Anders Nordström

Responding to the global human resources crisis.

The global community is in the midst of a growing response to health crises in developing countries, which is focused on mobilising financial resources and increasing access to essential medicines. However, the response has yet to tackle the most important aspect of health-care systems--the people that make them work. Human resources for health--the personnel that deliver public-health, clinical, and environmental services--are in disarray and decline in much of the developing world, particularly in sub-Saharan Africa. The reasons behind this disorder are complex. For decades, efforts have focused on building training institutions. What is becoming increasingly clear, however, is that issues of supply, demand, and mobility (transnational, regional, and local) are central to the human-resource problem. Without substantial improvements in workforces, newly mobilised funds and commodities will not deliver on their promise. The global community needs to engage in four core strategies: raise the profile of the issue of human resources; improve the conceptual base and statistical evidence available to decision makers; collect, share, and learn from country experiences; and begin to formulate and enact policies at the country level that affect all aspects of the crisis.

Financing of health systems to achieve the health Millennium Development Goals in low-income countries

Concern that underfunded and weak health systems are impeding the achievement of the health Millennium Development Goals in low-income countries led to the creation of a High Level Taskforce on Innovative International Financing for Health Systems in September, 2008. This report summarises the key challenges faced by the Taskforce and its Working Groups. Working Group 1 examined the constraints to scaling up and costs. Challenges included: difficulty in generalisation because of scarce and context-specific health-systems knowledge; no consensus for optimum service-delivery approaches, leading to wide cost differences; no consensus for health benefits; difficulty in quantification of likely efficiency gains; and challenges in quantification of the financing gap owing to uncertainties about financial commitments for health. Working Group 2 reviewed the different innovative mechanisms for raising and channelling funds. Challenges included: variable definitions of innovative finance; small evidence base for many innovative finance mechanisms; insufficient experience in harmonisation of global health initiatives; and inadequate experience in use of international investments to improve maternal, newborn, and child health. The various mechanisms reviewed and finally recommended all had different characteristics, some focusing on specific problems and some on raising resources generally. Contentious issues included the potential role of the private sector, the rights-based approach to health, and the move to results-based aid. The challenges and disagreements that arose during the work of the Taskforce draw attention to the many issues facing decision makers in low-income countries. International donors and recipient governments should work together to improve the evidence base for strengthening health systems, increase long-term commitments, and improve accountability through transparent and inclusive national approaches.

Reassessing the value of vaccines

In May, 1974, WHO launched the Expanded Programme on Immunization—the global programme to immunise children worldwide with a set of (at the time) six core vaccines. 40 years on, the GAVI Alliance has brought us together, a group of 29 leading technical experts in health and development economics, cognitive development, epidemiology, disease burden, and economic modelling to review and understand the broader outcomes of vaccines beyond morbidity and mortality, to identify research opportunities, and to create a research agenda that will help to further quantify the value of this eff ect. What is the value of immunising every child with all 11 vaccines that WHO now recommends, 1 beyond the prevention of illness and death? The full benefi ts of childhood vaccination could reach well into a childs life, through adulthood, into the wider community, and, ultimately, the national economy. 2 Some evidence of these benefi ts has already been generated, but gaps in knowledge remain. For example, preliminary research suggests that a 5-year improvement in life expectancy can translate into 0·3–0·5% more annual growth added to income per head. 3 Similarly, results of research done in Bangladesh show that the benefi ts of antibodies from maternal tetanus vaccinations passing from a mother to her unborn child can lead to gains of about 0·25 years of schooling for children whose parents did not attend school. 4 And fi ndings from the Philippines showed that vaccinations induced improvements in test scores in children, 5 which had a return on investment as high as 21% when translated into the earning gains of adults. 6 Meanwhile in South Africa, researchers have shown a signifi cant association between coverage of measles vaccination and the level of school-grade attainment in sibling-pairs, after controlling for intrinsic factors such as birth order, education levels of parents, and household wealth. 7 This research suggests that, on average, 1 year of schooling is gained for every six children vaccinated against measles. But evidence to link health inputs and wealth outcomes needs to be further assessed and investigated. Vaccines are usually given when the rate of brain development is at its peak, which can benefi t cognitive development through prevention of illness and its neurological complications (eg, encephalitis). But so far, the only evidence for this model is based on observational studies; such studies are an important fi rst step, but more work is needed. Similarly, evidence for the positive …

