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Global Health: 11 to Follow in 2011

As we reflect back on the global health stories that made the news in 2010—and some that didn’t—here are 11 top stories we will be following in 2011.

Health worker migration: WHO’s unprecedented stand on recruitment

In 2010, we celebrated the World Health Organization’s release of the WHO Global Code of Practice on the International Recruitment of Health Personnel and global recommendations for the retention of health workers. The code, adopted in May 2010, highlights the critical issue of human resources for health. This new code (only the second code adopted in WHO’s history) is an ethical framework that guides member states in the recruitment of health workers, specifically discouraging active recruitment of health workers from developing countries that face the most critical health workers shortages. The code also encourages “destination” countries to collaborate with “source” countries to support and sustain human resources for health development and training.

In 2011, we hope to see the rapid rollout of the code, and to see the US Government’s Global Health Initiative fully develop and implement a strategy for human resources for health. As IntraHealth’s Maurice Middleberg proposes in Saving Lives, Ensuring a Legacy: A Health Workforce Strategy for the Global Health Initiative, “the GHI should promote evidence-based approaches to increasing retention and productivity,” because “incentives that keep workers are also those that foster high productivity—retention and productivity are in many ways two sides of the same coin.”

201011 is the International Year of Youth: did you know?

Another seemingly underreported story in 2010 was the UN’s declaration, in August 2010, of the International Year of Youth, 2010–2011.The UN declared that the year would be devoted to encouraging more investments in youth, and that this would be accomplished, in great part, by listening to the youth themselves. More investment is needed in innovative strategies to reach youth, especially girls, through adolescent reproductive health education and services—and health information in general. Many countries in which IntraHealth works have a few successful pilot programs, but “adolescent reproductive health” is often buried somewhere in the ministry of health, or youth, or both, and few have a well developed, scaled up, national program.

Girls and boys are looking for information and services—and not finding them easily. In many countries, more than half of young people are sexually active[1]. But condom use is low. And access to other modern contraception is extremely limited by lack of knowledge and lack of access to youth-friendly health workers and health facilities. At least one-fourth of the estimated 20 million unsafe abortions per year are performed on women aged 15 to 19.[2] Teenage pregnancies in the US rose in 2006 for the first time in a decade.[3]

“Contrary to the perception of many parents and community leaders, adolescents engage in sexual activity, and they suffer grave consequences in societies that deny this reality and fail to prepare them adequately for sexual experience,” as noted in Removing barriers to adolescents’ access to contraceptive information and services.

Adolescent girls need more information on reproductive health, but also protection against gender-based violence; one in three women will experience some form of sexual violence in her lifetime. The efforts of partnership such as Together for Girls and the Girl Effect are laudable, as is the Global Health Initiative’s focus on women and girls.

We hope that 2011 will really be the year of the youth, both girls and boys—and that we will see increased attention to, and resources dedicated toward, the health of adolescents.

Open source and mobile technologies: need rigorous review and documentation to scale up

As Kate Otto notes in her Huffington Post blog on “a prediction of global health prosperity for 2011,” several technologies have been “created, tested, piloted and evaluated in the field” that will allow for improved surveillance, more effective medical records systems, better linkages of hospitals and health centers through cellular communication, and the creation by local software developers of “culturally relevant tools to improve health care delivery and communications.” Otto isn’t alone in her optimism. The mHealth Summit last November was a huge success in generating public interest and new investments in such initiatives; Bill Gates delivered the keynote and companies like HP pledged $1 million to mobile innovations.

IntraHealth is excited about uses of open source technology that foster the capacity of local developers. Our human resources information system for health does just that, allowing ministries of health and other stakeholders to adapt the software to their needs, and often with limited technical assistance. Our partnership with board member Josh Nesbit’s Medic Mobile in Africa also focuses on technology that allows health workers to send alerts, communicate data and make decisions on a timely basis.

Now, with so many technological advances and so many key players paying attention, what will it take to get from prospect to “prosperity”—how will promising technologies become transformative, large-scale solutions for global health? Only with more studies and thorough documentation of results to create a rigorous evidence base. Some innovations work; some don’t. We have to be willing to share our successes, but also admit when something doesn’t work and learn why.

Maternal health: celebrating good news, but more scale up needed

In 2010, we learned that the number of women dying from pregnancy or childbirth has declined by 34% since 1980—from an estimated 546,000 to 358,000 in 2008.[1] The New York Times covered the story in April, citing research published in The Lancet.

This progress shows that we know what’s needed to prevent maternal deaths. We know that most of these deaths are related to lack of access to family planning and basic services, and caused by postpartum hemorrhaging, infections, hypertensive disorders, and unsafe abortion. But progress is only occurring at half the pace necessary to reach Millennium Development Goal (MDG) 3’s target of reducing maternal mortality by 75% by 2015,[2] and the risk of a woman in a developing country dying from a pregnancy-related cause during her life is still 36 times higher than that of a woman living in a developed country.

