Geneva Health Forum Archive

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Improving Access to Healthcare Services through Leadership Development and Organisational Effectiveness: A Case study of Jharkhand state in India

Author(s): A. Kumar*1, K. Nayar2
Affiliation(s): 1Department of Rural Development, Xavier Institute of Social Service, Ranchi, 2Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Keywords: Health, access, health services delivery

Health status of population is one of the significant indicators of social and economic well being. Despite the government policy, programmes, effort and planning to improve the health services and make it accessible to all, we are not able to achieve those in last 60 years knowing the challenges and problems. Recognising this, the Government of India launched National Rural Health Mission (NRHM) in 2005 to expand the coverage of public health services. It also envisaged for developing infrastructure and enhancing the capacity of its people for the expansion of health services. But despite these efforts by the government to improve the health services and make it more accessible to poor, Jharkhand as one of the poorer states in India, continue to share a number of characteristics such as high infant mortality, low immunization of children and expectant mothers, high mortality due to infectious and contagious diseases, and high maternal mortality. These coupled with poor access to healthcare facilities and high costs of treatment by households have made all achievements in health sector look insignificant in the state.


Considering the challenges in strengthening the public health services and political economic conditions, the explanation of bad performance in terms of health access and services, the paper highlights and recommend a model and mechanism focusing leadership development and organisational effectiveness to improve health services delivery and access involving civil societies, local bodies and appropriateness of Public-Private-Partnership model in strengthening access of health services.


Major factors and hindrances behind access to health services are due to lack of leadership, team building, developing systems, non existing inter-sectoral linkages between different stake holders and involvement of local bodies.

Lessons learned:

Existence of services in terms of structure will never insure its utilization to fullest unless until there is proper channel between different stake holders which can link people to these services.

Making It Better: NZ GPs Improving Access to Elective Services and Bridging the Primary/Secondary Gap

Author(s): R. S. J. Gellatly*1, R. Naden1, c. Perry1, J. Palmer1
Affiliation(s): 1Elective Service team, Ministry of Health, Wellington, New Zealand
Keywords: GPs (general practitioners), primary/secondary interface, GP Liaisons, elective services

Ministry of Health committed to improving elective services waiting times from 1999.The idea of using GP Liaisons (GPs who liaise) to assist this work came from an article in the BMJ. Since the inception of the role, changes in the NZ health system such as District Health Boards being responsible for regional health needs (rather than a focus on hospital services only) and the implementation of the primary healthcare strategy require better communication across that interface.GPLs now have a broad range of activities in improving the patient journey across the primary/secondary interface.


The range of roles and activities of GPLs around the country will be described, in relation to various sized district health boards in urban and rural New Zealand. Examples of improvements in which GPLs have been involved will be detailed, such as triaging referrals, changing pathways to improve patient access, providing a primary care perspective in hospital settings. Opportunities for further collaboration and innovation will be highlighted.


Elective service access has been improved. One of the factors in this has been GP Liaisons. As hospital-based consultants and administration staff gain confidence working with GPLs, other areas for improvement are identified. These vary with the local areas needs. Primary care benefits from having a voice in the hospital and a recognised conduit for issues and ideas to be raised.

Lessons learned:

Building relationships based on improved outcomes has opened up communication across the primary/secondary interface. GPs have a combination of practical can-do attitude, experience of working in both primary and secondary care, and the ability to see the big picture in the complex system that is healthcare delivery. Supporting the GPL network is important for its success. GPLs use many tools gleaned from leaders in health. Having paid time in the day is also a success factor.

Crossroads of Inequality: Health of Elderly Populations and Access to Healthcare

Author(s): N. Chikhladze*1, N. Pitskhelauri2
Affiliation(s): 1Faculty of Medicine, Department of Public Health, 2Faculty of Medicine, Tbilisi State University, Georgia
Keywords: Inequality, access to healthcare, ageing

Increase of the elderly people number brings a sharp question of the main recourse. The mentioned situation creates serious problems for the society, because expenses, allocated for healthcare and social protection of the contingent is a hard burden to the country’s economy. The consequences of the economical crisis in Georgia have the most serious impact on persons over 60.


We have studies basic tendency of Georgian Population’s general structure, peculiarity of structure by sex and age, what determine demands of healthcare, trends of core health indicators, accessibility to healthcare.


