tag:theconversation.com,2011:/us/topics/tedros-ghebreyesus-39006/articlesTedros Ghebreyesus – The Conversation2017-07-16T10:20:56Ztag:theconversation.com,2011:article/808982017-07-16T10:20:56Z2017-07-16T10:20:56ZAfrican academics set out what Dr Tedros needs in his toolbox to tackle health ills<figure><img src="https://images.theconversation.com/files/178244/original/file-20170714-3488-1i1rcen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New World Health Organisation Director-General De Tedros Adhanom Ghebreyesus. </span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p>Africa has the highest burden of HIV/Aids and malaria with escalating rates of non-communicable diseases. How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? The Conversation Africa asked academics across the continent what impact his appointment will have, and for advice on what he needs to do, to manage the challenges.</p>
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<p><strong>What is the significance of his appointment?</strong></p>
<p><em><strong>Dr Thumbi Mwangi, Washington State University, Kenya Medical Research Institute:</strong></em> It’s two fold. As an African he has been closely involved in the battle against <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-5-240">neglected tropical diseases</a> like rabies, trachoma, guinea worm and others which affect <a href="http://www.who.int/mediacentre/news/releases/2017/ntd-report/en/">1 billion</a> people. He was <a href="http://www.reuters.com/article/us-health-who-idUSKBN18J278">health minister</a> in Ethiopia where neglected tropical diseases are common. He needs no lectures on why the WHO must remain at the forefront of fighting them.</p>
<p>Secondly, his ownership of the agenda as set out in his campaign <a href="http://www.drtedros.com/">manifesto</a> – to work towards “a world where everyone can lead healthy and productive lives, regardless of where they are or where they live” – should be seen and felt.</p>
<p><em><strong>Dr Andrew Githeko, Kenya Medical Research Institute:</strong></em> Dr Tedros
brings a <a href="http://www.who.int/dg/tedros/en/">wealth of experience</a> and skills in governance, diplomacy, advocacy and resource mobilisation.</p>
<p>His efforts as <a href="https://www.usaid.gov/news-information/frontlines/child-survival-ethiopia-edition/interview-dr-tedros-adhanom-ghebreyesus">health minister</a> in Ethiopia produced measurable and significant outcomes. He’s familiar with addressing infectious diseases like malaria as well as non infectious diseases.</p>
<p>He also led <a href="http://www.drtedros.com/publications/">research</a> into effective ways of controlling malaria and greatly improved the ways in which it’s prevented and controlled.</p>
<p>On top of this, he played a momentous role in bilateral and multilateral malaria initiatives including those supported by <a href="http://www.rollbackmalaria.org/">The Roll Back Malaria Partnership</a> and the <a href="https://www.theglobalfund.org/en/">Global Fund</a>. </p>
<p>As a researcher he will be sympathetic to the plight of researchers from developing countries.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> Dr Tedros comes from The Horn of Africa which remains a politically fragile setting, vulnerable to the impact of conflict and natural disasters. What this means is that he’s been in the health care trenches, like many of us who live and work in health settings across the continent. This is precisely where it’s been shown that Africa can find African solutions to African problems. </p>
<p>A leader like this is needed at the helm of the WHO. Dr Tedros will understand that Africans can be included in partnerships rather than dominated in the quest to find solutions to the unique challenges that the continent faces. </p>
<p>From an African health policy and systems research perspective, there are many reasons to laud his appointment. He brings the combined perspective of having been a researcher, a health systems manager, minister of health for Ethiopia, and a policymaker. </p>
<p><em><strong>Professor Bob Mash, Stellenbosch University:</strong></em> Dr Tedros is the first WHO director-general to have firsthand knowledge of the challenges facing African countries and health systems. One of his priority areas is “health for all” and providing universal health coverage. This implies a commitment to the strengthening of health systems, particularly primary health care. </p>
<p>This should stimulate research on disease orientated programmes as well as cross cutting systematic issues like the primary care workforce, access to care, patient-centredness, community orientated primary care as well as continuity, coordination and comprehensiveness of care. </p>
<p>But his experience in Ethiopia may not have sensitised him as much to the global problem of non-communicable diseases that’s also becoming a problem on the African continent. One of my concerns is whether he will give sufficient attention to the epidemic of diseases such as hypertension and diabetes.</p>
<p><strong>What are three biggest challenges facing him? What should he tackle first?</strong></p>
<p><em><strong>Dr Mwangi, Washington State University, Kenya Medical Research Institute :</strong></em> The WHO has faced <a href="http://www.who.int/topics/financial_crisis/financialcrisis_report_200902.pdf">financial constraints</a> addressing global health challenges including outbreaks of emerging infections.</p>
