Symposium on Medical Education and Global Healthcare in Africa Hosted by People to People and University of Kentucky University of Kentucky

Hospital 27 November 2012 Coordination, Cooperation and Commitment to the Health Sector David H. Shinn Adjunct Professor, Elliott School of International Affairs George Washington University Thank you for inviting me to make remarks at this important symposium. It is a pleasure to address a diaspora organization that is contributing something constructive back to its country of origin. I also commend the University of Kentucky for taking such an active and positive role in this conference and its support of People to People. I am a political scientist not a medical practitioner. My approach to medical education and global healthcare in Africa reflects the views of a former diplomat and current academic specialist on African affairs. Let me begin with the obvious. Massive Health Care Needs in Africa African countries have massive health care needs. A few basic facts as of 2009 provided by the World Bank about Sub-Saharan Africa illustrate the point. I will also provide the comparable figures for Ethiopia since most of you are part of the Ethiopian diaspora and helping your country of origin. In 2009, life expectancy at birth for Sub-Saharan Africa was 52.5 years; for Ethiopia it was 55.7 years. The under-five mortality rate in Sub-Saharan Africa per 1,000 children was 130; for Ethiopia it was 104. The prevalence of HIV in the 15-49 age group in Sub-Saharan Africa was 5.4 percent; for Ethiopia it was about 2 percent. The incidence of TB per 100,000 people in Sub-Saharan Africa was 344 cases; for Ethiopia it was 359 cases. The total number of clinical cases of malaria reported in 2009 for all of Sub-Saharan Africa was 72 million; Ethiopia accounted for 3 million of these cases. The number of reported deaths from malaria for all of Sub-Saharan Africa was 113,000; Ethiopia reported 1,100 of these deaths. The share of GDP devoted to health care in Sub-Saharan Africa averaged 6.6 percent; in Ethiopia it accounted for 4.3 percent. The countries in Sub-Saharan Africa generally, including Ethiopia, have a long way to go before they can be satisfied with their health care systems. 1

Ethiopia does better than average on a number of these indicators, but poorer on several others even after allowing for its large population. Health Care Coordination There are numerous actors trying to improve health care in Africa. They include host governments, bilateral donors, international organizations, NGOs and private foundations. There is always room for improvement in the coordination of health care assistance from donor governments and organizations destined for developing nations. The governments of recipient nations have the primary responsibility for assuring coordination. The resident offices of the World Health Organization and ad hoc donor groups frequently contribute to the coordination process but only the host government can assure that effective coordination takes place. This is not an important role for an NGO such as People to People. On the other hand, if People to People identifies deficiencies in the coordination of health care, it should bring them to the attention of the host government. There will be occasions when its activities on the ground offer an ability to identify deficiencies that might be missed by the host government or the donor organizations. Some of the more recent or returning donors in the health sector such as China, India, Brazil, Turkey, Chile, South Korea and Cuba have little experience with donor coordination and may, for example, need to be encouraged by host governments to coordinate more closely with larger and more established donors such as the European Union, World Health Organization and United States. The more information that is shared by donor governments and organizations early in the decision-making process, the easier it will be for the host government to improve health care delivery and assure that resources are not wasted or duplicated. It is also essential to bring foundations such as Gates, Packard, Carter, Clinton and Soros that have made significant contributions to the health sector into this process. An organization such as People to People is well placed to encourage coordination with Ethiopian diasporas in other countries and with other NGOs such as the Ethiopian North American Health Professionals Association that is also focused on aiding the health sector. Health Care Advocacy There is one particular role organizations like People to People can play that should occupy a much higher priority in the next several years. The national budgets of most donor governments, including the United States, are under increasing stress. There will simply be less money available to support all kinds of assistance programs in the developing world. Because People to People has a focus on the health sector, it is in its interest to advocate with appropriate elements of the United States government and governments in other countries where it can make its voice heard in favor of maintaining financial support of the health care sector.

There may be a tendency by governments to cut all foreign assistance sectors until there is significant improvement in the global economy. In any event, it is not realistic to expect increases in funding over the next several years, but good advocacy work can help in maintaining existing funding. The first goal is to ensure that governments continue to keep health care as a top priority in their foreign aid programs. Over the past four years, the health sector has had powerful backers in the form of Secretary of State Hillary Clinton and Assistant Secretary of State for African Affairs Johnnie Carson. But both of these officials will be leaving government early in the New Year and their successors are not known. People to People can advocate after their successors are named to retain health care as a top priority and perhaps suggest ways that a focus on health care is institutionalized in the State Department. People to People is even better placed to advocate how finite funding resources in the US and possibly other donor countries should be utilized. For example, has the time arrived when more of the limited U.S. funding should shift from a heavy focus on combating HIV/AIDS, malaria and TB to more attention on influenza, neglected tropical diseases or some other health challenge? This is not my area of expertise, but it is a question that People to People should be asking itself and then discussing with the government of Ethiopia just as health care NGOs operating in other countries should be doing with the governments in their countries. Other health care NGOs in Ethiopia should be asking themselves the same question, coordinate their conclusions with all health care NGOs and then raise the issue with the government of Ethiopia. If there is a consensus that the current expenditure mix is not the right one, People to People and similar organizations can be an important voice in trying to change the mix even if additional financial resources from donor countries and organizations are not available. This message is most effective vis--vis donor organizations when it comes from recipient governments such as Ethiopia in combination with well-established NGOs such as People to People. The Brain Drain Finally, let me turn to the brain drain. The medical professiondoctors, nurses and technicianshas probably been more impacted by the brain drain than any other skill sector in Africa. Ethiopia has lost many of its professional medical staff over the past 40 years. This is another area where organizations like People to People could make a contribution by brainstorming and then proposing recommendations to the governments in their country of origin for slowing the outward migration of medical talent. Most of the solutions for dealing with this issue such as increasing pay and benefits for medical personnel are well known and would not add constructively to the dialogue. But there may be some innovative and low cost ideas that have worked in some African countries but not been tried in others. 3

Alternatively, organizations such as People to People can propose additional ways to advance medical education in their home countries by making greater use of telemedicine and medical education over the Internet for use by medical staff in Ethiopia. Some African diaspora health care NGOs may have already developed this idea and it is only a question of copying what others have done. Conclusion My modest goal has been to stimulate some thinking and discussion in areas that may not have been covered by others at this symposium. I wish all of you every success with your deliberations and I wish Ethiopia additional success in meeting the health care challenges of the country.