Geneva Health Forum Archive

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GHF2006 – PS16 – Managing International Mobility of Health Professionals

Session Outline

Parallel Session, Friday, September 1 2006, 11:00-12:30
Chair(s): Manuel Dayrit, Switzerland, Peter Suter, Switzerland
Lola Dare, Exectuvie Secretary, African Council for Sustainable Health Development, Nigeria 
Nurses on the Move: International Nurse Migration
Mireille Kingma, Consultant, Nursing and Health Policy, International Council of Nurses, Geneva, Switzerland
Opportunity Knocking: Exploiting e-Health for Global Health Human Ressources Planning
Kendall Ho, Continuing Professional Development & Knowledge Translation, University of British Columbia, Vancouver, Canada

Session Document

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Session Report

Contributors: Melissa Bonnefin (ICVolunteers), Robert Strange (ICVolunteers)

Sudan, Zalingei-Garsila road, Darfur. Relief convoy. Image: © ICRC/ T. Gassmann

The global phenomena of massive migration of health professionals and the advent of e-Health solutions are evidence of the fact that significant trends in health are no longer regional. Worldwide, doctors, nurses and ancillary staff are increasingly seeking better prospects for themselves, not only in the northern economic powerhouses but also in developing countries. However, a severe lack of knowledge-sharing mechanisms and appropriate funding has meant that patients and health professionals in poor countries are still denied the opportunity to benefit from pioneering e-Health programmes now being developed in countries such as the UK and Canada.

Ms. Lola Dare from Nigeria, representing the African Council for Sustainable Health Development, referred to the work of the Global Stakeholder Alliance and the African Platform, as she emphasised that srategic responses to migration involving local stakeholders are essential to ease the burden on poorer countries of the brain drain of qualified health workers. In a similar vein, Ms. Mireille Kingma of the International Council of Nurses (ICN) in Switzerland stressed the importance of the ICN's nurse-specific reports, both in supporting individual nurses who elect to migrate and in devising measures to combat the shortfall in skilled professionals in both rich and developing nations.

The negative effect of the skills gap on the health services of countries in Africa and South-East Asia is acute. But, as Ms. Dare illustrated, budget caps imposed by international monetary institutions are critically hampering the attempts to redress the balance. In Nigeria, for example, it is estimated that current spending on health sector wages would need to increase almost four-fold, to 8.7 million dollars, in order to reach the minimum health-worker to patient threshold advocated by international experts. This is of particular importance in terms of a nation's health, since there is a direct correlation between incidence of disease and the patient to health professional ratio.

Aside from monetary concerns, both Ms. Dare and Ms. Kingma highlighted the importance of addressing the wider issues constituting the "push factor" behind the decision of professionals to migrate. Studies have revealed that improvements in working conditions, greater job satisfaction and patriotism can be key in persuading them to remain in their countries of origin. It is also important to ensure that the right type of human resource policies are in place, so that "anchor effects" can stem the migratory tide. As Ms. Kingma explained, a policy of retaining older nurses while denying employment prospects to newly qualified professionals has caused high nurse unemployment in certain African countries.

Facing such prospects, and given other contributory factors, it is hardly surprising that large numbers of health professionals choose to chance their hand abroad. Their right to professional mobility should not be denied, not only due to  the advantages migration may bring to them as individuals and to their new host countries, but also in view of the indirect benefits which almost always accrue in the supplier countries.

While the latter point might seem counter-intuitive, it is not only host countries which gain from the global movement of health personnel. Nurses who have spent a period abroad are able to apply their increased expertise to their work if and when they choose to return to their native countries. More importantly perhaps, remittances sent home amount to a total of 225 billion dollars, more than the sum of all the world development aid budgets.

Given the precarious state of health infrastructures in many poor countries, it would appear that their citizens and health professionals are unlikely to benefit in the near future from the breakthroughs in e-Health. However, as Dr. Kendall Ho from the University of British Columbia in Vancouver, Canada emphasised, with the appropriate investment in new technologies and with improved access to knowledge, it would be feasible for the benefits brought by e-Health to "underserved populations" in outlying areas of British Columbia (Canada) to be replicated even in poor parts of the globe.

Health informatics and e-learning can be effective tools in providing support to doctors in rural areas and also to patients in urban environments, for example in post-operation situations. As long as appropriate networks are established and the necessary resources are put in place, the capacity of e-Health to bridge geographical gaps could become a key factor in improving access to health and support to health professionals in poor countries. Dr. Ho highlighted the urgent need for "global debate" on e-Health.

It is vital that human resource policies are adapted to take account of the new global realities. Appropriate support should be provided for workers choosing to exercise their right to professional mobility, while funding and other strategic issues clearly need to be revisited in order to alleviate the crisis situation faced by health services in many poorer countries. The debate should now focus on the full complexity of the issue, including advantages for supplier countries and non-financial measures geared to retaining health professionals. Furthermore, we must grasp this opportunity to share knowledge and transfer technology so that patients and health professionals in developing countries are not excluded from the e-Health revolution in the rich nations that is beginning to deliver on access and quality.



GHF2006 – PS15 – Disease Control Programmes: Undermining Comprehensive Care?

