This week, as part of our interview series with the shortlisted candidates for Director General of the World Health Organisation, we were fortunate to speak to HE Dr. Tedros Adhanom Ghebreyesus, Ethiopia’s candidate. Dr. Tedros spoke articulately about his desire of achieving universal health care, his experience addressing a chronic shortage of health workers when he was Minister of Health in Ethiopia, and the need to strengthen health systems, among other issues.

1) Why do you want to be Director General of the World Health Organisation, and how does Africa feature in your world view?

I want to be Director General of the WHO for three reasons. First, I have a deep-rooted passion for global health. I envision a world where everyone can lead healthy and productive lives regardless of who they are or where they live. Second, I believe in the power and potential of the WHO to drive change and push toward the goal of achieving universal health care. Third, I am uniquely qualified with the required technical, diplomatic and political skills, a track record of addressing the greatest health challenges of our time at their roots, and driving change and getting results, both nationally and internationally through reforming bureaucracies.

I am inspired by the energy, progress and potential of Africa just as I am inspired by the progress we have made in other regions. I have witnessed this first hand as Chair of the Executive Council of the African Union. Here, I facilitated the drafting of Agenda 2063, a global, strategic framework aimed at accelerating Africa’s economic, political and social development through regional cooperation and solidarity. This framework offers an enormous opportunity to put universal health care front and centre in the political agenda in Africa and improve the lives of Africans.

Our efforts to advance universal health care can build on the tremendous progress made and experiences gained in the last two decades tackling HIV, tuberculosis, malaria, neglected tropical diseases, and child and maternal mortality. We also need to strengthen primary health care systems with integrated community engagement to address communicable and non- communicable diseases such as cancer, heart disease, chronic respiratory diseases and diabetes, and injuries. These efforts will help not only to deliver evidence-based health promotion, prevention, treatment and rehabilitation services, but also to enhance prevention, detection, and response and recovery efforts for health emergencies such as the Ebola crisis. I believe I have the political acumen and technical competence to lead and assist in this process – and it’s the progress I’ve seen in Africa and other regions that continues to inspire me to want to do more.

2) According to the WHO, the continent “bears the brunt of more than 24% of the global disease burden, but has access to only 1% of health workers”. What can Africa do to train and retain high-quality health professionals?

Building a strong and well-functioning health workforce is among the most noticeable health system challenges in Africa. I’ve thought about this issue a lot because the goal of achieving universal health care depends in part on solving this challenge.

I faced similar challenges when I was Minister of Health of Ethiopia, and the lessons we learned there can be instructive. When I started as Minister of Health, among other health worker shortages, there was only one physician for more than 40,000 people. For us, it was first important to candidly assess the problem at a political level and identify the challenges. Then we could come up with solutions to address the challenges. Here, we looked at best practices of other countries and tailored those solutions to our context. That is how we ended up prioritising the task sharing and flooding strategies. Task sharing is about sharing the burden of health professionals with lower-level, community-based providers who have appropriate training and follow up procedures in place. For example, we trained Surgical Officers who shared the tasks of surgeons for life-saving, emergency laparotomy and cesarean section services. Meanwhile, to achieve the flooding strategy – growing the overall number of health care workers in the system – we found innovative ways to train and retain new medical doctors and other health professionals in the country. We increased the number of medical schools from six to 30, and because of that, the number of medical doctors who graduate in the country increased from about 150 in 2004 to nearly 3,000 in 2016.

This experience demonstrates how, with the right political commitment to identify challenges and a focus on implementing practical and contextualised solutions, we can address challenges such as the shortage of healthcare workers in Africa. To do this everywhere, we’ll need to share best practices and encourage co-operation among countries – both roles the WHO can play as a platform. In addition, African governments and all stakeholders will need to deliver on existing global commitments to train and retain health care workers, and address the brain-drain. The commitments include the High-Level Commission on Health Employment and Economic Growth, the global strategy on Human Resources for Health: Workforce 2030 and the Code of Practice on the International Recruitment of Health Personnel.

3) In December, the World Health Organisation’s Africa office announced a steep rise in risk factors for non-communicable diseases. What steps can African countries take to combat these diseases?

Fast economic growth and changing lifestyles are increasing the risk and burden of non- communicable diseases (NCDs), such as cancer, heart disease, chronic respiratory disease and diabetes, in the African region.

Addressing NCDs requires us first to strengthen political leadership and foster multi-stakeholder engagement. NCDs are not just a public health challenge. They require working across all sectors, mobilising communities and individuals, and building consensus. Governments, global and regional institutions, civil society, the private sector and academia all have a role to play to meet the goals laid out in the 2011 UN Political Declaration on NCDs. This includes accelerating implementation of the WHO Framework Convention on Tobacco Control.

Second, integrating NCDs into primary health care and embedding them into community-level health activities will help scale evidence-based approaches to prevention, diagnosis and treatment. With the right interventions – delivered through a firm primary health care design – it is also possible to encourage healthier lifestyles.

Here, we can also learn from our collective years of experience addressing communicable disease. Africa has made remarkable progress in controlling communicable diseases over the past few decades. That experience gives us a unique perspective on how to prevent and control NCDs. Not only can those learnings advance approaches in Africa, but I also believe that the rest of the world can learn from Africa especially on ways to reach all people in need.

