Geneva Health Forum Archive

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GHF2014 – LS02 – Evidence Informed Decision Making in Achieving UHC: the Role of Macro HTA

Evidence Informed Decision Making in Achieving UHC:
the Role of Macro HTA

Dr. Nick Drager
Honorary Professor, Senior Fellow, Global Health Programme, The Graduate Institute, Geneva
Mr. Adrian Griffin
Vice President, HTA Policy, Johnson & Johnson
Dr. Franz Pichler
Director, Global Public Policy, Eli Lilly and Company
Dr. John-Arne Røttingen
Norwegian Knowledge Centre for the Health Services
Dr. Eva Maria Ruiz de Castilla
Executive Director, Esperantra (NPO, Peru)

As a number of countries aspire to implement universal health coverage frameworks, many are looking at methods to best structure their health system to ensure citizens obtain the health services they need. Given cost constrained environments, many low and middle income countries have increasingly focused efforts on prioritization and determining value for investments in health. As such, a significant focus has turned towards the use of research evidence as a tool to support decision making. However, historically, this type of evidence has rarely been applied to support overall health system decision making. In the context of developed countries, a narrow interpretation has placed a significant emphasis on decisions related to coverage and reimbursement of healthcare technologies, such as medicines and diagnostics. 1 Healthcare technologies are only one of several inputs in the overall health system. The organization and delivery of a health care system is a complex matter, which requires a number of decisions regarding the resources necessary to ensure access to services, the mix of interventions required and the means to achieve optimal results.2 Limiting evidence based decision making to coverage decisions tends to obscure the potential role to apply to the overall health system as a whole, such as interventions that facilitate access, service delivery, and aim to improve quality of care.

Therefore, as countries embark towards universal health coverage, it is important that decisions related to coverage of health products and benefits packages are only one part of the discussion. Many low and middle income countries have extensive inefficiencies in their health systems, including issues related to service delivery, quality of care and treatment standards that transcend the need to focus specifically on coverage of health technologies to determine value for investments in health.

This session will explore the role of evidence informed decision making in achieving universal health coverage, looking specifically at the role of "macro" HTA as it is applied to overall health system efficiency and quality of care. This unique session will provide the audience with a view of different perspectives from various sectors in the healthcare space - patient, industry, academic and payer/NGO. Through live interaction, the audience will be able to participate and provide thought provoking questions/answers amongst the group to explore this innovative topic.


Nick Drager M.D., Ph.D
Honorary Professor, Senior Fellow, Global Health Programme, The Graduate Institute, Geneva

Former Director of the Department of Ethics, Equity, Trade and Human Rights and Senior Adviser in the Strategy Unit, Office of the Director-General at the World Health Organization- now is Honorary Professor, Global Health Policy, London School of Hygiene & Tropical Medicine; Professor of Practice, Public Policy and Global Health Diplomacy, McGill University; Adjunct Professor, Department of Epidemiology and Community Medicine, University of Ottawa; Adjunct Research Professor, Norman Paterson School of International Affairs, Ottawa; and Senior Fellow, Global Health Programme, The Graduate Institute, Geneva.

  • Work focuses on current and emerging issues related to global health, in the areas of global health security/diplomacy/governance, foreign policy and international trade and health including intellectual property and health.
  • Extensive experience working with senior officials in over 100 countries and major multilateral and bilateral development agencies in health policy development, health sector analysis, strategic planning and resource mobilization and allocation decisions and in providing strategic advice on health development negotiations and in conflict resolution.
  • Deep experience in global health diplomacy and high-level negotiations on international health security and development issues.
  • Represented WHO, serves as chair, keynote speaker at major international events and conferences; lectures and teaches at Universities in Europe, North America and Asia.
  • Editor/author of books, papers and editorials in the area of global health; global health diplomacy; trade and health including IP; foreign policy and health. Has an M.D. from McGill University and a Ph.D. in Economics from Hautes Etudes Internationales, (the Graduate Institute) University of Geneva.


AdrianGriffinAdrian Griffin
Vice President, HTA Policy, Johnson & Johnson

Adrian Griffin is Vice President, HTA & Market Access Policy at Johnson & Johnson.  He has been involved in the fields of health economics, outcomes research, and reimbursement policy within the healthcare industry for 16 years, with experience across the pharmaceutical, medical device, and diagnostic sectors.

Mr Griffin graduated in Medicinal Chemistry from University College London, obtained a post-graduate teaching qualification from Oxford University, and spent several years teaching chemistry before joining the UK’s Medical Research Council.  He then received his MSc in Health Economics at City University, London, before joining the healthcare industry.  Mr Griffin has held positions at GlaxoSmithKline, Pharmacia, and most recently Johnson & Johnson, where he has been since 2003.

In addition to undertaking outcomes research from the industry perspective, Mr Griffin has also served as a ‘decision-maker’, on the NICE Technology Appraisal Committee, where he has been a committee member for 10 years.  Mr Griffin is also active in numerous multi-stakeholder forums where key issues of HTA and access policy are debated and shaped, such as the HTAi Policy Forum, and initiatives that have brought regulators and HTA agencies together with companies, thus improving transparency and appreciation of different stakeholder perspectives.

Mr Griffin has contributed to several UK industry-government task-force and working groups, aimed at developing policy and processes to improve equitable access and uptake for patients to new innovations.

Within Europe, Mr Griffin has engaged through Company and Industry Association activities with EUnetHTA, with the aim of ensuring that what comes out of HTA collaboration across Europe is fit for purpose, with the ultimate aim of improving healthcare for patients.

Mr Griffin is currently on the Board of Directors of ISPOR, (the International Society for Pharmacoeconomics and Outcomes Research), and continues in his position as a member of the NICE Technology Appraisals Committee


Franz_Pichler2Franz Pichler, PhD
Director, Global Public Policy, Eli Lilly and Company

Franz Pichler has been Director, Global Public Policy at Eli Lilly and Company since 2012. This role encompasses development of external policy positions; provision of strategic advice; and external engagement around policy-related issues. A key focus of the role relates to the European environment, in particular with regards to Health Technology Assessment (HTA) and market access. He represents Lilly on the EuropaBio HTA and Market Access Group and the EFPIA HTA Task Force Steering Committee. He participates in the EUnetHTA Stakeholder Advisory Groups related to relative effectiveness assessment and methodological guidelines development. He is co-chair of the Medicines Adaptive Pathways to Patients initiative and is a participant of the Innovative Medicines Initiative (IMI) project ‘Incorporating real-life clinical data into drug development’ (GetREAL). He was a founding member of the HTAi interest sub group on HTA-Regulatory Interactions which he currently chairs. Franz joined Lilly after serving as the manager of the HTA Programme at the Centre for Innovation in Regulatory Science (CIRS) – a non-profit, independent medicines policy and research think tank. Prior to joining CIRS, Franz worked for over 10 years in molecular biology with specialties in functional genomics, population genetics and bioinformatics. He obtained his BSC in biology and PhD in population genetics at the University of Auckland in 1997 and 2002 respectively.


