Margaret Chan: Securing a Healthier Future in a Changing World 16 Liberia: Reconstructing the Health Sector 24 Awa Coll-Seck: A Malaria-Free World is Within Reach 04
Issue 11
SUMMER 2011 $4.95 U.S.
Securing a Healthier Future www.globalhealthmagazine.com —
Issue 11
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letter from the editor
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Global Health
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Executive Editor
Tina Flores Interns
Maggie Bronson Gahan Furlane Graphic Design
Shawn Braley Web
Winnie Mutch E-mail:
magazine@globalhealth.org
Securing a Healthier Future in a Changing World This issue of GLOBAL HEALTH Magazine takes the pulse of the international health community in a changing world. In her article, World Health Organization Director-General Dr. Margaret Chan discusses the challenges in global health. We have to tackle the dual burdens of infectious and noncommunicable diseases, as well as those of obesity and malnutrition. There is also a need for increased access to services, sustainable programs, more research and better health equity. Daniel Cotlear and Phillip Hay discuss the consequences of a shifting Latin American demographic as its population grows and ages. We need to address the health worker crisis as well as the opportunity that young professionals provide to the global health sector. Change can also be a sign of progress. Richard Brennan and Jacob Hughes offer the story of Liberia as it revives its health sector from the ruins of war to post-conflict development. Multi-sectoral partnerships provide opportunities to facilitate better health outcomes. Awa Marie Coll-Seck notes the gains in malaria, but at the same time, notes the need to assist those with fewer resources. For the world’s poor, the so-called shifting burden of disease is, perhaps, better characterized as the added burden of disease. But how do we finance a future that provides greater access to health to the world’s poor? Read on. Tina Flores Executive Editor, GLOBAL HEALTH tflores@globalhealth.org
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Global Health Council Board of Directors
Joel Lamstein, SM, chair William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Christopher Elias, MD, MPH Elizabeth Furst Frank, MBA Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Patricia McGrath Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org
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issue 11
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In this issue:
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04 Securing a Healthier Future in a Changing World
08 Is Latin America Ready for its Aging Revolution?
COVER STORY: Securing a Healthier Future
11 La Sage-Femme Bouche-Trou: The Stopgap Midwife
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16 Post-Conflict Liberia: Reconstructing the Health Sector
14 NCD Prevention Begins in the Womb 20 Paying for a Healthier Future 22 Opening the Door to Global Health Talent
Cover photo by Lisa Marie Albert
24 A Malaria-Free World is Within Reach
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02 Does Country Wealth Determine Cause of Death? 03 Does Country Wealth Determine Age of Death? 03 Does Country Wealth Determine Inactivity?
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Global health statistics
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Does Country Wealth Determine Cause of Death? Total Deaths (Millions)
Males
FeMales
18
18
16
16
14
14
12
12 Injuries
10 8
Non communicable diseases
6 4
communicable, maternal, perinatal and nutrional conditions
2 0
8 6 4 2 0 high-income
upper -midele income
Lower -midele income
Low -Income
high-income
upper -midele income
Lower -midele income
Low -Income
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10
Source: WHO and World Bank
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Does Country Wealth Determine Age of Death? 1%
36%
21%
10%
44%
29%
70%
46%
43%
Low-Income Countries
Middle-Income Countries
Deaths among people 0-14
High-Income Countries
Deaths among people 15-69
Deaths among people over 70 Source: World Health Organization
Does Country Wealth Determine Inactivity? (% of population, insufficient physical activity*) 60 50 40
Men
30 Women
20 10
Both sexes
0 Low -Income
Lower-Middle Income
Upper-Middle income
High-Income
(*Insufficient physical activity is defined as less than five times 30 minutes of moderate activity per week, or less than three times 20 minutes of vigorous activity per week, or the equivalent.)
Click on the source at C www.globalhealthmagazine.com
Source: Source: World Health Organization
Securing a Healthier Future in a Changing World By DR. Margaret Chan
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Photo by WHO/TDR/Crump
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The consequences can also be profoundly unfair. Developing countries have the greatest vulnerability to adverse events and the least resilience. They are often hit the hardest and take the longest to recover. The Double Threat of Communicable and Non-communicable Diseases Nearly 80 percent of the burden of diseases like cardiovascular disease, diabetes, cancer and chronic respiratory diseases is now concentrated in low- and middle-income countries. In poor and vulnerable populations, people with these diseases fall sicker sooner and die earlier than their counterparts in wealthier societies.
A tsetse fly trap is sprayed to with insecticide to reduce sleeping sickness. Photo by WHO/TDR/Edwards
In sub-Saharan Africa, the risk of a woman dying during pregnancy and childbirth is nearly four hundred times greater than it is in Japan, a country that has one of the lowest rates of maternal and childhood deaths in the world. This is the starkest statistic in public health: the difference in mortality rates between rich and poor countries. There are many more health inequities within and between countries, and the differences in life expectancy, health outcomes, and access to care are greater today than at any other time in recent history. A world that is greatly out of balance is neither stable nor secure. And there are other ominous trends, linked to the world’s unprecedented interdependence. All around the globe, health is being shaped by the same powerful forces. Globalization and Equity Globalization produces numerous benefits, but it has no rules that guarantee the fair distribution of these benefits. Equity is rarely an explicit policy objective in the international systems that govern finance, economies, commerce and trade. Since the start of this century, the world has experienced multiple crises on multiple fronts: a fuel crisis, a food crisis, a financial crisis, and a climate that has begun to change. These crises are revealing the dark side of living in a closely interdependent and interconnected world. As the past decade has shown, the consequences are highly contagious, quickly moving through the international systems that bind countries together.
Dr. Margaret Chan is director-general of the World Health Organization.
The burden of these non-communicable diseases was initially concentrated in affluent societies. Effective treatments and procedures were made available through strong R&D capacities and are constantly being improved. In wealthy countries, deaths from heart disease and strokes have declined significantly, cancer patients are being cured or surviving longer, and people with diabetes have better access to essential and effective treatments. But this apparent success gives a distorted picture. It leaves the impression of a manageable situation and conceals what is, in reality, an impending disaster. Worldwide obesity rates have almost doubled since 1980. An epidemic of diabetes, which is closely associated with obesity and urbanization, has skyrocketed in rich and poor countries alike. This is a world in which more than 40 million preschool children are obese or overweight. At the same time, many poor countries continue to struggle with infectious diseases. Diseases such as malaria, AIDS and tuberculosis are very closely associated with poverty and are dominant in subSaharan Africa and South Asia. There are at least another 17 diseases called neglected tropical diseases because they share one main feature: all occur almost exclusively among very poor people living in tropical parts of the world. Even though they impair the lives of an estimated 1.2 billion people, the problem has been easy to ignore because these people have little political voice and low visibility on national and international agendas. The immense suffering caused by these diseases is often endured in silence, accepted as an inevitable consequence of being poor. Today, health services that have struggled with the longterm problems of these infectious diseases now have
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Photo by WHO/TDR/Craggs
Photo by WHO/TDR/Edwards
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the double burden of trying to meet the rising level and long-term nature of non-communicable diseases. The Need for Research to Increase Equity and Access We need to continue to innovate, and in ways that are focused on the needs of the poorest. Advances in medicine and science have raced ahead at unprecedented speed, but most in the developing countries are being left behind – lacking both the capacity to develop new health products and access to inexpensive medicines and basic health care. Current drugs for many diseases are losing their effectiveness due to parasites developing resistance, and diagnostics need to be adapted to the field conditions in these poor countries. We need these new tools to be developed against diseases of poverty, but we also need ingenious lowtech innovations that help streamline operational demands and stretch resources and drugs even further. The community-led programs in Africa to deliver treatments against river blindness (onchocerciasis) are an excellent example of this. The Special Programme for Research and Training in Tropical Diseases (TDR), in collaboration with the African Programme for Onchocerciasis Control, brought researchers, clinicians and communities together to develop sustainable, affordable solutions that are managed by the local citizens in coordination with regional health services. This approach is now increasingly being used as an integral approach to primary health care to provide access to additional critical services to more than 60 million Africans across the continent.
