In Marrakesh, during one of the side-events organized by Public Services International (PSI), European Public Service Union (EPSU), WHO, the Friedrich Ebert Stiftung and the governments of Germany and the Philippines, we presented a discussion paper: Global Skills Partnerships & Health Workforce Mobility: Pursuing a race to the bottom? As many of you may know, Michael Clemens, from the Centre for Global Development, has been the driving force behind this Global Skills Partnerships (GSP) concept . By now, the concept has become part of the Compact under objective 18. GSP have the aim to “Invest in skills development and facilitate mutual recognition of skills, qualifications and competence.” PSI commissioned research to us as to critically assess the skills partnership concept, its drivers and discourses, as GSP might have an impact on health equity and health systems development in both source and destination countries.

Unlike the treatment the average migrant gets at European borders nowadays, the world of ‘migration and development’ welcomed us at this UN Global Compact conference. Perhaps we were biased, but other pre-sessions seemed to indicate a big contribution (and interest) of the private sector in the economic potential of migration contributing to development. In line with mainstream economic thinking, migration was largely framed as a potential economic enabler, facilitating ‘win- win’ solutions. GSP clearly fits in this frame. By using a critical discourse lens it is evident that foremost an economic development approach and indirectly a trade and health objective are pursued through these public-private skills development partnerships facilitating health workforce mobility. The GSP seems to be a short-term cost-effective solution to address deficits in health care systems by sourcing skills transnationally. The investment case and economic benefits are projected to be sustainable and inclusive but both the literature review and interviews that we conducted failed to provide evidence of this. The GSP concept as it currently stands doesn’t adopt a human rights-based approach to health systems development nor does it give much attention to health care services as a global public good.

So, our stance versus GSP is somewhere stuck between a rock and a hard place, currently. The (GSP) picture could of course be improved, in the short-term, by assuring that trade unions and governments are strongly involved when pursuing bilateral labour agreements that include new skills partnerships; and in the longer-term by pursuing regional, and perhaps global governance and public finance model(s) to mitigate the benefits and externalities of health personnel migration.

This requires, however, in our opinion, strong public, multilateral engagement and shouldn’t be left to the market, philanthropy and the private sector. If government and trade union aren’t at the table to protect and promote the public interest, the other parties have ample space to jump in, with other interests. The risk for exactly that to happen is rather high, unfortunately, in the current international environment.

This is the political economy irony and dichotomy (of the rock and the hard place) of global labour migration and skills partnerships. They are being promoted as an efficient solution in places where care demands and financial gains are high. If there is no direct benefit [in the receiving countries] of different types of labour migration, things are, however, instantly framed as a ‘crisis’ that needs to be contained, surveilled and securitized. A more nuanced and fairer political narrative on labour migration in the health care sector (and other sectors) needs to be pursued.  And of course, in an ideal world, decent public investment in health care staff would just make GSP redundant. But we don’t live in an ideal world.

As an end-of-year thought, let us share a quote displayed in bright neon letters at the Irish emigration museum in Dublin: “We All Come From Somewhere”!   

In Iran, we had been invited by colleagues from the Teheran University of Medical Sciences, School of Public Health with whom we collaborate on developing Global Health Educational programs. After visiting the bustling, captivating but polluted capital city, Teheran, we all went to Shiraz, another big city in Iran, to participate in the International Congress on Health for Peace.  This congress, coordinated by the University of Shiraz and co-organized by WHO, UNICEF and UNESCO made the strong plea that working towards health (by the medical community and others) is vital for peace and stability. Presentations referred to SDG16, working towards peace, justice and strong(er) institutions. Interestingly, WHO’s program on Health as a Bridge to Peace was being promoted as a way to contribute to peace in the Middle Eastern region which is, sadly, prone to so much violent and non-violent conflict, and this already for decades. Members from the International Physicians for the prevention of Nuclear War  provided some inspiration on how sustained international action can reduce the likelihood of nuclear (and other) wars. Other inputs during the conference included a great concern about the impact of the new American sanctions on public health in Iran as well as the ongoing humanitarian disaster in Yemen and the dire situation in Syria. After 15 years of an international political push towards global securitization, it was refreshing to hear this strong call for International Peace, in line with the Paris Peace Forum which took place at the same time, exactly 100 years after the end of World War I.

Over to PHA4 then. In Bangladesh, where we work with the BRAC university school of Public Health on reforming health education, the 4^th People’s Health Assembly took place. The People’s Health Assembly is the global gathering of the People’s Health Movement (PHM) , and takes place every 5 years or so. This unique, international social movement for health has been (politically and otherwise) mobilizing people and organizations towards the goal of ‘Health for All’ since (and actually already before)  the first People’s Health Assembly in 2000. This first gathering also took place in Bangladesh, at Gonoshasthaya Kendra (GK) Savar. I have been active in this great health movement since 2003, and am a representative of the Medicus Mundi International (MMI) Network in the PHM Steering Council. The organization team of PHA4 did a great job as they had to relocate – at the last minute! – the venue of the assembly from GK to BRAC premises due to domestic political issues. International participants were (temporarily) denied entry to the country and the entire assembly almost had to be canceled! Against this rather worrying backdrop, it brought much unity, relief and energy that the 4-day gathering could eventually take place and 1400 participants from 73 countries could engage in great discussions and solidarity actions to advance Health for All! To get a good impression of all action in Dhaka, check the tweeter feed #PHA4 and related stories and coverage on People’s Dispatch.

A major question is now: will these great Peace and Social Justice Health movements be able to (politically) contribute to a safer and fairer world? This is where the reflection and somewhat sobering analysis comes in. In my latest blog I wrote how mainstream global health actors are trying to ‘save’ multilateral liberal global health governance, one way or another.  In a (more ambiguous) way, peace and social movements are doing something similar, with one major difference.

The aim of all mainstream actors in global health and development is to ‘save’ the 20^th century multilateral United Nations order as it has developed after WWII, based on a democratic, capitalist, open trade and rule-of-law model of governance with nation states being sovereign (in theory, at least) in choosing their own path towards development. This is known as the so-called Bretton-Woods compromise. Progressive social movements share this focus on nation states – they aim for an International Economic Order where autonomy (non-alignment), solidarity, and respect for sovereignty and human rights between nation states is key.

My main point is, this entire construct is becoming defunct in the globalized 21^st century! I am increasingly becoming convinced that the nation state construct is a hindrance towards global ecological and social justice. The political economist Dani Rodrik describes this as the “Political trilemma of the World Economy”. In this theory, he argues that deep economic integration, the nation state, and democratic politics are mutually incompatible: we can combine any two of the three, but never have all three simultaneously and in full. This is where the ambiguity comes in; both in Iran and Bangladesh, the externalities of deep economic globalization are very visible, with respectively a water crisis  and floods due to climate change. Bangladesh has with > 4000 kilometers the longest border fence in the world as India has to protect its “national security”. In general, due to a worldwide rise in nationalism, border fences and walls have globally exploded over the last 15 years.  In contrast, democratic policies and practices are under tremendous pressure in many countries. This democratic regression is by now a global phenomenon.

I consider ecological degradation and socio-economic inequalities as the most urgent global, complex challenges of our times. All our attention must go towards avoiding more catastrophic scenarios and we should thus move towards a post-capitalist and just order, also in an attempt to avoid global conflict, which I believe by now has become a major possibility. The close interrelations between capitalism, the nation state and transnational companies have been for centuries major drivers of these global pathologies. While we, in the social movements and in our analysis, have constantly been bashing capitalism and private wealth, I think it’s time we also seriously challenge the unique legitimacy of nation states, and their international organizations.  Soaring nationalism is merely an expression of global anxiety to maintain an old but dilapidated order, to divide between ‘us’ and ‘them’.  In a 21^st century update of that famous saying of Ronald Reagan (in Berlin), we do need to tear these national walls down, and allow ourselves to imagine a new politics to provide for a circular economy that respects planetary boundaries and ensures human capabilities for all.

I realize, the above is dangerous political thinking. In fact, it is anarchy. But perhaps such civil disobedience is a good start to find a channel to have the Old die respectfully and let the New be born!

A quote by Hafez, the great Sufi poet from Shiraz, might provide some inspiration:

“Leave the familiar for a while. Let your senses and bodies stretch out. Like a welcomed season onto the meadows and shores and hills. Change rooms in your mind for a day.”  (from: All the Hemispheres)

People’s Health Movement Steering Council 2018

While it is encouraging to see that the academic and policy debate on health policy, systems and research is becoming less superficial and more thoughtful in its proclaimed aim to challenge power, politics and inequity, it is less clear whether the health systems global community itself has powerful agency, or whether the political actors it tries to engage in order to make change possible, are appropriate. During HSG2018 the onus was put on domestic finance, country processes and governance, at the same time, there was very little discussion around actual globalization and health policy pathways and politics that structurally limit or enable health systems to function. Issues like restrained policy and fiscal space in which to invest in health systems due to the effects of economic global straightjackets, the financialisaton of health care, capital flight and tax evasion were not explored or questioned. All in all, it is not so strange that HSG2018 did not delve into these issues, as the conference is financed by major global health actors & institutions, governments and philanthropy all of which adhere to the main SDG narrative of partnerships and convergence, rather than one of (global) discord and conflict.

Real power, money and politics were to be found at the World Health Summit in Berlin. After 10 years, the German capital has become a de facto core Global Health hub – if one did a social network analysis of key actors in Global Health, Berlin would no doubt have been a big red dot on the map, last week. The place felt like a beehive, with swarming bees everywhere and honey to be found! This development is remarkable as at its launch in 2009, the legitimacy of the WHS was seriously questioned, with Medico International saying “instead of creating a new body sponsored by the pharmaceutical industry, it would be better to strengthen the existing structures of the World Health Organization.” Yet for better or for worse, a WHO reform proposal (par. 87) to create a World Health Forum in Geneva was rejected by the World Health Assembly in 2011. Fast forward to 2018, when it is, in fact, the director general of the WHO, Dr. Tedros, who came to Germany to launch the multilateral Global Action Plan for health and wellbeing for all at the WHS, and present WHO’s investment case to funders (notably the Gates foundation, Germany and Norway). There is a certain wry irony in the fact that philanthropy shapes (to a large extent) the current global health agenda and it is also used as a resort to try “save” liberal multilateral health governance. Then again this is not new in history – we have seen the Rockefeller Foundation doing something similar before and after World War II.

