Geneva Health Forum Archive

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Certificate Course In Evidence Based Diabetes Management: Capacity Building of Primary Care Physicians in Diabetes Care, India.

Author(s) Shivangi Vats1, K Srinath Reddy2, V Mohan3, Sandeep Bhalla 4
Affiliation(s) 1Training, PHFI, Delhi, India, 2PHFI, PHFI, New Delhi, India, 3Dr Mohan’s Diabetes Specialities Centre, Dr Mohan’s Diabetes Specialities Centre, Chennai, India, 4CCEBDM, PHFI, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Education and Research
Summary CCEBDM is a pan India program for the capacity building of primary care physicians in the field of diabetes. As the country is becoming the diabetic capital with a lack of trained physicians in this field this program is launched in 2010. An evaluation was done to assess the short impact of the program and it was found that the program was effective and the skills of the physicians improved after attending the training program.
Background Diabetes is considered one of the major contributors to the global burden of disease. It exemplifies management challenges because of long latency, chronicity, multi-organ involvement and long term care. In India, health system is constrained in term of trained manpower and limited institutional capacities for diabetes management. A balanced approach to equip primary care physicians with advanced and newer evidence based knowledge for better diabetes management is fundamental.
Objectives This article/paper is aimed to assess the impact and effectiveness of PAN INDIA Certificate Course in Evidence Based Diabetes Management (CCEBDM).
Methodology CCEBDM is an evidence based diabetes management course with the objective of improving the treatment outcomes for patients by serving as an evidence based guidance for clinical decision making in risk assessment, diagnosis, prognosis and management of diabetes. Improvement in knowledge of physicians was assessed by quantitative and qualitative methods. For quantitative analysis pre and post test scores were used and for qualitative analysis, end-line evaluation as a cross-sectional survey was conducted with 100 and 125 randomly selected physicians from CCEBDM Cycle-I and cycle-II respectively using pre tested scheduled questionnaires two months after completion of cycles.
Results Pre-post test scores of 2776 physicians were assessed for the knowledge improvement and it was found that there is significant improvement (P value < 0.05) in knowledge regarding basics of diabetes, pharmacological treatment, acute and chronic complications with management. Once the course was completed the frequency of treating diabetic patient/physician/month increased (38% 501 to 1,500 patients per month and 44% stated that they treated about 101 to 500 patients per month), and the confidence level of physician increased in the field of diabetes diagnoses and management. Frequency of physicians who were confident to manage diabetic complications like hypoglycaemia (73%), peripheral neuropathy (94%), skin complication (82%), sexual dysfunction (78%), diabetic foot (74%) and nephropathy (71%) increased. 90% were confident about managing patients on insulin independently.
While assessing the clinic structure it was found that 66% of physicians had provision for laboratory facilities routine blood screenings, 53% had on-site dieticians who help the diabetic patients, 35% had a counsellor to guide the patients, 49% were using DBMS, 79% had full time nurses on duty, and 76% used various forms of Patient Education Resources to elicit awareness about diabetes. The majority of the physicians agreed that the course contributed significantly to their knowledge of diabetes management and added value to their treatment skills. All agreed that curriculum was up-to-date with latest advances and guidelines and faculty’s personal clinical experience added to their teaching were very useful as now they can consult the diabetic experts anytime for references.
Conclusion CCEBDM is an evidence based course and uses recent clinical findings in developing clinical guidelines for better management of diabetic patients and is very effective in improving the knowledge of physicians and clinical practices in diabetes management. Also by building the capacity of primary care physicians in diabetes management, it seems to be a solution to control the increasing burden of diabetes and to improve the productivity of people who are living with diabetes.

Integrating Ayurveda: Clinical Studies on the Ayurvedic Treatment of Rheumatoid Arthritis Offer New Perspectives.

Author(s) Olivier Talpain1
Affiliation(s) 1 Associate researcher at the University Institute of History of Medicine and Public Health in Lausanne, Switzerland
Country - ies of focus India
Relevant to the conference tracks Education and Research
Summary From the Ayurvedic point of view, Ayurveda is largely underused despite the fact that it has much to offer, for chronic diseases for example.How could this be recognised? Is modern research the best way? Could it be assessed as a whole system? How could it be integrated into global health solutions?

This ethnographic case study presents modern clinical studies that positively assessed the Ayurvedic treatment of rheumatoid arthritis. It shows that, due to a recent paradigm shift in modern clinical research, Ayurvedic and conventional physicians can collaborate successfully to conduct research that can assess the relative efficacy of individualised and multimodal Ayurvedic treatments.

Background The main traditional system of medicine of India, Ayurveda, considers to be largely underutilised as it has much to offer globally, especially to prevent and treat chronic diseases.Ayurveda uses its own knowledge system / epistemology (a specific way to the acquisition and validation of knowledge) whose underlying principles have remained unchanged for millennia. It applies to life in general (human, animal, vegetal), and is said to be remarkably adept at addressing complexity –considering living beings in a holistic manner from diagnosis to treatment– and particularly cost effective and accessible:

-       It enables early diagnosis (assessing energy imbalance), helping to maintain health before pathological symptoms arise;

-       It stresses on prevention;

-       It primarily uses simple technology / low-tech approaches (relying mainly on dietary / life style change, herbal remedies and manual therapies).

Although Ayurveda is increasingly used globally, it is relative to modern medicine still marginal, even in India.

Good up-to-date clinical research showed promising results.

So why has Ayurveda not yet been part of integrated health solutions – especially in the west but also in India?

Objectives Considering what Ayurvedic physicians and researchers claim Ayurveda can offer globally and the positive results of clinical trials, why is this seemingly powerful and promising health system currently so marginal?Since Ayurveda has been observed and studied by the West for centuries –especially in the modern era by the British who governed India–, one might hastily conclude that modern research has shown no advantage of Ayurveda compared to conventional medicine. However, the answer is more complex, ensuing from the relations between India and the West, Ayurveda and modern medicine, and in the history of these systems of medicine.

This study aims to understand why there is such a gap between what Ayurveda claims and shows through modern clinical research on the one hand, and the way it is used and considered globally on the other hand. Specifically, we aim to answer the following questions: How could Ayurveda be recognised in cases where it offers a positive alternative to conventional medicine? How could it be recognised as a whole and specific system of medicine? How could it be integrated as part of global health solutions?

Methodology Social sciences / In the fieldUsing an ethnographical approach, the study was conducted in South India where Ayurveda is the most widely accepted and used.

