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GHF2006 – PS08 – Access to Vaccines: Obstacles and Solutions

Session Outline

Parallel session PS08, Thursday, August 31 2006, 11:00-12:30
Chair(s): Paul-Henri Lambert, Switzerland & Jean-Marie Okwo-Bele, Switzerland
Access to Vaccines: New Approaches
Jean-Marie Okwo-Bele, Immunization, Vaccines and Biologicals, WHO, Geneva, Switzerland 
Immunization: Obstacles to Financing
Jacques-François Martin, President, Parteurop, Lyon, France
New Life for an Old BCG
Stefan H.E. Kaufmann, Immunology, Max Planck Institute for Infection Biology, Berlin, Germany

Session Document

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Session Report

Submitted by: Patricia de Guzman (ICVolunteers); Contributors: Irene Amodei (ICVolunteers), Tatjana Schwabe (ICVolunteers)

This 2000 photograph depicted a mother holding her child, while displaying a polio vaccination record that indicated the child having been properly vaccinated. Image courtesy Chris Zahniser, B.S.N., R.N., M.P.H., a STOP Transmission of Polio (STOP), The Public Health Image Library (PHIL) http://phil.cdc.gov/Phil/.

More than 2,600,000 deaths have been prevented in 2003 thanks to the Hepatitis B vaccine currently available. This is only one impressive example of the benefits of good vaccination and immunisation programmes. Although vaccination programmes are very cost-efficient, costing as less than 1,000 USD per life saved, the world still faces over 100,000 neonatal tetanus deaths and over 400,000 deaths from measles per year. The international community has a very ambitious plan: to completely eradicate diseases which are preventable by global vaccine coverage. How can such a goal be accomplished?

According to Mr. Paul-Henri Lambert, co-chair of this symposium, vaccine development is 10 to 20 years ahead of drug development. Although vaccines are the first step in ensuring global access to health, many challenges, especially with regard to finances, remain. The symposium reviewed the implementation of immunisation at a global level, addressed the financial issues regarding the implementation of vaccine programs, and analysed the availability of new vaccines to understand whether research is helping to facilitate access, specifically in the context of tuberculosis vaccines.

Dr. Jean-Marie Okwo-Bele, the Director of WHO Department of Immunisation, Vaccines and Biologicals in Geneva, Switzerland, first presented the global progress achieved so far and then discussed the challenges faced with respect to access to immunisation services. Vaccines have been widely used since the 1970s and continue to be one of the best health investments for various reasons, including their safety, sustainability, and high cost effectiveness. The Global Immunization Vision and Strategy (GIVS) is helping to achieve the goal of reducing vaccine preventable childhood mortality by 25% by the year 2015. The following provides a quick summary of some immunisation advances achieved so far:

  • DPT (diphtheria, tetanus and pertussis)Progress with the level of DTP3 combination vaccine coverage has been good, increasing from about 20% in the early 1980s and to over 70% in the mid-2000s. The number of countries in which DTP3 coverage remains below 50% has decreased by half within the last 15 years.
  • MeaslesGlobal measles mortality for all ages has been reduced by half within a 15-year period from 1999 to 2004 to currently just over 400,000 deaths per year. The dramatic decline in the number of reported measles cases (91% reduction) in 19 African countries from 2000 to 2003 is attributable to accelerated measles control activities. Four regions (the Americas, Europe, the Eastern Mediterranean and the Western Pacific) have set measles elimination goals and two regions (Africa and Southeast Asia) will try to reach measles mortality reduction goals. The overriding global goal established by the World Health Assembly was to reduce measles deaths by half by the year 2005.
  • Polio While polio prevention has not been reaching the set target dates, good progress is still being made. Polio presently exists only in some districts within about 10 countries and efforts are being undertaken to completely eradicate this disease in the near future. One possible reason why prevention targets have not been achieved was raised during the question and answer session question. It is possible that either a generalized vaccine is being administered efficiently, but is not fully effective for an entire population or that only a small portion of the population is not receiving the vaccine, thus creating a pool for new infections.

Overall, vaccination and immunisation activities have achieved success due to good partnerships and governance, and strategies among institutions ranging from the local to the global level. Dr. Okwo-Bele reminded the audience of several problems to be addressed in order to ensure global vaccination.

1. Access to immunisation services

Child survival intervention through vaccines remains low. 50% of all cases of severe pneumonia can be prevented by Hib and Pneumo vaccines. It is speculated that such vaccines could more easily administered than community-based management of pneumonia which reaches less than 20% of children. Several programmes have successfully addressed the challenge of reaching every district in a country. Through mobile and outreach services in Sudan, nearly 60% of children were immunized in 2005. In some African countries, the Reach Every District (RED) strategy has improved the number of districts with DPT3 coverage, by re-establishing outreach services, supportive supervision, community links with service delivery, monitoring and use of data for action, and the planning and management of resources. In the Democratic Republic of Congo, the Ministry of Health's Expanded Program on Immunization (EPI) implemented the RED strategy in 161 of 515 districts in early 2003, resulting in a substantial decline of the number of not immunised people. Although these results are encouraging, they remain insufficient. Better immunisation coverage particularly in East and Southern Africa, is needed and could be achieved through a mix of interventions such as "nationwide packages."

2. Access to technology

Ensuring availability of vaccines in developing countries with weak infrastructure.

3. Ensuring financing

The cost of immunisation is on the increase, and spending has recently doubled, especially to fund campaigning efforts. Certain countries can not afford these expenditures. Adult vaccination, an issue which was raised during the discussion, could already be dealt with by the logistics currently in place but can not be funded at the moment.