However, the real dissonance in these global health fora comes from the fact that they neglect to address some of the crucial issues of our times and, indirectly, in this respect, continue to defend a politico-economic order that keeps preaching the (nowadays, “inclusive”, “sustainable”, … take your pick) economic growth gospel as a magic solution to improve health and development outcomes.

The latest International Panel on Climate Change (IPCC) report predicts that we can reduce emissions fast enough to keep under 1.5 degrees, but only if we’re willing to fundamentally change the logic of our economy. It calls for a scaling down of global material consumption by 20 percent, with rich countries leading the way. This approach requires that we evolve beyond the rigid constraints of capitalism, a system which clearly is not fit for purpose in the 21^st century, with planetary health boundaries knocking increasingly at our door. Co-incidentally, the 50th anniversary summit of the Club of Rome also took place last week. In a new report to the club of Rome, called Come On! the authors call for a ‘new Enlightenment’, characterized by a vastly improved balance between human beings and nature, and between private consumption and public goods. This call for a circular economy is politically very uncomfortable, but urgent and by now more than overdue: the original Limits to Growth publication and recommendations from 50 years ago turn out, decades later, not to have been too far-fetched...

So, are enough of us, “humans of late capitalism”, able to connect the dots in Global Health? Will we be able to connect the dual aims of social and ecological justice? At the heart of this debate is a (global) political conflict around what is required to advance human wellbeing and planetary health. It is about Economic man vs. Humanity. It is time we bust the SDG myths of multi-stakeholder partnerships and of being “one happy family”, in order to ensure that “no one is left behind”, and instead focus on different narratives and collaborations of hope. As decent people we need to take serious and fair climate and economic action, as this is the best way to deal with  living in conditions of crisis and violation, and fuel our spirit, conscience and society, in order to advance global health equity.

Health for All in the 21^st century demands no less.

Footnote: having said all this, as global health researchers, we also need to tackle the cognitive dissonance within ourselves.  I flew back and forth between Liverpool & Berlin last week. In this new era we have to adapt and organize in different ways, in order to reduce our carbon footprint considerably.

True, to a certain extent, WHO’s financial difficulties for running its operations and organization are not new. Since its initiation in 1948 the organization has been partly dependent on financing by actors other than its member states, e.g. in the early years from the Rockefeller Foundation.  In that sense it is not entirely surprising that its philanthropic “successor”, the Gates Foundation, is paying for approximately 25% of WHO’s overall budget, nowadays. Still, the partnership model in global health and the so called “Trojan multilateralism” trend have “inspired” a shift away from broader systemic goals sought through multilateral cooperation, in recent decades.

It is in this light that the preparatory EB document “Better Value, Better Health” should be read. There is a certain irony in the title because the documents mainly talks about value for money, hardly about any value for health. The value for money trend is part of a continuing push for UN organizations (by their funders) to focus on performance and results.  This ‘New Public Management’ (NPM) approach, since a few decades the business-inspired “mantra” for public organisations and institutes, is now also firmly embraced by WHO under Dr. Tedros, it appears. The document makes it abundantly clear that the aim is to function from now on as a global public institute in a networked, multi-stakeholder manner with its private partners, providing “value for money” (which supposedly will lead, in turn, to better health for the billions).  In the ‘Better Value, Better Health’ document WHO benchmarks itself by mapping 12 other multilateral organizations. As for how they are doing in terms of value for money,  “… all the organizations mapped had incorporated value-for-money principles to varying extents…. all took into account efficiency and effectiveness, but there was no evidence anywhere of an ethics consideration”.

Wait, aren’t we talking here about the main global authority working on health policy norms and guidelines? Shouldn’t public health ethics, defined by WHO itself as “principles of respect, good will, justice and not causing harm” be much more central to such a ‘Better Value’ approach?

Unfortunately, this indicates a broader trend, whereby human rights and health equity –  i.e. an ethical value base for international health cooperation and global health diplomacy, have quietly been sidelined as policy drivers for sustainable development. It is painful to see that the ‘NPM’ discourse has become so dominant in a multilateral public health organization while in many European (domestic) public health constituencies NPM has been considered a ‘cruel disappointment’. Public sector transformation via private sector performance criteria has led to an expanded role for management consultants, an ‘audit society’ and risk management procedures, the typical NPM ‘package’. This is exactly what we now see being pushed through at WHO.  Analysis suggests that within the British Health care System, for example, NPM has failed to deliver on its goals with ‘significant undesirable side effects and misfits between policy announcements and implementation’.

While there is certainly a need for the WHO to work more efficiently and effectively, NPM is not the answer. WHO itself also warns for “over-institutionalizing” Value for Money in the organization. Rather, there must be a constructive public dialogue with its members (and third actors) on what WHO should and should not do, including with respect to its financing. There is currently a large push by many funders for WHO to be more operational, while others argue that its main role should remain norm-setting and evidence-based program guidance.

The key difficulty remains to have the core tasks of WHO properly financed.  Voluntary tied financing and a minor (3%) increase of assessed contributions by Member States complemented with philanthropic funding have perhaps managed to keep WHO afloat in recent years, but drifting in (too) many directions. I would rather argue  that WHO’s normative role is a Global Public Good for which alternative innovative public financing mechanisms should be developed, e.g. via earmarked taxes coordinated between countries, Financial Transaction Taxes or other global levies.

This, however, requires WHO’s member states to be firmly committed to democratic multilateralism, which is far from a given in our current chaotic multi-order. But who knows, perhaps 2018 will be a new start, including for the WHO?

Geneva, over to you!

At the summit, Maria Neira, Director of Public Health and the Environment, WHO presented some of  the worrying figures on the impact of environmental pollution which causes 23% of all global deaths, currently. Put differently, 12.6 million of lives can be saved per year, if we would get this right.  The current pollution crisis in Delhi is a stark reminder of the (dire) situation, in case it’s still needed.  Nick Watts from the Lancet Countdown on Health and Climate Change presented the 2017 report.   The rest of the day featured interesting panels and a “world café” format where participants discussed different sorts of inter-sectoral health mitigation and adaptation measures, as well as the role of the health sector and health professionals in this area till now, and hopefully, in the future.

It’s wonderful to see that the global climate and health alliance has grown so strongly over the last years after it was formed during the COP in Durban in 2011. It is a much needed alliance, too, as a collective global health network, knowledge hub, and advocacy have all been sorely missing in the climate debate till recently. Fortunately, that is changing now, long overdue. In Bonn, health is now (finally) a rather important topic, as a stark sentinel indicator on the impact of climate change, and also a key factor for adaptation and mitigation programs.

Still, the network can and should be strengthened further, including in terms of its linkages with other groups. Firstly, there are many global health networks out there, with many valuable ‘causes’ (e.g. on UHC, NCDs, Every woman, Every Child etc.). Not much coalition building (and coordination) between these networks has taken place so far to broaden the health cause at other fora (for example the climate related one). Secondly, the network mainly consists of white, high-educated, well-connected, Anglophone, public health professionals (I fit the bill pretty well, I admit  ). More diversity in terms of socio-cultural aspects, language and professional background could deepen the network and its representation. Lastly, there was hardly any representative from other sectors at the summit. We were preaching to the converted, once again, while what is urgently required now is real engagement (including tough advocacy, and political “fights” (in the positive meaning of the word)) with those member states and actors investing in energy, agriculture, mineral resources  etc. The public health community is in general not very well equipped to do so, so it needs to seek alliances with (typically more politically skilled) environmental justice groups, farmer movements and food activists, etc.   Such a young global health alliance should get the time and space to develop itself, but the (urgency of the)  challenge requires it to move fast and with clear strategic directions on political aims, allies and enemies.

As for WHO, the organization organized its own COP23 high-level meeting on health actions to implement the Paris agreement, on 12 November. WHO DG Tedros spoke there, and no one less than “honorary” (?) Arnold “I’ll be back” Schwarzenegger had a key note. Speaking of political “heavyweights” to enroll in the climate fight  .   The former governor of California is currently heading the R20 Regions of Climate action foundation so The Terminator keeps coming back. In the fight against climate change that’s probably not a bad thing.

I could unfortunately not join all this excitement and returned home in the evening, making my way through piles of plastic garbage, empty cans, bottles littering around, and of course, many drunk folks. The world of health and climate change negotiations still tantalizingly close, yet so far away.

This episode was remarkable for several reasons. First and foremost, there is the fact that this was an incredibly odd and surprising selection given Mugabe’s role in ruining his country’s once strong health system (strongly articulated in the PHM Zimbabwe statement on the appointment). Second, the decibel level of the outrage in the media and on Twitter appeared to be far louder than anything we have seen so far in global health. And third, the WHO reacted swiftly, within a matter of days, to rescind the controversial appointment.

Our focus here is not on the decision itself, which we agree was inappropriate, but with the global response, and what the response tells us about the power dynamics flowing through global health governance, serving as another example of the intense power that the Global North (still) has in shaping discourse in global health.

A key question in this entire episode is whether the outcome would have been different if we, hypothetically, replace Mugabe with a different authoritarian leader. Mugabe might have been an ‘easier’ target, given his advanced age and diminishing role in geopolitics. But had the decision to revoke Mugabe’s appointment been made with a more powerful, globally ‘relevant’ (from the perspective of high-income countries), authoritarian-style leader, would the criticism have been as vociferous? Possibly not. Several countries with leaders with questionable human rights records have played and do play key roles in global health diplomacy (examples here and here). Keeping in mind the ideas of social justice and fairness that the global health community is meant to espouse, this begs the question about what we consider ‘tolerable’ behavior from a political standpoint.

Consider another example playing out in real time – the World Bank’s women’s entrepreneurship fund, launched in partnership with the Trump Administration, (represented by Ivanka Trump). The incongruity of this alliance (captured beautifully in Bill Easterly’s tweets) is underscored by the fact that the head of this Administration has a particularly dismal history with women’s empowerment – an example of which is the number of sexual harassment charges that have been brought against him.

When it comes to powerful international actors with less than stellar track records on issues ranging from muzzling civil society, to cracking down on free speech, to promoting ethno-nationalism, there appears to be a recognition that partnerships with those countries are warranted for political reasons, increasingly so in today’s climate where multilateralism is in crisis. But such an argument did not seem to have much traction in the backlash against the Mugabe decision. For example, many articles in the US media for example focused on the loss of ‘goodwill’ for the WHO more broadly, particularly in light of the negative coverage the institution received during the Ebola epidemic. What is interesting is that such discussions about the reputation of these institutions become far more nuanced when Northern actors are deeply involved. To our knowledge, few are challenging the World Bank’s legitimacy in light of the Trump partnership.