Interviews and visits

A series of interviews were conducted to understand the overall situation of Ayurveda and, more specifically, its relation with modern medicine and research. Interviews of over 50 Ayurvedic (registered) physicians and about 50 researchers, teachers, students, and managers of public and private health services were conducted between 2006 and 2013. Visits to hospitals and pharmaceutical factories and laboratories that subscribed to the Ayurvedic system also contributed to the study.

Literature review

A review of scientific literature related to Ayurveda was conducted in 2012 (forthcoming) by the AVP Research Foundation using its specific online database (dharaonline.org). This offered a valuable and concrete insight into the history of research on Ayurveda.

History of modern medicine

Further literature review and interviews with researchers of conventional and complementary and alternative medicine (CAM) shed light on the evolution and current position of modern research vis-a-vis CAM.

Results First, it is apparent that the marginalisation of Ayurveda, both in India and in the West, is a result of its historical relation with modern medicine and more widely from societal modernisation. That is, in a modern globalised world, also in India, patients expect modern scientific evidence regarding traditional medicine. The Indian Ayurvedic community largely considers its recognition by modern science the best way to gain validation and recognition on a global scale. Thus, a lack of modern scientific evidence about Ayurveda contributes to its marginalisation independently of its efficacy.Why has Ayurveda hardly been assessed by modern medical research?

We observed that almost all the modern research on Ayurveda did not aim at assessing its clinical value, but its pharmacopoeia. Historically, modern scientific research into Ayurveda has been driven by a pharmacological approach to identify active principles of the Ayurvedic drugs.

The biomedical approach that largely dominated the medical field in the 20th century might partly explain this situation. Such a radically different and complex system of medicine as Ayurveda may not be well suited to the biomedical approach. Ayurvedic formulations often comprise tens of substances, which in turn contain numerous active principles, and Ayurvedic practice is individualised, and multimodal (medicines, massage, diet, etc.). Even with the understanding of its specific theories, the task of bio-molecular explanation of its treatments appears colossal.

In the last decades, a paradigm shift has occurred in conventional medical research: the clinical assessment of any treatment can in principle now be valued even in the absence of a bio-molecular explanation (Evidence-based medicine). This allows the assessment of complex treatments like Ayurveda.

Taking an integrative perspective, the assessment of a treatment alone is not enough; it needs to be compared to other treatments. Through our case study, it was observed that comparing a complex Ayurvedic treatment to a conventional medical treatment through the best current standards of clinical research is possible. In fact, the NIH-NCCAM case study has been considered a blueprint for further clinical research on CAM, as a double-blind comparison was previously thought to be too difficult with such a complex treatment. The innovation of that study lies in the use of seven placebos, each of them representing a type of Ayurvedic medicine (tablets, decoctions, etc.).

Conclusion With the evidence-based approach, as a result, modern clinical research can assess Ayurvedic treatments like that of rheumatoid arthritis. Ayurveda, a complex system of medicine that delivers individualised and multimodal treatments, can on this basis get better and wider recognition in India and around the world.The challenge for modern clinical research lies in designing effective clinical trials that can assess all types of Ayurvedic treatments. For example, in the NIH-NCCAM case study, a major modality of the classic Ayurvedic treatment of rheumatoid arthritis –enema with medicated oil– has not been used because of the difficulty of double-blinding. Nevertheless, even the partial Ayurvedic treatment showed comparable results to Methotrexate with fewer undesirable side effects. Once the whole Ayurvedic treatment can be assessed, it may show different results.

Still further questions remain.

How can research on Ayurveda evolve? How is the support to this research defined? How can international collaboration take place to enhance research on Ayurveda?

When assessing and integrating Ayurvedic treatments into an evidence-based modern health system, how would the difficult-to-assess Ayurvedic practices be evaluated? How to avoid neglecting or rejecting the Ayurvedic practices that would be more difficult to assess?

Princeton’s University Global Health Program: Research and teaching at the nexus of science, policy and social science

Author(s) Kristina Graff1, Peter Locke2
Affiliation(s) 1Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 2Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 3.
Country - ies of focus Global
Relevant to the conference tracks Education and Research
Summary Princeton University’s Global Health Research and Teaching Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
What challenges does your project address and why is it of importance? Global health challenges go far beyond clinical issues. These problems are rooted in economic, social and political forces, geographical and logistical hurdles as well as the dynamic impacts of globalization and governance. Solutions to global health problems demand an interdisciplinary response –one that integrates the expertise and perspectives of a range of sectors and specialties. A holistic approach to global health looks beyond what medicine alone can achieve and addresses all the elements that contribute to improved wellbeing, ranging from population and system-based interventions to an understanding of how broad public health initiatives affect individual lives.
Princeton University’s Global Health Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
How have you addressed these challenges? Do you see a solution? Princeton’s Global Health Program operates integrated research and teaching initiatives that span the breadth of faculty expertise. The global health program supports a multi-disciplinary research agenda and curriculum bridging engineering, the humanities, and the social and natural sciences.The University sponsors innovative and exploratory research, which is scaled up to draw external grants. Faculty lead projects that engage undergraduates, graduates and postdoctoral researchers. They extend into the classroom and into students’ research and internships.The global health program also supports students’ internships and research in laboratories and field sites around the globe, academic and public events, and student participation in external conferences. This program model simultaneously fuels research and teaching in key areas of global health.A key program focus is on high-quality, hands-on learning. Students conduct research and internships in 20+ countries, based at research centers, NGOs and grassroots organizations, academic institutions, hospitals and clinics. Junior researchers mentor many student projects, providing training in topics such as technical methods for research and analysis, to the ethics and principles of sound and responsible global health research. These field experiences are life changing for many students and form the basis of their future pursuits in domestic and global health.A final critical factor in the success of Princeton’s global health program is a strong and longstanding partnership with the institutions where students and faculty conduct research. Solid institutional relationships allow for regular exchanges, high-quality research, expanded opportunities for collaborative projects and more efficient administration. Two key governing principles for the program’s collaborations are reciprocity and on-site advising by Princeton researchers based in the field. Princeton hosts faculty members and graduate students from partner institutions for varying periods of time. Postdoctoral fellows have proven highly effective as on-site research coordinators and advisors.

By centering its research and teaching activities on interdisciplinary and integrated principles, Princeton’s global health program facilitates cross-departmental engagement of faculty and prepares students to address the increasingly complex slate of global health challenges.

