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Healthcare for All Means Investing in Community Health

This guest post was written by Crystal Lander, Director of Advocacy, Living Goods. Living Goods supports networks of ‘Avon-like’ health entrepreneurs who go door to door to teach families how to improve their health and wealth and sell life-changing products such as simple treatments for malaria and diarrhea, safe delivery kits, fortified foods, clean cookstoves, water filters, and solar lights. Living Goods is a Global Health Council member.

We live in an age of medical and technological miracles. Yet, six million children still die each year from preventable or readily treatable illnesses like malaria, diarrhea, and pneumonia.

We have the means and the medicines to save lives—they just aren’t reaching the families who need it most.

Living Goods community health promoter Janat visits a young mother who she supported throughout her pregnancy. Photo credit: Living Goods

To reach the 400 million people who currently lack access to essential health care—and work toward Universal Health Coverage—we need to put families first, reaching them when and where they need it. In areas where doctors and nurses are scarce and resources are limited, community health can be a critical linchpin connecting families in hard-to-reach areas with the formal health system.

Despite its transformative potential, community health is often underfunded and underutilized in many parts of the world. Where they do exist, community health workers (CHWs) often receive minimal training and supervision, and don’t have access to the medicines they need to treat sick patients. It’s like asking a student to learn without schools, teachers, books, and supportive learning environment. Living Goods, and other like-minded organizations are seeking to change this by working with governments to strengthen community health care systems and help CHWs reach their full life-saving potential.

Living Goods partners with the governments of Kenya and Uganda to transform dedicated women and men into highly-effective CHWs. The CHWs go door to door supporting pregnant mothers and newborns, assessing and treating sick children, targeting early nutrition, offering family planning guidance, and selling health-focused products including fortified porridges and modern contraceptives.

We help CHWs operate at full throttle—giving them hands-on training and support, motivating performance-based pay, and building reliable supply chains for life-saving medicines. By blending best practices from business and public health, we’re working to overcome the biggest challenges in community health.

Living Goods community health worker Janat uses her mobile phone to test a sick child’s breathing patterns. Photo credit: Living Goods

Research shows that it’s working: a randomized controlled study demonstrated a 27 percent reduction in child mortality in areas where Living Goods CHWs were present. Families in the catchment area were five times more likely to receive a visit from a community health worker, and those with newborn babies were over 70 percent more likely to receive a home visit within the baby’s first critical week of life.

Our robust mobile platform, developed in collaboration with our tech partner Medic Mobile, helps drive performance and health impact across all levels of operation. It provides CHWs in the field with on-demand medical know-how, and gives supervisors access to real-time performance data that helps them pinpoint exactly where their support is needed.

The platform is the backbone of the Living Goods system—enabling real-time supervision, quality assurance and accuracy, and ensuring that every client has access to the compassionate, high-quality care that they deserve. As one Living Goods CHW puts it, “it’s like having a doctor in the palm of your hand!”

Integration of Frontline Health Workforce Will Determine Success of SDGs, Universal Health Coverage in 2018 and Beyond

Global Health Council will continue the conversations started at its 2017 Global Health Landscape Symposium (GHLS17) through a 2018 blog series focused on the four Symposium tracks: Integration, Investment, Partnerships, and Mobilization to Action. The post below is the first in our series. Follow the blog: www.globalhealth.org/ghls/blog-series. If you would like to submit a blog post, please email us.

This guest post was written by Vince Blaser, Director, Frontline Health Workers Coalition (FHWC), and Advocacy and Policy Advisor, IntraHealth International.  The post was originally published on the FHWC website. The Frontline Health Workers Coalition (FHWC) is an alliance of United States-based organizations working together to urge greater and more strategic U.S. investment in frontline health workers in developing countries as a cost-effective way to save lives and foster a healthier, safer and more prosperous world. FHWC is a Global Health Council member.

As 2018 begins with the clock already ticking on the 2030 Sustainable Development Goals targets – the heroic, sometimes harrowing, and heartwarming stories of six frontline health workers from four continents delivered on a crisp November evening in Dublin reflect both the promise and the tangled reality of the policy planning and program implementation needed to fulfill the promise of unprecedented global consensus on health and development.

What I hope stuck in the minds of thousands of the top global health experts that had gathered in Dublin for the Fourth Global Forum on Human Resources for Health was not the geographic diversity of these health workers’ stories, but rather their diversity of skills.

