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  • 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 ...

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