Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Public Private Partnership in the Management of Primary Health Centers in India.

Author(s): Samal Sarangahdar1
Affiliation(s): 1National Youth Service Action and Social Development Research Institute, Bhubaneswar, India
1st country of focus: India
Relevant to the conference theme: Redesigning health services
Summary: In the PPP model, the skills, assets, risks, and rewards of delivering a service or facility are shared between public agencies and private sector entities through a contractual agreement. This innovative model of healthcare delivery has been successfully piloted over five years for two local community health centers in Orissa, India and is now being scaled up to other areas of the state and the country, with scope for it to be replicated in similar underserved rural settings around the globe.
What challenges does your project address and why is it of importance?: The public health sector in India is unable to provide basic services to the marginalized segments of the population due low investment (3% of GDP), poor infrastructure, inadequate management, physician shortages, lack of patient education or awareness, and shortage of resources in terms of manpower, medication, and supplies. In the state of Orissa, 90% of the 1166 government-run primary health centers (PHCs) are irregularly functioning or defunct. On the other hand, the private health sector has the capacity to provide high quality, efficient, accountable, and patient-centered care but cannot be accessed by poor, rural communities. There is thus a disconnect where the private sector has resources, knowledge, and skills that the public sector has never tapped into.
How have you addressed these challenges? Do you see a solution?: Based on the philosophy that synergy leads to better health outcomes, we introduced the PPP model in which public and private development organizations complement and supplement each other in a combined effort to reach joint goals. To rehabilitate two local defunct PHCs (Khankira GP, Dhenkanal district and Atta GP, Jajpur district), our NGO, NYSASDRI, partnered with the government at the local and state level. To ensure success, we ascertained that several key requirements of the partnership were met: commitment from the top by political leadership, the selection of the right private partner, active involvement of the public sector throughout the process, a well-thought out contract with clearly defined responsibilities and methods of dispute resolution, a dedicated income stream, the judicious use of resources, and collaboration with stakeholders in the local community.
How do you know whether you have made a difference?: Performance was measured through the routine monitoring and evaluation of outcomes by all parties involved. Categories assessed include quantity of services provided or advanced, percentage of the populationwho  receiving specified services, quality of service provided (e.g. waiting time), hospital care parameters (e.g. length of stay, cost per admission, patient turnout, facilities utilization), and the health status of the population (e.g. nutrition markers, health awareness). Qualitative analysis was done through patient feedback surveys and quantitative analysis was done via the comparison of predefined health indicators with both baseline and benchmark values.
Have you or the project mobilized others and if so, who, why and how?: To make management more participatory and ensure local ownership of the PHC, a hospital management committee (HMC) was formed with representatives of Panchayati Raj Institutions (a local system of governance), government health department officials, NGO representatives, women’s self help groups (SHGs), Kishori clubs (adolescent girls clubs), and other important villagers of the area. These participants were mobilized by holding multiple local and state level meetings for needs assessment, discussion, and negotiation. The HMC looks after the day-to-day operation of the PHC, customizing decisions to local priorities regarding which services will be rendered and the process of implementation.
When your donor funding runs out how will your idea continue to live?: In the two villages which conducted our pilot project, building renovations, the installation of basic facilities (electricity, telephone connectivity, medical equipment), and appointed staff members (doctors, attendants, pharmacists, sweepers) will remain permanent assets of the PHC under the oversight of the government and HMC even after the partnership ends. Meanwhile, the capacity building facilitated by our project has not only empowered the members of the local community organizations to act as advocates for their village’s healthcare, but inspired neighboring communities to do the same. Finally, on a larger scale, the success of our venture has paved the way for other private players to play a role in strengthening the rural healthcare systems in Orissa. Our political advocacy efforts brought about the necessary policy level changes to allow other NGOs and corporate institutions to partner with the government in the revival of other dysfunctional PHCs throughout the state. The PPP model has thus emerged as an important strategy for health care reform in the state of Orissa.