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I write this article just as TDR has been awarded the 11th prestigious Gates Award for Global Health, an award coordinated by the Global Health Council. TDR is hosted by WHO and co-sponsored by UNICEF, UNDP, the World Bank and WHO. It epitomizes an international program that promotes partnership-driven innovation and action, while building local capacity and promoting local ownership, engagement and responsibility for long-term sustainability. Together with several other UN and WHO-supported programs, it demonstrates what can be achieved through collective action. Universal Health Coverage is Needed WHO’s Member States have set themselves the target of developing their health financing systems to ensure that all people can use health services, while being protected against financial hardship associated with paying for them. WHO recommends moving toward universal coverage. It will be a challenge, but we must begin. Universal coverage, in practical terms, means that all people within a country should receive some degree of financial protection from the costs of at least some basic health services. In ethical terms, no one in need of health care, whether curative or preventive, should risk financial ruin as a result of having to pay for care. We estimate that a minimum package of key health services in the world’s 49 poorest countries amounts to around $44 per person per year. Most spending on health comes from domestic sources, even in some very poor countries (despite increasing international aid). Only eight of these countries have any chance whatsoever of generating the funds required to reach the health-related Millennium Development Goals from domestic sources alone. Global solidarity is required. If donor countries would immediately meet their financial
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pledges for health development, external funding for health would more than double overnight and the estimated shortfall needed to reach the MDGs would virtually disappear. Aid Needs to Be More Effective to Create Sustainable Local Solutions Solely increasing international funding will not be sufficient to address the problems. Despite the best intentions, much aid for development is ineffective. For a long time, the blame was placed on weak capacities and poor leadership in recipient countries. The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action are instruments that codify best practice in development by calling for developing country involvement in identifying needs, and can be readily applied to the health sector. Rapid progress has been seen in some countries, but by no means in all. Some observers argue that Paris and Accra would have greater traction if they were part of a more formal legal framework. Some donors recognize that their own policies have created problems. For example, in 2009 alone, Vietnam dealt with more than 400 donor missions to review health projects. Rwanda has to report annually on 890 health indicators to various donors, with nearly 600 relating to HIV and malaria alone. The best aid is channeled in ways that strengthen local capacities and infrastructures. Building parallel systems for drug procurement and delivery, or data collection and reporting, is not the right answer. The best aid aims to eliminate the very need for aid. It does so by building the capacities that move countries towards self-reliance. Countries want capacity, not charity. Consequently, development initiatives must be country-owned. Assistance must support national health plans and strategies, and match national priorities.
Jon Hrusa/EPA
Accountability is an essential element of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health. The Commission on Information and Accountability for Women’s and Children’s Health, of which I was a vice chair, presented its report at the World Health Assembly this year. Several of the Commission’s recommendations relate to building capacity in countries to track resources and results, in terms of better health outcomes for women and children. Most fundamentally, this includes the ability to capture vital health information, such as births, deaths and causes of deaths. Another approach to better matching local priorities with action is set out in The Global Strategy and Plan
In Pondicherry, India, health workers prepare a rapid ICT blood test to check a patient for lymphatic filariasis. Photo by WHO/TDR/Crump
of Action on Public Health, Innovation and Intellectual Property, which has been endorsed in resolutions at the World Health Assembly. Essentially, it outlines principles for prioritizing R&D against diseases that disproportionately affect developing countries, calling for more opportunities for innovative research and development from within countries where the diseases are endemic. When the problems are identified and owned within the countries, the solutions are more often long lasting and sustainable. Ensuring the Security of Health for All I take you back to the typical rural woman in subSaharan Africa – overworked, undereducated, with numerous children who often die of childhood diseases. If we cannot secure the health for the most vulnerable, we have not done our job. Everyone should have equal access to health services and treatments – whether they live in Japan or Myanmar or Mali or Peru. Every country should be able to identify its own set of health priorities and have the capacity to conduct the research and produce the products necessary. As I stated at the beginning of this article, a world that is greatly out of balance is neither stable nor secure. We know that ensuring the security of health for everyone has never been more challenging than today. The impact of globalization, the complexity of multiple partners and organizations, the growing gap between rich and poor, expanding threats from non-communicable diseases doubling the impact from the already devastating problems of infectious diseases, and the empty pipeline of new treatments for when the current drugs stop working – all of these are critical issues that need to be addressed. But we have the guidelines on how to address these issues, and together, we must find solutions. We cannot do less. GH —
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By Daniel Cotlear and Phillip Hay
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Is Latin America Ready for its Aging Revolution?
Population aging is a global issue that affects virtually every country around the world, especially at a time when family support and other traditional safety nets have become far less certain in the aftermath of the global economic crisis. In Latin America, for example, life expectancy has jumped by 22 years over the last 50 years and its population is now dominated by workingage adults with significantly fewer children and now faces the prospect of rapid aging. A new report from the World Bank’s Human Development Network warns that governments and communities in the region cannot afford to be complacent about its ‘greying revolution,’ given that
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the next 50 years will be very different from its past half century. According to Population Aging: Is Latin America Ready?, countries with large numbers of elderly people will find it more challenging to achieve economic growth and to meet the health care, pension, and other needs of their elder population will be especially difficult for low- and middle-income countries to afford. Early planning for the region’s powerful demographic shifts with the right policies and institutions will be vital to safeguard Latin America’s social and economic future. OECD countries have been getting used to the idea of rapid aging over previous decades as a result of smaller family sizes, better health, more money and longer
Daniel Cotlear is a World Bank lead health economist and co-author of the new book Population Aging: Is Latin America Ready?; Phillip Hay is a communications adviser with the World Bank’s Human Development Network.
