Question: As Director-General of the World Health Organization, what will be your three priorities to advance progress in ending AIDS by 2030 as part of the Sustainable Development Goals?
To defeat the epidemic, the World Health Organization (WHO) needs to continue work in partnership and push the ambitious agenda approved at the United Nations General Assembly High-Level Meeting on Ending AIDS. Universal access to early safe treatment—getting to universal coverage still needs a lot of work—and countries need support to be able to work out how to deliver lifelong treatment. WHO will strive to be sure that we are on top of the evidence and able to fail fast and fix fast as new evidence sheds light on how to reach people and sustain them on treatment to reduce the community viral load.
Only then can we expect to curb transmission. For prevention—while we now have some effective interventions to programme—we still need to add to our toolkit and WHO will work to ensure new evidence and experience is brought into programmes as quickly as feasible. Addressing HIV requires universal health coverage for the core evidence-based package, a rights-based approach and an understanding of the key role of social determinants.
With that in mind we need to focus on ending transmission. This means continuing to promote universal testing and treatment, with a focus on the most vulnerable groups, including adolescent girls and people who use drugs, understanding the value of pre-exposure prophylaxis and, of course, ultimately we need a vaccine.
WHO’s role in this is to continue to provide evidence-based policy guidelines and build up our toolkit to make progress towards universal health coverage. We know that countries are struggling to implement the existing guidelines. WHO needs to continue to bring rigor, evidence and a public health approach to the response so that we can provide practical and clear guidance on how to deliver services in different contexts (rural, urban) and to those people that don’t normally have contact with the health system.
WHO also needs to support countries to have the data and management systems in place to deliver a real-time public health response, with a view to actually preventing transmission.
Question: How important do you feel the lessons learned in the AIDS response are in shaping the future of global health?
The AIDS response more than any other has taught us four critical lessons for the future of global health. The power of ambition, power of community engagement, the benefits of a multisectoral response and lessons to reorient acute-care health systems towards chronic disease management.
On the first point, the AIDS community was one of the first to push for universal access. Seen as heretical at the time, the AIDS community said everyone, everywhere can and should be treated. Through South–South cooperation antiretrovirals were made accessible to those that needed them most and millions of people are now alive because of it.
Second, the AIDS response has shown us that the community matters and health is everybody’s business. Community health workers trained in treatment literacy were key to breaking down social stigma and encouraging people to get tested and to take up treatment.
Thirdly, the AIDS response has shown us the power of partnership and while the outcome of a disease may be a health outcome (e.g. people get sick or die) prevention and treatment on a universal scale requires engagement of all players—government, private sector, faith-based organizations, community-based organizations, civil society, academia—and all sectors—education, food security, water and sanitation, transportation.
In the fourth place, the scale-up of services in lower-income countries has created the first large-scale continuity care programmes. Although HIV and chronic noncommunicable diseases (NCDs) are thought of as different challenges, there are many commonalties, as far as the health systems response is concerned, since the availability of treatment has transformed HIV into a chronic condition. HIV programmes have developed the systems, tools and approaches needed to support continuity of care. These lessons can help in mainstreaming the management of NCDs in country health systems planning.
Overall, we have also learned that we cannot see any disease area in isolation—to address HIV/AIDS we need an effective, strong system, which means people, funding, hardware, leadership and data to drive decision-making.
Our experience with HIV has shown us the shortcomings of systems built around one-time episodic care and that success is only possible when the beneficiary and the provider embark on a journey together as part of the continuum of care. As countries are grappling with a declining burden of communicable disease and a rise of NCDs, we need to build strong health systems that are sustainable and more responsive. This requires a long-term view focused on both people and systems.
Question: As the AIDS response has scaled up to reach millions, one of the key challenges has been the lack of community health workers and the capacity of the health system to deliver services at scale. How will you address the challenge of building up the health system to prepare for the next disease outbreak and to meet current health challenges, including AIDS and noncommunicable diseases?
Here you raise three separate but important issues: the lack of health workers, the need to deliver services at scale and the challenge of building health systems, and how best to prepare for the next disease outbreak.
First, community health workers form the backbone of health services in many countries—in many cases the health workers are women. We must do better in remunerating these women on time for their work, as a pure volunteer model is not sustainable in the long run if we want to retain this part of the workforce. More broadly, implementation of the recommendations of the High-Level Commission on Health Employment and Economic Growth will work well, both for addressing health workers’ shortages as well as economic growth and health systems strengthening, overall.
I have always believed that strong health systems can deliver on any disease-specific goal. In fact, this has been the message of my book, Choked Pipes. In addition to disease-specific targets, strong and effective systems can also be crucial for the response to pandemics. I will ensure WHO embarks on a course to strengthen the international framework to coordinate and consolidate efforts towards the achievement of universal health coverage, with health systems strengthening as one of its key features. This will also include efforts to overcome systemic barriers and address collusion in health systems, and provide technical support to countries to develop new stewardship mechanisms to tap the potential of providers of services in the non-state sectors, which play a predominant service delivery role in many parts of the world. Under my leadership, WHO will promote universal health coverage as a health policy goal for all countries, and will help ministries of health galvanize commitment at the head of state level. Embracing universal health coverage means building on previous commitments to primary health care and including long-term social policy commitment, domestic resource allocation and a move linking coverage for essential services to financial risk protection.
Finally, on disease outbreaks, there are actions to be taken both in countries as well as within WHO. WHO must work more effectively with Member States to enhance their core public health capacities as demanded by the International Health Regulations. Improvement in disease surveillance will improve health planning, and quick detection and response to outbreaks will save lives. Internally within WHO a new Health Emergencies Programme has been initialized, which I am strongly supportive of and which I will strengthen as a priority.
Question: How will you ensure that people affected by HIV, especially key populations, such as sex workers, gay men and other men who have sex with men, people who inject drugs, transgender people and migrants, are not left behind in efforts to achieve universal health coverage?
Everyone has a right to health. As with all areas of its work, while recognizing the criticality of national sovereignty, to fulfil its mandate of health for all, WHO must also be the steward and champion of both the right to health and a human rights approach to health.
The 2030 Agenda and the Sustainable Development Goals reaffirm the responsibility of Member States to “respect, protect and promote human rights, without distinction of any kind as to race, colour, sex, language, religion, political or other opinions, national and social origin, property, birth, disability or other status,” signalling a renewed commitment to human rights in the coming global health and development agenda.
Throughout my work as a doctor, in government, civil society, academia and working with international agencies, I have always based my work on the foundation that everyone has the right to quality health services. It was this strong grounding that led me to set up an innovative financing facility in Pakistan that assists the poorest and most marginalized communities to avoid catastrophic expenses when accessing health. I will continue to walk the walk on the right to health as Director-General of WHO.
Question: What does UNAIDS mean to you?
UNAIDS was one of the first examples of a partnership that harnessed the strengths and core competencies of all the United Nations agencies. Under the stewardship of UNAIDs, the United Nations has driven an ambitious agenda, and collectively we have pushed farther and faster towards ending the epidemic—ambitious goals for access to treatment and prevention of mother-to-child transmission of HIV are being met in some countries, and, for the first time, epidemic control and ending transmission seems as possible in a handful of African countries hardest hit.
UNAIDS has also played a key role to keeping a human rights-based approach to our response and ensuring that access to critical prevention and treatment is extended to key populations at risk, including harm reduction for intravenous drug users, and adolescents. UNAIDS has also led the way on how we in health can work with multiple actors—civil society, communities, volunteers and the private sector—to improve coordination and to better leverage the skills, experiences and resources of partners.