4. Management

Due to the increasing complexity of immunisation programmes, efficient management becomes more and more of a challenge.

Mr. Jacques-François Martin, President and CEO of the consulting company Parteurop, focused his presentation on the importance of financial tools in the implementation of immunisation strategies. He presented the Global Alliance for Vaccines and Immunization (GAVI), one of the first major public-private partnerships (PPP) to have emerged at the end of the 1990s. The GAVI Fund, whose president Mr. Martin was from 2000 to 2004, aims to attract different partners and bringing together various stakeholders in order to circumvent the lack of political will and the weakness of country-level management, which can be major obstacles to global vaccine coverage. Mr. Martin pointed out that GAVI acted as a catalyst by mobilizing people and resources, including industries, and openly dealing with possible conflicts of interest. He stated that "GAVI attracts, not receives money, and this happens because of its strong vision." The result is that the GAVI Fund has so far raised 1,704.39 billion dollars between 1999 and 2005, and 1.6 billion is expected between 2006 and 2015. While Mr. Martin praised the achievements of the GAVI Fund, he also raised the political issue involved: Is it acceptable for a PPP such as GAVI to receive half of its global financing for its immunisation activities from a single private source, namely the Bill and Melinda Gates Foundation?

He concluded that these new financing tools (also including for example the International Finance Facility proposed by the UK government) represent a valuable resource for immunisation projects because they are sustainable and have been conceived with long-term programme management in mind, and they operate with a notion of accountability for the proper expenditure of donated funds through self-monitoring of their performance.

Important challenges, however, still lie ahead, such as the high price of the new vaccines which are or will soon be introduced in developing countries (e.g. HIB, Pneumo, Rotavirus, HPB), the new risk related to the possible emergence of pandemics and, most of all, the need to vastly increase funding dedicated to vaccines.

Mr. Martin suggested some strategies which could improve the financing of immunisation and vaccination programmes:

  • prioritizing planning and forecasting, taking into account that it takes one year to produce a newly launched vaccine
  • advanced purchase commitments
  • tiered vaccine prices, meaning the strategic use of price differentiation based on consumers wealth in a system agreed upon by the global society

Concerning the last point, Mr. Martin conceded possible complications such as parallel imports, coexistence in different market segments in one country, difficulties in convincing emerging economies to accept an intermediate price, problems of a potential monopolistic condition. However, he affirmed that with a strategic allocation of costs it should be possible to address all direct costs to rich countries in order to sell vaccines to developing countries at near marginal costs.

Concluding, Mr. Martin stressed the importance of a global and integrated approach, where investment in immunisation and vaccination is not only a simple means of prevention but also a way to improve the health care system in general.

Prof. Stefan H. E. Kaufmann, an immunologist at the Max Planck Institute for Infection Biology in Berlin, Germany contributed a detailed scientific presentation on the historical use and current improvement of BCG (Bacillus Calmette-Guérin), the vaccine that protects against severe forms of childhood tuberculosis, and the future potential of a new and better generation of BCG. This new vaccine (rBCG delta ureC-Hly), based on recombined M bovis BCG, is particularly efficient to prevent pulmonary tuberculosis in adults and has been licensed to a private company for vaccine development (Vakzine Projekt Management GmbH). Mr. Kaufmann offered his field experience to illustrate one successful pattern that, if supported and properly tested, could help decrease the occurrence of a disease that every year affects around 8 to 9 million people, causing up to 2 million deaths. He was convinced that the new vaccine which his group is helping to develop has advantages and could potentially help make access to TB vaccines easier.

In sum, as Dr. Okwo-Bele stated, the immunisation agenda is an ambitious one. However, more progress is expected, given the experiences and momentum achieved so far. To sustain progress, strong national health systems are needed and investments must be made to increase access to services and provide adequate levels of supplies.

GHF2006 – PS07 – Addressing Health Inequalities in Modern Europe

Session Outline

Parallel session PS07, Thursday, August 31 2006, 11:00-12:30
Chair(s): John-Paul Vader, Switzerland, Gaudenz Silberschmidt, Switzerland
Public Versus Private: Is the Debate Still Valid? 
Josep Figueras, Director, The European Observatory on Health Systems and Policies, Brussels, Belgium 
Using Private Providers to Improve Patient Experience
Wiliam H. Wells, Chairman, NHS Appointments Commission, London, UK
Health Systems in Eastern Europe
Bakhuti Shengelia, Country Health Systems and Policies, World Health Organization, Regional Office for Europe, Copenhagen, Denmark

Session Document

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Session Report

Submitted by: Brooke Bishara (ICVolunteers); Contributors: Asta Lim (ICVolunteers)
Image: courtesy of The Public Health Image Library (PHIL) http://phil.cdc.gov/Phil/

Populations of modern Europe live in different national socio-economic settings, making the study, evaluation and comparison of their respective healthcare systems a complex exercise. Correspondingly, health inequalities within this vast region are also intricate and multiple. The three speakers provided interesting insights on the different determinants of these inequalities, mainly focusing on the roles played by the public and private sectors, whilst revealing the often misconceived correlation between the inequality in access to healthcare and the private and/or public delivery of healthcare services.

