Geneva Health Forum Archive

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Collaborative Patient Care Pathway Model: Comprehensive Care Coordination for Geriatric Population

Author(s): Alakananda Mohanty1
Affiliation(s): 1Kissito Healthcare, Roanoke, United States
1st country of focus: United States
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): Current trends in healthcare reform include penalties for high readmission rates that put providers at risk if patients are rehospitalized within 30 days. The goal of recent incentives under healthcare reform is to promote increased attention to chronic disease self-management competencies of patients, alter healthcare delivery systems to have increased responsibility for preventable readmissions and enhance quality care while using resources wisely. Kissito Healthcare has designed an unique collaborative model, the Collaborative Patient Care Pathway (CPCP)TM Model, which aims to deliver quality patient-centered care, greater continuity of care and improved patient outcomes at a reduced cost. The Model primarily focuses on chronic illnesses such as Congestive Heart Failure (CHF), Pneumonia, Acute Myocardial Infarction (AMI), Diabetes, Orthopedic Conditions, Depression and COPD/Asthma
Background (max 200 words): While traditional post-acute care in skilled nursing facilities focuses primarily on treatment, recuperation and short-term rehabilitation, Kissito Healthcare’s CPCP Model has chronic disease self-management as the fourth component, which is unique. The Model is currently being implemented at three Post Acute Care sites in the states of Arizona, Texas and Virginia.  The Model is based on three tenets: 1. Four Domains of Self-Management Competence 2. Patient-Centered Communication 3. Family-centered Approach to Self-Management
Objectives (max 100 words): At the patient and family (individual) level, outcomes include: Increased awareness/ knowledge of their disease, change in motivation (adherence), increased competency in recognizing red flags and responding with appropriate action and increased confidence in communicating with the health care provider. At the program and systems level, outcomes include: reduction in preventable hospital readmissions, reduction in hospital readmission rates and appropriate use of primary and community-based care options
Methodology (max 400 words): As indicated earlier, the model is based on three tenets.  1. Four Domains of Self-Management Competence. These domains are based on recent evidence in chronic disease management and outcomes: Disease Awareness - Patients are taught the disease etiology and progression, and to recognize “red flags” as a call to action.  Adherence Attitudes - patients are educated to overcome personal challenges related to the disease through  a structured assessment.  Treatment and Medication Management Competence -  patients are taught how to take their medications and adhere to their medication regimen at home. MedAction PlanTM - a web-based user-friendly software that continues to guide patients at home on their medications, and also includes powerful information to support continued health literacy of patients and families.  Healthcare Communication - patients are coached to improve their ability to communicate with their care providers.  2. Patient-Centered Communication which is “ask – tell – ask”. This unique patient-centered tool, based on adult learning theory, is used to bring the patient’s experience, perspective and concerns into a dialog, promoting shared decision making with his/her care providers, and is essential to self-management education and competence.  3. Family-centered Approach to Self-Management -  strengths, weaknesses, availability and willingness of family members (who play an important  role in the patient’s self-management team) are evaluated through structured assessment tools such as Beliefs about Medicine Questionnaire (BMQ), Patient Activation Measure (PAM) and Care Transitions Measure (CTM) Tools. Upon admission  to a Kissito Post  Acute Care Facility an assessments of the four domains of self-management competence was conducted.  An individualized care plan was designed by the Interdisciplinary Team (IDT) for attainment of optimal, patient-centered outcomes based on the assessments. The patient was educated for enhanced communication with his/her care providers. The patient was educated to perform a range of routine duties that he/she hoped to perform  at home under the self-management competence program. Medication reconciliation was carried out based on the patient’s current and planned discharge medications. In-home safety assessment was conducted prior to patient’s discharge to ensure that the home environment was safe for the patient.  Prior to the patient’s discharge, the same assessments conducted upon admission were repeated to assess progress and identify areas for continued attention.  Post Discharge calls were made between 24-48 hours,  in 2-3 weeks, after 30 days, and as often as needed in between, to ensure adherence to medication, diet, self-monitoring and physician visits.
Results (max 400 words): The following preliminary results indicate the percentage increase in patients’ understanding and behavior about self-management (compared to pre-intervention baseline data):• There was a 20% increase in disease awareness (n=50)• There was a 18% increase in signs & symptoms (n=50)• There was a 31% increase in motivating concerns (n=50)• There was a 26% increase in current status awareness (n=50)• There was a 33% increase in reflags awareness (n=50)• There was a 22% increase in understanding of RX  (n=50)• There was a 18% increase in meal preparation (n=50)• There was a 31% increase in disease self management (n=50)• There was a 19% increase in exercise activity (n=50)
Conclusion (max 400 words): The CPCP model is in its early implementation stage therefore evidence of the Model’s effectiveness remains inconclusive, although based on intermediate results there are positive outcomes.  Preliminary results demonstrate reduction in hospital readmissions within 30 days of post acute care discharge and successful transition to home among geriatric patients. We are in the process of establishing collaborative relationships with hospitals, Managed Care Organizations, Home Health Agencies, Physician (Community) Practices and other key stakeholders to improve the flow of patient information, prevent readmissions and develop systems and processes to ease and manage care transitions for patients and their families. The components of the Model are constantly being refined to establish best practices, benchmarks, databanks, and setting standards to ensure that national standards  are met and exceeded. The goal is to improve patient outcomes at a reduced cost through the CPCP Model that can be widely implemented and ultimately translated into a national standard.
 