Intuitive though it may seem, ensuring access to a proper skill mix – represented in part by Mexican- American community health worker Maria ValenzuelaLiberian nurse Miatta GbanyaZambian nurse-midwife Marjorie Makukula, South African paramedic Rushaana GallowBurmese community doctor Hay Mar Khine, and Irish cardiac physiologist Paul Nolan at the “Lives in Their Hands” storytelling night in Dublin – is a complex yet fundamental equation for global health policy leaders to solve in 2018 and beyond.

Maria Valenzuela, a community health worker for Esperança in Phoenix, Arizona, speaks at the “Lives in Their Hands” storytelling night Nov. 13, 2017, co-sponsored by the Frontline Health Workers Coalition, Global Health Workforce Network, Women in Global Health, and the World Health Organization. Photo courtesy Frontline Health Workers Coalition and IntraHealth International.

How do you move from policy to implementation to deliver “truly patient-centered” care?

How well this question – posed at a side session in Dublin led by Medtronic Foundation and IntraHealth International – is answered and acted upon will determine the success of SDG3 to “ensure healthy lives and promote well-being for all at all ages” and the success of all disease- and health issue-specific compacts and targets under SDG3’s umbrella.

As borne out in several sessions in Dublin, community health workers (CHWs) are a key part of the answer, as they are already helping to deliver tremendous progress in dozens of countries around the world. At the Medtronic Foundation and IntraHealth session – Hafeez Ladha of the Financing Alliance for Health detailed a new analysis finding that in sub-Saharan Africa, about $1.1 billion is spent annually on community health programs. This spending has helped lead to major improvements on health indicators from HIV/AIDS to maternal and child survival in countries like Ethiopia. And, as Mallika Raghavan of Last Mile Health presented at the same session, CHWs are a central pillar of Liberia and other countries’ plans to ensure their entire populations receive patient-centered care and are protected from threats like Ebola in the years to come.

However, CHWs’ potential is still largely underreported, untapped, disaggregated, and severely underfinanced. The Financing Alliance for Health estimates about $3.1 billion is needed annually to implement sustainable community health programs in sub-Saharan Africa, about $2 billion less than what is being spent now. New efforts – such as USAID and UNICEF’s partnership on community health program integration in 7 low- and middle-income countries and the Bill & Melinda Gates Foundation’s work to improve primary health care (PHC) performance – are aiming to address this gap.

Skill mix, teamwork key to successful community health

For a surge in community and primary health programs to be effective, we must learn from the past. As pointed out by IntraHealth’s Laura Hoemeke during the Medtronic Foundation-IntraHealth session in Dublin, CHW and PHC programs of all shapes and methods have been tried since the Alma Ata Declaration of universal primary health care in 1978 to widely different outcomes.

Critical components of success – as noted in first-ever Global Strategy on Human Resources for Health: Workforce 2030 – is a “collaborative primary care approach built on team-based care” that reflects “a more diverse skills mix …  to harness the potential contribution of all health workers for a more responsive and cost-effective composition of health-care teams.”

Less than 40% of current spending in sub-Saharan Africa is supporting integrated CHW programs, according to the Financing Alliance for Health – underscoring a need for disease-specific programs to more effectively integrate their health workforce strengthening efforts, as well as a need to better integrate CHW programs into national HRH plans. The Frontline Health Workers Coalition in 2013 worked with several donor agencies and partners on a CHW Harmonization Framework to improve integration of CHW programs – an essential ongoing effort our members continue, that must be firmly embedded in the World Health Organization’s (WHO) first-ever guidelines on CHW programs, expected to be finalized in 2018.

As recent reports like Midwives Realities, Midwives Voices and labor disputes such as the doctors’ strike in Kenya remind us – ensuring a resilient health workforce able to deliver universal health coverage (UHC) and meet global health targets requires that we listen and meaningfully include frontline health workers of every cadre in the policymaking and advocacy process. By doing so, we can chip away at any misperceptions and apprehensions between cadres and health workforce delivery models to better answer and act on the question of how to implement truly patient-centered care.

