Geneva Health Forum Archive

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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, ICVolunteers.org

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 – PS23 – Research Networks in Partnership

Session outline

Parallel session PS23, Friday, September 1 2006, 14:00-15:30
Chair(s): Eduardo Gotuzzo, Peru, Dominique Sprumont, Switzerland
A Short Overview of the KFPE and an Introduction to the Session
Jon-Andri Lys, Commission for Research Partnership with Developing Countries, KFPE, Bern, Switzerland  
Marie Hirtle, Biotika Inc., Mont-Royal, Canada 
Research Ethics in Africa: Needs and Opportunities
Peter Ndumbe, Microbiology, Haematology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon 
Research Ethics in Africa: The Question of Resources 
Ogobara Doumbo, Professor, Malaria Research and Training Centre, University of Bamako, Mali

Session Document

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Session Report

Submitted by: Hassatou Conde (ICVolunteers); Contributors: Melissa Bonnefin (ICVolunteers)
Image: Jorge Garbino, ICVolunteers.org

Research is the basis of developing sustainable health care to communities. However, research must be conducted ethically and persons participating in medical research, especially in clinical drug trials, must be protected. This means that the many actors who participate in international collaborative research must apply the highest ethical standards. Universities and health training institutions must provide leadership in ensuring that research is conducted in an ethical manner.

Mr. Jon-Andri Lys of the Commission for Research Partnership with Developing Countries (KFPE) in Bern, Switzerland, opened the Symposium with a presentation of the KFPE. It is a collaborative effort of the four Swiss Scientific Academies and seeks to contribute to the sustainable development of developing and transition countries through the promotion of development-oriented research and the elaboration of research strategic concepts. Mr. Lys expounded Training and Resources in Research Ethics Evaluation (TRREE), a new partnership on ethics in research in Africa that will provide training in research ethics evaluation. It will specifically address the ethics of clinical trials conducted in Africa to help ethics committee members make sure that they comply with international ethical standards. Mr. Lys highlighted that creating partnerships and rendering them successful is a task in itself that requires specific steps to ensure success and equality amongst the partners. This is too often misunderstood or underestimated, leading in some cases to avoidable failures.

Mr. Marie Hirtle from Biotika Research and Consulting in Mont-Royal, Canada, then presented the TRREE project for Africa. TRREE is a project to expand what was intially a grass-roots-led effort to provide Canadian research ethics committee members with a flexible training program adapted to their specific needs. Today, TRREE includes international members from Canada, Europe and Africa.  Ms. Hirtle presented the efforts of TRREE, concentrating on the issue of protecting persons participating in research, especially in clinical drug trials. The many actors in international collaborative research must apply the highest ethical standards for research involving humans. However, many fail to apply these standards, while others, who do seek to apply them, find it difficult to ensure that these standards are applied in concrete situations. Mr. Hirtle sees the TRREE programme as an important strategy to ensure, partly through the development of a distance learning programme on research ethics, that research participant protection is improved and that the highest ethical standards are promoted in all international collaborative research.

Dr. Peter Ndumbe of the Department of Microbiology, Haematology and Infectious Diseases and the Faculty of Medicine and Biomedical Sciences at Yaoundé University, Cameroon, concluded the Symposium with a presentation on Research Ethics in Africa: Needs and Opportunities. Dr. Ndumbe concentrated on the fact that the development of health policy, as well as the teaching and practice of health sciences ought to be guided by evidence. Hence, the collection and validation of this evidence has to depend on methodologically and ethically acceptable standards. Often, the methodological issues are well respected, but ethical issues are too frequently neglected, both through ignorance and thorugh a sense that a good objective justifies the means. While it may be difficult to address ethical issues adequately in low-income countries such as Cameroon, they should not compromised.

In order to improve this situation, health training institutions should take the leadership and provide appropriate training has to be provided both to the teachers and to the students in this area. The Faculty of Medicine and Biomedical Sciences in Yaoundé has grappled with this issue for over 15 years. The major concerns that are encountered are the neglect of research in the daily decision making and the assumption that the provision of health services is inherently good and therefore cannot be challenged. Dr. Ndumbe concluded that training institutions must provide leadership in ensuring that research is conducted in an ethical manner.