Session Outline

Parallel session PS15, Friday, September 1 2006, 11:00-12:30
Chair(s): Malcolm Segall, UK, Monique Van Dormael, Belgium
Consequences of International Funding for Universal Access to Health: The Case of Tanzania
Bergis Schmidt Ehry, Deutsche Gesellschaft fuer Technische Zusammenarbeit, GTZ, Tanzania 
Integrated Service Delivery and Increased Immunization Outputs: The Case of Uganda
Sam Zaramba, Director General of Health Services Uganda

Session Document

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GHF2006 – PL05 – Global Gaps in Research, Capacity Building and Human Resources

Session Outline

Plenary session, Friday, September 1 2006, 9:00-10:30
Chair(s): Jean-Louis Carpentier, Switzerland, Tikki Pang, Switzerland
Putting Research Evidence into Practice
Nirmal Kumar Ganguly, Director General, Indian Council of Medical Research, New Delhi, India  
Manuel Dayrit, Human Resources for Health, World Health Organization, Geneva, Switzerland   
Towards Improving Transparency in Clinical Trials
Odette Morin, Director, Regulatory and scientific Affairs, International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), Geneva, Switzerland
Can Research Make a Difference in Global Access to Health?
Stephen A. Matlin, Executive Director, Global Forum for Health Research, Geneva, Switzerland 

Session Documents

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Session Report

Submitted by: Anne May (ICVolunteers)

Image: Dominic Monnier

Plenary V addressed the current challenges and conditions for effective capacity building in the health workforce as well as medical research to improve health and give access to health care in developing countries.

Dr. Manuel Dayrit, of Human Resources for Health at World Health Organization (WHO), discussed the current challenges and conditions for effective capacity building in the health workforce. Although Mr. Dayrit's focus was on human resources for health, he insisted throughout his presentation on the fact that capacity building was constantly taking place in a much broader context of socioeconomic and political circumstances, institutions, and involved many actors from different horizons. Hence, it is essential, in order to be effective, that capacity building be systemic. However, failure to address the capacity constraints (political, institutional) limiting the achievement of overall capacity building project objectives has repeatedly been shown.

Mr. Dayrit defined "capacity building" as "a process by which individuals, groups, institutions, organizations and societies enhance their abilities to identify and meet development challenges in a sustainable manner." As set forth by WHO's late Director General, Dr. Lee Jong-wook, the ultimate goal of capacity building is "to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere."

The health workforce, Mr. Dayrit noted, must be understood as "all people engaged in actions whose primary intent is to enhance health," not only doctors and nurses, but also such diverse professionals as economists, drivers, cooks, etc.

Mr. Dayrit, provided various illustrations of the strong positive correlation observed worldwide between the proportion of health workers in the population and population's health measured by various indicators. The latest WHO World Health Report (2006) provides ample evidence supporting the view that shortages of health workers in certain areas in the world must be addressed as one key step to improve overall health. The causes of such shortages are many and diverse and may be grouped into three tiers: the entry level, including planning, education and retirement; the workforce level, including supervision, adequate compensation, continuing education; and the exit level, limiting emigration, changes in career and ensuring the health of the workforce. Only a strategy tackling these three aspects (a "lifespan strategy") may lead to effective sustainable results. To illustrate this point, Mr. Dayrit described the case of Thailand where multiple strategies have helped to improve the retention of trained health workers in rural areas. With concerted regulatory, economic, educational, managerial and social strategies, the country has indeed managed to shift the ratio of health workers in Bangkok v. those in the northeast of the country from a 22:1 ratio in the eighties to a 10:1 ratio in 1999.

In conclusion, Mr. Dayrit reiterated the view that capacity building efforts will succeed only where they take adequate account of the prevailing local politics, economics and institutions and are country-owned rather than donor-driven. To that effect, he noted that countries have to take the lead in developing capacity building efforts and that donors should harmonize their support around the countries' priorities.

Ms. Odette Morin, Director of Regulatory and Scientific Affairs of the International Federation of Pharmaceutical Manufacturers and Association (IFPMA), presented the newly created IFPMA Clinical Trials Portal, launched in 2005, that is the first portal to provide public, online information about on-going and completed clinical trials sponsored by pharmaceutical companies worldwide.

The portal was developed as a response to various pressures for improved trial transparency. Through their associations, the pharmaceutical companies have taken a joint position on the disclosure of clinical trial information that has led to the creation of the portal. Pursuant to ongoing public pressures, the number of clinical trial postings on the portal has almost doubled during the first months of its launch.

The portal is not a database but is structured as a platform giving access to various sources which centralize information, such as national industry associations, governments or international organizations. It allows multiple-criteria searches in English, French, German, Japanese and Spanish.

The portal is not only useful to doctors and patients, it is also an essential tool, as was discussed after Ms. Morin presentation, to inform health systems management. Of course, the portal may be only as good as the information made available by companies and governments. It was hence emphasized that national registries should be improved in many regions to improve coverage.

 

Mr. Stephen A. Matlin, Executive Director, Global Forum for Health Research, discussed the crucial role of health research in ensuring that people everywhere have access to health. Mr. Matlin first provided an overview of the changing face of health problems worldwide. Although infectious, communicable diseases (CDs) remain the major health burden in Africa, there is an overall increase in non-communicable diseases (NCDs) among low and medium income countries (LMICs). Health research agenda should adapt to these evolving needs.

Health research, Mr. Matlin highlighted, is not limited to biomedical research and the development of new products. The health research agenda should also focus on systemic aspects such as strengthening health policy and systems, the promotion of health equity, the study of social and other determinants of health including the availability of public transport networks for access to health resources.

It is widely recognized that there is a major lack of spending on health research for the needs of developing countries, both by HICs and by LMICs themselves. Although global health research expenditure is growing at a rapid pace, only a small proportion of it (less than 5% in the 1990s) is devoted to diseases and health problems that are endemic in LMICs. As a result, during the last few decades, very few new products for diseases that are mainly endemic in poor countries were registered for clinical use. In parallel, health systems and health research capacities in LMICs have not been sufficiently developed.

