Keizo Takemi

Global health security: the wider lessons from the west African Ebola virus disease epidemic

Summary The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security—its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

Global action on health systems: a proposal for the Toyako G8 summit

The G8 summit in Toyako off ers Japan, as the host government, a special opportunity to infl uence collective action on global health. At the last G8 summit held in Japan, the Japanese government launched an eff ort to address critical infectious diseases, from which a series of disease-specifi c programmes emerged. This year’s summit provides another chance to catalyse global action on health, this time with a focus on health systems. Global eff orts to improve health conditions in poor countries have embraced two diff erent strategies in recent decades, one focusing on health systems, the other on specifi c diseases. The interactions of these two strategies have shaped where we stand today. The fi rst strategy has emphasised systemic approaches to health improvement. In the late 1970s, the world embarked on a major eff ort to strengthen health systems from the bottom up, through the primary health-care movement. WHO and UNICEF launched this movement at the Alma Ata conference in 1978, which was attended by nearly all their member countries. The movement used an integrated multisectoral approach to health development, with special attention to disadvantaged populations in each country. This became known as a horizontal approach. This approach confronted many challenges. The problems were particularly severe in sub-Saharan Africa, because of “low fi nancing of health systems, bad governance, the human resources for health crisis, the high level of poverty of the people, the debt burden, the emergence of new diseases and the deterioration of the social system in many countries.” Today, with the 30th anniversary of the Alma Ata Declaration in 2008, calls have arisen for renewed attention to primary health care. Indeed, WHO’s annual report in 2008 focuses on primary health care and its role in strengthening health systems. The second strategy emphasised disease-specifi c approaches to health improvement. The last decade of the 20th century witnessed a rise in many diff erent single-disease control programmes. The Okinawa Infectious Disease Initiative, announced by Japan at the G8 summit in 2000, led to strengthened global eff orts on several diseases, in particular HIV/AIDS, tuberculosis, and malaria, but also poliomyelitis, parasitic diseases, and other neglected tropical diseases. These eff orts contributed to the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as other single-disease control programmes, ushering in a new era in global health cooperation. These programmes represent the vertical approach to health improvement. The disease-specifi c strategy has attracted substantial support in recent years and produced major results. Donors believe that this approach creates tangible products that can yield measurable improvements in health status. Development assistance for health is estimated to have grown from about

G8 and strengthening of health systems: follow-up to the Toyako summit.

6 billion in 2000 to

Future of Japan's system of good health at low cost with equity: beyond universal coverage

14 billion in 2005. In addition to the Global Fund, collective eff orts to improve global health have included the GAVI Alliance, the Global Polio Eradication Initiative, the global health activities of the Bill & Melinda Gates Foundation and other private foundations, and various initiatives to develop new treatments for neglected tropical diseases. Various assessments suggest that these disease-specifi c partnerships have contributed to improvements in health conditions in poor countries around the world. However, the surge of disease-specifi c eff orts has also generated concerns about the unintended consequences of creating a fragmented array of uncoordinated programmes supported by multiple donors that recipient countries must struggle to manage. By focusing on specifi c performance measures, these programmes have sometimes not fully dealt with broader system failures. Yet such failures seem to lie behind the inadequate progress many countries have made on several key targets of the Millennium Development Goals (MDGs) for health—those related to child mortality (MDG 4), maternal mortality (MDG 5), and the prevention of HIV/ AIDS, malaria, and other diseases (MDG 6). Progress on these and other health improvements that depend on health system performance has been disappointing, especially when we consider the health status of poor and marginalised groups, for whom health status indicators (eg, infant mortality and maternal mortality rates) can be 50–100% higher than those of more advantaged population groups. The world is also facing the impending health threats of climate change. The potential consequences include enlargement of the geographical range of tropical diseases and massive fl ooding of low-lying inhabited areas, both of which would pose major challenges for health systems and disease control programmes in poor countries. Climate change could thus trigger negative interactions between poverty and health around the world, especially in poor countries. Addressing the health problems of poor countries can only move forward with a more balanced approach between specifi c-disease focus and system-based solutions; like weaving a piece of cloth, we need both the vertical and the horizontal threads to form strong fabric. Input-oriented approaches to health improvement (eg, Lancet 2008; 371: 865–69

Moving towards universal health coverage: lessons from 11 country studies

The 2008 G8 summit in Toyako, Japan, produced a strong commitment for collective action to strengthen health systems in developing countries, indicating Japans leadership on, and the G8s increasing engagement with, global health policy. This paper describes the context for the G8s role in global health architecture and analyses three key components-financing, information, and the health workforce-that affect the performance of health systems. We propose recommendations for actions by G8 leaders to strengthen health systems by making the most effective use of existing resources and increasing available resources. We recommend increased attention by G8 leaders to country capacity and country ownership in policy making and implementation. The G8 should also implement a yearly review for actions in this area, so that changes in health-system performance can be monitored and better understood.