The episode also highlights whether we are more willing to turn a blind eye when considering certain political figures as global role models, in a similar vein as the Goodwill Ambassador position. For example, it is well accepted that politicians from the Global North, many of whom have been deeply connected to war and conflict in other parts of the world, can leave office and go on to have a second life as architects of world peace and development ( e.g. Tony Blair and his role as UN envoy). Why does our bandwidth for forgiveness and acceptance extend in the case of elite Northern actors? One explanation is that the power that Northern leaders wield, and the way in which we as society are conditioned to view them, strongly shapes what is tolerated, and what is not.

Finally, the nature of the response in both the news coverage and on social media reflects the continued dominance of Northern voices in shaping global health debate and discussion. The US media coverage for example was largely decontextualized and stripped of any views from Zimbabwe or the broader region. Such context is an essential part of understanding this decision, as put forward in a recent piece by Simukai Chigudu. The news coverage and heated social media debate also neglects the longstanding discontent amongst LMICs with Northern dominated global governance ‘discourses’ e.g in diplomatic relations with the African Union. There is a tendency that countries and regions withdraw from multilateralism partly because of its ‘capture’ by high-income countries.

Beyond the media narrative, views on social media appeared to focus on dominant Northern voices – even if the outrage had much broader and deeper roots. This matters, because as social media becomes a platform for protest in the global health community, some views will gain traction and visibility over others, perhaps due to their geographic locations (eg. in certain democracies people feel more comfortable voicing their views on Twitter) or the power of these individuals relative to other stakeholders in global health. Therefore, we need to think about whether these platforms will mimic other fora, including academic journals, where voices from low and middle income countries do not receive the same amount of attention. Compared with other, arguably more fraught areas of international diplomacy – trade, nuclear security, climate change – global health remains, for a part, a relatively ‘safe’ diplomatic space where post-colonial viewpoints, including a considerable role for philanthropy, still play out (McCoy and Singh, 2014). Therefore, we need to closely engage with the evolution of this new territory of social media activism.

One positive lesson from this entire experience is that there is a role for the broader global health community to play in shaping the trajectory of global health policy, perhaps in a way that we have not seen in the past. But we need to also reflect upon and question our own agency, norms and values in taking these stances, and ask whether we are in some ways contributing to existing power structures in global health, or whether we are trying to strengthen the legitimacy of diverse and alternate discourses to ensure further meaningful change for health, equity and social justice.

The three-day event marathon began in Berlin with “Leaving no one behind in global health – What should Germany’s  contribution be?” followed by a workshop of the Medicus Mundi Network the next day on “Health cooperation beyond aid” (also in Berlin). The third event of the week was a seminar on “complex systems thinking in international aid and health development” in Antwerp.

The meetings signal a certain trend. First, it is clear that global health is becoming an issue of significance for both foreign and domestic policy development of countries, hence the need to take an integrated, inter-sectoral approach involving multiple actors, including the government. Secondly, the SDGs call for a universal, transformative approach to health, moving beyond working in silos and vertical programs, and the (now artificial) divide between ‘developed’ and ‘developing’ countries. Buse and Hawkes have eloquently described the implications of this in their paper Health in the sustainable development goals: ready for a paradigm shift?  They identify five challenges in the way to address global health.

The (much-abused) term ‘paradigm shift’ was introduced by Thomas Kuhn in his essay,  ‘The Structure of Scientific Revolutions’ (1962). Kuhn defines a scientific paradigm as “universally recognized scientific achievements that, for a time, provide model problems and solutions for a community of practitioners”. Kuhn explains how scientific progress is not linear, nor cumulative, but rather occurs in phases – ‘normal science’, periods of crisis and revolutionary changes in world view, respectively. In the last phase, the crisis is resolved by a revolutionary change in world-view in which the now-deficient paradigm is replaced by a newer one.   Moreover, he argued that competing paradigms are “incommensurable,” that is to say there is no objective way to assess their relative merits. Or, in more general words, contrasting paradigms and their merits cannot be compared with each other on the basis of scientific validation, as they are bound by the specific communities, moment in time, and societal conditions that structure them.

The question then is whether something similar is now going on in international health cooperation and the sustainable development agenda. This merits a longer discussion, but perhaps the answer is ‘yes’, as the current major focus on evidenced-based interventions in health development programs is increasingly being questioned.  Let me use this “paradigm shift” angle to reflect on these three global health meetings.

The VENRO Global health seminar in Berlin focused on the (increased) prominence of global health on the German foreign policy agenda and Germany’s global health leadership within the G7 and G20. Germany chaired the G7 in 2015 and will be chairing the G20 in 2017; global health expectations are high after the positive track record of the Merkel government in 2015. The German government has developed a roadmap of their policy approach called “Healthy Systems – Healthy Lives”.  The seminar explored how actors such as NGOs could work in synergy with the German government to attain global health objectives. With global health having become more prominent at the UN (see the last UNGA71 meeting for example), and in the G7 and G20, the paradigm shift could be explained then as a next phase of the global health revolution, a concept elaborated by scholar David Fidler, “global health has been lifted from political neglect into more prominence among States, intergovernmental organizations (IGOs), and non-State actors.”

The MMI workshop (disclaimer: I was one of the organizers) focused on the changing role of NGOs, but also on health cooperation in general. A discussion paper critically analyzes the relevance, legitimacy and effectiveness of health cooperation and its actors in a fast changing environment.  A central point in the paper – also discussed in the workshop – is that currently much attention goes to ‘output’ legitimacy in the work of NGOs and health development (i.e. accountability, transparency and effectiveness) while ‘input’ legitimacy of NGOS – deliberation and representativeness –gets far less attention. What are health NGOs and who do they really represent in global health advocacy and policy shaping? How do they discuss and convene to come to their policy decisions and what are their values and own socio- political or even financial interests? The needed paradigm shift here consists of creating more (self) reflection and awareness in the agency of NGOs and health cooperation agencies as to strengthen their relevance in global health programs and UHC more specifically.

At the complexity & aid meeting in Antwerp, an initiative by ITM and the Belgian Development Cooperation, the recent publication Development cooperation as learning in progress was discussed. The meeting focused on the need to approach health development and programming from a non-linear perspective, allowing complex adaptive system (CAS) thinking, reflection and learning to inspire health cooperation programs – so yet another paradigm shift is required, it turns out. Two nice quotes that were presented during this meeting, perhaps: “Power corrupts, absolute power corrupts absolutely. Charity also corrupts, absolute charity corrupts absolutely!”, a quote originally from Halfdan Mahler (former WHO DG), and “International development agents often have a myopic view. TWP takes the naivety out of institutional relationships by understanding that change happens as a result of decisions that invariably have a political dimension.” (Geert Laporte, ECPDM, on Thinking and Working Politically, TWP).

Reflecting back, can we really speak of a ‘paradigm shift’ in global health policies and international cooperation?  If we include the framework by Buse and Hawkes, we now have four different approaches of what a paradigm shift should entail for global health in the SDGs era. The differences between these four concepts might indicate that there is “discontent with the status quo”, that we have entered a period of crisis and “debate over fundamentals” of what is the appropriate conceptual framework to advance global health.

My personal take on this is the following.

First, I hesitate whether a philosophy of science concept like ‘paradigm shift’ can (easily) be translated to the politics of global cooperation for development goals. Second, I am in doubt (call it a personal scientific crisis) about the ‘phase’ we are in, currently. The SDGs, in spite of their undeniable transformative language and universal potential, are still structured on the Western development model initiated after WWII. This follows the principles of economic growth (increase of production and consumption) based on capitalism, free trade, democratization, good governance and the rule of law via cooperation between sovereign nation states. However, there are analyses that health related human rights are undermined in the sustainable development agenda.  Moreover, we are facing a deep financial, ecological and social crisis. Issues like widening global income inequalities, thinking on a post-capitalist society,  the notion of planetary  boundaries and limits to growth,   global demographic projections and their implications for mass migration, reflections on cosmopolitan realism and the erosion of national sovereignty,  but also high-level political attention to health security threats like Antimicrobial Resistance all challenge  traditional development thinking and the status quo. There is fierce debate on the fundamentals going on and because of these structural global drivers and challenges world views on global health concepts might actually enter a revolutionary new phase.  For example, the recent ratification of the Paris Agreement on climate change by the EU, China, India and the US might trigger an energy revolution that will have a deep impact on global health outcomes in the years and decades to come. Hence, ecologically oriented frameworks such as the manifesto on planetary health  would guide us, eventually, towards a new paradigmatic worldview.

Ten recommendations (six on transforming the workforce, four on enabling change) are outlined in the High-level Commission report (supported by an expert group report providing the evidence). A new global momentum towards investing in the health workforce is now obvious.  Moreover, the inter-sectoral collaboration between the multilateral agencies WHO, ILO and OECD, as well as the strong political support by the commissioners and chairs positions the health workforce as crucial to the global development process.

One of the key messages, backed by significant evidence, is that the health workforce shouldn’t be regarded as a cost, but as an investment with a triple return – for health, economic growth and global health security.  The returns on investment in health are estimated to be 9 to 1. Job creation in the health sector might also help improve social protection and cohesion, and provides an attractive pathway for women’s economic participation and empowerment. On the whole, the sector needs to reform to prioritize primary care and people-centered health systems, respond and detect public health risks emergencies, and embrace new information and communication technologies.

The report reflects the urgency of the need to invest in the health workforce; evidence points towards a projected shortfall of 18 million health workers, primarily in low- and lower-middle income countries by 2030, unless additional investments are made. To address this considerable policy challenge, the report offers four powerful recommendations. The first, and perhaps most important one, is to address the issue of political commitment, critical to generate sufficient funding from both domestic and international resources. While there is moderate optimism about increasing fiscal space in lower-middle income and middle-income countries and its potential for (more) domestic investments in the health workforce, there is also a strong call for collective action and international financing to invest in health jobs in low-income and fragile states.  The second recommendation concerns the promotion of inter-sectoral collaboration at national, regional and international levels. The third one is on international health workforce migration– a trend that will likely increase further. The Commission calls for an updated broader international agreement on health workforce mobility, with lessons to be adapted from the Paris Agreement on Climate Change, including provisions for resource transfers and investments in capacity building of health workers to ensure the sustainability of health systems in source countries. The fourth recommendation is on strengthening data, including an appropriate global framework for independent accountability across the SDGs, and data exchange managed by the Global Health Observatory.