Family-Managed Health Monitoring Scheme Towards Health Empowerment: Philippines

Author(s): Maria Loida Sevilla1
Affiliation(s): 1Plan International, Makati City, Philipinnes
1st country of focus: Philippines
Relevant to the conference theme: Redesigning health services
Summary: The Family-Managed Health Monitoring (FMHM) Scheme addresses prevailing community problems such as: delay in seeking care from a health professional, poor compliance with preventive health practices, and inadequate information provided by patients for effective and efficient case management.  The scheme targets families as direct beneficiaries and, indirectly, the health professionals. FMHM Tool makes families aware of basic healthy practices and available services, motivated to seek timely care and have a means to record their health problems.  The scheme provides useful and practical information about disease prevention and health promotion and increases knowledge on healthy behaviors to reduce the risk of disease.
What challenges does your project address and why is it of importance?: Thirty-five per cent of deaths among Plan’s (Plan International-Philippines) under-five year old sponsored children are due to infectious diseases which if attended and treated without delay could have been prevented.  The right to health indicates that even if a person’s good health cannot be ensured nor can it be protected against every possible cause of human ill health, he or she has the right to the enjoyment of a variety of facilities, goods, services, conditions and a protective health system. This system includes having knowledge on preventive, curative, rehabilitative and promotive measures that are provided through various communication channels. There is a growing belief that any future innovations made in improving the nation’s health will not result only from amazing biomedical breakthroughs. Rather, advances will stem from personally-initiated actions that are directly influenced by the individual’s or the family’s health attitudes, beliefs and knowledge. At the same time, health service care providers are faced with inaccurate and incomplete history of the condition of the patient who comes for consultation.  Patient and/or caregivers often have difficulty recalling the important facts which happened prior to the consultation, thus, health service providers have inaccurate and incomplete basis for appropriate case management.
How have you addressed these challenges? Do you see a solution?: Plan International-Philippines and its local government and community partners are implementing an intervention project addressing prevailing community problems affecting the health of individuals and these are: delay in seeking care at the appropriate health service provider, lack of and poor compliance to preventive health practices and, inadequate information provided by patients to health care providers resulting in ineffective and inefficient case management. The scheme mainly uses a Family-Managed Health Monitoring Tool to make family members aware of basic healthy practices and services available, be prompted to seek care at an optimum time and have a means to record all health problems encountered by the family.  Apart from this, the tool also provides useful and practical information about disease prevention and health promotion and increases knowledge on healthy behaviors, ensuring wellness and reducing the risk of disease. The content of the family health record are as follows:• General family information (demographics)• Past medical history of each family member (include diseases that run in the family)• Journal of all illnesses experienced by any member of the family at any given time• Vital and anthropometric statistics• First aid measures for common health conditions and signs that need professional health care• Information on the prevention of common health conditions such as cardiovascular disease, malnutrition, mental health, tuberculosis, communicable diseases, hygiene and environmental sanitation The activities undertaken to implement the intervention included stakeholders’ consultation to validate the health information needs and perceived usefulness of the scheme; gathering of baseline information; the development of the mechanics of the scheme; the crafting of the design, content and form of the tool; the pre-testing of the tool; the development of the training design for family- participants; the formation of the training team; training of family-participants; printing and launching of the tool; and the implementation, monitoring and evaluation of the scheme.
How do you know whether you have made a difference?: Cases of illness have significantly decreased in the villages implementing the scheme. The use of antibiotics without prescription significantly decreased from 35%  to 17%. Cough and cold preparations decreased from 11% to 7%.  There is significant increase in the pattern of applying the appropriate first aid. Prior to the introduction of the tool, the majority of users waited for 2-3 days before seeking care. During the use of the tool, a majority now wait for only 1 day before going to a health service provider. For health service providers, the section where the family records the events that happened or experienced prior to the consultation enables the tracing of medical history easier and allowed easier evaluation of the patient’s illness. Participants to the scheme concur that the tool is important when a family member gets ill. An even bigger proportion say they are able to use the first aid tips provided in the tool. They also said the tool is easy to read, contains easy to follow instructions, needed information can be readily seen because of the labeled index pages and contains enough information to canvas all the types of symptoms occurring within the family.  The majority of the tool's users said it helps them because 1) they have easy access to information on appropriate first aid and proper care for the sick; 2) additional knowledge; 3) they are given priority in the partner health facilities; 4) facilitates faster consultations; 5) know when to seek medical attention, and, 6) are able to record and monitor the progression of illness of a family member. For them, this indicates financial savings because they do not have to panic and immediately seek the services of a doctor. The mothers are more active now because the project allowed them to help their neighbors and teach them on what they have learned from the tool.  Village health workers (VHWs) find ease in managing illnesses since the families apply first aid at home. Mothers and other record keepers in the household are now recording these illnesses and management practice into the health tool. Mothers and the VHWs see patterns of illness episodes and assess possible reasons why some household members are frequently ill. Midwives observed a reduction in the number of severe cases of illnesses during their regular visits to the community because the participants already know to apply first aid treatment.
Have you or the project mobilized others and if so, who, why and how?: The project has technical working groups (TWGs) at both national and local levels. The central TWG is composed of national-level policy and decision makers with expertise and experience in developing health projects. It provides guidance in the overall development of the scheme and the health tool, and had lent a top-level perspective to the management of health intervention and development initiatives. It had a total of 8 meetings from the initial social preparation until the evaluation of the scheme. The TWG is composed of the representatives from the Department of Health (DOH), Association of Municipal Health Officers of the Philippines and two non-government organizations. The role of the community TWG is important in the identification of community issues and concerns regarding the project. It facilitates the acceptability and ownership of the health tool by involving community stakeholders in the planning and decision making process. It is the guaranteed ally in the advocating for the use of the tool in the community. It is a venue and can provide feedback on project implementation. Immediate and concrete actions are made because of the presence of the local officials and key decision-makers in the TWG. Sub-committees ensure that project activities are in order and policies related to the committee’s tasks are set. The sub-committees are on resource mobilization, social marketing, and service delivery.  At the household level, the mother leaders facilitate immediate coaching of other participants on the use of the FMHM tool. Families find it easy to go to the mother-leader whenever they have questions or whenever they encounter issues and problems. Participation of mother leaders during community meetings enable them to actively contribute and facilitate community acceptance and project ownership. The project team identifies strategies that worked in local situations due to inputs of mother leaders and other community stakeholders. The Project Team also channeled the feedback from each monitoring visit and other implementation issues to the mother leaders, and this information was then reiterated to their respective group members. Mother-leaders remind or monitor their group members, VHWs remind or monitor the mother-leaders, the Rural Health Midwife (RHM) reminds or monitors the VHWs and the Public Health Nurse (PHN) reminds or monitors the RHM. Most importantly, the content, form, design and title of the tool were done by the community members. Rural Health Midwife, says, ”they (parents) know now when to bring the patient to a doctor.”.
When your donor funding runs out how will your idea continue to live?: The results of the evaluation show an overwhelming support for the project by the local stakeholders due to the active support of the local village officials and community workers towards the project, and active participation of mother leaders and beneficiaries with regards to project activities.  The support and leadership given by the Village Development Council also led to other initiatives such as inclusion of FMHMS-related concerns and updates during meetings of the Village Health Council. Participants and VHWs are also able to impart skills and knowledge they have learned through the project during the roll-out trainings they give to other villages targeted for project expansion. This in particular has buoyed up their enthusiasm as health advocates and empowered them with additional skills as trainers. The use of the health records to identify reasons for absenteeism was adopted by the elementary school. The school is also able to make use of the health tips in the health record in teaching subjects as Science and Health and Social Studies and Home Economics. This would then ensure that the use of the health record would be sustained and eventually integrated into the school’s regular data collection methods in an effort to keep a comprehensive profile on their students. The clinic teacher uses the tool in monitoring student absences and data gathering of student’s health status easier.  As attested by mother leaders and VHWs, the roll-out training of the tool in other villages empowered them because they were able to interact and impart skills to other community members. The Local Government Unit gave a counterpart share for the reproduction of the tool in recognition of the benefits to the health of the constituents. FGD also reveals that the community members are willing to share in the cost of reproducing the tool. The scheme was also featured as a best practice in the official magazine of the DOH and during a national health forum where other local government units and non-government organizations wrote to Plan International-Philippines seeking clearance to adopt the scheme and tool. Ms. Nanette Cortes, a mother of two says, ”the family-managed health monitoring tool (FMHMT)  is a very good tool worthy to be shared to all mothers.”   “The training I attended taught me not to panic whenever mother is not around and if a member of the family got sick,” says a 12 year old boy, Michelle Gallardo.

