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Global Responsibilities in investing in the healthcare workforce

November 1, 2006




Global Responsibilities in investing in the healthcare workforce
for sustainable health

1st November 2006

Dr Asma Elsony, President of the International Union Against TB and Lung Disease (IUATLD)
Dr Nils Billo, Executive Director of the Delegates of the IUATLD
Ladies and Gentlemen
Dear Friends

First of all, I would like to say some words praising the miracles of technology. I felt very sorry when I realised that I couldn’t be with you on this very special occasion due, to an unexpected retinal detachment surgery preventing me from flying to Paris. But eventually I am most happy to have the opportunity to address the Conference and to be somehow present, thanks to the fantastic means of on-line communication!

Let me now underline that I was extremely pleased to accept the kind invitation to take part in the opening session of the current 37th edition of The Union annual international Conference.

May I greet this huge audience made up by tuberculosis and lung health experts, health policy makers, TB and HIV managers, healthcare professionals, patient advocates and activists from around the world ?

I was very much looking forward to meeting you and to introducing myself. As you might know the United Nations Secretary-General, Mr. Kofi Annan, has appointed me as his first Special Envoy to Stop Tuberculosis. It is indeed in this capacity that I am here today.
Above all, my role as Special Envoy to Stop TB, as I see it, aims at helping in achieving the Millennium Development Goal (MDG) target to “have halted and begun to reverse the incidence of TB by 2015” as well as The Stop TB Partnership’s 2015 targets – to halve prevalence and death rates from the 1990 baseline.
It is why I consider that my action has to focus on giving additional political visibility to this sometimes neglected disease; on helping generating public awareness about TB; and on continuing persuading world leaders to play their part in fully funding and implementing the Global Plan to Stop TB (2006-2015).

Meus amigos, afinal não nos devemos nunca esquecer: a TB é uma emergência, continua a matar 1.7 milhões de pessoas por ano, ou seja 5.000 homens, mulheres e crianças diariamente e, no entanto, estamos a falar de uma doença curável. Como recusar ser porta-voz desta pandemia e lutar contra esta vergonha civilizacional ?


Let me now share some thoughts with you on the subject I was asked to address here today: “Global Responsibilities in investing in the healthcare workforce for sustainable health”

I shall divide my presentation into three main parts:
I will begin by outlining the progress made in assuming global responsibilities in global health, particularly in the global fight against infectious diseases like HIV-AIDS, Malaria and TB during the last years;
Secondly, I will examine the problem of the health care workforce, particularly in low income and high burden disease countries;
Thirdly, I would like to focus on which strategies could better ensure a sustainable health policy regarding its human component in order to meet MDG and Partnership’s targets to stop TB .


First point: progress made in assuming global responsibilities in health – a major achievement: health is in the global agenda

I think everybody could agree that today health issues are clearly on the global development agenda and they are seen as an ever more global public good. These are the good news.

In the increasingly globalized world, marked by migrations and fast movements of persons at a worldwide scale, public health issues indeed call for domestic policies but require also international measures and a regional integrated approach as events overseas affect each country’s health. Communicable diseases are a most obvious example of these externality aspects of public health. That is, no single country can alone prevent or contain communicable diseases in order to protect the health of its population.

This increasing awareness of cross-border and global issues in health is clearly expressed in the growing attention paid to health by non health sector bodies, such as the World Bank, the United Nations or the G8, as well as by the private, corporate and charity sectors.
Let me recall a few examples:

– First of all, in January this year, President Obasanjo of Nigeria, Mr. Bill Gates and Mr. Gordon Brown, UK Chancellor of the Exchequer, launched the Stop TB Partnership’s Global Plan to Stop TB, 2006-2015. At that time, Mr. Gates pledged $900 million more for TB research and development efforts so essential for TB elimination.

– In July, the G-8 Summit, held in St Petersburg, included in its agenda, among key global issues such as energy security and education, the fight against infectious diseases including tuberculosis. G8 leaders committed to further support for the Global Fund to fight AIDS, TB and Malaria and to mobilize resources to fully fund the Global Plan to Stop TB. As you remember, last year, at Gleneagles Summit, the G8 had already pledged to help meet the needs to respond to the TB epidemic in Africa.

– The European Union is playing a leading role not only in being the second biggest donor to The Global Fund but also in planning to go further with an ambitious proposal to set up a 3 billion euros fund to promote good governance in Africa.

– The International Community is committed to developing innovative financing mechanisms such as the International Finance Facility and the UNITAID, which as you know, is an International Drug Purchase Facility being established by France, Brazil, Chile, Norway and the United Kingdom funded by an international air-ticket solidarity levy.