<p>Countries that are adversely affected by <a href="http://www.who.int/neglected_diseases/diseases/en/">neglected tropical diseases</a> need his voice and the diplomacy of his organisation to keep these diseases high on the global agenda, as well as top priority in affected countries.</p>
<p>Dr Tedros needs to make three focused commitments while he’s at the helm. </p>
<p>The first is domestic financing: for a long time countries affected by neglected tropical diseases have relied mainly on external funds. He needs to urge them to commit their own budgets to these diseases. Domestic budgets can help significantly. We need relatively low cost solutions such as drug tablets that are out of patent, improved hygiene for the affected populations and existence of effective vaccines.</p>
<p>Dr Tedros should also encourage partners to keep their commitments.</p>
<p>Secondly, there should be a deliberate effort to integrate the detection, surveillance and treatment of these diseases into the health system. Countries stand a much better chance of reducing and finally eliminating neglected tropical diseases if the interventions are embedded in primary health care systems.</p>
<p>The <a href="http://apps.who.int/iris/bitstream/10665/43485/1/9789241594301_eng.pdf">One Health</a> concept that brings together the human and animal health perspectives should also be practised. Dr Tedros supports this <a href="http://www.sciencedirect.com/science/article/pii/S0140673610614651">concept</a>. His challenge will be how to break the current silos in individual sectors. </p>
<p>Innovations offer important toolkits to consider. This includes <a href="http://www.sciencedirect.com/science/article/pii/S0277953613006485">mobile phones</a> to diagnose and report diseases as well as attempts such as use of <a href="http://www.gavi.org/library/news/gavi-features/2016/rwanda-launches-world-s-first-national-drone-delivery-service-powered-by-zipline/">drones</a> to supply emergency medical care and use of <a href="https://news.wsu.edu/2016/10/24/rabies-vaccine-effective-warm/">rabies vaccine</a> that needs little refrigeration that can be delivered by community health workers.</p>
<p><em><strong>Dr Githeko, Kenya Medical Research Institute:</strong></em> When it comes to malaria his greatest challenge will be to sustain – and increase – resources to the various control programmes, particularly in sub Saharan Africa.</p>
<p><a href="http://www.who.int/malaria/areas/drug_resistance/overview/en/">Resistance</a> to malaria medicines is a global health threat. Dr Tedros should support malaria endemic countries to expand and accelerate national efforts to control and eliminate malaria.</p>
<p>The WHO should urge member states to improve the training of health workers so that they closely follow the protocols in the treatment and management of malaria. This will save more lives.</p>
<p>The infrastructure in health facilities should also be improved to test for malaria, and to treat it more efficiently. This can only be achieved through concerted efforts and commitments by WHO member states.</p>
<p>The research wings in various countries need to be supported to encourage novel research of drug and insecticide resistance. Support for research will be critical to address scientific, behavioural, and socioeconomic factors that affect malaria control.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> There is a vicious cycle in which the burden of increased communicable and non-communicable diseases weaken health systems. Dr Tedros has the challenge of strengthening these systems, something he’s already committed to. </p>
<p>This has to be supported by sound health policy and systems research, to help find solutions to the continent’s health challenges. But better home grown solutions need more investment in national and Pan African centres of excellence. Dr Tedros could help by enabling greater WHO investment in health policy and systems research. These centres of excellence should be founded on close collaboration between researchers, health systems managers, health systems policymakers, as well as communities and civil society organisations. </p>
<p>Centres of excellence could facilitate closer collaboration between health policy, the research community and the WHO. This could help ensure that research is more closely aligned to the real challenges faced in our own countries. We will hopefully begin to reduce the “know-do gap” where research evidence exists, but isn’t taken up in implementation.</p>
<p><em><strong>Professor Mash, Stellenbosch University:</strong></em> One of his greatest challenges will be strengthening health systems at primary health care level. Governments need to be convinced to invest in primary health care as the hub and not the marginalised periphery where poorly trained and low level health care workers offer fragmented and poor quality care. Strong multidisciplinary teams should include a family physician.</p>