How do you know whether you have made a difference? The Princeton Global Health Program tracks the impact of its research and teaching programs over time, and it also devotes ongoing attention to ensuring that its international partnerships are mutually beneficial. For research we monitor how the work is scaled up into larger programs, published in academic and other journals, and translated into policy and practice changes. We do this through reporting by recipients of internal grants and through tracking global health faculty member’s work.For teaching we follow the threads of students’ academic progress over multiple years and then track their career trajectories once they graduate. We do this through a combination of quantitative measures (number and proportion of global health students who pursue related graduate study and careers) and qualitative data (asking students over time how their experience in Princeton’s global health program shaped their understanding of global health issues and the evolution of their careers). We also link current students to program alumni, in order to create an informal network for advising and guidance.For international partnerships we work with our collaborating institutions to identify mutually beneficial projects at the start of our cooperative efforts. We also commit to a true exchange, whereby our partner institutions can send faculty or graduate students to Princeton for periods of research or study. We communicate frequently to keep things running smoothly, set agreements about use of data and publications resulting from the collaboration, send as many field-based researchers to our partner sites as possible, and conduct periodic site visits for monitoring and relationship management.
Have you or the project mobilized others and if so, who, why and how? The international partnerships have resulted in a range of studies, projects and grants to address global health challenges around the world. Some of these have been the result of student projects that were designed to address pressing issues facing a particular partner institution. Princeton’s participants were called upon to address the economic, social, cultural and logistical factors affecting health care access and overall wellbeing. One example is Princeton’s global health program partnership with Wellbody Alliance, a community-based healthcare organization in rural Sierra Leone. Under the supervision of a global health program postdoctoral fellow, Princeton students conduct summer field research focused on helping Wellbody to better understand community needs and evaluate the impact of its services.Based on a student’s project analyzing barriers to tuberculosis (TB) treatment adherence, Wellbody applied for and received a grant from the World Health Organization’s STOP-TB Partnership to implement an innovative district-wide home-based TB screening and treatment system. As part of this project, Wellbody Alliance has hired and trained 150 community health workers, upgraded laboratory and administrative capacity, and secured additional medication needed to treat hundreds of new TB patients. All patients diagnosed with TB in Kono District are now assigned a Wellbody Alliance community health worker who visits patients in their homes to administer medication and evaluate their progress. Additionally, community health workers offer early testing and treatment to high-risk individuals, saving lives and preventing others from becoming infected.In the summer of 2013, students returned to support and evaluate the implementation of the program by accompanying supervisors and health workers as they carried out their duties in the community. Their findings will be essential to identifying and overcoming unexpected challenges in the field and to facilitating the renewal of the WHO grant beyond the first year.
When your donor funding runs out how will your idea continue to live? In the research dimension, the University’s initial investment in global health research is being translated into support from external donors whose primary agenda is to further these lines of inquiry. The research projects will then ultimately become a self-sustaining entity. The program also maintains endowed funds so that there will always be avenues to seed innovative ideas and projects until they can be scaled up for broader external funding. In the teaching dimension, the philosophy of Princeton’s global health program is present in the University’s core educational curriculum. Therefore the program and its guiding principles will remain at the center of all pedagogical initiatives as ongoing and standard academic offerings.In its international collaborations, these costs will ultimately be moved from the category of “special initiatives” over to a standard part of normal program operations, so that they become part and parcel of global health partnerships – both at Princeton and within its partner institutions. When the partnerships prove to be mutually beneficial they can then merit a spot as an essential element of both collaborators’ regular operating budgets.