We hope that 2011 brings news of increased investment in maternal health, more focus on what works—such as active management of the third stage of labor to prevent postpartum hemorrhage—and resources to scale up proven interventions in maternal health.

HIV: Prevention = treatment = need for more and better trained health workers

We heard a lot in the news and social media last year about the potential of microbicide gels and male circumcision for HIV prevention, about escalating protests over HIV/AIDS funding shortfalls, and the good news that both AIDS-related deaths and new HIV infections have significantly decreased—stories that dominated headlines for months before and after the International AIDS Conference in Vienna. But less talked about was the release of Treatment 2.0, UNAIDS’ new approach to overcoming the AIDS pandemic. Treatment 2.0 calls for wider and earlier access to antiretroviral therapy, linking early treatment to lower costs, 10 million fewer AIDS-related deaths, and one-third fewer HIV infections by 2025—compared with staying the course.

Only 40% of HIV-positive individuals are aware of their status, according to UNAIDS. The majority of them do not find out until they begin showing late-stage symptoms before the onset of AIDS. So reducing stigma and increasing counseling and testing are key components of Treatment 2.0. But this requires more decentralized high-impact services in hard-to-reach areas—and more health workers trained in the basics. Still, the data show that caring for people who aren’t aware of their status until the very late stages costs hospitals and health systems far more than the cost per person of beginning ART early. In short, long-term treatment is more effective than late-stage diagnosis—both in saving health costs and lives and preventing more new infections.

Moving toward Treatment 2.0, which envisions universal coverage of ARTs, could contribute to averting an estimated 10 million deaths by 2025. With universal coverage, Treatment 2.0 could reduce new HIV infections by up to one million annually if countries provide treatment to all people in need.

Making Treatment 2.0 and universal access to ARTs a reality, however, requires investments not only in drugs and facilities, but also in the health workforce, as outlined in Harvard School of Public Health’s Universal antiretroviral treatment: The challenge of human resources. The report poses the question we all need to consider: “Who will achieve universal ART coverage?”

Family planning: Happy Birthday, Pill!

In 2010, “the pill” turned 50, providing the opportunity to reflect on the history and importance of family planning. Birth Control Pill Turns 50: 7 Ways It Changed Lives, in US News and World Report, acknowledged that “the pill opened the door for other hormonal birth control methods,” including Depo Provera injectable, the progesterone-releasing intrauterine device, skin patches and vaginal rings, and leads to lower rates of unplanned pregnancies and abortions[3].

When the pill was “born” in 1960, only about 10 percent of couples used contraception; today, about 63 percent do. However, worldwide, 215 million women want to use contraceptives but don’t, for a multitude of reasons, including lack of information and lack of access to services.

We are encouraged that the Global Health Initiative highlights family planning goals, which are: “Prevent 54 million unintended pregnancies by meeting unmet need for modern contraception. Contraceptive prevalence is expected to rise to 35 percent across assisted countries, reflecting an average 2 percentage point increase annually. First births by women under 18 should decline to 20 percent.”

How will the U.S achieve these goals without proportionate funding? In 2010, the U.S. government appropriated $648.5 million for family planning[4]—and $5.7 billion for HIV/AIDS, which doesn’t include contributions to the Global Fund. US bilateral funding for international family planning assistance has declined by about $100 million since 1995. We hope that, in 2011, the GHI will start to make good on its promises to invest significantly in family planning, and prioritize it among its maternal and child health goals.

Malaria: quality care means more attention to diagnosis

More good news in health this past year: the World Malaria Report 2010 shows that in 11 African countries, the malaria burden has dropped by more than 50% since 2000. The under-reported part of the story, it seems, is that the decrease in incidence rates means that how we respond to and treat malaria needs to change rapidly.

Initial community-level successes in treating malaria, like IntraHealth’s work in Rwanda and Senegal, were based on presumptive treatment, or assuming that every child with a fever who did not have other symptoms was presumed to have malaria, and treated with antimalarials. The 2010 malaria report declared, for the first time, that “everyone with suspected malaria has a right to a confirmatory diagnostic test.” The report says that fever can no longer be equated with malaria, and that “inexpensive, quality-assured rapid diagnostic tests . . . can be used all the way down to the community level.”

The use of rapid diagnostics can not only save the unneeded use of hundreds of thousands of antimalarials, but also allow for better surveillance. National malaria control programs, donors and implementers need to respond quickly to ensure that rapid diagnostic tests are in the hands of those who need them, and that the frontline workers have the skills to use these tests.

Workforce development: making medical schools more socially accountable

In many countries—including the US—medical schools have traditionally been seen, and treated, as part of the education system, with no real responsibility to serve the greater good of the communities in which they operate or society at large. Often housed within ministries of education, schools have produced doctors, but not always doctors who are ready to meet the needs of the communities they serve.

Perhaps one of the most under-reported global health stories in 2010 was the Global Consensus of Social Accountability of Medical Schools. The Consensus focuses on the responsibility of medical schools—and, by extension, nursing schools and other health professional schools—to improve the health of the most vulnerable. The document has ten strategic directions for schools to become more socially accountable, highlighting improvements needed to respond to current and future health needs and challenges in society, reorienting their education, research, and service priorities accordingly.