– Last May, the Global Business Coalition Initiative, led by Mr. R. Holbrooke announced that it will include TB among its critical issues for action;

– Last but not least, at the UN Millennium Summit (2000), among the eight global goals adopted by the entire global community – rich and poor countries together – health has been given maybe for the first time particular attention.

I do think that these examples are obvious indicators of health moving up the global agenda and thus being considered part of a minimum for a decent world.

In my view, at the international level, there is a clearer political commitment, a stronger public awareness and more resources available. These favourable conditions give renewed impetus to the fight against infectious diseases, but also create added responsibilities in view of producing better results.

Our shared aim, our common commitment and our motto has to be “to do more, to do faster and to do better”.

“More, fast and better” since emergencies, like TB, cannot wait.

Second point: the critical problem of the health care workforce, particularly in low income and high burden disease countries

Let’s start by taking two examples: TB and African region.
Firstly, as you all well know, but probably not the average person, TB is a preventable, curable and affordable disease. The medicines that cure TB cost about ten dollars per case of illness.
Secondly, let me remind you that the African Region has the highest TB burden per capita. Although with only 11% of the world’s population, Africa contributes approximately with 25% of TB cases. In 2004, about 2.3 million people fell ill with TB in the African region, where TB incidence is rising at over 4% a year fuelled by the HIV epidemic. Thirty-four of the 46 member States in the region face an estimated TB prevalence rate of 300 per 100,000 people and 9 countries are among the 22 Global TB high burden countries.
Now where is my point ?
Apparently TB could be thought of as a not too difficult global health problem as it is preventable, curable and affordable disease. But, in reality, it is a quite complex one. Why ?
Mainly because of the lack of infrastructures, apart indeed from all the problems related to poverty, malnutrition, sanitation, shared by all developing countries.
By infrastructures I mean physical, institutional and human components of the health care system. Because of infrastructure gaps millions of people dye everyday.
Now let me concentrate in the human resources component, the blood of the all health care system.
Of course there is a severe shortage of physicians, nurses, health care workers in many places around the world.
I have to underline that the crisis in human resources for health is one of the greatest challenges in TB control and for the Millennium Development Goals in general. To overcome this gulf, action is dramatically needed across all levels of the health system, all programs, partnerships and global stakeholders.
Allow me to tell you a story. I had the opportunity to attend a WHO African Regional Committee, last August, in Addis Ababa where I met several African Ministers of Health on a bilateral basis. If I had to summarize shared remarks, I would say that they all pointed out the lack of human resources at all levels as a major if not the main problem. In this regard, I remember particularly how a Minister coming from a big country put it bluntly, asking me if I knew that there are more doctors in big size hospital in Lisbon then in all his country twice populated than Portugal and 10 times bigger !
Moreover they all complained about lack of appropriate training and asked for help in this regard. All mentioned difficulties in recruitment and retention because of the disincentives of the work environment. All complained about “brain drain” that draws away health professionals.
I recall this personal experience because, in my view, it gives a quite accurate picture of the global health workforce crisis going on particularly in low-income, high disease burden countries. As you probably know the shortage is about 4.3 million health care workers of all sorts.
But in Africa this problem is much more acute as, while they have about 25% percent of global disease burden, only 1.3 percent of the world’s health care workers actually work there.
These figures show pretty well how the global burden and resources are unequally distributed with huge asymmetries, disparities and inequalities within the countries themselves, between urban and rural areas, as existing resources tend to be clustered in urban areas. These are the bad news.
Now I would like to end this point with good news. And the good news are success stories about ways of overcoming concrete problems. In this respect, I will briefly recall the Ethiopian experience in training primary health care people.
Firstly, Ethiopian policy makers have identified the main areas of action – actually, four main areas: maternal health, child health, HIV-AIDS-TB and malaria. Secondly, they decided that the best solution to address these four problems was to focus on primary health care particularly in rural areas. The next step was to identify the workforce that could really help with primary health care – and they decided that it was low level and mid level health extension workers. After, they decided to train as many as possible health extension workers – and, surprising and stimulating thing, they were able to train 9.900 persons in two years and deployed them within a plan that intends to achieve the total amount of 30.000 trained health workers in the next two years.
How they could produce such results in a such brief time ? According to my knowledge, by implementing an ambitious but realistic strategy, based on the use of existing assets – for instance, instead of start building nursing schools, they use existing technical and vocational training centres, so that it was like a shortcut. Instead of building down, they build up, they invest in outcomes of infrastructure in tangible ways, banking on increasing the horizontal caring capacity of the health system. They based their strategy on the will of individual communities to develop a sense of ownership over their own infrastructure, on engaging people in achieving improvements in order to guarantee the sustainability of health systems.
I think all of us can learn from the Ethiopian lessons. Of course there is a huge difference between our developed countries and countries in Africa, Asia or South America as well as between countries within these regions. But solving global health problems means sharing experiences and designing and implementing common strategies to better overcome gaps and challenges.