Making profession of family doctors attractive for future doctors: Kyrgyzstan

Author(s) Salima Sydykova1, Nurlan Brimkulov2.
Affiliation(s) 1Hospitral Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan, 2Department of Hospital Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan.
Country - ies of focus Kyrgyzstan
Relevant to the conference tracks Education and Research
Summary One of the main current healthcare problems is a shortage of family doctors/general practitioners, especially in rural areas. Medical students are not motivated to choose the specialty of family medicine because they don't find it prestigious. The community also has disrespectful and discriminating feelings about this specialty.
The Kyrgyz State Medical Academy has the very challenging task of re-orienting the training in order to find a training approach that would change this situation. This abstract is about one of the new teaching modules, “Human, Society and Health”. Its primary goal is to set a positive “pro-family medicine” attitude from the beginning of the undergraduate training.
What challenges does your project address and why is it of importance? The burning problem of health education and the healthcare system is a dramatic lack of general practitioners/family doctors in the field, particularly in rural areas. Many villages do not have even a single medical professional however it is considered that  the number of medical students in Kyrgyzstan is sufficient. Another figure is the low number of students who have their post-graduate education in family medicine as opposed to the giant number of residents who do their post-graduate education in the field of surgery, gynecology, cardiology and other narrow specialties. The major reason why students are not motivated to become a general practitioner/family doctor is a negative and disrespectful image of this specialty in the eyes of the community as undertrained and poorly qualified doctors.
Kyrgyz traditional health education system, both at undergraduate and post-graduate levels, is based on a curriculum with longitudinal disciplines that are taught separately and in isolation. The teachers of different departments are used to focusing on the narrow competencies of their discipline without knowing the general goal of the curriculum.
How have you addressed these challenges? Do you see a solution? KSMA is the largest medical educational institution that provides undergraduate and post-graduate and continuous medical education. To meet the needs of the healthcare system and to help to overcome the crisis in family medicine, the KSMA started working actively to change the curriculum and to change the whole approach to teaching the curriculum. The working groups of KSMA realized that the current curriculum needs one main goal that would connect and link all teaching units. The main task and challenge was to introduce the integration principle, so called vertical and horizontal integration, and build the curriculum around the core competencies to provide the country with well-prepared and motivated general practitioners.
After setting the main teaching goal as producing well-prepared General Practitioners/Family Doctors, the Department of the training, organizational and methodic work (DTOMW) has assigned working groups consisting of the representatives of each teaching Department/Chair to revise the existing modules and training programs.
Current modules were revised and some new integrated modules were developed in place of the longitudinal isolated disciplines.
One of the new modules was module “Human, Society and Health” for the 1st year of medical study. It involves the following disciplines: public health, psychology, philosophy, anatomy and physiology, biology and physics and clinical component. The revolutionary piece of the module is bringing the students to a real clinical environment, in the setting of a family medicine at a primary health organization. The module has a dual goal: the first is technical and the second is “ideological”. All the disciplines of the module built their teaching around these two goals. The first goal is to introduce a new medical student into the specialty of General Practice/Family Medicine, to orient medical students towards the specialty of general practice/family medicine and make them comfortable and aware about the goals of the undergraduate training. The second goal is to set a positive attitude towards the specialty of family medicine and help students understand the challenges and advantages of this specialty. The module explains the most important yet challenging role of the family doctors especially in neglected rural areas and the key role of primary health professionals in sustaining the health of the nation.
How do you know whether you have made a difference? Students are trained in the module “Human, Society and Health” in the beginning of their 1st year of study. To test the effectiveness of the module and our success in achieving our “ideological” goal each student was asked to make a visual presentation in any format to describe his vision and feelings about being a family doctor. Different formats were proposed: Power Point presentation, video, illustrated personal story, poster. Students were encouraged to work in groups. The idea behind the group work was to facilitate discussions and enhance creativity.
At the end of the module we conducted an anonymous survey among the students to assess the organizational and methodological aspects of the new module.
The students worked really hard on their projects and created motivational presentations and videos describing the challenging but fascinating work of a family doctor. All of them acknowledged that it is one of the most difficult jobs and admitted that their vision about the image and perspectives of a family doctor has been changed in the process of the training.
The anonymous survey of 221 first year medical students showed that 96% of the students found visiting doctor’s office interesting and helpful. 88% of the students found it the most interesting and motivational part of the training which allowed them to understand this profession better.
At the first meeting with students, each student was informally asked about future career plans and very few students had plans to become a family doctor, which was very shocking. A question about the choice of the profession was included into the survey.
25% of students responded that they “would like to work as family doctors in future”, 48% - “don’t know yet”, 27% - “would not like to work as family doctor” (explaining that they would like to become narrow specialists such as neurosurgeons, cardiologists, gynecologists, etc.).
48% of students who don’t know yet whether they would become a family doctor illustrates the possibility of using the 6-year training process to further encourage family doctor as a career choice. All the teachers of the KSMA have to be dedicated to the idea behind all the teaching units which is to build a positive and respectful attitude towards family medicine in our future doctors.
Our module allows us to understand the feelings and career plans of our future doctors, orient them into family medicine, and form positive attitudes to the primary healthcare professions.
Have you or the project mobilized others and if so, who, why and how? The disciplines were mobilized to form the working group and elaborate the training plan for the module “Human, Society and Health”. The most difficult part of the work was to re-orient the teaching staff into the integration mode. Traditionally every department would teach the discipline in isolation with its own competencies not being linked with the core global competencies of the whole master curriculum. Teachers of various departments had difficulty discussing the general training plan of the module and finding links to their discipline. They would tend to develop their part of the module without considering integration and interrelation with the other parts of the module. The coordinator of the module (the author of this abstract) took over the role of ensuring the integrity of the module and interconnection of the various disciplines and maintaining regular communication between the departments.
Now that the module is developed it is important to motivate the departments to continue collaboration and monitor the effectiveness of the new module in order to provide dynamic development and yearly improvement of the module.
If considered successful by the Main Training and Methodic Committee of KSMA, this module will be recommended to other medical schools in Kyrgyzstan.
When your donor funding runs out how will your idea continue to live? Our activity is not funded externally or internally. It is an internal initiative within the frames of the current health education reform which was started several years ago to meet the needs of the Kyrgyz health care system. To help with the revisions of the overall health education strategy and re-shaping the curriculum the KSMA has been granted funding for technical support by the health education experts of the Faculty of Medicine of Geneva University. They have provided field trainings for the KSMA leaders and faculty about the integration principles, competencies-based teaching and teamwork.
The reform at the KSMA is impeded by the lack of motivation of the faculty staff because their extra work is not funded and the only motivation to change is professional interest.
We need to discover other opportunities to motivate the faculty staff to improve their performance, to be engaged actively in this challenging but fascinating process in order to improve the training of future doctors!

Mapping the rapid expansion of India’s medical education sector: planning for the future.