John_Arne_Rottingen_squareDr. John-Arne Røttingen
Norwegian Knowledge Centre for the Health Services

John-Arne Røttingen is Director of the Division of Infectious Disease Control at the Norwegian Institute of Public Health; Professor of Health Policy at the Department of Health Management and Health Economics, Institute of Health and Society, Faculty of Medicine, University of Oslo; Visiting Professor at the Department of Global Health and Population, Harvard School of Public Health; and Institute Visiting Scholar at the Harvard Global Health Institute.

He is Associate Fellow at the Centre on Global Health Security, Chatham House; research associate of the European Observatory on Health Systems and Policies; Chair of the Board of the Alliance for Health Policy and Systems Research; member of the Scientific Oversight Group of the Institute for Health Metrics and Evaluation, University of Washington, Seattle; and member of the International Advisory Committee for the Global Burden of Disease study.

He has been Director General of the Norwegian Knowledge Centre for the Health Services; Oxford Scholar at Wadham College; and Fulbright Fellow at Harvard Kennedy School.

He received his MD and PhD from the University of Oslo, an MSc from Oxford University and an MPA from Harvard University.


EvaMaria_Ruiz_de_CastillaEva Maria Ruiz de Castilla, PhD
Executive Director, Esperantra (NPO, Peru)

Dr. Eva Maria Ruiz de Castilla is a co-founder and since 2006 Executive Director of ESPERANTRA, a not-for-profit cancer and chronic disease patient advocacy organization in Lima, Peru. Her work at Esperantra is to improve the quality of life of patients with chronic conditions, health promotion, and to advance the recognition of the rights of patients to achieve access to timely diagnosis, treatment, and follow-up care. She has been instrumental in a number of national initiatives focused on cancer, including the government’s Plan Esperanza launched in 2012 to provide basic cancer care coverage for the poorest and most vulnerable Peruvians.

In addition to her work with Esperantra, Dr Ruiz de Castilla consults part-time for various Peruvian ministries, including Health, Social Development, Housing, Women, and Water-Sanitation to help design and coordinate the country’s public-sector social assistance programs. From 2011 to 2012, Dr Ruiz de Castilla was Director General of the Peruvian Ministry of Health’s (MINSA) International Coordination office and before that served as MINSA’s Director General of Health Prevention and Promotion. She has in-depth experience working with donor country agencies and multilateral organizations such as the World Bank.

As a Board Member of the International Alliance of Patients’ Organizations (IAPO) since 2010, Dr Ruiz de Castilla has been a global leader in patient-based organizational capacity building and has led various workshops on patient empowerment and networking. Her experience and involvement with building the capacity of civil society organizations focused on cancer in Peru earned her the American Cancer Society’s “Excelencia Latina 2009” Award. In 2011, Dr Ruiz de Castilla was named a Global Cancer Ambassador by the American Cancer Society, and was invited by the World Health Organization to participate as a civil society representative during the UN High-Level Meeting on non-communicable diseases (NCDs).

Dr Ruiz de Castilla’s academic credentials include degrees in Industrial Engineering and a PhD in Economic Development at the EHESS in Paris, France, and in Political Science at the Sorbonne University Paris 1. In Europe, she consulted for the United Nations on food and agriculture issues for the southern common market (MERCOSUR). Dr Ruiz de Castilla has authored a number of publications and papers on social development, health, and citizen engagement, and has been invited to speak at more than 200 national and international congresses.

GHF2014 – PS17 – Antimicrobial Resistance: A Global Health Challenge. What Are the Integrated Solutions?

Antimicrobial Resistance: A Global Health Challenge.
What Are the Integrated Solutions?

Prof. Didier Pittet
Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
Dr. Benedetta Allegranzi
Service Delivery and safety department, WHO, Switzerland
Dr. Dominique Monnet
Senior Expert & Head of Programme, Antimicrobial Resistance & Healthcare-Associated Infections (ARHAI)
Office of the Chief Scientist,
European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
Dr. Benedikt Huttner
Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
Dr. Jean Pierre Bru
Hôpital de Annecy, France

Didier_Pittet_squareProf. Didier Pittet

Didier Pittet, MD, MS, is the Hospital Epidemiologist and the Director of the Infection Control Programme at the University of Geneva Hospitals and Clinics (2500 beds), Geneva, Switzerland; Professor of Medicine and Hospital Epidemiology at the University of Geneva; and Attending Physician in Adult and Paediatric Infectious Diseases, University of Geneva Hospitals. He is also Visiting Professor, Division of Investigative Sciences and School of Medicine, Imperial College London, London, UK. Professor Pittet serves on the editorial boards of the American Journal of Infection Control, the American Journal of Respiratory and Critical Care Medecine, The Lancet Infectious Diseases and Infection Control and Hospital Epidemiology. He is also an editorial consultant of the Lancet. Professor Pittet currently leads the First Global Patient Safety Challenge “Clean Care is Safer Care” of the WHO World Alliance for Patient Safety. He was awarded the CBE in 2007 by Her Majesty Queen Elisabeth II for services to the prevention of healthcare-associated infection in the UK. Current major research interests include the epidemiology and prevention of nosocomial infections, methods for improving compliance with hand hygiene practices, and methods for improving the quality of patient care and patient safety.

Allegranzi PhotoDr. Benedetta Allegranzi

Benedetta Allegranzi, MD, is a specialist in infectious diseases, tropical medicine, infection control and hospital epidemiology. She currently works at the World Health Organization (WHO) HQ (Service Delivery and Safety department), leading the “Clean Care is Safer Care” programme ( focused on hand hygiene, infection control and antimicrobial resistance in health care. Since 2013, Dr Allegranzi has gathered the title of full professor of infectious diseases in the official Italian professorship list and is adjunct professor of public health at the Faculty of Medicine, University of Geneva, Switzerland. She closely collaborates with the team at the Infection Control Programme and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals (Geneva, Switzerland), as well as with the Armstrong Institute for Patient Safety and Quality, John Hopkins University, (Baltimore, USA) for clinical research projects. She has experience in clinical management of infectious diseases and tropical medicine, and clinical research in healthcare settings in both developing and developed countries. She has thorough skills and experience in training and education.