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Early planning for the region’s powerful demographic shifts with the right policies and institutions will be vital to safeguard Latin America’s social and economic future.
lives, all of which has been a huge social plus. But we should all be worried that rapid aging is no longer a rich country phenomenon and that many poorer countries are now catching up, but largely without the money and advanced planning to cope with the social and economic challenges of this profound social change. The demographic makeup of Latin America and the Caribbean (LAC) has changed dramatically since the 1950s. At that time, the region had a small population of about 160 million people, less than today’s population of Brazil. Two-thirds of Latin Americans lived in the countryside. Families were large and women had one of the highest fertility rates in the world, low levels of education, and few opportunities for work outside the household. Investments in health and education reached only a small fraction of the children, many of whom died before reaching their fifth birthday. But fast forward and the region’s LAC population has now tripled and mostly lives in cities. Far fewer children die from the illnesses of previous decades thanks to health and education advances; and 50 percent fewer babies are born as a result of women taking advantage of education and significantly more opportunities to work outside their homes. As a result, demographic change in LAC during the 21st century will be dominated by rapid population aging. Aging is being felt initially in the countries of high
European immigration, which were the first to initiate the demographic transition during the early 20th century and which also have the most extended social security systems. The rest of LAC will continue to benefit from a falling dependency ratio for a few more years, but will then also face rapid aging. And this process will not take a century as it did in Europe; these changes in LAC will take place over two or three decades. Globally, a fourth of the countries that are aging most rapidly are in the region. In a note to the authors of the new Bank study, Alejandro Toledo, the former President of Peru, says “this book describes the issues that compel us to craft a new social agenda for Latin America which now needs to incorporate the challenges of the growing aging population…Governments and the private sector must learn to balance the needs, the demands posed by a rapidly growing population of seniors while continuing to invest in the education of our youth and the needs of the poor.” So how can governments manage the inevitable aging of their smaller populations? It’s important to note that it is not a case of either pensions or poverty being the only options. We need to understand the economic life cycle, elderly work and incomes, family support, gender and also the cost of health care in old age. In the long run, pension coverage needs to cover more people, especially those who work off the radar in the informal jobs market where government regulations and protections just don’t apply. The new report advises countries and communities to develop a number of policies that support long productive lives for their workers and keep the elderly healthy and mobile for as long as possible. For example, health care systems that can provide the elderly with healthy living and geriatric health services will be essential. This is especially important since diabetes, obesity, heart disease and other noncommunicable diseases predominantly strike people in middle age and beyond and can be a source of financial hardship and worse still, sudden poverty, as people are forced to pay for their own treatment. Promoting healthy aging is without doubt one of the best strategies to keep older people healthy and active, and involves the adoption of preventive medical and social approaches to forestall the need of elderly for clinical or long-term care services. Standard measures relate to lifestyle changes, including diet, weight and exercise. Increasing efforts to confront growing rates of obesity – both reducing the weight of obese elderly and
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More People are Growing Older in Latin America and the Caribbean 2010
2050
80 years and over
80 years and over
70-74 Female
-40,000,000
60-64
70-74 Male
60-64
Female
50-54
50-54
40-44
40-44
30-34
30-34
20-24
20-24
10-14
10-14
0-4
0-4 40,000,000
in preventing additional elderly from becoming obese – is of particular importance. Many dependent people and their families turn to the health sector, in particular hospitals, when they really need effective social care. Long-term care provided by the health system might not be sufficient. For example, as many as 12 million Americans are expected to need long term care by the year 2020, and the need in the developing world will rise by as much as 400 percent in the coming decades. In Brazil, five times as many people are projected to need care by non-family members in 2040 compared to today. In most countries, there is a lack of community-based care such as daycare, assisted living and home-based care. Patients overwhelmingly prefer to be taken care of at home; in many cases it is also the more effective and affordable solution. Examples of such designs are the neighborhood and community-based arrangements termed “care-friendly districts” in the Netherlands and “Open Care Centers” in Greece. These arrangements introduce a category of care that is part medical and part social, located between home care and primary care. With caring for the elderly likely to take up more and more national economic activity over the coming years, the report says that the public sector cannot be expected to care of this responsibility on its own. The public sector needs to prioritize its core services and buy long-term care services from the private sector, including NGOs and community groups. Instead of retiring in their early 60s, workers could wait until much later to leave the workforce as they now do in Singapore and some European Union countries; governments can provide life-long learning programs for
-40,000,000
Male
40,000,000
people in their 50s and 60s, expanding them from their current audience of adults mostly in their 30s. Enacting laws against age discrimination should be explored because of indications in some Latin American countries that older workers already face real discrimination in the workplace. Attracting more women into the jobs market is another policy option since the numbers of women in the region’s workforce vary widely. Countries with fewer women employed outside their homes may want to think about this as an opportunity to expand their workforce in the context of population aging. LAC countries will also want to continue reforming their pension systems, seeking to achieve greater coverage of the population and to increase life savings. Many countries in the region have championed reforms that have been largely successful at reducing costs, but have failed to expand sufficient coverage for older people. For example, LAC countries projected increase in pension spending of about 2.4 percent – similar to most countries in the European Union – but cover only 40 percent of the elderly. On the other hand, where coverage is high – as in Brazil, Costa Rica and Cuba – population aging alone over the next 40 years is set to add between 10 and 18 percent of GDP to public obligations. The World Bank is working with countries to tackle these problems with lending and innovative policies. So, just as OECD countries have shown over recent decades, early planning for the region’s profound demographic shifts with the right policies and institutions will be vital to safeguard Latin America’s social and economic future. GH —
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C Read Population Aging: Is Latin America Ready?
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La Sage-Femme Bouche-Trou
The Stopgap Midwife By Hawa Talla and lindsey freeze Photos by clement tardif
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Midwife Céline Nataye Sow (photographed, left, in white) manages the Sampathe Health Post in Thiès, Senegal, 50 miles northeast of Dakar.
The Stopgap Midwife: that’s what her Senegalese colleagues affectionately started calling her for her willingness to work on all fronts. Like many health workers in Africa and other regions where human resources are scarce, 47-year-old midwife Céline Nataye Sow is spread thin, working beyond traditional boundaries to fill in gaps where she can. But here, as in other countries where health systems are strained, “stopgap” means much more than the phrase might conjure. Céline, manages the Sampathe Health Post, in Thiès, Senegal (50 miles from Dakar), which serves 16,100 Hawa Talla is team lead, Health Partnership and Communication, IntraHealth International, Dakar. Lindsey Freeze is an external relations officer, IntraHealth, Chapel Hill.
people. One of only a few midwives in Senegal working as a health post manager, she usually sees 40 to 45 clients per day, while serving as a constant mentor to a busy staff of 19. And under Céline’s leadership, the post has undergone major renovations and reduced waiting times. The health post now receives twice as many clients as it did before she came in 2008. Céline lives with her 11-year-old daughter, Mamina, the youngest of her three children, in an apartment above the Sampathe pharmacy. It is about 100 miles away from her husband who is a nurse at the Kaolack Regional Hospital, southeast of Thiès. He visits every
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Senegal Population
12,211,000
Infant mortality
5.7%
Under-five mortality
10.8%
Maternal mortality Per 100,000 pregnancies 401 Contraceptive prevalence
11.8%
Fertility rate
5.0
Physicians Per 10,000 people 1 Nurses/midwives Per 10,000 population
4
Births attended By skilled professional 52%
strain throughout the region – Céline relies on interns from private training institutions. On average, she mentors about 30 each year. Almost one-quarter of the people who live in the Sampathe Post’s four-to-seven-mile vicinity are women ages 15 to 49, who will likely need a range of reproductive health services during child-bearing years from family planning, HIV- and STD-testing, to antenatal and newborn care.