There is now a global framework for the health workforce agenda with five immediate strategic actions to be taken. A first step will be the organization of a summit in December 2016 at the WHO to develop a five-year implementation plan for the ten recommendations.

While I am in general enthusiastic about this global HRH policy framework and the political momentum it has created, I would like to add to some words of caution on its implementation.

First, there is a need to think through the quality of the economic growth that is to be obtained. The rationale behind the report is based on social-liberal ‘New Deal’ policies and Keynesian economics that argue for government intervention and investment during recessions. Nobel Prize winning ‘New Keynesian’ economists like Paul Krugman and Joseph Stiglitz adhere to principles of fiscal expansion to foster demand in the economy.  David Stuckler argues in the (highly recommended) book ‘The Body Economic: Why Austerity Kills’ why public investments in the health system in times of recession are so crucial. While these Keynesian interventions provide a necessary levelling ‘antidote’ to the excesses of transnational capitalism, more structural macroeconomic and political interventions will be required to regulate transnational finance and its devastating effect on global income equality.  The democratic sovereignty of states to intervene in their own economies has been considerably diminished in our times of ‘deep globalization’.  It is hence important that the health, labor and growth market agenda is connected with SDG10 on reducing inequalities, which among others requires the democratization, regulation and monitoring of global financial markets and institutions. Moreover, development economists argue that, in a carbon-constrained world, we must ‘shift our attention from global economic growth itself, towards improving the distribution of the benefits of global production and consumption ’.

Second, the current international health landscape shows fierce political competition and disagreement between states and other actors on priority global health issues.  For sure, a strong health workforce is critical to achieve global health objectives such as UHC, Women and Child health, Global health security  and the need to tackle Antimicrobial Resistance. With many of these health issues now part of high politics and foreign policy (see the growing attention for global health at the UNGA) one also needs to consider the discourses, agency , alliances and powers that put these issues on the agenda and examine why action on them is pursued (or not). Developing the workforce requires committed investments, a longer timeframe and sustained political engagement. States are, however, under (political) pressure to demonstrate that ‘any money invested in global health (e.g. in GF, GAVI or WHO) must directly lead to progress’.

Hence, considerable health diplomacy will be required by all actors (state and non-state ones) involved in the global workforce movement to seek synergies with other global health issues and to keep the health workforce on the (political) agenda.

Let me end with the concluding words of Guy Ryder, Director-General of the International Labour Organization, during the launch event at the UNGA this week:

 “There is no time for complacency. We have a considerable agenda ahead to mobilize the international political and financial support.  We will have to face major issues such as the sensitive issue of health workforce migration and its governance “.

As I have been working on health workforce policies since a long time,  it is encouraging to see that the health workforce has – at last – become a prominent element of the global health revolution.

That said, I have in the past expressed my concerns about a narrow labour market approach to health workforce development, hence the irony in my active involvement in the meetings and input to the commission over the last weeks.

The meeting in Abidjan focused on 5 themes: financing and budget space; economic impact; international mobility; institutional reform and governance; and investments in education. The governments present (from Africa, Europe and Haiti) included representatives from ministries of Health and Social affairs.  Unfortunately, as is so often the case in international public health meetings, there weren’t that many finance persons or ministries present. When discussing public budgets and economic policies, they would have come in handy, to say the least. Each country had to provide a position and policy recommendations on the 5 themes during the consultation.

In the remainder of this blog, I will focus on the international mobility of health workers – a theme which led to intense discussion among the participants.  Firstly, all present agreed that the migration of health personnel is directly related to domestic mobility of health workers. If governments enable decent employment and living standards for health workers in rural areas, this reduces the ‘push’ for personnel to move to the country capital or migrate abroad.  Secondly, many had difficulties with the term ‘control’ (‘maîtrise’) of health workforce migration. The mobility of skilled health workers to “greener pastures” (usually high-income countries) is seen as a right to the development and transfer of skills, as well as a source of remittances to the home country, contributing to economic growth. Yet, there are also repercussions on the health workforce of the often low-resource settings of source countries. In an attempt to address these issues, the ‘Global Code of practice on the international recruitment of health personnel’ was negotiated in  2010. Participants recognized its importance, but it was not used as a relevant policy tool in HRH governance by most. At a time with the largest refugee streams globally since World War II, ‘controlling’ migration has become a sensitive topic.

The consultation led to three key messages on international health workforce mobility. First, mobilize the diaspora via agreements between sending and receiving countries, including financial resource transfers to fund health systems in countries of origin;  Second, to strengthen cooperation with countries benefiting from the migration of health  personnel via investments, such as in education and health equipment. Lastly, there was a call to work towards the international standardization (and recognition) of qualifications and diplomas at the regional level, e.g. in the Economic Community of West African States.

The consultation was successful in eliciting some key policy recommendations and identifying obstacles (also for the other themes) that will find (some) reflection in the final report of the UN-HEEG commission. The consultation would have been richer if also non-governmental entities like NGOs, academia, labour unions, private sector and other stakeholders would have had the opportunity to participate. Also, organizing an exclusive Francophone consultation seems outdated and disconnected from 21st century reality.  With modern technology for (simultaneous) translation, it should be possible to organize wider regional consultations, for example a regional pan-African consultation on the topic, especially with the South-African head of state being one of the co-chairs. Lastly, there is increasing recognition that health employment is a key sector for economic growth. However, what kind of ‘inclusive economic growth’ actually benefits public health urgently requires political analysis and debate by researchers and policymakers.

From a diplomacy perspective it is also interesting to note that in 2016 both in France and in South-Africa  there have been serious societal tensions on labour law and educational reforms. How do these countries relate their domestic challenges with this foreign policy initiative? In essence it requires us to approach global health workforce development not only from a public health perspective but also from a political economy and foreign policy angle, including the relation between workforce development and security interests.

The adoption of the global HRH strategy: workforce 2030 during the recent 69th World Health Assembly, in combination with the UN-HEEG commission provides the global momentum to commit to the financing of health workforce development at national and international levels. The IMF acknowledges that an alternative to the neoliberal politics is necessary to secure public goods and services. Scholars have provided the evidence that there is a considerable fiscal multiplier of social sector employment.  There are already proposals for financial mechanisms to redress inequalities in the global health labour market. The final report of the UN-HEEG at the UNGA in September 2016 will lead to further debate on how to translate this into (international) policies.  One can count on IHP to critically analyze this process and to be engaged in the next steps.

A decade ago, The World Health report 2006 already estimated a global shortage of 4.3 million health workers. Since then, the Global Health Workforce Alliance has tried to address  the HRH governance challenges,  albeit with a mixed impact. A major reason for this is that  governments have not made, or were not in the position to make considerable additional investments in the health workforce. There were some notable exceptions, including in Low and Middle-Income  Countries (LMICs), but in general the outcomes have been below expectations.  Both within domestic and international health financing, recurrent expenditure (salaries and education) for health workers has lagged behind other health investments.

The new Sustainable Development Goals (SDGs) include as target 3c.  ‘Substantially increase health financing ……of the health workforce in developing countries….’. Workforce 2030  uses a new benchmark indicator, the so called SDG composite method (see annex 1 of the Global Strategy). It estimates that 4.45 health workers per 1000 population are needed to reach the SDG health targets. This amounts to a total global deficit of 17.6 million health workers relative to current supply, with a projected deficit of 13.6 million health workers  in LMICs alone.

Workforce 2030 is a strong building block for integrating health workforce development in broader health and socio-economic development. However there is an ambiguity underlying the strategy that merits attention, not unlike the one in the overall SDG agenda: social development still relies on the old model of (industrial) economic growth.

‘Workforce 2030 makes the case that investment in the workforce offers a triple return; social- and economic benefits, improved health outcomes and robust front-line defense for global health security’. (par.9)

Health equity will be at risk in this approach. The strategy relies on the assumption of (strong) economic growth in LMICs to finance workforce deficits. The global additional wage bill needed to scale up the workforce in LMICs is considerable. A major question is: who is going to finance that bill? Will domestic revenue suffice or will this be a shared responsibility, with also an international financial framework?

Workforce 2030 argues for public sector intervention to ‘recast insufficient provision of health workers and their inequitable deployment’  and public HRH investments should be supported by ‘appropriate macro-economic policies’ while ensuring ‘adequate fiscal space’ (par.38) The next paragraph mentions ‘expected growth in health labour markets …as a way to create qualified jobs’ (Par.39).

The crux is that the prevailing, resilient macro-economic model (the ‘Washington consensus’) has led to fiscal contraction, austerity measures across the globe,  privatization of services, liberalisation of trade and capital, deregulation of labour markets etc. Although the Washington consensus has been criticized by some national governments and others, key tenets of it are still very dominant with impacts visible worldwide.

Emerging economies like Brazil face serious economic difficulties while the expected growth in many African countries seems overestimated. It is a fallacy and a myth to believe that such a monetarist economic model and the “labour market” will overcome the workforce deficits, and  improve health outcomes. Privatization of education  and health services will indeed create highly skilled,  professional, medical staff, but these will be only accessible for those who can afford them (e.g. via health insurance schemes). This will stimulate further (global) mobility of the skilled medical workforce while limited public funding and philanthropy will need to cover other public health functions as well as the deployment of lesser skilled Community Health Workers (CHWs) to impoverished neighborhoods and rural areas.  CHWs are essential for integrated, people-centred health services but the scenario above leads to parallel systems; access to a skilled medical professional for those who can afford it, poor services for the ones that rely  on minimum health coverage.

The good thing is that there are alternative pathways if we dare to imagine and attempt them.  A key advice for Workforce 2030 and the actors working on it would be to de-emphasize the instrumentalist, utilitarian role of the health workforce in economic growth and labor markets, and rather emphasize the intrinsic value of a competent workforce in improving health outcomes and reducing health inequalities. Inspiration can be sought from those that already aim to transform economic performance and policies, and consider them as a means towards social and health outcomes, rather than as the goal.  In this scenario, Health workforce 2030 would not merely be a technical program or leading to yet another global health initiative. It could become part of a wider social and political project of which the time has come. Then, Health workforce 2030 would be a truly progressive agenda that could help to transform the current global health paradigm.

