Geneva Health Forum Archive

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Health Professionals for a New Century: A Proposal for Implementation

First: Lenias
Last: Hwenda
Name your project or intiative: Health professionals for a new century: A Proposal for Implementation
1st country of focus: International
Relevant to the conference theme: Health governance
Summary: Factors contributing to the on-going global health workforce crisis include the globalisation of the labour markets. 'Pull' factors, including targeted recruitment efforts from wealthy destination states, combine with 'push factors' in source countries, such as low wages and unsafe working environments to exacerbate acute health workforce shortages. Ageing populations and a growing demand for chronic care are driving up demand for health workers globally whilst global under investment in health professional education is limiting the supply of health professionals. Furthermore, health professional education has not evolved to meet the health challenges of the 21st century. This has generated disparities between population health needs and health professional education.  Despite health professionals being the backbone of well-functioning health systems, total global expenditure on their education represents a meagre ~US$1billion, 1.8% of total global expenditure on health. A global analysis of health professional education by Julio Frenk et al commissioned by the Lancet concluded that health professional education in the 21st century is out-dated, produces health professional who are poorly-equipped to meet the heath population needs of the communities they serve and therefore needs reform. This presentation considers some of the inadequacies of health professional education today, based on the study by Frenk et al. and discusses whether the WHO Global Code of Practice on the International recruitment of Health Personnel could provide an international legal framework for implementing health professional education reforms needed to generate a 21st century health workforce.
What challenges does your project address and why is it of importance?: The inadequacies of health professional education in meeting the population health needs of the 21st century. It considers how the proposed reforms in health professional education can be implemented global using existing international legal frameworks. It is important to understanding how global health professional education could be reformed through international cooperation.
How have you addressed these challenges? Do you see a solution?: I have made a proposal of a possible framework for implementation and delineated how this framework might work and why it would be useful in implementing the necessary reforms.
How do you know whether you have made a difference?: So far, there has been a proposal for health professional education reform but no existing framework of how these reforms can be implemented. Therefore, my proposal fills a gap that exists towards putting solutions into practice.
Have you or the project mobilized others and if so, who, why and how?: This idea has been discussed by other health professionals at the 125h anniversary of the Norwegian Medical Association as well as amongst other health diplomats in Geneva. The ideal was proposed because putting the reforms into practice requires a international legal framework and highlights how this can be done within existing frameworks.
When your donor funding runs out how will your idea continue to live?: This idea is not donor funded since it is being explored within the context of multilateral health discussions which are ongoing.

Strengthening Health Systems for Improved Access to Health Services for Pregnant Women in Rural Areas: Nigeria

