Geneva Health Forum Archive

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Inequalities in health care utilization in Mexico.

Author(s) Christine Göppel1, Linus Grabenhenrich2, Peter Tinnemann3.
Affiliation(s) 1Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany, 2Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany, 3Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany.
Country - ies of focus Mexico
Relevant to the conference tracks Social Determinants and Human Rights
Summary Mexico´s way towards Universal Health Coverage: Are the Mexican poor still at a disadvantage in health care utilization?
Background The cornerstone of the Mexican health reform towards Universal Health Coverage is the 2003 introduction of a voluntary Popular Health Insurance (Seguro Popular). It aims to ensure access to health care services for vulnerable population groups and to address inequities in health care utilization for those facing financial hardship through sickness.
Objectives To quantify the Mexican health reforms success we identified the characteristics of population subgroups that contribute attributably to disparities in health care utilization of older adults and evaluated socio-economic inequities considering the distribution of needs for health services across the income groups.
Methodology Data of the WHO “Study on global AGEing and adult health” (SAGE) Wave1, conducted 2009/10 in Mexico, was examined for determinants of health care utilization. The concentration curve and index of health care utilization were used to measure socioeconomic inequalities in health care utilization and standardized for health needs to assess inequities in health care utilization.
Results Among the SAGE Wave1 participants from Mexico, less than half of the population saw a doctor in the 12 months prior to the survey. Income is by far the strongest determinant of an older person´s probability of using health care services. Other associated factors are chronic conditions, rural residence and education of the household head respectively. Achieved access of health care services is concentrated on the richer quintiles of the population. Poor population subgroups use outpatient services less frequently, despite presenting worse health conditions. Pro-rich-inequalities in health care service utilization appear as a matter of inequity and reflect, at least partly,  inequitable distribution of health care services utilization.
Conclusion The study measures specific indicators of the Mexican health system performance as it moves towards Universal Health Coverage. Ongoing socio-economic inequalities in health care utilization are confirmed. No evidence is found that insurance coverage increases health care utilization among the elderly poor. Mexican health policy makers should address prevailing financial obstacles and improve policies to further promote equitable and sustainable access to health services.

Promoting institutional obstetrics and newborn care in Bangladesh by subsidising out of pocket costs.

