples in different parts of the world – including the “haves” and “have-nots” within the high-income world – he presented an overview of “Closing the gap in a generation: Health equity through action on the social determinants of health” (http://www.who.int/social_determinants/en/). That report was commissioned by the World Health Organization (WHO) and released last year; Sir Marmot served as the Chair of the Commission on Social Determinants of Health.

Criticizing those who justify initiatives in global health solely on economic grounds, Sir Marmot argued that addressing the social determinants of health is a matter of social justice.

He presented data and discussed the report’s three primary recommendations: 1. Improve daily living conditions; 2. Tackle the inequitable distribution of power, money, and resources; and 3. Measure and understand the problem and assess the impact of action.
Stating that the World Health Assembly resolution on the social determinants of health was only meaningful as a first “baby step,” Marmot urged the audience to consider how research and policy advocacy can address the social determinants of health so that all individuals can lead flourishing lives.

Examples from Asia include

• the high risk of maternal mortality (1 in 8) in Afghanistan;
• the steep gradient in under-5 mortality in India (with the rate almost three times higher for the poorest quintile than for the wealthiest quintile);
• less than half of women in Bangladesh have a say in decision-making about their own health care;
• a large share of the world’s population living on less than US$2 a day reside in Asia;
• social protection systems like pensions are possible in lower and middle-income countries, with Thailand as an example;
• more can be done to address the millions impoverished by catastrophic health expenditures, such as in southeast Asia; and
• conflict-ridden areas and internally displaced people, such as in Pakistan and Myanmar, are among the most vulnerable.

He also responded to questions about the role of freedom and liberty in social development – contrasting India and China – and commented on the peculiar contours of the US health reform debate.

Professor Marmot closed by noting that, in exhorting everyone to strive for social justice and close the gaps in health inequalities all too apparent in our 21st century world, he hoped he was not too much like Don Quixote, going around “doing good deeds but with people all laughing at him.” 
Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, is Director of the International Institute for Society and Health and MRC Research Professor of Epidemiology and Public Health at University College, London. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities.

Lucky Gunasekara, a student at Stanford's School of Medicine, and Tom Wiltzius, a student in Stanford's Computer Science program, took us through the rationale behind working with mobile phones and the content of their project working with health workers in Malawi.

According to the International Telecommunication Union, there are now more mobiles in the developing world than developed world. Mobile phone connectivity is much more common in Africa than internet connectivity. And mobile phones are much cheaper, around $35 for a standard phone compared to $200 for even the designed-to-be-affordable One Laptop per Child. Mobile phones are therefore the obvious tool of choice for groups interested in exploring the use of technology for development in Africa.

FrontlineSMS is a free software platform enabling large-scale, two-way text messaging using a laptop, mobile phones, and a GSM signal. FrontlineSMS:Medic uses this platform to support Community Health Workers (CHW), initially piloting this work in Malawi. The role of CHWs is to provide continuity of care in places where there are limited health professionals. However, they can be extremely disconnected from the patients they are serving, often responsible for huge geographical areas. Having access to mobile phones through the FrontlineSMS:Medic project has enabled CHWs to respond to actual need and what is happening in the villages they serve. It has also resulted in significant efficiencies, both in saved healthcare hours spent on the road, visiting areas where there is no immediate need, and in fuel costs.

The team is now working with a number of clinics to implement a system to replace paper collection of clinical data with simple forms on mobile phones with the aim of improving accuracy and efficiency of collection and analysis. All FrontlineSMS:Medic's work is characterized by a commitment to provide solutions that are locally owned, genuine replicable and shaped by user feedback.

Tom outlined a number of current challenges, including:

• Reliability of cell phone networks: This is not always high in remote areas, creating difficulties in emergencies. Overload on the network can result in messages being held in a queue, delaying sending
• The ability of older or less literate individuals to use the system: improving the interface to ensure it is as intuitive as possible will be important in addressing this
• Cost of data transmission: individual texts are not expensive but if many CHWs throughout different clinics are each sending multiple messages a day, this becomes a significant cost. One solution may be not to send the data via text but to transfer it onto another phone via GPRS when in range

How do countries in the vast and diverse Asia-Pacific region differ in “prescribing cultures”? How do health systems in the region balance access to pharmaceuticals with incentives for innovation? How do the forces of globalization shape, and in turn are shaped by, cultural legacies about health and health care? These are the key questions addressed by the new Asia Health Policy Program book, Prescribing Cultures and Pharmaceutical Policy in the Asia Pacific.

AHPP held a book launch event September 23rd with three authors of the book detailing how pharmaceutical policies are interlinked globally and at the same time deeply rooted in local culture.