Lincoln Chen

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA (A Pablos-Mendez MD); Public Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Human resources for health: overcoming the crisis

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the worlds poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

Expansion of cancer care and control in countries of low and middle income: a call to action

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health communitys assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.

Emergence of chronic non-communicable diseases in China.

China has experienced an epidemiological transition shifting from the infectious to the chronic diseases in much shorter time than many other countries. The pace and spread of behavioural changes, including changing diets, decreased physical activity, high rates of male smoking, and other high risk behaviours, has accelerated to an unprecedented degree. As a result, the burden of chronic diseases, preventable morbidity and mortality, and associated health-care costs could now increase substantially. China already has 177 million adults with hypertension; furthermore, 303 million adults smoke, which is a third of the worlds total number of smokers, and 530 million people in China are passively exposed to second-hand smoke. The prevalence of overweight people and obesity is increasing in Chinese adults and children, because of dietary changes and reduced physical activity. Emergence of chronic diseases presents special challenges for Chinas ongoing reform of health care, given the large numbers who require curative treatment and the narrow window of opportunity for timely prevention of disease.

Tackling the challenges to health equity in China

Summary In terms of economic development, China is widely acclaimed as a miracle economy. Over a period of rapid economic growth, however, Chinas reputation for health has been slipping. In the 1970s China was a shining example of health development, but no longer. Government and public concerns about health equity have grown. Chinas health-equity challenges are truly daunting because of a vicious cycle of three synergistic factors: the social determinants of health have become more inequitable; imbalances in the roles of the market and government have developed; and concerns among the public have grown about fairness in health. With economic boom and growing government revenues, China is unlike other countries challenged by health inequities and can afford the necessary reforms so that economic development goes hand-in-hand with improved health equity. Reforms to improve health equity will receive immense popular support, governmental commitment, and interest from the public-health community worldwide.

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.

Understanding morbidity change.

The authors develop an approach to morbidity definition and measurement review specific methods and present a framework for classifying different types of morbidity indicators. They examine various approaches to the interactions between morbidity and mortality change illustrating these with selected data from India the United States and Ghana. (SUMMARY IN FRE AND SPA) (EXCERPT)

Population policies reconsidered : health, empowerment, and rights

In this volume, scholars, policy-makers and womens health advocates suggest a new consensus on population policy directions for the 21st century, centred on health, womens empowerment, and human rights. They argue that public policy should assure the rights and well-being of people, rather than simply attempting to limit the ultimate size of the worlds population.

Sex differentials in mortality in rural Bangladesh

This study provides conclusive documentation of higher female than male mortality from shortly after birth through the childbearing ages in a rural area of Bangladesh. The higher male mortality rates during the neonatal period are consistent with reports from developed countries; but whereas in developed countries this higher male mortality risk continues through childhood and adolescence the differential is reversed during the post-neonatal period in Bangladesh with female mortality exceeding that of males by as much as 50 percent. Son preference in parental care and feeding patterns food distribution and treatment of illness favoring male children are possible causes of such aberrant childhood mortality differences by sex. (SUMMARY IN FRE SPA)

The Bangladesh paradox: exceptional health achievement despite economic poverty

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the countrys success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as womens empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.