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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.

Is Assessing Diabetic Distress An Efficient Pathway To Tailor More Effective Intervention Programs?

Author(s): Davoud Shojaeezadeh1, Azar Tol2, Golamreza Sharifirad2, Ahmadali Eslami2
Affiliation(s): 1Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Iran, 2Department of Education and promotion, School of Public Health, Isfahan University of Medical Sciences
1st country of focus: Iran
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Type 2 diabetes is one of the most important health concerns worldwide. Many studies revealed that distress can significantly affect diabetes-related health outcomes, especially patients’ self-management. It is necessary that health experts and professionals take steps to better understand the nature of diabetes distress and its effects on health outcomes. Distress and its manner of management are powerful predictors of adopting self-management behaviors and affect the achievement rate of diabetes control. This study aims to assess the diabetes distress score and its related factors among patients with diabetes. The study can help decision- makers tailor appropriate and timely interventions.
Background (max 200 words): This study was performed to assess diabetes distress score and its related factors among type 2 diabetic patients. Considering the fact that different variables affect diabetes control in diabetic patients, this study tried to determine and analyze related effective variables. Identification and focusing of the modifiable determinants of diabetes distress plays a key role in appropriate intervention planning programs to achieve the best possible outcomes.
Objectives (max 100 words): The purpose of this study was to assess the diabetes distress score and its related factors among type 2 diabetic patients in order to tailor more effective intervention planning.
Methodology (max 400 words): A descriptive – correlation study was conducted for a period of six months in 2011. The study population was type 2 diabetic patients referring to Omolbanin, an outpatient diabetic center in Isfahan. 140 diabetic patients met the inclusion criteria and all participated in the study. A patient's diabetes distress was measured by DDS( Diabetes Distress Scale ) self-report scale with subscales reflecting four domains including Emotional Burden (5 items), Physician Distress (4 items) ,Regimen Distress (5 items) and Interpersonal Distress(3 items). Collected data was analyzed by using SPSS software version 11.5.
Results (max 400 words): The response rate was 100%. Participants were between the ages of 37 and 75 with a mean of 53.23 years (SD=7.82).  54.3% were female, 97.1% were married, and 57.1% had education levels  lower than diploma. Mean of duration of diabetes was 7.1 (SD=5.63) years. 69.3% of participants had borderline metabolic control according to World Health Organization criteria (Table 1).  The average score of total diabetes distress was 2.96 ± 0.83. The average score of each domain was (3.40 ± 1.18), (2.57 ± 0.88), (2.97 ± 0.90), (2.76 ± 0.91) respectively. ‘Emotional Burden’ was considered as the most important domain in measuring diabetes distress. Total diabetes distress revealed a significant relationship between variables such as age (p=0.02), duration of diabetes (p<0.001), marital status, comorbidity, and complications (p<0.001), and history of diabetes (p=0.01). The relationship between each domains and sociodemographic and health related factors has been shown in Table 2. With the intention of tailoring more effective intervention planning, we decided to distinguish which item in each domain had more weight on the score. Table 3 revealed the domains and more frequent response rate in each domain. Furthermore, the Pearson correlation coefficient also revealed that diabetes distress of type 2 diabetic patients had a direct relationship with HgbAlc (r = 0.63, p<0.001). This means that by increasing diabetes distress score, HgbAlc is increased and diabetes control becomes worse.
Conclusion (max 400 words): As outlined in our research it seems some keywords have a pivotal role in diabetes distress, such as emotional support, communication with patient and physician, self-efficacy and social support. All of these points are achievable through an empowerment approach to a diabetes care plan