two weeks. This living situation is not uncommon for health workers – in Senegal and elsewhere. Here’s the story of one day in Céline’s life. 6 am Céline’s day starts, like that of many mothers, rising to help her daughter get ready for school. She heats water for Mamina’s shower before school and makes snacks. 6:45 am Prayer beads in hand, Céline walks her daughter to catch the bus every morning, about a hundred feet away from the house. She worries about Mamina’s safety on the road. Although road safety in Senegal has dramatically improved in the last decade, Africa still has the highest traffic fatality rate in the world. 6:55 am Before returning to her apartment above the health post, she checks on the matron and midwifery intern in the main ward. To ease staffing shortages – a
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7:00 am Céline goes back to her apartment to enjoy a cup of coffee and get ready for her day. Putting on make-up, she pays close attention to the noises below – chairs moving, doors opening, brooms falling, staff greeting each other – listening as the health post gets busier. 8:00 am Céline makes her way back downstairs to start her official work day. 8:15 am Rushing to the main ward, she is alerted by the cries of a child whose foot was run over by a car. Once the child is bandaged up, Céline urges the mother to return for a follow-up visit. 8:28 am Cleaning her desk, opening the registers, and gathering the supplies needed for morning consultations. The day quickens: Céline has 22 antenatal visits, 12 family planning clients, and four general consultations – all before lunchtime. 1:30 pm After 40 consultations, Céline passes an empty waiting room. Home for lunch, Mamina waits outside.
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The stories of her patients, and the different emotions each brings out in her, keep Céline going throughout the day.
Once upstairs, they sit at the table and watch TV; Mamina calls her father in Kaolack to let him know what she’s been up to… 3:10 pm Mid-afternoon, Céline goes to a computer class – for Excel – offered by the health committee. The classes help strengthen providers’ IT skills and improve their overall productivity. At the health post level, they generate resources which complement the funds used to pay for operating costs, including water, utilities and stipends paid to community health workers. 4:15 pm Céline attends another meeting, this time at the district health offices for a meeting on the health post’s partnership with training institutions. From her mentor, Anna Ngom, Céline learns that a partner is about to allocate funds to buy new equipment for the Sampathe post – now a spacious facility that includes a consultation room, waiting room, a delivery ward, another for critically injured patients, one devoted to postpartum patients, a pharmacy, a staff room and two observation rooms (one for women and one for men). In 2009, under Céline’s watch, the health committee renovated the health post in response to problems identified during an on-the-job training approach (called tutorat, introduced by IntraHealth through the USAID-funded bilateral project in Senegal). 5:30 pm Thiès Regional Hospital – Céline trains future health workers in obstetrics, gynecology and contraceptive technology. In collaboration with the hospital’s gynecologist, she facilitates participatory training sessions where students are encouraged to demonstrate individual leadership. One third of low-income women in Senegal lack access to modern family planning, contributing to the country’s
high maternal and newborn mortality rates. In Senegal, nearly 400 of every 100,000 pregnancies end in the mother’s death. On the days she doesn’t teach, Céline helps community health workers from the health post organize special events that promote child health in nearby communities. They weigh children to monitor growth and nutritional status. 7:00 pm The day nears an end. Before going home, Céline goes back to the health post to see if any new patients have arrived and ensure that the nightshift is in place and everything is running smoothly in her absence. 7:40 pm At home. She helps Mamina with her homework. They talk about school. They cook and have dinner together. For Céline, it’s the best time of the day; she finally has time for her daughter and herself. 9:00 pm Céline’s day is finally over…unless something comes up at the health post during the night. GH —
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By Priya Matzen and Nicolai Lohse
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NCD Prevention Begins in the Womb As little as 10 years ago, the prevailing wisdom held was that the major chronic diseases of Westernized societies were due to poor lifestyle choices or genetic inheritance. But recent research indicates that adverse environmental conditions in the womb – undernutrition, overnutrition or exposure to harmful toxins as a result of maternal malnutrition, obesity, stress, smoking, etc. – is an equal, if not more, significant determinant of a person’s future vulnerability to non-communicable diseases. Diabetes during pregnancy, with its associated high blood glucose levels and link to maternal obesity, creates such an adverse environment and is a condition that poses a significant risk to both mother and child if it is not detected and managed. Diabetes often occurs for the first time during pregnancy, so-called gestational diabetes. Babies of mothers with diabetes are typically larger, which contributes to health problems like damage to shoulders during birth, low blood glucose at birth, a higher risk of breathing problems, and the need for delivery by caesarean section. Gestational diabetes is also associated with an increased risk of spontaneous abortion and pre-term delivery. Women who suffer from gestational diabetes and their offspring are at a high risk of developing chronic diseases during their lifetime. Pregnant women who experience gestational diabetes are more than seven times more likely to develop type 2 diabetes later in life – and their children are at a four to eight times greater risk of developing the disease – than those whose pregnancies were not affected by diabetes. In a recent Lancet series on stillbirth, screening and management of diabetes mellitus in pregnancy is recommended as part of the intervention package to reduce stillbirth prevalence in countries with moderate to low rates of stillbirth. However, the positive effects of this intervention on broader maternal and child
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Diabetes Prevalence among Pregnant Women
Source: A Jiwani, E marseille, N Lohse, JG Kahn. “Gestational diabetes mellitus: Results from a survey of country prevalence and practices”. J Mat Fetal Neonat Med 2011, in press.
health continue to be downplayed and underestimated, particularly in countries with high prevalence of stillbirth. Based on a conservative estimate, 5 to 10 million pregnant women of 136 million pregnancies worldwide have gestational diabetes each year. Despite scattered evidence, the global prevalence of gestational diabetes appears to be increasing, reaching 17.8 percent in urban areas in India. It varies from low rates in some countries to nearly 30 percent in others. New diagnostic criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups operate with lower thresholds and are likely to increase prevalence two to three-fold, for example from 13 percent to 38 percent in the United Arab Emirates. Thus, the exact scale of the problem is likely to be underestimated, and screening is often not available or poorly implemented.
Priya Matzen is program director, Early Origins of Health at Novo Nordisk. Nicolai Lohse, MD, PhD is program director, Changing Diabetes in Pregnancy at Novo Nordisk.
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To address some of these challenges, Novo Nordisk has set up local public-private partnerships in India, Colombia and Nicaragua, working with local health authorities as well as academic and implementing partners to train health care professionals, build capacity in the health system for gestational diabetes screening and management, and test innovative ways to change the lifestyle of mothers with gestational diabetes and their families with the aim of identifying cost-effective ways of reducing the burden of diabetes-related disease both in the short and long term.
of health literacy, nutrition, research, access to health, and connecting people, ideas and resources. In joining this effort, partners acknowledge the need for positively influencing the women’s standing in society, including the cultural, family-related, political and societal contexts set for maternal and child health. The development of health literacy among mothers and those influencing their health will be a key indicator for the program. Our focus will be on women living in low- and middle-income countries where the unmet needs are most prevalent and where the full impact is greatest.