In order to tackle the disease burden in LMICs, concerted approaches should be implemented by both LMICs and HICs. HICs should focus on research that generates leads for LMICs and support country-based research and capacity building in LMICs. LMICs should similarly support their own research capacity and utilization. They should focus on the development of national health research systems, foster innovation and ensure that local research capacity addresses local priority health needs.

There is an emergence of innovating developing countries, such as Brazil, China, India and South Africa. These countries have demonstrated a growing capacity to undertake health innovation and assume an increasing role in the development of new drugs, vaccines and diagnostic tools, as well as of new techniques and new policies in health systems and services. One characteristic of these countries is that they manage to span the spectrum from innovative research to product delivery.

One major source of funding for, in, and by, LMICs is philanthropy. Over the 1993-2003 period, the 50 most generous philanthropists collectively donated over 50 billion USD. Public-Private Partnerships (PPPs) are playing a growing role in the financing of health research for LMICs. PPPs' Research & Development (R&D) expenditure has increased dramatically since 2000 and 75% of all neglected disease R&D projects are currently conducted by PPPs. The public sector should devote an increased share of available R&D resources to the health needs of developing countries, as they have fallen short of meeting the the targets set at the 1990 Commission on Health Research for Development (2% of government health budget on essential health research).

Mr. Matlin concluded by highlighting areas to which government financing of health research for development should focus. In HICs, greater priority should be given to national research programs and more health research should be included in bilateral and multilateral channels. In LMICs, in additional to giving greater priority to national health programs, capacity building for national health research systems and innovation should be emphasized.



GHF2006 – PL04 – A Critical View on the Role of Hospitals in Increasing Access to Health

Session outline

Plenary session, PL04, Thursday, August 31 2006, 18:00-19:30
Chair(s): Peter Saladin, Switzerland, Elisabeth Leforestier, France
Hospitals Promoting Access to Healthcare
Gillian Morgan, The NHS Confederation, London, United Kingdom 
Adeleke Olusegun Pitan, Honourable Commissioner for Education, Lagos State Ministry of Education, Lagos, Nigeria 
Redesigning Hospital Care to Meet the Needs of the Community
Wim Schellekens, Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Optimizing Hospitals in the Health Sector
Saleh Meky, Minister of Health, Eritrea 

Session Document

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Session report

Submitted by: Irene Amodei (ICVolunteers); Contributors: Melissa Bonnefin (ICVolunteers)

"Brain drain in health systems is a political issue". Image: Viola Krebs, ICVolunteers.org

Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices.

Mr. Adeleke Pitan, Honourable Commissioner for Education in Lagos' State Ministry of health from 1999 to 2006, began the plenary session with a detailed overview of the state of the health care delivery system in Nigeria and urban Africa. "Access to health has always been, and still remains, a problem in many urban areas" stated the former Minister, "due to uneven distribution of hospitals, inadequate health personnel, limited financial resources and weak motivation of the workforce". He then narrowed his focus criticizing the current inadequate knowledge and health education of the population (estimated at 150 million people) who still prefer alternative medicine practitioners. About 75% of Nigerian government hospitals are in urban areas and 25% in rural ones and on average 2.2 million patients are treated each year. The need to increase access to health has pushed the government to develop 'packages' to attract the elderly and most vulnerable groups; to introduce a number of free health services including free anti-natal care, free medical treatment for children aged between 0 and 12 years and for people over the age of 60. The Health Sector Reform programme also included free heart surgery for patients with heart defects, free eye treatment including surgery for cataracts and glaucoma and free breast cancer screening. Mr. Pitan described the opportunities that the reform offered such as Public-Private Partnership initiatives (PPP's),  the B-O-T system (build, operate and transfer), transfer of technology, training and re-training of health personnel. While the reform process has helped to assist the most vulnerable part of the population, trying to bring health to the doorstep of all citizens continues to be a major problem due to the small number of hospitals, shortage of specialist manpower, the lack of equipment and under-funding of the health care system.

'Reform' was also the key word of the presentation by the Minister of Health in Eritrea, Mr. Saleh Meky, who explained in detail the series of strategies adopted nationally in order to increase the cost-effectiveness of the health system and of its delivery services. "Change means new ways of thinking and acting", stated Mr. Meky, "and must be managed to ensure the result is a real improvement. Moreover, the quality of clinical services must not suffer during periods of rapid change". As a result of the concerted efforts made in Eritrea to build new health facilities and give them the necessary equipment and skilled health personnel, access to primary health care within 10 km from the health structures increased in the last years to around 70%. A good deal, given that 50% of the population lives within an area of 5 km.

Mr. Meky illustrated the main goals of the national reform, namely:

  • To ensure the equitable distribution of health services to rural and urban areas;
  • To strengthen Primary Health Care especially in remote and inaccessible areas;
  • Actively to promote the dissemination of accurate information on health practices;
  • To use a strong evidence-based decision-making process.

According to Mr. Meky, the basic principles of any health system reform are the improvement of management (namely the Health Management Information System, HR management, quality and financial management) and the decentralization of functions "to that level where optimum value can be attained". A country in transformation, like Eritrea, has to deal with additional challenges, for example the urgent need to control both tropical (historical) and 'rich-countries' (new to Eritrea) diseases. For that reason, the decentralization process is often not easily manageable. As a solution Mr. Meky introduced the concept of "hospital autonomy", an alternative method of organizing and financing health care services. Hospital autonomy could also be seen as an effective merge of the best elements of the public and private sectors; a kind of parastatal hospital that works in a private way from the point of view of finance and bureaucratic reduction, which when properly implemented, enhances effectiveness and efficiency.