And as new and better health workforce data starts to be collected via the National Health Workforce Accounts, the WHO-ILO-OECD Working for Health data collaborative and other sources, we as advocates in 2018 and beyond must do all we can to ensure the interest, momentum, and enthusiasm to improve access to primary, essential services is harnessed to country-led, sustainably financed approaches that deliver a team of connected frontline health workers with the passion and skills shown on that stage in Dublin to enable their communities to thrive.

Solving The Cervical Cancer Crisis In Tanzania

This guest post was written by Jennifer Bentzel and Emily Esworthy of IMA World Health as part of our Member Spotlight series. Founded in 1960, IMA World Health is a global, faith-based nonprofit that works with communities to overcome their public health challenges. Their mission is to build healthier communities by collaborating with key partners to serve vulnerable people. Their vision is health, healing and well-being for all. IMA World Health is a 2017 GHC Member.

Nurse Joy Agutu enjoys her work. She, along with a doctor and a few other nurses, conducts cervical cancer screening and treatment for women at Shirati KMT Hospital in Tanzania’s Lake region. Agutu is a true champion for cervical cancer screening, encouraging and counseling women wherever she goes and getting periodic screenings herself. She also enjoys working with elders and community leaders, whom she describes as “cooperative and encouraging,” to promote village screening campaigns. Her days are rewarding.

Indeed, reducing cervical cancer deaths in Tanzania should be easy and rewarding; health workers know screenings are important, and the supplies cost only a few cents per patient. Plus, demand is high. The screening campaigns IMA World Health has conducted in Tanzania’s Mara and Lake regions have frequently shattered expectations, with lines of women snaking through the neighborhood as they wait their turn.

YET YEAR AFTER YEAR CERVICAL CANCER CONTINUES TO KILL MORE WOMEN IN TANZANIA THAN ANY OTHER TYPE OF CANCER.

For more than six years, IMA World Health—with funding from the IZUMI FoundationAmerican Baptist Churches (USA)Week of Compassion, the U.S. Centers for Disease Control and Prevention and private donors—has supported Shirati and other health facilities to ease the burden of cervical cancer by training health workers, providing testing and treatment supplies and equipment and creating referral linkages to larger hospitals for those who require additional treatment. Through this support, 24,000 women have been screened to date—most of whom would otherwise have no access to these services.

But the challenges are many, and few have a better understanding of them and their solutions than Agutu and the team at Shirati. Recently, they sat down with IMA staff to highlight the challenges and discuss how, together, we can strengthen the response to the rising number of cervical cancer diagnoses and deaths.

BARRIERS TO CERVICAL CANCER TREATMENT

CHALLENGE: LACK OF SUPPLIES

Nurses Moureen Mbise and Janeth Sila pose with a donation of screening supplies and Luke King, Country Director for IMA Tanzania. Photo by Jennifer Bentzel for IMA World Health.

The basic supplies for cervical cancer screenings are fairly inexpensive and easy to obtain: gloves, speculum, vinegar, cotton swab, flashlight. But considering the volume of need, these supplies vanish quickly. Shirati relies on donations from IMA World Health and partners to maintain their stock of screening supplies. These are in such demand that the health workers who conduct the screenings, like Nurse Agutu, work as volunteers so that all funds can go to supplies and outreach.

Nurse Moureen Mbise prepares to perform a screening. Photo by Paul Jeffrey for IMA World Health.

CHALLENGE: LACK OF FOLLOW-UP

Shirati staff estimate that about one third of the women they have screened recently have signs of cervical cancer. Patients with larger or suspicious lesions require referrals for treatment at a larger facility. Women who present large or suspicious lesions require a referral to a larger hospital for more advanced treatment; Shirati staff estimate 1 in every 4 women screened need further testing.

The trouble is the closest referral hospital is Bugando Medical Center, which is nearly 300 kilometers away—a minimum five-hour trip by car. In addition to the distance and cost of bus fare, the cost of treatment at Bugando is a prohibitive factor. As a result, Shirati staff say only about 2 percent of women with the most troubling signs of cervical cancer get the follow-up treatment they need. Additionally, women whose screenings show early stage symptoms can receive cryotherapy treatment the same day at Shirati for free, but many refuse because they have to abstain from sex for a month after treatment.

CHALLENGE: LACK OF EDUCATION

Many women know someone who has died of cervical cancer, which often prompts their desire to be screened. Still, the full scope of prevention and treatment is not well understood. This lack of understanding is another reason some women neglect to follow through on referrals or refuse treatment altogether. Nurse Moureen Mbise, the Nursing Officer in Charge at Shirati, says many of their patients mistakenly believe they are not in danger unless they have noticeable symptoms. By then, it’s often too late.

