on Wednesday, 18 May 2016.

Dear Colleagues,

Here is our topic for May and June 2016.
The next 69 World Health Assembly (WHA) will start next week, 23 – 28 May, 2016 in Geneva, Switzerland. Member states must be now be in advanced stages of preparing for this annual event and in one of our previous discussions we addressed the ideal approaches for preparing for the WHA and other international meetings. I have looked at the agenda for the 69 WHA and want to draw the following Agenda items to the special attention of the African delegations.

1. Agenda 11 on WHO Reform: WHO has gone through tough times in the last few years and there are voices that are calling for the role of WHO downgraded. Yet without a strong global organization which brings together all member states with equal voice around one table to address global health matters, global health and health security will be at increased risk. We need to support and strengthen WHO. The funding of WHO needs to be increased but also the monitoring of performance and accountability by WHO by member states should increase. Elections for the new Director General of WHO are around the corner and it is high time that an African occupied this position.

2. Agenda 12.6 on Control and Prevention of Non-communicable diseases (NCDs): Africais experiencing an explosion of NCDs. Diabetes mellitus, cancer, cardiovascular disease, mental health need to be prevented through aggressive health promotion programs as most of them are life style related.

3. Agenda 13 on Health through the life course including a review of MDGs and embracing the SDGs through Multisectoral action. This will call for stronger health leadership and governance which is presently taken for granted and not given the high priority that it needs. Without strong leadership and governance of health at country, regional and global level, we will not achieve our goals.

4. Agenda 14 on Preparedness, Surveillance and Response to infectious diseases and implementation of the International Health Regulations. The outbreak of Ebola in West Africa last year showed that a weak health system in any corner of the world is a health security risk for the whole world. The International Health Regulations adopted by the WHA some five years ago remain unimplemented in most countries. Independent Assessment of the status of implementation of these in our countries should become routine if we are to assure national and global health security. Integrated Primary Health Care systems owned and driven by communities is the way forward. To establish and sustain these calls once againfor strong health leadership and governance.

5. Agenda 15 on Communicable Diseases especially HIV which is still a major health challenge in Africa despite the achievements that have so far been scored in its control. Access to vaccines is a pillar of disease prevention and we should be active in discussing the Global Vaccine Plan. Another important issue is Anti-microbial resistance. Misuse of anti-microbialagents in many of our countries is a major issue due to proliferation of unlicensed vendors and informal health
service providers.

6. Agenda 16 on Health systems especially Health Workforce and Services. Skilled and supported health workers are the essential vehicle for delivery of integrated people centered services and yet there are reports from WHO that African health workforce densities have not changed over the last ten years. Indeed in 22 African countries the densities have deteriorated in spite of aggressive advocacy. It is therefore gratifying that a new Global Strategy on Human Resources for Health will be tabled for adoption by the 69 WHA. There will also be discussions of the level of implementation of the WHO Code on the International Recruitment of Health Personnel and I hope that more countries in Africa will have submitted reports this time round.

I urge African delegations to the 69 WHA to look out for opportunities to share on this topic and to learn from each other on how to improve HRH programs in the countries. This once again calls for strong leadership at country level. Tools and instruments for scaling up education and training and retention of health workers where they are most needed are available and are waiting for interested leaders to apply them. Under agenda 16 is another important item on the WHO Strategy on Research for Health. Without effective and relevant research programs in our health systems, we will not have the intelligence for direction, focus and cannot learn how to improve our performance. I urge all delegations to participate in this agenda item and go back home with commitment to prioritize research for health.

Your comments are welcome and I wish you all fruitful deliberations at the 69 WHA and safe travel.



Comments (1)

  • Adamson S. Muula

    Adamson S. Muula

    14 June 2016 at 08:26 |
    Thank you for sharing the agenda for WHA. For Malawi, the HRH problem
    now is not so much of training the right numbers but employing them
    after training. The article I wrote summarizes the current grind:
    How IMF’s loan freeze will affect health care in Malawi

    The International Monetary Fund’s (IMF) recent decision to withhold its latest loan money to the Malawian government could have dire implications for the provision of health care in the country.
    In response to the loan freeze, Malawi has put on hold the hiring of 51 medical graduates and a host of nurses and health professionals to cut its burgeoning wage bill.

    The IMF is holding back a US$20 million disbursement of the US$150 million loan facility it has with Malawi because the country failed to meet some of the loan conditions. This was partly due to overspending on the wage bill but it was also exacerbated by revenue and external financing shortfalls. The extended credit facility is the fund’s tool to lend at zero interest to low-income countries.