Dr. Willy Palm, Dissemination Development Officer of the European Observatory on Health Systems and Policies in Brussels, Belgium, argued that while soaring health care costs is a draw for private sector involvement, it is unclear what private sector involvement in healthcare entails. Advocates for privatization of healthcare services favour the potential for increased efficiency, choice, service, and quality of care.  Opposing groups, however, believe that privatization will undermine the solidarity principle, whereby the rich and healthy subsidize the care of the poor and sick. Dr. Palm's slides showed a private-public continuum, in which various 'hybrid' health systems are revealed. His graphs demonstrated that all European countries have a mixed stream of funding to pay for health care, including taxes, social security, user charges, and private insurance. On average, governments funding covers 75% of all health care costs. Dr. Palm stressed that governments considering change should first identify their goals for health care, followed by an assessment of the benefits and tradeoffs of introducing private actors into a public system. Results of such assessments may sometimes be contrary to expectations. For example, improved efficiency in privately run primary care facilities in Estonia increased the number of people receiving care, and therefore led to increased spending. In the Netherlands, the principles of competition and solidarity are combined in its health system reforms. He concluded that governments should act as careful stewards of health systems, providing clear regulations for all involved public and private actors.

Sir William Wells, Chairman of the NHS Appointment Commission, gave a documented overview of the British Public National Healthcare System (NHS), discussing the problems it now faces and the solutions which have been implemented. A well established system of 60 years and a widely used "role model" in many countries, the NHS is nevertheless, according to William Wells, "in need of rejuvenation". Living in a general misconception about its initial objectives (a system that was meant to provide healthcare to all who need it but it was not designated to provide ALL healthcare services), the NHS will have to quickly tackle its low productivity. Measured in terms of number of patients treated per doctors, the 4% rise in productivity is astonishingly low compared to the increased amount of taxpayers' money received by the NHS (30 billion £ in 1997, 70 billion £ in 2006, and 90 billion £ in 2008). For the system to be "fit for purpose", it will require a reorientation of staff towards a more patient/customer friendly attitude, increased competition and smaller management groupings. Thus, by introducing contracts for private healthcare providers, which started in 2003, NHS is progressively opening to the private sector and encouraging competition. This phenomenon is uprooting the traditional staff culture and clearly pointing the way forward for the entire system. William Wells emphasized both the importance of these reforms and the fact that the system would not be entirely changed; after a major national debate it was decided that taxpayers should continue paying for healthcare service but that in return, the increase in taxes meant the NHS should provide the patient/customer "value for money". The controversial and "revolutionary" approach of allowing the private sector into NHS is part of a new trend in creating hybrid health systems.

Dr. Bakhuti Shengelia, Regional Adviser for Health Policy and Equity, Division of Country Health Systems at the WHO, examined the health systems of Central and Eastern Europe, where the former Soviet Republics have seen a five to eight year decrease in average life expectancy since the collapse of the Soviet Union in the early 90's. An estimated 3.2 million deaths, concentrated among men aged 20 to 60, would not have occurred in these countries had the health systems not suffered in the wake of political collapse. Since 1995, the rate of HIV infections has also increased at an alarming rate, making this one of the fastest growing AIDS epidemic region in the world. While public health has taken a setback in the Central and Eastern European societies, the poor are the most affected. Even though governments often promise a public health care system to meet the populations' needs, in reality they fail to provide these services, allowing for the growth of a de facto private system of informal payments. Other increased health risks among the uneducated and the poor such as higher incidence of smoking and heavy drinking also adds to the burden on existing health care systems. The dramatic disparity in access to health care is ironic, given the level of solidarity that once existed in these countries' health systems. In Georgia and Azerbaijan, for example, out of pocket payments by patients cover approximately 90% of all health care costs. To ameliorate the inequalities of the system, out of pocket payments by patients need to be drastically reduced and funding redistributed to target vulnerable groups. Aid from the European Union could be instrumental in achieving these goals.

All three speakers seemed to agree that the public vs. private debate is no longer relevant because the definitions of these terms have blurred considerably. The most effective health systems should well utilize both public and private actors. As one forum participant well pointed out, we should focus on the functionality of the system in reaching performance benchmarks, rather than the type of system.

GHF2006 – PS06 – Financing Health Systems Pro Poor

Session Outline

Parallel session, Thursday, August 31 2006, 11:00-12:30
Chair(s): Raphael Bengoa, Switzerland, Jacques Martin, Switzerland
Health Insurance: Is it Globally Relevant?
David B. Evans, Health Systems Financing, World Health Organization, Geneva, Switzerland 
Alternatives in Healthcare Financing: Examples from Low and Middle Income Countries
Sania Nishtar, President, Heartfile, Pakistan
The Impact of Sustainable Private Sector Investments
Guy Ellena, Director, Health and Education Department, International Finance Corporation, World Bank Group, USA 

Session Report

Submitted by: Philippe Berset (ICVolunteers); Contributors: Martin Elling (ICVolunteers), Jocelyn Poirier (ICVolunteers)
Image: Viola Krebs, ICVolunteers.org

Financing of health systems is well known for raising controversial ideas and provoking stormy debate. This session put the accent on whether a prepayment system should be applied to deficient health systems in under-developed countries. Different judgements on the global relevance of insurance were presented.

The first speaker, David B. Evans from the World Health Organization (WHO), began his presentation about health system financing by evoking the reversals which took place during the 1990's in the sub-Saharan and south-east Asian regions. In these regions life expectancy has reduced despite health improvements worldwide. In comparison to the most developed countries which spent a lot on health, expenditure in developing countries has remained insufficient. This fact recently led the WHO to adopt a resolution urging countries to develop health financing systems that ensured that their population had access to necessary healthcare, without financial risk to the recipient. But health financing systems are far from being realized in many developing countries as is demonstrated by the fact that a high proportion of health spending in these countries comes 'out-of-pocket'. In south-east Asia the 'out-of-pocket' proportion of spending is up to 70 per cent. These upfront costs discourage the use of health services and cause people to discontinue treatment. In China, more than 40 per cent of people in need of treatment do not seek it and this places a burden of care on family members with negative consequences for their ability to work.