Author(s) Yogesh Sabde1, Vishal Diwan2, Ayesha De-Costa3, V Mahadik 4
Affiliation(s) 1Community Medicine, R.D.Gardi Medical College, Ujjain, India, 2Golbal Health, R.D.Gardi Medical College, Ujjain, India, 3Community Medicine, R.D.Gardi Medical College, Ujjain, India, 4Community Medicine, R.D.Gardi Medical College, Ujjain, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary India is in the midst of rapid expansion in the medical education particularly in private sector. We tracked the growth of medical schools over the last 7 decades in the context of geographic distribution across the country. The number of medical schools rose from 23 in 1947 to 355 in 2012. The poor performing provinces with a population of 620 million had only 94 (26.5%) medical schools. Private sector owned 195 (54.9) schools of which 38 (40.4%) were in poor performing provinces. Thus rapid expansion of private sector in medical education in the country was located primarily in the better off provinces. This paper also does an allocation analysis to find optimum location for new medical schools.
Background Medical schools are a vital component of any health care system as they produce the necessary human resources. In India medical schools as academic institutions connected to large hospitals have the potential to influence the local health care system, the health of the local population as well as local economy. The number of medical schools in India has expanded during the six post independence decades and the country now has the largest medical education system in the world. India stands at the top of a list of countries with the largest numbers of privately owned medical schools. Given the role that medical schools play in supporting the health care and general development of the local community, it is important to ensure that all regions (particularly underserved ones) in a large country benefit from the opportunities that medical schools in the area would create. India’s National Rural Health Mission plans to further expand the medical education system to cater for the country’s human resources health needs. At this point in time, it is relevant to historically trace and map the development of medical education in India, to locate where this growth has occurred, trace the changing role of the public and private sectors and importantly to enable strategic planning for the future.
Objectives This paper supports planning for this expansion by identifying districts that would benefit most from the location of new medical schools. The present paper studies (i) the growth of the medical education sector in the country since independence, and the relative contributions of the public and private sectors (ii) the distribution of medical schools in the public and private sectors of India (ii) the current geographic distribution of medical schools (public and private) across the country, and identifies ‘underserved ‘areas to support locational planning of new medical schools in the future.Setting: India is a union of 28 provinces with 833 million (68.8% of the 1210 million) of the population living in rural areas. India’s provinces have widely varying socio-economic and health indicators. Eighteen provinces, which account for about 51% of India's population, have been designated ‘high focus provinces’ under India’s ongoing National Rural Health Mission. These provinces have relatively poor socioeconomic indicators; 25-50% of their populations live below poverty line (based on a defined degree of deprivation) as per national surveys carried out by the Indian government. These provinces have relatively higher MMRs, infant mortality rates (IMR) and higher birth rates than the national averages of 212/100,000 live births, 50/1000 births and 22.5/1000 population respectively. The government of India has designated these provinces as ‘high focus provinces’ implying more focussed attention to and greater allocation of resources towards strengthening the health systems in these provinces [14]. In this study, high focus provinces as a group are referred to as “poor performing provinces” to differentiate them from the group of other provinces which are referred to as “better performing provinces”Provinces in India are divided into administrative units called districts, each with a population of between 0.5-5 million (1.5 million approximately). As per official records there are 640 districts in India that show wide variation in health and economic indicators. Districts have been used as a unit in the location-allocation analysis.
Methodology Information on the medical schools was obtained from the online database maintained by the Medical Council of India (MCI) as of 30th January 2013. The proportions of medical schools in public and private sector were compared for poor and better performing provinces in the country using OR (95% CI). The cumulative total numbers of medical schools and their annual intake capacity each decade were calculated since 1950 till 2010 and plotted using line diagrams.
A digital map of the medical schools was prepared based on their locations indicated in the MCI database. The map was superimposed on a digital map of India purchased from the office of Survey of India and subjected to further analysis using geographic information system (GIS) as follows;
1)Thematic maps: The distribution of public and private medical schools across the districts in poor performing and better performing provinces of India was shown using thematic maps.
2) Euclidean distances: The straight line distance of each district from the nearest medical school was used as an indicator of geographic access to the services of medical school. The Euclidean distances for the districts in poor and better performing provinces were compared using histogram and independent samples Mann-Whitney U test.
3) Ring Buffer analysis: Rings of radius 50 kilometers were plotted around the location of each medical school. The region outside these rings was considered remote region and the number of districts in this region was calculated.
4) Near analysis: The median distances between the adjacent schools in poor and better performing provinces were compared using independent samples Mann-Whitney U test.
5) Location-allocation analysis was performed to identify districts which are likely to benefit most from services provided by medical schools. Districts were the unit of analysis. This twofold analysis simultaneously located medical schools and allocated demand for them. The suitability of location of new institutions was based on following criteria;
a. Euclidean distances above 50 kilometers
b. Population over 1 million
c. Rural population above 80%
d. District rank was lower than 300 (as per National Population Stabilization Fund, Ministry of Health and Family Welfare in India that ranks the districts based on five maternal and child health indicators)
e. Proportion of population with low Standard of Living Index (SOLI) above 20% (as per a national district level household survey in 2007-08)
Results There were 355 medical schools in the country enrolling 44250 students into physician training annually in 2012. Private sector with its 195 (54.9%) medical schools trains more students than the public sector (24205, 54.7%). The 18 poor performing provinces with a population of 620 million (51.3%) had only 94 (26.5%) medical schools. The number of privately owned schools (38, 40.4%) was significantly lower in poor performing provinces compared to 157 (60.2%) schools in better performing provinces.
The geographic distribution of medical schools revealed the dominance of public sector institutions in the poor performing provinces, while the private sector is largely located in the better performing provinces. The maps of medical schools in each decade showed that the foci of private sector schools began in the south in the 1960s and then ‘spread’ to the north in 1970s. The number of public sector schools also grew during this time. By the 1990s there were many more private schools concentrated in the southern peninsula and the rich northern provinces. After the 1990s, the public sector (not expanding anymore) remained the major provider of medical education in the poor provinces. This trend continued into the last decade, with the establishment of private schools beginning in the poor provinces. Only in the last decade have we started to see some spill over of privately owned schools into the poor provinces.
The mean distance between districts and their nearest teaching hospitals in 2012 was 49.2 kilometers (median 45.5 kilometers). Of a total of 267 districts that were located outside 50 km buffer of a medical school, 215 (80.5%) were in poor performing provinces (p value)
Conclusion The number of medical schools has increased in all parts of world with increasing population, advances in technologies and increasing lifespan. Asia witnessed the largest part of this growth as it has 44% of the total medical schools in the world. Privatization of medical education over past several decades has substantially contributed to the growth of medical education in Asia. The entry of the private sector into medical education has been beset with controversy as to whether it has resulted in a dilution of standards in medical education, and on whether it makes medical education the purview of the rich.
The study used geographic information system (GIS) which is a comprehensive, graphical modeling of the distribution of medical schools and its relationship with other variables in Indian medical education system, the largest in the world. The present study highlighted important concerns i.e. differential growths of private sector in richer and poorer provinces in terms of the proportion of medical schools, distances of districts from medical schools and the distances between adjacent medical schools. Thus far, the existing regulations for opening of new medical schools mainly focuses on the infrastructure requirements, assets and financial capacities of the owners and no consideration is given to the existing health services in the local geographic area in the accreditation process of new medical schools. In such an environment, private medical schools are more likely to locate themselves in forward provinces, unless future expansion is planned for both public and private sector schools.
The National Rural Health Mission of India plans steps for the expansion of medical education to address the human resources health crisis in India. We have conducted a location-allocation analysis to identify districts that can benefit most by the services of medical school. The identified 94 districts had no medical schools within 50 kilometers of their main towns and they had reasonably large populations of over a million. The selection criteria applied in this study were chosen from an equity perspective, so that districts with poorer population in terms of economy, health and infrastructure were prioritized. Given that majority of these districts were located in poor performing provinces, the establishment of medical schools at these locations will help support the healthcare services to the district populations.

Cardiovascular Risk Factors among adolescents of Nepalgunj Municipality in Nepal.