Mr. Meky ended his presentation by stressing the need for stronger community involvement as the only way to overcome the always present danger of brain drain. "Brain drain in health systems is a political issue" stated the Minister. "If we want to have some chance to stop it we must provide a comfortable ecological and financial environment, to train as many people as possible, to appeal to people's nationalism and, most importantly, to make people think that they really are the owners of their hospitals".

Mr. Wim Schellekens, CEO of the Center for Innovation and Development in The Netherlands, offered the plenary a mostly self-critical 'first-world' point of view. "How effective and safe is hospital care?" questioned Mr. Schellekens, "How to do a better job?".

Despite the progress of medical science, we still see a huge amount of errors in the way we deliver care (overuse, under use or misuse of drugs), in the way we organize care (coordination problems and delays) and in the way we take care (absence of transparency, empathy and patient-involvement). In the USA, there are 44,000 to 98,000 deaths in hospitals each year (8th-3rd cause of death) and there is no correlation between cost and mortality. Care for patients should be safe, effective, patient-centred, timely and efficient, with equity for all. Patients, of course, do not expect needless deaths, needless pain, unwanted waits and helplessness. In short, quality is the big issue. To support his claims Mr. Schellekens described the successful IHI Boston experience in 2004, which, with six simple interventions (like the creation of a Rapid Response Team), resulted in 122,300 lives saved in the 3,000 hospitals involved. The key to success is to have vision, a strategy and leadership ("First study, then act; first plan then do!"). The theory affirms that when we have convinced 20% of our target, the rest will automatically follow. In The Netherlands the "Better Faster" programme, that aimed to get breakthrough results in 20 % of Dutch hospitals in four years, succeeded by acting at four levels of intervention: system level, institutional level, level of care-process and patient level. According to Mr. Schellekens the mission of hospitals has shifted from "delivering specialized care to our patients" to "responsibility for the care in our region" to "promote health to all our citizens".

GHF2006 – PS14 – Research & Access to Health: Ethical Concerns

Session Outline

Parallel session PS14, Thursday, August 31 2006, 16:00-17:30
Chair(s): Nirmal Kumar Ganguly, India, Alexandre Mauron, Switzerland
Eduardo H. Gotuzzo, Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru 
Ethical Aspects of Clinical Research in Africa: A Positive Experience from Mali
Ogobara K. Doumbo, Professor, Malaria Research and Training Centre, University of Bamako, Mali  
The Importance of the National Laws in the Implementation of International Regulations in Developing Countries
Dominique Sprumont, Institute of Health Law, University of Neuchâtel, Neuchâtel, Switzerland

Session Document

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Session Report

Submitted by: Shibani Bandyopadhyay (ICVolunteers); Contributors: Tatjana Schwabe (ICVolunteers)

The symposium on "Research and Access to Health: Ethical Concerns" has highlighted the fact that strong laws are a powerful tool to protect participants in experimental clinical trials. Presentations on Clinical Research in Latin America and the importance of national laws in the implementation of international regulation in developing countries introduced some of the complexities of ethics involved in clinical trials.

The co-chair, Dr. Alexandre Mauron from the Medical Faculty of the University of Geneva, Switzerland, introduced the topic of ethical concerns in health research, stressing that clinical trials had become a global activity, requiring discussion about ethics in research to be a priority.

Dr. E. H. Gotuzzo from Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru presented his paper on "Clinical research in Latin America: constraints and opportunities". He pointed out that currently between 11 - 25 % of all clinical trials (CT) are being conducted in Latin America, involving numerous sites and professionals in the trials themselves and the related ethical review work. Dr. Gotuzzo first listed the advantages of conducting clinical trials in Latin America:

  • A vast heterogeneous study population with patients suitable for many CTs available in the mega cities of Argentina, Mexico, Brazil and Colombia;
  • Minimal drop out rates;
  • Trained personnel with good clinical practices;
  • Potential markets for pharmaceutical industries;
  • Possibility to conduct year-round trials on seasonally induced diseases (e.g. diarrhoea or respiratory diseases) in combination with countries in the Northern hemisphere;
  • Dr. Gotuzzo pointed out that most clinical trials in Latin America are being carried out by private industry, while only about 100 trials are being conducted by the US-American National Institutes of Health (NIH), universities or other public institutions. About 80 % of the clinical trials in Latin America analyse new vaccines against rotavirus, papilloma virus or HIV.

However, clinical trials in Latin America face a number of challenges including:

  • Lengthy approvals due to government regulations;
  • Corruption (as large sums of money are often involved in CTs);
  • Forged CT results;
  • Low priority of clinical trial output product;
  • Severe unrest threatening the continuation of  CTs as seen in Argentina (2001), Venezuela or Peru (1990);
  • Ethical issues such as acquisition of study subjects and informed consent.

Regarding the last point, Dr. Gotuzzo explained that in the paternal patient-doctor relationship in Latin America, informed consent of patients was an unfamiliar concept. During the question and answer session, the issue of informed consent by vulnerable, handicapped or mentally ill patient was briefly raised. Answering a question from the audience, the speaker argued that the hope to improve the health situation was the main reason for countries with limited resource and increasing drug resistance to participate in CTs.