Reinvesting in health post-2015

www.thelancet.com Vol 382 December 7, 2013 1861 During the past few years we have jointly forged a strong case for health and its links to sustainable development in the post-2015 agenda, with an overarching goal that seeks to maximise health at all stages of life, and with universal health coverage and access as the key means to its achievement. We have acknowledged the need to accelerate progress on the current Millennium Development Goals; to broaden the agenda to en compass non-communicable diseases; and to give more prominence to sexual and reproductive health, with particular emphasis on the health of adolescents. The review of, and lessons learned, in the past 20 years since the launch of the World Bank’s 1993 World Development Report, Investing in Health, is strategically important and timely. Since the early 1990s, health gains and economic progress have been extraordinary. The number of people living in low-income countries has fallen from 3·1 billion people (57·8% of the world’s population) in 1990 to 820 million (11·7%) in 2011, and much of the world’s poor population now lives in middle-income countries. For the fi rst time in history most countries see their citizens living longer, and fewer of their babies and infants dying unnecessarily. Life expectancy in such countries as China, Ethiopia, Mexico, and India has almost doubled. These are transformational shifts. So clearly we are on the right path. The results of both the Lancet Commission on Investing in Health and the Global Investment Framework for Women’s and Children’s Health make a powerful case that the full impact of health investments goes beyond gross domestic product (GDP) to the value of being alive and well, the most basic human right of all: when Reinvesting in health post-2015 and strengthen the quality and cost-eff ectiveness of preventive and treatment services off ered by the health system. And fi nally, institutions of independent accountability—monitoring, reviewing, and remedying defi ciencies in the health system. These institutional functions deserve our greater attention, which would allow space for the proper discussion of a broader set of political determinants of health. A second contextual issue is the notion of sustainable development itself. The global community has yet to comprehend fully what sustainable development means. It is an entirely diff erent concept from poverty reduction, the overriding objective of the MDG era. Sustainable development is about all of us, not some of us. It is about taking the health of future generations as seriously as we take our own. And it is about rethinking the economic models on which our present highly consumptive societies depend. The kind of economy one needs to deliver sustainable and inclusive development is likely to be very diff erent from the economy of today. The third and fi nal contextual issue is the meaning of health itself. We believe we need to move beyond the concept of global health towards the broader idea of planetary health. Planetary health includes global health, but it adds two further dimensions. One is the health of the physical planetary systems our species depends upon for life. Another is the health of the human civilisations we have created (and which, as history attests, can so easily collapse). The “health” of these two systems can be summed up in a single word—resilience. Investing in health means investing in resilience. Health without resilience is unsustainable. Resilience without health fails to satisfy one of the most important human qualities we value—which our Commission on Investing in Health at last makes so abundantly clear.