Author(s) Manita Pyakurel 1, Anup Ghimire 2, Paras Pokharel 3.
Affiliation(s) 1Community medicine, Nepalgunj Medical College, Kathmandu, Nepal, 2School of public health and community medicine, B.P.Koirala Institute of Health and sciences, Dharan, Nepal, 3School of public health and community medicine, B.P.Koirala Institute of Health and Sciences, Dharan, Nepal 4.
Country - ies of focus Nepal
Relevant to the conference tracks Education and Research
Summary The aim of this study was to find out the prevalent risk factors of CVD and the association of Metabolic syndrome (MS) with behavioral risk factors (BRF).  A cross sectional study was done among 736 school going adolescents. A Systematic random sampling was done to select the sampling unit. CVD risk factors were assessed by World Health Organization (WHO) STEPwise approach. MS was defined based on National Cholesterol Education Programme (NCEP, 2003) criteria. Chi square test of association and multivariate logistic regression were applied. The prevalence of MS was 23(3.1%). Unprotective HDL and increased TG were the most common metabolic risk factors.
Background Over the centuries we have experienced great transitions in social, economic structures and home environments leading to the shift from agricultural and rural societies to industrial urban societies. These transitions have resulted in major changes in physical activity, eating habits and other lifestyle factors. We now face the rise of non communicable diseases (NCD) in addition to the remaining issues of communicable diseases. As a result low and middle income countries are facing a double burden of the modern risks of NCD. [1]
CVD is responsible for 16.7 million (29.2%) of total global deaths. CVD accounts for approximately 80% of deaths in low and middle income countries. [2] India predicts 64 million cases of CVD in year 2015. [3] In Nepal hypertension has the highest prevalence among the CVD at the tertiary level. [4] Cardiovascular risk factors vary with increasing age, gender, and ethnicity. Behavioral, genetic and metabolic risk factors are established risk factors. [3] In Dharan municipality prevalence of CHD is 57 per 1000. [5] Major behavioral risk factors in Nepal are tobacco smoking 23.3%, physical inactivity 14.2%, high blood sugar 8.4% and obesity 9.1%.[6,7]  Adolescence is the appropriate age range for tracking CVD as the evidence of increased chance of atherosclerosis occurrence increases with age and unhealthy behavioral activities. [8-11]
Objectives General objective.
To determine the prevalence of cardiovascular risk factors among the school going adolescents of the Nepalgunj municipality.Specific objectives:
1. To find out the prevalence of common risk factors of cardiovascular disease among the adolescents.
2. To evaluate the statistical relationship of cardiovascular risk level with sociodemographic variables & lifestyle.Research question.
What is the prevalence of risk factors of cardiovascular disease among the school going adolescents of age 10-19 years?
Methodology 2.1. Study population
A cross sectional study was conducted among a total of 736 adolescents of public and private schools of Nepalgunj municipality of Banke district Nepal from September 2012 to February 2013. Ethical approval was obtained from the institutional review board of B.P.Koirala institute of health sciences. The study was conducted with the financial and logistic support from Nepalgunj medical college. Data collection was done using the STEPS questionnaire of WHO.
2.2. Anthropometric measurements.
Blood pressure was measured with standard mercury sphygmomanometer with adequate cuff size and systolic blood pressure was taken by first heart sound (Kortokoff phase I). Diastolic pressure was recorded at the level when sound disappeared (Kortokoff phase V). Two reading were taken on the right arm at least 5 minutes apart. Before measuring blood pressure the respondent rested for at least 5 minutes or as required. This excluded those who had smoked within the last 30 minutes.
Waist circumference was measured using a nonelastic tape to the nearest 0.1 cm over the unclothed abdomen at smallest diameter between coastal margin & iliac crest. Tape measure was horizontal. Respondent was relaxed with arms held loosely by the side. Measurement was taken at the end of normal breath. Both arterial hypertension and abdominal obesity was categorized according to NCEP (2003) criteria.
2.3. Biochemical tests.
A venous blood sample was collected after fasting 12 hours to assess the serum levels of triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and fasting blood sugars were collected and brought to biochemistry lab of Nepalgunj medical college. Automated biochemistry analyzer was used to analyze the lipids.
2.4. Diagnostic criteria.
Among the behavioral risk factors dichotomous variable dietary habit was defined as unhealthy for less than 22 minimum score (sum of salt score, frequency of: fruit intake, vegetable intake, food consumed outside). Physical activity was categorized as inactivity for less than minimum score of 77 (sum of moderate / heavy vigorous exercise and sleep). MS was categorized as positive and negative according to NCEP criteria (2003).
Results Analysis was done among 736 adolescents(331 boys,405 girls). The mean age of the study population was 15.22 ±1.79. Among the behavioral risk factors, adolescents who consumed tobacco were 62(8.4%) and alcohol 51(6.9%). Adolescents with unhealthy dietary habit were 726 (98.6%). Physical inactivity was present in 591(80.3%). Also 345 (46.9%) reported stress at any point of time. Among the genetic factors, family history of chronic diseases were present among 547(74.3%) and 1.9% were diagnosed for congenital heart disease. MS was present among 23(3.1%) with 1.3% among male and 1.7% among female.
Baseline characteristics of metabolic risk factors shows mean SBP, DBP of 110.6 ±12.3, 70.3±10.6 and 104.6±11.7, 66.1± 10 mm of Hg among male and female respectively. Level of MS was categorized in 5 levels based on clustering of the risk factors according to sex distribution, described in table no.1, 2 and 3.Bivariate analysis shows no significant association between age, sex, ethnicity, religion and MS. Significant association of 3.9times increased odds of, (95% CI: 1.7-9.2) was established between positive family history and MS as compared with reference category of negative family history.
Multivariate analysis among male adolescents shows positive family history have 10.85 increased odds of (95% CI: 2.42-48.61) MS as compared to its counterpart negative family history. Among the female adolescents non refined oil consumption showed 8.24 increased odds of (95% CI =1.05-64.78) MS as compared to the refined oil consumers. Whereas non stressful adolescents have 4.22 increased odds of (95% CI=1.08-16.4) MS compared to the stressful.
Conclusion From our findings the most prevalent behavioral risk factors were consumption of non refined oil, unhealthy dietary habit, physical inactivity and stress. Among the genetic risk factors, prevalence of 1.9% CHD and positive association of family history with MS were alarming. More than ¾ of adolescents have at least one risk factor of MS. Among the components of MS, dyslipidemia was the most common risk factor affecting the adolescents. Males with positive family history and a non refined oil consumer and non stressed females were important risk factors for identifying adolescents at risk for later CVD onset. The result suggests that preventive measures including consumption of refined oil may be warranted for these adolescents. In conclusion, the presence of behavioral and metabolic risk factors for CVD is an important health problem among the adolescents of Nepalgunj municipality. There is a need for a national programme to control cardiovascular risk factors among these adolescents.

Strengthening Referral Linkages for Malaria in Nigeria.