The presentations were followed by a lively discussion chaired by Eduardo Gottuzo from Peru and Dominique Sprumont from Switzerland that focussed, amongst other issues, on the idea that ethical research should constitute the basis of health programs and that local communities also have a responsibility in this. Legislation will need to be improved to allow the creation of ethics committees. Assistance from high-income countries through programmes such as KFPE and TRREE can play an important role in this.

GHF2006 – PS20 – Gender, Sexual & Reproductive Health: Access Issues

Session outline

Parallel session 20, Friday, September 1 2006, 14:00-15:30
Chair(s): Mary Anne Burke, Switzerland, Priscilla Daniel, India
Microfinance and Health Intermediation 
K. Narendar, Chief Executive, DHAN Foundation, Madurai, India
Micro-credit Financing and Impact on Female Genital Mutilation
Berhane Ras-Work, NGO, Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, Geneva, Switzerland
Mainstreaming Gender-Based Analysis of the Women's Hospital of Costa Rica
Zully Moreno Chacón, Hospital of Costa Rica, San José, Costa Rica

Session Report

submitted by: Anne May (ICVolunteers)
Sudan, Garsila, Western Darfur. Preparations for a distribution of basic household items with support from Sudanese Red Crescent volunteers. Image: © ICRC/ T. Gassmann / 2004

The session addressed the various manners in which gender and social inequalities may negatively impact on population health and general wellbeing. It further looked at ways in which women can be empowered to allow them to develop a holistic approach to their specific health and other related needs. Examples showed that implementing gender-based analysis can produce profound changes in the treatment of women's specific problems.

Mr. K. Narendar, Chief Executive of the Development of Humane Action Foundation (DHAN), Madurai, India, presented the activities of his organization, which promotes improved health outcomes through microfinance intervention. To put his foundation's work into perspective, Mr. Narendar first reminded the audience that population health is strongly correlated with poverty. Microfinance programmes have emerged as one of the significant mechanisms to address the deep-rooted causes of poverty. There is a growing body of evidence showing that access to microfinance services is positively correlated with factors that have a positive impact on health, such as nutritional intake or contraceptive usage, he said.

The microfinance programme of the DHAN, through savings, credit and insurance, is aimed at developing appropriate savings that can be devoted to health care. Specifically targeted at women, it enables poor women to increase expenditure on the well-being of themselves and their children, which ultimately affects the health outcome at the family level. Mr. Narendar cautioned that such schemes are not appropriate to address higher health care needs, for which social security measures such as health insurance must be in place.

Mrs. Berhane Ras-Work, from the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) addressed the problem of female genital mutilation (FGM) in Africa. FGM is a widespread problem on the continent, affecting at least 28 countries. It is rooted in and nurtured by tradition, culture, religion, far-reaching misconceptions and socio-economic circumstances. All members of the community are participants in the continuation of this most brutal form of violence and governments tend to be silent, thereby justifying this violation of Human Rights, she said.

NGOs have played a key role in giving international recognition to gender inequality and violence. The IAC has initiated action and shown that it is possible to impact positive changes of attitude through the empowerment of women along two lines. First, by offering them micro-credits aimed at curbing their economic vulnerability. Indeed, women accept gender-based violence to ensure the security of their marriage and the survival it provides. Second, by giving them education and information to erase the misconceptions perpetuating the practice of FGM and to develop women's valuation of their bodies and health. In parallel, the IAC has embarked on a micro-credit scheme with excisers themselves, to help their conversion to other income-generating activities. Such schemes have already been successful in persuading excisers to stop their traditional practices.

Mrs. Berhane noted finally that such strategies should be further developed but that their success depended on accompanying, additional measures starting with strong political commitment and investment.

Mr. Manuel Carballo, from the International Centre for Migration and Health, Vernier, Switzerland, focused on the problems faced by migrants, an ever growing population worldwide. The migrant population was officially 195 million in 1995, but certainly amounted to three times that number when illegal migrants were taken into account. The health problems of migrants are a complex issue, combining pre-migration health profiles, diseases and health problems acquired during transit and newer ones acquired in the host country. Hence, care should be specifically tailored to the migrants' health profiles, a course which is undermined in times of increased socio-political resistance to migrants.