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Author(s): Chioma Nwuba1, Umoh Mary1, Lawal Salimat2, 3Livinus Ibiang
Affiliation(s): 1Management Sciences for Health, Kwara, Nigeria, 2Kwara State Ministry of Health, Nigeria, 3Management Sciences for Health, Abuja, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Redesigning health services
Summary: In Nigeria, the uptake of Prevention of Mother to Child Transmission (PMTCT) services for HIV positive women remains notably low despite significant advances in HIV/AIDS care and treatment. The burden of traveling long distances from their villages and waiting for long hours in order to access treatment has resulted in a most pregnant women opting out and this poses a barrier to the effective implementation of PMTCT programs. Thus, strengthening of health systems is vital in addressing these challenges of limited health service that prevent large numbers of HIV positive pregnant women in rural communities from accessing care and treatment services.
What challenges does your project address and why is it of importance?: Eligibility for antiretroviral therapy (ART) for the over 360,000 children and 1.6 million women living with HIV in rural areas in Nigeria is based on absolute CD4 count. This laboratory investigation is only available once a week on clinic days making it difficult for the vast majority of children and pregnant women who test positive on non clinic days to have access to baseline CD4 estimation. In addition, the burden of travelling long distances to and from clinics for initial blood draw and receipt of test results has led to attrition in the number of pregnant women who test positive to HIV versus the number who eventually commence antiretroviral therapy.. Furthermore, shortage of human resources for health also made it difficult to have enough workers attend to patients promptly. Patients have to wait for the few available doctors who are already overburdened by huge workloads to fill laboratory and pharmacy request forms before accessing laboratory investigations or collecting their antiretroviral drugs.
How have you addressed these challenges? Do you see a solution?: In order to increase uptake of CD4 monitoring for pregnant women attending HIV care and treatment clinics in North Central, Nigeria, the USAID funded PrO ACT project of Management Sciences for Health, strengthened existing systems using the following data driven interventions: 1. Provided hands-on facility based capacity building on HIV rapid testing for antenatal and maternity clinic staff. 2. Established point of service HIV testing in the antenatal clinics (ANC) and maternity units. 3. Introduced point of care CD4 sample collection for clinics where the laboratory is far from the ANC/maternity unit. 4. Task shifting to data clerks to fill laboratory request forms for CD4 investigations instead of the few available doctors. 5. Bridged the gap in human resources for health by task shifting to laboratory technicians on the use of automated CD4 equipments after consistent onsite training and supervision. 6. Adopted a flexible duty roster which ensures that a staff is always available every working day to attend to clients. 7. Task shifting to pharmacy technicians and assistants to assist in dispensing drugs daily. 8. Initiated daily (Monday – Friday) access to CD4 investigations for all pregnant mothers in order to capture women who test positive to HIV on non clinic days and ensure that they have access to baseline investigations on the same day.  9. Establishing daily investigations to provide an opportunity for pregnant women attending clinics from long distances and difficult terrains to have access to laboratory and pharmaceutical services on any day of the week. 10. Instituted 24 hours turnaround time for receipt of CD4 test results for all pregnant women to ensure rapid initiation of eligible clients on ART. 11. Harmonized patient appointments for antiretroviral drug pick up and laboratory monitoring on the same day in order to improve adherence to clinic appointments.  12. Integrated ART laboratory into existing general laboratory ensuring that the same phlebotomy point is used for all clients irrespective of their HIV status.
How do you know whether you have made a difference?: At the end of 12 months, the number of HIV positive pregnant women who accessed baseline laboratory CD4 investigations at our comprehensive care and treatment clinics increased from 53.8% to 90%. In addition, the number of pregnant women placed on antiretroviral therapy increased from 50% before the initiation of our interventions to 83% after the interventions. Laboratory turnaround time for CD4 result, which used to be 7 days, has reduced to 24 hours resulting in rapid initiation of eligible patients on antiretroviral therapy. Average client waiting time on clinic days reduced from 4 hours to 1 hour 30minutes resulting in more pregnant mothers being willing to access care and treatment services at our clinics. Furthermore, the number of patients lost to follow up reduced from 58.7% to 10.7% at the end of twelve months. More importantly, after the intervention, the number of exposed infants who tested negative to HIV increased from 85% to 100%.
Have you or the project mobilized others and if so, who, why and how?: The successes recorded after strengthening health systems for effective delivery of HIV care and treatment services at our pilot treatment center (Specialist Hospital Offa) prompted us to implement these strategies at two other treatment centers in Kwara state (General Hospital, Omuaran and Children Specialist Hospital, Ilorin).  At each clinic, we held a sensitization meeting with the hospital management committee, community leaders, health workers, community women groups and other relevant stakeholders. At these meetings, we presented data on the prevalence of HIV in each community as well as the number of women who tested positive to HIV since the inception of the program. We went further to highlight the number of HIV positive pregnant women who did not commence ART or were lost to follow up . Data concerning the high rate of under five mortality in these communities were also discussed.  Thereafter, working as a team, participants at the meetings made suggestions as to why most women who are diagnosed with HIV do not access treatment or are lost to follow up. Some of the suggestions made include ignorance about mother to child transmission of HIV, distance and difficult terrains of some communities, long waiting time encountered by most patients at the clinics, stigmatization by health workers, long turnaround time for laboratory results, different appointment days for laboratory investigations and drug pick up etc.  Possible solutions were then proffered by each group present. The women’s group agreed to have community health talks regarding HIV transmission given at their meetings. The hospital management committee introduced the idea of having more than one clinic day in a week. Working in collaboration with the Kwara state Ministry of Health we assisted in building the capacity of available health workers and adopted task shifting approaches to address the shortage of health workers. The capacity of data clerks and nurses were built up to enable them to fill laboratory and pharmacy request forms thereby reducing client waiting time and alleviating the workload on the few available doctors.  The laboratory unit instituted “same day CD4 system” ensuring that CD4 investigations are done five working days of the week for all patients who test positive to HIV. Test results are also released on the same day to ensure rapid initiation of eligible patients on antiretroviral therapy. Appointment days for laboratory investigations and drug pick up were harmonized to improve adherence to clinic appointments.
When your donor funding runs out how will your idea continue to live?: At the inception of this program, we strengthened the capacity of health sector institutions, systems and personnel to plan and manage the delivery of sustainable comprehensive and quality prevention, care and treatment support services. To also ensure that the program continues to survive and succeed even after our donor funding runs out, we instituted the following measures• Each hospital management committee drives the program and makes independent decisions necessary for the delivery of quality services. • On the job trainings facilitated by each unit head is held for incoming new staff on HIV rapid testing, filling of laboratory and drug request forms, use of automated equipments for laboratory investigations, ARV drug dispensing, adherence etc. This will ensure that more trained health workers are available to attend to patients.• At the laboratory unit of each clinic, quality assurance meetings led by the heads of each unit are held to address issues relating to improvement in the quality of services provided.• The idea has a 100% buy in from the state government as we neither employ nor pay the salaries of health workers working in the hospitals. The state government does so.