Author(s) Mst. Farhana Akter1, Ubaidur Rob2, Ismat Ara Hena3.
Affiliation(s) 1Poverty, Gender and Youth, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh, 3Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary Maternal and child health programs are yet to achieve the  impact on the obstetric and newborn care services utilization from institutions in Bangladesh. This paper explains whether subsidizing out of pocket costs for women promotes the utilization of institutional obstetrics and newborn care or not. Coupons were provided to poor pregnant women and mothers of newborn babies to cover transportation, medical costs and incidental costs for receiving institutional services. A rigorous process of community assessment and use of poverty tool was employed to select eligible women. Three-fourths of the poor pregnant women were identified as eligible for coupon distribution from 20,833 pregnant women.
Background Maternal and neonatal health programs are yet to achieve the desired impact on the utilization of obstetric and newborn care services from public-sector health facilities in Bangladesh. Home delivery and untrained providers during delivery largely contribute to the underutilization of the existing obstetric and newborn care services provided at facilities. Demand-side barrier costs remains a key challenge to the utilisation of skilled maternal newborn and child health (MNCH) care. The cultural and social belief system, social stigma associated with pregnancy and birth, distance of the facility, lack of information on sources of care, lack of awareness on the value of maternal health services, and high access costs (e.g. direct and indirect costs) are considered important demand-side barriers (Ensor 2004). Cost concerns hinder the seeking of professional maternity care and emergency obstetric care, and contribute to maternal death (Koeing 2007; Rob et al. 2006). Poor families face resource constraints and other disincentives to make use of health facilities. High transportation costs due to distance to health facilities and other out-of-pocket costs contribute to limited access to health care by those who need it most (Glassman, Todd, and Gaarder 2007; Khan 2005).
Objectives The Population Council implemented Pay-for-Performance (P4P) for providers and subsidised out of pocket costs for clients to improve MNCH services by addressing supply and demand-side barriers in Bangladesh with funding from UNICEF. This paper explores whether the subsidisation of out of pocket cost of clients promotes the utilisation of obstetrics and newborn health services. Financial assistance in the form of coupons were provided to poor pregnant women to cover transportation, medical and incidental cost for receiving services from facilities.
Methodology A rigorous process consisting of community assessment and use of the poverty tool was employed to select eligible women from the six upazilas of two northern districts of Bangladesh. Information about coupon utilization was collected from the pregnant mother’s identification list, distribution list, and the service statistics. During the service provision period, a quick survey was conducted among the coupon recipients to know the challenges and opportunities of coupon utilization at the health facilities, which would contribute to service utilisation at the facilities. Coupons were distributed during the period January 2011 to June 2011 among the pregnant women who were supposed to deliver by November 2011. The coupon distribution process was used the government field level workers, supervisors and NGO workers to make them aware of the project as well as develop ownership. Two quarters into the implementation, coupon counselling was conducted by the NGO field workers in all coupon project areas. The main objectives were to identify the causes of not using the coupon by the pregnant mothers.To collect detail information about coupon utilisation, service statistics were collected monthly from the service facilities. Process documentation was done from the in-depth interviews that used coupons as well as those that didn't. This paper will describe the experiences of coupon distribution, utilisation and services utilisation as a whole (coupon and non-coupon) from the health facilities of 2 northern district of Bangladesh.
Three-fourths of the poor pregnant women were identified as eligible for coupon distribution among the identified 20,833 pregnant women in the intervention areas, and of them, 92 percent received coupons. Coupon cards cover transportation, medical and incidental costs for antenatal care, delivery care, post natal care, pregnancy complications, neonatal complications and under five children complications.Coupon card distribution started in January 2011 in one district and in March 2011 in another district. Coupons were distributed using NGO workers in the case of the unavailability of government workers. Due to poor utilization rates of coupon beneficiaries, 284 field workers were oriented and engaged for coupon promotion and validation of the coupon distribution activities in September 2011.
Results About 88 percent coupon card holders in a district and 72 percent coupon card holders in another district reported that those eligible to receive the coupons did so. The remainder either damaged or lost the cards or did not receive the cards from the fieldworkers. Among the two districts, 40 percent of coupon recipients used their coupons in Gaibandha district and in Kurigram district 60 percent of coupon recipient used their coupons to receive services from the public-sector health facilities. The coupon clients responded well in terms of receiving the antenatal care services but were reluctant to have deliveries at the facilities and use coupon for newborn care. Coupons were mostly utilised for receiving antenatal care services (79 percent) followed by institutional delivery (17 percent), postnatal care (16 percent) and pregnancy complications care (13 percent) (Table 1). Findings suggest that about one in ten users used coupons for receiving neonatal and under five complication related services from the selected public-sector health facilities, with a significant variation across the areas. The majority of the coupon users used their coupon for antenatal care followed by PNC and delivery care with no variation across the areas. Process documentation suggests that due to the unavailability of fieldworkers, coupon distribution was not performed appropriately as the project used the government field-workers. Similarly the field-workers who were active in distributing the coupons were not interested in counselling the client to use coupons. The most cited reasons for non-use of coupon is inadequate knowledge about the coupon (41 percent) followed by not perceiving the need to receive services from the health facilities (22 percent), long distance and poor transportation facility (9 percent) and delay in receiving the coupon (8 percent).The challenges of transportation remained a reality in some places in spite of offering transportation costs through the coupon. Travelling to the facilities involving multiple vehicles including rickshaw, auto-rickshaw, boat, and bus from the remote char unions are cumbersome; and the transportation cost offered was not adequate for round-trip transportation cost to the facilities.There are several low performing areas located very far from health facilities. There were no usual transportation systems available in those areas. The majority of those people depend on walking and boat and it needs 4 to 7 hours to reach health facilities.
Conclusion • Intensive advocacy at the community levels and increasing the quality of antennal care may encourage women to plan delivery at the facilities.• Awareness raising activities are essential in generating demand for services and to encourage use of coupon cards at the facilities.• Including roundtrip transportation and additional cost of other arrangements (like, vehicle, ambulance, etc.) for the client for reaching the health facilities may increase the use of coupons and health facilities.