The nature of their health problems is only one element in all those undermining migrants' health, Mr. Carballo said. Access to health care for migrants is dependent on the availability of specific services adapted to their different psychosocial, cultural and linguistic backgrounds. The availability of such existing services should be known to the migrants, but this has been shown not to be the case in almost half of those migrants surveyed in Geneva. Such services should also be legally available, for example through a scheme of health insurance, and they should be affordable, taking into consideration the overall low income of migrants.

As migration continues to increase, Mr. Carballo concluded, medical insurance coverage which includes migrants, specific training of health personnel to handle multicultural differences and outreach to the migrant population for health promotion and disease prevention is more critical than ever.

Mrs. Zully Moreno Chacon, from the Hospital of Costa Rica in San José came with a concrete example of how gender-based analysis helped the transformation of the Women's hospital in Costa Rica from a traditional one to one working with women themselves to design tailor-made strategies addressing specific needs. The transformation was a far-reaching process involving strategic planning; revision of physical infrastructure, working processes and administration; space distribution; challenge of management structures; allocation of budgets; new practices and methodologies.

The key to the success of this initiative was to empower women in the process and to develop a holistic approach to their specific health and other related needs. Active participation was fostered by the creation of associations and a health network. Employees' training was carried out to improve the sensitivity of care for women.

Mrs. Moreno noted that implementing gender-based analysis produced profound changes in the treatment of women's specific problems and that female patients demonstrated a real appreciation of the new approaches and resources that were developed.

GHF2006 – LS02 – Access to Safe Healthcare

Session Outline

Lunch Session LS02, Friday, September 1 2006, 12:30-13:45
Chair(s): Didier Pittet, Switzerland, Liam Donaldson, UK
Patient Safety: A Global Challenge
Liam Donaldson, Chair of the WHO World Alliance for Patient Safety, Chief Medical Officer for England, UK 
The role of the Informed and Involved Patient in Access to Safe Healthcare: The Power of Partnerships
Susan Sheridan, Patient Safety, Consumers Advancing Patient Safety, Chicago, USA  
Access to Safe Care in Developing Countries
Stuart Whittaker, Research and Information, The Council for Health Service Accreditation of Southern Africa, Pinelands, South Africa 

Session Report

Contributors: Martin Elling (ICVolunteers), Marie Mac Gehee (ICVolunteers), Caroline Rheiner (ICVolunteers), Carissa Sahli (ICVolunteers)

The reality in many African countries is that patients may risk violence in hospitals, outdated x-ray machines, questionable hygienic standards. Image: Viola Krebs, ICVolunteers.org

The speakers stressed the importance of concentrating on system failures rather than individual mistakes and errors. This involves the setting of standards and the development of systematic improvement programs that are complemented with constant performance monitoring. The experience of other high-risk industries such as the aviation industry highlights the importance of sustained action over the long term. The symposium also dwelt on the importance of involving consumers in the reduction of patient hazards.

Sir Liam Donaldson, Chair of the WHO World Alliance for Patient Safety and Chief Medical Officer for England, opened the symposium with a presentation that focused on the assertion that patient safety could be greatly improved. Sir Liam highlighted the importance of putting patient safety first and that the health sector could learn a lot from the experience of other high-risk industries such as the aviation or nuclear industries.

The airline industry, for example, has greatly improved safety by not merely dealing with individual (pilot) mistakes, but by concentrating on failures in the overall system. This requires a broad approach that includes transforming the culture, attitude, leadership and working practices of everybody involved in the industry. It also involves a much more systematic monitoring and constant training of the professionals active in the sector. In this respect he favorably compared the constant checking and training of pilots with the existing situation in the health care system. According to Sir Liam, the health sector, by following the approach of the airline industry, could greatly improve patient safety and significantly reduce the risk to patients.

However, even in countries that have sought to address this issue for years, progress is slow and further systematic efforts need to be made. Another issue concerns the balancing of patient safety against financial objectives and the regrettable lack of public accountability of health care professionals when patient safety issues are concerned.

