‘Global health’ is coming of age, at least as measured by the increasing number of academic centres, especially in North America, which use this title to describe their interests (1). Most global health centres are in high-income countries although several have strong links with low- and middle-income countries. A task force is establishing a mechanism to coordinate European Academic Global Health initiatives through ASPER. Two recent papers raise important issues about the meaning and scope of global health (2, 3) and highlight, yet again, the need for a common definition of global health which is short, sharp and widely accepted, including by the public (4). Koplan et al. from the Consortium of Universities for Global Health Executive Board point out that without an accepted definition of global health, it will be difficult to agree on what global health is trying to achieve and how progress will be made and monitored (2). This is particularly important given the recent global crises – climate change, economic, food and energy crises – that make global health efforts even more challenging (5). Koplan and colleagues propose a definition of global health which they hope will receive wide acceptance and thus encourage global health efforts. They distinguish between global health, international health and public health; tropical medicine has close connections with international health (1). However, there is widespread confusion and overlap among the three terms. International health, in Koplan's view, focuses on the health issues, especially infectious diseases, and maternal and child health in low-income countries. However, elsewhere international health is also used as a synonym for global health. For example, Merson et al. view international health as ‘the application of the principles of public health to problems and challenges that affect low and middle-income countries and to the complex array of global and local forces that influence them’ (6). The term ‘international health’ has also been used to refer to ‘the involvement of countries in the work of international organizations such as WHO, usually through small departments of international health in the Ministries of Health and as development aid and humanitarian assistance’ (7). Public health is usually viewed as having a focus on the health of the population of a specific country or community, a perspective shared by Koplan et al. (2). Fried et al. dispute any distinction between public health and global health and suggest that ‘public health is global health for the public good’ (3). Their strong arguments are based on the need for both global and public health to address the underlying social, economic, environmental and political determinants of health, irrespective of whether the primary focus is national or global health. Current definitions of global health Koplan et al. define global health as: ‘an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide’. This is a useful definition with a broad focus on health improvement and health equity. However, it is wordy and uninspiring. Kickbush defines global health as: ‘those health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people’ (7). This definition also has a broad focus but has no clear goal, is passive in its call for action, and omits the need for collaboration and research. Elsewhere, the European Foundation Centre calls for a European approach which makes global health a policy priority across all sectors based on a global public goods foundation (8). In an important policy document, the UKGovernment refers to global health as ‘health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions. Global health is focussed on people across the whole planet rather than the concerns of particular nations. Global health recognises that health is determined by problems, issues and concerns that transcend national boundaries’ (9). This definition contains important ideas but is convoluted and not outcome focussed. Macfarlane et al. usefully describe global health as being the ‘worldwide improvement of health, reduction of disparities, and protection against global threats that disregard national borders’ (1). Proposed definition Our proposed definition for global health is collaborative trans-national research and action for promoting health for all. This definition is based on Koplan et al. but has the advantage of being shorter and sharper, emphasises the critical need for collaboration, and is action orientated. Key aspects of the definition deserve further explanation. The term global health is used rather than global public health to avoid the perception that our endeavours are focussed only on classical, and nationally based, public health actions. Global health builds on national public health efforts and institutions. In many countries public health is equated primarily with population-wide interventions; global health is concerned with all strategies for health improvement, whether population-wide or individually based health care actions, and across all sectors, not just the health sector. Collaborative (or collective) emphasises the critical importance of collaboration in addressing all health issues and especially global issues which have a multiplicity of determinants and a complex array of institutions involved in finding solutions. Trans-national (or cross-national) refers to the concern of global health with issues that transcend national boundaries even though the effects of global health issues are experienced within countries. Trans-national action requires the involvement of more than two countries, with at least one outside the traditional regional groupings, without which it would be considered a localised or regional issue. At the same time, trans-national work is usually based on strong national public health institutions. Research implies the importance of developing the evidence-base for policy based on a full range of disciplines and especially research which highlights the effects of trans-national determinants of health. Action emphasises the importance of using this evidence-based information constructively in all countries to improve health and health equity. Promoting (or improving) implies the importance of using a full range of public heath and health promotion strategies to improve health, including those directed at the underlying social, economic, environmental and political determinants of health. Health for all refers back to the Alma Ata Declaration and positions global health at the forefront of the resurgence of interest in multi-sectoral approaches to health improvement and the need to strengthen primary health care as the basis of all health systems. Global health: a high-income country concern? Although the burden of preventable disease is predominantly in middle- and, especially, low-income countries, most global health centres are located in high-income countries. There are several explanations for this anomaly including the following: Centres in low- and middle-income countries are engaged in global health issues but under other labels. For example, several centres in low- and middle-income countries have recently been funded by the National Heart, Lung and Blood Institutes to undertake chronic disease prevention activities, though the focus seems to be on national programmes of work (see http://www.fogartyscholars.org/articles/nhlbi-centers). Global health builds on international health interests stemming from institutions in high-income countries over a century ago. Global health may be seen to be divorced from the health needs of low- and middle-income countries which are grappling with a range of pressing and challenging health issues. An interest in global health stems from strong national public health institutions which are usually not a feature of low- and middle-income countries. Whatever the explanation, encouraging and supporting the establishment of global health centres in low- and middle-income countries, and south–south collaborations, are essential if countries with the greatest burden of diseases are to have the best opportunity to respond appropriately. Development agencies, foundations and national ministries of health could do much more to build public health capacity at the national level. By doing so, they will also strengthen research and policy interests in global health and its evaluation (10). Robert Beaglehole and Ruth Bonita University of Auckland, New Zealand