In 1989 the Georgian population was at the medium level of demographic ageing (14.4%), during a very small period (5 years), in particular, in 1994 the index has reached level of ageing in developed countries (16.2%). From 2000 the very high level of ageing (18.4%) was evident and continuous to increase up till now. An absolute number of long livers goes up, their share in the population’s general structure is still high, and these tendencies are still the most prominent in indigenous Georgian population. In 1970-2006 population under 15 years was decreased by 1/3, from 31% to 21.5%, and share of the elderly population (65 and over) increased from 8% to 13%. Geriatric practice in older population increase risk of morbidity and polypathology. For the life of older population healthcare issues are very important. Interesting tendency is in the process of study of sex structure of 60-year and over age group. In 2006 this age group was constituted of women for 60%, 40% - men. With increase of the age interval, women’s share also increases. If in 60-64 year age group men were 43,21%, women 56,9%, in 100-year and over age group men were only 11,2%, women – 88,8%.
While the expenses on the social needs sharply shortened, the change of the ‘Soviet’ model of healthcare, which provided the population with free medical service for tens of years, took place. The new model of the healthcare payment was at first unacceptable both psychologically and economically. Persons over 60 have no means to buy neither expensive, nor cheap medicines, as well as different aid apparatus (hearing aid, glasses and other), it is absolutely inaccessible to purchase for them. Also it is inaccessible to get high quality out-patient and in-patient medical services.

Lessons learned:

Concerning the Caucasus long livers phenomena, Georgia even in the beginning of XXI century is the hearth of traditionally long liver population and reserves one of the leading places in the world twenty of long livers populations. This fact in spite of the difficult economic and social situation of transition period needs in-depth study-complex research of the Georgian long livers contingent, taking into account medical (especially Mental Health-Mild/Vascular Cognitive Impairment), social, economic, and psychological factor of their life.
It is necessary to carry out special measures to overcome poverty and eradicate extreme indigence through- out the country in the following directions: improvement of health policy and the system of access to healthcare for population under 60, reform of social security and the system of social assistance.

A Technology Enabled Social Enterprise to Increase Access and Quality of Rural Healthcare

Author(s): M. Gautham*1, S. Prashant1, M. Ganesan1, A. Jhunjhunwala1
Affiliation(s): 1Rural Technology Business Incubator, Indian Institute of Technology Madras, Chennai, India
Keywords: Rural health providers, social enterprise, Information Communication Technology

Only 20% of India’s medical professionals serve in rural areas where 70% of the population resides. The bulk of rural primary healthcare is delivered by private providers trained through informal apprenticeships, who do not have a statutory medical qualification. Innovative, scalable strategies are needed for further training and regulating these providers.


To describe how Information Communication Technology is used to reach out a blended learning package, supportive supervision, and other service support to rural healthcare providers (RHPs) in a pilot venture in rural Tamil Nadu.


19 village clinic based RHPs with diverse paramedical, alternate healthcare and vocational nursing backgrounds are included. 10 RHPs are linked to existing internet kiosks in their villages and 9 have invested in setting up their own kiosks. RHPs have been trained in basics of computer use and receive locally relevant distance learning modules in the local language, fortnightly. Tutorial support is provided by a Field Coordinator and content support by medical experts through video/audio conference links. Every module has an online self assessment. Currently the venture is developing modalities for RHPs to: purchase essential quality medicines (modern and indigenous) online; monitor and maintain computerized child and maternal health records; use online and mobile referral links; and use computerized multi-modal treatment guidelines as procedural aids for standardizing service quality. Future plans are to develop a franchisee based social enterprise.

Lessons learned:

RHPs have shown great interest and motivation in improving their skills and quality of services through this venture, and it will be possible to establish quality regulation and rational drug use in rural areas through this approach. Use of technology will enhance the scalability and replicability of the venture and also keep the running costs low.

Access to Insulin and Diabetes Care in Mali, Mozambique and Zambia

Author(s): D. H. Beran*1, J. S. Yudkin1, M. de Courten1
Affiliation(s): 1International Insulin Foundation, London, UK
Keywords: Diabetes, Sub-Saharan Africa, access, Latin America

Access to care of Type 1 diabetes in developing countries is often difficult due to various factors. The aim of this work was to identify what barriers exist and relate these to estimated life-expectancy.


A Rapid Assessment Protocol developed by the International Insulin Foundation was used to collect information from government organisations at central, regional and peripheral health units, as well as patients and their carers. Cross checking between different data sources was used to establish validity. Between 100 and 200 interviews/discussions were undertaken in each country.


The overall life-expectancy for a child (0-14) with Type 1 diabetes was 0.96 years in Mali, 3.5 years in Mozambique, 22 years in Nicaragua and 11.2 years in Zambia. Estimates of life-expectancy in Mozambique differed by around 6-fold between the capital city and the rural area, but these differences were only twofold in Zambia. In Mali it was estimated that 90% of the country’s known diabetic patients received care in the capital city. Insulin was available in sufficient amounts at the national level in all countries, but supplies to peripheral units were more variable. Most health units in Mali and Mozambique lacked any means of measuring blood or urine glucose, for diagnostic or monitoring purposes. Knowledge of Type 1 diabetes was poor among most health workers in these countries.

