Global Health Trends Research Articles

Bridges to care: A collaborative, community-based model of rehabilitation in Dominican Republic using the World Health Organization’s framework of community engagement

Background: The most recent national population survey of the Dominican Republic (DR) estimated that ∼12.4% of all people in the country live with a disability. Ischemic heart disease is the number one cause of death in the DR, followed by stroke and road accidents, all of which, if survived, can cause significant suffering, disability, and need for rehabilitation. Methods: This study describes a sustainable, culturally responsive collaboration between the local health systems of the DR and the Rehabilitation Department of a U.S. medical school. Results: Over a period of 7 years, 855 patients were seen around 10 locations within a regional health area in teh DR. The majority of patients reported musculoskeletal pain, which reflects global health trends. Conclusion: The described collaborative work fosters a bidirectional partnership as well as enhanced rehabilitation access in a global context.

SUBSTANTIATION OF THE CERTIFICATE PROGRAM «GLOBAL HEALTH» AS A COMPONENT OF THE TRAINING OF PUBLIC HEALTH SPECIALISTS

The aim: to develop a modern certification program "Global Health" for the continuous professional development of public health professionals. Materials and methods. The study employed bibliosemantic, informational-analytical, medical-statistical, sociological methods, and content analysis method. The research program included an analysis of the main competencies of public health professionals, as defined by the Association of Schools of Public Health in the European Region (ASPHER) and the higher education standard for specialty 229 "Public Health" for the second (master's) level of higher education; analysis of existing certification programs on global health; conducting sociological surveys of public health professionals regarding priority topics and preferred learning methods. The research was based on normative documents, electronic resources, and the results of sociological research. Statistical processing and mathematical analysis of materials were conducted using statistical analysis methods. Results. It was established that global health issues are significant in shaping the professional competencies of public health professionals, considering the requirements of the higher education standard for specialty 229 "Public Health" for the second (master's) level of higher education and those, defined by the European List of Core Competencies for Public Health Professionals ASPHER. The study of these issues was identified as important for continuous professional development based on sociological surveys of disease control and prevention center employees (38.4 out of 100 respondents). Among various forms of education, webinars (62.2±3.8 out of 100 respondents) and online learning (60.4±3.8) are most in demand. Analysis of the obtained data led to the justification of the "Global Health" certification program. In the developed "Global Health" certification program, 26.7% of the workload corresponds to lectures, 33.3% to practical classes, and 40% to preparatory work. Structurally, it covers 2 modules and 8 topics on current issues of the impact of globalization on health and analysis of global health indicators. Conclusions. The "Global Health" certification program meets the requirements of normative documents, considers contemporary challenges and consequences of globalization on health, highlights global health trends, and its topics are in demand among disease control and prevention center professionals.

Substantial discrepancies in dengue case estimates between the Global Burden of Disease Study and Taiwan Centers for Disease Control.

Taiwan's dengue cases vary annually, peaking in infrequent epidemics, which differ substantially from the Global Burden of Disease Study's (GBD's) projections. Although the GBD study provides invaluable insights into global health trends, its modelling approach fails to capture the dynamic change of dengue transmission.