The Italian Network for Education in Global Health: An Innovative Experience Bridging the Gap between University and Civil Society

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Author(s): Ilaria Camplone1, Alice Fabbri1, Angelo Stefanini1
Affiliation(s): 1Centre for International Health, Department of Public Health, University of Bologna, Bologna, Italy,
1st country of focus: Italy
Additional countries of focus: Poland, Romania, Latvia, Bulgaria, Malta and Hungary
Relevant to the conference theme: Research and education
Summary: A greater focus on the social determinants of health and on the global scenario, together with the  transformation of conventional health training is demanded within the Italian academy. Students have been leaders in advocating for such change, finding suitable theoretical and practical tools in the emerging field of global health (GH). Public health academics, NHS professionals and NGOs have followed, leading in 2009 to the creation of the Italian Network for Education in Global Health (RIISG), whose main objective is to improve population health and to reduce health inequalities through improving knowledge, attitudes and practices of health professionals.
What challenges does your project address and why is it of importance?: Globalisation processes, the financial crisis, climate change, the growing complexity of a multicultural European society are strongly re-shaping the health of both global and European populations and highligh the importance of the action on the social determinants of health (SDH).  As reaffirmed by the World Health Organization (WHO) in the recent World Conference on Social Determinants of Health, held in Rio de Janeiro in October 2011, health inequalities within and between countries are politically, socially and economically unacceptable, and largely avoidable. The promotion of health equity is essential to sustainable development and to a better quality of life and well-being for all. This in turn can contribute to peace and security. Therefore, the three overarching recommendations of the Commission on Social Determinants of Health are, now more than ever, crucial: to improve daily living conditions; to tackle the inequitable distribution of power, money and resources; and to measure and understand the problem and assess the impact of action. Those challenges are questioning the capacity of medical education institutions to enable health professionals to effectively address the health needs of modern society.
How have you addressed these challenges? Do you see a solution?: Current Italian medical education and life-long learning programmes, most of them traditional and with a narrow biomedical approach, has proved unable to provide health professionals with the necessary knowledge and skills to understand the interrelations between health,its broader determinants and therefore to tackle health inequalities.  A transformation of conventional health training has been asked for in the past few years within the Italian academy, with students taking the lead in the advocacy for such a change, and public health academics, NHS professionals and NGOs have followed suit. In 2009 this process led to the creation of the Italian Network for Education in Global Health (RIISG), whose main objective is to improve population health and to reduce health inequalities through improving knowledge, attitude and practices of health professionals. RIISG activities have been carried out in connection with similar networks from other European countries (UK, Ireland, Germany).  Thanks to the project “Equal Opportunities for Health, action for development”, co-financed in 2011 by the EU, RIISG in the next 3 years will also be operating in connection with academic and civil society partners from Malta and Eastern European countries, such as Poland, Romania, Latvia, Bulgaria and Hungary. This wide connection will provide RIISG with the ground for further dissemination of the experiences made, towards a broader European engagement in the GH field.  Through its education and public awareness activities, the project “Equal Opportunities for Health, action for development” aims to enable health professionals and the wider public to become active opinion makers in their communities and society as a whole, in order to promote the development of fairer health policies, locally, nationally and globally. It is meant to be carried out by fostering GH teachings within and outside academic institutions and by promoting public debate.
How do you know whether you have made a difference?: The most significant innovation introduced by RIISG resides in its founding principle of coherence between its practice and the values of GH. The network is indeed participatory and horizontal, avoiding the reproduction of the power imbalances that affect the Italian University, leaving students, young scholars and civil society out of the decision making process. The role played by students in advocating for change, in setting up self-organised training and eventually in stimulating the creation of RIISG, is also a quite distinctive feature of the Italian experience about GH education. This indeed influenced the student-centred teaching methods used in the trainings, particularly designed to foster the active engagement of participants. In addition, multidisciplinarity represents both an attempt at equality and a challenge. Some teaching course have been actually established in faculties others than medicine, and some of the trainers involved come from different backgrounds, but the imbalance between medicine and other disciplines has not been overcome yet.
Have you or the project mobilized others and if so, who, why and how?: The movement was initiated by students with previous experience in developing countries, who organised themselves in study groups, taking as point of reference the research and teaching work of the Centre for International Health (CSI) of the University of Bologna and of the Italian Global Health Watch (OISG). Soon the debate among those students was enlarged to others, involving also part of the Italian Medical Students Association (SISM) in a self-educating path. Optional trainings at local and national level have been implemented with the support of trainers belonging to CSI and OISG, some of which are academics. This movement went rapidly viral, so that so far, over the first seven years, six editions of a three-day intensive national courses have been delivered.  When the student movement met with some like-minded academics, NHS professionals and the NGO “CUAMM”, RIISG was created and the mobilization strategy was enriched. In order to foster and disseminate GH teachings within Italian universities, RIISG proposes a suitable curriculum to be used at local level. In addition, a pattern of learning objectives were drafted and opened to public consultation. They were articulated to simultanously develop knowledge, skills and attitudes: a triple scheme that highlights the transformative and ethical approach to GH.  Innovative action to create knowledge and to mobilise participants consists in organising training-of-trainers (ToT), with the aim of enabling them to implement autonomous training at local level, and to politically support the demand for the introduction of GH teaching into the core curriculum of medical education.
When your donor funding runs out how will your idea continue to live?: As the movement started with no dedicated funds, the mobilisation of students and the voluntary help always provided by the trainers, as well as the frugality of the meetings, are themselves the guarantee for further continuation of the activities