She is the author or coauthor of more than 150 scientific publications, including articles published in high-profile medical journal such as the Lancet, Lancet Infectious Diseases, New England Journal of Medicine and the WHO Bulletin, and six book chapters.

Dominique_Monnet_squareDr. Dominique Monnet

Dr. Monnet received his degrees in pharmacy (PharmD) and clinical microbiology (PhD) from the University of Lyon, France, and then obtained further education as a hospital infection control specialist and epidemiologist.

Before joining ECDC in 2007, he worked in French hospitals, at the US Centers for Disease Control and Prevention (1993-1995) and at the Danish Statens Serum Institut (1997-2007) where he was coordinating surveillance of antimicrobial resistance and antimicrobial consumption in humans in Denmark.

His research interests include surveillance of antimicrobial resistance and antimicrobial consumption, the relationship between consumption of antimicrobials and resistance, and the factors that affect antimicrobial usage, both in hospitals and in primary care.

SONY DSCDr. Benedikt Huttner

Dr Benedikt Huttner is an infectious disease physician at the Infection Control Program of Geneva University Hospitals.

After medical studies in Munich (Germany) and Nice (France) he came to Switzerland in 2002 to train in internal medicine (Ticino) and infectious diseases (Zurich and Geneva). After a short stay in pediatrics he joined the infection control of Geneva University Hospitals (Prof. Didier Pittet) in 2007. Between 2010 and 2012 Benedikt was a research fellow at the division of epidemiology of the University of Utah (Prof. Matthew Samore) and the VA Salt Lake City Health Care System.  Benedikt’s research focuses on antibiotic stewardship and antimicrobial resistance, in the inpatient and outpatient setting. He is also an infectious disease consultant for the university’s geriatric hospital in Geneva.

Bru_squareDr. Jean Pierre Bru

MD, infectious diseases clinician, head of ID department at Annecy Hospital, a 1200 non-teaching French hospital.

Has experience in the management of infectious diseases, antimicrobial stewardship programs, and clinical research both in developing and developed countries.

Was expert in the field of antimicrobial treatments for twelve years at the French agency for medicine and health product safety.

Is editor in chief of ANTIBIOGARDE, a hospital digital guide that offer the particular feature to allow customization to serve as local frame of reference.

GHF2014 – PS04 – Integrating Traditional and Alternative Medicine into Health Systems

PS04 TUESDAY, 15 APRIL 2014 ROOM: 18 ICON_Fishbowl
Integrating Traditional and Alternative Medicine into Health Systems
Dr. Edward Kelley
Director, Department of Service Delivery and Safety, World Health Organization, Switzerland
Dr. Bertrand Graz
Geneva University, ISG, Switzerland
Making Heath Care Affordable to Poorest Communities Through Acupuncture: India
Mr. Walter Fischer
Founder and Project Manager, Barefoot Acupuncturists, India
Integrating Ayurveda: Clinical Studies on the Ayurvedic Treatment of Rheumatoid Arthritis Offer New Perspectives
Mr. Olivier Talpain
Associate researcher at the University Institute of History of Medicine and Public Health in Lausanne, Switzerland
Dr. Zhang Qi Coordinator, Traditional Medicine, World Health Organization, Switzerland
Research and integration of traditional/complementary medicines into the health system. The case of malaria in Mali and diabetes in Pacific islands.
Dr. Bertrand Graz

MD, MPH, Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland
Across the world, traditional medicine (TM) is either the mainstay of health care delivery or serves as a complement to it. In some countries, traditional medicine or non-conventional medicine may be termed complementary medicine (CM).Starting from specific experience, we will discuss WHO Traditional Medicine Strategy 2014-2023, which states that:"The demand for TM/CM is increasing. Many countries now recognize the need to develop a cohesive and integrative approach to health care that allows governments, health care practitioners and, most importantly, those who use health care services, to access T&CM in a safe, respectful, cost-efficient and effective manner. A global strategy to foster its appropriate integration, regulation and supervision will be useful to countries wishing to develop a proactive policy towards this important - and often vibrant and expanding - part of health care.

Kelley_EDr. Edward Kelley

Dr. Kelley directs the Department of Service Delivery and Safety at the World Health Organization.  In this role, he leads WHO’s efforts at strengthing the safety, quality, integration and people centredness of health services globally and manages WHO’s work in a wide range of programmes, including health services integration and regulation, patient safety and quality, blood safety, injection safety, transplantation, traditional medicine, essential and safe surgery and emerging areas such as mHealth for health services and genomics.  Prior to joining WHO, he served as Director of the U.S. National Healthcare Reports for the U.S. Department of Health and Human Services in the Agency for Healthcare Research and Quality. These reports track levels and changes in the quality of care for the American health-care system at the national and state level, as well as disparities in quality and access across priority populations. Dr. Kelley also directed the 28-country Health Care Quality Improvement (HCQI) Project of the Organization of Economic Cooperation and Development. Formerly, Dr. Kelley served as a Senior Researcher and Quality Assurance Advisor for the USAID-sponsored Quality Assurance Project (QAP) and Partnerships for Health Reform Project Plus (PHRPlus). In these capacities, he worked for ten years in West and North Africa and Latin America, directing research on the Integrated Management of Childhood Illness in Niger. Prior to this, Dr. Kelley directed the international division of a large US-based hospital consulting firm, the Advisory Board Company.  His research focuses on patient safety, quality and organization of health services, metrics and measurement in health services and health systems improvement approaches and policies.

Physician and specialist in public health/international health (MPH from John Hopkins University

Dr. Bertrand Graz

Physician and specialist in public health/international health (MPH from John Hopkins University, today with Lausanne and Geneva universities), Bertrand Graz has been conducting development and research activities in Switzerland and in tropical countries, while keeping clinical activity as well. His doctoral thesis led to the validation of a non-surgical treatment for trachomatous trichiasis in Oman and China. After this, he has been leading many studies on the health effects of local traditional practices, such as  herbal treatments for malaria in Mali and diabetes in Palau, early rice feeding in Laos, Greek-Arab medicine in Mauritania, self-care for dysmenorrhoea in Switzerland. Now he aims at studying the effect of such research process in terms of optimisation of health resource's use and public health impact.