A Chronic Disease Surveillance System: Bangladesh

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Author(s): Sheikh Mohammed Shariful Islam1, Dewan Shamsul Alam1
Affiliation(s): 1Center for Chronic Diseases,Dhaka, Bangladesh
1st country of focus: Bangladesh
Additional countries of focus: India
Relevant to the conference theme: Non-communicable chronic diseases
Summary: Chronic diseases have emerged as a major public health threat globally and for the developing countries. There is a need for comprehensive nationally representative chronic disease surveillance system in many South East Asian countries. ICDDR, B in collaboration with LSHTM and SANCD initiated a project in Bangladesh for conducting chronic disease surveillance by using WHO STEPS 3 approach.  The project will test the feasibility of integrating a chronic disease component in the well established Matlab health and demographic cohort and using electronic data capture for socio demographic information, anthropometric measurement, blood pressure, lung function and vision tests and biological sample analysis.
What challenges does your project address and why is it of importance?: This project will provide a measure of burden of chronic non-communicable diseases and their risk factors, and help understanding the wider consequences of chronic diseases. An important component of this study will be the ability to link data collected on chronic diseases and their risk factors with historical data on these participants from the ongoing health and demographic surveillance system (HDSS) in Matlab.   Through this study, we will assess the feasibility, scalability and efficiency of conducting this field-work in rural households, including children (aged 2 years and above) and adults.  We will test the reliability and applicability of chronic-disease questionnaires and techniques using standardized tools and an electronic data capture system. This study will include interviewer-administered questionnaires (on diet, physical activity, socio-economic position, quality of life, disability and functioning) along with physiological measures (blood pressure, body weight, height, leg length, lung function) and blood measures for people above 12 years of age (fasting glucose, lipids and cotinine levels) and 24-hour urine (salt excretion).
How have you addressed these challenges? Do you see a solution?: We have linked historical data from Matlab HDSS through Census, Socio Economic Survey and regular bi-monthly updates with the participant information in the electronic data capture system developed for the project. In addition RKS (Record Keeping System) data from the Matlab Hospital and Hospital Surveillance System data was explored for incidences of diarrhea, pneumonia, breastfeeding history and immunization among others. Data regarding hospitalization of any participant of the study was also linked with the electronic data capture system used by the project.  Using notebook computers with specialized software data was collected from all members of the rural households and physical measurements, blood pressure, lung function and vision tests performed at the household levels by field workers supervised by a medical doctor and project manager. A nurse was engaged to collect fasting blood from the participants at the household levels and transporting the samples for analysis and storage for future genetic analysis at the Matlab laboratory.
How do you know whether you have made a difference?: This project attempts to assess the acceptability, feasibility and reliability of a surveillance system for chronic diseases and its risk factors in the developing countries where nationally represented surveillance for chronic diseases has not yet been established. The project used electronic data capture system for data collection in the field-work which has reduced the use of paper based questionnaire and data entry for routine surveillance. The project has also incorporated new chronic disease events as part of the regular surveillance for demographic data conducted every 2 months in Matlab. It has demonstrated the feasibility of home based collection of blood for bio assays and DNA extraction for future genetic and epigenetic studies and the feasibility of linking historical data collected on study participants from the existing Matlab demographic and health database.
Have you or the project mobilized others and if so, who, why and how?: This project is a role model for establishing a chronic disease surveillance system in a developing country with the need for minimum resources and collecting entire data from the household levels. Following the initiatives of this project at Matlab, Bangladesh, two other similar project was initiated by South Asia Network for Chronic Diseases in Goa and Chennai of India in collaboration with NGOs using similar protocols, methodologies and guidelines prepared by this project.
When your donor funding runs out how will your idea continue to live?: The project has established linkage with the Matlab Demographic and Health Surveillance System database and created a set of questionnaires to be included in the routine surveillance using existing infrastructure and human resources. So, without any external donor assistance and additional funds the chronic disease risk factor project will continue to live and provide valuable information for research and strategies for detection, prevention, treatment and management of chronic conditions.

An Evaluation of the Lime Tree Project: The Creation of a New Village Centre and an Intergenerational Living Space: Geneva, Switzerland