In his conclusion, Dr. Gotuzzo urged for more transparency and clear requirements, amongst others through the strengthening of health systems, to determine whether a clinical trial is carried out according to appropriate ethical standards. CT participants-and possibly also the institutions and countries in which these CTs are conducted-should benefit more directly from the CTs as today, frequently, the CTs only benefit western development.

In the absence of Dr. Doumbo from Mali, Dr. Hassan Mshinda, Director of the Ifakara Health Research and Development Centre in Tanzania kindly agreed to talk about his experience regarding ethical is regarding clinical trials in Africa. In partnership with the Special Programme for Research and Training in Tropical Diseases (TDR) and the WHO, skills in applying ethical standards in CTs have been developed by the training of staff in Standard Operating Procedures (SOP), Good Clinical Practice (GCP) and ethics.

Dr. Mshinda pointed out that Tanzania is taking several steps to ensure that ethics standards are applied in clinical trials. Ethical clearance is mandatory and a licence is required for each product to be tested in a CT. The composition of the ethical board has changed to include independent legal and gender representatives in addition to professional scientists and clinicians. Tanzania accepts the responsibility for all research work undertaken in the country, for example by refusing to engage foreign nationals as principal investigators of any research work or by including an independent country representative in the data monitoring safety board of a multi-centric study by a foreign pharmaceutical company. This is crucial, as a local investigator will, unlike most foreign stakeholders, still be there to take responsibility should a problem arise after completion of a research protocol. He also pointed out that in this particular biosocial context, verbal consent was largely prevalent over written consent. Implementation of community consent also raises largely unexplored difficulties. Such socio-cultural issues can pose problems for ethical guidelines requiring individual and written informed consent.

Dr. Dominique Sprumont, Director of the Institute of Health Law at the University of Neuchatel, Switzerland introduced the "Importance of the National Laws in the Implementation of International Regulations in Developing Countries". At the beginning of his talk, he pointed to the complex documents regulating research on an international level such as the Geneva Convention, the Nuremburg Code, the Declaration of Helsinki, the International Convention on Civil and Political Rights, WHO International Ethical Guidelines and European Union (EU) Directives. Both the EU directives and the National Law aim predominantly at protecting the subjects of clinical trials. Another body to issue guidelines on Good Clinical Practice (GCP) was the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). In its principle 26, it demands that all CTs be conducted under the supervision of an Institutional Review Board (IRB) and Independent Ethics Committee (IEC), both of which have to be approved by the "competent body". What constitutes a competent body is left open to interpretation in the document and definitions differ from country to country. Another area, where definitions differ is that of informed consent. Dr. Sprumont presented examples from Benin, Mali and Senegal, where the definitions of child, incompetent adult and legal representative vary. Even across Europe, concepts concerning the competent authority for consent and legal competency are not uniform. In the light of the heterogeneous world of many diverse but equal sovereign countries, Dr. Sprumont concluded that national regulation was the only way to provide specific rules on key issues in biomedical research. He stated that the respect for national regulations was essential for partnership in international research and capacity building.

Dr. Mauron concluded the session by emphasising the importance of including only fully informed participants in clinical trials. To avoid the disseminating of misleading information, clinicians and research workers need guidance from other disciplines, including legal experts, to prepare the information that is to be shared with patients.

Clinical trials are the most important tool in medical research to find the best therapy or method for intervention. While CTs have so far been mostly ruled by biostatistics, more emphasis is now being placed on human rights and ethical concerns. Since research is becoming more and more industrialised, national law has to ensure that international regulations and ethics guidelines are implemented in each country and hence the need to ensure that research protocols are compatible with different local laws. This in turn leads to the question of which research institute has the final say in multi-centre research.



GHF2006 – PS13 – Access to Health at a Time of Pandemics

Session Outline

Parallel session, Thursday, August 31 2006, 16:00-17:30
Chair(s): Claire-Anne Siegrist, Switzerland, Flavio Del Ponte, Switzerland
Global Response in Case of Crisis 
Keiji Fukuda, Coordinator, Global Influenza Program, World Health Organization, Switzerland 
Can Global Vaccine Needs Be Covered?
Jean R. Stephenne, General Management, GlaxoSmithKline Biologicals, Rixensart, Belgium 
Ressource Management on a Worldwide Scale
Mike Ryan, Director, Epidemic and Pandemic Alert and Response, WHO, Switzerland 

Session Report

Submitted by: Brooke Bishara (ICVolunteers); Contributors: Milena Lawrence-Samuel (ICVolunteers)
Image: Photograph taken in 2005 at the Center for Disease Control and Prevention in Atlanta. Doctor examining reconstructed 1918 Pandemic Influenza Virus inside a specimen vial containing an orange-colored supernatant culture medium. Image courtesy http://phil.cdc.gov/Phil/

A flu pandemic is inevitable, scientists say. Yet we are the first humans ever to have had fore-knowledge of a pandemic, which gives us a unique opportunity to act to address the crisis before it occurs. Sustained political attention and collaboration between the public and private sector hold our greatest hope of effectively managing this disastrous event.