Public health trends in neurologically relevant infections: a global perspective

Neuroinfectious diseases represent a growing threat to public health globally. Infections of the central nervous system remain challenging to diagnose and treat, partially driven by the fact that a high proportion of emerging pathogens are capable of causing neurological disease. Many of the trends driving the emergence of novel pathogens, including climate change, ecological degradation, urbanization, and global travel, have accelerated in recent years. These circumstances raise concern for the potential emergence of additional pathogens of pandemic potential in the coming years, necessitating a stronger understanding of the forces that give rise to the emergence and spread of neuroinvasive pathogens and a commitment to public health infrastructure to identify and treat these diseases. In this review, we discuss the clinical and epidemiological features of three types of emerging neuroinvasive pathogens of significant public health consequences that are emblematic of key ongoing trends in global health. We first discuss dengue viruses in the context of climate change, considering the environmental factors that allow for the expansion of the geographic range and seasonal population of the viruses’ vector. We then review the rising prevalence of fungal meningitis secondary to medical tourism, a trend representative of the highly globalized nature of modern healthcare. Lastly, we discuss the increasing prevalence of antibiotic-resistant neurological infections driven by the intersection of antibiotic overuse in medical and agricultural settings. Taken together, the rising prevalence of these conditions necessitates a recommitment to investment in public health infrastructure focused on local and global infectious disease surveillance coupled with ongoing development of novel therapeutics and vaccines for emerging pathogens. Such emerging threats also obviate the need to address the root causes driving the emergence of novel infectious diseases, including a sustained effort to address anthropogenic climate change and environmental degradation.

Global health trends of human papillomavirus‐associated oral cancer: A review

AbstractOral cancer is a malignant neoplastic disease, it constitutes the most common cancer in the head‐and‐neck region, and it is the 16th most common and 15th deadliest cancer type affecting humans. Despite the global efforts channelled towards global cancer control, the burden of oral cancer is still increasing. Every year, several thousands of people across 195 countries/territories die of oral cancer, and only about 40%–50% of the victims of oral cancer barely survive for 5 years after diagnosis. Within the past few decades, there has been a paradigm shift in the epidemiological trend of oral cancer risk factors. Oral sex – a major route of transmission of human papillomavirus (HPV) – was found to be increasing at an alarming rate, whereas tobacco and alcohol use had been on the decline. This narrative review critically discussed the contemporary challenges facing the global eradication of HPV‐associated oral cancer, with reasonable recommendations. The challenges discussed in this review are major, ranging from clinical to public health policy issues, which include the lack of validated and inexpensive oral HPV screening and diagnostic tools, high global public illiteracy on oral HPV infection, diverse sociocultural factors, weak global research capacity on oral HPV infection and HPV‐associated oral cancer and the absence of policies across different countries on national preventive programmes on HPV‐associated oral cancer. This review also identified the need for more attention towards the prevention and control oral HPV infection and HPV‐associated oral cancers globally.

‘It breaks a narrative of paramedics, that we’re lifesavers’: A qualitative study of health professionals’, bereaved family members’ and carers’ perceptions and experiences of palliative paramedicine

Background: Paramedic practice is diversifying to accommodate evolving global health trends, including community paramedicine models and growing expertise in palliative and end-of-life care. However, despite palliative care specific clinical practice guidelines and existing training, paramedics still lack the skills, confidence and clinical support to provide this type of care. Aim: To elicit paramedics’, palliative care doctors and nurses’, general practitioners’, residential aged care nurses’ and bereaved families and carers’ experiences, perspectives, and attitudes on the role, barriers and enablers of paramedics delivering palliative and end-of-life care in community-based settings. Design: A qualitative study employing reflexive thematic analysis of data collected from semi-structured online interviews was utilised. Setting/participants: A purposive sample of 50 stakeholders from all Australian jurisdictions participated. Results: Five themes were identified: positioning the paramedic (a dichotomy between the life saver and community responder); creating an identity (the trusted clinician in a crisis), fear and threat (feeling afraid of caring for the dying), permission to care (seeking consent to take a palliative approach) and the harsh reality (navigating the role in a limiting and siloed environment). Conclusion: Paramedics were perceived to have a revered public identity, shaped by their ability to fix a crisis. However, paramedics and other health professionals also expressed fear and vulnerability when taking a palliative approach to care. Paramedics may require consent to move beyond a culture of curative care, yet all participant groups recognised their important adjunct role to support community-based palliative care.

Epigenetic Regulation of Macrophage Polarization in Cardiovascular Diseases.