• Rigorous involvement of fieldworkers ,especially government fieldworkers in the coupon mechanism, may increase the coupon utilization.

• The poorest areas with greater geographical drawback will benefit from a combination of a demand plus supply side P4P approach in Bangladesh.

• Government should introduce subsidising out of pocket costs across the country, especially in underprivileged and disadvantaged areas.

Irregular migration: malaria re-introduction in elimination settings.

Author(s) Kolitha Wickramage1, Sharika Peiris 2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Infectious Diseases
Summary Irregular migration in the form of human smuggling and human trafficking is recognized as a global public health issue. Beyond the criminality and human rights abuse, irregular migration plays an important, but often forgotten, pathway for malaria re-introduction. We describe 32 cases of Plasmodium falciparum that were detected in 534 irregular migrants returning to Sri Lanka via failed human smuggling routes from West Africa in 2012, who contributed to the largest burden of imported cases in Sri Lanka which had entered elimination phase. Active surveillance of the growing numbers of irregular migrant flows becomes an important strategy as Sri Lanka advances towards goals of malaria elimination.
Background Sri Lanka is heralded as a ‘success story’ for malaria control in Asia having succeeded in reducing malaria cases
by 99.9% since 1999 and is aiming to eliminate the disease entirely by 2014. Since the end of the protracted civil conflict in 2009, there have been an unprecedented number of migrants leaving Sri Lanka to countries such as Australia, Canada and the UK via ‘irregular migration’ routes. An irregular migrant is defined as someone who, owing to illegal entry or the expiry of his or her visa, lacks legal status in a transit or host country. Irregular migration takes many forms, ranging from human smuggling to trafficking of persons for purpose of exploitation. Globally, the numbers of undocumented cases have increased despite spending on enforcement measures at the major destination countries.
Objectives This report focuses on a migrant flow of major importance for malaria importation that, until recently, has received little attention from public health authorities.
Methodology From the end of 2011, local and international law enforcement authorities intercepted people-smuggling operations from Sri Lanka to Canada across nine West African nations: Togo, Benin, Guinea, Sierra Leone, Mali, Ghana, Senegal, and Mauritania. In close coordination and partnership with the Governments of Sri Lanka, Canada and West African nations, IOM assisted these irregular migrants who were intercepted or detained, and returned to their place of origin. From January to December 2012, all irregular migrants returning from West African countries were subjected to malaria screening upon arrival at the Bandaranayke International Airport (BIA) in Sri Lanka. Screening was conducted on site using the rapid diagnostic test kit CareStart™ Malaria HRP2/PLDH, with 98% sensitivity and 97.5% specificity for Plasmodium falciparum, and microscopic examination of blood smears, collected at the airport and performed at the national reference laboratory. Health personnel from the airport medical unit, Anti-Malaria Campaign (AMC) and IOM officials were involved in facilitating the on-arrival screening process. Under a directive from the Anti-Malaria Campaign, repeat RDTs were carried out for all returnees at the district level within one week of their arrival at home destination. This intensive follow-up was carried out with the collaborative efforts of both the AMC and IOM field staff.
Results Of the total number of returnees screened (n=534), 32 were positive for P. falciparum. Nearly two thirds (n=19) were identified at the point of entry at the BIA and 13 during district level follow-up. The total number of malaria cases from irregular migration routes accounted for 76% (32/42) of the total number of P. falciparum cases detected in Sri Lanka in 2012. This route contributed to 46% (32/70) of the total number of imported malaria cases in the same year. Imported cases overtook indigenously acquired cases of malaria for the first time in Sri Lankan in 2012, contributing to three-quarters of the total malaria burden (70/93). The largest number of irregular migrants (n=17) had returned to Jaffna district which has the highest API of >0.2 to 0.3 in comparison to other districts in Sri Lanka.
Conclusion Malaria incidence in returnees from source countries has proven to be a sensitive predictor of malaria risk, particularly where there is sub-national transmission. The fact that the largest number of migrants returned to districts with the highest API indexes reported nationally is also significant. Re-introduction and risk of spreading the parasites occurs when there is a long-term return into areas of endemicity with presence and prevalence of the mosquito vector. For this reasons the close follow up and monitoring performed by the AMC and IOM field based teams is an important strategy. Unlike other categories of inbound migrants, such as tourists, who may also import malaria to the country, returning Sri Lankan citizens from endemic areas are more likely to be exposed to mosquito bites and hence are more likely to contribute to the spread of malaria upon return to their homes within locally endemic regions. Other inbound migration categories include: returning Sri Lankan labour migrant workers, Sri Lankan armed forces personnel from UN peace keeping missions, and returning students. The attack rate for malaria in this migrant group using irregular modes of travel is considerably high (sixty cases per 1,000) when compared to the risk of contracting malaria for regular travellers returning from West Africa at three per 1,000. For the migrants themselves, their ‘illegal’ status and clandestine nature of movements enhanced health vulnerability, including having little or no access to health care in transit countries.

