At the upcoming World Health Assembly, which will take place in Geneva, Switzerland, from 22 to 31 May, the new Director-General of the World Health Organization will be elected. For the first time, and after a selection process that started in September 2016, all World Health Organization Member States will cast their vote for one of the three final candidates for the position.
Since their nomination, all three candidates have been presenting their ideas and vision around health-related topics. The three final candidates, David Nabarro, Sania Nishtar and Tedros Adhanom Ghebreyesus, have spoken to unaids.org about the AIDS epidemic and global health.
Question: As Director General of WHO, what will be your three priorities to advance progress in ending AIDS by 2030 as part of the Sustainable Development Goals?
DAVID NABARRO
The first priority must be to stop tackling HIV/AIDS as an isolated issue and make services for people affected by HIV/AIDS an integral part of universal health coverage, and also linked with services for other chronic diseases.
The second is to review the lessons of work to empower people at risk of HIV/AIDS using a Sustainable Development Goal (SDG) lens and then use the information derived from this review as a basis for mainstreaming HIV-related action across all the SDGs (see below).
Just as the AIDS movement redefined public health between 2000 and 2015, it now needs to help bring public health into the SDGs with a completely new narrative. This narrative must emphasize the interconnections between the SDGs and the need to leave no one behind, and show that health is central to achieving this.
SANIA NISHTAR
To defeat the epidemic, the World Health Organization (WHO) needs to continue work in partnership and push the ambitious agenda approved at the United Nations General Assembly High-Level Meeting on Ending AIDS. Universal access to early safe treatment—getting to universal coverage still needs a lot of work—and countries need support to be able to work out how to deliver lifelong treatment. WHO will strive to be sure that we are on top of the evidence and able to fail fast and fix fast as new evidence sheds light on how to reach people and sustain them on treatment to reduce the community viral load.
Only then can we expect to curb transmission. For prevention—while we now have some effective interventions to programme—we still need to add to our toolkit and WHO will work to ensure new evidence and experience is brought into programmes as quickly as feasible. Addressing HIV requires universal health coverage for the core evidence-based package, a rights-based approach and an understanding of the key role of social determinants.
With that in mind we need to focus on ending transmission. This means continuing to promote universal testing and treatment, with a focus on the most vulnerable groups, including adolescent girls and people who use drugs, understanding the value of pre-exposure prophylaxis and, of course, ultimately we need a vaccine.
WHO’s role in this is to continue to provide evidence-based policy guidelines and build up our toolkit to make progress towards universal health coverage. We know that countries are struggling to implement the existing guidelines. WHO needs to continue to bring rigor, evidence and a public health approach to the response so that we can provide practical and clear guidance on how to deliver services in different contexts (rural, urban) and to those people that don’t normally have contact with the health system.
WHO also needs to support countries to have the data and management systems in place to deliver a real-time public health response, with a view to actually preventing transmission.
TEDROS ADHANOM GHEBREYESUS
Over the last 20 years, we have made tremendous progress on combating AIDS. I commend the advocacy and leadership role of UNAIDS in achieving these results and coordinating and harmonizing the United Nations system’s response to the AIDS epidemic. If elected as Director-General, I will have the following three priorities as part of the health sector AIDS response.
First, I will champion efforts to sustain the progress we have made so far without complacency and to renew our commitments to end AIDS as a public health problem by 2030. The global commitment for the Sustainable Development Goals offers a profound opportunity to tackle the structural, social and economic changes needed to end AIDS. I will ensure the World Health Organization (WHO) is part and parcel of these efforts, working alongside UNAIDS, the United Nations system, Member States, civil society and community groups.
Second, my topmost priority as Director-General of WHO will be universal health coverage, and I will work to ensure that each person living with HIV has access to the HIV prevention, treatment and care services they need. We will give due emphasis to HIV prevention and addressing comorbidities, such as HIV-associated tuberculosis, as well as the growing concern of noncommunicable diseases. Universal health coverage will also help key HIV populations, such as sex workers, men who have sex with men, people who inject drugs, transgender people, migrants and adolescents, reach HIV prevention, treatment and care services. WHO will provide Member States with the normative tools, guidance and support they need to implement these policies.
And finally, I would prioritize building strong, community-based health systems which can design and implement locally tailored prevention and treatment programmes. This will include strengthening primary health-care systems to deliver HIV prevention, treatment and care. Ensuring investment in health systems will not only help us manage HIV/AIDS, it will also support our efforts to prevent and treat other communicable and noncommunicable diseases, as well as prevent and respond to future health emergencies.
