Geneva Health Forum Archive

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GHF2010 – PL01 – Globalization and Health Systems: Regional Perspectives

Session Outline

Plenary session PL01, Monday, April 19 2010, 9:00-10:30, Room 2
Chair(s): Yibeltal Assefa, Medical Services Directorate, Federal Ministry of Health, Ethiopia, Bruno Marchal, Department of Public Health, Institute of Tropical Medicine Antwerp, Belgium
Summary: The aim of this session is to introduce some of the complex challenges that countries face in meeting health-related needs in contexts of rapid economic and social change. The recent financial crisis and the increased involvement of several African, Asian and Latin American countries in global negotiations have highlighted the global nature of many of these challenges. It also underlines the importance of strengthening communications and learning between researchers and policy actors in different regions. Three thinkers from India, China and Brazil will introduce key issues that are taking on growing importance, followed by discussion and reflexions by a discussant from Africa to reflect on efforts to address major public health problems in that continent.
The Private-not-for-Profit Healthcare Sector in Uganda
Josefien van Olmen, Research Officer and Coordinator, Network Health Systems, Department of Public Health, Institute of Tropical Medicine Antwerp, Belgium
Training of Medical Doctors in DR Congo: Consequences of Uncontrolled Explosion of Medical Schools
Sara van Belle, Department of Public Health, Institute of Tropical Medicine Antwerp, Belgium
Experience with People-Centred Care in Thailand: From Demonstration Diffusion to Policy Transformation
Yongyuth Pongsupap, National Health Security Office, Nonthaburi, Thailand (via visioconference)

Session Documents

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Session Video

This session is available to watch using Dudal. To watch it you will need to have Java installed on your computer.

Session Report

Submitted by: Promila Kapoor-Vijay (ICVolunteers); Contributors: Nan Hsin Chang (ICVolunteers)

Photo by John Brownlee, ICVolunteers.org

The opening session of the 2010 Global Health forum addressed health issues in the context of globalisation, crisis and health systems. These issues are currently affected by food and fuel supply, economics and natural disasters. Chairperson Dr Yibeltal Assefa of Ethiopia, from the Institute of Tropical Medicine Antwerp, Belgium, provided an Introduction to regional perspective of health system representing countries of the south based on studies from Uganda, Thailand and the Democratic Republic of Congo (DRC).

Dr Josefien van Olmen, coordinator for the Network Health Systems of the Institute of Tropical Medicine Department, Antwerp, gave an overview of the World Health Organization (WHO) framework of six building blocks and provided a regional perspective based on network experience in African countries. Resources (financial, human, administrative and information), core health care services (organized and influenced by the local authorities) and have shared values and principles with the beneficiaries. Interaction with the population is key. Dr van Olmen outlined the models from Uganda, DRC and Thailand to illustrate existing health systems, their strengths and challenges, and true lessons to learn.

Private, not-for-profit organizations are an important factor in health care delivery in Uganda. Their motto is “Health is not a business, health is a calling”. The sector is coordinated by faith-based religious medical bureaus. Dr van Olmen, representing Dr Sam Orochi Orach (Executive Secretary of Uganda Catholic Medical Bureau), described the system as having community approval in its target communities, most of which are deprived. Finance is the main constraint in providing health delivery: since funds from churches are drying up, the gap is being filled with resources from private donors. Uganda’s government does not have the resources to support this category of health care. Dr van Olmen emphasised that the key strengths of this health care derive from decentralization and the principle of subsidiarity. The values and objectives of this system need to be recognised and rewarded.

Another imbalance in a health system model was discussed by Dr Sara Van Belle, based on the studies of Dr Chenge Mukalenge of Congo, describing the consequences of the recent explosion in the number of medical schools in the country. An increase in the number of medical faculties is a source of profit to politicians, but has resulted in an excess of poorly trained medical workers practicing low-standard medicine. The current dependence of the population on badly equipped private clinics demands quality assurance mechanisms.

A model of a system implemented recently in Thailand seems to be working smoothly, according to Dr Yongyuth Pongsupap, who presented the people-centred-care health strategy. This reform from the hospital-centred system happened thanks to political pressure from the population for universal health coverage. Family doctors train in rural areas, primary health facilities absorb the whole community and integration with district hospitals is made by referrals from rural centres. A new approach based on listening/understanding/negotiating has been stressed and tools for the proper flow of patients have been created, including registration, information, payment and community meetings. These policy changes have made it possible to provide primary care to 600,000 community residents. Remaining challenges are to consolidate family practice, maintain quality and access, and ensure synergy between the different parties.