Objectives are to improve the quality and efficiency in service delivery and help countries to optimize their health coverage. Most developed countries have systems based on a mix between insurance contributions and different sorts of taxes. Mr. Evans gave many examples to illustrate the major part private funding plays in emerging economies. Some countries, like Moldova, succeeded in transitioning quickly and balancing both approaches to financing health. The solution put forward by the speaker is to set up progressive tax systems and provide for insurance contributions based on income. But how to raise the contributions is the greatest problem and that requires increasing inflows of external assistance. It must not be forgotten that the key to the whole system is the way the funds raised are used. The speaker concluded that transition can take considerable time and that insurance can play an essential role, but has to be supplemented by taxation.

In the second part of the symposium Mr. Guy Ellena, Director of the Health and Education Department at the IFC (World Bank), presented and lead discussion on the impact and role of the private sector in health care. Mr. Ellena made it clear that the question of whether the private sector's contribution is good or bad is not relevant here. Private sector investment in health care exists and needs to be dealt with. In fact, it impacts as much the poor as it does the rich (for example in the Dominican Republic, most middle class people use the public system). Mr. Ellena elaborated on four different questions: Does the private sector matter? Is it sustainable? Does it serve the poor? How can the private sector investment be supported? The fact is that poorer countries tend to rely more on private sector funding (for example the Democratic Republic of Congo 80%, versus Japan only 20%) and private sector funding is closely related to the capacity of a government to collect taxes. Since people, regardless of their origins or the country they live in, are willing to pay for good services and accessible health care system, the private sector not only matters but becomes an essential piece of the puzzle. Unfortunately, in order for the private sector to be sustainable, it needs to be profitable. Consequently, in order for the private sector to be well integrated into the public system the right conditions need to be established. Governments play a major role, since the private sector is also their responsibility, by regulating it without imposing burdensome constraints and by providing an improved business environment. To do this they need to understand private sector health care so that they are aware of how it contributes and improves existing health care systems.

Financing health is a challenge and, as statistics show, it is not necessarily a profitable business in some countries, which means banks tend to shy away from investment in it. Private financing in health care is not always looked on favourably by public opinion. This is where the World Bank comes into play by helping financing the private sector into health care in under developed countries.

Private funding in health care is a reality which affects populations all over the world; more specifically in under-developed countries. The key is to influence poorer countries to establish balanced funding of their health care systems through government, insurance and the private sector.  The combination of these will lead to a transfer from richer to poorer groups and especially from the healthy to the sick.

GHF2006 – PL01 – Access to Health: Where Do We Stand?

Session Outline

Plenary session PL01, Wednesday, August 30 2006, 14:00-15:30
Chair(s): Fred Paccaud, Switzerland & Thomson Prentice, Switzerland
Social Determinants of Health
Eugenio Villar, WHO, Switzerland 
Healthcare for All: The True Millennium Development Goal 
Bruno Gryseels, Director, Institute of Tropical Medicine, Antwerp, Belgium
Leadership and Access to Healthcare: Global Public Goods for Local Decision-Making
Julio Frenk, Secretary of Health, Ministry of Health, Mexico 

Session document

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Session report

Submitted by: Jennie Hery-Jaona (ICVolunteers); Contributors: Marc Menichini (ICVolunteers), Tatjana Schwabe (ICVolunteers), Sarah Webborn (ICVolunteers)
Image: Viola Krebs, ICVolunteers.org

The Forum began with a welcome address by Dr. Louis Loutan representing the Organizing Committee. Dr. Loutan acknowledged the presence of over 800 participants from 80 countries encompassing Switzerland, Europe and the rest of the world and emphasized the objective of the Forum "to foster debate on access to health through the exchange of experiences, collaboration and the creation of partnerships". Following this theme, the three speakers raised the key issues of social determinants of health, health care for all (3 of the 8 Millennium Development Goals focus on health) and leadership and access to health care.

The first speaker, Eugenio Villar, Coordinator of the Department of Equity, Poverty and Social Determinants at the World Health Organization (WHO), Switzerland, discussed the recent initiatives of WHO about social determinants of health (SDH). It is paradoxical to treat people in poor countries only to send them back to the social reality that made them sick.

Social determinants must be emphasized, he said, because: they have a direct impact on health; they predict the greatest variation in health; they influence and structure health behaviours of individual and institutions; and they interact with each other. Socio-economic, cultural and environmental conditions thus have a great impact on health.

The importance of Europe's achievement of a welfare system was illustrated with the case of Sweden which from the XIXth century has adopted a two stage approach: content (addressing health inequalities and social determinants of health instead of individual diseases); and process (the objectives and including the relevant participants). "Health policy should focus on the need to reduce health inequity", he said.

Other case studies were presented, illustrating the fact that social reforms in health or access to education are achievable even within a short-time period. For instance countries such as Sri Lanka and South Africa have made important progress in only seven years.

A second issue addressed by Dr. Villar was "WHO and Equity". Referring to the late Dr. Lee's WHO Commission on Social Determinants of Health, Dr. Villar emphasized the need for realizing goals through "action, learning, advocacy and leadership". He also mentioned the importance of nine knowledge network themes, among which are health systems and child development, in order to build health and health equity.