<p>Strong primary health care is a prerequisite for providing universal health coverage. Ideally this should be through a national health insurance or systems that – at the very least – don’t impoverish people or increase inequality.</p><img src="https://counter.theconversation.com/content/80898/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from European Union to strengthen primary health care through primary care doctors and family physicians in South Africa.</span></em></p><p class="fine-print"><em><span>Karen Daniels is a Specialist Scientist for the Health Systems Research Unit of the South African Medical Research Council, and a member of the Health Systems Global Board. The opinions expressed here are based on her own independent thoughts and views.</span></em></p><p class="fine-print"><em><span>Thumbi Mwangi receives funding from Wellcome Trust, GAVI and World Health Organisation.</span></em></p><p class="fine-print"><em><span>Andrew Githeko does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? Africa’s academics have some tips.Andrew Githeko, Chief Research Officer, Kenya Medical Research InstituteBob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityKaren Daniels, Specialist Scientist, Health Systems Research Unit, South African Medical Research CouncilThumbi Mwangi, Clinical assistant professor, Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/791262017-06-29T15:01:33Z2017-06-29T15:01:33ZHow access to knowledge can help universal health coverage become a reality<figure><img src="https://images.theconversation.com/files/175369/original/file-20170623-27888-n157q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Shutterstock</span> </figcaption></figure><p>The World Health Organisation’s Director-General Dr. Tedros Ghebreyesus has set universal health coverage as one of the main priorities for his term. </p>
<p>Universal health coverage is defined by the WHO as free access to promotive, preventive, curative and rehabilitative health services. These have to be of a sufficient quality to be effective but without causing unnecessary financial hardship when paying for the services. </p>
<p>But Ghebreyesus’s goal is a challenging one, especially for low and middle income countries which make up around 84% of the world’s <a href="http://data.worldbank.org/income-level/low-income">population</a>. Yet they only have access to half the <a href="http://data.worldbank.org/indicator/SH.MED.PHYS.ZS">physicians</a> and a quarter of the nurses that high income countries have access to. </p>
<p>Similarly low and middle income countries only <a href="http://data.worldbank.org/indicator/SH.XPD.PCAP">spend</a> around US $266 per capita on health care. In contrast, high income countries spend a whopping US $5 251 per capita.</p>
<p>This means that attaining universal health coverage in poorer settings is challenging to say the least. Large cuts to foreign aid investment from a number of <a href="https://blog.oup.com/2017/05/pandemics-disease-control-science-trump/">high income economies</a> only compound this challenge. </p>
<p>To address this, affected countries need to start thinking smarter, and not simply work harder. Optimising available resources requires local researchers to apply themselves. In other words, these countries need to grow their knowledge economies.</p>
<p>High income countries already have access to significant resources. This is mainly due to their own knowledge economies flourishing. To match this low and middle income countries need to increase the investment in their research activity. This includes increasing the number of institutions and supervisors that support research.</p>
<p>Although low and middle income countries have seen an increase and improvement in all these areas, access to existing knowledge remains poor. Particularly when compared to access in higher income countries.</p>
<h2>The ideal knowledge economy</h2>
<p>A healthy knowledge economy needs:</p>
<ul>
<li><p>investment (funding set aside for generating knowledge), </p></li>
<li><p>people who create research and consume information, </p></li>
<li><p>higher education institutions, and </p></li>
<li><p>reasonable access to knowledge (existing, published research). </p></li>
</ul>
<p>Low and middle income countries <a href="http://uis.unesco.org/apps/visualisations/research-and-development-spending/">invest</a> around a third of what high income countries invest in research. They also have access to around a fifth of the <a href="http://uis.unesco.org/indicator/sti-rd-hr-res">researchers</a> high income countries have access to. To top it off, less than a quarter of the <a href="https://www.timeshighereducation.com/world-university-rankings">Times Higher Education</a> ranked universities are located in low and middle income countries.</p>
<p>Yet of all the cogs that make up the knowledge economy, access to knowledge is likely the easiest to achieve. Although accessible knowledge remains a problem, strides have been made with increased support of open access publication on a global scale. </p>
<h2>How accessible knowledge helps</h2>
<p>Given the growing penetration of the internet into low and middle income countries, information has never been more <a href="http://www.pewglobal.org/2016/02/22/internet-access-growing-worldwide-but-remains-higher-in-advanced-economies/">accessible</a> at any point in history than today. Yet
access to a sizeable and ever growing bulk of health care research remains poor.</p>
<p>Open access publishing has become a strong global movement. Roughly 20% to 50% of all published research is currently freely available online - depending on its year of <a href="https://www.theguardian.com/science/occams-corner/2012/oct/22/inexorable-rise-open-access-scientific-publishing">publication</a>. </p>
<p>Some have remained sceptical of open access publishing. Despite that many funding agencies and higher education institutions now insist on accessible research reporting from their beneficiaries, staff and students.</p>