Lessons learned:

Type 1 diabetes is associated with poor outcomes in developing countries, particularly away from urban hospitals. Better outcomes were observed in Nicaragua and Zambia due to access to free insulin, health worker training and advocacy by diabetes associations. Improvements in healthcare systems, pharmaceutical supply, and health worker training are important to tackle Type 1 diabetes and will likely have an impact for other non-communicable and communicable diseases.

Do Global Funds Really Facilitate Access to Health?

Presenter(s): Lola Dare, Marcos Cueto, Wibulpolprasert Suwit
Chair(s): Elisabeth Fee, Bernardino Fantini
Author(s): Elisabeth Fee1, Bernardino Fantini2, Marcos Cueto3 Lola Dare4, Wibulpolprasert Suwit5
Affiliation(s): 1Chief, History of Medication Division, National Library of Medicine, USA, 2Director, History of Medicine and Health Institute, Faculty of Medicine, University of Geneva, Switzerland, 3Professor Principal, Universidad Peruana Cayetano Heredia, Peru, 4Executive Secretary, African Council for Sustainable Health Development, Nigeria, 5Ministry of Public Health Advisor, Ministry of Health, Thailand
Summary (max 100 words): Numerous international funds have been set up in recent times to address global health challenges such as HIV, TB and malaria, in an effort to provide sustainable funding for selected diseases affecting billions of people in the poorer regions of the world. Despite impressive investments in terms of money and stakeholders  involvement at national and international levels, enabling the scaling up of specific health initiatives, the collective impact of these initiatives has sometimes created or exacerbated problems such as the poor coordination or duplication of programmes, heavy burdens on local health practitioners, variable degrees of country ownership, and a lack of alignment with country systems. Relying on the establishment of inclusive partnerships, financial institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria do not take full responsibility for implementing funded programmes which require the active participation of partners in proposal development and realization (through Country Coordinating Mechanisms). One of the major reasons for the apparent ineffectiveness of global interventions is the historical weakness of the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds. What are the pros and cons of the global funds from different country perspectives? In theory, the global funds programmes are to be continued and sustained in the long term by the countries themselves. Is this a reasonable expectation? Is the money coming into the global funds programmes (from the donors and also the recipient countries) new money, or is it simply being shifted from one health programme to another? How can the funds best support equity, universal coverage, and sustained improvement in health systems? performance? What are the key steps needed to implement the Paris declaration, with its guiding principles of ownership, harmonisation, alignment, results, and mutual accountability? This round table session will debate the pros and cons of the ways the global funds work (or fail to work) in practice and try to answer the above questions.

GHF2006 – PS19 – How to Increase Access to Medical Information?

Session Outline

Parallel session PS19, Friday, September 1 2006, 11:00-12:30
Chair(s): Guy Olivier Segond, Switzerland, Antoine Geissbuhler, Switzerland
The iPath Project: Global Exchange of Medical Knowledge and Information Using Virtual Communities
Kurt Brauchli, Pathology, University of Basel, Basel, Switzerland
Hopes: Lessons from a Practical Example
Line Kleinebreil, Direction informatique, Hôpital européen Georges Pompidou, Paris, France
The Raft Network: Five Years of Distance Continuing Medical Education and Tele-Consultations via the Internet in French-Speaking Africa
Cheick Oumar Bagayoko, Informatique Médicale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
The Digital Solidarity Fund
Alain Clerc, Secretary-General, Digital Solidarity Fund, Switzerland

Session Documents

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Session Report

Submitted by: Jennie Hery-Jaona (ICVolunteers); Contributors: Lyne Calder (ICVolunteers)
Giving training not only on health care but also on the use of computers. Image: Jorge Garbino,

As part of the broad topic on how to provide equal access to health, this symposium discussed how tools such as telemedicine can increase access to medical information and contribute to the reduction of the global digital gap. According to Guy Olivier Segond, former president of the State Council of Geneva and President of the Executive Committee of the Digital Solidarity Fund, information technology (IT) remains a "key tool to access health and improve the effectiveness of health systems".

In this context the four speakers presented different pilot projects to illustrate how Information Communication Technology (ICT) has positively influenced health care in rural areas.

Mr. K. Brauchli, a Swiss biologist and computer specialist, described the iPath project of global exchange of medical knowledge and information with virtual communities. He used the case of the Solomon Islands with a population of 450,000 to illustrate the challenges brought by limited resources and the shortage of trained staff and infrastructure, which lead to the lack of access to diagnosis. In this context, the telepathology service, launched in 2001, has been a successful experiment with more than 1,500 users and handling over 9,000 cases to date. Health workers are a major resource and they need access, not merely to information in general, but specifically to relevant and up-to-date information, as well as training and guidance. Mr. Brauchli argued that the key aspects of telemedicine are "its potential for sustainable transfer of knowledge, quality control and immediate feedback; the capacity to foster communication within the health system; overcoming professional isolation and, most importantly, to reduce the brain drain effect and the promotion of South-South collaboration". Telemedicine is also "accountable and transparent", and remains a useful tool as an "archive of material for later review and reference". He concluded that telemedicine can effectively contribute to strengthening health systems, because it "supports diagnosis and is timely and accurate" with a 90-97% concordance with clinical relevancy.