Establishing Pre-hospital Emergency Medical System in Sri Lanka

First D.D.M.Lakruwan
Last Dassanayake
Name your project or intiative Establishment of Pre-Hospital  Emergency Medical System in North Central Sri Lanka: Gaining some thing from nothing in a resource poor setting

1st country of focus

Sri Lanka

Relevant to the conference theme

Emergencies
Summary By the year 2009 there wasn’t a pre-hospital Emergency Medical System in Anuradhapura. This project was designed fulfill that requirement. There were no local institutions providing training on developing, management and monitoring Pre-hospital EMS. The knowledge was gained through a training program arranged by JICA at Osaka. Establishment of pre-hospital EMS was achieved by fulfilling a set of objectives. Operations of pre-hospital EMS were monitored during first 6 months to understand the technical, logistic and legal issues. During initial 6 months they provided emergency health care to 213 patients and trained 650 population in suburbs on basic life support
What challenges does your project address and why is it of importance? Trauma has become a leading course of hospital admissions in Sri Lanka. Annually average 600,000 admitted to government sector hospitals following trauma. The contribution of the private sector is unknown. During the last 3 decades road traffic accidents have increased by 249%. Therefore an effective pre hospital EMS is essential to reduce morbidity, mortality and secondary injuries.

Rapid urbanization had disrupted the organic solidarity in many cities of Sri Lanka with in few decades, that prevailed for centuries giving minimal or no time to flourish a reasonable mechanical solidarity to compensate. Furthermore increased life expectancy and demographic transition had increased the proportion of the elderly in community who are with more non communicable chronic disorders and emergencies related to them in urban societies
In suburbs it was found on a survey the knowledge and practice of proper and safe initial care and transport of a trauma victim is less than 10% which would lead to secondary injuries even though there volunteerism is high. Furthermore on direct observation it was seen vehicles like three wheelers and motorcycles are used more and more in transporting trauma victims to hospital with little or no care regarding secondary injuries
How have you addressed these challenges? Do you see a solution? Establishment of the emergency ambulance service in the municipality of Anuradhapura

An initial survey was carried out by direct communication and site visits with the potential pre hospital care providers of the municipality of Anuradhapura. The possible institutions with the capability of generating the human resource and the infrastructure were
1. Teaching Hospital Anuradhapura
2. Municipal fire and rescue team
3. Red cross Anuradhapura
All these three institutions had the some extent of infrastructure that can be used in the pre-hospital emergency services and the man power that can be trained for that purpose. Yet the institutions were not engaged in the pre hospital emergency medical services due following reasons
1. Not adequate knowledge in pre-hospital EMS system:
2. Inadequate resources
3. No proper training
4. Different motives and working objectives
5. No interest
There were no academic institutions in Sri Lanka as per 2009 providing a formal education on Pre-hospital EMS, developing, management and monitoring Pre-hospital EMS. Required knowledge was gained by attending a relevant group training program in Pacific Resource center, Osaka, Japan and studying the EMS of Senri emergency and critical care center and the pre-hospital EMS of Osaka fire department.
Establishment of the pre-hospital emergency medical system was achieved by fulfilling a set of fine objectives which included community mobilization communication, developing community and institutional pressure groups, Public private partnership to obtain training and equipments, telecommunication, identification and strategic collaboration with the key partner institutions ( Police, Teaching Hospital Anuradhapura, Australian Sri Lanka Charitable Health fund, Medical Teams International (MTI), human resource development, infrastructure development, acquisition of equipments, formulations of standard operations plans, establishment of codes of practice and designing the EMT documentation formats, studying the possible legal implications and preventive methods through brain storming sessions with relevant expert panels.
Community training on Basic life support
This was designed under the umbrella of the pre hospital EMS of Anuradhapura to increase the chances of survival of the rural population until they are transported to the hospitals from their remote locations following medical or surgical emergencies considering the fact the high level of volunteerism of the village community and low skill levels. This program was developed to run as a collaborative program with the national blood service of Sri Lanka. The stake holders are usually the blood donors of the village community who usually having the higher tendency in volunteering in such emergencies
How do you know whether you have made a difference? During the first six months (01/06/2010 to 30/11/2010) the Pre-hospital EMS had dispatched 211 victims followed by medical and surgical emergencies. It had conducted 14 basic life support skill development programs targeting the rural communities with a participation 645 villagers. In additions it had provided emergency medical care in 4 mass population gatherings during that period