Human security approach for global health

Japans premier health accomplishment in the past 50 years has been the achievement of good population health at low cost and increased equity between different population groups. The development of Japans policies for universal coverage are similar to the policy debates that many countries are having in their own contexts. The financial sustainability of Japans universal coverage is under threat from demographic, economic, and political factors. Furthermore, a series of crises-both natural and nuclear-after the magnitude 9·0 Great East Japan Earthquake on March 11, 2011, has shaken up the entire Japanese social system that was developed and built after World War 2, and shown existing structural problems in the Japanese health system. Here, we propose four major reforms to assure the sustainability and equity of Japans health accomplishments in the past 50 years-implement a human-security value-based reform; redefine the role of the central and local governments; improve the quality of health care; and commit to global health. Now is the time for rebirth of Japan and its health system.

Re-invigorating Japan's commitment to global health: challenges and opportunities

In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls--but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

The future leadership of WHO

The concept of security has shifted over the past 15 years, and has moved beyond a focus solely on the security of nations to include a focus on the security of individuals and communities. However, it was not until the 1990s that the concept of human security began to take clearer shape after it was reappraised within the UN. In particular, the UN Development Programme’s (UNDP) Human Development Report, 1994 fi rst made the connection between human security and the dual freedoms from fear and want, which were originally outlined in the US Secretary of State’s report on the 1945 San Francisco Conference. The UNDP report is also said to be the fi rst document to provide a comprehensive defi nition of human security, covering economic, food, health, environmental, personal, community, and political security. In practice, the need for an expanded conceptualisation of security was triggered by a series of tragedies around the world. The genocides in Rwanda (1994) and Bosnia and Herzegovina (1995) starkly illustrated to the world that the traditional concept of security as the protection of national borders was not suffi cient to save lives in the face of civil confl ict. In both cases, national security failed to protect individuals and communities within their own national boundaries, which thus provided justifi cation for expanding the object of security. To urge the international community in the new millennium to take action on the needs of individuals and communities around the world—in other words, to ensure human security for all—a second infl uential report was published in 2003 by the Commission on Human Security, co-chaired by Sadako Ogata and Amartya Sen. The refi ned defi nition of human security in this report advocated “protecting individuals’ and communities’ freedom from fear, freedom from want, and freedom to live in dignity.” The report also highlighted ten immediate areas requiring concerted action by the international community, with access to basic health services identifi ed as one priority. In parallel with the UN’s growing interest in human security, Japan has been one of the strongest proponents of the concept. As the generation of Japanese whose pacifi sm is based on the devastation they experienced fi rst-hand during World War II is nearly gone, Japan needs to develop a new motivation for pacifi sm. At the same time, Japan is trying to secure its position in an ever-changing world and fi nding that human security off ers a framework for a future-oriented pragmatic pacifi sm. The evolution of human security into a pillar of Japanese foreign policy thus refl ects the country’s quest to solidify its position as a global civilian power. This focus is prompting Japan to expand the pool of actors who are involved in policy making, as is happening around the world. First we saw the common framework transition from bilateral to multilateral diplomacy, and now the framework is being further expanded to include non-governmental organisations and other civil-society networks. This framework allows us to view the community not only as the endpoint of top-down policy making, but also as the starting point for a bottom-up approach to decision making. 1 London AJ, Kimmelman J. Justice in translation: from bench to bedside in the developing world. Lancet 2008; 371: 82–85. 2 Council for International Organizations of Medical Sciences. International ethical guidelines for biomedical research involving human subjects. 2002. http://www.cioms.ch/frame_guidelines_nov_2002.htm (accessed May 21, 2008). 3 World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects, 5th revision. 2000. http://www.wma.net/e/policy/b3.htm (accessed May 23, 2008). 4 Chege K. ‘Turn words into action’ Rwandan president urges. SciDevNet Jan 31, 2007. http://www.scidev.net/content/news/eng/ turn-words-into-actions-rwandan-president-urges.cfm (accessed May 21, 2008). 5 Mugabe J. African fund will advance science on the continent. SciDevNet May 1, 2007. http://www.scidev.net/content/opinions/eng/ african-fund-will-advance-science-on-the-continent.cfm (accessed May 21, 2008). 6 Angwafo F, Hamdy O, Worku K, et al. Health research for disease control and development. June 15–17, 2006. http://www.cohred.org/main/ Assests/PDF/communique-accra.pdf (accessed May 21, 2008). 7 Deen JL, Clemens JD. Issues in the design and implementation of vaccine trials in less developed countries. Nat Rev Drug Discov 2006; 5: 932–40. 8 WHO/UNAIDS/IAVI International Expert Group. Executive summary and recommendations from the WHO/UNAIDS/IAVI expert group consultation on ‘Phase IIB-TOC trials as a novel strategy for evaluation of preventive HIV vaccines’. AIDS 2007; 21: 539–46. 9 Participants in the 2001 Conference on Ethical Aspects of Research in Developing Countries. Moral standards for research in developing countries: from “reasonable availability” to “fair benefi ts.” Hastings Cent Rep 2004; 34: 17–27. 10 COHRED. Priority setting in health research: a management process for countries. http://www.cohred.org/main/prioritysetting.php (accessed May 21, 2008). 11 Jamison DT, Breman JG, Measham AR, et al. Priorities in health. Washington, DC: World Bank, 2006.