PS04_Walter_Fisher_squareMr. Walter Fischer

He has always needed to change lives and jobs whenever he knew he had hit the wall. Since early age, he chose traveling as a major mean to change and grow.  After 4 years of college, studying business and international trade, he started his professional career as export manager in a multinational. A few years later, he left and explored Asia. he went back to a (successful) business before definitely realizing that his way was elsewhere, in something hopefully more meaningful and useful to society. Studying and practicing acupuncture were a life changing experience to him. He finds it fair to share it with those most in need. He is a strong believer in the change we can bring together, with adequate tools and true intention. Humanitarian healthcare faces unlimited challenges, together with different and complementary professional approaches, situation of millions can be improved.

O_Talpain_squareMr. Olivier Talpain

As a former producer of fiction and documentary films myself, I particularly enjoy watching good documentary films. Thanks to Indian film maker Pan Nalin, I discovered Ayurveda for the first time, through his documentary film which struck me. I was impressed by the sophisticated holistic approach of the Ayurvedic system of medicine and the complexity of its medicines. Many Ayurvedic formulations are produced using tens of substances, through several long and complex processes. The testimonies of patients about unhoped-for recoveries touched me. I’ve eventually found it hard to believe that what seemed to be a remarkable blend of knowledge and know-how was kept aside and even threatened. Something didn’t make sense; I had to understand.

When I went back to university to study social sciences, I chose Ayurveda as the key issue of my research. I wrote the final dissertation of my Master in Development Studies on the recognition of Ayurveda through modern scientific research. I focused on two clinical trials on the Ayurvedic treatment of rheumatoid arthritis (1976-2012) that were funded by WHO and NIH-NCCAM. They both showed that the treatment gives positive results.

Still many questions remain. Why was the first study not published by the modern physicians in charge of it? Why is there so little research to assess Ayurveda? I am currently working on a PhD project to find some answers.

Zhang_Qi_squareDr. Zhang Qi

Dr Zhang Qi is leading the Traditional and Complementary Medicine Programme(TCM) in the Department of Service Delivery and Safety(SDS), WHO. He studied both conventional medicine and traditional medicine. He used to be a doctor, researcher and governmental official responsible for traditional medicine in China. He led the work of integration of traditional medicine services into national healthcare system in the department of healthcare services and headed the department of international cooperation, State Administration of Traditional Chinese Medicine, Ministry of Health In China. He used to lead the supervision on services, management and clinical research in the five hospitals affiliated to China Academy of Chinese Medical Science which is the national research institution for traditional Chinese medicine in China.



GHF2014 – PL01 – Integrated Care, Empowered People

Dr. Nick Goodwin
PhD, Chief Executive Officer, International Foundation for Integrated Care, United Kingdom
Mrs. Alice Njoroge
Managing Director, Eastern Deanery AIDS & Relief Program, Kenya
Dr. Joachim Stumberg
Associate Professor of General Practice, Department of General Practice, The Newcastle University, Australia
Mr. Bertrand Levrat
Chief Executive Officer, Geneva University Hospitals, Switzerland
Prof. Nicolas Fernandez
Assistant Professor, Center for Pedagogy Applied to Health Sciences (CPASS), Faculty of Medicine, University of Montréal, Canada
This plenary debate seeks to define the meaning and logic of ‘integrated care’ from the service users’ perspective. In particular, the panel will examine what it means to deliver more ‘patient-centered and co-ordinated care’ to people and communities and why this should be seen as an important design principle for health care systems.
Integrated care is a term that has come into common usage, yet people struggle to agree with what integrated care means and particularly how it can be applied. At its most basic, integrated care is a simple idea – combining different parts of the care system in order to optimize care and treatment to people where fragmentations in care have led to a negative impact on their care experiences and outcomes. Integrated care, therefore, is by definition ‘people centered’ since its core principle is to better co-ordinate care around people’s needs.The principles of integrated care from the person’s perspective therefore should:

  • seek to combines a range of care strategies that involve users and communities in the design of care programmes ;
  • create partnerships between people and professionals so that there is ‘co-production’ of health ;
  • support people to have the autonomy to make their own choices over care and treatment option ;
  • ensure that care is well co-ordinated around people’s needs by a team of care providers who communicate with each other to achieve more integrated service provision ; and
  • enable people to feel self-empowered.

Some of the questions to be discussed by the panel in this plenary include:

  • What do we mean by integrated care?
  • Is there a difference between the goals of integrated care from the person’s perspective compared with a systems perspective?
  • Why should integrated care be regarded as an important design principle for the future of health care systems?
  • What do we mean by person-centered care?
  • What are the benefits to be gained from better involving and empowering people and communities?
  • How can people and communities be better involved and empowered in making decisions about how care should be provided to them?

How can the ability of people to self-manage their own health be encouraged?


Nick_Goodwin1Dr Nick Goodwin, PhD

CEO, International Foundation for Integrated Care

Nick is a social scientist, academic and policy analyst with a specialist interest in investigating the organisation and management of primary, community and integrated care. Nick is co-Founder and CEO of the International Foundation for Integrated Care (IFIC), a not-for-profit membership-based foundation dedicated to improving the science knowledge and application of integrate care across the World ( and is Editor-in-Chief of its scientific periodical the International Journal of Integrated Care ( Nick also works as a Senior Associate at The King’s Fund, London supporting its programme of research and analysis for improving and integrating care to older people and those with long-term conditions (LTCs).

In addition to his role in leading and developing the various work programmes at IFIC, Nick continues to be very active in research, development and support for integrated care at both a political and practical level. Nick’s current portfolio of work includes UK, US and European-based research and development studies examining the impact and deployment of integrated care to people with complex and long-term health problems.  Nick continues to work with the UK government to support its policies on integrated care, including the evaluation of its Health and Social Care Integration Pioneer Programme and the Commission on Whole-Person Care. Nick’s international commitments include the EU FP7 Project INTEGRATE ( and the European Innovation Partnership on Active and Healthy Ageing. Nick is working with the World Health Organisation to support the development of a Global Strategy to develop person-centred and integrated care, and is on the Expert Advisory Team to WHO Regional Office for Europe’s Framework for Action Towards Coordinated/Integrated Health Services Delivery (CIHSD).