Prevention of Non-Communicable Diseases There is a growing recognition that the development of many non-communicable diseases may have their roots in the uterine environment and up to the age of two years. A healthy pregnancy has been primarily thought of as a key to a healthy infancy and childhood, but new evidence is showing that the effects linger well into adulthood. Therefore ensuring optimal health of women and their children early in life is critical for the prevention of non-communicable diseases and intergenerational transmission of poor health
Policy Implications The Early Origins of Health initiative provides a unique platform for bringing together actors from many health agendas, thereby breaking the silo focus that is too often predominating global health thinking. The initiative will foster a multi-stakeholder policy dialogue around the specific links between MNCH, non-communicable diseases and the MDGs. The time is ripe for such a multi-stakeholder dialogue, and the concept of early interventions to address lifelong prevention provides us with a unique opportunity to bring together stakeholders also from the infectious disease communities to address integration of services at the programmatic level for a public health goal that reaches across the lifespan and across disease areas.
This new evidence underlines the importance of early intervention in the prenatal and early childhood years as a cost effective means of preventing later chronic diseases. Through strengthened maternal health policy and early interventions, current initiatives could be expanded to achieve multiple goals: preventing non-communicable diseases, ending the intergenerational transfer of ill health, reducing child mortality and advancing human development.
A Multi-Sector Partnership The challenge presented by non-communicable diseases is of such a magnitude that we need to carefully consider how the global health community can have the greatest impact over the short and long term. Early Origins of Health is an initiative aiming to design timely early interventions that can reduce the risk of developing non-communicable diseases in adult life. This initiative needs a broader focus than diabetes only, and therefore Novo Nordisk is building partnerships with Johnson & Johnson, PepsiCo, Steno Diabetes Center, the World Diabetes Federation and the United Nations Foundation who will provide their expertise in the field
A strong policy statement in the outcomes document from the UN High-level Meeting on non-communicable diseases in September 2011 on the link between early environment and prevention of non-communicable diseases will spur the much needed innovation on early interventions required to turn the tide of the NCD epidemic. Conclusions Pregnancy provides an opportunity to intervene that may enable us to prevent non-communicable diseases over the entire lifespan. Policy makers need to recognize that the promotion of maternal health is a central component of diabetes prevention strategies. To achieve sustainable outcomes, the private sector needs to partner with other sectors and take an active role in designing practical and scalable solutions. This will also enable us to provide a healthy start to life that is passed on to future generations. GH —
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By Richard J. Brennan and Jacob Hughes
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Post-Conflict Liberia Reconstructing the Health Sector Liberia is the oldest republic in Africa, having been settled by freed American slaves in the 1820s and becoming a sovereign nation in 1847. Decades of oppression of the indigenous population by the ruling elite culminated in a vicious coup in 1980 and, subsequently, 14 years of civil conflict between 1989 and 2003. Following free and fair elections, President Ellen Johnson-Sirleaf assumed the presidency in 2006, becoming the first female head of state in Africa. She inherited a nation with major disruption of every sector. With it came very low levels of trust between this former “pariah state” and the international community, as well as between the citizens of Liberia and their government. It is never easy for the leadership of a country emerging from conflict to set a course for national reconstruction in the face of enormous loss, or to make the difficult choices among overwhelming and competing demands.
One sector that has documented considerable success is health – in large part due to the leadership and vision of the country’s Ministry of Health and Social Welfare. In many ways the ministry is on its way to fulfilling its ambitious 2007 goal of becoming a “model of postconflict recovery in the health field.” Nonetheless, the challenges facing Liberia are considerable, including the persistent corruption, the global recession, and the
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Photos by Richard Brennan
But in many ways, Liberia’s recent progress has been as impressive as any post-conflict country. Over the past five years, the Sirleaf government has gained widespread respect both nationally and internationally for the return to peace and stability, the progress of its poverty reduction strategy, and the successful negotiation of $4.6 billion in debt relief. recent arrival of an estimated 158,000 refugees from the conflict in neighboring Côte d’Ivoire. Evolution of the Health System Liberia’s health sector has recently evolved through several discernible phases. Throughout the war years and into the early post-conflict period, service delivery was based on a largely a humanitarian model – heavily
Richard J. Brennan, MBBS, MPH, is chief of party, Liberia. Rebuilding Basic Health Services at JSI Research and Training Inc. Jacob Hughes, MPA, is a consultant for USAID and JSI.
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Liberia at a Glance (November 2010) Topic
Status
Population Living on Less than a Dollar a Day
76.2%
Life Expectancy
57.9 years (2009 UNDP)
Under Five Mortality
114/1000 live births (DHS)
Maternal Mortality Rate
994/100,000 live births (DHS)
Access to Improved Drinking Water
75% (93% urban, 58% rural) (2009 LMIS)
Access to Adequate Sanitation
44% (63% urban, 27% rural) (2009 LMIS)
HIV seroprevalence
1.5% (1.8% female, 1.2% male) (2007)
Vaccination Coverage (full)
51% (2010)
Source: Demographic and Health Survey (2007), UNDP Human Development Report (2009), Liberia Malaria Indicator Survey (2009), UNDAF framework (2008), Liberia Poverty Reduction Strategy (2008), Core Welfare Indicator Questionnaire (2007), World Bank and IMF’s Economic Outlook (April 2010).
dependent on short-term funding from international donors and on operational support from non-governmental organizations. Because of the war, during the humanitarian phase people lost faith in the intentions and priorities of their government – the social contract had been broken. Beginning with the launch of a new National Health Policy and Plan in 2007, the sector entered a transition phase, including a clear medium-term vision and plan, a well-defined basic package of health services, and a wider donor funding base. More recently, the MOHSW has embarked on the exciting process of developing a 10-year development policy and plan that will include a longer-term vision, an expanded package of services, and detailed strategies for decentralized management of service delivery and health systems strengthening. Time of Transition – The 2007 Plan Before the transition phase, most substantive discussions on service delivery were held outside of the domain of government. The high-level Health Sector Coordinating Committee meeting was held in the office of the World Health Organization. Donors funded their non-governmental organizations to implement their health projects. The international footprint overshadowed government in almost every aspect. Under the Sirleaf administration, and with new leadership in the Ministry of Health and Social Welfare, government began to gradually assume leadership functions and assert its authority. Within the first year of the administration, virtually every interagency committee in the health sector had a new chairperson – a senior member of the ministry.