Sugar, tobacco, and alcohol taxes to achieve the SDGs

More than a decade after the adoption of the WHO Framework Convention on Tobacco Control, there is compelling evidence that raising tobacco prices substantially through taxation is the single most effective way to reduce tobacco use and save lives. Similarly, alcohol taxation is a cost-effective way to reduce alcohol consumption and harm. With growing evidence, sugar taxes are another fiscal tool to promote health and nutrition. Mexico’s sugar tax reduced sugarsweetened beverage sales by 5% in the first year, with an almost 10% further reduction in the second year. Tobacco taxes in South Africa contributed to tobacco consumption decreases of about 40% between 1993 and 2003. When Finland reduced taxes on alcohol in 2003, alcohol-related mortality increased by 16% among men and by 31% among women. As part of a broader public health approach to promote a life-course approach to prevention and to address commercial determinants of health, it is now time for governments to adopt sugar, tobacco, and alcohol taxes (STAX). Despite their potential, taxes on sugar, tobacco, and alcohol are underused by policy makers. The 2017 WHO Report on the Global Tobacco Epidemic showed that only 10% of the world’s population is covered by sufficiently high levels of tobacco taxation. According to this report, the tobacco industry undermines taxation efforts by lobbying policy makers and exaggerating their industry’s economic value and the risk of illicit trade. The alcohol and food industries are now deploying similar tactics—one example is successful efforts to erase language on alcohol and sugar taxes in the Montevideo Roadmap on non-communicable diseases (NCDs). Despite industry efforts, taxation is gaining more attention from policy makers as a win–win–win policy measure for public health, domestic resource mobilisation, and equity. Taxes on sugar, tobacco, and alcohol have been, or are now being, introduced in diverse contexts, including Botswana, Chile, Ecuador, India, Mexico, Nigeria, Peru, Saudi Arabia, South Africa, the United Arab Emirates, and the UK. Tobacco and alcohol taxes are recognised by WHO as “Best Buys” to prevent and control NCDs; taxes more broadly are a focus of the Bloomberg Task Force on Fiscal Policy for Health in advance of this year’s UN High-Level Meeting (HLM) on NCDs. NCDs are estimated to account for 72% of all deaths globally and this proportion is growing. Worldwide, tobacco is estimated to kill more than 7 million people and alcohol more than 3 million people each year. The global number of young people aged 5–19 years who are overweight and/or obese has increased from 11 million in 1975 to 124 million in 2016. Sugar consumption is a major contributor. High body-mass index is estimated to claim at least 4 million lives each year. The consumption of tobacco, alcohol, and sugar are risk factors for health and NCDs that disproportionately affect people with low socioeconomic status and low-income countries, which are the least prepared. STAX could help mitigate these risk factors. Yet existing efforts are inconsistently applied. Scaled-up country support is needed to accelerate and implement STAX as a cost-effective fiscal policy to contribute to the Sustainable Development Goals (SDGs). STAX not only contribute to improving health and saving lives, but they can also raise resources. For example, Thailand’s Health Promotion Act of 2001 established a tax on tobacco and alcohol, which now contributes about US

What's next for WHO?

120 million annually for domestic health promotion efforts. In 2012, the Philippines raised taxes on tobacco and alcohol and are using the revenues to supplement efforts towards universal health coverage (UHC). After 3 years of implementation

What do people want for health in the post-2015 agenda?

3·9 billion in additional revenues were collected, 80% of which was used to finance the extension of health insurance to the poorest 40% of Filipinos. Unfounded concerns about the potentially regressive impacts of STAX continue to impede implementation. Published Online May 29, 2018 http://dx.doi.org/10.1016/ S0140-6736(18)31219-4

Global fund for AIDS, tuberculosis and malaria

The unexpected and shocking death of Lee Jong-wook Director-General of WHO on May 22 the first morning of the Fifty-ninth World Health Assembly placed WHO in the unprecedented situation of being without its leader at a peak decision-making season. Where does Dr Lees death leave WHO? Remarkably WHO has not been incapacitated although his loss continues to be deeply felt. The organisation has maintained momentum in part because of his management style which strategically devolved responsibility and also because of a change in the way in which WHO is finding solutions to global health problems. In the past there was sometimes a conceptual divide between the adoption of a resolution by the governing bodies as a generally good principle and the more painful realisation of it in practice in countries. The watershed came with tobacco control. The process to arrive at the WHO Framework Convention on Tobacco Control was slow and difficult fraught with legal complexities and detailed negotiations over texts. But the end product is a powerful instrument that is already proving useful to Member States in enforcing a rigorous internationally supported approach to improving health. (excerpt)