    It is not the first time that Malawi’s funding has been withheld. In October 2013, after it was discovered that US$45 million in public funds had been stolen, donors also withdrew funding. Donor funding used to account for as much as 40% of the country’s budget.

    The need for doctors
    The latest delay means that the nurses and other health professionals (except doctors) who were earlier offered employment contracts had their offers rescinded after the IMF’s visit in September.

    By not employing the intern doctors Malawi will miss out of the clinical services that junior doctors provide. It will also have wasted millions of dollars spent on their training. The medical program at the University of Malawi takes six years, and the government spends US$10,000 on each student annually.
    Anecdotal evidence in the last few years shows that Malawai has managed to retain more than 90% of these intern doctors.

    There has been a common narrative that low-income countries do not have the necessary doctors to service their health sectors because of low production from medical schools as well as the brain drain.

    Malawi does not have a brain drain problem but it does have other challenges. Research shows that Malawian health facilities have a 65% vacancy rate for nurses and nurse-midwives. It put the doctor-to-population ratio at 0.2 doctors for every 10,000 people. The nurse-to-population ratio is 3.4 for every 10,000 people – one-third of the World Health Origination’s recommended ten nurses for every 10,000 people.

    In Malawi, just over 10% of the population between the ages of 15 and 49 years are living with HIV. It is estimated that 55,000 new HIV infections occur every year.

    Healthcare challenges in Malawi include inadequate human resources and a skewed distribution that favours urban areas. There is also inadequate financing, infrastructure and equipment for Malawi’s estimated population of 16 million.

    The health system has been largely supported by “development partners”. In the 2014-15 financial year, US$4.5 million (K65.2billion) of its US$122 million (K635.6 billion) went to health. Foreign grants made up 14.7% of the budget.

    The intern doctors were due to participate in an 18-month internship, which needs to take place for them to receive regulatory body licenses (the Malawi Medical Council of Malawi). Their internships are split into three months tranches in internal medicine, pediatrics and child health and two six-month stints in surgery and obstetrics and gynecology.

    Only two public tertiary care hospitals, Kamuzu Central Hospital and Queen Elizabeth Central Hospital, are accredited to host the interns. The interns are employed within the civil service as Professional Grade Eight officers. This is the second-lowest graduate among new entrants with a first degree into the civil service.

    A medical doctor, who has not completed their internship, by law, cannot be registered or licensed. No license means that one may not be employable or practice independently. However, doctors can complete their internships in any other country, which will allow them access.

    Task shifting
    The health system has heavily relied on task-shifting – a strategy where non-qualified (often non-medically qualified) health workers are given responsibilities normally performed by highly qualified and highly skilled professionals.

    Task-shifting gained momentum in 2004 when Malawi’s when anti-retroviral treatment was initiated and needed to be scaled up amid a shortage of medical doctors.

    Until recently, task-shifting was said to be on account of lack of adequate numbers of doctors. But with the excess junior doctors available but not employed, it will be interesting to understand the government’s explanation for shifting the healthcare responsibilities to non-physician cadres.
    Finding an alternative
    The responses to the doctor hiring freeze have varied. In October, the Doctors Union of Malawi and the Society of Medical Doctors issued an ultimatum to the government to employ the junior doctors or there would be a nationwide strike.

    The strike has not taken place, partly due to a lack of consensus among the doctors represented by the union and society. Some activists, who appear not conversant with the concept of medical internship, have called for the removal of the internship before the doctors can be fully registered. There have also been reports that just under half of these junior doctors have left for Lesotho, where they received employment.

    The current stalemate is that the Malawi government has been pushed to the wall: if the country wants to satisfy the IMF, then is must not employ the doctors.
    The long-term solution is a Malawi that does not need the IMF or World Bank loans and grants. How such a Malawi will emerge is not clear to many.

    Going forward an alternative may be for Malawi to consider whether health facilities run by religious denominations, such as the Christian Health Association of Malawi, and selected private hospitals could host interns. This would remove the burden on the Ministry of Health as the sole entity for training interns.

    But these other facilities need resources themselves in terms of specialist doctors' posts and commensurate equipment and patient load. And it would mean that the junior doctors could be employed and service the people who need health care most.

    Adamson S. Muula PhD, MPH, MBBS, CPH
    Professor of Epidemiology and Public Health
    University of Malawi, College of Medicine
    School of Public Health and Family Medicine
    Department of Public Health, Malawi
    follow the link below for details....

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