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Author(s): Sandrine Motamed1, Susan B Rifkin2, André C Rougemont1, the community from Meinier
Affiliation(s): 1Institute of Social and Preventive Medicine, Geneva University Hospital, Geneva Switzerland, Colorado School of Public Health, Aurora, United States,
Name your project or intiative: An evaluation of the Lime Tree Project: the creation of a new village center and an intergenerational living space near Geneva, Switzerland.
1st country of focus: Switzerland
Relevant to the conference theme: Equity and empowerment
Summary: To examine a case study in Geneva - the Lime Tree, a community participation project  and to examine how equity and empowerment improve health outcomes using an analytical framework called CHOICE (Capacity building, Human Rights, Organizational Sustainability, Institutional Accountability, Contribution, Enabling Environment).   The Lime Tree Project is a community, university and local authority partnership in its tenth year. Its aim was to help the residents to identify and express their own health needs and to meet the challenges that were mainly of socio-economic and psycho-social in nature.  The inhabitants drew together to develop a more just society which over the years, resulted in a novel concept about how healthy living emerges.  Ref: Rifkin SB. A framework linking community empowerment and health equity: it is  a matter of CHOICE. J Health Popul Nutr. 2003 Sep;21(3):168-80.
What challenges does your project address and why is it of importance?: The Commission on the Social Determinant of Health has identified equity and empowerment as key to the improvement of health outcomes, especially for the poor.  In the case of our project the learning and experience gained in terms of community participation and of behavioral and social health determinants has been very important for all concerned. Old people felt isolated and wished to remain in the village, even when they lost their autonomy, rather than enter a nursing home elsewhere. Young families could not get established because of a lack of available housing, the cost of living and nonexistent day care facilities for children. Social links between people had diminished, especially between the generations. Further difficulties arose from poor mobility, both for work and leisure.  The challenge was to improve health (defined by WHO as mental, physical and social well being of the individual) outcomes.
How have you addressed these challenges? Do you see a solution?: The project address the challenges through participation and involving a comprehensive life style approach to a situation which threatened to lead to deterioration of the good physical and mental health of the community. CHOICE is a framework that identifies six areas that are critical to examine as they influence the empowerment and equity of health outcomes. By modifying the questions to describe each domain it is possible to create an assessment tool to link equity and empowerment to the good health outcomes that we are seeing in our project.  We describe these links by answering the following questions.  Capacity building: Can local people obtain and act upon new skills and/or knowledge to improve their health?  Human Rights: By exercising their rights, can the communities influence the circumstances that change their poor health conditions? Organizational Sustainability: Can organizations be developed and maintained to ensure sustainability of health gains for the poor? Institutional Accountability: Can mechanisms be developed to ensure resource allocation and decisions that benefit those most in need? Contribution: How does the contribution of a program’s intended beneficiaries reflect its development? Enabling environment: What is the contribution of the existing environment to pursuing equity and empowerment for health improvements?
How do you know whether you have made a difference?: A vision of health living in the commune has been drawn up. One prominent aspect of the reality of the project is the creation of a new village center, with its sheltered housing for the elderly, affordable accommodation for young families, child day care, a games library, shops and a restaurant as well as an intergenerational park and living space. By analyzing the data in the 6 domains of CHOICE we describe how equity and empowerment lead to better health outcomes. Capacity building: One can mention the numerous thematic evenings that have been organized. Themes as varied as the importance of mealtimes to family life, the connection between architecture and health or how to prepare for and draw up an advance directive have been tackled. The project's newsletter, entitled “Tilleul”, ran for two years. There have been communal events aimed at getting the inhabitants to know one another (such as a photographic exhibition). Events and lectures by people from the villages, demonstrating their special skills, were highly successful.  Human Rights: The governance of the project is the community. We have respected the country's quasi-direct democratic system. We asked the population to proceed in the direction negotiated during the twice-yearly general meetings (about 400 people, out of 2000 residents, took part). A multidisciplinary group worked on this and, when it thought it had reached the end of a phase, presented it to the community, for a wide ranging discussion of all options. When the agreed specifications were finished a budget for the building work was presented to the citizens by local authorities and was voted through.  Organizational Sustainability: Our organization strategy is a “community-campus-authorities partnership” which is a process of community participation. The university has a role of emulating the competences of the community. In addition it brings its learning and know-how which mesh with those of the community and the local authorities, in our case, with those of the other partners (architects, etc.). Everything depends on each one's capacity and willingness to exchange experiences and ideas and to meld all this into one integrated cooperating whole.  By continuing to support the factors identified by the CHOICE framework, the project will find sustainability by involving communities and supporting their efforts.  Institutional Accountability: The community consists of all residents of the commune (village, electoral district). It was imperative that there was “something for everyone” in this project and essential that none of the various subpopulations seized the reins guiding the project's principal orientation. We have taken care that everyone can have their say adding to our meetings a newsletter and/or a website, so that information can be passed around. Furthermore, an appeal mechanism called a referendum can be called for by the community to recall actions not in accordance with agreed directions. Contribution:  The university was the facilitator that brought together community residents to shape a program meeting the articulated needs of the community.   The local authorities contributed the management for different service providers to work together to meet these needs. Finally, community residents contributed their skills and time to create the center that became the focal point of the project.  All these groups were brought together in a multidisciplinary group that was created to ensure these contributions were debated, shared and coordinated. Enabling environment: Community participation is created. Healthy  Partners including professional and community people worked together toward the goal of creating a project to address improved health in a most comprehensive context.  Good health is a result of social, political and economic factors and medical interventions. The partnership's success is due to a conjunction of personalities and the respect of the democratic process.
Have you or the project mobilized others and if so, who, why and how?: Our Institute has been contacted by other local authorities (Geneva State) to know more about community participation process. An international symposium has been organized by the authors in Washington D.C. to share on experiences from developed and developing countries around implementation of health democracy in national health policies. A book has been recently published based on those experiences. New collaborations between universities have followed.
When your donor funding runs out how will your idea continue to live?: The financing of the number of consultants working in partnership, including the architects and from time to time the university, came from public funding, i.e. from tax revenue. The fiscal agent is the village's administration. There was never an overall budget provision nor an external sponsor; the commune's elected representatives voted on the finance necessary for each of the project's phases. The key to sustainability is the ownership of the community.

Family Medicine Initiative: Rwanda

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Author(s): Rene Kabera1
Affiliation(s): 1Faculty of medicine, National University of Rwanda, Butare, Rwanda
1st country of focus: Rwanda
Relevant to the conference theme: Redesigning health services
Summary:
Rwanda is an African under developed country with 10.412.820 population. Maternal and infant mortality rates are still high. Infant mortality: 50/1000 -2010, Maternal mortality: 383/100,000 -2009. Rwanda has a ratio of 1 medical doctor per 18.000 people, only 20% work in the rural areas where the majority of the Rwandan population lives. In spite of increasing specialization in the various fields of medicine, authorities have recognized that the health and well-being of a population is still dependent on high quality primary health care. Family Medicine was established in Rwanda in 2008.
What challenges does your project address and why is it of importance?:
  • Redesign the curriculum of the program according to local needs.
  • Lack of Trainers and Faculty staff in different districts hospitals.
  • Education priorities and resources at the district training hospitals.
  • Assurance of budget and continuous funding allocated to the program.
  • Mobilization of Family Medicine postgraduates to join the program.
  • Importance of Family Medicine is seen at several levels:
  • Humanistic and comprehensive care of the whole family.
  • Broad-based care of the person rather than focusing on the disease.
  • Biomedical, behavioral and social sciences integration.
  • Community based healthcare.
  • Mindful of the cost effectiveness related Primary health care services.
How have you addressed these challenges? Do you see a solution?: To overcome such challenges we advocate for Family and community medicine and highlight its role and importance in Rwanda health system :