The Eighth Asia Cancer Forum: Seeking to Advance the Outcomes of the UN Summit: ‘Global Health as the Key to a New Paradigm in Cancer Research’

Over the past 50 years, Japan has successfully developed and maintained an increasingly equitable system of universal health coverage in addition to achieving the worlds highest life expectancy and one of the lowest infant mortality rates. Against this backdrop, Japan is potentially in a position to become a leading advocate for and supporter of global health. Nevertheless, Japans engagement with global health has not been outstanding relative to its substantial potential, in part because of government fragmentation, a weak civil society, and lack of transparency and assessment. Japans development assistance for health, from both governmental and non-governmental sectors, has remained low and Japanese global health leadership has been weak. New challenges arising from changes in governance and global and domestic health needs, including the recent Great East Japan Earthquake, now provide Japan with an opportunity to review past approaches to health policy and develop a new strategy for addressing global and national health. The fragmented functioning of the government with regards to global health policy needs to be reconfigured and should be accompanied by further financial commitment to global health priorities, innovative non-governmental sector initiatives, increased research capacity, and investments in good leadership development as witnessed at the G8 Hokkaido Toyako Summit. Should this strategy development and commitment be achieved, Japan has the potential to make substantial contributions to the health of the world as many countries move toward universal coverage and as Japan itself faces the challenge of maintaining its own health system.

Japan—a call for research papers

www.thelancet.com Vol 387 January 23, 2016 321 In about 3 months time, the Director-General of WHO will call for nominations from the Executive Board and Member States for her successor. The selection process will then be launched and a new Director-General elected in 2017. Over this coming year WHO has a huge amount of work to do. There are real and exciting opportunities, encapsulated in the Sustainable Development Goals and building on the progress made during the Millennium Development Goals before them. To take just one example, strong WHO leadership can help us all push ahead to achieve universal health coverage, leaving no one behind. Alongside such opportunities, the world also faces colossal challenges that WHO must help us all solve: the threat of antimicrobial resistance in humans and animals; the looming problem of ageing societies; the rise of noncommunicable diseases; and the eff ect of climate change on diseases and humanitarian disasters. It is only through tackling these issues that we can construct a global health architecture that can respond to health crises and support resilient and sustainable health systems. Meanwhile, west Africa is recovering from the worst ever Ebola outbreak. Although the international response to Ebola was vital, it could have been better. WHO’s action was also imperfect, but the organisation is working hard to reform the way in which it responds to emergencies and is accountable for them. This reform will be essential since other disasters, such as the Nepal earthquake and fl oods in Pakistan last year, have shown that WHO has an important role in response and recovery. We need one organisation with strong leadership and command that is able to respond quickly and coherently to health threats, including pandemics. That organisation is WHO. The myriad recent reports and commentators on WHO all agree that it is a vital institution—the preeminent international body within the UN system dealing with threats to international health and health security. As the Constitution of WHO states, its purpose is: “to act as the directing and coordinating authority on international health work...to establish and maintain eff ective collaboration with the United Nations, specialised agencies, governmental health administrations, professional groups and such other organisations as may be deemed appropriate. To assist governments, upon request, in strengthening health services and to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of governments”. WHO does all of this— and much more—as the leader of the Global Health Cluster, bringing together more than 40 international humanitarian health organisations. 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