Nicolas_FernandezProfessor Nicolas Fernandez

Nicolas Fernandez is Professor of the Faculty of Educational Sciences of the Université du Québec à Montréal (UQAM) and Associate Professor at the Center for Applied Pedagogy in the Health Sciences (CAPHS) of the Faculty of Medicine at the Université de Montréal. Recipient of a transplanted kidney in 2008, Nicolas learned to manage his dialysis treatments, both peritoneal and hemodialysis, over a period of eight years. This life transforming experience, combined with his academic career in educational research and teaching, allowed Nicolas to develop unique insights into self-management of chronic illness as well as into development of patient self-efficacy. His doctoral thesis was completed in large part during treatment sessions in the dialysis unit of his local hospital.

Nicolas has published in the field of higher education and cognitive science as well as in the field of group development and collaboration. Since 2010, Nicolas has been active in the Direction of Collaboration and Patient Partnership of the CAPHS and contributes regularly to initiatives aimed at integrating patient perspective into training of health professionals and organizational change in clinical settings.

A quote from Prof. Fernandez:

‘The transformative power of illness hinges on the answer to a simple question: can I live with it or not? If the answer is no, then you are nearer to death. If the answer is yes, you are not farther from death, but a lot closer to life.’ 


Joachim_SturmbergDr. Joachim Sturmberg is Conjoint A/Prof of General Practice in the Department of General Practice, The Newcastle University, Newcastle, Australia. He graduated from Lübeck Medical School, Germany, where I also completed his PhD. Since 1989 he works in an urban group practice on the NSW Central Coast, with a particular interest in the ongoing patient-centred care of patients with chronic disease and the elderly. In 1994 he started to pursue systems and complexity research with an inquiry into the effects of continuity of care on the care processes and outcomes. Since then, his research has expanded and includes the areas of understanding the complex notion of health, health care and healthcare reform, showing that health is an interconnected multi-dimensional construct encompassing somatic, psychological, social and semiotic or sense-making domains, that health care has to embrace the patient’s understanding of her health as the basis for effective and efficient care, and that an effective and efficient healthcare system ought to put the patient at the centre. He has published extensively on these topics. He is joint chief editor of the Handbook of Systems and Complexity in Health, and joint chief editor of the Forum on Systems and Complexity in Medicine and Healthcare which appears in the Journal of Evaluation in Clinical Practice. Together with Carmel Martin and Jim Price he chairs the Complexity Special Interest Group (SIG) in the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians WONCA.


23.07.2013_Bertrand Levrat, 23.07.2013_Bertrand LevratMr. Bertrand Levrat

Chief Executive Officer , Geneva University Hospitals, Switzerland

Bertrand Levrat is an « engaged humanist ». Lawer by training, he has successively worked for seven years at the International Committee of the Red Cross on field missions as delegate, chief of under-delegation, legal advisor for Asia and Latin America and representative of the ICRC at the United Nations in New York.

Since returning to Geneva in 2001, he has continued to be committed to helping vulnerable persons during three years as deputy director for social affairs.  He was in charge of policies for the disabled and substance dependence.

In 2004, he became Director General of the Hospice General, a Geneva institution with 1000 collaborators in charge of socially dependent persons and asylum seekers. During nine years he entirely reformed this institution.  Under his leadership, the Hospice Général recovered long term financial  balance and rigorous management, but what is essential to him is something else: “Most important to me was to make collaborators proud to work there”.

Appointed new Director General of the Geneva University Hospitals (HUG) in June 2013, he intends to respond to the challenges that face him as head of this major institution.


Alice_NjorogeMrs Alice Njoroge, Managing Director, Eastern Deanery AIDS & Relief Program, Kenya

Alice Njoroge is a Nurse Leader working in resource limited settings.  She is very passionate about high quality care for clients. To accomplish this she has learned over the years to be innovative and at the same time being very sensitive to proper utilization of resources allocated for various activities. She always strives to maintain high standards of care, as well as stretches available resources as far as possible.

Learning from evidence: Advice-seeking behaviour among Primary Health Care physicians in Pakistan.