Next Generation University & Global Health for Students UK – Revolutionizing Scientific, Public and Global Health Education Worldwide

Author(s): Mustafa Abbas1, Iulia Hammond2, Kate Tairyan3, Erica Frank4
Affiliation(s): 1UCL Medical School, London, United Kingdom, 2Sheffield University, United Kingdom, 3Simon Fraser University, Canada, 4University of British Columbia, Canada
1st country of focus: N/A - this is a worldwide online education programme available to all countries equally.
Relevant to the conference theme: Research and education
Summary: Imagine if we could use the globalisation of communication and the sheer power of a world connected by the internet to deliver this training? What if we could deliver courses, teaching and training online? The projects presented here do precisely that. NextGenU.org delivers an unprecedented breakthrough in teaching in health sciences, public health, and global health, with outstanding Founding Collaborators and Funders, including the Canadian government, the U.S. CDC, NATO's Science for Peace initiative, World Bank, WHO, and the World Medical Association. Global Health For Students UK is a multi-disciplinary, multi-institutional collaboration of academics, researchers and students in the UK dedicated to advancing high quality and cutting edge online global health education.
What challenges does your project address and why is it of importance?: Access to education in public and global health is a problem for every country. There is an urgent demand for large numbers of people in developing countries to be trained and educated in public and global health. Teaching and training is the basis of all health systems. We cannot advance health systems without addressing and solving the problem of education.  We identify three major barriers that severely limit our opportunity to advance education. First, education is too expensive. Books alone cost hundreds of dollars, courses cost tens of thousands and travelling internationally for years at a time for education is too great a financial burden for too many in LMICs.  Second, there is a geographical barrier. We have fountains of knowledge and plentiful universities in HICs, but transferring this knowledge internationally is a challenge we have so far not overcome. We need to avoid brain drain and greenhouse gas emissions by focusing on teaching and training that does not require international travel.  Third, there is abundant information available on the internet but no one before has identified the best of it and organized it a whole university of courses.
How have you addressed these challenges? Do you see a solution?: The two projects presented here address these challenges for students all over the world, both in LMICs and in HICs. In the first instance, it is worth considering what an ideal solution would be to overcome these challenges. What would an ideal education model look like? First, the financial, geographical and material accessibility of the system would be high. It would be financially free of cost. It would be available to anyone all over the world without the need for geographical relocation. The teaching and resources would be tailored towards the learning needs of the students. Second, the quality of the material would be excellent. The range of courses would fully cater for any need of the student. Courses would range from basic sciences in health, to public health, to global health. They would combine education with training in skills for project management, field work, and public policy.   Third, the system would be highly collaborative. The preparation of the teaching and courses would be highly multidisciplinary and highly multi-institutional, involving academics and students from multiple disciplines, universities and countries. The teaching system would be a two-way partnership between the system and the students. Responding to feedback would be a central aspect of the project and the students would be seen as more than just clients; they would be seen as dedicated future health professionals.    The learning model would build on educational best practices, including using high-quality online learning materials (e.g., text, videos, images), interactive peer activities (e.g online chat rooms, and  creating and assessing peer-generated  case studies, images, and multiple choice questions), and hands-on mentored experiences (e.g., seeing and discussing patients).  This model mirrors and expands on the traditional university experience through interacting with peers and experts in the field of study, while learning basic knowledge on one’s own via online learning materials.  Global Health For Students UK is a highly multidisciplinary and multi-institutional project. It is a collaboration between the top UK universities in global health, between academics and professors from multiple disciplines, between students across the country and around the world, and between researchers, academics, NGOs, and policy makers alike. Through engagement with a full range of disciplines it presents the field of global health in an advanced way, exploring and explaining issues of international economics, globalization, global governance, global justice, all tailored towards the need for more advanced teaching on the economic, social, political, legal and ecological foundations of global health.