The second speaker, Bruno Gryseels, Director of the Institute of Tropical Medicine in Antwerp, Belgium, looked backwards in time to the 1976 WHO World Assembly's agenda on the need for primary health care, and the 1978 WHO and UNICEF conference at Alma Ata (see outcome declaration), which set the ambitious goal of "Health for all by the year 2000". By the year 2000, however, on the one hand progress had been made on mapping the human genome, while on the other hand unprecedented health crises took place in some developing countries, with a breakdown of access to health care resulting in a requirement for major health sector reforms. There was also a shift in the key role played by WHO with the emergence of organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM - www.theglobalfund.org), Bill & Melinda Gates Foundation (BMGF - www.gatesfoundation.org) and Private Public Parternships (PPP). In addition, the Millennium Development Goals (MDGs - www.un.org/millenniumgoals) then replaced the 'Health for All' agenda.

Dr. Gryseels also mentioned the World Bank's 2006 publication on Disease Control Priorities in Developing Countries (www.dcp2.org/pubs/DCP). He highlighted the fact that input from developing countries was limited to only 1 out of 9 editors and 42 out of 346 contributors. On a lighter note, the top-down approach of priority-setting at a global level and the difficulties in integrating the numerous health-care programmes which resulted were illustrated by cartoons.

Most importantly, Dr. Gryseels emphasized that access to health care is a universal human right and claimed that: "Healthy people have many dreams... the sick have only one".  A graph comparing life expectancy and child mortality in the Northern and the Southern hemispheres illustrated a continuing lack of equity despite the declaration of universal human rights.

Among the themes related to quality of health care, Dr. Gryseels noted that research remains useless if there is no health care system to implement any innovation. Striving for accessible health care was hence "the mother of intervention" (paraphrased from F. Zappa).

Reiterating his key point, Dr. Gryseels stated that in order to have efficient international health policies, there is a clear need to curb the top down approach. He discussed the alternative between vertical approaches based on specific campaigns and the horizontal approaches centered on primary health care. He shared an illustration showing the advantage of the 'verticalist' over the 'horizontalist' in that the former is "standing up". He suggested a synthetic or 'diagonal approach', able to combine selective actions with the need to develop community-based health care, since the last is a "strong motor for political empowerment and democratization", he concluded.

The final speaker, Julio Frenk, Minister of Health in Mexico, shared his reflections on real life experience as a minister of health. He focused his lecture on instrumental value of knowledge in improving health, as knowledge is essential in everyday behaviour and produces the evidence necessary for correct decision making. Each innovative move must be tried because it is an experiment for increasing knowledge.

Dr. Frenk mentioned the global consensus that health plays a key role in development and highlighted the importance of scientific knowledge. He argued that these two issues are the "driving force for health progress", as they change individual behaviour by "empowering people to promote their own health". Describing Mexico's case, Dr. Frenk said that half of the total expenditure in Mexico was 'out of pocket' because half of the population lacked insurance and social protection. Reform was therefore badly needed in order to provide universal or popular health insurance (in Spanish "seguro popular". Democratic financial reform thus took place at the macro level, in addition to which there was managerial reform. The reform was put in place in 2003 and provides seven years of public funding for the "seguro popular". Dr. Frenk emphasized the need for integrating vertical and horizontal approaches so as to form a 'diagonal', but also the requirement to define priorities to drive overall improvements in health systems, so as to serve the poor more successfully. Moreover, he noted that a well-functioning health system will be helpful to fight HIV/AIDS. On balance, he described the 'hallmarks' of Mexico's reform as: the investment in research, the evaluation of resources and decision-making. Emphasizing the importance of knowledge, he said that "reform is inform or else deform". There is thus the need to share knowledge through international collective action and the transformation of countries' self-interest into common interest. In this manner, the creation and dissemination of knowledge remain the most important issue, according to Dr. Frenk. Everyone will win: the knowledge-producers, the translators, the citizens and more. In summary, this forum's objective should be to "bridge divides", such as the vertical-horizontal, analysis-advocacy and national-global divides. There is a need for a more integrated approach on global public health, based on three components: exchange, evidence, empathy, "as we all are members of the same human species", he concluded.

GHF2008 – PS19 – Physicians in Global Health

Session Outline

Parallel session PS19, Tuesday, May 27 2008, 11:00-12:30, Room 18
Chair(s): Jean-Michel Gaspoz, Head of Department, Community Medicine and Primary Care, University Hospitals of Geneva, Switzerland, Charles Boelen, International Consultant in Health Systems and Personnel, Former Coordinator of the WHO Programme, Human Resources for Health, France
Physician Leadership for Health
Otmar Kloiber, CEO, The World Medical Association, Switzerland
Access at the Frontier of Healthcare, Advocacy and Research
Hans Wolff, Head, Penitentiary Medicine Unit, Department of Community Medicine and Primary Care, University Hospitals of Geneva, Switzerland  
The Experience of Primary Health Care Reform in Bosnia and Herzegovina
Nicolas Perone, Chief Resident, Division of International and Humanitarian Medicine, Department of  Community Medicine and Primary Care, University Hospitals of Geneva, Switzerland
From 5-Star Doctors to Intersectoral Action for Health 
Maaike Flinkenflögel, Coordinator, Primafamed-Network, Belgium

Session Documents

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Session Report

Submitted by: Cathy Matovu (ICVolunteers)

Doctors are not only care givers; they are also community leaders, decision makers, communicators and excellent managers. These are the characteristics of a 5-star doctor. Speakers challenged the role of the physician in the health care system and question whether these are the only qualities that can be attributed to him.