The second presentation, given by Dr. Line Kleinebreil of the Hôpital Européen Georges Pompidou, described another programme linked with ICTs and also using telemedicine. Health Operations Programme through Education and Sentinel networking (HOPES), originally started by Cheik Modibo Diarra in Mali, aims to contribute to the achievement of the Millennium Development Goals (MDGs) through updating and increasing the availability of training for primary care professionals. In 2003, HOPES entered into a partnership with the Université Numérique Francophone Mondiale (UNFM) based in Paris and is now essentially a North-South programme. Established in Mali and Burkina Faso since 2005, this programme sets up multi-media classrooms to create dialogue between medical students and professionals. Most of the teaching takes place at the Hôpital Européen Georges Pompidou through satellite video-conferencing. Although this technology is not new in itself, Dr. Kleinebreil stressed the programme's innovation in being linked with African universities and in giving training not only on health care but also on the use of computers. Recorded courses are also available offline on DVDs which have apparently proved very popular. This is a powerful way to disseminate information. Through re-watching the conferences, medical students and professionals are given the opportunity to discuss and comment. The programme is free of charge except for a registration fee for exams. Concerned with sustainability, HOPES shares classrooms with enterprises and aims to increase public-private partnerships. The goal is for the African centre to become independent after three years and to extend the system to other areas.

Trained in medical informatics, Dr. Cheick O. Bagayoko from Mali introduced the Réseau en Afrique Francophone pour la Télémédecine (RAFT) project, a "network for eHealth in Africa" and a key strategy in developing South-South training and links. Launched in Bamako, Mali, in 2001 the network soon expanded to reach countries like Mauritania, Senegal, Tunisia, Morocco, Burkina Faso, Niger and Madagascar. The training's main characteristic is its hybrid aspect, which encompasses "dialogue between concerned experts, the development of skills, fieldwork, collaboration with other projects and evaluation". Dr. Bagayoko emphasized the importance of telemedicine as a tool against professional isolation, which tends to discourage doctors from practicing in remote villages, where they are most needed. An important aspect of the RAFT project is the fact that the South can also share its experience with the North. For instance, some courses on tropical medicine are transmitted from Mali to the University Hospital of Geneva. On the whole the success of the project is illustrated by the 122 courses which took place between 2003 and 2006, 30% of which have been given from the South. However, challenges remain with organizational and individual problems; linked with a need for field knowledge. Dr. Bagayoko concluded his presentation by raising the question of ethics: "Is the installation of antennas and thus transmission of information more important than access to clean water?". There is no easy answer.

Mr. Alain Clerc, of the Digital Solidarity Fund (DSF), urged the information society to create a network to combine the various smaller projects involved in the same field, relating specifically to ICTs. He stressed equality of access as the main focus for spreading information. The DSF, recently inaugurated in Geneva after the two World Summits on the Information Society in Geneva and Tunis, is an organization aimed at reducing the global digital divide. The figures concerning this digital divide are striking: in developing countries only 2% of the population has access to new technologies whereas over 80% of the population does in more developed countries. The structure of the Digital Solidarity Fund is new in that it not only involves governments but also civil society and the private sector. The Fund does not operate on the ground; rather it is concerned with finding funds for local projects. It is aiming to establish an innovative financing mechanism: obtaining 1% of the value of all digital and material transactions to invest in the 80% of the population without access to new technologies. Mr. Clerc stressed that the Fund finances local projects in order to have a direct effect on the rural population and therefore help decrease or prevent brain drain. He concluded with a call to companies and hospitals which are not already doing so to invest 1% of their transaction costs according to the Fund's guidelines.

Following the presentations, important questions such as how to deal with the high cost of satellites and how to reach self-sufficiency were raised. It was noted that there is the prospect of launching an African satellite and that self-sufficiency will be boosted by communication centres funding multisectorial projects and by initiatives such as the Digital Solidarity Fund sponsoring South-South collaboration.

In conclusion, this symposium discussed the importance of IT particularly through telemedicine, and of the need for equity in the information society in order to achieve knowledge and health access for all.