Dr. Keiji Fukuda, of the Global Influenza Program of the World Health Organization (WHO), led the symposium with an overview of the pandemic threat. Historical evidence (three pandemics in the last century), the abundance of viruses among wild birds and substantial levels of contact between humans and animals all point to the inevitability of a flu pandemic. The H5N1 virus is the most lethal flu virus discovered to date, but Dr. Fukuda pointed out that it is only one of many that could spread to humans. Therefore, we do not know of which form of flu virus the pandemic will comprise, so there is a high degree of uncertainty which preparedness plans must take into account. For example, it is difficult to predict the degree of capacity needed in hospitals, but Dr. Fukuda pointed out that our current system operates at about 95% of its full capacity, so there is very little room for the surge that would come from a pandemic. Health care systems will suffer from staff absences, increased deaths and little to no help from other countries, because all will be dealing with the crisis. Ethical dilemmas (whom should we vaccinate?) and technical obstacles (how can we produce a vaccine more quickly?) are also challenging to preparedness planners.  The recent passage of the new International Health Regulations by the WHO is an encouraging development, as it provides countries with a standard framework for responding to and reporting health crises. The WHO's strategic plan for Pandemic Influenza includes reduction of human exposure to H5N1 through education about animal contact; intensification of early identification and rapid response to outbreaks; and coordination of global scientific research efforts. Dr. Fukuda concluded that 1) the threat is real; 2) we must focus on our preparedness rather than the threat itself and 3) we must balance our preparedness between specific preparations for the flu pandemic and building infrastructure to address all future infectious diseases.

Jean Stephenne, President and General Manager of GlaxoSmithKline Biologicals (the pre-eminent flu vaccine producer), spoke about the company's efforts to address the pandemic threat. He first stressed that with current technology, there is not enough vaccine capacity to protect the world from such a pandemic. A vaccine for a newly discovered virus can be produced in about four to five months, but current predictions show that by then the pandemic would be close to reaching its peak.  In addition the number of doses available would be woefully inadequate to protect all those at risk.  Instead, Mr. Stephenne suggests two solutions: 1) a Pre-pandemic flu vaccine which includes the H5N1 strain giving a safe vaccine with a broad immune response; 2) by adding adjuvants boosting the immunogenicity, the existing capacity could yield a ten-fold of vaccine doses. In 2008 he predicted the global capacity to reach 600 million doses which by adding adjuvants would translate into 6 billion doses, enough to cover the world-wide demand.  Mr. Stephenne stressed the need for such a vaccine to be made available more widely than to just those countries that can afford to pay for it, especially because there is a high probability that the pandemic will start in a developing country.  Innovative thinking and vaccines are only part of the solution, he stated. The vaccine has to get to the right people and our health systems must be prepared.

Finally, Dr. Michael Ryan, Director of Epidemic and Pandemic Alert and Response of the WHO in Switzerland, presented a sobering picture of our current health infrastructure's ability to handle disease outbreaks and stressed the need for permanent collaboration between the public and private sectors. New pathogens are emerging, like avian influenza, but "old" diseases like cholera, yellow fever, and dengue fever are also resurging in Africa, despite the fact that we have plenty of well-established, readily available, low-cost cures. A population that is increasingly urban, while also coming in close contact with intensively farmed animals, runs a greater risk of infectious disease.  Dr. Ryan also stressed that the complexity of our health systems can actually prove to be a hindrance in a crisis, as simple systems are easier to fix when they fail. He echoed Dr. Fukuda's call for greater capacity in our health systems in order to deal with the surges in demand created by epidemics. But no single institution has enough capacity to deal with the threats, he noted, and so the looming flu pandemic is driving us to professionalize and collaborate on all levels. He added his enthusiastic endorsement of the new International Health Regulations mentioned earlier.

After a few questions from participants, Chairwoman Siergrist closed the session by noting that during the SARS outbreak, news of it filled the airwaves in Switzerland. Yet there was not one reported case in the country.  Meanwhile, 671 people suffered from measles, a disease with a well-developed vaccine. How can we expect to handle pandemics when we are so lax about those diseases we can control? She urged attendees to work to change public perception of common vaccines and to work against our greatest enemies: ignorance and complacency.

GHF2006 – PS12 – Ensuring Access to Health for Migrants

Session Outline

Parallel session PS12, Thursday, August 31 2006, 16:00-17:30
Chair(s): Danielle Grondin, Switzerland, Sandro Cattacin, Switzerland
Global Mobility: Rethinking the Practice of Care
Brian Gushulak, Migration Health Consultants, Vienna, Austria 
Closing the Gap: Migrant-Friendly Health Systems in America
Patricia F. Walker, Department of Internal Medicine, University of Minnesota, St Paul, USA 
Status-Related Access Dilemma: A European Perspective
Francesco Castelli, Infectious and Tropical Diseases, University of Brescia, Italy

Session Documents

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Session Report

Submitted by: Stephanie Berry (ICVolunteers); Contributors: Hassatou Conde (ICVolunteers)

Image: IOM helping Lebanese refugees in Syria 2006. Photo: Ranjitha Balasubramanyam, 2006.

The fifth largest nation in the world does not have sufficient access to health. Indeed if migrants were seen as a country, they would represent a significant nation in terms of population. How can we explain that so many people do not have access to health care? The focus of this symposium, chaired by Anita Davies from the International Organization of Migration (IOM) and Sandro Cattacin from the University of Geneva, was on the unequal provision of health services for migrants.

Inequalities are caused by problems that we can classify on three different levels:

  • At the patient level: language, culture and social circumstances can inhibit access.
  • At the provider level: the inability to communicate with patients makes physicians reluctant to deal with foreign patients.
  • At the level of the care delivery system: legal restrictions and administrative complexities make it difficult to provide effective service for migrants.