Author(s) Asmat Malik1, Cameron Willis2, Saima Hamid3, Anar Ulikpan 4, Peter Hill 5.
Affiliation(s) 1Department of Research and Development, Integrated Health Services, Islamabad, Pakistan, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Maternal and Reproductive Health, Health Services Academy, Islamabad, Pakistan, 4School of Population Health, The University of Queensland, Brisbane, Australia, 5School of Population Health, The University of Queensland, Brisbane, Australia.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Systems
Summary Access to information is critical for creating and maintaining high performing Primary Health Care (PHC) systems. Among multiple sources of information, advice-seeking from humans possesses significant importance for the physicians in their clinical settings because they are looking for readily available answers to their questions. We used Tuberculosis and measles as a lens for analyzing the advice-seeking behavior of PHC physicians in Pakistan. The study concludes that the heath care providers are falling prey to stagnant system behaviour. There is a need to better understand system behaviors and to identify system principles such as information flows and feedback loops.
Background The available studies provide some insights into how physicians seek information while working in PHC settings. However, as this literature is largely confined to developed countries, there is relatively little known about how physicians in low-middle income countries access or use information when faced with difficult to diagnose conditions. In these settings, where access to electronic information sources is often scarce, understanding advice seeking behaviors from human sources becomes particularly important. Using methods grounded in systems science, this study examines the advice seeking behaviour of PHC physicians in a rural district of Pakistan, analyzes the degree to which the existing PHC system supports their access to advice, and explores ways this system might be strengthened to better meet provider needs.
Objectives Tuberculosis (TB) and measles are currently providing major challenges to PHC physicians in Pakistan. We used these two conditions as a lens for analyzing the advice-seeking behavior of PHC physicans in Pakistan. The specific research questions of this study were:
• To what degree does the existing structure of the PHC system in Pakistan support physicians in accessing advice on difficult to diagnose cases of tuberculosis and measles?
• To what degree are physicians satisfied with their current access to advice on difficult to diagnose cases of tuberculosis and measles?
• What changes, if any, do physicians recommend to improve their access to advice on difficult to diagnose cases of tuberculosis and measles?
In order to answer these research questions, this study has the following specific research objectives:
• To document the flow of information on diagnosing TB and measles cases in the PHC system of Pakistan;
• To describe the advice seeking behaviour of physicians in situations of difficult to diagnose cases of TB and measles;
• To explore physicians’ satisfaction with their access to advice in difficult to diagnose cases of TB and measles;
• To identify and describe possible changes, if any, that physicians recommend to improve their access to advice in difficult to diagnose cases of TB and measles.
Methodology This study was conducted at the district level in Pakistan from January 2013 to August 2013. The organization of health services at a district level is similar across Pakistan. With a cross-sectional study design we employed three research methods comprising:
1. Mapping of formal system of flow of information for diagnosing TB and measles.
Through documentary review and targeted key informant interviews with five district health administrators and line-managers of vertical health programs, we mapped the existing system of the flow of information for assisting physicians in diagnosing TB and measles cases. Illustrations of formal information dissemination systems were developed in the form of flow charts showing the direction of flow of information and roles and responsibilities for providing information/feedback at various hierarchical levels.
2. Survey for social network analysis of physician advice seeking behaviour.
A semi-structured questionnaire was used to conduct a survey for mapping professional networks. The key questions were structured to identify whom each physician had contacted for advice whenever faced a difficult to diagnose cases of TB and measles. Out of the 61 BHUs in district Attock, only those with an appointed physician (n=49) were invited to participate. The compiled data was imported in UCINET software for generating sociograms.
3. Key stakeholder interviews.
Based on the analysis of the findings from Sociograms, the BHU physicians were divided into three groups:
• Physicians who sought advice from a designated person (formally notified by the health department)
• Physicians who sought advice from someone other than a designated person
• Physicians who did not seek advice from any other person
This grouping provided the basis for selecting 11 study respondents for in-depth interviews. All study participants agreed to one-on-one interviews and consented to audio recording. Three separate interview guides were used during these semi-structured in-depth interviews among the three groups of study respondents. The average interview time was 20 minutes. The researchers using an inductive process identified categories, sub-themes and themes. The research team then compared their findings to optimize the data conformity. The final themes were presented after the research team’s consensus on the analysis process.
Results The present configuration of the primary health care system in Pakistan is largely a result of the push for universal health coverage and Health for All under the declaration of Alma Ata Conference on PHC in 1978. Under the influence of this global movement, an extensive network of PHC clinics (5449 Basic Health Units and 579 Rural Health Centers) has been established as the first point of contact for those seeking healthcare across all districts in Pakistan.
Early detection of both TB and measles is critical to decrease morbidity and mortality rates. There are multiple sources of information available to assist physicians in diagnosing cases of TB and measles including clinical guidelines, case definitions and case detection protocols. While these information sources are largely provided through government agencies, the precise channels used for their distribution and the ways in which physicians make use of these channels have not been made explicit. Mostly they use their personal social networks in order to seek guidance in clinical care from their friends, peers, and other disease-specific experts.
With a systems approach, the thematic analysis has been categorized under four key areas. Firstly, the health leadership designs health programs and interventions without placing competent experts and a pathway to seek information on difficult cases (system organizing). Referral systems are not functional and there is no feedback on the patients’ from whom advice is being taken. As a consequence, patients are lost to the private sector. Secondly, PHC clinics do not have functional linkages with tertiary care hospitals (system network). In addition, no needs assessment for refresher trainings is conducted by the health department. Thirdly, the PHC physicians are not provided any feedback on patients sent to higher level centers (system dynamics). There exists no formal system of communication and dissemination through which the latest research or related materials are shared. In addition, there exist no opportunities where PHC physicians can be placed at secondary or tertiary care hospital on a rotation basis. Lastly, the focus of the health managers and administrators is more on administrative running of programs and meeting targets (system knowledge). Consequently, capacity building in clinical management has become a neglected priority.
Conclusion The analysis of the PHC system in Pakistan clearly demonstrates that the problems in the health sector are deeply rooted and complex in nature. The evidence from this study demonstrates that in situations where PHC physicians require further advice in diagnosing potential cases of TB or measles, it is unclear from whom this advice is being sought, or the degree to which the current PHC system enables physicians to seek this advice.
PHC level acts as a driver for healthcare delivery system whereas human resources are the main driving force behind a functional health system because they provide a human link that connects the system building blocks. However, in Pakistan, the heath care providers are falling prey to  stagnant system behaviour. The solutions require a systems’ thinking that views public health problems as a part of a wider and dynamic system, with a focus on in-depth understanding of the linkages, relationships, interactions and behaviors among the sub-system components that characterize the entire system. It is imperative to better understand system behaviors and to identify system principles such as information flows and feedback loops.

Eldercare in Cameroon: attendance of a proximity hospital in Yaoundé.

Author(s) Jossy Eyenga-Oli1, Armelle-Lucrèce Ngougni-Kana2, Marcel Azabji-Kenfack3, Eddie-Karistan Lakoudjeu 4, Nkodo Mendimi 5
Affiliation(s) 1Direction, Hôpital de District de la Cité Verte, Yaoundé, Cameroon, 2DESSAF, DESSAF, Yaoundé, Cameroon, 3Department of Physiological Sciences, Faculty of MEdicine and Biomedical Sciences, Yaoundé, Cameroon, 4Social Affairs, DESSAF, Yaounde, Cameroon, 5Direction, Hôpital de district de la Cité Verte, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Health Systems
Summary Cameroon is entering a demographic transition era, as elsewhere in Subsaharan Africa, with more old persons in proportion to the general population. But, our hospitals are not prepared for elderly care in terms of attendance, since there are no baseline data. This study examined the attendance of a proximity district urban hospital, and gives the basic statistics of hypertension, diabetes and elderly admission in a 3-months period. We underlined the neccessity of planning a policy in terms of capacity building for elderly.
Background In recent years, several studies have reported that African countries are facing an era of demographic transition, with a marked increase in the proportion of elderly people. In Cameroon, recent statistics reported approximately 6% of older people in the general population.
Because our health services are not fully prepared specifically for the care of the elderly, it is essential to establish a statistical observatory hospital attendance by the elderly. This is in order to build better care policies for this population group. For this purpose, we have conducted this pilot study to provide baseline data in terms of attendance.
Objectives To describe the attendance and basic epidemiological patterns of elderly patients (≥60 years old) admitted to outpatient departments during a 3-months period, monitoring routine activities related to chronic health problems, hypertension and diabetes mellitus.
Methodology It was a cross sectional retrospective study conducted from June to August 2012. Data were collected from medical records, including age, sex, social status, medical history and type of treatment. Incomplete records were excluded from the study. Ageing was defined as follows: Group-A= “Younger patients”, aged 65 years. Statistical analysis was performed using MS Excel 2003.
Results At the outpatients department, we recruited consecutively from the registers a total of 1714 patients during the study period. The mean age of the whole attendance in adult consultations diabetes/hypertension unit was 39.5 years (21-87 years) and the sex ratio (male:female) of 1.08. We recorded 47,8%, 30,7% and 21,5% respectively for Group-A, Group-B and Group-C. Among them, 447 were definitely admitted for Diabetes and 171 for complicated hypertension. The diabetic patients were divided into 18,3% for Group-A, 48,3% in Group-B and 33,3% in Group-C. Hypertension patients were divided into 31,0% for Group-A, 41,5% in Group-B, and 27,5% in Group-C. The main comorbidities associated were chronic kidney disease (25.4% of the total attendance) and chronic heart disease (15,3%).
Conclusion These data show that, both in the outpatient department and admission wards, the proportion of older people varies between 20% and 45% of our health care activities, which is huge compared to the proportion of 6% the age in Cameroon. This pioneer work is an urgent plea to establish a more detailed preliminary for a plan that is dedicated to elderly care in district hospitals statistical observatory. A phase of capacity building of staff in aged care is also a conducive form of retraining.