Shirati KMT Hospital, Tanzania

The cervical cancer team includes Dr. Simon Ogendo, nurse Janeth Sila, nurse Joy Agutu, and head nurse Moureen Mbise. Photo by Jennifer Bentzel for IMA World Health.

OFFERING SOLUTIONS TO THE CHALLENGES

Limited resources and competing priorities have made cervical cancer a low priority across both national and local levels of the health system in Tanzania. While they continually go the extra mile for their patients, the team at Shirati know there is so much more they could do if they had more resources. In addition to purchasing more screening supplies, they would seek additional training for themselves and their colleagues.

More funding would also help with patient follow-up: the staff could buy phone credits to contact patients, train community health workers to follow up with patients, pay for biopsies, and cover transportation costs to take women with more advanced cancer to Bugando.

The team says they would provide materials to religious leaders, such as sermon guides, posters and pamphlets, to increase community awareness. They would incentivize these influential leaders to educate community members about the importance of screenings and follow-up treatment. They would purchase a LEEP machine, along with the requisite training, that would allow them to treat both small and large lesions onsite.

This wish list is basic, but these health workers know it will save lives. IMA World Health has seen the impact of a well-supported cervical cancer screening and treatment program, and IMA is committed to supporting Shirati KMT Hospital and other hospitals to address the challenges that make cervical cancer so deadly in Tanzania.

Related

1) The 4-cent test that saves lives in Tanzania: https://imaworldhealth.exposure.co/the-4cent-test-that-saves-lives-in-tanzania
2) Learn more IMA’s cervical cancer work: https://imaworldhealth.org/cervical-cancer/
3) GHC blog from ACS CAN: Conquering cervical cancer worldwide: http://globalhealth.org/conquering-cervical-cancer-worldwide/

Video link: https://youtu.be/O-JQxgPrQ2I

Why UHC Day is a Call to Action for the World’s Youth

This guest post was written by Arush Lal, Global Health Corps Fellow at Frontline Health Workers Coalition (FHWC) c/o IntraHealth International.  The post was originally published on the FHWC website. The Frontline Health Workers Coalition (FHWC) is an alliance of United States-based organizations working together to urge greater and more strategic U.S. investment in frontline health workers in developing countries as a cost-effective way to save lives and foster a healthier, safer and more prosperous world. FHWC is a 2017 Global Health Council member.

It’s no accident that Universal Health Coverage Day December 12 — falls on the heels of Human Rights Day. Universal health coverage (UHC), the goal of ensuring that all people can access essential health services without exposure to financial hardship, is a dignity and a right not afforded to many around the world.

Today, I remember Gabriel, a Panamanian boy half my age who first taught me how a fractured health system fails people. I met Gabriel in the waning hours of our fourth clinic day, where our team of passionate doctors and volunteers was visibly exhausted after treating hundreds of patients in the remote islands along Panama’s rugged coastline. I vividly recall watching him bear the sweltering heat as he waited to be examined, and felt proud when I saw him leave with a much-needed bottle of Albendazole and a bag of nutritional supplements for his sister back home. As I instructed the team to wrap up for the day, I suddenly noticed Gabriel running the winding path back to the clinic, stopping in front of me wide-eyed and out of breath. He urgently explained that his disabled grandmother needed medications to control her diabetes, but no health workers reached their part of the island. I asked him if he could bring her to the clinic before we left, but he informed me she was too weak to make the hour-long journey to meet us. I desperately wanted to help, but we were short-staffed, facing a surge of patients and a setting sun. As the leader of the group, I was faced with an impossible decision: provide the medication without an examination or send the boy home empty-handed. I was forced to choose the latter.

Gabriel is one of 400 million people who lack access to health workers, and that number grows every day. In fact, it’s estimated that the world will face a shortage of 18 million health workers by 2030, meaning a shameful rise in stories like Gabriel’s.

Where someone lives should never determine if they live, but although illness is universal, healthcare isn’t. As a vocal advocate for UHC, I now focus on health workers, because without them, health doesn’t happen. Frontline health workers are the first and only point of contact for many marginalized populations, often facing unsafe conditions with limited training, equipment, and resources needed to perform their lifesaving duties.