GHF2006 – LS01- Improving Access to Quality Medicines: Health Partnerships for the Developing World and the Fight against Counterfeiting

Session Outline

Lunch Session LS01, Wednesday, August 30 2006, 16:00-17:30
Chair(s): Eric Noehrenberg, International Federation of Pharmaceutical Manufacturers and Associations, Geneva, Switzerland
Anna Wang, Medicine for Malaria Venture, Geneva, Switzerland
Dirk Engels, Department of Neglected Diseases, World Health Organization, Geneva, Switzerland
Julian Morris, International Policy Network
Tesfamicael Ghebrehiwet, International Council of Nurses, Geneva, Switzerland

Session Report

Submitted by: Caroline Rheiner (ICVolunteers); Contributors: Martin Elling (ICVolunteers), Marie Mac Gehee (ICVolunteers), Tatjana Schwabe (ICVolunteers)

Image: Jorge Garbino,

The availability of quality and non-counterfeit drugs is an essential part of any health care delivery service. This session presented the audience with information related to the expansion of private-public partnerships (PPPs) for the development of safe drugs and of drugs for neglected diseases. The speakers also pointed out the danger of counterfeit drugs and the efforts undertaken to combat this serious and life threatening menace.

Dr. Eric Noehrenberg, Director, International Trade & Market Policy, Partnerships and Public Health Advocacy, of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), opened the symposium with a presentation on neglected diseases.

Dr. Noehrenberg reminded the audience that today, more than 65 million people are infected with HIV/AIDS and that 95% of them live in developing nations. Although 23 drugs have been developed since 1987, HIV/AIDS, TB and Malaria together kill more than 20,000 people each day. The research-based pharmaceutical industry has recognized the issue and has developed a business model with the following key elements:

Preferential pricing, such as "not-for-profit" pricing, and also major donation programs for drugs in well over 100 countries as well as community investment, in many countries. Commitment to innovative partnerships that include for example voluntary licensing granted for medication for HIV/AIDS or multi-drug resistant TB. IFPMA Members also promote research and development (R&D) into vaccines for neglected diseases through Public-Private Partnerships (PPPs). Today, an unprecedented level of research has been stimulated to develop badly needed new drugs for diseases such as Chagas' disease, African trypanosomiasis, onchocerciasis, leishmaniasis, schistosomiasis, leprosy, lymphatic filiriasis, Dengue fever, Guinea worm and blinding tracoma. According to the London School of Economics (LSE), the PPP model is working and the landscape of R&D into these diseases has been transformed. Today, there are already 63 new drug projects for neglected diseases, excluding HIV/AIDS.

Dr. Noehrenberg concluded that PPPs are successful but require additional resources. Well funded PPPs can bring the expertise of a range of partners together and create an innovative environment well beyond what individual partners would be capable of alone.

Ms. Anna Wang of the Medicine for Malaria Venture (MMV) addressed the positive impact PPPs can have on the fight against malaria. For example, MMV's mission is to discover, develop and deliver safe, effective and affordable anti-malaria drugs. Other PPPs can also play a catalytic and innovative role in the development of affordable drugs. For most local communities, the biggest obstacle is not the lacunae of medication, but political commitment and funding. The pooling of collective knowledge, talent and resources can improve the situation and consequently save millions of lives (

Dr. Dirk Engels, from the Department of Neglected Diseases at the WHO, explained how the best applicable tools for use in the field were those that were simple to detect and administer, and that were cheap and safe. Drugs for most neglected diseases were increasingly available through public-private partnerships, access programmes and donations from pharmaceutical companies and generics but that certain diseases, such as leishmaniasis, African trypanosomiasis, and the bureli ulcer were still lagging behind due to increased drug resistance and the cost or complexity of diagnosing and treating these illnesses. The key to treating neglected diseases lies in a long-term commitment by all stakeholders, especially governments, and through mass interventions like vaccination campaigns, community directed care and door-to-door interventions. This also implies sustained funding and breaking the cycle of insufficient generic production which was caused the lack of market opportunities for this group of diseases. Supplementary information on this subject by Dr. Engels and his colleagues can be found at the following website:

The symposium continued with a presentation by Dr. Julian Morris from the International Policy Network on the dangers posed by counterfeit medicines. Counterfeit medicines are a n important and growing threat to patients' safety. This problem is not restricted to lower income countries, although it is more pronounced there: the percentage of counterfeit and substandard drugs can reach 25% in low and middle income countries (and even 40% in certain Chinese cities). The impact is devastating. For example, the WHO reported that in 1995 more than 2,500 deaths were caused by counterfeit meningitis vaccines. Other risks concern the hazard of increased drug resistance and the increased cost of treatment. A trend is for local communities to return to their traditional medicines as they lose faith in modern drugs.

Dr. Tesfamicael Ghebrehiwet, Consultant, Nursing & Health Policy of the International Council of Nurses (ICN) in Geneva, Switzerland, made a presentation on ICN's efforts to raise awareness of the dangers of counterfeiting in many countries. The ICN takes this issue very seriously. As nurses are the largest group of health care providers who, in addition, are also close to the patient, they are often the first to recognize treatment failure.