  • Advocacy for the role of family medicine with government ministries, universities, health districts and the public The commitment of the trainees, to be engaged in the daily work, in order to highlight the importance of family medicine
  • Full support from the Government by delivering the budget and funding the trainees
  • The financial and academic support from Tulane University (USA), Colorado University (USA) and  Primafamed Edulink ACP EU project (Ghent university-Belgium)
How do you know whether you have made a difference?: 2008:  The program started with 7 trainees   1 faculty member and 2 sites of training(Kabgayi and Ruhengeri Hospitals)    Family and Community Medicine was not recognized  as a specialty in Rwanda

2011:   The program has 6 permanents faculty members and  Visiting expatriate professors joined the program,  17 trainees in 3 training sites(Kabgayi Hospital,Ruhengeri Hospital,and Rwinkwavu Hospital) Family and Community Medicine is fully recognized as a specialty in Rwanda
Have you or the project mobilized others and if so, who, why and how?: With advocacy and determination the Family and Community Medicine concept is growing and being understood in Rwanda and we are planning to join International Organizations of Family medicine

Partnership was raised with the Limpopo University in South Africa
When your donor funding runs out how will your idea continue to live?:
The Program is fully supported from the government who has allocated a budget for the training of traunees.
  • The funds are helping in different ways:
  • To build capacity to establish Family Medicine as a specialty in Rwanda
  • To support country to build its capacity in the trainig of trainers in Family Medicine
  • To support strengthening of the health care services in Rwanda including primary health care, by incorporating family medicine in the national health system.
  • With above interventions local graduates will continue to support and work on sustainable program.

Partnering Strategically with Faith Based Organisations: The Case of Moravian Diploma Nursing School in Mbozi, Tanzania

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Author(s): Alexander Bischoff1, Sunoor Verma1
Affiliation(s): 1Division of International and Humanitarian Medicine, Geneva University Hospital, Geneva, Switerland
1st country of focus: Tanzania
Additional countries of focus: Switzerland
Relevant to the conference theme: Communicable chronic diseases
Summary: To address chronic conditions effectively, investments need to be made training nurses with additional and new skills. This is even more relevant in the rural low-income setting where the trained workforce has a high turnover due to economic migration.  In this presentation we will use the partnership between the University Hospitals of Geneva, "Solidarité internationale" and the Moravian Church of Tanzania which has led to the establishment of the Moravian Diploma Nursing School (MDNS) as a case study. We look at the potential and challenges of partnering with a faith-based organisation especially in the broader context of the global chronic conditions epidemic and the human resources in health crisis.
What challenges does your project address and why is it of importance?: The global epidemic of chronic conditions leads to an acute shortage of health workers. The workforce crisis is particularly serious in low-income countries in sub-Saharan Africa, compounded by the fact that the few health workers that are trained in these countries often migrate to the richer countries in the North. Two main strategies exist to address the human resources crisis: either to put into place retention policies in rural areas or to invest in new capacity building. In Tanzania the projections given by the Ministry of Health and Social Welfare (MOHSW) show the need of nursing officers is 20,008 but only 3,280 are in the market. The gap is therefore 16,728.To fill this gap, 18 new schools would need to be built. In Tanzania, the MOHSW is expanding the health services infrastructure in order to ensure universal access to quality health care. The MOHSW has to increase the training capacity in order to train an adequate number of skilled and competent human resources to provide the much needed health services. Currently, there is a huge discrepancy between available infrastructure and available trained health personnel, in particular nurses. While Tanzania is used as an illustration, this scenario is valid to many other low and middle income countries around the world.
How have you addressed these challenges? Do you see a solution?: The need for more nurses is such, that more nurse training institutions are urgently needed. Therefore, the MOHSW is encouraging private institutions, in particular faith-based organizations (FBO) to start or increase their respective nurse training capacities. It is against this background that the Mbozi Diploma Nursing School project was launched.  The Tanzanian Human Resources for Health strategic plan foresees and encourages Private Public Partnerships and FBO driven initiatives to address the shortfall in health workforce:  In Tanzania, 83 hospitals are run by churches (FBO). Overall FBOs provide more than 50% of the health care services in the country.  The MDNS project is constructed as a PPP between the FBO, i.e. the Mbozi Mission Hospital of MCT-SWP, HUG, Solidarité and the MOHSW. It should be mentioned that the FBO is adhering to all policy and clinical guidelines regarding health care in general and HIV/AIDS in particular, issued by Government and WHO. Also, MDNS nurse graduates will receive governmental (MOHSW) certificates and will be free to seek employment wherever they want (they are in no way bound to stay at the MMH or at another FBO health facility).  This project attempts to address the human resources for health shortage by providing diploma nursing education in a rural area where there are few training opportunities. It is an initiative by the Moravian Church of Tanzania South-West Province (MCT-SWP), via its own Mbozi Mission Hospital (MMH) and the Swiss-based partner organization DIHM in Geneva. The DIHM (Division of International and Humanitarian Medicine) is part of HUG (Hôpitaux Universitaires de Genève, Switzerland).  The establishment of an institutional partnership between the MMH Nursing School and the SMIH/HUG will ensure the provision of clinical, educational, management and evaluation support by a different HUG services. The donor is SSI, “Service de solidarité international”, a governmental (cantonal) international development organization.
How do you know whether you have made a difference?: The project is in the first phase of implementation hence it is premature to gauge impact. However if the community participation can be an indicator to how well a need is being addressed, then this project is certainly making a difference. The community has been enthusiastic in its support of the infrastructure development phase of the project. There is increasing pressure from the community to increase the number of enrolments in the school. The overall goal of the project is: to improve access to quality primary health services for the population in Mbeya Region by training nurses in a new Nursing School, attached to Mbozi Mission Hospital. These are the 6 objectives: (A) Decrease nurse shortage, (B) Improve quality training (nursing skills), (C) Improve quality of care /services,  (D) Balance between Human Resources (HR) and infrastructure, (E) Influence health policy (on Human resources), (F) Guarantee sustainability. A detailed project monitoring plan that lists the deliverables (progress indicators) at 6 points in time, i.e. every six months in the 3-year-duration-project shall measure whether the present project makes a difference.
Have you or the project mobilized others and if so, who, why and how?: The present project has been able to mobilize a number of actors in the region. We obtained support and/or go-aheads by different federal governmental officials at district level by district council authorities, the MCT-SWP (church central level). Also, we obtained agreement for nursing student internships at the following health facilities: Vwawa Hospital, Tunduma Health Centre, Mbeya Referral Hospital, Mbeya Regional Hospital.
When your donor funding runs out how will your idea continue to live?: This is an initiative that addresses well articulated needs and wants of the community in which it is embedded. Partnership arrangements are such that they ensure that once the training facility and program is established, it will be integrated into the national chain of such schools.  With up-to-date infrastructure as well as the investment in HRH in the health sector, the project will have a sustained impact, also beyond the project duration. Accommodation facilities that are well-built, well-run and well-kept, will be seen as a well organized school. FBO programmes have been generally acknowledged for their long-term commitment and sustainability as they are well rooted in the community and the community members have a direct stake and control over the direction of the initiatives. The project setting is unique at this moment because the MOSHW is actively encouraging PPPs and has been a reliable partner in international funding and is seeking pilot-projects which can be replicated elsewhere. There is therefore a pronounced interest by the MOSHW that this project works and is sustainable. In the future, the nursing school will be able to generate funds thanks to the student tuition fees.