These inequalities are also worsened by adopting a national view. Brian Gushulak, a migrant health specialist, emphasized the importance of a global perspective when dealing with the issue of access to health for migrants. According to this speaker, a national view of the problem at hand would limit the solutions and prevent them from being linked to development, economic and security matters. Indeed, all the participants agreed that migration was part of globalization and that it should be treated from a global point of view. "There are no local diseases and therefore there are no local solutions" Patricia Walker from the Department of Internal Medicine of the University of Minnesota, in the USA, pointed out.

One must not look upon the immigrant community as a homogenous group; its members have different social and cultural backgrounds. In order for the care delivery system to be effective, it has to be culturally competent and knowledgeable about both ethnic and social differences. This is illustrated by the fact that most patients from this community do not dare consult a physician due to language barriers and in turn 78% of the doctors do not like taking care of immigrants due to the complexity of the process.

However, the unequal access to health care was not the only point that was discussed. It was pointed out that providing better health services for migrants is in fact beneficial for host countries. We particularly have to focus on fast intervention because, not only does it prevent diseases like Tuberculosis from spreading, but also reduces the cost of treatments. Indeed, the further the illness is developed, the more complex and expensive it becomes for both patients and health care providers. Focusing on illegal immigrants, Dr. Francesco Castelli from the Infectious and Tropical Diseases Unit of the University of Brescia in Italy, pointed out that more than 70% of HIV infected people are unaware of their condition.

Thus, in order to ensure access to health for migrants, it is important to insist that health should be regarded as a human right and that all citizens, migrants or natives should be entitled to it.

GHF2006 – PS11 – Public-Private Partnerships: Beneficial or Undermining?

Session Outline

Parallel session PS11, Thursday, August 31 2006, 16:00-17:30
Chair(s): Roy Widdus, Switzerland & Guglielmo Pacileo, Italy
From Basic Research to Drug Delivery: When are Public-Private Partnerships Needed?
Louis J. Currat, Switzerland 
Global Public-Private Partnerships and Global Health Governance
Eduardo Missoni, Italy
Public Responsibility in Research and Development Partnerships
Bernard Pécoul, Switzerland

Session Document

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Session Report

Submitted by: Marc Menichini (ICVolunteers); Contributors: Camille Mercier-Sanders (ICVolunteers)

In order to answer this controversial and challenging question, the three speakers explained some of the benefits but also the drawbacks of PPP's, each one focusing on particular issues. What conditions lead to efficient PPP's? Should we reject PPP's all together? Should governments do more in terms of Research and Development (R&D)? There are no straightforward answers but the speakers came up with convincing and very interesting solutions.

Dr. Louis J. Currat, former Executive Secretary of the Global Forum for Health Research, insisted on the problems regarding health products for the poor, stating that there were "very little new products for the diseases in the LDC's". A "structural disconnection" between the private and public sector explains this lack of interest and engagement for neglected diseases. The two have specific failures, e.g. high costs for the private sector and a lack of expertise for the public sector, but also complementary capacities which they do not use. Dr. Louis J. Currat suggested that in order to "reconnect the private-public pipeline", you needed a "multi drug therapy" made of an increase in resources in the international agencies, "push and pull" interventions by national governments and the development of PPP's. The latter, not being a "panacea", should pass the cost/benefit calculus and be certain that no other more sufficient way to deal with the "reconnecting of the pipeline" process exists. This will allow us to know "when and where PPP's are useful but also when they should be stopped".

Eduardo Missoni from the Faculty of Sociology at Bicocca University in Milan, Italy, insisted on the controversial meaning of the "partnership" concept which has been value-laden and sometimes misleading. Hence, he stressed that during the definition process of the concept of PPP's, many have forgotten that it implies equal partners and that it has become a key word in political discussions, but most of the time there is a lack of reflexion and sufficient understanding. Emphasizing on Global PPP's (GPPP's), Eduardo Missoni pointed out the growing influence of Western private donors (such as the Bill and Melinda Gates Foundation) in the PPP's agenda setting, thus revealing the inequality among the so-called "partners". This phenomenon has led to the fragmentation and disempowerment of the WHO at the global level and to the one of the countries at the national level, thus questioning the alleged positive elements of GPPP's: What accountability, but more importantly what sustainability? To tackle these issues, Dr. Eduardo Missoni stated that the WHO should regain its legitimate leading role in global health governance (i.e. keeping a "democratic platform" which does not mean excluding the corporate sector from the whole picture but leaving the governing function to the WHO), more transparency among the international agencies and the necessity to develop a country level approach so that local players are re-empowered.

Eighty percent of the world population represent only twenty percent of the pharmaceuticals market and over the last thirty years, only twenty-one of the 1500 new marketed drugs were for the neglected diseases treatment. This is why Dr. Bernard Pécoul, Executive Director of the Drugs for Neglected Diseases Initiative (DNDI), presented the numerous gaps in the neglected diseases R&D chain where basic existing knowledge is not translated into clinically trialled and therefore never reaches the needing patients. In order to bridge these gaps, his NGO strongly believes in building partnerships and pushing governments to assume their responsibility. DNDI wishes to involve and commit the public sector through political leadership, sustained financial support and setting rules to respect intellectual property rights.

Comments from the floor brought stimulating reactions to Dr. Missoni's presentation. Some agreed that PPP's were fragmenting global health solutions, proving that they were "going down the wrong path". Jean François Martin, President of Parteurop, declared that one should make a difference between principles of PPP's and actual management of PPP's. Principles are good even tough the management needs improvement. Reacting to Dr. Pécoul's assumption, a spokesperson of a pharmaceutical company stated that R&D is costly for governments who should really concentrate on providing rather than developing the needed drugs.