Cardiovascular diseases (CVDs) are the leading cause of hospitalization and death worldwide, especially in developing countries. The increased prevalence rate and mortality due to CVDs, despite the development of several approaches for prevention and treatment, are alarming trends in global health. Chronic inflammation and macrophage infiltration are key regulators of the initiation and progression of CVDs. Recent data suggest that epigenetic modifications, such as DNA methylation, posttranslational histone modifications, and RNA modifications, regulate cell development, DNA damage repair, apoptosis, immunity, calcium signaling, and aging in cardiomyocytes; and are involved in macrophage polarization and contribute significantly to cardiac disease development. Cardiac macrophages not only trigger damaging inflammatory responses during atherosclerotic plaque formation, myocardial injury, and heart failure but are also involved in tissue repair, remodeling, and regeneration. In this review, we summarize the key epigenetic modifications that influence macrophage polarization and contribute to the pathophysiology of CVDs, and highlight their potential for the development of advanced epigenetic therapies.

One Health training needs for Senegalese professionals to manage emerging public health threats

Global health trends, marked by increasing epidemics and pandemics, call for enhanced human resource preparedness to prevent and respond to emerging and future health problems. Indeed, according to the World Organization for Animal Health (WOAH), at least 75% of the pathogens responsible for emerging and re-emerging human infectious diseases originate from animals. These health problems involve environmental, economic and social factors. Because of their multidimensional nature, addressing these health problems requires the adoption of a One Health approach. To achieve this, training of human resources is a priority.This descriptive cross-sectional study was conducted from September 12 to 22, 2021 in 6 regions of Senegal, namely, Dakar, Thiès, Diourbel, Kaolack, Saint-Louis, and Ziguinchor. Questionnaires were administered online and in person to 217 professionals in human, environmental, animal health and agriculture. Data were statistically processed, and bivariate analyses enabled a better correlation between training needs for professionals according to their occupational group.The survey sample was 64% male and 36% female. More than half of the professionals surveyed (53.5%) had less than 10 years of experience. Human health workers were the most represented (46%), followed by animal health workers (34%) and environmental workers (16%). Agriculture, fisheries, and food security were weakly represented. Few had received training in the One Health approach and entry-level One Health skills predominated. The One Health competencies in which professionals want to build capacity differ by sector. Globally, public health and epidemiology, health risk management, basic of One Health concepts, animal health and biotechnology are the priorities.The development of training programs could then enable these expressed needs to be addressed.

The Innovation Imperative in Global Health: Gendered Futurity in the Sayana® Press

In this Position Piece, we explore the hegemony of innovation and the construction of gendered futures in global health through the Sayana® Press, a device that delivers a version of the contraceptive drug commonly known as Depo-Provera. The device has generated tremendous enthusiasm amongst global family planning advocates for its effectiveness and ease of use, including administration by community level providers and self-injection. Claims about its potential are compelling: advocates hope it will dramatically increase access to contraceptives, and thereby unlock the social and material emancipatory promise of family planning. We offer preliminary observations about Sayana Press as an ethnographic and discursive object and further the scholarly conversation on humanitarian design by considering the gendered dimensions of global health technologies. The advent of Sayana Press reflects several significant trends in global health including the intensification of the innovation imperative and the bypassing of investments in infrastructure—both bolstered by the recent rise of the ‘self-care agenda’. Further, we suggest that global health technologies are also techniques in the Foucauldian sense—scripting new subjectivities and bodily norms towards gendered futurities. Finally, we note the dual role of the state in sexual and reproductive health as both source and object of reproductive governance.