How do you know whether you have made a difference?: NextGenU.org began in 2001, but the University is only now (in 2011) moving into Beta, as is Global Health for Students UK, so there are still plenty of questions about how effective teaching is or will be. There are many indications thus far of the worthiness of and need for both projects.  There has been an immense upwelling of support for both projects from innumerable actors in global health all of whom have been only too keen to be involved. NextGenU.org was founded by Erica Frank, MD, MPH, with the Canadian government, U.S. CDC, NATO's Science for Peace initiative, World Bank, WHO, and the World Medical Association are among its founding collaborators and funders. Global Health for Students UK has been strongly supported by the top universities, including University College London and the London School of Hygiene and Tropical Medicine. Both projects are rapidly gaining pace and rapidly expanding. NextGenU is  formally testing our revolutionary method every place we can --our first focus groups from Latin America have called our approach “genius”, North American presenters have been told it’s “an answer to our prayers”,  and “Nobel Peace Prize worthy”, and (from the former Director of the U.S. Centers for Disease Control) “a visionary undertaking”.  Global Health for Students UK has been effective in joining together a full range of actors in global health in the UK. This is the first collaboration of this scale, and even the joining together of these different sectors has made a difference to each group in the approach we all take to working together. In the future, we will be measuring our success and effectiveness across several indicators. First will be the number of students signing up and where they are based – the best outcome will be a very high number of students without any geographical restrictions in where they are based. Second will be the adherence of the students to the courses – the best outcome will be students completing courses they start in an appropriate time. Third will be the change in knowledge base of the community – we fully expect these projects to have a significant effect on health education, and we will ensure our ability to measure these outcomes. Fourth will be the feedback we receive – we hope for positive feedback but strongly encourage being advised on areas we can improve.
Have you or the project mobilized others and if so, who, why and how?: Both of these projects are highly collaborative involving multiple groups as part of the team, and as external partners. Across both we take a position of leadership in setting the direction of a global system of education. A core aspect of this is mobilising groups worldwide. This is a central aim of ours in attending GHF2012 – we are consistently attempting to link worldwide with as many partners as possible. Public and global health education is not an issue just for universities, but involves the full range of actors and the full range of disciplines. In the interim between present day and Beta launch, NextGenU is working in two main areas that advance collaborations and networks. First, using best practices for teaching, including using online high-quality learning resources from organizations certified to give training and degrees (e.g. universities, professional specialty societies, government health organizations), local mentored and local and distance peer-to-peer training, and many other educational innovations. Second, partnering with existing credentialing organizations to get objective data – for example, our surgical trainees will be allowed after completing our training to take surgical boards in 9 countries through the College of Surgeons of East, Central, and Southern Africa.  Global Health for Students UK has mobilised three groups of actors in global health. First are individual actors – these are team members involved in researching and preparing the material. They are multidisciplinary and include professors, institute directors, course leaders, course tutors and lecturers, medical doctors, PhD students and MSc students. Student organisations, in particular Medsin – a national student global health campaign – are heavily involved in identifying the needs of the students and in contributing to advancing accessibility for students. Third are university institutes. We have, or will have, all the key centres of global health in the UK and have their support as institutional collaborators.  Fourth is the NGO sector – we are especially keen to realise that public health and global health is an applied and practical subject, and engaging groups who specialise in transferring evidence into policy is crucial.
When your donor funding runs out how will your idea continue to live?: There are abundant educational resources that already freely exist, so the training is not expensive to make.  The expert-derived competencies on which we base our trainings are already freely posted, as are the expert-created online resources that help address those competencies.  We identify, organize, and link the competencies and resources, and pair them with free interactive experiences that trainees do with mentors and peers.   Global Health for Students UK is an entirely voluntary project. All of our academics, tutors, students, external partners and institutes are non-funded. This is in keeping with our objective of advancing high quality public and global health education at low cost and low financial necessity. Our material will be uploaded onto the site of NextGenU.org. The NextGenU business model is five words:  grateful learners and inspired donors.  Grateful learners include the 10s of 1000s of professionals who have freely posted the resources NextGenU links to, and the course creators and staff who have created this site, either as volunteers or earning <=$25 U.S. dollars/hour.  We also expect that many of NextGenU’s graduates will donate money and/or time to create additional trainings, or to serve as mentors.   In summary, both models are initially low cost to create, thereby minimizing the financial needs of initiation. Both models are also very low cost to maintain in the future. With a steady stream of very small donations the project will be able to keep itself working. No project can exist with zero funding, but these projects are in the lowest of bands of how much financial support is needed. They work on human capacity and human knowledge more than material.