Breast cancer screening for everyone.

Author(s) Patrick Brander1, Marius Besson2, Béatrice Arzel3
Affiliation(s) 1Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 2Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 3Fondation genevoise de dépistage du cancer du sein, Fondation genevoise de dépistage du cancer du sein, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Social Determinants and Human Rights
Summary As breast cancer is the most prevalent cancer in women, a screening program has been developed in the canton of Geneva since 1999. The University Hospital’s CAMSCO service (Consultation ambulatoire mobile de soins Communautaires) is devoted to people living in precarious conditions which includes mainly undocumented migrants and women working in the domestic’s fields, those without health insurance, and inclusive of those aged over 50 years old. Since 2006 a collaboration between the cantonal breast cancer screening program and the CAMSCO was developed allowing for these undocumented women to have access to information in their own language and also mammography screening. Since 2008 280 women have had mammography screening.
What challenges does your project address and why is it of importance? Access to health systems for undocumented migrants in Switzerland is difficult and differs greatly between cantons. Some swiss cantons have organized a system to allow these people to have access to primary care and preventive medicine. Breast cancer screening is recommended by international guidelines and should, as such, be offered to every women between 50 and 74 years old.
How have you addressed these challenges? Do you see a solution? A collaboration between the CAMSCO and the “Geneva Breast Screening program” has been developed since 2006, allowing the undocumented women between 50 and 74 years old and living in Geneva to be offered mammography screening. This program is financially supported by public funds and the mammography itself is paid 90% by patients’ insurance with a 10% (19.15.-swiss francs) contribution by the patient. The exception is disadvantaged women, for whom this amount is supported by screening program through private funds.
How do you know whether you have made a difference? Due to this collaboration 280 migrants women without health insurance had access to mammography screening. Their number has been about stable since 2010 averaging 65 for each year.
Have you or the project mobilized others and if so, who, why and how? The project has mobilized the Geneva hospital gynecology service as they do the mammography and assure that any anomaly is investigated and treated as needed. Medical doctors working in the Geneva hospital primary care service are also encouraged to plan mammography for their undocumented migrants as indicated
When your donor funding runs out how will your idea continue to live? Our collaboration may be funded by public funds, as it is already in part. Otherwise, it could only be funded by patients themselves, which is impossible.