READ INDIVIDUAL INTERVIEWS
Question: How important do you feel the lessons learned in the AIDS response are in shaping the future of global health?
DAVID NABARRO
The response to AIDS taught us a great deal, and was extremely important in shaping global health. First of all, it taught us to focus on the people and patients, as opposed to the medical condition or the virus. By shifting the focus in this way, the movement was effective in engaging civil society and a wide range of actors in combatting the condition, and, importantly, also the stigma attached to it. The second important issue brought to light in the AIDS response was ensuring that all persons at risk—whatever their place in society—were able to have full access to the services they needed: leaving no one behind. Hard work was done to ensure that HIV status, a person’s gender, sexual preference or substance use should never be an excuse for discrimination, which is certainly crucial to all global health areas of work. Thirdly, the AIDS response demonstrated the importance of multistakeholder and intersectoral approaches and broke new ground in providing a good model of how to work in an integrated way across agencies on complex health issues within the United Nations.
SANIA NISHTAR
The AIDS response more than any other has taught us four critical lessons for the future of global health. The power of ambition, power of community engagement, the benefits of a multisectoral response and lessons to reorient acute-care health systems towards chronic disease management.
On the first point, the AIDS community was one of the first to push for universal access. Seen as heretical at the time, the AIDS community said everyone, everywhere can and should be treated. Through South–South cooperation antiretrovirals were made accessible to those that needed them most and millions of people are now alive because of it.
Second, the AIDS response has shown us that the community matters and health is everybody’s business. Community health workers trained in treatment literacy were key to breaking down social stigma and encouraging people to get tested and to take up treatment.
Thirdly, the AIDS response has shown us the power of partnership and while the outcome of a disease may be a health outcome (e.g. people get sick or die) prevention and treatment on a universal scale requires engagement of all players—government, private sector, faith-based organizations, community-based organizations, civil society, academia—and all sectors—education, food security, water and sanitation, transportation.
In the fourth place, the scale-up of services in lower-income countries has created the first large-scale continuity care programmes. Although HIV and chronic noncommunicable diseases (NCDs) are thought of as different challenges, there are many commonalties, as far as the health systems response is concerned, since the availability of treatment has transformed HIV into a chronic condition. HIV programmes have developed the systems, tools and approaches needed to support continuity of care. These lessons can help in mainstreaming the management of NCDs in country health systems planning.
Overall, we have also learned that we cannot see any disease area in isolation—to address HIV/AIDS we need an effective, strong system, which means people, funding, hardware, leadership and data to drive decision-making.
Our experience with HIV has shown us the shortcomings of systems built around one-time episodic care and that success is only possible when the beneficiary and the provider embark on a journey together as part of the continuum of care. As countries are grappling with a declining burden of communicable disease and a rise of NCDs, we need to build strong health systems that are sustainable and more responsive. This requires a long-term view focused on both people and systems.
TEDROS ADHANOM GHEBREYESUS
I have no doubt that the lessons we learned in the AIDS response have been critical to shaping the future of global health, both in terms of what we need to do and how we need to do it. The AIDS response first and foremost taught us the importance of political advocacy, community mobilization and determination to overcome despair with ambition and solidarity. The lessons of the AIDS response showed us the value and power of multistakeholder engagement and that we cannot address a health issue at its root only by focusing on the health sector. We also learned that with global solidarity we can innovate and mobilize dramatic domestic and international resources for health, which not only had a profound impact on HIV, but also on the broader health system. For example, when I was a Minister of Health of Ethiopia, we created a 2% HIV Solidarity Fund (a pool fund of 2% salary contributions of civil servants) to initiate our HIV treatment programme. Particularly in the face of changing political climates, we need this type of creativity, commitment and multisectoral response as we work to place universal health coverage at the centre of the implementation of all Sustainable Development Goals.
Question: As the AIDS response has scaled up to reach millions, one of the key challenges has been the lack of community health workers and the capacity of the health system to deliver services at the scale. How will you address the challenge of building up the health system to prepare for the next disease outbreak and to meet current health challenges including AIDS and non-communicable diseases?