<p>It’s hard to argue the possibilities if the 2.7 million plus health care publications published within the last three years were freely accessible in low and middle income countries. It would likely confer a tremendous benefit to both health care professionals and patients (or even universal health coverage).</p>
<p>It is important to understand that the purpose of access to knowledge generated in high income countries is not simply to copy it verbatim into lower income settings. The comparative resource restrictions that apply renders direct implementation largely unfeasible. However, accessible knowledge, wherever generated, provides the references needed to generate locally appropriate applications thereof.</p>
<h2>Navigating the challenges</h2>
<p>For many low and middle income countries, open access comes with barriers as a result of infrastructural challenges.</p>
<p>The <a href="http://www.who.int/hinari/about/en/">Hinari</a> programme is an example of this. It has been around since 2002. It’s supported by the World Health Organisation along with a large number of publishers and provides access to a substantial amount of published material for researchers from low and middle income countries. </p>
<p>But during its 15 year existence it has remained <a href="http://www.research4life.org/wp-content/uploads/2014/07/IPL-HINARI-Research4Life-Survey-Analysis-final.pdf">poorly supported</a>. Ironically, for a programme that has existed so long, the main reason for this appears to be poor access.</p>
<p>To solve this problem publishers could easily provide equitable access for low and middle income countries using <a href="https://docs.nexcess.net/article/what-is-geoip.html">geolocation internet protocols</a> in the same way Netflix does. As a video streaming service, Netflix controls the content its users can access based on where they are accessing the service from. If geolocation is now an industry standard for various similar information sharing, internet based services, why not also for publication?</p>
<p>For publishers contributing to Hinari, such a step should be fairly straight forward. Use of <a href="https://docs.nexcess.net/article/what-is-geoip.html">geolocation internet protocols</a> will allow researchers in eligible countries to access to research from participating publishers on any device, anywhere where they have an internet connection. This would include the patient’s bedside - not just the academic library. </p>
<p>Much of the knowledge required to establish the universal health coverage Ghebreyesus wants, already exists. Poor access to this knowledge presents a major barrier to achieving universal health coverage. </p>
<p>To unlock this knowledge for everyone’s benefit, policymakers and publishers need to seriously consider more innovative ways to provide access. Ironically, these solutions probably already exist as well.</p><img src="https://counter.theconversation.com/content/79126/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stevan Bruijns is a senior lecturer with the Division of Emergency Medicine at the University of Cape Town, South Africa, and the editor-in-chief of the African Journal of Emergency Medicine, a fully open access journal.</span></em></p>A critical part of attaining universal health coverage is access to published research.Stevan Bruijns, Senior lecturer in the Division of Emergency Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/782772017-05-24T19:35:30Z2017-05-24T19:35:30ZThe WHO’s new African leader could be a shot in the arm for poorer countries<figure><img src="https://images.theconversation.com/files/170793/original/file-20170524-31373-qq2v03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tedros Ghebreyesus, the newly elected Director-General of the World Health Organisation.</span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p><em>Dr Tedros Ghebreyesus is the first African to be elected as the <a href="http://www.who.int/mediacentre/news/releases/2017/director-general-elect/en/">Director-General</a> of the World Health Organisation (WHO) in its 70 year history. The WHO is the United Nations body that directs its member states on international health issues. David Sanders explains to The Conversation Africa some of the main challenges Ghebreyesus will face in his five-year term.</em> </p>
<p><strong>What is the significance of this appointment?</strong></p>
<p>This is the first time the entire 194-strong WHO assembly voted for the position. Votes were cast by secret ballot. Previously the organisation’s Executive Board selected the DG. The massive margin for Tedros – 133 votes vs 50 for the UK candidate David Nabarro – suggests that the entire Global South voted for him. The size of the landslide had not been expected. </p>
<p>The vote almost certainly represents a vote against <a href="http://www.ghwatch.org/sites/www.ghwatch.org/files/D1_0.pdf">big power domination and machinations</a> in the WHO which often appears to ignore the main challenges and aspirations of low and middle income countries.</p>
<p><strong>What does he bring to the table?</strong></p>
<p>As Ethiopia’s former Minister of Health Ghebreyesus spearheaded major reforms to their health system. This included a massive expansion of primary health care infrastructure and a dramatic increase in health human resources at all levels. He oversaw a rapid increase in the training of doctors, shifted the responsibility for key interventions such as caesarean sections to mid-level workers, and the introduction of community-level workers (Health Extension Agents). </p>