 

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The Illness of “Pilotitis” In mHealth – Early Lessons from the KimMNCHip Partnerships in Kenya

 

Author(s): Stefan Germann1, Amer Jabry2, Judy Njogu3, Ronald Osumba3
Affiliation(s): 1World Vision International, Geneva, Switzerland, 2e-merge consulting, Twickenham, United Kingdom, 3Safaricom, Nairobi, Kenya
Name your project or intiative: The illness of pilotitis in mHealth - Kenya KimMNCHip brokering partnerships for national scale up early lessons
1st country of focus: Kenya
Relevant to the conference theme: Health information and technologies
Tags:
Summary: Currently there are a proliferation of mHealth pilots. It is time to stop with new pilots as the field suffers from the contagious disease of 'pilotitis'. What is needed to move the mHealth space ahead, is solutions at national scale that are cost effective and use evidence based approaches for health outcomes. In Kenya, a partnership brokering process started 18 months ago to bring together the largest mobile phone provider and NGOs to work with government aimed at scaling up mHealth for Community Health Workers and pregnant women at a national scale.
What challenges does your project address and why is it of importance?: mHealth solutions are promising to enhance health outcomes at scale, especially when integrated with mobile financial services for social protection and other measures to enhance demand creation to access essential health services, especially in the context of reproductive, maternal, neonatal and child health. Currently most mHealth approaches are project based, most often of a pilot character. Hence we term this the illness of 'pilotities' in mHealth. There is urgent need to move from this stage to national mHealth solutions that are cost effective and evidence based in terms of health benefits. Brokering multi-stakeholder partnerships towards creating convergence and new business models is needed to bring solutions to scale.
How have you addressed these challenges? Do you see a solution?: KimMNCHip is a national-scale mHealth initiative to offer pregnant women in Kenya more choice, control and care during their pregnancy, and improved medical care for them and their babies during and after delivery.  In 2008, the (adjusted) maternal mortality rate in Kenya was 530 per 100,000 live births, while the infant mortality rate was 56 per 1,000 live births.  These figures place Kenya in the highest 15% of countries for maternal mortality, and the highest 20% for infant mortality (source: data.worldbank.org).  As part of its commitment to the UN Global Strategy for Women’s and Children’s Health, Kenya will recruit and deploy an additional 20,000 primary care health workers; establish and operationalize 210 primary health facility centres of excellence to provide maternal and child health services to an additional 1.5 million women and 1.5 million children; and will expand community health care, and decentralize resources. KimMNCHip aims to support this commitment through one integrated system, providing women with mHealth support along the continuum of care from pre-pregnancy to post-natal stages.  It will  initially offer three complementary services:  1. Public information via an MNC mHealth advisory service for pregnant women who register and provide their due date.  They will receive a mix of “push” SMS and voice messages, and access to call-in advisory hotlines and information data bases for MNCH issues.  These will provide the women with timely health information scheduled in accordance with the national MNCH plan.   SMS/voice charges to be covered by private partners (funded via txt/voice message advertising – following advertising code). 2. mFinancial services for health that provide pregnant women with electronic vouchers to redeem in a collaborating clinic of their choice.  The vouchers act as an incentive for clinics to enhance the quality of their services and attract more pregnant women, through a results-based payment system.  The voucher also includes a social protection cash transfer to support the women with the costs of delivery.  We will explore other uses of mPayments to support maternal and newborn care. Funding of the vouchers will be sourced from social protection funds and contributions from donors and the private sector. 3. Primary care via mSupport services along the continuum of care, for mothers and for primary health care workers (PCHWs). These will be based on access to electronic medical records, appointments, reminders, and checklists to deliver better community health services, and monitor and respond to MNCH indicators.  The initial partners of this national scale initiative are Safaricom, World Vision, the mHealth Alliance, CARE International and NetHope.  They are developing, in collaboration with other strategic mobile health partners, the preliminary enterprise and technical architectures necessary to support the continuum of care.  This initiative will represent a model implementation of the Maternal mHealth Initiative’s Global Framework.  Members of the KimMNCHip consortium will participate in developing the Framework, and the project will seek to apply the Framework.
How do you know whether you have made a difference?: The recognition of the power of multi stakeholder partnerships is well documented, especially when convergence is achieved among the various partners. KimMNCHip has both a partner brokering monitoring framework in place and an operational research is being currently designed to measure the mHealth solutions effectiveness with scientific rigor.
Have you or the project mobilized others and if so, who, why and how?: The partnership is mobilizing the government and across the world is sharing this approach via NetHope and mHealth Alliance. The CEO of Safaricom was speaking at the UN Secretary General's Every Women Every Child event sharing about KimMNChip in New York during the September 2011 UN General Assembly.
When your donor funding runs out how will your idea continue to live?: The project is not donor funded at present and Safaricom is developing a business case for affordable mHealth solutions for all Community Health Workers in Kenya. Safaricom with MPESA, banking for the unbanked, demonstrated its ability to create business models that are affordable for all. World Vision is using its own resources to support the partnership brokering process.