On the heels of the next major health systems event in a country that feels refreshingly “new” since yesterday, the Emerging Voices for Global Health team is also gearing up for a shift.

A few months back, EV alumni organised themselves to come up with a new globally representative governance structure comprised of EV alumni from all regions:

* Prashanth Nuggehalli Srinivas (Institute of Public Health, Bangalore) (South-East Asian region)- Chair;

* Dorcus Kiwanuka Henrikson (Karolinska Institutet) (East/South African region)- co-chair;

* Jin Xu (Peking University) (Western Pacific region) – treasurer;

* Arsene Kpangon (University of Parakou) (West/Central African region);

* Vladimir Gordeev (London School Of Economics) (European region);

* Asmat Malik (AMZ Consulting, Pakistan) (Eastern Mediterranean region) – co-chair;

* Elena Vargas (Independent Researcher) (Region of the Americas) – Secretary.

Two liaison (and not elected) members complete the Governance team:  Kopano Mabaso (liaison with HS Global); Kristof Decoster (liaison with ITM).

Together, the new EV4GH governance hopes to improve the scope, reach and impact of the EV event in future editions. After the new governance team was put together, the EV4GH group has been closely interacting with the WHO Alliance for Health Policy and Systems Research as well as with Health Systems Global, both entities being important partners and well-wishers for us. Indeed, over the coming months, EV4GH hopes to pursue a systematic collaboration with Health Systems Global and eventually integrate in some way with the society.

This month, with the help of ITM’s EV team, a new secretariat is being established for the EV4GH at the Institute of Public Health Bangalore (IPH). IPH has been an early partner of the EV4GH having been involved since the first edition that was held in association with the first global symposium on health systems research in Montreux. For the coming year, the team at IPH (including Prashanth N S, the Chair of the EV governance group and Sophia Thomas, the secretary for the EV governance) hopes to take forward this new phase in the EV4GH evolution.

IPH is of course not alone in this. With the support of various EV partner institutions including the Institute of Tropical Medicine, Antwerp (ITM), Belgium;  the Public Health Foundation of India (PHFI); University of Cape Town (UCT), South Africa; University of the Western Cape (UWC), Cape Town, South Africa; Peking University Health Science Center (PUHSC), Beijing, China, the new secretariat at IPH is all set to launch a call for fresh EVs to participate in the 4th global symposium at Vancouver. We foresee a new and vibrant bunch of researchers, implementers and other health system actors to be selected in this edition to participate and constructively engage and challenge the global health discussions at the symposium. This year, the new EV2016’s will gather a few weeks before the symposium in Vancouver for a face-to-face training and will again try to enliven the discussions at the symposium. We look forward to welcoming a fresh batch of Emerging Voices for Global Health!

Stay tuned for the call details on the website of the 4th Global Symposium for Health Systems Research and on the EV4GH website.

The term now also frequently appears in global health policies. “Resilient health systems” was the theme of this year’s World Health Assembly, but in the first meeting of the WHO Review Committee on the Role of the International Health Regulations in the Ebola Outbreak and Response in August, the concept was not mentioned. It also doesn’t appear in WHO DG Margaret Chan’s opening remarks to the Review Committee. On the other hand, the World Bank favors the resilience approach, and also the Rockefeller Foundation has developed much interest in resilient health systems. This is not surprising as its president Judith Rodin is the writer of the book “The Resilience Dividend”. The theme of next year’s 4th Global Symposium on Health Systems Research in Vancouver will be “resilient and responsive health systems for a changing world”.

I argue that we should distinguish between the resilience discourse as applied in complex adaptive systems, ecology and psychology and its use in normative, political, decision making for health systems. While the first is a useful method to assess the flexibility, responsiveness and shock-absorbing capacity of health systems there is much criticism of the resilience discourse by political scientists. One of those critiques is that the resilience discourse colonizes our political imagination. It hinders us to develop universal and strong systems based on the principles of health equity and to take action on the Social Determinants of Health. As resilience is mainly about anticipating a future crisis, we maintain the status quo. My analysis of the resilience approach to health systems is that it is a modern expression of the decades-old debate of selective versus complementary primary health care, and the political choices behind it. In a recent interesting political sciences article called “Exhausted by resilience” the authors even move beyond this: “The real tragedy for us is the way the doctrine forces us to become active participants in our own de-politicisation… It promotes adaptability so that life may go on living despite experiencing certain destruction. Indeed it even demands a certain exposure to the threat before its occurrence so that we can be better prepared. Resilience as such appears to be a form of immunization. Yes, the doctrine of resilience at the level of policy and power is ubiquitous. And yet in terms of emancipating the political, it is already dead.”

The authors challenge their readers to “a new imaginary for rethinking politics, emancipation and the formation of political communities in the twenty-first century.” Applied to global health, this would mean a reformulation of what we consider as the necessary conditions for a meaningful, dignified and healthy life. The capability approach developed by Martha Nussbaum and Amartya Sen can guide us. Universal access to essential health services whether people live in high-, low- or middle-income countries would be a core element in this. Such a cosmopolitan approach will move us beyond the iron cage of the nation states we live in and the false security it brings.

Yes, it is a re-imagination of an alternative world order. But we can’t continue with the status quo where we continuously consume beyond Earth’s carrying capacity, global temperature is to rise, global financial markets are casinos beyond control, and refugee patterns are likely to continue. There is no other option than moving beyond the status quo and working on true alternatives for social justice and health. At the minimum, we have to move beyond resilience.

(This article is cross-posted from the MMI Network September newsletter, where it was first published as the editorial)

In a nutshell, Neocleous connects the resilience agenda, which originates from physiology, psychology and ecological systems thinking, directly to the security issue. Security is central to liberal-capitalist order and state formation. Resilience should be seen as a state of constant threat, awareness  and preparedness for future catastrophes (e.g. bioterrorism, a natural disaster or a global economic melt-down). Besides a focus on building resilient ‘systems’, this also leads to  individuals subjectively  dealing with the uncertainties and instability of contemporary capital(ism) and the insecurity of the national state.  In essence, resilience prepares us, “good subjects”,  for war: surviving all the structural insecurities in life and just  ‘bouncing back’ from all the difficulties we’ll face in the future, from wage freezes, greedy CEOs & politicians, cuts in pension, health care and education, to terror attacks  and pandemics (and we probably forget a dozen others). By accepting this resilience discourse, the status quo is maintained. The people will remain individually and collectively insecure, and are not allowed to mobilize (politically) against  the oppressive structures & ruling classes that maintain structural violence and inequity. Worse, resilience disables us from imagining an alternative (“another world is possible”).

Two empirical cases exemplify the argument. First, the resilient health systems discourse,  promoted amongst others by the Rockefeller foundation and its president Judith Rodin (a psychologist by training). The resilience mantra slowly becomes the main modus operandi for health systems development in the nearby future. Health systems must be aware, diverse, self-regulating, integrated and adaptive in order to be able to deal with future crises such as another Ebola epidemic or airborne virus, climate change, wide-scale antibiotic resistance or severe health workforce shortages . Even more interesting is what the resilience concept does not cover. Although paying some lip service to Universal Health Coverage, there hasn’t been any reference to universal principles and rights-based approaches to health care and the determinants of health.  Moreover, the concept of health equity and action on the more upstream social determinants of health are completely neglected.  Only a few scholars have pointed out the political pathologies of the Ebola crisis and the need to confront the social ‘vectors of disease’ (e.g. finance capitalists and multinational corporations) . The majority of the global health community remain (resiliently) in their comfort zone, talking about ‘incentivizing recipient governments towards crisis preparedness and reducing the potential for moral hazard’. To some extent, the resilient health systems frame even reminds us of the political debate on comprehensive vs. selective health care from three  decades ago.

On the second issue I can be short. In my view, the Greek tragedy that has unfolded over the last weeks can (and should) be seen through a resilience lens as well.  There Is No Alternative. The Greek people, and their elected government, need to swallow the bitter pill of structural  adjustment, even if this is considered madness and killing the European social project.  The Greek Demos resisted and voted  in majority “Oxi” (No) to the austerity package in the referendum on the 5^th of July.  But now they are being told by the European leaders that this new (and even harsher) neoliberal package is the price to pay for daring to imagine a political alternative (i.e. the leftwing Syriza government). Europe is “stuck in a political trap” and we (the European citizens) are brainwashed to believe that this crisis is a normal state of affairs and that we should further prepare economic and monetary reforms so as to continue business as usual.  These are dangerous times, as the related deep sense of injustice will eventually be channeled one way or another. History tells us that.

In the ensuing discussion with Mark Neocleous, at the conference in Frankfurt, the metaphor of ‘Zombies’ came up. While ‘Vampires’ could be considered an apt  metaphor for capitalism in the 19^th century, perhaps the ‘Zombie’ can be considered the creature capturing best our modern times, the resilient living-dead creature willing to kill its fellow (still) humans, having been relentlessly brainwashed. “If vampires are the dreaded beings who might possess us and turn us into their docile servants, zombies represent our haunted self-image, warning us that we might already be lifeless, disempowered agents of alien powers”.

Luckily the seeds for change are already there. There is a new generation that really imagines (and engages in transnational action for) a different, fairer and more dignified society. We only need to remember and live the words of the Latin-American writer Eduardo Galeano, who passed away this year:

“I  advance two steps, it goes two steps backward.  I take ten steps and the horizon moves ten steps forward. No matter how far I walk, I will never reach it. What is the use of utopia? That’s its use: to help us walk”.

The notion that investing in health leads to (potentially enormous) economic returns is nothing new, though. By way of example, let’s have a look at excerpts from a medical article from the Dutch Colonial Indies, 1879, modern Indonesia:

”The Deli planters association purpose was to implement unity in the handling of the workforce, and to co-operate with regard to importing workers and organizing work. According to this arrangement, the workers brought in from overseas were obliged to work on the plantation for a fixed wage and under stipulated conditions, while the employer was bound to provide housing, food, and, amongst other things, free medical treatment and medicine. This sort of agreement was of the greatest importance for the viability of the enterprises because of the huge losses which sickness caused to the productivity of the plantations. And a high mortality rate was equally damaging to the company’s good name and could cause problems for recruiting new workers. Humane and economic considerations clearly went hand in hand” (Source: Dutch Medicine in the Malay Archipelago, 1816-1942, p.75).

