Cortinois, Downey, Closson and Jadad from Toronto's University Health Network (UHN) are to be congratulated for taking on the challenge of writing the lead for HealthcarePapers on globalization. The issues are intricate and complex. As editor, I thank them for being so bold as to put their views in writing. They begin their paper by first addressing the problem of definition. The authors compare different definitions of globalization and conclude that it is a complex, multi-faceted phenomenon that includes economic, ecological, legal, political and cultural perspectives and is clearly still in a process of evolution. The authors proceed to draw links between globalization and important social structures for education, housing, public welfare and security, economic development, cultural continuity and consequently for health and healthcare delivery.

Building on UHN's recent strategic planning initiative, Cortinois and colleagues speculate in their paper about how sophisticated academic health sciences centres might evolve in a global environment in the next decade based on a foundation of technically advanced information and communications technologies. They conclude with a discussion of how global strategies might be realized to benefit as many people as possible worldwide.

One of the important aspects of this issue of HealthcarePapers is a reflection on the difference in perspectives between "international health" and "globalization" and the way we have come to perceive these terms. The goal of globalization, as suggested by Leggat and Tse, is to achieve health for all but in practice globalization has tended to highlight some of the inequalities in both health and healthcare. Jain, one of the world's foremost experts on international health, clearly points out the differences in perspectives - it all depends upon whether you are part of the country that feels it has something to offer to another country or a member of the community that is receiving what is offered. In relative terms the receiving country is usually poor and the country offering to help or provide services is usually rich. Jain points out the importance of "fit" between the goals of the partners and the development of ongoing relationships that can be satisfying to all. In a similar vein, Ellis emphasizes how critical it is for the organizations or individuals offering services to actually understand what another country needs. This is the major dilemma.

A number of commentators (Bennett, Amadis and Hathaway, for example) raise questions about whether developing countries need hospital services or perhaps a more basic type of health service such as primary healthcare. They emphasize that the hospital structures and processes as we know them in North America may not be the appropriate format for other countries. Bennett makes a plea for more patient-centered approaches rather than hospital-centered strategies for managing the health needs of populations in developing countries.

Macleod makes the point that hospitals have a history of protecting themselves and of self-interest. He believes to be successful in a global environment there needs to be a different model of governance for healthcare. MacLeod describes regionalization as a type of governance familiar to most Canadians where healthcare is governed by representatives from a variety of interests that might work in the international arena. In support of a community-based approach, Ellis discusses the importance of empowering populations and individuals in order to make progress in developing countries. He stresses the need to give greater consideration to the local cultures and values.

Academic health sciences centres, like UHN, have expertise in highly sophisticated aspects of health services delivery. Many developing countries are still struggling with finding resources to provide primary healthcare in local isolated regions where basic public health needs such as safe water, shelter and freedom from infectious diseases are the pressing priorities. Leggat and Tse suggest that it does not make sense to focus on high-cost specialized services of hospitals. Another area where academic medicine has shown some success is that of telemedicine. Is this an endeavor where a teaching hospital could be successful? Perhaps, although Leggat and Tse indicate that healthcare may be one of the services where an actual physical presence is essential.

The expectation from many developing countries that are desperately poor is that the more fortunate countries will be willing to make an investment overseas and help their less fortunate sisters. This noble cause may not be the only motive for entering into the global marketplace.

We tend to associate globalization with the idea of multi-national corporations where big business and worldwide transactions take place in highly sophisticated environments. While this picture may be somewhat exaggerated, the literature on the knowledge and skill needs of global managers tends to support a growing need for highly developed negotiation skills, knowledge of languages and cultures, sophisticated communication skills as well a liking for cross-continental travel. What does it take to operate successfully in global markets? If the goal is parallel to other businesses then the goal must be to make a profit but there are challenges. Wassenaar succinctly describes the struggles of an Internet pharmacy service started in Toronto to sell pharmaceutical services at a low cost. The experience was fraught with unanticipated challenges; for example, the pharmacists were initially limited to filling prescriptions of only those physicians licensed to practice in Canada. A dilemma, but Ontario found ways around this by having Canadian physicians re-write the prescriptions.

In concluding, Cortinois and colleagues rightly suggest that academic health sciences centres such as the University Health Network can offer sophisticated diagnostic and treatment services, especially those with information technology solutions. There is certainly room for much more health services research that compares health systems in different countries so we can learn from the strengths and rich experiments in local environments in different countries. Perhaps, as Leggat and Tse indicate, we can all benefit from the creation of an international teaching and research network to improve global health. Through such a network of hospitals in partnership with other providers we can begin to identify where there can be the greatest impact on global health.

Suggestions for where to begin with globalization include the needs for basic public health and primary healthcare services. The idea of taking a population perspective and a regional approach to health services delivery would help those with a noble interest in helping others to understand the local cultures and values. Clearly hospital services and especially tertiary and quaternary health services are needed and we need to develop partnerships that can lead to win-win solutions.

Finally, globalization has happened much faster in other industries. Why? What can we learn perhaps from these experiences? What is not yet clear is the extensiveness of the market for Canadian information and communication technologies in relation to health and health services in other countries. Who is interested in paying for such services? And how will we evaluate their impact on global health? Cortinois and colleagues have certainly thought a great deal about these issues and we thank them for bravely sharing their thoughts.

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