Access to Care for Migrants: Focus on NGO-Based Systems

Author(s): K. S. Almeida1
Affiliation(s): 1Medecins du Monde, Neuchâtel, Switzerland

Gateway means of access to the health system for those excluded, medical network, applying the fundamental right to healthcare


NGOs like Médecins du Monde or Médecins sans frontière have experience of access to healthcare for vulnerable people in their projects. In Switzerland, they carried out pilot projects for the most vulnerable populations: the undocumented migrants : RSM, Fri-santé, Meditrina.These projects outline the weakness of the national health system at two levels firstly in the access to the health structures and secondly in the access to the insurance, LAMal. Health is a luxury for certain categories of population.


The medical network is not foreseen as a substitute to the health structures but as facilitated gateway to it. The projects have two objectives: 1: access to health care, 2 : health promotion. They have in common free guidance and treatment at reduced fees.RSM has two components: a health component with a nurse attending the patients and a social component to facilitate administrative work.


Right to healthcare exists but the actual access conditions do not allow the most vulnerable to exercise it.The people who benefit from the NGO structures are a majority of undocumented migrants (asylum seekers, NEM, dedoutés) but also Swiss who can not or do not know how to gain access to healthcare. The barriers are ignorance of the system, fear of being denounced and financial problems. Within the insurance problems, the NGO are the intermediary to assistance with administrative procedures and advise. The advise can be positive to get the insurance but can also be negative if the financial or geographical problems are to important. The need of a special structure is variable and changing according to the size of the canton (therefore the number of undocumented migrants),but still very pertinent.
The population is mixed so its is difficult to have a strait message.Promotion of healthcare is important to improve the beneficiaries environment. and for an improved reception in the existing structures.
The ultimate objective of most NGOs is that the state answers to its responsibilities and thus the projects becomes obsolete. Generally speaking, society accepts the right to good health but it is the application witch is sometime controversial. Financing of the project is difficult. It is often a grey zone with state support but without total financing, therefore a long term planning difficult. The patients have confidence in a NGO structure, but they often give importance in knowing of official support. For the patients as for the NGO the support gives legitimacy.

Self-Medication among Undocumented Latin American Migrants in Geneva, Switzerland: A Good Solution for Improving Access to Healthcare?

Author(s): M. Besson*1, D. Lazzaro2, Y. Jackson2
Affiliation(s): 1Community medicine and primary care department, University Hospitals of Geneva and University of Geneva, 2Community medicine and primary care department, University Hopitals of Geneva and University of Geneva, Geneva, Switzerland

Self-medication. Undocumented Latin American migrants. access to medicines. Antibiotics. Importation of medicines. “Lay injection”


Self-medication is a frequent response to common health problem worldwide, the risks and benefits of which are a concern for medical practitioners. Self-medication practices are influenced by personal, sociocultural and economic factors, as well as by drug sale policies and legal frameworks.
For people living in precarity, with poor access to health care, self-medication is often the only treatment option. We conducted a study among patients attending the UMSCO (Unité Mobile de Soins Communautaires), a primary care clinic for the uninsured people in Geneva. The purpose of our study was to describe self-medication practices among undocumented Latin American patients (the main patient population at the UMSCO), and in particular to explore the use of antibiotics and injectable medications (“lay injection”), as well as the importation of medicines from patients’ home countries.


We conducted a qualitative study through semi-structured interviews with patients attending the UMSCO during a three-month period. All undocumented Latin American patients who reported practicing self-medication were eligible to participate. After obtaining signed consent to participate in the study, a trained nurse conducted semi-structured interviews with patients. All interviews were conducted in either Spanish or French and lasted approximately 35 minutes.