DAVID NABARRO
Governments are increasingly focused on how best to develop health-care infrastructure and staffing so that all people are enabled to access essential health care while—at the same time—ensuring that there are appropriate facilities within which care can be offered to persons who have or are at risk of HIV/AIDS, providing them with health services and lifestyle information. Governments seek to ensure that procurement mechanisms for AIDS medicines work well and enable people in need to access the medicines and take them as directed. They also work hard to ensure the necessary political support to ensure that health infrastructure is rolled out in ways that are sensitive to the needs of people living with HIV. The services offered should take account of the reality that people living with HIV may well end up developing noncommunicable diseases. To this end, national authorities in several countries are looking for ways to incorporate AIDS care within the programmes for chronic diseases. All governments will wish to encourage regional and global collaboration on funding, on technical assistance, on ensuring access to medicines and diagnostics and on securing access to vaccines as they become available.
SANIA NISHTAR
Here you raise three separate but important issues: the lack of health workers, the need to deliver services at scale and the challenge of building health systems, and how best to prepare for the next disease outbreak.
First, community health workers form the backbone of health services in many countries—in many cases the health workers are women. We must do better in remunerating these women on time for their work, as a pure volunteer model is not sustainable in the long run if we want to retain this part of the workforce. More broadly, implementation of the recommendations of the High-Level Commission on Health Employment and Economic Growth will work well, both for addressing health workers’ shortages as well as economic growth and health systems strengthening, overall.
I have always believed that strong health systems can deliver on any disease-specific goal. In fact, this has been the message of my book, Choked Pipes. In addition to disease-specific targets, strong and effective systems can also be crucial for the response to pandemics. I will ensure WHO embarks on a course to strengthen the international framework to coordinate and consolidate efforts towards the achievement of universal health coverage, with health systems strengthening as one of its key features. This will also include efforts to overcome systemic barriers and address collusion in health systems, and provide technical support to countries to develop new stewardship mechanisms to tap the potential of providers of services in the non-state sectors, which play a predominant service delivery role in many parts of the world. Under my leadership, WHO will promote universal health coverage as a health policy goal for all countries, and will help ministries of health galvanize commitment at the head of state level. Embracing universal health coverage means building on previous commitments to primary health care and including long-term social policy commitment, domestic resource allocation and a move linking coverage for essential services to financial risk protection.
Finally, on disease outbreaks, there are actions to be taken both in countries as well as within WHO. WHO must work more effectively with Member States to enhance their core public health capacities as demanded by the International Health Regulations. Improvement in disease surveillance will improve health planning, and quick detection and response to outbreaks will save lives. Internally within WHO a new Health Emergencies Programme has been initialized, which I am strongly supportive of and which I will strengthen as a priority.
TEDROS ADHANOM GHEBREYESUS
Scaling up community health workers and health system capacity must be a fundamental component of our efforts to achieve universal health coverage, which will be my topmost priority if elected as Director-General. These efforts can build on the tremendous progress made and experiences gained in the last two decades tackling HIV, tuberculosis, malaria, neglected tropical diseases, and child and maternal mortality. As part of this effort, we also need to strengthen primary health-care systems with integrated community engagement to address communicable and noncommunicable diseases, such as cancer, heart disease, chronic respiratory diseases, diabetes and injuries. These efforts will help not only to deliver evidence-based health promotion, prevention, treatment and rehabilitation services, but also to enhance prevention, detection, response and recovery efforts for health emergencies.
As Director-General, I will build on my first-hand experience addressing this capacity gap in Ethiopia to support Member States and national health authorities’ efforts to develop and implement policies aimed at ensuring universal health care. In Ethiopia, for example, our flagship Health Extension Programme deployed nearly 40 000 community health workers in every village of the country. HIV prevention was one of their key activities—a focus which has resulted in a 90% reduction of new HIV infections between 2001 and 2012. WHO has a key role to play in sharing these types of lessons learned across countries. It also needs to help build and maintain partnerships among the diverse group of players involved in global health—country governments, donors, the private sector, civil society and academics—to overcome barriers to achieving universal health coverage, including improving access to quality diagnosis and care, essential drugs and financial protections. Finally, I will also work to put and keep universal health coverage on the agenda at the highest political levels possible, maintaining the political will and resources needed to achieve these goals.
Question: How will you ensure that people affected by HIV especially key populations-such as sex workers, gay and other men who have sex with men, people who inject drugs, transgender people and migrants are not left behind in efforts to achieve universal health coverage.
DAVID NABARRO
I see many examples of health professionals, civil society, faith groups, the United Nations and others with an interest working with governments with a view to reducing the stigma in relation to persons who are at risk of HIV and reducing the extent to which they are subject to discrimination that results in their not being able to have proper access to care. To be better able to do this work, health professionals and other stakeholders need support so that they can practice in ways that reduce stigma and discrimination, need access to evidence, need to be able to interact with the general public and need to be able to work closely with each other in solidarity, as it can be challenging and difficult work associated with setbacks as well as successes.