Considering the cohort of victims there was a gradual rise in the number of victims with the advancing age until the third decade of the life. There was a relative reduction in fourth and fifth decades and rise again in the sixth decade attributing to the retiring age. After that the number gradually reduces
Medical emergencies (52.5%) were slightly out numbering surgical emergencies (44.13%). Obstetric cases represented only 2.3% . Two cases were obviously dead according to the working criteria when approaching the scene which account for 0.9% of the cases. Two patients were in cardiac arrest when team reaching the incident (Acute collapse had been witnessed by the bystanders). They were brought to hospital while continuing cardiopulmonary resuscitation. One was confirmed death at the out patient department and the other admitted to Emergency treating unit and diagnosed as an acute myocardial infarction and survived in the acute phase
The majority of the surgical emergencies were road traffic accidents (32) that accounted for 34% of the total surgical emergencies. There had been significant bleeding in 32 cases representing 15% of the total victims which necessitated vigorous active measures to arrest the bleeding. Spinal stabilization was done in 54 cases representing 24.8% of the total number of victims
Considering the medical emergencies the main cause for dispatch was chest pain and difficulty in breathing (34) the key words leading to urgent cardiac or respiratory emergencies. This accounted for 30.4% of all the medical emergencies.
In three instances the advice of the doctor was requested over the phone by the EMTs in the field which is 1.5% of the total cases. Since the multiple casualties were hypothesized doctors of the unit in person attended to mass population gathering during “Pichchmal pooja” and “poson” religious ceremonies held in the municipality and directly involved in managing 16 critical cases which represent 7.5% of the cases
30 % of the cases were attended in less than 5 minutes form the call and 69.7% of the cases were attended with in 10 minutes from the call
Have you or the project mobilized others and if so, who, why and how? A strong community mobilization, formulation of a pressure group with in the institution and the community and obtaining the support of the local and the regional health administrators and the other collaborative bodies were prime objectives of this project.

Convincing the necessity of the pre-hospital EMS to municipality of Anuradhapura to the local and the regional health authorities was the key to the successful commencement and the continuity of the project. Evidence based data, national level annual data of the Ministry of health regarding the current trauma admissions and the trauma management and the health benefits in line with the health master plans that could be expected form the pre hospital EMS considering the effectiveness of the Pre- hospital EMS of the Osaka prefecture were used as the solid information. Multiple levels of health management were invited (local, regional, national) for the initial discussions to obtain the liaison and come in a collective decision in order to prevent the complexities. The initial discussions were conducted in a non directive manner as round table discussions and lectures. Director Teaching Hospital Anuradhapura, Regional Director Health Services, Anuradhapura, National Coordinator, Disaster Preparedness and Response Unit, Ministry of Healthcare and Nutrition Sri Lanka, Governor of North central Province, Mayer of Municipality of Anuradhapura were the invited participants for the initial discussions. In the discussions it was agreed that the pre-Hospital EMS is an important element missing in our health system. It was agreed Pre-Hospital EMS need to be established to cover the entire district of Anuradhapura and as a pilot project to proceed with a service to cover the municipality with a population with 70000 or an area of 5km radius from the town center.
A separate series of lectures were arranged to the hospital workers regarding the EMS in Osaka convincing them this is another area of healthcare and it can increase the chances of the survival of victims. This communication was extended to the community leaders (politicians, influential clergy), professional groups (lawyers, General Medical Officer’s association), and Business community of the municipality. It was expected to develop a pressure group for this project by this communication which ensures the continuation of the program.
When your donor funding runs out how will your idea continue to live? Since the Teaching hospital Anuradhapura was the largest health care institution of the municipality with a large human resource out numbering other small institutions it was selected as the host institution to establish the Pre-Hospital EMS. Municipality and the Fire and rescue were also evaluated as the potential hosts. Yet due to lack of man power, difficulty in establishing the monitoring methods in those two institutions and more importantly the less success in the Fire department based pre-hospital EMS in Colombo lead to select Teaching Hospital Anuradhapura as the host organization. And a separate unit was established in the hospital to carry out this function as Disaster Preparedness and Response Unit which later developed to Disaster Preparedness and Triage Unit. Nurses are working as the EMTs and the EMT level two raining was provided to them by collaboration of Medical Teams International. During that training 5 doctors in the hospital were trained as trainers who could carry out this trading in the hospital for more nurses if necessary with out external support. The Ambulance to the Unit was donated by the Australian Sri Lankan charitable health fund and it was incorporated to the regular ambulance fleet of the hospital and through that it was deployed to the unit so it is maintained as a regular ambulance in the hospital.