The Prevalence of Coexisting Lumbar Spondylosis and Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

A systematic review. This study aimed to evaluate the prevalence of coexisting lumbar spondylosis (LS) and knee osteoarthritis (KOA), which has clinical implications on the screening, diagnosis, and management of orthopedic patients. Due to current global health trends, the number of affected patients is expected to increase substantially. However, no prior systematic reviews have discussed this topic. A systematic literature search was conducted in June 2021 in the PubMed, Embase, Scopus, CINAHL, and Cochrane CENTRAL databases. Clinical and epidemiological studies that reported quantitative data on the prevalence of coexisting LS and KOA were included. Studies which reported data on only LS or KOA alone were excluded. Odds ratios (ORs) and 95% confidence intervals (CI) for LS or KOA were retrieved or calculated for meta-analysis. Fixed-effects and random-effects models were used, and statistical significance was considered when p<0.05. Heterogeneity was evaluated using Cochran's Q test and the I2 statistic. Risk of bias was assessed using the MINORs (methodological index for nonrandomized studies) criteria. This review included nine studies (5,758 patients). Four studies (4,164 patients) defined KOA and LS by a Kellgren-Lawrence (KL) grade of ≥2 and were included in the meta-analysis. Two other studies defined KOA and LS by a joint space narrowing grade of ≥2. The remaining three studies reported other outcomes. The combined ORs of having KOA of KL grade ≥2 due to LS was 1.75 (95% CI, 1.22-2.50; p=0.002), while the combined OR of having LS of KL grade ≥2 due to KOA was 1.84 (95% CI, 1.23-2.77; p=0.003). In patients with either KOA or LS, the odds of having a concurrent knee-spine presentation are significantly increased. This may have implications for clinical decision-making and treatment strategies. Further high-level studies with larger patient populations are required to confirm these results in specific populations.

Effective Demand Forecasting in Health Supply Chains: Emerging Trend, Enablers, and Blockers

Health supply chains aim to improve access to healthcare, and this can be attained only when health commodities appropriate to the health needs of the global population are developed, manufactured, and made available when and where needed. The weak links in the health supply chains are hindering the access of essential healthcare resulting in inefficient use of scarce resources and loss of lives. A chain is only as strong as its weakest link, and demand forecasting is one of the weakest links of health supply chains. Also, many of the existing bottlenecks in supply chains and health systems impede the accurate forecasting of demand, and without the ability to forecast demand with certainty, the stakeholders cannot plan and make commitments for the future. Forecasts are an important feeder for budgeting and logistics planning. Under this backdrop, the study examines how improved forecasting can lead to better short-term and long-term access to health commodities and outlines market-related risks. It explores further how incentives are misaligned creating an uneven distribution of risks, leading to the inability to match demand and supply. For this purpose, a systematic literature review was performed, analyzing 71 articles from a descriptive and content approach. Findings indicate the emerging trends in global health and the consequences of inaccurate demand forecasting for health supply chains. The content analysis identifies key factors that can pose a varying degree of risks for the health supply chain stakeholders. The study highlights how the key factors emerge as enablers and blockers, depending on the impact on the overall health supply chains. The study also provides recommendations for actions for reducing these risks. Consequently, limitations of this work are presented, and opportunities are identified for future lines of research. Finally, the conclusion confirms that by adopting a combination of approaches, stakeholders can ensure better information sharing, identify avenues of diversifying risks, and understand the implications.

The ICD-11 and opportunities for the osteopathy profession

As the global osteopathic profession continues to evolve, so does our understanding of the clinical presentations managed in osteopathic practice. While this data builds knowledge of the role of osteopathy in pain management, a limitation is a universal understanding and data collection strategy about diagnosis.The International Classification of Diseases (ICD) represents the international standard for identification and reporting of global health trends and epidemiological data. There are issues with ICD-10, particularly with respect to reporting chronic pain complaints. A task force developed new codes for chronic pain for the ICD-11 update.ICD-11 was ratified by the WHO in May 2019, and is scheduled for implementation in 2021. The adoption of the ICD-11 coding system in osteopathy education, practice and research would build upon previous research and enable enhanced reporting of chronic pain presentations.The ICD-11 offers a significant step towards a universal categorisation system that enables the identification of pain complaints amongst the plethora of diseases, disorders, injuries and other related health conditions. Practitioners, educators and researchers in osteopathy could use ICD-11 coding to facilitate data collection and evaluate treatment responses and explore the cost-effectiveness for osteopathy care. The introduction of the primary and secondary chronic musculoskeletal pain categories removes the need to allocate a tissue-causing-symptom diagnosis and allows the addition of pain mechanisms to facilitate appropriate care of a patients’ presenting condition.