Slowing Down Non-Communicable Chronic Diseases in Mali with Inclusive Education and Learning Nests

Author(s): Maryvette Balcou-Debussche1, Xavier Debussche2, Stéphane Besançon3
Affiliation(s): 1LCF-UMR 8143 CNRS, Université de La Réunion, Saint-Denis, La Réunion, 2CHU de La Réunion, Saint-Denis, La Réunion, 3ONG Santé Diabète, Bamako, Mali
Name your project or intiative: Slowing down the burden of non-communicable chronic diseases by developing an inclusive educational approach: the learning nests
1st country of focus: Mali
Additional countries of focus: Burundi, Reunion, Mauritius, Botswana, Mayotte, French Guiana
Relevant to the conference theme: Non-communicable chronic diseases
Summary: To face the burden of non-communicable chronic diseases efficient and feasible actions devoted to prevention and education are urgently needed. Emerging from a co-construction of expertise of social scientists and medical world, the theoretically-based learning nest approach is matched to the special characteristics of chronic diseases in plural contexts. Complete sets of educational materials can be used for small groups of learners at close quarters by trained social workers or peer educators. The first implementations in Africa and Indian Ocean have yielded results that open the way to a constructive reflection on the issues of prevention in chronic diseases.
What challenges does your project address and why is it of importance?: Most African countries are faced with contagious diseases (HIV, malaria…) but recent data show the extensive although silent burden of non-communicable diseases. This progression arises in the general context where professionals and institutions are primarily focused on curative aspects, and available drugs are costly. Moreover, human resources for health are scarce and the external resources coming via ONG and/or experts are overall characterized by the translation of questionable occidental models that cannot easily integrate actual culture, languages, literacy, and social dimensions. African countries can nevertheless mobilize major assets, such as community networks and social dynamics, in order to drive, anticipate and convey health and prevention. The present project takes into account the gaps, but also the assets that can be utilised for a sustainable approach, consistent with the localised environment. The challenge consists in changing the predominant paradigm of health care: from the focus on communicable diseases to the consideration of chronic diseases; from the curative perspective to the preventive and educative one; from the costly prevalence studies to the rapid development of actions with the harvest of relevant indicators, and consideration of actors involved in social dynamics (social workers, peers educators).
How have you addressed these challenges? Do you see a solution?: The development the learning nests aims to allow the implementation of preventive and educative actions for adults with high risk of cardiovascular diseases. The action is based on complete sets of educational material for educators and learners, which have been validated by experts from biomedical sciences and from human and social sciences. The approach is focused on the cognitive work of learners for the appropriation of knowledge in group sessions taking into account the specificity of individuals and their integrative environment, as well as conditions needed for action. Sessions take place in a comfortable and non-conflictual environment designed to encourage the emergence of new knowledge and self-esteem (hatching), self efficacy and autonomy in the social, cultural, and economic environments of persons at risk. The development of this approach relies on the identification of existing organizations and voluntary people. During a short-term pragmatic training (3 days), actors focus on the cognitive issues and on the educational approach that aims to promote a long-lasting appropriation of knowledge by the persons concerned with non-communicable diseases. In a first self-assessment session, patients work on their own clinical and biological factors that influence health maintenance (blood glucose, blood pressure, lipids, weight, waist circumference, smoking), before looking at lifestyle effects, and the specific impact of eventual changes, the focus moves to scrutinizing the feasibility of action planning and implementation in real life, taking into account all individual, social, and contextual dimensions. At the end of the session, 2 other complementary sessions are scheduled: physical activity - food and control of fat intake. Sessions are based on specific booklets, for learners and for educators, with a curriculum written protocol (EPMC booklets; Education Prévention des Maladies Chroniques), including those with literacy difficulties. In each session, patients will become aware of issues they can manage on a priority basis, taking account not only of medical dimensions (level of HbA1c, other risk factors, treatment, etc.), but also psycho-sociological, contextual, environmental, cultural and economic dimensions. This approach is possible thanks to attractive and clear supports, presented in the form of educational notebooks, a current and constant adaptation of supports for various contexts in Africa, and continuous work for more than 10 years to model an educational successful basic cycle, along with the potential fast distribution of the information and its relevance for the short and longterm. Finally, the approach integrates the possibility of working everywhere, with a single requisite equipment: supports notebooks and pencils.
How do you know whether you have made a difference?: The learning nests have been trialed from 2004 to 2011, with more than 10 000 persons exposed to cardiovascular and renal diseases, in various settings and countries (Reunion island, Mauritius, Burundi, Mali, French Guiana, Botswana, Comoros). Training sessions of educators have involved more than 500 health educators: health professionals, social workers and peer educators.  In Mali, peers educators have been trained during 3 days sessions and involved in educational sessions for persons with diabetes in Bamako and Sikasso community health centers for more than one year. A randomized control trial is being conducted, with 4 educational sessions: control of cardiovascular risk (blood pressure, waist circumference, smoking, cholesterol, glycaemia), control of Food (balance, fat, carbohydrates), physical activity management, insulin management carried out. 150 persons have been educated.  In Burundi, during the 2 months following the first training session of educators, 12 educational sessions have been held involving 109 subjects at high risk for CVD, and 7 among the ten health structures of the capital Bujumbura (hospitals, health community centers, NGO, diabetic patients associations). During the first six months a total of 60 sessions involving 567 subjetcs, and at 20 months, 2000 subjects have beneficiated from educational sessions. In Reunion, From 2004 to 2007, 394 educational sessions with a mean of 7 high risk patients have been completed : a total of 1220 patients were involved in 1 to 3 sessions (CV risk: 1009 subjects; Food regulation and fats: 837 subjects; exercise: 501 subjects).  Results in terms of intermediate health indicators (blood glucose, blood pressure, waist circumference) are positive and encouraging, as well as the evolution of the total health modifiable risk (calculated on the basis of health indicators collected during educational sessions). Trained educators continue to invest in group education for patients and evolve in education skills and practices. Presentation of this project has been chosen int the pre-selection of « Ten ideas for Africa » in 2010 by Unesco (16 pre-selected projects).
Have you or the project mobilized others and if so, who, why and how?: The Learning nests approach have been implemented in Mauritus for the structuration of diabetes education programmes (APSA Diabetes Care Centre). In Botswana, the supports booklets have been adapted and translated in English and in Setswana, and ministry of heath implemented the project in 2010-2011 for diabetes self-management education and cardiovascular risk prevention. In Mayotte (French Comoros) and in French Guiana, training of educators and health professionals has commenced. 
When your donor funding runs out how will your idea continue to live?: Funding support will help to diffuse the approach in countries who wish to halt the progression of non-communicable chronic diseases, in a long, realist, low-cost way that is adapted to local contexts. This approach is very relevant in towns where new products invade marketplaces, and sedentary lifestyles increase.   The support could take place in diverse forms:- targeting persons who are able to financially support the program.  Training, 1st round, of these ressource persons in order to initiate and implement educational sessions− Development and analysis of first actions and implementations− Training, 2nd round, of resource persons with reflections and feedback on experiences and results.− Diffusion of action and approach via these resource persons. In financial terms, donor funding would thus allow to support the costs generated by− Training− Specific equipment (documentation, internet, computers) − Impression of paper supports − Translation and adaptation to the national and\or regional languages and contexts.