The Dutch did not call the project “Global health 1890, a convergence within a generation” (generations were considerably shorter then); the colonial administration found the title a tad too revolutionary and just considered it “robust tropical medicine”.

On a more serious note, key questions regarding the ‘Global Health 2035’ agenda are then: who (really) benefits (most) from the foreseen economic benefits, in the long run, and who (really) benefits (most) from the reduced mortality in LMICs?

National and global political economy discourses and the debate on social justice and health equity come into play here. Global Health 2035 uses the concept of growth in a country’s ‘full income’, which is mainly GDP change adjusted for the value of mortality change (“the income growth measured in national income accounts plus the value of additional life years (VLYs) gained in that period”). But the report doesn’t refer to ‘full income‘ distribution over socio-economic quintiles nor does it take into account negative externalities impacting on health (e.g. natural resource depletion and climate change). The report also fails to fully recognize the massively unequal and unjust social and living conditions that shape the health status of communities, the so-called upstream determinants of health.

The CIH recommendation for progressive universalism as a pro-poor pathway towards Universal Health Coverage is presented as an efficient way towards health and financial protection.  We will not deny it has obvious merits. However, if we really want health inequalities to reduce substantially, UHC must be embedded in broader social protection schemes, both at national and global levels.  So far the thinking on a grand convergence for global health has not included reflections on global social protection mechanisms.  To kickstart this – in our opinion vital – debate in a further globalizing world, the health community could perhaps discuss and frame UHC in the context of ILO’s Social Protection Floor initiative. The example from the Deli Planters Association from more than a century ago demonstrates that a social contract is needed to guarantee both human security and economic objectives.  As the economic case for health investments is nowadays made for many global health topics, such as maternal, neonatal and child health or the health workforce,  we feel there should also be some reflection on how universal and equitable access will be guaranteed to such services as part of the Post -2015 development framework. In short, how can a social contract theory be applied to current investments and governance arrangements in global health?  Is it still national governments that have the main responsibility for guaranteeing their citizens’ rights, or should there be supranational arrangements, involving also non-governmental actors, at the regional (e.g. EU) or at the global level?

The latest episode in the ‘investment for health’ saga is the notion of ‘resilient health systems’. This has become a major lesson of the Ebola outbreak in West-Africa. In the words of Jim Yong Kim, medical doctor by training but more importantly the president of the World Bank group:

“The other main goal of a pandemic facility (by the World Bank) is to promote greater country investments in preparedness, which starts with having a strong, resilient health system. The Ebola crisis lays bare the consequences of inadequate public health capacity, from disease surveillance and laboratory analysis to frontline health services and community health workers: People die; economic growth rates decline; and countries, their neighbors, and the entire world, are put at risk.”

Although still very much in love with UHC, WHO has also rather eagerly embraced the concept of a ‘resilient health system’ lately, so resilience is likely to become a leading theme in the health SDG and broader post-2015 development framework. I am still struggling to fully understand the concept of a resilient health system, its scope and implications from a human rights and health equity perspective. If you already see clearer, please do not hesitate to get in touch.

In the meantime, let us learn from history and think of social contracts fit for this era. It might make the planet and the human species just a tiny bit more resilient.

More in general, the global health workforce requires serious attention. Due to demographic growth in different regions in the world, an ageing workforce  and an epidemiological transition to chronic disease worldwide, there is a desperate need for more skilled health workers, to contribute to a balanced workforce tailored to countries’ needs. In 2013, approximately 7.2 million more midwives, nurses and physicians were “missing and thus not in action” – and this shortfall is predicted to rise further to at least 12.9 million in the coming decade.  The gap is most obvious in low- and middle countries (LMICs), but has become an issue in other regions as well, including in the North. See for instance Europe, where many health workers have decided to migrate to countries in Northern Europe for employment reasons. This has created inequalities in access to health services.  In sum, the global health workforce crisis is  (or should be) a major issue for the post-2015 development agenda.    The public health community has been convinced of this for a long time, now hopefully also Obama, Cameron and other Xi’s are on board.

In 2015 four important global policy discussions take place that will shape the direction of the health workforce development for the coming decade. First, the relevance and effectiveness of the Code of Practice on the international recruitment of health personnel (WHO Code) will be discussed at the 68^th World Health Assembly in May 2015. Secondly, WHO and the Global Health Workforce Alliance are developing a global strategy on Human resources for health. Thirdly, the future institutional development of the Global Health Workforce Alliance (GHWA), the Global health initiative created in 2006 to raise the global profile and funding of the health workforce, is hotly being debated. Finally, the position of the health workforce within a future 3^rd (Health) Sustainable Development Goal is to be defined.

1. WHO Code

During the first round of reporting on the Code in 2013, the WHO Secretariat informed the Assembly that only 84 designated national reporting authorities had been established and that it had received even less (51) reports. A WHO Assistant Director-Ggeneral admitted during a side-event at the WHA that year that progress was ‘painfully’ slow. We will have to see how Member States will contribute to the second round of national reporting due this year.

Unethical recruitment and inadequate investment in self-sufficiency in high-income countries are crucial contributors to global health workforce imbalances, underlying the continuing relevance of the WHO Code. The WHO Code needs to be properly implemented, including in Europe, and national health workforces need to be developed, nurtured and retained.  Having said that, one should not shy away from also asking the (obvious?) question whether the voluntary nature of the Code detracts from its effectiveness, and WHO should thus move to the negotiation of a more binding instrument to address recruitment and migration issues in the context of a broader HRH strategy. In a joint statement during the Executive Board meeting of WHO, we recommended Member States to consider rescheduling the commitment to report on the relevance and effectiveness of the Code to the World Health Assembly in 2016. This would allow some more time for a proper process, including full consideration of the information gathered through this second round of national reporting. It also would align more closely the processes of Code review and the development of a global HRH strategy planned for this year.

2. Health Workforce 2030. A Global strategy on human resources for health

In 2013, the Board of the Global Health Workforce Alliance facilitated the development of strategic thinking on human resources for health.  8 Thematic working groups wrote a thematic  paper as input for a global strategy; a synthesis report summarizes the papers of these 8 thematic working groups. The Medicus Mundi International  (MMI) network, together with several others, has been following this process closely, providing feedback for further dialogue. Our main critique is that the global strategy mainly mentions  national responsibilities and requirements (multisectoral approaches and labour market analyses) to develop the workforce, but fails to recognise the transnational dimension, international legal frameworks and human rights aspects of health workforce governance. The international moral responsibility and ethical imperative that everybody should have access to skilled health workers providing essential health services is lacking from this strategy. The synthesis paper takes a rather narrow approach: it makes the ‘instrumental’ economic and health security case for investments in the health workforce, but doesn’t recognise the intrinsic value of developing public services for health, the social role of health workers nor the role they can play as change agents in society.

3. The future of Global Health Workforce Alliance

GHWA’s mandate ends in 2016. There is now a debate on how to move forward with a GHWA 2.0. GHWA is currently hosted by (and working in close cooperation with) WHO. Alternative options would be for GHWA to work in close cooperation with other institutions such as the World Bank or the International Labour Organisation, or that it becomes a more autonomous, independent organisation. We think there are already too many global health initiatives, and too much fragmentation and bilateral control within the existing agencies and policies. GHWA should remain closely affiliated with the WHO, so that the latter’s social justice & equity values and health objectives also remain key priorities for GHWA. These aspects could be neglected in case of an “ever closer union with” the World Bank, as the Bank mainly focuses on poverty alleviation and harnessing economic growth.

4. The place of the Health Workforce in the Sustainable Development Goals.

The proposed Health sustainable Development Goal (3) has four suggested modes of implementation. One of them is 3c: “Increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS”. The SDG agenda will be negotiated and decided upon in the coming months  (if God and Mr Putin allow so). There is already much discussion on what a truly ‘universal’ framework implies within international cooperation, and whether  blatant inequalities (as is the case with the workforce) will be redressed. A crucial element will be what comes out of the financing for development summit, later this year in Addis Abeba, Ethiopia. If all goes well, an agreement there should provide the financial means (national and global taxation?) for investment in the workforce in countries that lack an essential level of health workers.

The GHWA board will come together on 25/26 February 2015 to discuss the further process and policy direction for at least 3 of the 4 issues above (except the SDG framework, for which the main action takes place in New York).  WHO will discuss both policy and process during the upcoming World Health Assembly in 2015. It is important to follow these policy debates closely, and to engage with them as much as possible, via a critical but constructive dialogue with all actors involved. A good way to kick off this dialogue is via Twitter. One could approach GHWA and its director Jim Campbell via @GHWAlliance  resp  @Integrare.  The hashtag  #GHWAboard18 could be used to take part in the policy debate during the board meeting itself, from a distance. Many of the GHWA board members  use Twitter as well and could perhaps be contacted. The notes of the 17^th board meeting are also accessible.

Many steps still need to be taken this year to take the various (abovementioned) processes forward. The important thing, as always, is that we walk in the right direction…

Last Sunday,  WHO director-general Margaret Chan  and David Nabarro, United Nations Secretary-General’s Special Envoy on Ebola,  both addressed country delegates during a historic WHO Board meeting.  There was a lot of press around and NGOs were also all over the place. WHO found itself once again in the spotlight, as it is the agency that should lead the international community to prevent and respond to pandemics. An emotional speech was given by Nurse Rebecca Johnson, who got infected while treating Ebola patients in Hastings, Sierra Leone, and survived the disease. Her final message was “Even though there is no certain cure for Ebola, early treatment is your best chance at survival.”

The relative lack of urgency expressed by the country delegates struck me, though. Sure, there was a lot of talk about the slow and inadequate response, and on how WHO quickly needed to  be equipped with the tools to respond swiftly and effectively to future outbreaks. The UK  even  ended its intervention with “Today is the day we must move from words to action so we never face this again.” Fine words, no doubt, fit for the occasion. At the end of a long day the Executive Board then adopted a resolution that should enable and strengthen WHO to respond to future outbreaks. Member State diplomats had negotiated for 3 weeks to arrive at this resolution, including at least one night session. So they have obviously worked very hard to reach this global consensus on how to respond to future outbreaks. The adoption of the resolution led to a cheerful ambiance in the room, with member states representatives applauding each other with the result.

The question is, though:  will this resolution really make a difference?