Microbial insurgency: Theorizing global health in the Anthropocene

Several recent international health crises have revealed significant vulnerabilities in global pandemic preparedness. The 2014 Ebola fever epidemic expanded into an international threat far more quickly than experts anticipated, and the 2018 Ebola fever epidemic continues to expand, even with new technological innovations designed to control the disease. The 2015 yellow fever outbreak in Angola exhausted global vaccine supplies and put millions of people at risk. This article argues that global health authorities failed to anticipate the magnitude of these outbreaks because the field has not been updated to address the ways recent changes in international political economy are combining with environmental instabilities of the Anthropocene to increase epidemiological risks. Many public health textbooks and teaching materials continue to rely on variants of 20th-century modernization theory to explain and predict global health trends. Since the end of the Cold War, however, there has been a dramatic reconfiguration of governance in many parts of the world, and these macro-level changes are accelerating ecological destruction and fueling armed conflict in ways that will reduce the range and effectiveness of public health methods and prevention technologies that were successful during the 20th century. The combined effect of these institutional and environmental changes will increase global pandemic risks in the Anthropocene, even for infectious diseases that are easily preventable today.

Incorporating mammography into an overseas referral metric: Tongan doctors' assessments of patient eligibility for medical travel.

Tonga's largest public hospital received its second-although its first fully functioning-mammogram machine in 2016. If diagnosed with breast cancer, Tongan women must travel to New Zealand or Australia to access biomedical treatment (e.g. chemotherapy), but many can only do so with financial support from the Tongan government. Given limited funding, strict referral guidelines require doctors to quantify patients into calculations of risk. According to these guidelines, which I argue serve as an overseas referral metric, only "low-risk" patients-as determined by prognosis and treatment cost-are supposed to be funded. At present, doctors can sometimes draw on qualitative knowledge, such as long-term clinical experience, to circumvent referral guidelines. However, as mammography touts new epidemiological capabilities, it also has the potential to reinforce emphases on quantifiable evaluations of referral eligibility, which are often preferred by program funders. This could potentially exclude some women from treatment, as already-limited funding is increasingly reserved for those deemed "low-risk" according to numerical assessments. Based on recent ethnographic fieldwork (2016-2017) in Nuku'alofa, Tonga, I draw on in-depth interviews and conversations with local doctors to elucidate the interplay between mammography access and practitioners' processes of cancer diagnosis, patient risk assessment, and overseas referral. In following doctors' efforts to maximize accountability and risk management in referrals, I show how broader emphases on quantification and efficiency in global-health practice can generate intense moral dilemmas for those who must grapple with their implementation in the day-to-day. Significantly, these experiences demonstrate how numerical trends in global health not only permeate local health-care practices but also impact transnational health-care seeking, shaping a political economy of medical travel that structures opportunities for some women (and not others) to access biomedical treatment abroad.

Global Health Education for Pediatric Residents: Trends, Training Experiences, and Career Choices.

We analyzed GH-focused questions from national American Academy of Pediatrics surveys of graduating residents in 2008 and 2016. Logistic regression was used to estimate changes over time by using derived predicted values. A total of 1100 graduating pediatric residents participated; response rates were 58.8% for 2008 and 56.0% for 2016. The percentage of residents reporting that their programs offered GH training grew from 59.1% in 2008 to 73.1% in 2016 (P < .001). The majority were somewhat likely, very likely, or definitely planning to work or volunteer in a low- or middle-income country after their residency (predicted value of 70.3% in 2008 and 69.4% in 2016; P = .76). Fourteen percent of respondents reported having completed an international elective in 2016; of those, 36.5% did not receive formal preparation before the experience, and 24.3% did not participate in debriefing sessions on return. Overall, 27.3% of respondents in 2016 reported excellent (8.8%) or very good (18.5%) GH training. Although a substantial percentage of pediatric residents participate in international electives and plan to include GH activities in their careers, gaps remain, including suboptimal preparation and debriefing for GH electives.