The ministry then successfully engaged a broad range of stakeholders in the development of the 2007 National Health Policy and Plan, which were designed to guide the sector through the following five years. An impressive array of government ministries, donors, United Nations agencies, NGOs and technical experts contributed to the process. The cornerstone of the new service delivery strategy was the basic package of health services, which clearly outlines those services to be provided at each level of the health system. These three key documents – the policy, plan and basic package of health services – were well conceived, technically strong and based on sound public health principles. They set ambitious, but not unrealistic, targets for the period 2007 – 2011. Moreover, they were well written and concise, making them accessible to most health managers. The consultative, participatory approach employed by the health ministry in their development resulted in a strong sense of ownership at all levels – as well as affirming that it was the role of government to lead, although all would be welcome to participate. Throughout the implementation of its five year plan, the health ministry has continued to collaborate effectively and transparently with its partners, earning considerable trust and cooperation. Importantly, all major donors were deliberately and strategically engaged from the outset to garner their commitment to the ministry’s objectives, strategies and basic package of health services. By going to the sources of most funding for health, the ministry was able to quickly initiate health activities according to its policy and plan. Perhaps most
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Health has provided an opportunity for government to reestablish trust with its international partners and to demonstrate its commitment to fulfilling its role in the social contract. impressively, it was the first of any government ministry or agency to do so. Subsequently, several donors made large contributions to a common financing mechanism, the Health Sector Pool Fund – an innovative, government-managed multi-donor fund that breaths life back into the national system and ensures continuity of service delivery by funding NGOs. In early 2012, U.S. Agency for International Development will also begin to channel its direct support for health service delivery through the government’s national systems, with on-going technical assistance from U.S. government-supported projects. By mid-2012, three-fourths of all NGO-supported facilities in Liberia will be funded through the Ministry of Health and Social Welfare, thus making further progress to restoring public confidence in the government’s commitment to providing basic services – a major factor in sustaining the peace and prosperity gained thus far. Impressive progress has already been documented since the roll-out of the strategy and the basic package of health services. Institutionalization of government standards has been reinforced across the country by the ministry’s annual accreditation survey, which evaluates health facilities against inputs and services outlined in the basic package. In the January 2011 survey, 82 percent of health facilities were assessed as providing the basic package of health services – up from 36 percent just two years earlier. Facility-based deliveries have increased nationally and have tripled in some areas over the past two years, household ownership of insecticide-treated nets has more than doubled to 49 percent, and malaria prevalence among children has reduced by almost half. The mortality rate of 110 deaths/1,000 live births for children younger than
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5-years-old represents a 50 percent decline from war time estimates, although this improvement preceded the 2007 Policy and Plan, and can likely be attributed as much to improvements in peace as to expansion of services. Other important developments include the re-opening and strengthening of several nursing schools, the upgrading of the national health management information system, the establishment of important technical units within the ministry (e.g. nutrition department), and early successes with the introduction of performance-based financing of health services. Moreover, a number of important policies, plans and technical documents have been developed, including a community health strategy and an in-service training strategy and plan. Nonetheless, many challenges persist. Some important health outcomes have not improved (e.g. maternal mortality ratio of 994 deaths/100,000 live births) and coverage rates for some key services have made little progress (e.g. full immunization coverage of 51 percent). There are still major gaps in health worker numbers and skills, especially in rural areas. The institutional capacity of the ministry is limited and county-level capacity remains weak. Gaps in key policies and plans persist, while others remain to be implemented; and several support systems remain underdeveloped, such as the supply chain. Toward Development – The 10-year Policy and Plan Against this backdrop, the Ministry of Health and Social Welfare is now developing an updated strategy that will guide the health sector through the next
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decade. It is being informed by newly available data on demographics, the health workforce, infrastructure, financing and outcomes. The process is also being informed by and linked to other government initiatives, including civil service reform and the National Decentralization Policy. The participatory, 10-month policy and planning process is outlined in a comprehensive roadmap that includes several parallel, but intersecting tracks. Among the most important is county-level planning, which reflects the government’s commitment to making investments that address needs identified by its citizens. By July 2011, the ministry expects to unveil the 10-year National Health and Social Welfare Policy, Plan and Expanded Essential Package of Health Services at its annual national health review. The drafted policy, plan and essential package of health services all embrace several common principles and strategic approaches. The policy clearly articulates the government’s affirmation that access to quality health and social welfare services is a basic human right. The Ministry of Health and Social Welfare’s commitment to equity, efficiency, gender sensitivity and pro-poor focus are also evident throughout the documents. The primary health care model is the strategic foundation of the Liberian health system. Consistent with national priorities, the process of decentralization will result in resources and responsibilities being devolved from the central level to county health and social welfare teams over the next 10 years. Important lessons have been learned through implementation of the 2007 Policy and Plan that are being incorporated into the new strategy. For example, the earlier documents outlined a rather rigid model for facility-based care, with fixed staffing patterns, salary scales and service packages. But it did not take into account variations in facility catchment population size, distances from communities to facilities, or provider workloads. The draft 10-year policy and plan sanction a new type of clinic and outreach, more flexible staffing patterns, and a process for optimizing the distribution of facilities by county health and social welfare teams that will better meet the needs of their populations. Although the priorities are seemingly endless, national development in Liberia, as evidenced by the health sector, continues to follow a thoughtful, logical and incremental path. Health has provided an opportunity for government to reestablish trust with its international partners and to demonstrate its commitment to fulfilling its role in the social contract. Although many constraints persist, some impressive gains have already been
documented. Central to this success has been the clear vision and strong leadership of the Ministry of Health and Social Welfare. By adhering to principles of participation, transparency and accountability, the government is earning the support and cooperation of development partners as well as of its most important stakeholders – its citizens. It is expected that this strong foundational work will continue to translate into improved health outcomes. GH — www.globalhealthmagazine.com
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By Catherine Connor, Laurel Hatt and Thierry van Bastelaer
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Paying for a Healthier Future Development assistance for health has ballooned from $5.6 billion in 1990 to $21.8 billion in 2007. Until the recent economic crisis, many developing countries were enjoying economic growth rates of five to six percent, and stepping up their commitment to health. Despite these trends, unfortunately, many developing countries still face financing gaps that must be overcome to secure a healthier tomorrow. Given the magnitude of health issues remaining in many developing countries, there is a continuing need to accelerate investment in health over the coming decades. Increase Investment How much should a developing country spend on health? In 2009, the WHO set a target of $54 per capita for a basic package of essential health services in developing countries. Even under very optimistic assumptions, estimates show that governments in 28 African countries would still not reach that target by 2020. How can the gap in financing be bridged? Increase government budget allocations. This outcome depends on many factors, beginning with growth of the formal taxable economy – rising GDP in developing countries between 1995 and 2006 made it possible for governments to almost double the amount of resources going to health. Another factor is the capacity of governments to collect tax revenues efficiently by upgrading tax administration systems and staff capacity, and by upholding accountability and anti-corruption measures. In addition, the health sector – particularly ministries of health – must demonstrate to ministries of finance that budget allocations will be fully executed and spent efficiently. Finally, governments must resist the temptation to reduce their own budget allocations to health when donor funding for health increases. Leverage the formal private sector. A recent report by the International Finance Corporation estimates that $11–$20 billion of new investments could be raised in Africa from private investors in the next 10 years, largely in physical infrastructure for health. In order to encourage this type of investment, and to ensure that private spending achieves desired outcomes, it will
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be necessary to strengthen the capacity of public and private regulatory bodies, and to enhance the ability of public entities to procure services and manage contracts with private organizations. Countries can also promote tax policies that are friendly to private sector investment in the health system, and work to increase access to local and international capital for private investors in health. Support innovative financing mechanisms for new health technologies. Innovative financing mechanisms, such as advance market commitments for vaccines and the Affordable Medicines Facility for Malaria, provide revenue to stimulate the development and manufacture of vaccines for developing countries and to facilitate widespread financial access to malaria treatments, respectively. Improve Equity in Risk Sharing Formal and informal private spending on health is mostly in the form of out-of-pocket spending – the most regressive and exclusionary form of health financing, which accounts for an average of 34–50 percent of total health financing in developing countries. This contributes to the financial catastrophe that more than 135 million people suffer because of the costs of health care. In addition, the absence of financial protection against health costs generates a vicious circle: families postpone seeking care because of financial barriers, suffer worse clinical outcomes, leading to foregone income, and even higher financial vulnerability down the road. What are some options to reduce poor households’ vulnerability? Develop and strengthen health insurance systems. More extensive and sustainable risk pooling systems are needed to harness household spending – particularly for expensive, inpatient care – in an equitable and predictable way. These efforts can take several forms: . National or social health insurance schemes; . Community-based health insurance; . Voluntary private insurance programs targeting the poor, such as schemes managed by microfinance organizations.