School Based Intervention to Prevent Tobacco Use: Sousse, Tunisia

Author(s): Firas Chouikha1, Jihene Maatoug1, Imed Harrabi1, Wahbi Belhadj Khelifa1, Mylene Belkacem1, Sonia Hmad1, Karima Gaha2, Hassen Ghannem1
Affiliation(s): 1Department of Epidemiology, University Hospital Farhat Hached, Sousse Tunisia. 2College Khzema Ouest Sousse, Tunisia
1st country of focus: Tunisia
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The Chronic Disease Prevention Research Center in Sousse Tunisia is implementing a school based intervention to prevent tobacco use among schoolchildren. It is a quasi-experimental study including two groups: a control and an intervention group. This study canvassed a pre- and a post-evaluation of knowledge, attitudes and behaviors about smoking in each group. For this we used a stratified and proportional sampling and included 4003 schoolchildren aged 11 to 16 years in the questionnaire with 1929 and 2074 respectively in intervention and control groups selected from 8 intervention and 8 control schools. Intervention began in 2010 with the training of teachers to animate standardized courses about tobacco use and consequences. We also organized training for young leaders who participated in the animation days to prevent tobacco use in their colleges. On world 'No Tobacco Day' schoolchildren leaders celebrated with the help of the project team in each of 8 intervention schools. They prepared posters which were displayed in the schoolyard. They also distributed pamphlets about consequences of tobacco use and how to prevent smoking. In other schools, schoolchildren leaders presents sketches to their collegues and their teachers. A group of leaders visited the cafeteria of the University Hospital of Sousse and tried to discuss with patients the consequences of tobacco use. They also discussed with health care professionals about their role of models and the importance to help patients quit smoking. This school based intervention is a part of a community intervention program entitled “Together in Health” targeting 3 risk factors for chronic diseases: smoking, physical inactivity and unhealthy diets in 4 settings: schools, workplace, health care setting and neighborhood. This video is to illustrate their activities.
What challenges does your project address and why is it of importance?: Tunisia is facing an epidemiologic transition and cardiovascular diseases represent the primary cause of death. Tobacco use is an important risk factor and is the first preventable cause of death.
How have you addressed these challenges? Do you see a solution?: Tobacco use begins at early age among adolescents. Once this occurs tobacco cessation is more difficult than prevention. So, we propose to implement an intervention to prevent tobacco use among schoolchildren.
How do you know whether you have made a difference?: Our project consists of a research study. It’s a quasi experimental design with intervention and control groups. We began our study by an evaluation of knowledge about smoking, attitudes and behavioral intent before the intervention.
Have you or the project mobilized others and if so, who, why and how?: To implement our project, we have different partners. The National partners are: University Hospital Farhat Hached Sousse, Department of Pediatrics, Regional Direction of Health of Sousse, Primary Health Care, School Medicine Unit, and Regional Direction of Education of Sousse  Regional Direction of Youth, Sport and Physical Education of Sousse Tunisian Heart Foundation, Tunisian Association of Life and Earth Sciences Teachers. The International partners are: National Institute of Health and welfare of Helsinki, Finland, Division of International and Humanitarian Medicine, Department of Community Medicine, Primary Care and Emergency Geneva University Hospitals
When your donor funding runs out how will your idea continue to live?: In our project, we trained teachers and schoolchildren leaders so they could participate with the project team in intervention activities. We rely on teachers and leaders to continue our actions of tobacco prevention.