Health Promotion Policies for All in Taiwan

Health promotion was defined at the first International Conference on Health Promotion held by the World Health Organization in 1986 as a process that enables the public to improve their health. Moreover, the United Nations High-Level Meeting on the Prevention and Control of Non-Communicable Diseases in 2011 highlighted that non-communicable diseases (NCDs) account for 63% of deaths worldwide, with major NCD-related risk behaviors including tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diet. In 2013, the WHO announced the Global Action Plan for the Prevention and Control of NCDs 2013-2020, with the United Nations listing NCDs prevention and control as a major topic for nations in Sustainable Development Goal 3 (Health). Both Taiwan and the world face the dual threats of population aging and NCDs, adding to the importance of health promotion and NCDs prevention and control. This article first introduces the relevant global health trends and the corresponding status of Taiwan and then examines the major NCDs prevention and health promotion policies in Taiwan. In creating a health-supportive environment for all people and enhancing health literacy and empowerment among the general public, we hope to ensure that every individual, family, and city joins the ongoing effort in Taiwan to enable all individuals to make the best, informed decisions for their health.

Discourse with Visual Health Data: Design of Human-Data Interaction

Previous work has suggested that large repositories of data can revolutionize healthcare activities; however, there remains a disconnection between data collection and its effective usage. The way in which users interact with data strongly impacts their ability to not only complete tasks but also capitalize on the purported benefits of such data. Interactive visualizations can provide a means by which many data-driven tasks can be performed. Recent surveys, however, suggest that many visualizations mostly enable users to perform simple manipulations, thus limiting their ability to complete tasks. Researchers have called for tools that allow for richer discourse with data. Nonetheless, systematic design of human-data interaction for visualization tools is a non-trivial task. It requires taking into consideration a myriad of issues. Creation of visualization tools that incorporate rich human-data discourse would benefit from the use of design frameworks. In this paper, we examine and present a design process that is based on a conceptual human-data interaction framework. We discuss and describe the design of interaction for a visualization tool intended for sensemaking of public health data. We demonstrate the utility of systematic interaction design in two ways. First, we use scenarios to highlight how our design approach supports a rich and meaningful discourse with data. Second, we present results from a study that details how users were able to perform various tasks with health data and learn about global health trends.

Outcome Measures in Spine Surgery: How Far Can we Go Building Evidence?

There is an imperative need to alleviate the actual and predictably harder burden of spine disorders and particularly the share due to chronic nonspecific low back pain, both at the individual and community - based viewpoint. Studies on global health trends charge a relevant part of the onus to the proposed invasive procedures, raising concern over its inappropriately high and growing use, counteracting clinical guidelines recommendation of a prudent selection of patients, based on clear - cut indications. Part of this gap between evidence and practice stands from questionable assumptions regarding the usefulness of surgery. Uncertainty on relative benefits and harms in the face of increased risk of adverse events, or the higher costs and health care resources i nvolved, results in controversial decision - making to plan the intervention . Improvement of knowledge about these questions can be provided by the inclusion in the research agenda of comprehensive and standardized evaluation of outcomes after spine surgery. Such a protocol procedure would enable future systematic reviews to perform a consistent meta - analysis of data from trials, mandatory for high - quality evidence gathering. Outcome evaluation requires both subjective and objective assessments. This review a ims to clarify the role of outcome measures in support of the need to build reliable information on the effectiveness of surgical treatment of spinal disorders.