As IntraHealth’s Kate Tulenko, who participated in the development of the Consensus, wrote last year in Foreign Policy (Countries without Doctors), medical and nursing schools in the US also need to change. Medical and nursing schools in the US are “turning away tens of thousands of qualified applicants for lack of places and funding to accept and train them.” Reversing this trend in the US would “take years of building new medical schools, particularly in areas where there is already a shortage of doctors.”

Non-communicable diseases: a new Millennium Development Goal?

In 2010, we saw increased attention to cancer and other non-communicable diseases. Of about 7.6 million people who die of cancer every year, two-thirds come from developing countries. Expansion of cancer care and control in countries of low and middle income: a call to action, published in The Lancet in October (and authored by Paul Farmer, Julio Frenck and others) is, truly a call to action. The article focuses on a key message, the fact that low-resource countries that may not have a ready supply of oncologists and high-tech equipment can still employ efforts to prevent and treat cancer by empowering primary health workers and caregivers in general. The article laments the fact that the global health community seems to have accepted the idea that, for now, cancer cannot effectively be treated in developing countries, comparing the notion “to similarly unfounded arguments from more than a decade ago against provision of HIV treatment.”

In a resolution adopted last May, the UN recognizes “the enormous human suffering caused by non-communicable diseases” and links non-communicable disease to threatening internationally agreed upon goals, including the Millennium Development Goals, proposing the addition of indicators related to non-communicable diseases into the Millennium Goals monitoring system. This year, we will be following the lead-up to the United Nations’ First High-level Meeting on non-communicable diseases, scheduled for September 2011. We also will be looking at our own work, and ensuring that we are contributing to stronger health systems that can respond to non-communicable diseases.

Country ownership—let’s get real

“Country ownership” has been talked about for years, but became an even more popular phrase in global health this past year. The Global Health Initiative highlights country ownership as one of its pillars of success, describing it as putting countries in charge of defining priorities, coordinating assistance, and managing health and development efforts.

John Donnelly produced a blog series for the Aspen Institute’s Ministerial Leadership Initiative, In the Driver’s Seat: A Series on Country Ownership of Health Programs, in which he interviewed eight leaders on the “next steps in giving countries what they crave: ownership of their health programs.” Key lessons emerged: donors and implementers need to listen to in-country experts and authorities, the private sector and civil society (local and international NGOs) have key roles to play and, perhaps most importantly, countries themselves need to take the lead with strategic planning and unified national programs.

We hope that the global health community will seriously consider the issues raised by Donnelly’s series and echoed in countless stakeholder meetings and conferences around the world. Giving countries “what they crave” will require a new paradigm on the part of all stakeholders—donors, implementers, and the countries in which development funds are invested. As Nigel Crisp notes in the recently released book, Turning the world upside down—the search for global health in the 21st century, we need a new paradigm because “there is much to learn from each other . . . should we not be talking about our shared health issues, and taking this further, not about development but about co-development?”

Americans supportive of global health

In September, the Kaiser Family Foundation released the results of its recent survey on foreign aid.[8] (Ezra Klein of the Washington Post reported on the results in December in a nifty simplified graph.) The poll found that many Americans hold negative misperceptions about “foreign aid,” but are more supportive of such efforts when described more specifically as “improving health in developing countries.”

Six in 10 Americans (61%) say the U.S. spends too much, and four in 10 incorrectly think that foreign aid is one of the two biggest areas of spending in the federal budget. In comparison, when asked about “improving health in developing countries,” only 28 percent say the U.S. spends too much, while nearly two thirds say such spending is too little (23%) or about right (42%).

According to the poll, most Americans think that 25% to 30% of our national budget is spent on foreign aid, and say, on average, that our country should spend about 10% of the budget on foreign aid. But in reality, only about 1% of our national budget is spent on foreign aid.[9]

This leads us to wonder: are we telling our stories in the right way to reach the right people? Do Americans realize how much can be—and is being—accomplished with, relatively, so little? In 2011, ABC news is running a year-long series on global health; we will be watching attentively. And we hope that we can all, in sharing our success stories and lessons learned, contribute to greater awareness of—and passion about—global health.

[1] According to national Demographic and Health Surveys

[2] According to the World Bank’s Reproductive Health Action Plan 2010-2015

[3] According to the Guttmacher Institute’s study published in 2010, U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity.)

[4] Trends in maternal mortality, by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA) and the World Bank, 2010.

[5] To reach MDG 3, we need an annual decline in maternal mortality of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%

[6] According to a 2009 Guttmacher Institute study

[7] Including a $55 million contribution to UNFPA

[8] Source: Americans Remain Wary of “Foreign Aid” But Are More Supportive of Spending to Improve Health Abroad, Kaiser Family Foundation, 2010

[9] Source: CNN Fact Check, February 2010