(partial analysis) We conducted 67 interviews with patients coming mainly from Bolivia, Brazil and Ecuador. The participants were mostly middle-aged women, who migrated for economic reasons to Geneva and were employed in domestic work. We found that antibiotic for systemic use was frequent, especially with amino-penicillins. Oral administration was more frequent than by injections. We did not find significant differences in antibiotic use among different nationalities. Respondents believed that antibiotics are “strong”, “ kill everything” and are “very effective”. Reference to “bacterial” infection was rare. We also found that medicines from patients’ home countries were frequently used. These were usually sent to patients by family members, and included analgesics (nonsteroidal anti-inflammatory drugs and paracetamol), antibiotics and vitamins. Injectable medicines were occasionally purchased, and administered by “lay experts” (individuals with minimal health care skills) in the Latin American community. Self-medication is frequent in our sample and involves regularly prescription-only medicines. The clinical implications of this contextualized study may be summarize as follow: there is a need to systematically : 1) investigate self-medication and financial resources into the clinical encounter; 2) address patient’s social and personal representation of medicines (especially antibiotics); 3) look for patient’s informal and popular sector of health care.
Our results suggest the need for implementation of community health programs aimed at informing the undocumented Latin American community about the risks and benefits of self-medication and the appropriate use of medicines.

Community-Based Planning & Monitoring of Public Health Services

Author(s): N. K. Gupta1
Affiliation(s): 1Prayas Centre for Health Equity, Prayas, Jaipur, India
Keywords: Tribals, community based monitoring, participatory health planning

Tribals, as a community in India experience unfair health inequities on account of poor economic abilities and remote residence. This causes sustained harm to their health. High prevalence of infectious morbidity chief cause of premature mortality and large scale temporary or long term disability amongst them are clear evidences. An action research initiative of a civil society group “Prayas” to construct demand amongst tribals for “Safe, rational, effective and quality health & therapeutic care” by formulating sustainable convergence between public health care providers and users has shown reduction in grave health fatalities. Project area of this initiative was Chhotisadari block, Chittorgarh Dt. of India. Project initially covered 25 villages with total population of 19,638. Out of it 89.23% belonged to tribal community. Project’s assumption was that public health care services could be improved by establishing forums for communication and shared responsibilities between community and health services institutions. Morbidity and mortality data from 25 villages showed poor immunization coverage, very little antenatal care, almost no trained attendance during deliveries and excessively high out of pocket expenditure in medication. Other social indicators viz. literacy and awareness about entitlements were weak. Lack of livelihood opportunities and poor infrastructural development added complexities in life of people. While community had bagful of complaints towards insensitive attitude of health providers, the health personnel had their share of woes regarding people’s attitude. This led to tribals deprived of essential healthcare. Treatment seeking behaviour showed poor indulged in self treatment and very poor almost did nothing for illnesses. Many borrowed money to buy medication causing further impoverishment.


Interventions included - participatory health mapping to build community diagnosis, community based monitoring and awareness forums; formation of women’s and adolescent health groups; gender sensitivity and socioepidemiological skills building workshops of providers; organisation of representative village health assembly and committees comprising of community & providers; setting up of village health goals and charter; formation of convergence committees at primary and community health centres. Committee jointly reviewed and planned monthly health activities; organisation of public dialogues/hearing on access to health care.


Assessment after two years showed 76.53% increase in institutional deliveries, 74.95% rise in immunization of tetanus toxoid amongst pregnant women, artificial feeding which was 19% before the interventions reduced to 5.15%, hand washing by soap increased to 34.665 from 18.1%. Number of households having toilets increased from 1.1% to 11.74% and private bathrooms from 18.2% to 47.0%. As a result the decline in morbidity and premature mortality was significant.


Author(s): S. Vriesendorp*1, M. Mubarak2, S. Solter2, S. Hedyatullah2
Affiliation(s): 1Leadership, Management and Sustainability Program, Management Sciences for Health, Cambridge, United States, 2Leadership, Management and Sustainability Program, Management Sciences for Health, Kabul, Afghanistan
Keywords: Afghanistan, Provincial Public Health Offices, community health workers, leadership development

Despite the enormous obstacles to building a health system in Afghanistan, past projects and current work demonstrate the spirit of the Afghan people to unite around the issue of access to health care. The Technical Support to the Central and Provincial Ministry of Public Health (Tech-Serve) Project, led by Management Sciences for Health (MSH), works to strengthen the leadership and management of the Ministry of Public Health (MOPH) at the central and provincial levels by making managers more aware of their role as stewards of the health system and introducing accountability for results in 13 provinces that are supported by USAID. The project works under the assumption that through strengthening leadership and management skills of the health manager within the structure of the WHO’s health systems strengthening building blocks, the MOPH will be better able to perform its primary function as stewards for better health.