Subsequently, Ms. Suzan E. Sheridan, of the Patient Safety, Consumers Advancing Patient Safety, Chicago, USA, spoke about the role of local community involvement in improving patient safety. Ms Sheridan's involvement in this topic comes from her own family's dramatic experience with two serious medical system failures. Such failures can often be prevented by assuring that health care consumers and their care takers are actively involved in treatments, i.e. patients should not have to solely rely on health professionals. Ms. Sheridan challenged health care providers, institutions, organizations and agencies to recognize and embrace the value and power of partnerships in reshaping the future of healthcare so that it is safe, compassionate and just. In this context Ms Sheridan gave a poignant example of health services consumers' involvement, P.I.C.K. (parents of infants and children with Kernicterus). This initiative started some years with only eight Moms and is now a national campaign.

The last speaker was Mr. S. Whittaker of the Council for Health Service Accreditation of Southern Africa (Cohsasa) who spoke from the perspective of developing countries. Mr. Whittaker recognized the reality in many African countries patients are at risk as they have to deal with violence in hospitals, outdated x-ray machines, questionable hygienic standards, etc. It is a paradox that although staff is often serious, patients are still frequently put at risk

Cohsasa seeks to improve the situation by implementing its Wedge Model. The Wedge Model has a double approach. On the one hand, it implements a standard quality improvement program that aims at improving facility, clinical, management, clinical and non-clinical support and technical systems. Although there is good support for this in the hospitals, Cohsasa finds that in the provinces, where one has to deal often with demoralized staff, progress is difficult. On the other hand, Cohsasa monitors adverse events that aim at identifying and improving systems failures that impact on patient safety, while they are being improved by the standard improvement arm.

This two-pronged approach permits serious system failures to be identified and interventions prioritized to ensure that patient safety is maximized.

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, ICVolunteers.org

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 (http://www.mmv.org/rubrique.php3?id_rubrique=11).

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: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10%2E1371%2Fjournal%2Epmed%2E0030283.

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: http://mednet3.who.int/cft/.

Additional information can be found on the following websites: http://www.ifpma.org/pdf/IFPMA_counterfeit_conference_16Feb06.ppt#256,1 and http://www.who.int/bulletin/volumes/84/9/06-010906/en/index.html

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, ICVolontaires.org

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, ICVolunteers.org

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.



GHF2006 – PL03 – Public-Private Partnerships: Exploring the Framework

Session outline

Plenary session, Thursday, August 31 2006, 14:00-15:30
Chair(s): Louis J. Currat, Switzerland, Nick Drager, Switzerland
Health Impacts of Trade Agreements: A critical Reflection
Sisule F. Musungu, Acting Coordinator, Innovation, Access to Knowledge and Intellectual Property Programme (IAIPP), South Centre, Geneva, Switzerland
The Social Responsibility of the Private Sector and the Right to Health
Klaus Leisinger, Special Advisor on UN Global Compact to the UN Secretary General; Director, Novartis Foundation for Sustainable Development, Basel, Switzerland
Strengthening the Long-term Capacity of the Public Sector
Pascoal Mocumbi, European and Developing Countries Clinical Trial Partnership (EDCTP) High Representative, Mozambique
Public-Private Partnerships for Health
Roy Widdus, Global Health Futures Network, Geneva, Switzerland

Session Documents

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Session Report

Submitted by: Elise Magnenat (ICVolunteers); Contributors: Dr. Shibani Bandyopadhyay (ICVolonteers)
Image: Jorge Garbino, ICVolontaires.org

To tackle global health problems that disproportionately affect the poor, the skills and expertise of the private as well as the public sectors are needed; thus, Public and Private Partnerships (PPP's), which sharply increased in number between 1995 and 2005. As one of the speakers, Dr. Roy Widdus, said, "They can be seen as valuable 'social experiments' which achieve synergy through complementarity" and most of all "to which few, if any, realistic alternatives exist". The plenary session that took place this afternoon at the Geneva Forum comprehensively addressed the issues arising from PPPs.