Integration of snakebite management in rural Nepal: Challenges and solutions

Author(s) Sanjib Kumar Sarma1, Anup Ghimire2, Gabriel Alcoba3, Ulrich Kuch 4, Francois Chappuis 5
Affiliation(s) 1Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal, 2School of Public Helath and Community Medicine, B P Koirala Institute of Health SCiences, Dharan, Nepal, 3Division of Tropical and Humanitarian Medicine , Geneva University Hospitals, Geneva, Switzerland, 4Institute of Biomedical Research and Climate change, Institute of Biomedical Research and Climate Change, Frankfurt , Germany, 5Division of Tropical and Humanitarian Medicine , Geneva University Hospitals, Geneva, Switzerland.
Country - ies of focus Nepal
Relevant to the conference tracks Advocacy and Communication
Summary Snakebite envenoming is one of the most neglected public health problems in poor rural communities living in sub-tropical and tropical regions. In Nepal, proper management of snakebite envenoming relies on rapid access to a health facility where trained staff are able to administer antivenom and provide ventilatory support. Here, we report on an integrated care approach by which paramedics in the region were empowered in the prevention, management and research of snakebite envenoming.
Background Despite recent community-based data demonstrating the high burden it causes on health, snakebite has received little attention from stakeholders. South Asia is the world’s most affected region, with reported annual incidence and mortality rates of up to 1,162 and 162 per 100,000 population in rural southeastern Nepal.
Objectives We aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region
Methodology Community-based surveys, an intervention study, prospective and retrospective hospital-based surveys, a prospective observational clinical study and a randomized controlled trial were conducted to integrate different prospect of snakebite related issues in rural area of eastern Nepal.
Results Snakebite victims’ first encounter with the health care system in rural Nepal is with sub-health posts or primary health centers, where facilities for antivenom administration are non-existent. Access to adequate care is often not possible at secondary or even tertiary health care centres, from where patients are in fact sometimes referred to from smaller centres that are entirely specialized in the management of snakebite. In the absence of sufficient human resources to manage snakebite in rural Nepal, we aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region. Rapid transportation of victims by motorbike to a specialized snakebite treatment centre was identifed as a key life-saving measure in southern Nepal and a volunteer program was subsequently set up in this region. Research efforts have then focused on (i) the identification of snakes that bite patients in this region, (ii) the development of rapid diagnostic tests to identify the species of biting snakes and (iii) optimizing the dosage of antivenoms.
Conclusion The development of simple diagnostic tools and evidence-based antivenom dosage and ancillary treatment guidelines should facilitate the integration of snakebite management in the public health system as well as in the specialized centers run by paramedics. These efforts should be complemented by the routine integration of pre- and post-graduate training of healthcare personnel in snakebite management and an adequate commitment of medical authorities at both central (e.g., purchasing and deployment of free-for-patients antivenoms) and peripheral levels.

Maternal Health Workforce Management in Vietnamese Health Communes

Author(s) Thi Hoai Thu Nguyen1, Andrew Wilson2, Fiona McDonald3
Affiliation(s) 1Faculty of Health, The Queensland University of Technology, Hanoi, Vietnam, 2Menzies Centre for Health Policy, The University of Sydney, Brisbane, Australia, 3Faculty of Law, The Queensland University of Technology, Brisbane, Australia.
Country - ies of focus Vietnam
Relevant to the conference tracks Health Workforce
Summary As part of a study into the governance of health workforce in Vietnam, this study examined the impact of staff qualifications, training opportunities and other factors on reported ability to perform Essential Obstetric Care services (EOCs) in two provinces. While qualifications and training were the most important factors, national and district policies, such as which health professionals can prescribe essential medications, were also important factors in limiting provision of EOCs.
Background Vietnam’s national policies recognise the importance for an effective health system to ensure sufficient human resources (Politburo Resolution No. 46/NQ-TW dated 23 February). However, current analysis indicates a number of issues, including an imbalance and maldistribution of the essential health workforce, shortages of appropriately skilled health workers and constraints in management and utilization of health workers. Parallel studies on the impact of health policies on the health workforce, the implementation of health policies and provision of health care services in Vietnam have identified a number of governance-related issues, including a lack of staff accountability, quality control measures in relation to workforce training and skills maintenance, inadequate participation of community and civil society organizations, and an unreliable health information system. Underdevelopment of governance mechanisms may be a significant barrier to the effective implementation of policies. However, so far there has been no systematic analysis to identify the points of weakness and gaps in the governance and internal management of human resources in the health care system at the provincial and district levels in Vietnam.
Objectives Ensuring access to good maternal health services is critical for Vietnam to achieve the relevant Millennium Development Goals and this requires a well-qualified maternal health workforce able to provide the EOCs. This study aims to examine the impact of national and district policies relevant to human resource management and organisational factors on the maternal health services. Specific objectives were:a) To identify the availability and qualifications of maternal healthcare providers at commune level in two provinces.
b) To identify the ability of maternal healthcare providers to provide the EOCs and the barriers to providing these services.
c) To understand how the existing organizational and policy factors influence maternal healthcare provider’s ability to provide EOCs.
Methodology The research has been conducted in five districts in two provinces in the Northern mountainous area of Vietnam. A mixed methods approach was used consisting of a self-administered questionnaire given to commune level staff and in-depth interviews with commune maternal healthcare providers and managers engaged in maternal health at district and provincial levels. The questionnaire consisted of four sections namely: demographic information relevant to maternal healthcare providers, the training opportunities they attended, self-rated ability to perform EOCs and a scale to measure elements of work motivation.The sample for the quantitative survey is 192 maternal healthcare staff who volunteered to complete the questionnaire. In-depth interviews were conducted with 60 participants of whom 18 chosen to represent the different workforce groupings and have been fully analysed.Initial analysis to explore the differences in maternal health workforce between the two provinces consisted of two way tabulations with statistical significance testing using the Chi-square test. All variables found to be significant in this analysis and the potentially confounding variables were incorporated into multivariate regression analysis to identify the independent associations with the ability to perform EOCs.