Tech-Serve supports the move towards decentralization of health services management by building the capacity of Provincial Public Health Offices (PPHO) to successfully perform the core public health functions and tasks as defined by well-performing PPHOs. Decentralization of health services management is successful only when the central level trusts that the provincial level knows its responsibilities and its standards of performance and if, consequently, district and community levels are fulfilling their respective roles as implementers. The project works directly with provincial health directors and their teams to effectively articulate their health priorities to develop and implement strategies. A member of Tech-Serve project staff is embedded within each province, working closely with the Provincial Public Health Director and his/her team. Using the Leadership Development Program (LDP) approach developed by MSH with financial support from USAID/Washington, Tech-Serve has trained more than 1,800 health professionals (including senior-level MOPH and NGO managers) and scaled up the LDP to include 66 health facilities throughout the 13 focus provinces. In each of these places management and leadership has been demystified and translated into a number of behavior practices that help people produce intended results. At the community level, the project supports capacity building of Community Health Workers (CHWs). TechServe provided technical and financial assistance to the MOPH to celebrate the first National CHW Day to recognize the leadership role of CHWs in delivering health services in Afghanistan. With project funds, the MOPH produced a documentary film on the CHW’s role in the health system and their community activities.


A review of the work completed to date indicates that building provincial leadership and management capacity demonstrates improvement in health service results. With provincial public health teams more responsive to the needs of the population, a first step is taken to rebuild the trust of the population in at least some government services. Both access to healthcare in a time of conflict and the number of people accessing services, have increased. The number of health facilities where health managers are consciously and systematically leading and managing has increased from 40 in 2007 to 66 in 2008. These managers are showing improved results in vaccination coverage, access to family planning services, and in the areas of maternal and child health and combating communicable diseases. The most significant improvement in the targeted health facilities is visible in an increase of almost 70% in institutional deliveries, a 34% increase in DPT3 vaccination coverage and 28% increase in family planning consultations. Independent field observations and the national Health Management Information System data confirm the positive impact of the leadership and management strengthening interventions on the behavior and practices of health workers.

Post-Conflict Health Care Start Up and Health Systems Strengthening in Fragile States: MSF Experience in DRC

Author(s): M. Philips*1, E. Lampaert2, L. Luycfassel3, J. Janssen4, C. Vanoverloop5
Affiliation(s): 1Analysis and Advocacy Unit, Médecins Sans Frontières, Brussels, Belgium, 2Pool d’urgence, 3Pool d’urgence, 4Medical coordination, Médecins Sans Frontières, 5Medical coordination, Médecins Sans Frontières, Kinshasa, Democratic Republic of the Congo
Keywords: Post-conflict, fragile states, health impact, mortality, access to health care

Health care delivery in post conflict countries faces many challenges. Discussion on how best to tackle high mortality rates and weak health systems is ongoing. There are important differences in opinion what approach yields best results in terms of improved health status and restarting of essential health services. In spite of the existence of specific budget lines for most donor agencies, the question on necessary adaptations to classic development approaches remains highly topical. Humanitarian assistance is seen as temporary and important tensions exist between development and humanitarian approaches during this transition period.Evidence on outputs and outcomes is scarce in literature.


A comparative analysis will be made of basic indicators both in terms of health care offer and utilisation. Where available measures of impact at population level will be added. The experience of MSF supporting health care delivery in the isolated rural district of Lubutu will be discussed. Also indicators of health care offer and access will be shown in other districts and health facilities, supported by traditional development approaches. The latter information is based on field visits to these facilities by the MSF emergency teams when called in for crisis situations.