The Declaration of Alma-Ata established in 1978 by the World Health Organization was created to ensure and promote health for all people of the world. Dr. Otmar Kloiber, Secretery General of the World Medical Association, Ferney-Voltaire, France, claims that after thirty years of this declaration, there has been very little change and health has increasingly become an issue. The problem, he argues, is that health systems today have concentrated on primary care. Indeed, the basis of the health care system is primary care, but Dr. Kloiber suggests that once this structure is in place, we must continue to grow and develop it into a community based type of care. Developing countries suffer from their poor economies and the common phenomenon is the emigration of physicians from developing countries to the North. These are incredible challenges that health systems in developing countries face and physicians around the world must collaborate in order to create a better system for development. "Health care is trust and trust inspires hope," he says. "If we don't develop, people lose trust and go away."

Equally, Dr. Maaike Flinkenfl�¶gel, Coordinator of Primafamed-Network, Belgium, discussed the importance of community based primary care and the role of the family doctor or General Practitioner (GP). The 21st century is an era where the role of the family doctor has evolved. Today, GPs no longer work individually but collectively to promote health and to guarantee people access to health care. The community-oriented primary care, a system used in Belgium, strives to develop the health of the community as a whole, not just on an individual level. Physicians, as a result, spend a lot of time researching and gathering information that enable them to understand the needs of the community and treat them accordingly. Thus, the role of the 5-star doctor is broadened in which he becomes an advocate for social change and development.

Dr. Nicolas Perone, Chief Resident of the Division of International and Humanitarian Medicine at the University Hospitals of Geneva, Switzerland, also underlines the importance of the participation of GPs in research and raising awareness. Taking example from the former Yugoslavia health system, Dr. Perone maintains that physicians today must move beyond the "family doctor" structure and direct their work towards public health services.

Dr. Hans Wolff, Head of the Penitentiary Medicine Unit at the University Hospitals of Geneva, Switzerland, equally acknowledges this advocacy role explaining his personal experience as a physician for marginalized groups. The penitentiary medical unit at the Champ-Dolllon prison in Geneva aims to offer high quality care to the detainees and makes sure that they are treated like all other patients. However, disparities still exist within the system where there is low communication between the doctors and the patients, access to care is limited and prevention of violence is unsuccessful. Dr. Wollf insists that the world is changing and we must change with it. As advocates of social change, physicians all over the world must work together towards equality and harmony within the health system.

The Experience of Primary Health Care Reform in Bosnia and Herzegovina

Author(s): N. Perone*1, S. Aebischer Perone2, D. Sredic3, L. Loutan1
Affiliation(s): 1Médecine internationale, Geneva University Hospitals, 2RH San, ICRC, Geneva, Switzerland, 3Management, Fondacija fami, Sarajevo, Bosnia and Herzegovina
Key messages: 1 – General practitioners need to be included in the formulation of the needs and actively involved in the implementation of new health promotion and preventive activities.
2 – Multilevel commitment other than health professionals is a key factor for success.
3 – A feasibility and acceptability analysis is an important step before the implementation.
Summary (max 100 words):

The former Yugoslavia health system was centrally planned and specialists-oriented with little or no emphasis placed upon patient centred family medicine. Primary care physicians were mainly performing triage and providing little long term follow-up of patients. As a result of the 1992-1995 war, basic health infrastructure was severely damaged and many health professionals experienced severe trauma or left the country. By 1999, the BiH Ministry of Health established Family Medicine (FM) as a priority, reorganizing the health care system and reallocating resources to strengthen primary care.
The Swiss Agency for Cooperation and Development (SDC) was fast in offering support for this process of rebuilding and reorganizing, which underpins a paradigm shift towards family medicine. Financial support was used to facilitate training courses to upgrade doctors’ and nurses’ knowledge in family medicine. Additional efforts were made to build institutional capacity and ensure local expertise at the heart of suggested areas of change and improvement.
The reorganisation of the practices and the broader context of FM responsibilities offered a golden opportunity for having GPs more aware of their role in identifying and prioritizing the needs of their patients, to be able to have a critical look at the quality of the services offered and to empower them in these new roles. Activities and results include:
1 – Home bound patients: an assessment leading to high commitment of GP and nurses.
2 – Adolescent health: the evaluation of Youth Friendly health services as a starting point for future interventions.
3 – A European satisfaction survey on FM doctors. Higher patient satisfaction is following the implementation of FM services.
4 – Smoking cessation counselling: (i) expertise in classroom with on-site peer-to-peer (ii) support, commitment of the institution hierarchy (iii) strategy created and supported by MoH.
5 – Continuous professional development curriculum with Delphi method: better consensus on the needs, higher satisfaction and attendance to the training, a continuous quality improvement tool.
6 – Eight weeks curriculum to update knowledge of GPs and nurses on family medicine: an important tool to reach international norms and standards of FM.
7 – Continual quality improvement: through revision of practice (Audit), follow-up sheets for patient with chronic diseases and peer supervision.

Lessons learned:

1 – To maximize the chances of success, GPs were participated in the research studies. This helped defining the specific needs of the patients and the type of the services to be offered.
2 – Studies helped the GPs to understand how patients look at the quality of care provided and their remarks were translated into the implementation programme of FM.
3 – Having a national strategy and the support of health authorities is essential to have physicians involved in health promotion activities.
4 – Raising awareness of health professionals on specific health promotion activities is a crucial step before starting to implement them.
5 – Additional training is very often needed to improve the performance of existing services or to initiate new activities.