SANIA NISHTAR
Everyone has a right to health. As with all areas of its work, while recognizing the criticality of national sovereignty, to fulfil its mandate of health for all, WHO must also be the steward and champion of both the right to health and a human rights approach to health.
The 2030 Agenda and the Sustainable Development Goals reaffirm the responsibility of Member States to “respect, protect and promote human rights, without distinction of any kind as to race, colour, sex, language, religion, political or other opinions, national and social origin, property, birth, disability or other status,” signalling a renewed commitment to human rights in the coming global health and development agenda.
Throughout my work as a doctor, in government, civil society, academia and working with international agencies, I have always based my work on the foundation that everyone has the right to quality health services. It was this strong grounding that led me to set up an innovative financing facility in Pakistan that assists the poorest and most marginalized communities to avoid catastrophic expenses when accessing health. I will continue to walk the walk on the right to health as Director-General of WHO.
TEDROS ADHANOM GHEBREYESUS
Our efforts to achieve universal health coverage need to prioritize the needs of the vulnerable and marginalized. Specifically, I believe WHO must champion mechanisms to meaningfully listen to, learn from and engage these groups. This engagement—and what we learn from it—should then be at the centre of our efforts to mobilize resources and hold authorities accountable for the health of all, regardless of age, gender, income, sexual orientation or religion. In addition, it will be essential to improve our evidence base around effective ways to reach the most vulnerable and most marginalized. New research can help us develop data-driven and results-oriented solutions, which will help us maximize the impact of interventions we invest in. Part of this effort will also require us to build and improve the infrastructure for data collection and ensure that the data we collect are used to inform policies. Lastly, WHO is ideally positioned to address inequality in health care, and, if I am elected Director-General, I will be a strong voice and committed champion to ensuring everyone has the right to health care.
Question: What does UNAIDS mean to you?
DAVID NABARRO
UNAIDS is a very important expression of the spirit and solidarity with which we all need to work together to empower actions that will lead to a reduction of the disadvantage and suffering experienced by people who are at risk of HIV and AIDS, as well as those who are actually affected by the disease. It has had a powerful influence on the behaviour not only of the United Nations system but of the whole community of actors engaged in ensuring equitable access to requirements for HIV/AIDS prevention, diagnosis and treatment.
SANIA NISHTAR
UNAIDS was one of the first examples of a partnership that harnessed the strengths and core competencies of all the United Nations agencies. Under the stewardship of UNAIDs, the United Nations has driven an ambitious agenda, and collectively we have pushed farther and faster towards ending the epidemic—ambitious goals for access to treatment and prevention of mother-to-child transmission of HIV are being met in some countries, and, for the first time, epidemic control and ending transmission seems as possible in a handful of African countries hardest hit.
UNAIDS has also played a key role to keeping a human rights-based approach to our response and ensuring that access to critical prevention and treatment is extended to key populations at risk, including harm reduction for intravenous drug users, and adolescents. UNAIDS has also led the way on how we in health can work with multiple actors—civil society, communities, volunteers and the private sector—to improve coordination and to better leverage the skills, experiences and resources of partners.
TEDROS ADHANOM GHEBREYESUS
I will start with a personal note. It has also been a great pleasure and honour to have had a chance to chair the Programme Coordinating Board (PCB) during my time as Ethiopia’s Minister of Health in 2009–2010, and to consider UNAIDS a close partner for more than a decade. It was during my time on the PCB that UNAIDS increased its focus on health systems strengthening and HIV prevention, including country ownership—setting the stage for our universal health coverage efforts. We also worked to implement the new UNAIDS mission statement, which outlined its priorities and vision for the future.
I believe UNAIDS’ provocative leadership has been critical in addressing the AIDS epidemic and converting it from a death sentence to a chronic health condition. Its global role has not only garnered the highest political support for the AIDS response, but also ensured the voices of those affected by HIV and their families are at the centre of the response, including placing civil society within its governance structure. I believe consolidating these experiences will be useful to tackle the structural, social and economic changes needed to end AIDS as part of the Sustainable Development Goals. I also take note of the recent recommendations of the Global Review Panel on the Future of the UNAIDS Joint Programme Model.
If elected Director-General of WHO, I would look forward to continuing our work together and our close partnership.