For the qualitative analysis the subset of 18 interviews was transcribed. Inductive analysis was used to identify, code and organize themes arising from the raw data, with quotations servings as units of analysis. Data was analysed for consistently occurring themes or categories using a qualitative research package, N-Vivo software.

Results Analysis of the survey indicates there are distinct differences between the provinces as to the mix of maternal health professionals, their qualifications, their access to further training, and their self-reported ability to perform EOCs at the commune levels.The multiple logistic regression analysis showed that staff were more likely to report having training on all EOCs if they worked at district level, had higher qualifications (university and equivalent or higher) and obstetric expertise.In both provinces, only 21.6% of staff reported being able to perform all EOCs. The most common reasons reported by staff for not being able to perform EOC services is “Because I am not allowed to do this”, followed by “Lack of training” and “Lack of drugs and equipment”.

The most important determinants of ability to perform the EOCs were qualification and training. Although having attended training course in the last 12 months was not significantly associated with ability to perform EOCs in univariate analysis, in the multivariate analysis it was significant.

Data from the in-depth interviews confirms a common theme that respondents felt constrained in their potential roles by policies. It is also identified other organizational, policy and resource constraints faced by staff and managers at the commune and district levels.

Conclusion 1. The study provides a better understanding of the factors influencing the health workforce’s capacity and capability in the maternal health context in Vietnam.
2. The restrictions on who can perform EOCs should be reviewed to improve access to full EOCs.
3. To use health workforce most efficiently and effectively, all appropriately trained staff need to be given the authority to carry out all EOCs including prescription of essential medicine regardless of qualifications.Given that access to maternal health services provided by appropriately trained health care workers has been shown to be important to better maternal and child health, this reform would assist Vietnam to achieve the MDGs.

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

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

Experiences of a Programme to Integrate Prevention, Diagnosis and Treatment of Cardiovascular Risk Factors into Public Primary Care in Rural Cameroon

Author(s): N.D. Labhardt*1, E. Manga2, B. Stoll3, A. Bischoff3
Affiliation(s): 1Health Department Basel, Switzerland, 2Ministry of Health of Cameroon, Mfou, Cameroon, 3Universty Hospitals of Geneva, Switzerland
Keywords: Primary care in Africa, non-communicable chronic disease, diabetes, hypertension

Cardiovascular disease has become a major cause of morbidity and mortality in the developing world and is an important economic burden for individuals and their families. It is now the leading cause of death in Sub-Saharan Africa among people over the age of 30. The rise of cardiovascular disease in developing countries is attributed to an increase of the modifiable risk factors, especially among the poorer part of the population, which often does not have access to an appropriate care for these conditions. High blood pressure and diabetes type 2, two of the most important modifiable cardiovascular risk factors, are of high prevalence among the population in Cameroon. However, up to now, the district primary care is not appropriately equipped nor trained to deliver adequate prevention, diagnosis and treatment of these conditions.

Summary/Objectives: The programme’s objective is to integrate prevention, diagnosis and treatment of hypertension and diabetes type 2 into the public primary care service of the about 90 healthcare facilities in two semi-rural regions of Central Cameroon. A baseline evaluation and need-assessment before intervention showed that nearly all facilities lacked equipment to measure blood glucose levels or glycosuria and that only about half of them had functioning material to measure blood pressure and body weight. Adequate anti-hypertensive and oral antidiabetic drugs were available in only very few of the evaluated centres and the majority of the staff were not able to define hypertension or diabetes nor were they able to name an appropriate treatment. The programme provides to the staff of public health facilities an initial 3-day training, based on a manual prepared for the training modules and containing care-algorithms, a programme-focused supervision in the health centre every 3 months and a 1-day refresher course after 6 months. All the trained health facilities received equipment to determine blood glucose levels, glycosuria, blood pressure and body weight and an initial stock of 2 oral antihyperglycaemic and 2 anti-hypertensive drugs from the essential drug list. The drugs are to be sold on fixed prices, which allows the staff to renew the stock regularly. Training and equipment of the total of 8 districts takes place in 3 stages. In March 2007 the first 2 districts were trained and equipped, followed by another 3 districts in November 2007. The remaining 3 districts will be integrated into the programme in February 2008.

On the oral presentation we will show the results of the programme-evaluation of 52 facilities at 6 months and of 29 facilities 12 months after the programme’s start. In a preliminary evaluation of the 29 centres trained in March 2007, healthcare providers showed a significantly improved performance in a questionnaire testing their knowledge right after the initial training as well as 6 months later. 6 months after the programme’s start, most of the equipment was again operational and there were only 2 ruptures in drug supply. In the meantime medical treatments on 205 newly diagnosed hypertensive and 52 new diabetic patients were started. Preliminary data suggest that satisfactory control of blood pressure and blood glucose was obtained in most of the patients with the application of the care algorithms. However, a majority of patients seem to show a low adherence with nearly one half of patients lost to follow-up during the first six months.

Lessons learned:

Technically the integration of prevention, diagnosis and treatment of cardiovascular risk factors, especially hypertension and diabetes type 2, into the district primary care system in Cameroon seems feasible. However, patients’ adherence and long term follow-up are of major concern. We conclude that for patients suffering from chronic conditions in this setting, a system involving house-visits, community workers and family members should be established in order to assure adherence.