DebugIT for Patient Safety: Leveraging the Fight against Emergent Microbial Diseases Using Multimedia Data Mining of Heterogeneous Clinical Data

Author(s): C. Lovis*1, D. Colaert2, V. Stroetman3
Affiliation(s): 1Service of Medical Informatics, University Hospitals of Geneva, Switzerland, 2Agfa HealthCare, Agfa HealthCare, Brussels, Belgium, 3Empirica, IT, Germany
Keywords: Infectious disease, patient safety, semantic inter-operability, multimedia data mining, decision support, clinical outcome monitoring
Background:

Building a safer and more efficient care system has become the most shared goal of all actors involved in healthcare. While medical errors are under the spotlight, (re-)emerging infectious diseases are becoming major challenges. Among them, the rapid development of anti-microbial resistances, the spread of nosocomial and other infections, the inadequate care and missing appropriate tools to lead the care system facing these new emergent problems are major concerns. The issues around infectious diseases are strongly interrelated and have immediate and important effects on safety, quality of care and efficiency. In half a century of antibiotic use, new challenges have emerged: fast emergence of resistances among pathogens, misuse and overuse of antibiotics. Antimicrobial resistance results in escalating healthcare costs, increased morbidity and mortality and the (re-)emergence of potentially untreatable pathogens.

Summary/Objectives:

The DebugIT project is funded within the 7th EU Framework Programme (FP7). The main objectives of the project are to build IT tools that should have significant impacts for the monitoring and the control of infectious diseases and antimicrobial resistances in Europe. This will be realized by building a technical and semantic infrastructure able to (1) share heterogeneous clinical data sets from different hospitals in different countries, with different languages and legislations; (b) analyse large amounts of this clinical data with advanced multimedia data mining; and (c) apply the obtained knowledge for clinical decisions and outcome monitoring. The concepts and architecture underlying this project are discussed.

Results:

To achieve this system, several aspects will have to reach the frontiers of the current state of the art and beyond. Two strategies can be chosen for that. The first one is to invent something radically new. The second one consists of using existing knowledge and methods, putting them together, and trying to build upon this base. For most of its research, the second strategy is the one chosen in this project, because operational results for clinical information systems must be available and sustain the DebugIT outcomes after the end of the project. In order to meet these requirements, the project has been organized according to architectural component-based considerations: Interoperability Platform (IOP); Clinical Data Repository (CDR); Multimodal Data Mining (MDM); Medical Knowledge Repository and associated Knowledge Authoring Tool (MDR); Decision Support and Monitoring engine (DSM); Clinical applications.

Lessons learned:

This scientific and technical framework, associated with access to large amounts of clinical databases and led by experts in the medical field will lead to a serious advance in building a large IT infrastructure aiming at creating new knowledge in the field of monitoring, surveillance and efficient measures to fight infectious diseases.

Obstacles in Relation to the Health Workforce: Accessibility of Services in Fragile States and Conflict Zones

Author(s): S. T. Ismael1
Affiliation(s): 1Doctors for Iraq, London, Iraq
Key messages:

1 –Shortage, misdistribution and adequate mixture of skills are real challenges to health provision in fragile and arm conflict zones.
2 – Work overload, poor moral and health workers absenteeism are consequences that decrease the opportunity of accessing health care for local community.
3 – The relation between health provider and patient is unique and based on bilateral trust.

Summary (max 100 words):

Approximately 14% of the world’s population live in fragile states were governments are either unable or unwilling in delivering services to the majority of its population resulting in instability and insecurity in such countries; alongside additional fears of the wide spread global economical crunch and food crises manipulating more countries in becoming fragile states. In 2003, prior to the occupation of Iraq, there was a great short-age in the number of health workers, especially doctors, with 1.6 per 1,000 populations decreasing drastically to 0.5 by 2007. To date approx 2,000 doctors at senior level have been killed and 12,000 have migrated to other countries. The Doctor’s migration was not only across borders to Neighbouring countries, but also internally between governorates. Doctors tend to mimic the direction of movement of other sectors in the IDPs, following the logical search for secure and related hosting communities. This two-directional movement resulted in the shortage, uneven distribution and unequal mixture of skills geographically which affected the access of health services between communities in these areas. The shortage of the workforce within the health system is one of the major problems that we are facing today in the humanitarian sphere. Prioritisation, sustainability and balancing short and long term objectives should guide our decisions on how to deal with this obstacle through task shifting, incentives, providing education via chain of short training courses and other practical ways to combat this problem. The relationship between health care provider and patient’s is uniquely built upon trust and accountability. Disruption of this trust will ultimately affect the acceptance of health care services by the patients. Since 2003 the power struggle between the Iraqi political counter parts imposed it self on the society resulting in ethnical tension and division. Unfortunately this ethnical tension has manifested its way trough the health care facilities. Affecting not only the relation between health providers themselves, but also shattering the trust between them and patients. This has created fear and insecurity within Iraqi patients when they are seeking health care. Since the escalation of violence in 2006 towards Sunni Iraqis as a result of the attack on the Shiaa Holy Shrine, more patients have become sceptical on whom and where to turn to when seeking health care. Impartiality in relation to trust are fundamental to create secure system ultimately resulting in fair access to health care for all in conflict zones under attack of ethnical and religious tensions. It is a necessity for this to be addressed and it is our duty to provide education and advocacy of such principles to try and re-build the bonds that have been broken limiting further disruptions within the health care system.