Mr. S. F. Musungu is the Team Leader, Intellectual Property, Investment and Technology Transfer at the South Centre in Geneva. He is also Chairman of the Board of Directors of Health Action International - Africa (HAI Africa). Mr. Musungu, who has consulted for, and acted as an advisor to, various UN agencies, international organizations, non-governmental organizations and national governments, is the author of a number of publications and papers on intellectual property, trade, and human rights.

In his presentation about the health impacts of trade agreements, Mr. Musungu pointed out that in a globalized world; trade agreements have several health impacts. Indeed they are currently seen as the main framework for encouraging incentives as well as financing innovation in the health sector. They also provide a framework for the liberalization of health services and affect the provision of health-related services. Finally, they have a direct impact on pharmaceuticals and other health care products and equipment due to their role as tariff regulators. According to Mr. Musungu, PPP's are closely linked with trade agreements as they are shaped by them. However, even if PPP's can bring innovative solutions to health problems, they can also be the origin of public policy failure.

The speaker expressed his concerns about the current situation where there are no appropriate funding and incentive mechanisms for the creation of health products for the diseases that disproportionately affect developing countries. Moreover, even in cases where there are solutions, there is a tragic lack of access because of the absence of global mechanisms that seek to address the twin issues of innovation funding and access in an appropriate manner. Mr. Musungu then mentioned the World Health Assembly resolution 59.24, May 2006, which calls for the establishment of a global strategy and plan of action. He affirmed that this could be a critical opportunity to address the weaknesses and negative impacts of key trade agreements. But he concluded his presentation by posing the question to the healthcare community whether they would indeed be able to work towards this.

Professor K. M. Leisinger has been President and Chief Executive Officer of the Novartis Foundation for Sustainable Development since 2002. In 2005, he was appointed by the United Nations Secretary-General Kofi Annan as 'Special Advisor on the Global Compact'. In addition to these positions, he teaches and conducts research as Professor of Sociology at the University of Basel. He also serves as advisor to various national and international organizations dealing with sustainable development.

Prof. Leisinger's presentation raised the issue of corporate responsibility in the pharmaceutical industry and the right to health. Recognizing that responsible business can be part of the solution to the challenges of globalization, the Global Compact has been created to promote responsible corporate citizenship. In this way, the private sector - in partnership with other social actors - can help realize a more sustainable and inclusive global economy. Thus, Prof. Leisinger outlined various elements of an enlightened corporate business including organizing debates with other stakeholders, developing and implementing corporate guidelines and communicating with the public. He also emphasized the risks linked with corporate responsibility which are mainly due to the over-simplification of complex issues and the shift of national responsibilities away from the primary duty bearers, thereby providing an excuse to irresponsible governments.

Dr. P. Mocumbi was the Prime Minister of Mozambique from 1994 until 2004. He is representing the Medicines for Malaria Venture and is High Representative of the European and Developing Countries Clinical Trials Partnership (EDCTP). As a minister of health, he was responsible for the successful creation of the nurses' 'maternal-infantile health' basic level course and has wide experience of the role of the State in health provision.

Dr. Mocumbi's speech focused on strengthening the long-term capacity of the public sector. He reminded us that despite technical advances and repeated commitments from governments and international organizations, we are witnessing gross inequities across the world in the field of health and access to health. He insisted on the close relationship between poverty, security and access to health, declaring that "AIDS is a global security threat because of its impact on governance". Dr. Mocumbi went on to emphasize the challenges now facing the Public sector: financing of health systems, organization and structure of the healthcare system and finally human resources for health crises. All nations are expected to plan and lead the implementation of the basics: building health systems, providing affordable education and promoting gender equality and universal protection of human rights. Creativity and innovation are essential to find healthcare financing to address under-funded, poorly managed public health sectors. Additionally, exploring complementary financing to strengthen community participation and ownership could be seen as a key to improving health partnerships.

Dr. R. Widdus presently serves as Project Manager of the Initiative on Public-Private Partnership for Health at the Global Forum for Health Research. From 1995 to January 2000 he was Coordinator of the Secretariat to the Children's Vaccine Initiative. He has experience in a variety of work settings including research, teaching, biotechnology and pharmaceutical industries, and policy development for science and health in government and international agencies.