It is clear that there is an urgent need to raise public awareness regarding the dangers of counterfeit drugs. This will not only require the education of the general public and the dissemination of information, but will also include the lobbying for fair prices for authorized drugs and the monitoring and reporting of the occurrence of counterfeit drugs. Dr. Ghebrehiwet proposed greater collaboration between a wide range of technical and law-enforcement agencies including the International Federation of Pharmaceutical Manufactures and Associations (IFPMA), Population Services International (PSI) in Washington, the International Alliance of Patients' Organization (IAPO), Interpol and the World Health Professions Alliance (WHPA).

Dr. Eric Noehrenberg, wrapped up the presentations by stating that the IFPMA was working in collaboration with the WHO in order to raise awareness among policy makers, criminalize the production and distribution of counterfeit goods, allocate greater resources to curb the threat caused by such deleterious activities, tighten the screening and control of the supply chain, and increase interdisciplinary and international collaboration in the sustained fight against piracy, which has become a "public health emergency". IFPMA is collaborating with WHO in the IMPACT (International Medical Products Anti-counterfeiting Task Force) initiative and co-sponsored an international meeting in Rome to launch IMPACT. Details can be found at the WHO web site:

Additional information can be found on the following websites:,1 and

GHF2006 – PS01 – Do Global Funds Really Facilitate Access to Health?

Session outline

Parallel session PS01, Wednesday, August 30 2006, 16:00-17:30, Room 3
Chair(s): Elisabeth Fee, Chief, History of Medication Division, National Library of Medicine, USA, Bernardino Fantini, Director, History of Medicine and Health Institute, Faculty of Medicine, University of Geneva, Switzerland
Summary: Numerous international funds have been set up in recent times to address global health challenges such as HIV, TB and malaria, in an effort to provide sustainable funding for selected diseases affecting billions of people in the poorer regions of the world. Despite impressive investments in terms of money and stakeholders' involvement at national and international levels, enabling the scaling up of specific health initiatives, the collective impact of these initiatives has sometimes created or exacerbated problems such as the poor coordination or duplication of programmes, heavy burdens on local health practitioners, variable degrees of country ownership, and a lack of alignment with country systems. Relying on the establishment of inclusive partnerships, financial institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria do not take full responsibility for implementing funded programmes which require the active participation of partners in proposal development and realization (through Country Coordinating Mechanisms). One of the major reasons for the apparent ineffectiveness of global interventions is the historical weakness of the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds.

  • What are the pros and cons of the global funds from different country perspectives?
  • In theory, the global funds programmes are to be continued and sustained in the long term by the countries themselves. Is this a reasonable expectation?
  • Is the money coming into the global funds? programmes (from the donors and also the recipient countries) new money, or is it simply being shifted from one health programme to another?
  • How can the funds best support equity, universal coverage, and sustained improvement in health systems? performance?
  • What are the key steps needed to implement the Paris declaration, with its guiding principles of ownership, harmonisation, alignment, results, and mutual accountability?

This round table session will debate the pros and cons of the ways the global funds work (or fail to work) in practice and try to answer the above questions.

 Panelist 1: Lola Dare, Executive Secretary, African Council for Sustainable Health Development, Nigeria
 Panelist 2: Marcos Cueto, Professor Principal, Universidad Peruana Cayetano Heredia, Peru
 Panelist 3: Suwit Wibulpolprasert, Ministry of Public Health Advisor, Ministry of Health, Thailand

Session report

Submitted by: Hassatou Conde (ICVolunteers); Contributors: Elise Magnenat (ICVolunteers)

Image: Viola Krebs,

On the first day of the Geneva Health Forum, a roundtable took place on the subject of the efficiency of Global Funds in improving access to health for populations. The participants took a historical perspective on the efficiency of Global Funds programmes and recognized the importance of ensuring that all stake holders, including patients, community leaders and contributors to the fund, participate in its negotiation. "Global partnerships are increasing but results are missing", said Dr. Cueto, first panellist of the Symposium on Global Funds and Access to Health. The debate focused on the gap between the increasing number of global initiatives and expectations of local populations.

Dr. Marcos Cueto is a historian and a professor at the School of Public Health of the Universidad Peruana Cayetano-Heredia in Lima, Perú. His main focuses are the history of epidemic diseases and of public health in Latin America.

Dr. Cueto brought a historical perspective of international health in Latin America and discussed the Global Fund to Fight AIDS, Tuberculosis and Malaria. According to Dr. Cueto, a historical approach is essential for a better understanding of the present public health challenges. Dr. Cueto took the example of Malaria Eradication Campaigns and Primary Health Care Programmes set up during the 1950s and the 1970s in Latin America. He pointed out several drawbacks and shortcomings of the methods used, mostly related to the lack of communication between the major stakeholders and to the absence of adoption of the programmes by local actors. Most people in Least Developed Countries (LDCs) do not really see health system reforms as essential, he said, and this leads to misunderstanding between these populations and the decision takers.