Author(s) Chinazo Ujuju1, Ernest Nwokolo2, Jennifer Anyanti3, Chinwoke Isiguzo 4, Onoriode Ezire 5, Ifeanyi Udoye6, Wellington Oyibo7
Affiliation(s) Research and Evaluation Division, Society for Family Health, Abuja, Nigeria, Global Fund Malaria project, Society for Family Health, Abuja, Nigeria, Technical Services, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, College of Medicine , University of Lagos, Lagos, Nigeria, 8
Country - ies of focus Nigeria
Relevant to the conference tracks Education and Research
Summary Lack of referral linkage from PPMVs to health facility may have contributed to increased mortality due to the home management of malaria illnesses. This study showed that of the 461 clients who were tested for malaria at PPMV outlet, 88 tested positive while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. Only 18 referral cards were retrieved from health facilities. There is a need to integrate PPMVs into the national referral system to ensure appropriate treatment for severe malaria, other febrile infections and reduce morbidity and mortality due to home management of illnesses.
Background In Nigeria malaria remains a major cause of morbidity and mortality among children under 5 years of age. Most of the early treatments of fever and malaria occur through self medication with anti malarial bought over the counter from drug vendors. The Nigerian health system provides for three tiers of health care: primary, secondary and tertiary. The primary health centers should be the point of first contact for patients from where they are referred to other levels of health care. This is far from reality as Private Patent Medicine Vendors (PPMVs) found across Nigeria are the first point of call for malaria treatment. Global malaria initiatives highlight the potential role of PPMVs in improving access to early effective malaria treatment. Parasitological diagnosis before administration of anti-malarial treatment has recently been recommended by WHO for everyone presenting with symptoms compatible with malaria at all level of the health system.
Objectives In Nigeria, more than half of household members sought treatment for fever at PPMV shops. Anecdotal evidence suggests that PPMVs do not refer clients to the health facility. There is a need to explore whether PPMVs would actually refer clients who accessed the malaria rapid diagnostic test (RDT) from their outlet to a health facility. This study was conducted to determine whether PPMVs referred clients who visited their outlet for malaria diagnosis to a health facility.
Methodology A cross-sectional pilot study to explore RDT feasibility and use was conducted in six states (Adamawa, Cross River, Enugu, Lagos, Kaduna and F.C.T) of Nigeria, each representing a geo-political zone of the country. About 20 registered PPMVs were selected from each of the selected states. Multi-stage purposive sampling was used to select the state and the PPMVs that participated in the study. These outlets were grouped into clusters of 6 per state. Two days of curriculum based training was conducted for the selected PPMVs. Nurses and laboratory personnel were recruited to monitor the PPMVs as they conducted the malaria RDT. The RDT test was conducted for clients aged 18 years and above after obtaining informed consent to participate in the study. Clients who tested negative were referred to a higher health facility identified within the cluster for further diagnosis and treatment, while those who tested positive for malaria were offered a full course of medicine according to Nigerian malaria treatment guidelines. During the study, referral was tracked in two states; Kaduna and Lagos state. Ethical clearance was obtained from the National Health Research and Ethics Committee prior to commencing the study. Data generated from the study was entered and verified using data management software, CSPro 2.6. The data was subsequently imported into SPSS (version 18) for statistical analysis. Descriptive statistics were used and data for the two states where referrals were tracked were analysed for this paper. Socio economic status of the respondents was calculated based on reported household’s ownership of consumer goods, dwelling characteristics, source of drinking water and sanitation facilities. To construct the index, each asset was assigned a weight (factor score) generated through principal component analysis, which was divided into quintiles from one (lowest) to five (highest).
Results 461 clients who visited PPMV outlet in Kaduna and Lagos received malaria RDT as confirmatory diagnosis of their illness. The proportion of males in the population was slightly higher (58%) than the proportion of females (42%). More than half (69%) of the respondents were married. There was variation in the educational attainment of respondents who participated in the survey. While about 48% had attained a secondary level of education, about one in four (23%) of the respondents had attained a higher level of education. A higher proportion of respondents were aged between 25-34 years (36%) and ranked as average socio economic status (26%). The reported symptoms experienced by most of the respondents can be associated with malaria illness. These symptoms include fever (55%), headache (77%), joint pains (54%), tiredness (39%), bitter taste (27%) and poor appetite (25%). About 88 clients tested positive for malaria while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. A few visited the health facility for further diagnosis and treatment and 18 referral cards were retrieved from the health facilities.
Conclusion There is a need to integrate PPMVs into the national referral system and strengthening referral of client from drug store outlets to a higher quality of care. There is a need to implement malaria RDT among PPMVs and ensure that this group of health workers is trained and their activities monitored effectively to ensure proper management of malaria illness at the community level. It would also provide avenue for PPMVs to refer febrile clients who tested negative to malaria RDT to a health facility for further diagnosis and treatment. It would reduce the possibility of parasitic resistance as a result of repeated home treatment of unconfirmed malaria cases. Hence, this would increase clinical effectiveness of recommended drug regimen, Artemisinin-based Combination Therapies (ACTs). It would strengthen the referral linkages for treatment of severe malaria, treatment for other febrile infections and ultimately reduce the morbidity and mortality due to home management of illnesses.

The use of Insecticide Treated Nets among Pregnant Women in Nigeria.