The symposium's chair, Roy Widdus from the Global Health Futures Network, concluded by saying that "no one believes that PPP's are useless nor that they are deliberately harmful, making criticism addressed to PPP's very broad and not specific".


GHF2006 – PS10 – Hospital and Academic Networks

Session Outline

Parallel session PS10, Thursday, August 31 2006, 11:00-12:30
Chair(s): Peter Suter, Switzerland, Peter Saladin, Switzerland
Social Accountability of Medical Schools in a Globalized World
Kendall Ho, Continuing Professional Development & Knowledge Translation, University of British Columbia, Vancouver, Canada 
Troped Network: Bringing Together European Institutions for Higher Education in International Health 
Jean-Pierre Gervasoni, Unit for Cardiovascular Disease and Epidemiological Transition, IUMSP, and Swiss Tropical Institute, Basel, Switzerland
Capacity Building and Partnerships: ESTHER's Experience
Michel Lo Casto, Advisor for hospital relations, GIP ESTHER, France

Session Documents

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GHF2006 – PS09 – Community in Action for Health

Session Outline

Parallel session PS09, Thursday, August 31 2006, 11:00-12:30
Chair(s): Nicolaus Lorenz, Switzerland, Beat Stoll, Switzerland
Peer Education: Strategies of Prevention of Sexually Transmitted Infections; The Case of Nylon Health District in Douala, Cameroon 
Alphonse Um Boock, Regional Representative for Africa, Association aide aux lépreux, Emmaus, Switzerland 
Innovative Grassroots-level Initiative to Address the Challenges of Social Determinants of Health in Under-developed Areas in India
Alok Mukhopadhyay, Chief Executive, Voluntary Health Association of India, New Delhi, India
Arising Awareness about HIV/AIDS and Coping Strategies in the NGO's Work: The Example of Memory Work at the Level of Aidsfocus, Switzerland 
Irene Bush, REPSSI, Regional Programme, Terre des hommes schweiz, Basel, Switzerland

Session Document

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Session Report

Submitted by: Stephanie Berry (ICVolunteers); Contributors: Dr Beat Stoll (UNIGE), Martin Elling (ICVolunteers), Jennie Hery-Jaona (ICVolunteers)
The Million Memory Project work serves as an instrument to help HIV positive patients to mature and gain strength. Image: Viola Krebs, ICVolontaires.org

The traditional top-down approach to development is widely criticised as being inappropriate to meet the needs of local populations, especially the very poor. In order to improve this situation, some development organizations and non-governmental organizations (NGOs) favour approaches that integrate local communities in policy formation and implementation. Health, an important aspect of development, necessitates active involvement of the local population. The community remains the key actor in improving its own health standards and communicating its requirements to governments. The speakers A. Um Boock, A.N. Mukhopadhyay and I. Bush each provided examples of how health can be dealt with at the grass-root level.

Dr. A. Um Boock, Regional representative for ALES (Aide aux Lépreux Emmaüs-Suisse), kicked off the Symposium with a presentation focusing on Cameroon, a country particularly affected by the HIV/AIDS epidemic. In the past, Cameroon experienced serious shortcomings in the management of the disease and sexual education. More recently, however, an innovative approach incorporating a "peer education" strategy to prevent the spread of sexually transmitted disease has been adopted. As Mr. Boock explained, part of the strategy involves setting up "clubs de santé" or also known as, interactive discussion groups. These groups target youths aged between 8 and 21 years old with the focus on improving HIV-prevention by reducing risk behaviour, determining the level of knowledge in the local community and engaging parents in sexual education. These groups seek to facilitate the exchange of information regarding sexual issues and to raise awareness through distribution of flyers and posters. The results of this initiative have been promising, particularly in delaying the onset of first sexual intercourse and reducing the frequency of sexual activity amongst youths. Equally important, the youths have been the most motivated group offering their own thoughts and views to the debate on HIV prevention.

Mr. Alok Mukhopadhyay, Voluntary Health Association of India (VHAI), described how the reality of India is divided into "two cities", with 600 million people living in a thriving emerging economy, while another 400 million people have virtually no access to the corresponding benefits. Mr. Mukhopadhyay illustrated how VHAI endeavours to establish cooperation between the government and the local communities so as to promote economic and medical development through the KHOJ ('search' in Hindi) experiment. According to Mr. Mukhopadhyay, "Health is not everything, but everything is nothing without health". To sustain development, strengthening local health and development expertise as well as local community initiatives is vital. The KHOJ strategy has brought about successful improvements with its income generating programmes that focuses on sustainability. Notably, alliances have been built with farmer associations to improve food production and security, engineers to construct wells, and the government to provide more equity to minority groups. Mr. Mukhopadhyay well summarised the project's experience with a heartening quote: "Paths are made by walking".

Mrs. I. Bush, Terre Des Hommes Suisse, emphasised the importance of addressing the wider social well-being of affected groups. She provided an overview of the Million Memory Project that was initiated in 2003 which seeks to apply the method of Memory Work to 10 million HIV-affected children by 2010. This method involves simple actions such as "remembering, writing down and paying attention to people" to help affected people to overcome their tragic experiences that may include psycho-social problems, financial troubles and parents' disclosure of their HIV status to their children. Through this project, creativity is fostered within affected families and alliances are built with families concerned by HIV/AIDS to form new perspectives. The Million Memory Project work serves as an instrument to help HIV positive patients to mature and gain strength. Mrs. Bush urged the audience to practice the method of Memory Work so that they could experience the positive effects themselves.