The term 'public-private partnership' (PPP) is applied to a diverse range of ventures designed to improve access of poor populations to particular health products or services, said Dr. Widdus. PPP's came into being to fill the gap left by independent actors, mostly due to market inefficiencies, lack of government resources in poorer countries and insufficiency of international aid. PPP's include many actors, all coming either from the public sector, civil society or the for-profit sector. Each of them has a specific role and benefit which needs to be clearly identified but many possible collaborative relationships can occur between public and private sectors. Therefore Dr. Widdus split PPP's into different categories with regards to their strategy. The three most relevant types are: product development partnerships, 'Access' partnerships and global coordination or funding mechanisms. The speaker insisted on the need to segment PPP's as a means to address the issue better and to find the most effective solution for each problem.

GHF2006 – PS18 – Access to Health for People with Disability:A Right or a Favour?

Session outline

Parallel session PS18, Friday, September 1 2006, 11:00-12:30
Chair(s): Félix Bollman, Switzerland, Pierre Perrin, Switzerland
Reduced Access to Health for People with Disability: An Overview of Causes for an Effective Environmental and Human Rights Approach
Patrick Fourgeyrollas, Institut de Réadaptation en Déficience Physique de Québec - IRDPQ, Québec, Canada 
Nicolas Heeren, Department of Programmes, Methods & Techniques, Handicap International, Lyon, France 
Giampietro Griffo, World Council member, Disabled Peoples International - DPI-Europe, Trentola-Ducenta, Italy 

Session Document

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Session Report

Submitted by: Stephanie Berry (ICVolunteers); Contributors: Irene Amodei (ICVolunteers)
"The key point is always to link actions with long-term development processes". Image: www.refugeecamp.org

Although the estimated 600 million people with disabilities have formally been recognized, in reality they are still often being overlooked and by no means enjoy the same rights as the rest of the world's population. The goal is to ensure that all people, disabled and able bodied alike, have the same access to all kinds of services in society, in particular health care.

The reason why the disabled are overlooked, claimed Dr. Patrick Fougeyrollas from the University of Laval, Canada, is that the definition of disability is often too narrow. Disabled people are not only those sitting in a wheelchair but also those who are disabled for language reasons or age. Indeed he emphasized that most people are disabled at some stage of their life, which is why it is particularly important to pay attention to the diverse forms in which disability appears.

Ignoring the less able members of society can have several implications, not only for the person concerned, but also for the people around him/her. It can produce secondary, mental disabilities. The person may feel angry or neglected, which makes them become a greater burden for others.

The goal of equal access, regardless of physical ability, can only be achieved if the barriers to equal access are identified and if people with disabilities are included in the planning of public policy and their demands are not overridden.

Dr. Giampiero Griffo from Disabled Peoples' International, Italy, affirmed that we have to adopt a Human Rights approach towards disabled people, without which it is impossible to ensure social inclusion and recognition. This means that disabled people are not to be treated any differently than others. They should be eligible to the same rights and have the same claim to self-determination. During the last week there has been a turning point on this issue. The United Nations (UN) has now finally officially recognized the need to provide more services for persons with disabilities and to work for their integration into society. The UN has affirmed that it will work for the promotion of respect for all disabled people, and in particular for disabled women because they are doubly discriminated against. Dr. Griffo concluded that this will become a reality only if eople with disabilities if they are not truly included in the process and can actively contribute to it: in fact, "nothing for us without us."

A participant from the floor voiced the concern that, although the UN has taken this first step towards an improvement of the situation, in many of the official organizations none of the people actually have disabilities and thus are not sensitive to the problems of those who do. A lot remains to be done in raising awareness about the issues that more vulnerable people face.

Mr. Nick A. Heeren, Former Director of Programmes, Methods & Techniques of Handicap International, France, gave practical examples both in development contexts and emergencies. He began his presentation posing two principal questions:

1) How to guarantee the right of access to aid and services during emergencies for people with disabilities and other extremely vulnerable individuals?

2) How to take into account people with disabilities before, during and after emergencies through anticipated action, direct action of specialized actors and creating "disability-confidence" among generalist emergency actors?