Author(s) Martina Ezeama1, Felix Ezeamah2
Affiliation(s) 1Nursing science, Imo State University Owerri Nigeria, 2Private Practictioner, Ndukwu Hospital Amaifeke Orlu Imo State , Owerri, Nigeria,
Country - ies of focus Nigeria
Relevant to the conference tracks Education and Research
Summary The study was carried out to determine factors militating against utilization of insecticide treated nets by pregnant women. This was based on the background of the study which reflected low usage of ITNS by pregnant women in the study setting. A total 201 pregnant women were interviewed using questionnaire. Overall results showed that majority were aware of the insecticide treated net but usage was low. Most respondents reported experiencing excessive heat under net and were afraid of the chemical used in producing the net. Findings suggest the need for an intensive public enlightenment campaign to dispel fear of chemicals used in treating the ITNs and heat produced by ITNs to encourage use among pregnant women.
Background Malaria infestation during pregnancy has been associated with persistent high maternal and childhood morbidity and mortality among pregnant women especially in Nigeria were malaria is highly endemic. Malaria accounts for 11% of maternal death, 70% of morbidity in pregnant women and is responsible for 63% of all clinic attendances in Nigeria. It causes 25% of infant mortality and 30% of all childhood deaths. Malaria during pregnancy accounts for up to 15% of maternal anemia and 5-14% of low birth weight (Safe motherhood fact sheet 19). As a result the World Health Organization (WHO) launched Roll Back Malaria (RBM) initiative in 1998 with a major focus on the prevention & management of malaria during pregnancy by using insecticide treated nets (ITNs) among other measures. Although malaria is preventable, easily treated and curable, it assumes a deadly dimension when it occurs in pregnancy and it is not promptly managed.
Objectives The broad objective of this study was to determine factors militating against the utilization of insecticide treated net among pregnant women attending the antenatal clinics (ANC) in a tertiary health facility in Imo State Nigeria. Other objectives include:
 To determine the level of awareness of insecticide treated nets among pregnant women.
 Ascertain the frequency of the use of insecticide treated nets among pregnant women.
 Determine the measures that promote the use of ITNs by pregnant women.
 Determine the influence of socio-demographic characteristics of pregnant women towards the use of insecticide treated nets.
Methodology The study was descriptive in nature and because of its focus on the clinics within the teaching hospital, was a case study of the factors militating against the utilization of insecticide treated net among pregnant women attending antenatal care in teaching hospital Orlu, Imo State Nigeria. In the course of clinical experience at the antenatal clinic (ANC) and community posting, the researcher noticed that the usage of insecticide treated nets (ITNs) among pregnant women is still not encouraging despite awareness being created about the importance of this cost-effective and efficient method of malaria prevention and control.
The researcher conducted a study to ascertain the level of usage of insecticide treated mosquito nets (ITNs) among pregnant women attending antenatal (ANC) in Imo state teaching hospital and also the factors militating usage by asking the following questions:
 What is the level of awareness of insecticide treated nets among pregnant women.
 To what extent are insecticide treated nets used by pregnant women.
 What are the factors influencing the use of insecticide treated nets among pregnant women.
 What are the measures that could promote the use of insecticide treated nets by pregnant women.
 What is the influence of socio-demographic characteristics of the respondents towards the use of insecticide treated nets. The study was approved by the hospital Human Research Ethic Committee and informed consent was obtained from the patients. The sample size used was based on a simple proportion and prevalence of 13% from previous study. Data were collected on a pretested research administered structured questionnaire and analyzed using SPSS version 16 statistical software. Information collected included socio-demographic data, level of awareness and usage of ITNs, factors militating against usage and measures that could promote the use of ITNs by pregnant women. Descriptive statistics was obtained for quantitative variables while frequencies and percentages were used to present categorical variables. Chi Square statistical tests were carried out where applicable with the level of significance set at p < 0.05.
Results A total of 201 pregnant women were interviewed. Their ages ranged between 18 and 50 years with mean of 27% years. The majority 191(95%) were married, 150 (74.6%) had attained tertiary education and 137(68.2%) were multigravida while 64(31.8%) primigravida, 155(77.1%) were aware that insecticide treated nets (ITNs) could prevent malaria in pregnancy, but less than half 91(45.39%) of them were using ITNs. Their major source of information about ITN's was at the ANC. 71(35.3%) of pregnant women were in possession of ITNs. Constraints to the use of ITNs were 98(48.8%) and included not using ITNs because of the heat they experienced under the ITNs, 64(31.8%) reported fear of the chemicals used in treating the net, 24(11.9%) indicated non-availability of ITNs and 17(8.5%) lacked knowledge on how to install the nets. Measures to increase the use of ITNs by respondents included: the majority 91(45.3%) indicated the increase in ITNs awareness campaign, 74(36.8%) increase availability of nets, and 46(22.9%) indicated the need for increased education on how to install the net. There was no statistical significance between marital status (P=0731, Parity (P=0.538), level of education (P=0.269) and usage of ITNs.
Conclusion Although there was a high awareness about ITNs, the use of ITNs was low. Experiences of excessive heat and fear of the chemical used in treating the nets are major constraints. Intensive public enlightenment to dispel misconception about fear of the chemical used in treating the net, excessive heat and availability of ITNs may encourage the use of ITNs among pregnant women. The study is significant as it has pointed out factors that militate against the use insecticide treated nets by pregnant women. This study will equip health personals or care providers with more knowledge on how to create more awareness to the populace on the use of ITNs and will also help government and policy makers through supplying the populace with enough ITNs thereby reducing high mortality and morbidity rate. It is recommended that the major challenges of low usage such as fear of chemicals, excessive heat and inadequate supply be seriously addressed to encourage the use of insecticide treated nets by pregnant women to prevent malaria during pregnancy.

GHF2006 – PS23 – Research Networks in Partnership

Session outline

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

Session Document

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Session Report

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

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

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

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

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

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

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

Research Ethics in Africa: Needs and Opportunities

Author(s): Peter M. Ndumbe1
Affiliation(s): 1Microbiology, Haematology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon
Key issues:

It is a truism that health policy as well as the teaching and practice of the health sciences ought to be guided by evidence. The collection and validation of this evidence has to depend on methodologically and ethically acceptable standards. Whilst there is some agreement that issues related to methodology have been fairly well addressed in low-income countries such as Cameroon, the same is not true for ethical issues.

Meeting challenges:

Training institutions for the health sciences such as the Faculty of Medicine and Biomedical Sciences in Yaounde have to take the leadership in ensuring that research is conducted in an ethical manner. Appropriate training has to be provided both to the teachers and to the students in this area. Since its creation in 1969, the Faculty of Medicine and Biomedical Sciences has forged the research culture into its graduates. All graduates have to provide a thesis, dissertation, or research report as part of the requirements for qualifying. Within the last fifteen years, the faculty has grappled with the issue of conducting research in an ethically sound manner. This has resulted in the installation of an Ethical Committee at the Faculty. In order to ensure its recognition and use, training had to be provided first for the teachers, and later for the students. Continuing education sessions are required for the teachers whilst every new crop of students is immersed into the ethical culture of conducting research. The major concerns encountered are the total neglect of the research culture in daily decision making and the assumption that health provision services are inherently good and cannot be challenged. Issues related to the financing of research are commonly found to be poorly understood by researchers. Other challenges related to the functioning of the Committee (administrative, displeasure with results, use of other facilities, financial, follow-up of studies) are dealt with in innovative manners and the Ethical Committee is becoming well known.

Conclusion (max 400 words):

In conclusion, although wrought with difficulties in the beginning, training institutions should provide leadership in ensuring that research is conducted in an ethical manner in low-income settings. This not only safeguards the dignity and human rights of participants, but also ensures that medical practice becomes accountable to its users.