Charles Clift, from the Chatham House Centre on global health security already said that the devil will be in the detail.  In essence, this resolution is old wine in new bottles. It is a strong reminder that countries should implement their responsibilities outlined under the international Health Regulations  (as agreed upon by the World Health Assembly  in 2005). A 2011 IHR review committee made urgent recommendations after the Mexican flu (H1N1) epidemic in 2009, another so called “post-Westphalian” pathogen. It is basically these recommendations that countries are now urged again to implement in 2015, this time complemented by a commitment to support WHO’s central outbreak management. A core problem is that these recommendations are not (financial) obligations for states, so they can basically decide amongst themselves whether they like to provide funding for them or not.

I sincerely hope WHO will come out stronger after this latest health crisis. The structural problem is, however, that a Westphalian 20^th century UN institution has to deal with 21^st century post-Westphalian pathogens in an interconnected, globalized world. We have to start thinking beyond nation state sovereignty.

Finally, the United States asked for a memorial to honor all health care workers that have passed away during the Ebola epidemic. I think that’s a great idea and would like to make a humble contribution here, after my recent visit to Guinea.

In the two pictures below you can see the team of nurse Maria (excuse me that I didn’t note down her last name properly)  in a health post nearby Macenta, south-East Guinea. Their supervisor passed away a couple of months ago due to Ebola. A second picture indicates the working conditions of the team.

When this is all over, we will still remember these brave people and the dire conditions under which many of them were working.

One way to do that is by making sure that the resolution adopted at WHO’s EB special session on Ebola is properly implemented and sufficiently resourced this time.

My visit to Guinea made one thing very clear to me: there is considerable resistance within communities to adhere to regulations prescribed by the national Ebola coordination team as a way to overcome the epidemic. Programs like case contact tracing and follow-up, referrals to a health center when a case  is suspected, safe burial practices & disease surveillance at community level  are all functioning sub-optimally. The virus in Guinea  has shown to be tenacious and the epidemic has had a capricious character so far. In a sense, it sometimes goes ‘underground’ and then emerges  again later, leading to a sudden new peak in cases.  The epidemic in Guinea is thus far from over. The virus ‘hides’ in the different communities,  with at least a considerable number of them resisting the approaches favored by the government and international community. Ebola Outreach teams by the government and NGOs often meet angry or even violent mobs. This resistance, which was initially mainly noticeable in the forest region, has now spread all over the country. The question is why?

I don’t pretend to have a full explanation for this phenomenon – I’ve not been staying long enough in this country to understand the delicate sensitivities here.  I did gain some insights though, while being here.  So for what it’s worth, after speaking with a different range of people, this is my take.

The Ebola response is politicized. Political violence (ostensibly?) related to Ebola has its roots in already existing tensions between the different ethnic groups  in the country. The political representatives of these groups, and their representation in government and opposition ‘use’ the epidemic, frustration, and funding  it provides, for their own interests. In addition, and to some extent interrelated, there is the presence of the international community – NGOs, UN agencies and also transnational companies which exploit the rich natural resources (bauxite, gold, ore, diamonds, uranium) in the country. Let us also remind the reader that the country has a particular colonial history and joined during the postcolonial times the Soviet bloc. Many of the older generation of medical doctors have been trained in Cuba and the former Soviet Union. Last week in N’zerekore, some of them greeted me with a “Hasta la victoria siempre”! It is hence not strange that a contingent of Cuban doctors these days manage the Ebola Treatment Centre in Koya. Last but not least, in the 90s the country was on the verge of a civil war. It was affected by “spillovers” of the civil wars in Sierra Leone, Liberia and Cote d’ivoire. These are different countries but they show at least partly a similar ethnic mix of communities, especially in the interconnected forest region.

The initial resistance in this region to visit government health centers and isolate cases for Ebola was not only related to the poor quality of the services. Already before the Ebola outbreak, the government had “intervened” violently with the military in some villages, to quell a strike and opposition. It was in this already tense context that the perception that the government had introduced Ebola to kill certain people found fertile ground, and that injections provided by the health staff would distribute the virus further.

A second unfortunate perception also jeopardized the initial Ebola response. Médecins Sans Frontières (MSF) had planned to leave the country in December 2013. The emergence (and emergency) of the Ebola virus around this very time led to the suspicion that MSF actually wanted to stay, and moreover, wanted to draw blood from the local people to be sold and used in France. The fact that the first patients were treated by MSF in closed tents and died  seemed to “corroborate” this assumption for many people in the region. After this initial stage, MFS tried to undo this perception by ‘sensitizing’ the population and making its treatment centers more transparent to family members of infected individuals. As the epidemic continued, people from different ethnic groups got infected and the biomedical understanding of the virus and public health measures to contain it, increased. Interestingly, there is a political twist as well. The story goes that Bernard Kouchner, the founder of MSF, has close relations with the current Guinean “Président” Alpha Condé. Rumour has it that as a special deputy to his government, Kouchner helped Condé to win the presidential elections in 2010. There are allegations of fraud related to these elections. Moreover, the position of Kouchner, a former French minister of foreign affairs, would also indirectly secure the political-economic interests of the former colonizer. Diplomatie à tout prix! Whatever the real influence of Kouchner is, it is understandable that MSF keeps encountering resistance by certain groups that are opposing the current Guinean president.

Another political element is that the government enforces its control measures on the population in a rather heavy-handed way. They installed 1150 so-called Community Watch Committees (CWC, comités de Veille). These committees are expected to do early warning & surveillance tasks and facilitate communication with the people on how to quell the epidemic. There are 5 committee members per village. Ideally the members of these committees should be elected bottom up by the community. In reality they are selected by (and thus loyal to) the government. Each of these members receive a remuneration of US$50,- per month (in local currency), a considerable amount by Guinean standards. The World Bank and UNICEF provide the (substantial) funding required for the CWCs despite the fact  that their effectiveness has not yet been  demonstrated. The (local) health authorities complain that the government bypasses the existing health structures and governance mechanisms, creating a parallel structure, and furthering fragmentation and distrust in the process.

“The international community” is represented in Conakry – big time. By now many organizations have jumped on the Ebola Bandwagon (and yes , I admit, our institution is one of them) . I even met this morning a “famous Dutchman” (a BN, or a “Bekende Nederlander”) who has initiated his own charity to provide aid to Ebola victims. His wife even introduced herself to me; “Hi I’m the wife of Mr X., a BN’er” which was just hilarious.  (I was about to answer ‘Hi, I’m Remco van de Pas, on my way to become a BNer’. )

The Ebola coordination response includes actors like WHO, different UN agencies, NGOs, the Guinean government, US Centers for Disease Control, the European Union delegation, Institut Pasteur, the Red Cross, Foundations (Bill and Melinda are present of course, noblesse oblige), academic institutions, etc. Without any question coordination is taking place. There is however a wide variety of interests and pressure is huge, also because money needs to be spent quickly and there is little institutional absorption capacity at district level. Consequently, the response coherence is thus far from ideal in many cases, with sometimes very different and confusing messages eventually reaching the villages. What really seems to be lacking though, is a meaningful “people’s representation” and sociocultural sensitivity. Even the survivors have only recently started to organize themselves in an alliance. Their needs are not yet considered in the Ebola response programs.  A consortium of three research programs (with ITM part of it) is under pressure to finish the trials for possible Ebola treatment while the epidemic is ongoing  –  respectively vaccinations, antiviral medication and donation of blood plasma containing antibodies. Although all scientists involved hope the epidemic will be over soon, they also would like their cohort group (Ebola patients) to be large enough to publish results. This is a bit of a paradoxical situation, as you can imagine (We hesitate to call it a ‘conflict of interests’).

In sum, the Ebola outbreak response in Guinea is a vertical one, almost military-style in its execution, and international assistance is being channeled through a sovereign state arguably lacking support from a (substantial) part of its population. It’s all perfectly understandable as many actors involved sincerely want to end the epidemic as quickly as possible. At the same time there are some basic weaving errors in the response (accountability, checks & balances are missing) though, allowing political agendas to interfere with the actual programs on the field. E.g. the Red Cross with its urban representatives comes to a village to tell the forest people what to do in case of a burial, rather than adapting its safe burial practices to the traditional needs and customs of the people. There is one notorious case where a body (in a bodybag) was just ‘thrown’ on a truck to be taken to another place for a safe burial. This sort of episode creates resentment and even if only one of such bad practices happens, it is difficult to undo afterwards. Guinea has a growing number of unemployed youth. It is these youth who resist the government and NGO programs, feel politically violated and respond, sadly, often in an equally violent way.

To end with a positive note; alternatives do really exist. I have been able to speak with the intelligent and highly motivated director of a medium-sized NGO,  Dr. Aboulaye Sow. Dr Sow chairs the organization Fraternité Médicale Guinée (FMG) and runs around 6 clinics in the country. The clinics integrate several health services (HIV/AIDS, TB, maternal care) and include psychosocial ambulatory care. Their polyvalent staff, salaried by the organization, use a number of approaches, show quite some flexibility, and receive ongoing training on the job. The clinics are linked to several social programs in the communities, with quite some ownership and autonomy for the local people in defining priorities for program direction. He explained us that he didn’t encounter any community resistance during this Ebola outbreak. His team listens much better to the people, and maintains an open dialogue – these skills are also part of  “professional competency”… as other actors sometimes tend to forget.

In short, it is this kind of dialogue and these kinds of pilot programs that should guide the strengthening of the health services and workforce once the Ebola outbreak is over (and possibly even while the crisis is still ongoing).  One could imagine a health forum being installed at district and national level, at first to have a more inclusive discussion on the Ebola response, but afterwards broadening to other health issues.

In spite of all its flaws and shortcomings, it is to be hoped that the “international community” will remain engaged for a longer period as the effects of this epidemic will last for a while. Long term engagement in supporting solid health financing,  qualified workforce,  medical supplies, surveillance mechanisms as well as institutional reforms, will be crucial.

For now it remains to be seen how the Ebola epidemic will further unfold and whether all the efforts taken will be able to quell the outbreak in an acceptable way for the people. The epidemic might still simmer for a while, not clearly visible anymore for the authorities, to suddenly flare up again. If this scenario were to materialize, and go on for a while, it could further destabilize the already fragile relations between the different groups in society.

As I return home, preparing for a second phase of our research collaboration later in the year, I would like to express my sincere thanks to my colleague Dr. Eugene Lama for his hospitality and friendship and the great discussions we had. I have great respect for the dedication of the health workers to continue working with limited means and limited protection material while knowing all too well that a considerable number of their colleagues haven’t survived this epidemic.