Even though at the beginning the project needed assistance from the donor agencies it was designed as such it can be maintained by Teaching Hospital Anuradhapura with out much external support to ensure the sustainability

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.

RAFT: Telemedicine in Africa

The RAFT-Network provides telemedicine in African Francophone countries. The main challenge adressed is the de-isolation of care professionals working in remote areas of developing countries. The core activity of RAFT is the webcasting of interactive courses targeted to physicians and other care professionals. Courses are webcast every week, freely available, followed by hunderds of professionals who can interact directly with the teacher.


Project/Initiative Outline:

First Name
Antoine
Last Name
Geissbuhler
Name of project or intiative RAFT: de-isolation of care professionals in developing countries
1st country of focus Mali
Additional countries of focus Sub-Saharan Africa and Latin America
Relevant to the conference theme Health information and technologies
Summary Continuing education of healthcare professionals and access to specialized advice are keys to improve the quality, efficiency and accessibility of health system. In developing countries, these activities are usually limited to capitals, and delocalized professionals do not have access to such opportunities, or even to didactic material adapted to their needs. This limits the interest of such professionals to remain active in the periphery, where they are most needed to implement effective strategies for prevention and first-line healthcare.

In order to address these needs, the Geneva University Hospitals have developed a telemedicine network in Africa (the RAFT, Réseau en Afrique Francophone pour la Télémédecine), first in Mali, then in Mauritania, Morocco, Cameroon, and, since 2004, in Burkina-Faso, Senegal, Tunisia, Ivory Coast, Madagascar, Niger, Burundi, Congo-Brazzaville, Algeria, Chad, Benin, Guinea and DRC.
The core activity of the RAFT is the webcasting of interactive courses targeted to physicians and other care professionals, the topics being proposed by the partners of the network. Courses are webcast every week, freely available, and followed by hundreds of professionals who can interact directly with the teacher. 70% of these courses are now produced and webcast by experts in Africa. A bandwidth of 30 kbits/second, the speed of an analog modem, is sufficient, and enables the participation from remote hospitals or even cybercafés.
Other activities of the RAFT network include medical tele-expertise, tele-ultrasonography, and collaborative development of educational on-line material.
The network is currently organized and run by more than 40 national coordinators throughout Africa, and by a coordination team based in Geneva. In each of the partner countries, the RAFT activities are supervised by the focal point, a medical authority (usually a university professor) that links the project to the national governmental bodies (ministry of health, ministry of education). A local medical coordinator (a junior physician) and a technical coordinator take care of the day-to-day operations, including communication with the care professionals, identification of training needs, technical training and support of the various sites within the country.
Key partnerships include the Université Numérique Francophone Mondiale (UNFM) and the World Health Organization (WHO). The RAFT is recognized as an official WHO collaborating center for eHealth and Telemedicine.
The current priority is the large-scale deployment of these telemedicine tools along with IT-enabled diagnostic devices such as portable echography, to the regional and district hospitals in Africa. These infrastructures could also be used to facilitate public health activities including the collection and communication of surveillance and healthcare indicators to the ministries. The usefulness of these tools to support isolated care professionals has been demonstrated, as well as the sustainability of the implementation in large hospitals who can integrate the recurring connection costs in their operational budgets. Given the high costs of satellite connections (about 500 USD per month), which are the only options in remote areas, it has been evaluated that sustainability can currently be achieved down to the district-level hospitals who usually serve populations of 50’000 to 200’000, and operate as the first level of reference for dispensaries and rural hospitals.
In parallel, the network is extending to other linguistic areas: educational sessions have been produced in English since October 2008, and are available to hospitals in English-speaking Africa and the Middle East. Since 2011, the project is being implemented in Latin America.
What challenges does your project address and why is it of importance? The main challenge addressed is the de-isolation of care professionals working in remote areas of developing countries. In most countries, remote areas are understaffed, with a suboptimal use of existing resources, while main cities retain most of the skilled professionals and have overcrowded care facilities.
How have you addressed these challenges? Do you see a solution? The RAFT network provides distance education and tele-expertise services to isolated care professionals, by establishing South-South collaborations between reference hospitals and regional/district hospitals.
How do you know whether you have made a difference? We have many anecdotes showing that these tools are effective both for professional and social de-isolation, and help maintain skilled and motivated professionals in remote areas, thus strengthening thelocal health systems.
Have you or the project mobilized others and if so, who, why and how? The RAFT network has many partnerships in order to provide quality contents and mutualize technical and organizational resources. These include WHO (HUG is a WHO collaborating center for eHealth and telemedicine), UNFM (Université Numérique Francophone Mondiale), AUF (Agence Universitaire de la Francophonie), UNESCO (University of Geneva has a UNESCO chair for distance education), Université Senghor...
When your donor funding runs out how will your idea continue to live? In most countries, the network is supported by the MoH or hospitals within two to three years of the initial deployment in that country.