Investing in health workers isn’t just a cost-effective solution (the UN Secretary-General’s Commission on Health Employment and Economic Growth estimates a 9 to 1 return on investment), it’s essential to achieving the Sustainable Development Goals (SDGs) — eliminating poverty, fueling economic growth, reducing gender inequalities, and saving millions from preventable diseases.

In many ways, Gabriel reminded me of myself. Just as I, one of the youngest team leads in VAW, was busy overseeing our clinic operations to ensure rural populations had access to lifesaving care, so was he, a compassionate nine-year-old, spending his day scouting medications for his family rather than, well, being a kid. But where healthcare is scarce, everyone, including our youngest, must step up to the plate.

Arush Lal asks a question during a plenary at the Fourth Global Forum on Human Resources for Health in Dublin, Ireland, Nov. 13–17, 2017. Image Credit: Frontline Health Workers Coalition

With the support of Global Health Corps and IntraHealth International, I recently attended the Fourth Global Forum on Human Resources for Health, convened by the World Health Organization and several partners in Dublin, as a youth delegate and panelist. Along with 1,000 policymakers and advocates, we discussed possible solutions to the health workforce crisis and the pivotal role young people play.

Over half the world’s population is under 30, and young people have woefully untapped potential as crucial advocates and partners in achieving UHC. Youth aren’t just the leaders of tomorrow; they’re leaders today, as young doctors, policymakers, and researchers. Bold, innovative, and visionary, my peers are making noteworthy advances in the way we pursue global public health. Youth must be empowered to push for greater accountability, stronger policies, and sounder investments to improve access to frontline health workers and resilient health systems. Without over three billion of us at the table, world leaders will continue to struggle achieving their global health targets.

Innovative Education

As the next health workforce, young people must be actively involved in planning their future, and we should push for academic programs that cultivate students who are well-versed in the SDGs and UHC. This includes expanding models like the UN Regional Centers of Expertise, one of which I recently helped create in Atlanta, to bring the global goals onto college campuses. Similarly, there is a need to create effective education programs, like an undergraduate degree in global health systems and technology I proposed at Georgia Tech, aligning interdisciplinary curriculum with the goal of achieving UHC.

Taking Action

Young people should work with local governments and NGOs as implementers in the fight for UHC, because youth are effective at reaching vulnerable populations. IntraHealth is a shining example of how to mobilize young people as frontline health workers. Through its CS4FP Plus program, IntraHealth has trained 92 youth ambassadors to lead family planning campaigns, featuring advocates like 16-year-old Nina Kone of Burkina Faso, who pushes for gender equality while de-stigmatizing sexual education, and Abou Diallo, who ensures that young people have access to contraceptives and reproductive health services in Guinea.

A Voice For Change

Few things are more effective than a passionate young person with a platform and a voice to cut through cynicism and question the status quo. Youth can and should advocate globally, ensuring governments commit to the policies they enact.

The Dublin Declaration and an accompanying Youth Call to Action are promising examples of youth engagement in UHC done right. For the first time, “youth” appears as a key stakeholder in the Dublin Declaration — and for good reason too. Youth perspectives are catalytic in achieving the SDGs, and our fluency in social media to push our messages far and wide make us an asset to governments trying to drive change. The first generation faced with climate change and an innately powerful imagination for new technology, we apply innovative solutions to health systems gaps, creating database and information systems, training health workers online, and improving telemedicine.

Young people: Be proactive and vocal advocates for change in achieving UHC, building relationships with diverse stakeholders and holding leaders accountable when they fail to deliver.

Established leaders: Engage youth more meaningfully, as key partners and not as an afterthought or disconnected silos. Mentor us, empower us, give us a platform.

For me, the story of Gabriel regularly reminds me of two truths we simply can’t ignore:

Emboldened youth today are our future — it’s time we start recognizing it.
Our world needs more health workers — it’s time we start showing it.

Improving Health Outcomes and Health Care Efficiency in Medtronic Disease States for Underserved Populations through Models of Innovation, Scale, and Sustainability

This blog post was written by our colleagues from Medtronic Foundation. Medtronic Foundation focuses on expanding access to healthcare for the underserved worldwide and supporting healthy communities where we live and give. Medtronic Foundation is a 2017 Global Health Council member.