Third, we need new evidence and data that can support our understanding of the nature and extent of NCDs as well as possible solutions. For example, many African countries have very little data on the prevalence of NCDs. Without this type of data, we can’t fully understand what challenges we’re facing, determine what’s working or not, and identify where to focus and refine our efforts.

Finally, it is impossible to speak of non-communicable diseases and injuries without emphasising the need to tackle the grand challenge of mental health. Mental health conditions account for 13- 14% of the global burden of disease, and yet about nine out of 10 people don’t have access to mental health services. We need to flip this ratio, so that nine out of 10 people do have access. I believe we can do so best in the context of universal health care.

4) How can African countries ensure their wider preparedness for health emergencies?

African countries have suffered from numerous deadly public health emergencies that took thousands of lives. The recent Ebola viral disease outbreak, among others, tested the continent in real terms. It tore apart health systems. It created an unfavourable economic and social environment which strangled the growth of affected countries, their neighbours and the region. And it left communities scarred from losing loved ones. It is now time for Africa to say ‘No More’.

To be prepared for public health emergencies, we primarily need to invest in strengthening health systems. Countries with strong health systems have managed to prevent or easily control disease outbreaks. This includes smart and rapid repurposing of existing resources, investing in internal capacities such as robust human resources, reliable infrastructure, strong information systems, secure supply chains and adequate financing.

It is also very important for African countries to commit to implementing the International Health Regulations requirements comprehensively. This will require political commitment and South- South solidarity and support. The WHO can also assist countries in conducting Joint External Evaluations, but it is important that we ensure peer participation.

Given the number of players focused on this issue, we also need to harmonise and find synergies among efforts of various stakeholders. Sub-regional and regional organisations working on emergency preparedness need to be coordinated on technical assistance, capacity building and response activities. I believe that the establishment of the African CDC also provides an opportunity to strengthen emergency preparedness further and coordinated response efforts, and complement the work of the WHO.

Finally, availability of and access to essential vaccines and medicines is also among the crucial issues to address. The recent yellow fever outbreak showed us how essential it is to have availability and timely access to vaccines. WHO and all relevant stakeholders need to work toward securing sufficient supplies and ensuring that there is enough stockpile before and during such response operations. Our goal should always be preventing these types of public health emergencies, but we also need to be ready to respond.

5) The Sustainable Development Goals recognise the private sector as a key driver of development. How can for-profit businesses work with African countries and the WHO to achieve the SDGs’ ambitious agenda for health?

The challenges of global health and development are too big to be solved by any one sector alone. The role of partnership in particular is clearly recognised by SDG 17: “Strengthen the means of implementation and revitalise the global partnership for sustainable development.” I chaired the negotiations on financing the SDGs (the “Addis Ababa Agenda”) which recognised that Official Development Assistance could only be catalytic, and that private investment and resources from countries themselves are needed to reach the SDGs.

The burgeoning role of the private sector in health in African countries, fuelled by the increase in GDP, requires particular attention. The private sector brings many capabilities that are complementary to national governments, and I believe such partnerships can build on a shared vision and lead toward shared benefits. The WHO can play a critical role in facilitating such partnerships by helping to create accountability mechanisms, foster transparency, and protect against conflicts of interest. Effective application of the WHO’s Framework on the Engagement of Non-State Actors will also help play a facilitative role to enhance its engagement with the private sector.

6) If you were elected Director General of the World Health Organisation, what do you think global health will look like by the end of your term?

I would like my legacy to be the Director General who brought the world together to achieve Universal Health Care that is equitable and affordable for all. I am convinced that universal health care, with financial protections and strong primary health care linked to community engagement, is the key to a world where everyone can lead healthy and productive lives regardless of who they are or where they live. It is also the key to identifying and overcoming public health emergencies and giving us a safer world. Related, I would like to see the WHO help propel “health for all” into the centre of efforts to achieve all of the sustainable development goals – because we know when people are healthy, their families, communities and countries benefit.

In addition, I would like to see a world that is better prepared and more effective at responding to emergencies including anti-microbial resistance. For the WHO’s role specifically in this, I would hope that I’ve helped it better foster multi-sectoral and multi-agency collaboration to develop and leverage new tools, such as big data, new diagnostic tests and vaccines, that will help us more effectively predict, prevent, detect and respond to emergencies and emerging public health threats, including zoonotic diseases. Lastly, I would like to see an organisation that is positioned to better understand, prevent and mitigate the health impacts of climate and environmental change.

7) Following on from the last question, if you were appointed Director General of the World Health Organisation, what do you think the health outlook for sub-Saharan Africa will be by the end of your term?

I would like to see a continent where all citizens have access to universal health care with financial protection and can lead healthy and productive lives. I would like to see a continent that continued to intensify, sustain and consolidate the gains that it’s made on HIV, tuberculosis, malaria, neglected tropical and other communicable diseases as well as on polio and maternal, child and infant health. I would like to see that the experiences from these efforts have been used to tackle the growing challenge of non-communicable diseases with a primary health care platform that integrates effective community engagement. And, finally, I would like to see a continent with such strong health systems that it is capable of leading the prevention, detection, and response and recovery efforts around public health emergencies, antimicrobial resistance and the impact of climate change’s on health.