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GHF2012 – Welcome Message

Welcome to the fourth edition of the Geneva Health Forum (GHF), a key event for those wishing to hear the voice and insights of the global health frontlines.

We are introducing many new features to ensure that views from the frontlines are well represented at the Geneva Health Forum. It is with great pleasure that we offer you the new submission format, suited to submit project implementation experiences as well as scientific abstracts. You can generate more interest in your submission by also submitting photos and audio-visuals.

The GHF community can view your submission on-line, encouraging its members to share their experiences, while our Program Committee is reviewing your submission.

Continue reading "GHF2012 – Welcome Message"

GHF2006 – Interview with Mary Robinson

September 3, 2006

Submitted by: Viola Krebs (ICVolunteers); Contributors: Jean-Pierre Joly (ICVolunteers)

"With the human rights as a framework... the objective of 'access to health for all' will certainly have made some progress through the conference." Image: Viola Krebs, ICVolunteers.org

Mary Robinson, the first woman President of Ireland (1990-1997) and more recently United Nations High Commissioner for Human Rights (1997-2002) shared with the conference team some of the main challenges at hand when it comes to access to health for all: accountability, financing, the brain drain and the responsibility of those who have the means to make a difference, such as the private sector. She pointed out that the high turnout at the Forum was an indicator of the need for it and the urgency of discussing access to health. Access for all is the concern of all.

Q: Accountability of politicians for decisions affecting human health and dignity is a key issue. If everybody agrees on the principle, the question remains of how to assess their achievements and how to enforce accountability?

I speak more and more about accountability including accountability in the social context. Human rights help greatly. We know what the legal commitments mean for countries. The UN Committee on Economic, Social and Cultural Rights has provided guidance to governments and standards against which they can be held accountable. We have more and more ways to measure their ability to fulfill the right to health. Some of the core obligations such as ensuring that no one is discriminated against in terms of access to basic treatment are to be fulfilled regardless of available resources. The increasing sophistication of civil society groups also enhances social accountability. The Treatment Action Campaign case in South Africa proved that governments can be required to implement comprehensive and coordinated programmes in order to realize the right of access to medical treatment. On 4th September, I will be in London to help Paul Hunt, the UN Special Rapporteur on the Right to Health, to defend his ideas on this matter with the UK Government. It is an important move because we need to keep accountable rich as well as poor countries.

Q: Requesting from developing countries that they finance themselves the access to health for all at a national level seems unrealistic. On the other hand it appears that financing provided by the developed countries for the South has short term effects. Is there a methodology that could be followed to obtain long-term sustainable results?

The current situation is actually shocking. Public health systems in poor countries are broken, in particular in rural areas where many problems surface. We need absolutely to change the approach. It is being recognized that the local parameters have to be far more taken into account. Many errors have been made by the IMF and the World Bank, which actually weakened the ability of countries to take local action. The new trend amongst donors to privilege general budget support since the Paris declaration on aid will put more responsibility on the countries' decision makers. Health ministers will have to be very skilled managers which is not necessarily always the case currently. In quite a number of countries corruption also remains a major issue. Everything should be done to support health ministers and their ministries in order to allow them to manage funding from the GAVI (Global Alliance for Vaccines and Immunization), NGOs, foundations and other donors and to enable them to meet, amongst other things, the Abuja declaration which targets that 15% of national budgets would go to their health systems.