The Medtronic Foundation focuses on expanding access to healthcare for the underserved worldwide and supporting healthy communities where they live and give. They enable this vision by developing and driving strategies focused on:

1) Global Health:
Improve health outcomes and health care efficiency in Medtronic disease states for underserved populations through models of innovation, scale, and sustainability;

2) Community Well-being: Advance flourishing communities where we live and work through good corporate citizenship and by addressing social determinants of health; and

3) Volunteer Engagement: Activate a global volunteer workforce of patients, employees, and retirees who contribute to achieving the United Nations Sustainable Development Goals.

Their work in global health involves brokering, supporting, and managing partnerships across nonprofit and government stakeholders to deliver a clear set of results and best practices that advance health outcomes particularly for noncommunicable diseases (NCDs) and efficiency for the underserved.

Snapshot of Their Global Health Signature Programs:  Re-Designing Healthcare Systems to Improve Outcomes

The Foundation’s three Signature Programs are positioned to deliver evidence via multi-year, multi-stakeholder, multi-country initiatives focused on working closely with communities to redesign how healthcare is delivered to improve health outcomes and sustain gains. All involve strong local partnership/government/patient participation, provide an opportunity to test novel healthcare system interactions, and include rigorous evaluation partnerships for publication and cross-sector learning:

1) HealthRise: Improve Detection, Management and Control of Cardiovascular Disease and Diabetes for Underserved. Needs assessments across geographies found significant barriers to care, including supply chain disruptions, and long distances to NCD diagnostics and monitoring, in addition to cultural and linguistic barriers. HealthRise interventions are now active in four countries, working to address locally relevant barriers. Common strategies include empowering patients and communities in self-management, care navigation and addressing social determinants; strengthening frontline health workers (including community health workers, community paramedics); and together with key stakeholders, advancing key policies to support people living with chronic diseases over the long-term. https://www.health-rise.org/

2) HeartRescue: Improve Acute Cardiovascular Disease Outcomes for the Underserved. multi-country collaborative program to improve sudden cardiac arrest (SCA) survival rates. HeartRescue partners work toward integrating community response efforts, coordinating public and professional education about acute cardiac events such as SCA and STEMI, and introducing and applying best practice treatments. The program also helps hospitals implement a method for measuring SCA and STEMI performance and outcomes. HeartRescue fosters local ownership of each country program by engaging multi-sector stakeholders, including governments, medical professional societies, local healthcare providers, patients, and families. http://www.heartrescueproject.com/

 3) RHD Action: RHD Action is a coalition of global organizations leading the global movement to reduce premature mortality from RHD and contribute to both Sustainable Development Goals 3 & 4, reducing premature mortality associated with non-communicable disease by one third, by 2030. The RHDA global partners are working together to establish a scientific and technical support community available to all countries, draw on this technical knowledge to advocate for policy change for better heart health, support and empower all people living with RHD and to foster multi-sectoral partnerships to support and sustain the global movement. http://rhdaction.org/

Envisioning the Future

Low-middle income countries are increasingly facing a dual burden of infectious and non-communicable diseases. In fact, rates of NCDs are rising at rates roughly three to four times faster in countries like Bangladesh and Ethiopia than they are in higher income countries like the US and UK. Health systems are fundamentally not set up to allocate funding for or adapt health systems to address these changing needs.

How can global health stakeholders come together with others in the community to unlock new resources and accelerate health outcomes for global health’s most pressing challenges? How can they creatively harness the talent and resources that already exist in countries to address the healthcare worker shortage? How can they ensure underserved patients and frontline health workers are involved meaningfully in health policy, financing, and delivery conversations? How can they design programs for sustainability, scale and measurable health outcomes from the start?

Looking ahead, as the global community races to achieve the Sustainable Development Goals — with a sharp eye on Universal Health Coverage (UHC) and meeting key NCD targets — the Foundation recognizes the importance of ensuring that health equity remains a core focus of their effort. Enabling health outcomes and efficiency requires that value-bashed healthcare be elevated, translated and understood in the context of organizations aiming to reach the underserved.

Interested in addressing these same questions too? Join Medtronic Foundation in continuing this conversation at the following event:

▪ Global NCD Alliance Forum: Dec. 9-11, 2017, Sharjah

http://www.medtronic.com/us-en/about/foundation.html