An empirical investigation of funding trends in global health

www.thelancet.com/lancetgh 5 Published Online April 8, 2016 Vanderbilt University Institute for Global Health, Nashville, TN, USA (M Martin PhD); Tennessee State University, Nashville, TN, USA (M Streams PhD) Correspondence to: Marie Martin, Vanderbilt University Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37208, USA marie.h.martin@vanderbilt. edu An empirical investigation of funding trends in global health Marie H Martin, Megan E Streams Abstract Background Since 2005, funding for global health has increased, not only from donor OECD nations, but also from within low-income and middle-income countries via their own governmental health spending. However, there has been little analysis of budgetary trends in global health from a public fi nance angle. This study provides a quantitative analysis of the distribution of annual changes in country-level government expenditures for domestic health (1995–2012) using the theoretical lens of budgetary punctuated equilibrium theory (PET).Background Since 2005, funding for global health has increased, not only from donor OECD nations, but also from within low-income and middle-income countries via their own governmental health spending. However, there has been little analysis of budgetary trends in global health from a public fi nance angle. This study provides a quantitative analysis of the distribution of annual changes in country-level government expenditures for domestic health (1995–2012) using the theoretical lens of budgetary punctuated equilibrium theory (PET). Methods We used health fi nancing data from the Institute for Health Metrics and Evaluation to calculate country-level annual changes in government spending on domestic health for 150 countries between 1995 and 2012. We grouped countries into fi ve categories used by the World Bank for analysis: high-income, OECD; high-income, non-OECD; upper-middle income; lower-middle income; and low income. Premised on the importance of policy framing, issue salience, and institutional friction, PET suggests that budgetary change data would show periods of relative stasis, interrupted by punctuations of sudden large-scale change (generating a leptokurtic distribution) rather than steady incremental change. We tested for the degree of budgetary punctuation and compared distributional characteristics between income groups. Findings Overall, and when grouped by income, the distributions of countries’ pooled annual changes in government health spending were leptokurtic, consistent with PET. As country income decreased across the high-income-OECD, lower-middle income, and low income groups, the distribution of annual changes also became increasingly leptokurtic as hypothesised, and the proportion of annual changes that were positive decreased. Interpretation We anticipated greater departure from the normal distribution consistent with incrementalist budgeting as country income decreased, and we noted this pattern across the highest and two lowest income groups. However, the high-income non-OECD and upper-middle income groups diverged from this trend in interesting ways, suggesting areas for further research. Better understanding of distributional changes in year-to-year health expenditure patterns and their variation across country income groups could inform policymakers across income groups in ways that a focus on levels of spending alone cannot.

Global challenges posed by the growth of end-stage renal disease

Profound challenges confront societies worldwide due to the growth of end-stage renal disease (ESRD). Meeting these challenges requires a sober assessment of how overall global health trends affect ESRD, coupled with an understanding of how progress in the care of ESRD patients is most appropriately measured and monitored. For many affluent countries, incident ESRD rates have stabilized since about the middle of the last decade. For example, the number of new cases in the USA has remained stable at approximately 110,000 per year during this period, while in Japan, growth in annual incident counts appears to have stabilized as of 2012. However, incidence rates rose for many developing countries. An immense “renal replacement therapy (RRT) gap,” the difference between the number of people receiving RRT and the number needing it, was recently described, highlighting the magnitude of the difficulties these countries face as they continue to develop. To guide efforts to improve care, broad goals should be established by the worldwide renal health care community. For countries without universal dialysis access, expansion of RRT accessibility should be the first target in order to reduce the RRT gap; for countries that have moved beyond this stage, the goals should include reductions in ESRD incidence rates; all-cause, cardiovascular, and infection-related death rates; and cardiovascular- and infection-related hospitalizations. To inform judgements about progress in this area, measures beyond the traditional standardized mortality ratio are needed. Carefully determining trends over time within a given country, such as is done by the World Health Organization, might prove to be a more useful way to determine progress in combating ESRD and its complications.