Front Line Health Accountability – Citizen Voices and Action: Democratizing Health in Communities

Author(s): Stefan Germann1, Jeff Hall1, Thiago Luchesi1, Itunu Kuku2
Affiliation(s): 1World Vision International, Geneva, Switzerland, 2Graduate Institute of International and Development Studies, Geneva, Switzerland
Name your project or intiative: Front line health accountability - Citizen Voices and Action (CVA) - democratizing health in communities
1st country of focus: Uganda
Additional countries of focus: Albania: Armenia: Australia: BiH: Bolivia: Cambodia: Brazil: El Salvador: Georgia:  Haiti:  India: Indonesia: Kenya: Lebanon: Malawi: Mozambique: Pakistan: Peru: Philippines: PNG: Romania: Senegal: Sierra Leone: South Africa: South Sudan: Sri Lank: Tanzania: Zambia
Relevant to the conference theme: Equity and empowerment
Summary: Health related accountability mechanisms are critical to achieve better health outcomes for the money that is spent. There has been increased global attention to this. However, unless accountability efforts occur at the front line, we will not achieve increased health outcomes of well-intended interventions. Citizen Voice and Action is an approach that aims at increasing dialogue between ordinary citizens and organisations that provide services to the public. It also aims at improving accountability from the administrative and political sections of government (both national and local) in order to improve the delivery of public services.
What challenges does your project address and why is it of importance?: Over the past year there has been a significant increase in funding for global health issues such as communicable diseases, maternal, newborn and child health and some other areas. At the same time there has been the recognition that it is not just about ‘more money for health, but as well more health for the money’. Hence, in recent years there has been an increased focus on health related accountability issues and the recent concluded Commission on Information and Accountability is a demonstration of this. Inthe public clinic of many communities the absence of basic drugs and the frequent truancy of nurses and doctors have contributed to the chronic illness and death of dozens of community members. Others travel long, painful, and expensive distances for the most basic care. The cost of lack of front line accountability, with the provision of simple feedback loops for health services, is the loss of lives seen in large numbers of still birth, maternal, neonatal and child mortality over the 60 countries that are off track to achieve the health MDGs. Frontline accountability is critical to achieve health outcomes and ensure that limited resources are delivering good results.
How have you addressed these challenges? Do you see a solution?: CVA is a local level advocacy methodology that transforms the dialogue between communities and government in order to improve services like health and education that impact the daily lives of children and their families. It works by mobilizing citizens, equipping them with tools to monitor government services, and facilitating a process to improve those services. CVA includes one preparatory phase (Organizational and Staff Preparation) and three implementation phases (Enabling Citizen Engagement; Engagement via Community Gathering and Improving Services and Influencing Policy). Before beginning Citizen Voice and Action, the following preparations are needed: • Understanding the political and social context in relation to citizen and governance issues; • Training staff, partners and stakeholders to facilitate Citizen Voice and Action within communities, recognising the broader issues that relate to citizenship and governance within their country; • Contextualizing the CVA materials. We encourage staff to adapt CVA to respond to the civil society spaces that exist and use context analysis tools to better understand the power structures in society.  Phase 2 involves the following: Enabling Citizens Engagement: This Phase builds the capacity of citizens to engage with issues of governance and provides the foundation for subsequent phases. It involves a series of processes that raise awareness on the meaning of citizenship, accountability, good governance, and human rights. Importantly, citizens learn about how human rights translate into concrete commitments by their government under national law. Phase 3: Engagement via Community gathering: ―Community Gathering describes a series of participatory processes that focus on assessing the quality of health services and identifying ways to improve their delivery. Community members who use the service, health service providers and local government officials are all invited to participate. The process is collaborative — not confrontational. Generally, nobody wants an underperforming clinic in their community, and local authorities are often eager to work with citizens to improve these essential facilities. Phase 4: Improving Services and Influencing Policy: In this phase, communities begin to implement the action plan that they created as a result of the Community Gathering process. Citizens and other stakeholders act together to influence policy at both local and higher levels. In effect, communities organize what amounts to a local level campaign, with objectives, targets, tactics, and activities designed to influence the individuals who have the power to change the situations they face at the local level. Often, communities will work with other communities to identify patterns of government failure across large geographic areas.