Needs for People with Type 1 Diabetes: Guidelines versus Patient Requirements

Author(s): David Beran1,2
Affiliation(s): 1Advisor to the Board, International Insulin Foundation, London, United Kingdom, 2Researcher and Lecturer, University of Geneva, Geneva, Switzerland
1st country of focus: Switzerland
Additional countries of focus: Argentina, Indonesia, Kyrgyzstan, Mozambique, Nicaragua, Singapore, South Africa, Tanzania, Thailand, UK, USA and Vietnam
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): For the management of Type 1 diabetes guidelines exist and therefore international standards for care are defined. Yet people in most countries face challenges in managing their diabetes. Why does this occur? Do guidelines meet the needs of people with Type 1 diabetes?
Background (max 200 words): Type 1 diabetes is the most common paediatric endocrine disorder and the second most common Chronic Non Communicable Disease to affect children after asthma. Type 1 diabetes is characterised with the need for life-long care including daily insulin injections, management of diet and lifestyle as well as regular check-ups. For the management of Type 1 diabetes many guidelines exist and therefore international standards for care for people with Type 1 diabetes are clearly defined. In addition the Diabetes Control and Complications Trial showed that given the optimal conditions diabetes complications could be averted.
Objectives (max 100 words): To identify the needs of people with Type 1 diabetes and compare these to what the international guidance describes as the needs of people with diabetes.
Methodology (max 400 words): In order to identify the needs as defined by people with Type 1 diabetes, semi-structured interviews with 101 people from 13 different countries were carried out. Grounded Theory was used as a framework for collecting and analysing the data. Content analysis found that there was a difference between what guidelines stated and what people wanted.
Results (max 400 words): From the guidelines a varying level of importance was placed on some of the needs. For example identification, although stressed by the guidance, was not viewed as important by people with diabetes. The guidelines seemed to focus more on tangible health system aspects of care whereas the needs of people were more outside the health system. For example the importance of peer support and being open about their diabetes.
Conclusion (max 400 words): Although the Diabetes Control and Complications Trial (DCCT) found ways of decresing complications in Type 1 diabetes in reality people still face many challenges. This research highlights that there is a difference between the guidelines proposed by experts and what individuals with diabetes require.

Prevalence of Depression among the Elderly Population in Rizal Province Using the Geriatric Depression Scale

Author(s): Cheridine Oro- Josef1, Ma. Cristina dela Cruz1, Teofilo Salandanan Jr.1
Affiliation(s): 1Home Health Care, Quezon City, Philippines
1st country of focus: Philippines
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): The rate of depression (6.6%)  noted in this study was consistent with local studies done by Filipino authors. This prevalence rate among the elderly in the most populated province of the Philippines shows that depression can be present in Filipino healthy communities. However, it is considerable to note that a fourth (26.5%) of the population have scores suggestive of depression. This is a window for early intervention in the community level. Depression has been found to be associated with poorer prognosis, longer recovery times from illness, and increased health care utilization. Screening the elderly population for possible depression is important to decrease health care utilization and increase wellness for this age group. It is necessary for primary care physicians, geriatricians and caregivers to identify symptoms of depression in patients with scores suggestive of depression to avoid the development of outright depression. The Geriatric Depression Scale Short Form 15 has proven itself to be a fast, simple screen to quickly and efficiently identify those elderly who may be depressed.
Background (max 200 words): Depression in the elderly is an important public health concern worldwide. It is a silent disorder that afflicts many in the elderly population. It is the most common psychiatric disorder among the elderly yet unrecognized and under treated because attention is often focused on the physical medical conditions that are apparent during clinic visits. Typical signs and symptoms of depression are usually absent (such as lack of energy, loss of appetite, constipation, no interest in work, poor sleep or loss of weight) and are masked by physical manifestations of co-morbid conditions. In community practice case reports of elderly suffering from depression were regarded as consequences of the aging process. Contrary to this belief depression in the elderly is not physiologic. It is a pathologic condition that is reversible with prompt and appropriate treatment. Failure to recognize and treat depression increases the risk of a prolonged course of depressive illness as well as other conditions like malnutrition, significant metabolic illnesses, and a greater chance of dying.
Objectives (max 100 words): To determine the prevalence of depression and associated socio demographic and clinical conditions among the elderly in Rizal province. SPECIFIC OBJECTIVES: 1. To describe the socio-demographic and clinical conditions of the elderly in Rizal. 2. To detect depression among the elderly population using GDS SF 15. 3. To determine association between depression and socio-demographic and clinical conditions among the elderly
Methodology (max 400 words): A cross-sectional survey of the elderly population (aged 60 yrs old and above) in Rizal province, Philippines was conducted between August to October 2009. Simple random sampling was done to select 3 barangays from 3 municipalities in Rizal. A list of the elderly (60 years and over) was compiled from each of the barangays. All the subjects were contacted for a personal interview. The subjects' socio-demographic, socio- economic and clinical data were gathered during the interview wherein a structured questionnaire was completed. The Geriatric Depression Scale (GDS) SF 15 was used to screen for depression.
Results (max 400 words): The total number of elderly subjects included in this study was 196. There were 122 females and 74 males. Their mean age ± standard deviations was 67 + 6.89  (male 67.7±.6.7; and female 67.7±7) years. Most of the subjects were married, 56% (n=110) while 37.4% (n=73) were widowed. A few were single, (n=8, 4.1%) and separated (n=4, 2.1%). The majority were unemployed (n=173, 88.7%). Their source of financial support mostly came from their children (n=103, 62.8%). They live with either one or two married children (n=78, 40%) or their nuclear family (n=56, 28.7%). Most of the subjects were independent (n=127, 64.8%) and moved around without support (n=167, 86.5%). The top 3 medical conditions were Hypertension (n=75, 37.9%), Arthritis (n=50,25.3%) and other Heart diseases (n=18, 9.1%) . GDS SF scores suggestive of depression were reported in 52 (26.5%) of the subjects, and 13 (6.6%)  were in the almost always indicative of depression score group. Marital status (p= 0.044) and presence of multiple medical condition (p=0.018) correlated strongly with depression. Separated and widowed individuals are more likely to show symptoms of depression (R= 0.159).
Conclusion (max 400 words): Depressive symptoms are common among Filipino elderly in Rizal. Detection and early intervention may be helpful at the community level. A simple instrument such as the Geriatric Depression Scale SF 15 is useful and easily administered.