These health workers are the real heroes of the Ebola response.

Our research here focuses on the health workforce gap and the possibilities to improve the availability, quality and distribution of health workers required to quell the current Ebola outbreak. We would also like to explore how a  critical mass of health personnel could be put in place to provide essential health services. When speaking with the health authorities and health workers at different levels, we learned many things in the past days.

One key issue is employment. There are many nurses, auxiliary nurses and some midwives in this region that are not employed as government staff. Some of them have temporary contracts, but the local revenues for such contracts are largely non-existing. The government of Guinea is highly centralized, with limited decentralization of budget autonomy. Also, the government of Guinea spends 3% of its national budget on health prevention and medical services. This is low compared with neighboring countries. In 2001 African countries agreed to spend at least 15% of their national budget on health, in the so- called ‘Abuja agreement’.  In reality, many health workers work on a voluntary basis in public health centers. As they don’t receive a salary, they often ask for informal user fees from the people they care for. Another option for them is to open a small private consultation at home.  The demand for these services is mainly in (small) towns, which means that in the majority of rural villages there is no midwife or (auxiliary) nurse. It was in these settings, with a scarcity of tools, frequent medicine stock disruption and no protection material, that the Ebola virus could thrive so well. With the consequences we know by now.

147 health workers have been infected with the virus till now; 78 of them have passed away. Many  of them were working in non-regulated informal private settings, often in their own homes. During the initial phase of the outbreak (December ’13 – February ’14), people were looking for services who could deal with this new disease in the health centres around Gueckedou, and later in the district hospital of Macenta. The doctor in charge in Macenta told us “In the beginning we didn’t know what to do, we were overwhelmed with the patients and  their dramatic symptoms and eventual deaths. I have tried to reanimate the first patient when he arrived here. I didn’t use any gloves or other protection material, because it was not available. I am lucky that I didn’t get infected.” Others were not so fortunate. In total, 9 persons of this hospital got infected and 8 of them passed away, including the hospital director. It was then that the health authorities realized that something was very wrong.

The hospital had in fact become a site of transmission. People recognized that the hospital lacked the basic medical equipment and protection, and started to avoid its services. The attendance rate for different medical services dropped by about 70%.  The people retreated to their communities to find alternative care or  searched for treatment via  informal private providers. Indeed, most of the health clinics and hospitals that I visited here are empty. Both people and even (some) staff avoid to go to the hospital and get health services there. People are still afraid to get infected. This has amongst others an impact on the skilled birth attendance. A much lower proportion of deliveries are followed up. Complications during delivery are currently not dealt with at  the health centers. It is likely that the maternal mortality rate will increase substantially in the coming year. Vaccination coverage has also considerably decreased (from 80% to about 15%). In some sub-districts measles infections have returned as a result.

A group discussion with several directors of health centers in the district of Gueckedou  shed some more light on the structural deficiencies already existing in health centers before the Ebola outbreak. In the forest region, where there are many different ethnic groups, and analphabetism is about 50-60 %,  the dialogue between the government, health authorities and communities is limited. Trust is, consequently, fragile. This area had a large influx from refugees during the Sierra Leone war in the 90s, as well as people who migrated from other parts of Guinee to seek business opportunities. The autochthone ethnic groups feel that they are being ‘encroached’ upon by these newcomers . A certain form of resistance against the state that enforces its policies (including health) on the population has existed for quite some time.

The Ebola outbreak has aggravated this already existing distrust. The autochthone population has the impression that the government doesn’t take them seriously. There are many stories about communities that defy requirements by the state to have ‘safe’ burials (without the customary rituals like washing the body) or call for an ambulance to take a suspected case to a treatment center. There is even the sad case of Womey, about 50 km from N’Zerekore, where earlier in the year 8  health and governmental officials were murdered when they tried to inform the village of the dangers of the Ebola Disease.

When the Ebola outbreak will, eventually, be over, there will be much technical and organizational work to do. For instance training of existing (community) health workers to conduct regular surveillance and assess policy options to increase recruitment of health workers. There is much talk about decentralizing the services and have the local communities participating in allocation and accountability of the available health workers.

In my opinion, there is also an urgent need for some sort of  reconciliation process, both at the village and regional level. During such a process the communities of Ebola victims could share their grievances with the authorities. The government health responsibilities could explain their regrets, acknowledging committed errors and their willingness to evaluate and learn from the Ebola outbreak and its response. Dialogue and introspection seem required as a first step to rebuilding the health system in Guinea.

During my first days in N’zerekore, one of the main areas of the Ebola outbreak in Guinea, I met several health authorities & health staff and visited the regional hospital. I attended the funeral ceremony of my colleague Eugene’s mother who  passed away some days ago. And, as  you might remember from my first blog, I developed diarrhea and had to vomit. Before people are starting to get worried, let me explain a bit further.

In this district (prefecture) of N’zerekore, encouragingly, there have been no new cases of Ebola over the last 2 weeks. The Ebola coordination team follows up some contact cases but it seems that here the epidemic is really decreasing. This is not the case for all of Guinea as new cases have emerged in other districts. The Ebola control program (‘The fight against Ebola’) is in full swing, including a new program launched by the government to stop Ebola in 60 days. The international humanitarian system is also working in overdrive, with major UN agencies (UNICEF, UNFPA, WHO, UNHCR) present under  the coordination of the umbrella agency UNMEER (United Nations Ebola Emergency Response). There are several NGOs present as well (Guinean Red Cross , Save the Children, Plan Guinee, Alima) here. The district head and health authorities are coordinating the response. One person tells me ‘the epidemic that is (still) going on here is Reunionites”.

The funeral ceremony was a colorful one. The woman who passed away belonged to the Kpellé ethnic community. The majority of people here are Catholics but they still follow customary practices. It was  just wonderful to see this expression of solidarity. People and extended family came from far-away villages to attend the ceremony, bringing with them a financial contribution for the funeral. Each time an envelope with money was given, the master of ceremony (a designated elder) announced this publicly and accounts were kept  by a younger aide. Food was shared and people were given chicken(s) and rice to take home. Ritual dancing and singing took  place. People shook hands and (most likely) the women in the family washed the body of the deceased. And yes, in times of Ebola, the ceremony attendees were diligently washing their hands (frequently) with chlorinated water. They also know perfectly well now to distinguish between somebody who died because of “Le Maladie” (Ebola) and people who did so for another reason.

I also attended the Sunday morning mass in N’zerekore’s cathedral as part of the ceremony. The pastor let the choir sing extra loud and extremely long. In a charming and humorous  way he urged his community members to donate generous gifts to the church. This has obviously nothing to do with the Ebola response, but with the simple fact that the catholic mission celebrates its centenary anniversary this year and requires sufficient funds for the celebration activities. I had to smile as the whole thing looked remarkably similar to fundraising events in the North, including recently for  Ebola (see for example national television shows in European countries to boost aid when there are natural and humanitarian crises in the world).  And no, the pastor and choir unfortunately (?) didn’t sing “Do they know it’s Christmas”. That is already patented by Sir Bob Geldof, as you know.

And the diarrhea, you wonder? That must have been a  nasty gastro-intestinal microbe that I picked up while on the road. By now I have more or less recovered, thank you very much.

The panic and chaos which characterized the first period of the Ebola outbreak are over now. The government, health authorities, and communities are learning to deal with it. Ebola will however have a lasting impact on society in Guinea and the broader region.

During my first days in N’zerekore, one of the main areas of the Ebola outbreak in Guinea, I met several health authorities & health staff and visited the regional hospital. I attended the funeral ceremony of my colleague Eugene’s mother who  passed away some days ago. And, as  you might remember from my first blog, I developed diarrhea and had to vomit. Before people are starting to get worried, let me explain a bit further.

In this district (prefecture) of N’zerekore, encouragingly, there have been no new cases of Ebola over the last 2 weeks. The Ebola coordination team follows up some contact cases but it seems that here the epidemic is really decreasing. This is not the case for all of Guinea as new cases have emerged in other districts. The Ebola control program (‘The fight against Ebola’) is in full swing, including a new program launched by the government to stop Ebola in 60 days. The international humanitarian system is also working in overdrive, with major UN agencies (UNICEF, UNFPA, WHO, UNHCR) present under  the coordination of the umbrella agency UNMEER (United Nations Ebola Emergency Response). There are several NGOs present as well (Guinean Red Cross , Save the Children, Plan Guinee, Alima) here. The district head and health authorities are coordinating the response. One person tells me ‘the epidemic that is (still) going on here is Reunionites”.

The funeral ceremony was a colorful one. The woman who passed away belonged to the Kpellé ethnic community. The majority of people here are Catholics but they still follow customary practices. It was  just wonderful to see this expression of solidarity. People and extended family came from far-away villages to attend the ceremony, bringing with them a financial contribution for the funeral. Each time an envelope with money was given, the master of ceremony (a designated elder) announced this publicly and accounts were kept  by a younger aide. Food was shared and people were given chicken(s) and rice to take home. Ritual dancing and singing took  place. People shook hands and (most likely) the women in the family washed the body of the deceased. And yes, in times of Ebola, the ceremony attendees were diligently washing their hands (frequently) with chlorinated water. They also know perfectly well now to distinguish between somebody who died because of “Le Maladie” (Ebola) and people who did so for another reason.

I also attended the Sunday morning mass in N’zerekore’s cathedral as part of the ceremony. The pastor let the choir sing extra loud and extremely long. In a charming and humorous  way he urged his community members to donate generous gifts to the church. This has obviously nothing to do with the Ebola response, but with the simple fact that the catholic mission celebrates its centenary anniversary this year and requires sufficient funds for the celebration activities. I had to smile as the whole thing looked remarkably similar to fundraising events in the North, including recently for  Ebola (see for example national television shows in European countries to boost aid when there are natural and humanitarian crises in the world).  And no, the pastor and choir unfortunately (?) didn’t sing “Do they know it’s Christmas”. That is already patented by Sir Bob Geldof, as you know.

And the diarrhea, you wonder? That must have been a  nasty gastro-intestinal microbe that I picked up while on the road. By now I have more or less recovered, thank you very much.

The panic and chaos which characterized the first period of the Ebola outbreak are over now. The government, health authorities, and communities are learning to deal with it. Ebola will however have a lasting impact on society in Guinea and the broader region.