Catherine Connor is deputy director, Health Systems 20/20 project at Abt Associates. Laurel Hatt is a health economist, Health Systems 20/20 project at Abt Associates. Thierry van Bastelaer is health financing advisor, Strengthening Health Outcomes through the Private Sector (SHOPS) project, Abt Associates.
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Explore and develop alternative micro health financing tools. In settings where insurance is unavailable or unaffordable but microfinance services are offered, savings and loans can help spread the impact of the cost of health care over manageable periods of time. Health savings accounts can help accumulate amounts necessary to cover most outpatient expenses. Health loans allow poor households to borrow the amount necessary for most inpatient care, and repay it over several months – avoiding the necessity to sell productive assets at the time of a health crisis. Target fee exemptions and subsidies to the most vulnerable. Although large numbers of households in developing countries are financially able to contribute a small portion of the cost of health care, even small contributions may be out of reach for the poorest and most vulnerable households. Targeted subsidies via vouchers, conditional cash transfers, and targeted user fee exemptions are a central element of equitable health financing policies that have been proven to increase use. Increase Efficiency Even if sufficient funding for health becomes available and even if it is generated without placing an excessive financial burden on poor households, there remains an overriding need to ensure that existing and future resources are spent as efficiently and effectively as possible. According to a conservative estimate by the WHO, 20-40 percent of health resources are being routinely wasted. Addressing this means ensuring that the most effective interventions are prioritized, efficient providers (public or private) are selected, and that providers are incentivized to perform well in terms of health outcomes and quality. What are some options to increase the efficiency of resources devoted to health? Implement performance-based financing systems. By aligning financial incentives with the achievement of desired results, performance-based financing seeks to change behaviors among public and private sector providers by linking their payment to health outcomes and other measurable indicators of performance. Performance-based financing gives incentives to households, providers, and local governments to find on-the-ground, practical and effective solutions to health systems challenges. In addition to its ability to increase efficiency in financing, performance-based financing offers stronger incentives to health workers to provide higher quality of care and, more broadly, a better medical experience for patients.
Engage in public-private partnerships for the provision of care. By contracting with private sector service providers to expand access to high-quality services, governments and the private sector can each focus on their respective strengths. Appropriately qualified and certified private providers can bring the benefits of more efficient management and systems to the delivery of quality care, while governments can focus their efforts on raising fiscal resources for health, or subsidizing access by the poorest or most vulnerable citizens. Increase donor coordination and put donor spending on-budget. Improving coordination among donors so that agendas and priorities are aligned with those of recipient countries increases the efficiency of resource utilization and reduces the country’s reporting burden. Donor health financing that is “on-budget” (included within the country’s national budget) can help to foster sustainability, accountability and transparency. Improve public financial management systems. Improve systems to ensure that resources are used for the right purposes (financial accountability) and produce the desired results (programmatic accountability). Financial management systems in the public sector have been a problem in most developing countries due in part to lack of staff capacity, poorly functioning accounting systems (in many cases, hand-written ledgers are still used), and corruption. The Way Forward Health financing challenges are real, and these solutions are not simple. The good news is that, while these approaches are beneficial in their own right, they also can reinforce one another. A number of countries – Brazil, Cambodia, China, Ghana, Mali, Mexico, Rwanda, Thailand – are demonstrating that progress is indeed possible. Lessons from these country experiences highlight three principles of good practice in health financing. First, countries need to make choices based on sound evidence, local context and robust stakeholder input. Second, external technical support must be fully objective and sensitive to country-specific needs. Third, care should be taken to balance the urgency to respond to immediate priorities using short-term solutions with the importance of careful design of long-term health financing strategy and systems that will address both current and future health needs. GH —
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By Jonny Dorsey and Barbara Bush
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Photo courtesy of Global Health Corps
Opening the Door to Global Health Talent
Young people do amazing work toward building a world where everyone can access health care and live a full life. Yet all too frequently, they must struggle to break into opportunities within the global health community.
Consequently, many young people who have a desire to serve turn to other careers. If we want to win the battle against today’s enormous health challenges, we must build a robust pipeline of talent for global health, and harness the wave of energy, enthusiasm and skill of the millennial generation. Global Health Corps is a testament to the power of young people in action. Since its founding in 2009, Global Health Corps has placed 58 fellows from 10 countries in health nonprofits around the world to fill critical needs – welcoming them into a growing community of public servants while providing a stepping-stone into a career in public health. Importantly, fellows are placed in team of two: one American, and one peer from the African
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host country. A strong leadership pipeline must include young people from emerging and developing countries to create meaningful change and build leadership around the world. For example, at Partners In Health (PIH) in Rwanda, two Global Health Corps fellows – a Rwandan and an American – managed a $1.4 million procurement of medical equipment and supplies for the Burera Hospital in northern Rwanda. But they weren’t the only fellows who worked on this project; two other fellows worked as architects of the hospital. Another fellow created the operating plan for the hospital, which serves a community of 400,000 poor Rwandans. Other fellows helped plan the integration with the Rwandan government. Following their fellowships, one individual now works as PIH’s Africa procurement and logistics coordinator, while another oversees the construction and rehabilitation of health centers across the entire country in his new position within the Rwandan Ministry of Health.
Jonny Dorsey is co-founder of Global Health Corps and FACE AIDS. Barbara Bush is co-founder and CEO of Global Health Corps.
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Unfortunately, most of the young talent that seeks to work in this space is turned away. In fact, one of the fellows who worked on the Burera Hospital had difficulties getting a foot into the global health community, despite performing well in school, starting a campus AIDS coalition and providing hospice care in his home community. When he applied for Global Health Corps, he was bartending in Washington, D.C. to make a living. During his fellowship, he was so effective that he was hired and promoted by his placement organization – yet our sector almost missed out on his commitment, and his talent. Huge numbers of millennials want to serve in global health, and this desire is only growing. This year more than 2,000 young professionals applied for 70 Global Health Corps positions. Many organizations, including two we work with closely, FACE AIDS and GlobeMed, are further strengthening this pool of equity-focused studentleaders through engagement on high school and college campuses. The private sector has focused significant resources on building talent pipelines of young people. Entire programs at business schools and large corporations focus on recruiting, training and retaining talent. While the social sector cannot always use the same strategies as multinational companies, it can still invest in emerging leaders, and in exchange, reap great results. No organization proves this as clearly as Teach for America. Teach for America recruits more than 4,000 young teachers from the top colleges in America every year – many of whom emerge two years later not only with a dedication to continue to work in education, but also a commitment to create a world where every child has access to a good education. The young teachers receive training, mentorship, career development resources and a strong community committed to social justice. Several of the most innovative programs in education – from KIPP Charter Schools to The New Teacher Project – were founded by dedicated Teach for America alumni.