<p>All contributed to <a href="https://www.researchgate.net/publication/307509510_Reduction_in_child_mortality_in_Ethiopia_analysis_of_data_from_demographic_and_health_surveys">impressive improvements in health</a> outcomes – especially in child health. </p>
<p>This track record is certainly behind his election. But he’ll have his work cut out for him. The WHO is experiencing its greatest crisis since its founding in 1948. It’s biggest challenges are finance-related.</p>
<p>The organisation is facing a financial crisis with a <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_6-en.pdf">US$ 456 million deficit</a> this year. This is bound to mean that there will have to be a major cuts to some programmes. Some might even have to be closed. Retrenchments are also on the cards.</p>
<p>For the past few decades the organisation has increasingly relied on donor funds because member states – particularly richer ones – have been reducing their <a href="http://www.reuters.com/investigates/special-report/health-who-future/">contributions</a>. A full 80% of the organisation’s funding is now from sources other than member states. Donors such as the Bill and Melinda Gates Foundation are making <a href="http://www.reuters.com/investigates/special-report/health-who-future/">major contributions</a>. </p>
<p>This means that the priorities of donors tend to dominate, thus making it difficult for the WHO to carry out the policies identified by its member states. In addition, intergovernmental bodies such as the World Bank have <a href="http://ijme.in/wp-content/uploads/2016/11/1653-5.pdf">weakened the WHO’s role</a>.</p>
<p>And some key programmes have had their budgets significantly reduced. One example is the programme to control non-communicable diseases. They are now the top cause of <a href="http://www.who.int/gho/ncd/mortality_morbidity/en/">morbidity and mortality</a> globally, and in low and middle-income countries. </p>
<p>Some vital programmes central to the WHO’s mandate remain underfunded. Sometimes this is due to the fact that they conflict with the interests of rich countries and big donors, particularly those with links to industry. For example, governments have consistently opposed putting in place food regulations to <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">address the rise in consumption of unhealthy food</a>. This is presumably because they would affect big corporations that are <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)62089-3.pdf">prominent investors</a> in those countries. </p>
<p>The result has been that the WHO’s leadership role in global health has been undermined. </p>
<p>Another big challenge is strengthening health systems. The Ebola epidemic in West Africa in 2014 showed up <a href="https://theconversation.com/ebola-and-zika-epidemics-are-driven-by-pathologies-of-society-not-just-a-virus-54191">weaknesses in the WHO</a> as well as in the health systems of low and middle income countries. </p>
<p>Finally, health systems, particularly in Africa and Asia, face drastic resource shortages. Huge investments are required in human resources, the most expensive and important component. Africa in particular has an extreme shortage of health workers. Their numbers are further threatened by inadequate training programmes and external migration (<a href="http://www.bmj.com/content/343/bmj.d7031.full">‘brain drain’</a>) to rich countries. A WHO Voluntary Code of Practice on International Recruitment of Health Personnel has failed to impact positively on such losses. The clear challenge remains for health human resource shortages to be urgently and effectively addressed.</p>
<p><strong>What does he need to do to deal with these challenges?</strong></p>
<p>Ghebreyesus needs to use his strong mandate – notably from the Global South – to truly reform the WHO and its operations in favour of the world’s poor majority. </p>
<p>To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions.</p>
<p>He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries to control non communicable diseases is resisted. This will be difficult given that a framework has been passed that allows non-state actors to participate in WHO policy-making processes.</p>
<p>On top of this Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so that health emergencies such as infectious disease outbreaks can be contained.</p>
<p>The <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_16-en.pdf">current investments</a> in building surveillance capacity for infectious diseases are welcomed. But these efforts will remain inadequate without sustained investment in health systems. </p>
<p>This will ensure that agenda for health security isn’t focused on securing the health of rich country populations against contagion from the poor but on protecting all, particularly the most vulnerable. </p>
<p>What will be interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Ghebreyesus as their candidate is maintained during the debates and decisions about world health. Until now, rich countries have been dominant in WHO meetings.</p><img src="https://counter.theconversation.com/content/78277/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Sanders is the co-chairperson of the People's Health Movement, which sponsored his trip to the World Health Assembly in Geneva. </span></em></p>There are a number of challenges that the World Health Organisation’s new leader, Ethiopian-born Tedros Ghebreyesus, will have to navigate during his tenure.David Sanders, Emeritus Professor, School of Public Health, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.