Concerning the Global Fund fight against AIDS, Tuberculosis and Malaria, he noticed that the resources invested in this initiative are important and have a positive impact and he confirmed that the Global Fund represents a great opportunity for LDCs. But the question is: "Are we ready to catch this golden opportunity?"

Dr. Lola Dare, a community physician and medical epidemiologist from Nigeria, was the second panellist. In 2001 she was given an award by the African Regional Office of the World Health Organization for the 'Oriade Initiative', which aims to identify culturally sensitive and adaptive mechanisms for community co-financing and management.

Dr. Dare had a more critical perspective, highlighting the numerous constraints that Global Health Initiatives have to deal with, often leading to an absence of concrete results. Global Health Initiatives have been in existence since colonial times, but although "the goals change, the main issue of inequality in access to health remains", explained Dr. Dare. Hence, there seems to be a real problem as regards equality of access to health, as well as the increase in the number of initiatives.

Dr. Dare balanced her criticism by noting that the increase in Global Funds have also brought benefits, although often the receivers of the funds, local populations, are not always in a position to take advantage of them due to a lack of coordination.

Both panellists were in agreement on the question of the preparedness of countries to receive Global Funds and the necessity to align the objectives and programmes of Global Funds with country's priorities, policies and fiscal capabilities.

The participants of the Symposium agreed that one of the key goals for effective use of the Global Funds is to ensure access to health for local populations. Hence it is important that all stake holders participate in negotiations, including patients, community leaders and the contributors to Global Funds.

GHF2006 – PL06 – Global Access to Health: An Agenda for the Future

Session outline

Plenary session PL06, Friday, September 1 2006, 16:00-17:45
Chair(s): Marcel Tanner, Swiss Tropical Institute, Switzerland
An Agenda for Sustainable Development in Health
Hassan Mshinda, Ifakara Health Research & Development Centre, Tanzania
Partnerships to Promote Global Public Health Security
David L. Heymann, Representative of the Director-General for Polio Eradication, World Health Organization, Switzerland
Access: Opportunities and Challenges
Ruth Dreifuss, Switzerland
Is Health a Commodity?
 Mr. Alok N. Mukhopadhyay,  Voluntary Health Association of India
Role and Responsibility of Academic Institutions
 Bruno Grijseel, Institute of Tropical Medicine, Antwerp, Belgium
Conclusion to the 2006 Edition of the Geneva Health Forum
Marcel Tanner, Swiss Tropical Institute, Switzerland
Closing Remarks
Claude Lecoultre and Louis Loutan, Geneva University Hospitals and Faculty of Medicine, Switzerland

Session Report

Submitted by: Jean-Pierre Joly (ICVolunteers); Contributors: Asta Lim (ICVolunteers)
Image: Jorge Garbino,

The final plenary session of the "Geneva Forum: Towards Global Access to Health" was dedicated to summarizing the key issues which emerged during the three days of discussion and exchange and to formulate suggestions on how to develop these issues in the future. The final plenary was also a moment to thank all the contributors of the Forum for their effort and participation.

The first speaker, Dr. Hassan Mshinda, Head of the Ifakara Health Research & Development Centre in Tanzania, stressed that previous health initiatives have concentrated on aspects such as equity, participation, and multi-sector and comprehensive healthcare. However, Dr. Mshinda urged that as an increasing number of actors are becoming involved, and a greater pressure is put on immediate results.

According to Dr. Mshinda, there is a clear need for an agenda in order to achieve sustainable development of health. The Paris Declaration on Aid Effectiveness set out the principles for doing a better job in delivering and managing aid. Global Health Initiatives have their merits, but it remains indispensable that countries strengthen their national health systems, because this is the key to improving access to health care, said Dr. Mshinda. In any case, such initiatives will eventually have to be absorbed by governments' health systems.

National governments have a key role to play and it is their responsibility to have a long term strategy for sustainable development of health care systems. Long term commitments from partners, as well as monitoring and audit tools could certainly enhance this process. Dr. Mshinda said that the challenge of Global Health Initiatives is to realize their integration at the global, national and regional levels. To create the necessary interaction between those different levels, there is a need to establish even more contractual partnerships.

Dr. David Heymann, Executive Director, Communicable Diseases, of the World Health Organization (WHO), spoke about the role of partnerships in promoting health security, emphasizing the global character of health problems and, more specifically, the security issues related to infectious diseases. He said that while new infectious diseases are appearing, more worrying is that infections such as cholera and yellow fever, which were thought to have been eradicated, are re-emerging. Analysis shows that increased international travel has stimulated the worldwide spread of some diseases, such as SARS and malaria. While malaria is not contagious, it does get transported through mosquitoes to areas where it normally does not occur. As a result, these diseases occur far from their original source.