We must build a similar pipeline for global health – one that will produce thousands of leaders committed to health equity. Doing this will take significant investment. Teach for America spent $155 million in 2009. And this is just one of many efforts in education to train new leaders. In health we count on universities to do too much of the heavy lifting. Certainly, they are an important piece of the puzzle. But just as Teach for America is complementary to schools of education, and corporations’ leadership programs round out business school, we, in health, must build programs that support the rigorous academics of universities. Some foundations devote funds to building the leadership pipeline in health, but the examples are few and far between. Fortunately, some foundation leaders have shown a clear understanding of this challenge and opportunity; Bill Gates himself stated that the biggest challenge we face is getting the best and brightest to tackle our biggest problems. We must respond to that challenge with wise investments. Success would include robust recruiting programs that harness talent of all types – from computer scientists to managers to epidemiologists. Success would also include strong training and mentoring programs for young talent, and reasonable salaries that will retain them. Most importantly, success requires helping emerging leaders develop a set of values that will inspire them to not just build careers in the health sector, but also to work toward health equity. Though this endeavor will take many years, there are a few solutions that could be put into practice today to strengthen the global health sector’s leadership pipeline. E Pay interns. Our sector limits the talent pool we draw from when we tell inspired youth that they must go elsewhere if they seek to be paid. E Recruit more interns. Provide pathways into the field for young people with all the necessary skills in this movement – not just pre-medical students. E Provide strong mentorship. Ensure you have a structured mentoring program that develops young talent. Our world’s ability to provide quality care to everyone will depend largely on who steps up to work and create new solutions, and what values they bring with them. The millennial generation is knocking, eager to make a difference in global health with their talents, energy and commitment. Let’s open the door, and build a movement that will succeed. GH —
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By Awa Marie Coll-Seck
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A Malaria-Free World is Within Reach
A decade ago, far from public outcry or front-page headlines, malaria was killing 3,000 people every day, mainly African women and children. Few of the more than 3 billion people at risk had access to mosquito nets or effective malaria drugs. Chloroquine, the main malaria drug, had become ineffective against malaria’s deadliest strain, and the pipeline for new drugs, vaccines and other tools to control malaria was virtually empty. Since the moment when advocacy efforts shifted malaria from a neglected disease to global health priority, the results were tangible: a 30-fold jump in international funding, increased commitment by African leaders, a rapid expansion of research and development, and the creation of new alliances addressing malaria. The Roll Back Malaria Partnership, the global framework for coordinated action created in 1998 by the WHO, UNICEF, UNDP and the World Bank, is now a worldwide movement of more than 500 public and private sector partners. Change has been most dramatic in Africa, where enough insecticide-treated mosquito nets have been delivered to cover 76 percent of people at risk and 11 countries have reduced malaria cases and deaths by more than 50 percent. In just a decade, Africa has begun to extract itself from the grip of a disease that has held sway for millennia. The Global Fund to Fight AIDS, Tuberculosis and Malaria, now the source of two-thirds of all malaria funding, has been instrumental in realizing many of these gains together with the U.S. President’s Malaria Initiative, ISSUE 11 summer 2011
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the World Bank Booster Programme, UNITAID and other bilateral contributions. However, these gains are as fragile as they are impressive. While countries could soon be able to distribute enough bed nets to protect everyone at risk, achieving similar traction with treatment, diagnosis and indoor spraying has proven more difficult. More critically, growing drug and insecticide resistance, left unchecked, could leave millions without effective treatment and prevention options, essentially turning the clock back to the conditions of 10 years ago. The challenge now is to not only sustain these hard-won results, but also to make greater advances in areas where progress has eluded us most, particularly access to diagnostics and treatment. Without proper use of malaria drugs, we will never conquer resistance and eliminate malaria. As we go forward, two ambitious objectives are before us: the Millennium Development Goal target to halt and begin to reverse the incidence of malaria, and the goals of the Global Malaria Action Plan, particularly the milestone to reduce malaria deaths to near zero by 2015. To reach these goals we will need to both maintain our present gains and intensify our efforts. This cannot be done without greater commitment, innovation and new ways of funding malaria control and elimination. We have already seen the power of public-private partnerships, Prof. Awa Marie Coll-Seck is the executive director of the Roll Back Malaria Partnership and former health minister of Senegal.
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in countries with a large malaria burden, particularly those in Africa, the disease consumes up to a quarter of household incomes, trapping people in a cycle of poverty.
which have made drugs more affordable and available, nurtured innovative sources of financing, and furthered research and development efforts to create new drugs, insecticides, rapid diagnostics tests and vaccines. We cannot fail to meet these objectives. If we do, the price will be too high. In addition to the millions of lives which will be lost, the impact on development will be huge. Let us not forget that in countries with a large malaria burden, particularly those in Africa, the disease consumes up to a quarter of household incomes, trapping people in a cycle of poverty. About 40 percent of government health spending goes to malaria, a disease which costs Africa $12 billion in direct costs every year, and much more in lost productivity. Countries struggling with malaria and those that have long since eliminated it both have a role to play in fighting this disease. Political leaders in countries with malaria burdens must remain firm in their commitments, from increasing health budgets to improving supply lines. Donors must meet their own pledges and help find ways to bridge the gaps in necessary funding going forward. Malaria has proven itself to be a good investment. As the most cost effective single health intervention after childhood vaccination, universal malaria prevention coverage alone can save the lives of at least 3 million African children by 2015.
Photo courtesy of the UN Foundation
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The results of the last 10 years have shown us that with innovative public private partnerships and by increasing financial and political support; we can move many steps closer to controlling and eliminating malaria. The role of partners to drive success in these areas cannot be underestimated. This tremendous progress has laid the foundation for the next phase of the malaria fight. It is now clear that while creating a malaria-free world is challenging, it is possible. This year for World Malaria Day, the Roll Back Malaria Partnership and the UN Foundation’s Nothing But Nets campaign launched a photo exhibit at UN headquarters featuring portraits of some of the “Champions” in the fight against malaria. Among those highlighted were world-leaders, faith-leaders, musicians, and a 10-year-old girl – it is truly wonderful to see the vastly different faces that are driving progress against malaria. This diversity and close partnership at every level is the secret to our success. Going forward, I hope to see even more people join what really has become a “movement” to end malaria. It is clear that the momentum continues to build: teachers are telling their students about the disease and what they can do to help, students are telling their parents, parents are telling their government representatives, and governments are coming together with public and private organizations to take action quickly. We have an opportunity to end deaths from a disease that has killed millions of people over thousands of years. Let’s seize this incredible opportunity to ensure a healthier future for people around the world. GH —
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