Disasters, wars and crises raise new challenges for all, but people with disabilities are disproportionately the victims of complex emergencies and more impacted by them, because their coping mechanisms are confronted with a new environment while their support system is also dramatically altered. During an emergency, people with disability become more "invisible" than they usually are, because they are excluded from the emergency registration systems; they face communication difficulties and misinterpretation of the situation and, often, they suffer from an inadequate physical accessibility, or lack of mobility aids; not to mention emotional distress and trauma which can have long-term consequences. In order to mitigate the impact of the crisis on people with disabilities, medical attention has to be combined with social and economic interventions, to build so-called "disability-confidence". According to Mr. Heeren, "People with disabilities need special attention, which doesn't only mean the attention of specialists. Disability is in fact a cross-cutting issue that requires a double track (generalist + specialist) and a right-based approach". Time is also an important variant that should be taken into account. "Before the crisis we need awareness and training; planning and risk-and-resource mapping for an efficient early warning system; as well as preparation of local actors and rescue teams by strengthening their capacity building. On the other hand, after the crisis, it is important to deliver disability services, promote partnerships with disabled people's organizations and set-up outreach work. The key point is always to link actions with long-term development processes".

The symposium gave an overview, not only of the issue of disability/diversity, but also of underlying social factors. Strongly defending the right to be different that is the difference to be right.



GHF2006 – PS17 Challenges in Long-Term Drug Delivery (HIV & TB)

Session Outline

Parallel session, Friday, September 1 2006, 11:00-12:30
Chair(s): Bernard Hirschel, Switzerland, Alexandra Calmy, Switzerland
Sustainable Financing and HIV, Malaria, TB Control
Michel Kazatchkine, Ambassador on HIV/AIDS and Transmissible Diseases; Director, National Agency for Research on AIDS, Paris, France 
Long-Term Challenges for ARV Programmes on the African Continent: Experience from Southern Africa 
Eric Goemaere, Médecins sans frontières (MSF) South Africa, Head of Mission, Cape Town, South Africa
The New Stop TB Strategy
Mario Raviglione, Stop TB Department, World Health Organization, Geneva, Switzerland 

Session Documents

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Session Report

Submitted by: Elise Magnenat (ICVolunteers); Contributors: Martin Elling (ICVolunteers), Milena Lawrence-Samuel (ICVolunteers), Tatjana Schwabe (ICVolunteers)
"TB control is a marathon, not a sprint!" Image: Viola Krebs, ICVolunteers.org

The three speakers of this session all emphasized the increasing negative impact of diseases like HIV/AIDS, tuberculosis (TB) and malaria on economic and social development in the world today. As Mr. Kazatchkine said: "The health sector [...] was originally seen as a non-profitable source of expenditure, is now considered as a factor and a necessary investment for development". Indeed, the benefits of preventing and treating HIV/AIDS, TB and malaria outweigh the costs caused by such diseases. Other topics discussed included sources of funding for treatment and prevention of these diseases, as well as problems in providing efficient health care for victims in the developing world.

Mr. Michel Kazatchkine, the French Ambassador for HIV/AIDS and Transmissible Diseases and the Director of the National Agency for Research on AIDS in France opened the symposium by reminding the audience that HIV, TB and malaria are "by far the leading causes of ill-health and premature death in Africa". Their impact on development had led to a shift in perception of health. Whereas formerly, health was seen as a consequence of development, it is today considered as a factor of economic growth. This observation has become particularly evident with AIDS which has been a catalyst to bring link between poverty and access to health on international agenda. Mr. Kazatchkine insisted that it was essential to shift financing from an emergency mode to building sustainability by drawing on national resources of affected countries as well as external funding. In the latter category, Official Development Aid (ODA) clearly represents the most important contribution, with a significant increase over the last years. However, the increase of money addressed to the health sector has been smaller compared to education or governance, although the number of people affected by disease is increasing and treatments, which need to evolve with the target disease, become more and more costly. Sustainability is also difficult to achieve because governments contribution to ODA is based on their national budget and changes yearly. Another source of external funding is what Mr. Kazatchkine called "Innovative sources of funding" such as debt conversion or the International Finance Facility for Immunisation (IFFIM), proposed by the International Financing Facility (IFF). He went on to present in more in detail the air ticket levy to fund the purchase of drugs against AIDS, Malaria and TB, introduced by five countries including France since July 2006. This new tax was instigated to raise money from people who benefit from globalization and to redistribute it to people who do not. The funds raised do not transit through France's national budget. Mr. Kazatchkine considered this project, together with other alternative initiatives, a necessary condition to fill in the huge financial gap for 2006.