The spread of numerous infectious diseases is closely linked to animals and insects. The movement of animals to market is a key factor in spreading infectious diseases to other locations, especially when cattle is not vaccinated. Other diseases can be transmitted through international trade in agricultural products as in the case of Creutzfeltd-Jacob disease. Dr. Heymann reminded the audience that there is always a risk of existing viruses mutating and creating new pandemics.

Will non-immunized humans serve as an intermediate host in the transmission of diseases? The framework for International Health Regulations has been improved and updated on an ongoing basis since 1947, said Dr. Heymann. The WHO receives inputs from 110 different networks around the world, whose task it is to collect data and to continuously monitor the development of diseases in their region. The WHO reacts to information gathered through the Global Outbreak Alert and Response Network (GOARN).

Distribution of information and education related to infectious diseases still rests on weak ground in developing countries, claimed Dr. Heymann. In this context, it is not surprising that the three diseases with the highest death toll, TB, malaria and HIV/AIDS continue their expansion in sub-Saharan countries. He highlighted the staggering negative economic impact of those diseases by giving one example: GDP in sub-Saharan Africa would have been 100 billion USD higher in 2000 if malaria had been eradicated 35 years ago.

Only systematic partnerships between developed and developing countries will enable significant changes to present trends, stated Dr. Heymann. Those partnerships should focus on four areas: research and development, access to vaccines, prevention, and monitoring. The WHO clearly places health at the centre of development, because it is essential for sustainable economic growth. Although the WHO has a role to play and global partnerships have been expanding, the rolling back of infectious diseases is primarily a matter of high level political commitment in developing countries themselves. The declines in HIV/AIDS in Uganda and of TB in Peru are examples of such commitment.

Ms. Ruth Dreifuss, former President of Switzerland, drew attention to the underlying political issues of the topics discussed during this Forum. These include the interdependence between the North and the South, the search for new medicines, the outcome of the World Trade Organization (WTO) summit at Doha, pandemics, and so on. In this context, she underscored the important role of NGOs in raising public awareness and the necessity of forming partnerships between the public and private sectors, while it should remain the responsibility of governments to provide the engine for the process.

Ms. Dreifuss further stressed the importance of the recommendations and conclusions of the Commission on Intellectual Property Rights, Innovation and Public Health, which she had chaired at the World Health Assembly (WHA) and the report of which has recently been completed. Three concepts surfaced in connection with vaccines and medicines in general: availability, acceptability and accessibility. The commission's major conclusions were that present efforts are not sufficient to assure the continuity of existing programmes; the generosity of the private sector should not be a substitute for the public sector spending; and a global action plan is essential for meeting the public's health needs. In order to stop the current stagnation, the speaker proposed four levels of intervention. First, structuring health care to avoid competition between private and public sectors. Secondly, training health workers and seeking to prevent their exodus to rich countries. Thirdly, focusing on vulnerable and marginalized groups such as children and women. And finally, to seek innovation in the pharmaceutical sector and promote the use of generic drugs.

The next speaker, Mr. Alok N. Mukhopadhyay, C.E.O. of the Voluntary Health Association of India, stressed the interdependence of economy and public health. "Health is not an expense but an investment for governments", he continued. All people want to live healthily and have a basic right to claim the conditions to create and maintain their health. A vital question for the speaker was whether health had to be offered as a commodity in the marketplace. He pointed out that more spirituality was needed. In this context, Mr. Mukhopadhyay quoted Mahatma Gandhi's view that "the world has enough for everyone's needs but not for everyone's greed". He concluded by stressing the lack of dialogue between the different medical and health care systems and the difficulties in attracting workers and experts to public health care.

The final speaker, Professor Bruno Grijseels from the Prince Leopold Institute of Tropical Medicine in Antwerp, highlighted the role and responsibility of academic institutions. Academics and scientists could learn from taking a holistic approach to global health problems instead of focusing on isolated research problems. Access to quality healthcare is a real challenge which can only be won by establishing partnerships, he said. Scientists have the responsibility not to lose sight of reality and to develop systems which can be implemented for the benefit of the public.

In her closing remarks, Professor Le Coultre, Membre of the Forum Organizing Committee and Vice-Dean of the Faculty of Medecine of the University of Geneva, commended the quality of interaction and idea-sharing at the Geneva Forum. She mentioned that this Forum had been a starting point, called for feedback from the participants and promised additional efforts to bring more people from the developing world to the next Global Health Forum.

Dr. Louis Loutan, President of the Forum Organizing Committee and the Geneva University Hospitals, thanked the organizing team, the advisory board, the Forum participants, the sponsors and the volunteers --there were over 60 involved in the conference-- for their contribution to this first edition of the event. He closed the Forum by inviting participants to use the conference web site's feedback form to share their impressions in view of a next edition of the event.