Third point: Strategies that could better ensure a sustainable health policy regarding its human component

In order to meet Millennium Development Goals (MDGs) and Stop TB Partnership targets there is indeed a critical need to strengthen the workforce to improve global lung health.

Let me start by stressing that the Global Plan to Stop TB (2006-2015) outlines increasing human resources capacity as a priority TB control activity in the next 10 years. There is over US$30 billion funding gap for the Global Plan, and a strong need for increased funding of global TB control globally in Europe as well as in Africa.

But tackling the human resource crisis goes beyond TB control alone.
Three points have to be emphasized.

Firstly, it requires the implementation of human resource development strategies in the public health sector, e.g. more attractive career and salary structures, improved training as well as the establishment of partnerships with communities and all health care providers, in order to use and engage all available human resources. These strategies are designed to achieve the goals set up by public authorities.

Allow me to clearly emphasize that in my personal view equal access to health for all is a matter of human rights and only Governments offer rights. By this I mean that there has to be national health infrastructures so that we can make sure that poor people have rights. So an overall Human Resources Strategy in health sector has to be designed by Governments, who are responsible for it.

This is to say that private and corporate sector, NGOs, charities, associations and foundations have indeed an important part to play in the health field, but their action has to be regulated mostly by public powers.

Secondly, it requires the reinforcement of international action on health education and training.

Health education remains for me a critical point because it is the basis of everything, a way of empowering people in preventing health problems. Education for health is, in a way, much more fundamental than treating diseases…

Regarding training, needless to stress that it is essential to better coordinate international actions and initiatives in order to avoid overlaps and gaps and to ensure that they meet real needs of people. In this respect, I do think that national health authorities and national health policy makers have the most important role to play not only to strengthen the feeling of ownership but also to ensure long term sustainability of the efforts and results.

Foreign aid and help need to be well coordinated with national plans and policies in order to rain the right health workers. Most high burden disease countries need most urgently primary health care workers.

Thirdly, it requires a broad multilateral framework on migrations and for the cross movement of people avoiding brain drain from poor to rich countries.
As is well known, this problem is particularly acute in essential social services such as education and health. While domestic policies to increase the incentives and opportunities for skilled labor to remain at home are an important part of the solution, it has also been suggested that the industrialized countries should coordinate their hiring policies with developing countries facing such skill shortages in essential services.
Measures to stimulate a process of “skills circulation” (like training, tax incentives to stimulate return of skilled migrants to their home countries etc) could be considered because they would benefit both industrialized and developing countries. The former could still continue to hire skilled labor from developing countries. The latter could also benefit from this circulation without being deprived of the very category of workers that they need most and without suffering the loss from the investment in training.
The adoption of a kind of Code of good practices for health care workers migration could be a useful tool to prevent a permanent brain drain from poor to rich countries and to stimulate the return of skill migrant to their home countries.


Dear Friends

Some final remarks to conclude.
As United Nations Secretary-General’s Special Envoy to Stop TB, I am committed to developing new ways of supporting the fight against TB.
To ensure my role is productive, I’ll indeed be working closely with WHO and the Stop TB partnership, which are leading the fight against TB. But I will not neglect regular and direct contacts neither with national and local authorities, private or public partners, nor with the civil society, non governmental organizations, and individuals working together to ultimately achieve a world free of TB. And, in this regard, your own input, Dear Friends, is invaluable.
You can count on my committed efforts to increase advocacy to focus United Nations attention to TB control in general, and TB control in the context of the universal access principle.

I will spare nothing to continue advocating for additional resources mobilization for TB control and to reinforce international and national commitments for TB control and ensure that money flows down to those in great need.

In the last years, much progress has been achieved in placing health issues at the top of the international development agenda, particularly concerning the importance of the fight against infectious diseases and diseases of poverty like TB. But, indeed, to overcome the huge global challenges we are faced with in order to achieve the MDG and the Stop TB Partnership’ s targets, there is still much to do.
There is a need for enhanced collaboration, to bring all actors in the TB control field together to make a cohesive effort in the fight against TB. There is also the need for a strong TB movement to answer the TB crisis, equivalent to that for AIDS. The International AIDS Society (IAS) is the world’s leading independent association of HIV/AIDS professionals. A similar movement for TB is needed, I feel! Count on me to support your efforts in order to reinforce The Union, a way of calling on strength through unity!

Thank you very much.