Evolution of utilisation data in health facilities previously supported by MSF in Equateur province will be presented. Data on availability of essential services in Equateur during the transition period will also be shown. Trends in utilisation of health care, population based measures of access and mortality in Lubutu district show rapid decrease of mortality. Detailed analysis of data is ongoing at present.

Addressing Healthcare Needs of Tajik Migrants in Russia

Author(s): F. Dorobova*1, F. Daya2, V. Kobzeva3, J. Tomaro4, S. Jadavji5
Affiliation(s): 1Medical Coordinator, Health Programme, Aga Khan Foundation, Moscow, Russian Federation, 2CEO, Aga Khan Foundation, Moscow, Réunion, 3Monitoring and Evaluation Officer, Aga Khan Foundation, Moscow, Russian Federation, 4Director, Health, 5Programme Associate, Health, Aga Khan Foundation, Geneva, Switzerland
Keywords: Migrants, Russia, Tajikistan, Healthcare

Following the collapse of the Soviet Union in 1991, several of the newly independent republics, such as Tajikistan, had to rebuild shattered economies and to establish new polices and institutions. In many of these countries, employment opportunities were limited, forcing people to seek jobs elsewhere, especially Russia. Russia needs labour migrants because its native workforce is insufficient. The Russian Federal Service for Migration reports that in 2008, there were about 400,000 labour migrants from Tajikistan in Russia, while other sources estimate the number to be around one million. Some suggest that there are as many as ten million non-registered migrants. From Tajikistan, a landlocked country with limited natural resources and weak systems, more than 600,000 labour migrants move to Russia each year. Remittances provide better lives for Tajik families back home and greatly strengthen the national economy. In 2008, for example, remittances channelled through banks comprised about half of the national GDP. In addition, in 2007, 50% of the poorest households receiving remittances since 1999 rose above the poverty line. Migrants in Russia fall into one of three categories: i) those with Russian citizenship (most of whom arrived before the collapse of the Soviet Union), ii) those legally registered, and iii) those who are not registered. However, regardless of legal status, migrants face discrimination; have difficulty maintaining their registration and securing access to all legally defined benefits (e.g. access to health care and ability to apply for bank loans), and are often harassed by officials. While healthcare is free for Russian citizens and registered migrants with legal employment, those who are not registered must pay. Costs are often too high, forcing most migrants to wait until their illness is severe before seeking medical attention.

Methods: In 2008, in response to the health care needs of migrants in Moscow, a group of volunteer doctors from Tajikistan established a network called the Volunteer Ismaili Doctors’ Initiative (IDI) with assistance from the Aga Khan Foundation. The overall objective was to create a structured approach to the provision of health care and psychosocial care and to create awareness of healthier lifestyles among migrants. Since June 2008, the IDI has: i) operated a medical hotline that offers access to a treating physician; ii) carried out complementary home/workplace visits to provide diagnosis and basic health care; and iii) conducted seminars to raise awareness of socially significant diseases (TB, HIV/AIDS, STIs) and reproductive health. In July 2009, a fourth component was launched to address the psychosocial impacts of continuous stress related to financial problems and domestic and legal issues. This is a telephone counselling service that provides psychosocial and emotional support, as well as referrals.

Please see the Table for number of migrants reached through the IDI. Despite Russia’s need for labour migrants, the attitudes and practices in place are not always favourable for migrants, resulting in discrimination and restricted access to medical care and other social services. The AKF IDI approach, while necessary, is an interim solution; the programme works to engage the Russian public health system and corporate sector, through advocacy and policy influencing initiatives, in the provision of a more sustainable and equitable approach to ensuring access to health care for migrants. As migrants begin to access public health services, the current volunteer programme can phase out of healthcare and focus more on the promotion of healthy lifestyles.