How do you know whether you have made a difference?: The CVA methodology is a proven approach as was demonstrated by Bjorkman and Svensson (2009) published in the Oxford Quarterly Journal of Economics in an article entitled “Power to the People”. The researchers looked at a social accountability methodology nearly identical to CVA across 50 communities in 9 districts in a randomized field experiment.  In the communities using the CVA-like methodology, they found:• a 33% drop in under-five mortality • a 20% increase in the utilization of outpatient services; • a 58% increase in the number of deliveries at clinics, • a 19% increase in the number of patients seeking antenatal care; and • a 22% increase in the number of patients seeking family planning assistance. It is important to have a strong Monitoring and Evaluation component included in the CVA work. Monitoring and support of community members and groups is necessary in order to achieve the action plans to make sure that services are improved and policy influenced. Creating long term sustainable change is not easy. It is expected that power holders and duty bearers will be responsive to the voice of citizens. Often they respond, but this is not always the case. Monitoring and support serves a number of purposes:• to motivate those carrying out the actions• to see that planned actions are happening• to see that the strategies used are effective and helping to achieve the planned action• to enable problem solving if obstacles prevent the actions from being achieved• to report back progress to the community and users of the service. Monitoring will encourage the use of regular updates, report backs and feedback loops. All of these are useful to maintain citizen interest and commitment, which is often hard to sustain. Perseverance to achieve long term, sustainable change is often difficult to maintain. Starting with ‘quick wins’ – changes that happen easily to improve the services, is a good way to encourage initial citizen action and to build momentum for longer-term action. Documenting actions taken and progress made are very important to the monitoring and support process. Those responsible for carrying out the actions, should be encouraged to keep a record of what they are doing and the responses and results of their action. Regular reporting back of progress encourages other stakeholders, participants and the general community. World Vision conducted a number of CVA evaluations, the most recent one in Uganda (Waswaga, Winterford, Walker, Mugabi &  Otim 2011).
Have you or the project mobilized others and if so, who, why and how?: Citizen Voice and Action began with pilot programmes in Uganda and Brazil in 2005 and was jointly developed between World Vision and the World Bank. In 2008, CVA expanded to additional pilots in Peru, Kenya, Zambia, India, and Armenia. Today, driven by the demand of World Vision Offices, CVA operates in 29 countries in nearly 200 project sites and is recognized as World Vision’s premier local level advocacy approach. Below Map shows the countries and number of CVA project sites per country using colour coding:  Map uploaded Map 1: A number of World Vision partner organization have started to use the CVA or similar approaches, e.g. Professor Lynn Freedman at Columbia University, Mailman School of Public Health uses in several countries similar approaches for front line health accountability.
When your donor funding runs out how will your idea continue to live?: As the approach is a citizen’s empowerment approach, the sustainability is build into the process from the beginning as the only input costs are capacity related. However, it is critical that the process is followed and sufficient time of engagement is applied to ensure that citizen’s use voice and act for change. Whilst the communities that started using CVA over 6 years ago, are still actively engaged as citizen’s to improve their public services and to keep NGOs accountable as well, it is too early to have a definite answer on long term sustainability approaches, although other citizen empowerment approaches in the field of land rights or environmental community empowerment etc have shown to be long term sustainable and do not require donor funding after a solid empowerment process had been undertaken.

GHF12_176_1

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

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.

Images:

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.