Mr. Eric Goemaere of Médecins Sans Frontières (MSF) in South Africa provided a field perspective of long term challenges of anti-retroviral treatment (ARV) programmes against HIV/AIDS in Africa. The minimal objective of MSF is to offer an average of 10 years of survival treatment to AIDS victims. To attain these objectives, several issues have to be addressed. Firstly, Mr. Goemaere highlighted that the HIV/AIDS problem has no "quick fix", but is a long-term issue requiring long-term commitment from both the patients and care-givers. Although focus has been placed on prevention, this should not diminish the efforts to treat the millions of HIV/AIDS-diagnosed victims. Another concern is the financial cost of the HIV/AIDS treatment. For most of the HIV/AIDS infected people from developing countries, 40-60% of their income would have to be devoted exclusively to ARC treatments. As Mr. Bill Gates recently pointed out at the XIV International AIDS Conference in Toronto, "such a financial effort might not be sustainable if there is no improvement in the reduction of new infection rates", a sentence that could be interpreted as an early sign of donor's fatigue. There has been no major reduction in drug prices for the last two years despite enormous increases in drug consumption. Moreover, there is a need for cheaper and more user-friendly second line drugs, which are 5 times more expensive that first line drugs. The prerequisites for long term adherence to ARV treatment are free access to ARV, including user fees and collateral costs such as lab monitoring; peripheral rather than central approach; sufficient investment into human resources, in light of the recent high migration of nurses particularly to the UK and the USA; and counselling, community networking and peer support.

Some concern has been raised that "ARV programmes will pull away from the few resources available for primary health care service (PHCS) levels. Furthermore, the gap must be bridged between TB and HIV services, two obviously interlinked diseases. Mr. Goemaere stressed that broad health-care systems, patients, funding, and governments all have struggles that need fixing. He emphasized the current lack of strong political leaders, who have a key role as catalysts in changing public opinion and who should not be replaced by non-elected leaders.

Mr. Mario Raviglione, who represented the Stop TB initiative of the WHO based here in Geneva, focused his presentation exclusively on tuberculosis. He summarized the current burden of tuberculosis, a disease of poverty, whose control is a human right, a public good and a potential "quick-win" of the Millennium Development Goals (MDGs). Because TB is the biggest cause of death from a curable or preventable disease of today, Mr. Raviglione compared tuberculosis to "a SARS epidemic every day". Mr. Raviglione also stressed the link between TB and HIV/AIDS which are co-epidemics. TB is the first cause of HIV-related deaths in the world, causing more than 500,000 deaths per year. Moreover, the prevalence of multiple drug resistant (MDR) and extremely drug resistant (XDR) tuberculosis is on the rise. The economic impact of TB can be seen in both the macro- and micro-economic fields. Cost of diagnosis and treatment is a huge concern for those directly affected and the major funding is required for large-scale mobilization of health care (clinics, hospitals with adequate treatment). There is notably a loss in economic productivity due to the 1.7 million annual deaths caused by TB, with most of the victims being economically productive adults. The regions most affected by TB, and where effort must be focused in order to attain the MDGs, are Eastern Europe and particularly Africa. The 2005 World Health Assembly set the aim to detect at least 70% of infectious TB cases and to successfully treat at least 85% of the detected cases. Current worldwide figures are respectively 53% and 82%.

Mr. Raviglione presented the Stop TB initiative which aim at decreasing the global burden of tuberculosis by 2015 in line with the MDG and Stop TB Partnerships targets. The strategy includes the following main points: pursue and expand high quality DOTs; address TB/HIV-AIDS, MDR-TB and other challenges; contribute to health system strengthening; engage all care-providers; empower people with tuberculosis and communities; enable and promote research. He concluded, "TB control is a marathon, not a sprint!"