Lack of economic resources, retention of qualified professionals and the acceptance of tools to improve health services were the main problems discussed in this session. Key factors in achieving success could include an insurance system to make healthcare affordable for the population, decent remuneration and good living conditions for the employees, and strong government. In short, the commitment from every sector is vital for strengthening health care. Suggestions from the audience included investing in rural development and giving consideration to the role of private, for profit healthcare.

Regional perspectives of health systems show the use of differing approaches and models. Strengths demonstrated included tapping into local community resources and local leadership, assimilation with local values, the use of faith based religious organizations and not-for-profit health care systems. Weaknesses included poor funding, poor absorptive capacity, lack of infrastructure and poor quality training of medical professionals.

GHF2010 – PS35 – Pandemic Preparedness and Response: Lessons Learned from H1N1

Session Outline

Parallel session PS35, Monday, April 19 2010, 11:00-12:30, Room 2
Chair: Tessa Richards, Assistant Editor, British Medical Journal (BMJ), United Kingdom
H1N1 Preparedness and Response: Early Lessons Learned
Sandra Jack-Mounier, Lecturer, Department of Public Health and Policy, Communicable Diseases Policy Group, London School of Hygiene and Tropical Medicine, United Kingdom
Global Response to Pandemics: Navigating amidst Great Uncertainty
Dominique Legros, Medical Officer, World Health Organization, Switzerland
H1N1 Vaccine Production: The Industry Perspective
Norbert W. Hehme, Chair, IFPMA Influenza Vaccine Supply (IVS) International Task Force, Germany
The Ethics of Pandemic Preparedness for Migrants and Host Communities
Montira Inkochasan, Migration Health, International Organization for Migration, Laos

Session Documents

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Session Video

This session is available to watch using Dudal. To watch it you will need to have Java installed on your computer.

Session Report

Submitted by: Mary Picard (ICVolunteers); Contributors: Jane Marriott (ICVolunteers)

Healthcare practitioner administering the H1N1 live attenuated intranasal vaccine (LAIV), photo Public Health Image Library (PHIL) of CDC, James Gathany

Major lessons learned from the recent H1N1 flu pandemic were presented by representatives of the WHO, the International Organisation for Migration (IOM) and the pharmaceutical industry. Topics discussed were the importance of the revised International Health Regulation (IHR) in the sharing of information between governments, the necessity of communicating directly with the public and crisis management during the acute phase of the health crisis, and improved risk management models. Topics of ethics in pandemic preparedness among migrant communities and consequences for host governments were also examined.

Dominique Legros, Medical Officer for the World Health Organization (WHO), presented a talk entitled Global Response to Pandemics: Navigating Amongst Great Uncertainty. He discussed similarities and differences between the H1N1 pandemic and previous pandemics encountered in recent public health history such as Ebola, Marburg, SARS and Avian Flu.

The H1N1 pandemic varied from previous recent strains of influenza in that populations had very little immunity, the virus spread very quickly internationally and the concentration of deaths and complications were found in younger segments of the population. At the level of global coordination, it was the first time many countries were well prepared with stockpiles of vaccines and with coordinated and shared information and communication, due, in large part, to IHR which came into effect in 2007. Additionally, public access to information was not limited to government channels. Improved models of risk assessment by WHO and outside agencies allowed for improved tracking and coordination during the acute phase of the crisis. These models were used both in material (vaccine preparation) coordination and the tracking of health risks. For the first time, direct communication with the public became a critical factor. The speaker acknowledged that the handling of the pandemic by WHO was being reviewed by an external body, as outlined by the IHR, with preliminary findings being released in May of 2010.

Montira Inkoshasan, of Migration Health for the IOM Laos, spoke of the absolute necessity for the world and for individual governments to address the needs of migrant Groups and refugees in their planning. Ms Inkoshasan mentioned the fact that this vulnerable group is still largely neglected when it comes to host-nation planning, though this often occurs due to oversight rather than conscious neglect.

In a survey recently carried out by the IOM, it was found that only two global plans referred to the need for the clinical treatment of migrant workers and only one national plan recognised the risk of stigma and discrimination for these vulnerable groups. Language and addressing cultural differences is the key to creating viable planning options for migrant populations. It is the lack of fluency in the host-county’s language which has meant migrants and other vulnerable groups have been excluded in most of the National, Regional and Global Pandemic Plans.

The IOM will continue to promote awareness of migrant needs and their inclusion in pandemic preparation plans in all communities worldwide.

Ms Bernat of IFPMA Influenza Supply was standing in for Norbet Hehme of the same organization. She discussed the pharmaceutical industry’s review of the H1N1 pandemic, specifically the need for increasing global collaboration. The industry and WHO worked together to ensure that there was a plentiful supply of H1N1 vaccines before the start of the influenza season in November 2009 through constant communication and consultation.