Q: When one thinks of resources, a major one is the human resource. Developing countries suffer from an ongoing brain drain affecting deeply their health systems. How to stop and even reverse this trend?

It is of utmost importance to stop the brain drain. Mid-level workers need to be trained. These middle-skilled personnel are undervalued and invisible. Yet, these health personnel show more sustainability while not being tempted by migration like highly trained health professionals. A good example of this is the use of Tanzania's paramedical personnel to dispense anti-retroviral medication. On 12 September, we will have a high level meeting in New York on migration. The aim is to stimulate more bilateral agreements between countries to avoid permanent migration and to enhance shared training efforts. All countries should share responsibility in this field. In this respect, the pull factor is of importance, meaning that the rich may agree to train more. In the US, where I am currently living, 500,000 nurses and 200,000 doctors are needed by the year 2015. Nurses are being imported. The fact of acquiring them cheaply by not having to educate them is unacceptable. There are many ideas to think about.

Q: The pharmaceutical industry is often criticized. Do you think there is evolution to provide medicine at lower costs? Is there a will within those companies to become socially responsible beyond just a superficial marketing move?

We regard the private sector as an important player either providing good resources or a negative influence. We are keen to see them fully responsible and specific companies have taken this direction. Paul Hunt, the UN Special Rapporteur on Health, is developing guidelines related to the human right to health. The subject is vast and goes from intellectual property to pricing. It is evident that we need a structure and guidelines and pharmaceutical companies, as well as all other stakeholders, have to buy into this.

Q: What are your expectations from the debates during the present Forum and in what way can they influence decision makers?

The Forum comes at the right time. This is proven by the fact that the attendance overshot all expectations. I am convinced that we can initiate change in most of the fields which are on the agenda. The dynamics exist to accelerate a breakthrough in areas such as safer food and water supply, improving educational levels and other social determinants. The Millennium Development Goals have set a 0.7% of GDP level for the aid to be provided by the North to the South. The US Administration is today more willing to commit itself as well. All of this needs to be thought through. The errors of the past often found their origin in the non-coordinated approach of health issues and systems. This Forum gives the opportunity to encompass government representatives, healthcare specialists, donors and NGOs, to strengthen sustainable long-term health systems and to develop common views. With the human rights as a framework it seems that the objective of access to health for all will certainly have made some progress through the conference.

Q: A few weeks ago you attended the World Conference on AIDS in Toronto. What was your overall impression and what conclusions could be drawn from the debates?

My impression was quite similar to the one that prevailed during the previous conference two years ago in Bangkok. A lot of emphasis was put on the progress to be expected from fundamental scientific work. Subjects such as the status of development of microbicides were at the centre point of the majority of the debates, but the use of female condoms got little mention in the context of sub-Saharan Africa. The ability of women and girls to protect themselves from contracting the virus is as important as the process to prepare effective microbicides. The issue of the identification of risk groups did not seem to draw a lot of attention. It appeared as if there was a tendency not to want to address real problems. In a sense it was quite disappointing. Community groups know what they are doing and what they need, but they did not always get enough attention. The focus was more on well known guests than on rallies on women's issues and rights. A number of key issues were not addressed. The planning for the next conference in Mexico needs to put the priorities right.

More Information

For more information about Mary Robinson's current activities and work with Realizing Rights, see http://www.realizingrights.org.

GHF2006 – Interview with Dr. Julio Frenk, Minister of Health of Mexico

Improvement of health systems and poverty reduction go hand in hand. Image: Viola Krebs, ICVolunteers.org

September 2, 2006

Submitted by: Viola Krebs (ICVolunteers); Contributors: Jean-Pierre Joly (ICVolunteers)

Health reform is badly needed in many countries in the developing world in order to stop the burden of catastrophic healthcare costs remaining on the shoulders of individual families. We talked to Dr. Frenk, Minister of Health for Mexico, where an important healthcare system reform was launched in 2003. The reform implemented, among other things, a 7-year plan to finance "el seguro popular" or popular insurance.