However, Ms Bernat commented that for manufacturers to continue to strengthen their state of preparation, it is important to maintain and enhance both drugs and systems, particularly in regard to the support of developing countries. The industry is currently concerned with strengthening future preparedness and understands that information dissemination and communication are essential.

There is a need, underlined Ms Bernat, for WHO to work towards improving and standardising its communication systems to make future decision making more streamlined and therefore quicker and more effective.

Ms Bernat stated that the industry continues to learn from last year’s pandemic and is committed to improving its communication and vaccine production systems in conjunction with WHO.

The moderator, Mr R. Waldgate, a freelance journalist specializing in medicine and world health, most notably with the Lancet, stood in for Tessa Richards, assistant editor of the British Medical Journal. He began the discussion segment with the question of whether WHO was ready for a pandemic in South America. The answer was that it would depend, as always, on the level of demand for medication and that this was of course the unknown which makes a response so uncertain.

Mr Waldgate went on to ask whether public trust had been eroded by the controversy surrounding the response to last year’s H1N1 pandemic, which displayed communication failings and a rush to increase vaccine production which, in hindsight, may have been unnecessary.

Interestingly, Ms Bernat, speaking on behalf of the pharmaceutical industry, declined to respond but directed the audience to statements on this subject already issued by the industry’s official press.

A spokesman for Médicins sans Frontières (MSF) asked for some clarification of global capacity for vaccine production. Ms Bernat responded that total world-wide capacity is 4.49 million, which has to cover pandemic requirements as well as normal demand for doses of seasonal influenza vaccines.

There was a general consensus that more needs to be done to reach the world’s poorest populations and that this is largely the responsibility of individual countries. Intellectual Property Watch, here in Geneva, raised the point of unfair distribution of vaccines. During last year’s H1N1 pandemic, there was a shortfall in supply of vaccines in developing countries at the same time as there was a surplus elsewhere. The participants agreed that a fairer distribution needs to be made a priority in future.

An interesting question was raised by a manager from the University Hospital in Geneva (HUG) as to what can be done in the future about the significant number of the public who were reluctant to be vaccinated against H1N1, particularly here in Western Europe. The consensus was that this is a matter of better communication between health officials and the public. A new web-site is being planned by the Institut Pasteur in order to address the need for better dissemination of accurate information on health issues.

Interestingly, the public response differed around the world. In particular, there was a contrast between the public response in North America and that in Europe. The delegates believed the media had played a big role in this contrasting response and that communication between WHO and Governments needed to be looked at. Someone from the floor asked about how much the pharmaceutical industry had profited from the creation and distribution of the H1N1 vaccine. The panel referred to information published by individual pharmaceutical companies.

In an interview conducted after the meeting, Dominique Legros highlighted the role of a ‘no risk’ policy, which many governments around the world apply to public safety, in guiding them to err on the side of caution when judging possible vaccine requirements. Manufacturers plan production based on these government estimates. The current grounding of all commercial aircrafts in Europe is an example of this ‘no risk’ attitude at work.

Global Health Governance: What Does Complexity Theory Offer?

Author(s): A. E. Olusegun1
Affiliation(s): 1President and CEO, Life Gate Foundation, Ikeja, Nigeria
Keywords: Complexity Theory, Global Health Governance, systems, emergence
Background:

Global Health Governance shares the characteristics of Complex Adaptive Systems, with its multiple and diverse players, and their polyvalent and constantly evolving relationships, and rich and dynamic interactions. The sheer quantum of initiatives, the multiple networks through which stakeholders key (re)configure their influence, the range of contexts in which development for health is played out – all compound the complexity of this open system. The divergent development and health paradigms that shape policy and programme approaches, together with the variance between and within countries into which these are translated, contribute to the ‘ignorance’ within the system of what other elements of the system are contributing, with resultant duplication, redundancy, tension but also emergent synergies. The system shares an uneven distribution of attention and resources over the global burden of disease, and limited predictability in terms of outcomes over time. The patterns produced are not without a past: each new initiative arises from a particular conjunction, a specific relationship, a unique history; organizations emerge or die, challenge for dominance, re-assert or redefine roles; innovative alliances result in productive potentials; policy tropes are recycled and repackaged in an attempt to ‘tie down’ global partners with limited constraints of accountability.

Results/Conclusions: This paper argues that examining Global Health Governance through the frame of complexity theory offers insight into the current dynamics of governance, and suggests potential loci for intervention and influence, and strategic approaches to structural change.