Q: How do you see the development of a global health policy? What are the major issues?

Let me give you the example of Mexico to illustrate my views. It is about a real life experience regarding the deep transformation undertaken by my country in the field of developing and managing a health system. It has been a process of shared learning and innovation, inspired by other countries, including European nations. It is our aim to share our experience with others and make it available to them.

Many barriers have to be overcome when putting in place a coherent health system which provides equal access to health for all. Barriers are geographical, cultural and organizational. For example, bureaucracy will generate long queues and alter quality. In addition, a major stumbling block to enhancing health programmes is their financing. We, in Mexico, have understood that we need to demolish the financial barriers to make progress. Financing is of course not just an issue for Mexico. Indeed, nearly everywhere in the world, financing of health systems has not kept up with existing and forecasted needs. However, developing countries have to bear a double burden. Not only do they have to face health problems due to epidemic diseases but, at the same time, they have to build their infrastructure.

Hence, many low and medium income countries have been unable to adapt their health systems. But the changing environment requires them to do so. Several factors can provide pressure to trigger change. Today, we have to face new epidemic diseases such as AIDS which did not exist 25 years ago. Another factor is brought by technological evolution: there are new drugs available that can save lives. And then there is the growing pressure and awareness of populations that health is a fundamental right. Good pressures can help adjust health systems in order for them to respond better to needs.

Q: So, how did you go about bringing change to the health system in Mexico?

We decided to tackle the issue on several fronts, in particular the social, the financial and the cultural ones. What we have done is not perfect but it has produced good evidence. First, one has to understand the reality and become aware of the unacceptable paradox that the lack of financing healthcare in a country can itself create poverty. Next, you can transfer experience from elsewhere to adapt and improve the existing or non-existing system, taking into account the social, financial and cultural characteristics or limitations of the country. Once you have been able to produce good results of the interdependence between improvement of health systems and poverty reduction a new global dynamic appears.

In the Mexican case we took the decision to invest heavily in research to guarantee quality in the long run. Finally, it seems of utmost importance to me to articulate a clear ethical framework in which you can reflect the challenges of your people. Another element is the use of the ethical (universal human right) argument, to obtain the necessary political support in order to have your projects accepted.

Mexico has created a social protection scheme which is social insurance similar to what exists in several European countries and which allows poor people access to health care. This system of protection, also called popular insurance or "seguro popular" avoids that people are excluded from basic healthcare.

As I mentioned before, it is important to implement these new policies gradually in order to keep the finances of the country in balance. The Ministry of Finance only supported the changes on the basis of a sound financial plan. We adopted a 7-year horizon for the reform. A strict follow-up on the expenditure side increases credibility among parliamentarians and increases the chances of funding being continued in the future. Thanks to the support of the whole government we could create 2700 new facilities. It is true that in our case we started from a very low level and had a huge shortage, which explains why there were so many health facilities needed and created, in particular in the poorest parts of Mexico.

Our programmes also include education and training of medical staff. Another significant effort has been produced on the drug supply side. In this context, measures are taken that drugs are only obtained through prescriptions in order to have better control. And everything is done to spend the money in an efficient way.

We also are constantly assessing our policy, the state of the technology in place. A number of challenges need to be addressed. There are still existing geographical discrepancies, bureaucracy treating people without dignity, organizational and cultural barriers. 10% of the Mexican population is indigenous and more than 50 languages are spoken in the country. Health care in the patient's language is needed. Monitoring tools are being put in place and the reports are made public. The results of the present system are needed to convince members of parliament and taxpayers to continue their investment in the new social contract for health.

Q: Just some words about your candidacy to the World Health Organization (WHO) and what your plans are?

I very much value the legacy of Dr. Lee. We had the honour of working together under Dr. Bruntland. We were colleagues. Later, I followed his work being on the Mexican delegation to the World Health Assembly. Also, Mexico hosted the conference on health research for development in November of 2005, which was an opportunity to welcome Dr. Lee to Mexico. Unfortunately, his term was cut short by his sudden death. I would like to continue many of the reforms that were started under him. I was very much in line and agreed with Dr. Lee's approach, in particular his focus on Africa, AIDS treatment, partnerships and financing mechanism in those partnerships. The focus on the internal management being more accountable will also be one of my priorities. The improvements initiated by Dr. Lee must continue.