Lessons learned: 1 – Developing and retaining the health workforce in fragile states or conflict zones is a priority even in emergency phase. Task shifting is considered to be a practical solution when trying to tackle the problem of shortage within the health workforce.
2 – Neutrality, impartiality and bond of trust between health care providers and care recipient are very crucial in insecure fragile environments and need to be endorsed between health care providers in conflict zones.
3 – Work overload contributes to a decrease in motivation alongside increasing absences within the health care units.

GHF2008 – PL02 – Primary Healthcare Revisited in a Multistakeholder Landscape

Session Outline

Plenary session PL02, Monday, May 26 2008, 14:00-15:30, Room 2
Chair(s): Bruno Gryseels, Director, Institute of Tropical Medicine, Belgium & John Martin, Adviser, Office of the Director General, WHO, Switzerland
The Role of Public Services
Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda
Communities and Social Movements: Key Players in Realizing the Right to Health
Thelma Narayan, Public Health Consultant, Centre for Health and Equity, Community Health Cell, Sochara, India 
Clinicians’ Role in Primary Healthcare
Jan de Maeseneer, Secretary General, The Network: Towards Unity for Health (TUFH), University of Ghent, Belgium

Session Documents

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Session Video

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Session Report

Submitted by: Jay Wilson (ICVolunteers)

H.E. Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda, photo: V. Krebs, ICVolunteers.org

John Martin, Adviser, Office of the Director General, WHO, Switzerland, opened the session stating that the purpose was to deliberate on what the world could do to improve the health care of its inhabitants. Despite progress in technology and treatments, why is the impact not substantial? He defined "global health" as encompassing all people on the planet, over and above individual nations. Health care centres cannot do the job alone - to face the challenge of gross social injustice requires a gross political response.

H.E. Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda, stated that the centre - or glue - of a Health System is Human Resources (HR), supported by: financing, infrastructure, technologies, drugs, knowledge and information. He pointed out that health care workers (HCW) are the most important component of any health care delivery system. They design, manage and deliver prevention and care services. One of the key health indicators is the HCW to population ratio; the global average is 4 HCWs:1000. The critical threshold according to WHO is 2.28 HCW:1000 and Uganda has 0.81 HCW:1000.

Mr. Bukenya continued that another issue is weak HR management. There is an inequitable distribution in favour of urban versus rural, especially for academic degree holders. There is poor retention and low productivity; people with degrees move away. Furthermore, there is little relationship between public and private sectors. Institutional agreements create a gap between the health delivery system and communities, such as housing, environment, water, sanitation, nutrition, education, etc. Mr. Bukenya wondered why these communities are managed by people outside of the health system. Why is there not a stronger link between political will, industries and HCWs? He also stated that HCWs, along with other stakeholders, should know the country's vision and its strategic priorities, along with understanding the needs of the society they serve and learning to work with others who are dealing with similar issues, in order to affect change in the community.

He concluded that health is imperative for economic productivity. Efforts should be made to expand HR in the health sector, especially in Africa, in order to meet the standard ratio of 2.28 HCW:1000 population. He also said we must debate the idea of compensation mechanisms for migrant health workers working in the developed countries. Base countries must be indemnified for the educational investment in their people, who now use their skills to benefit other countries. Likewise, there must be an appropriate technology (i.e. Information Communication Technology, cheap effective drugs, etc) transfer to Africa to help facilitate health systems.

Thelma Narayan, Senior Public Health Consultant of the Centre for Health and Equity, stated that the community has enormous strengths. Local health traditions developed over generations have placed women health workers and women in the communities as the bearers of health care for several thousands years. When communities are involved in the decision making process, changes made are of quality and character. In these communities, health means access to water and livelihood; whereas to professionals in developed countries, health means something else. She stated that health for all is a fundamental right of each citizen; communities are agents of change. She questioned, "As experts, are we problem-solvers or are we part of the problem due to our own self-interest?"

Dr. Narayan said that she has been involved in many projects in India which use a community based approach to addressing health determinants. Communities include health facilities, elected representatives, health workers, volunteers and practitioners. They have successfully organized health awareness events where people seriously discuss health issues and how they can fix problems themselves. They have also involved the government in order to effect policy change. Similarly, they engaged the human rights commission, reviewed violation of health rights, and took judicial action to ensure the right to health.

Jan de Maeseneer, Secretary General, The Network: Towards Unity for Health (TUFH), stated that the health care system is a social determinant for health. Through various networks (education, work, economy, housing, etc), social cohesion and empowerment, good primary health care (PHC) can be accessible to the people. Additionally, the involvement of civil society is important in changing the level of health care. Community-oriented primary care (including community diagnosis, inter-sector cooperation and a focus on individual behaviour and living conditions) must be established in order to lessen unhealthy inequalities.

Principles of PHC are equity/accessibility, comprehensiveness, continuity, cost effectiveness and patient participation. Enabling patients to see the same doctor over a long period is cost effective, gives continuity of care, takes into consideration patient's expectations, and empowers the individual. In various studies, Dr. Maeseneer has shown that training of health professionals is a crucial part of PHC. HCWs must have access to continuous development; they need guidelines and medical supervision to assure adequate health care. According to the World Health Organization, a five star doctor is one who: assesses and improves the quality of care, makes optimal use of new technologies, promotes healthy lifestyles, reconciles individual and community requirements, and works efficiently in teams.

Dr. Maeseneer continued that highly skilled HCWs are taken from primary health care to specialist care and from local health care systems to vertical disease oriented programmes. Additionally, an international brain drain exists where HCWs move from central to southern Africa, then from southern Africa to Europe, Australia and North America. This phenomenon weakens the already weak state of HCWs in the local communities of underdeveloped and developing countries.

The PHC context has changed since Alma Ata, 1978. New problems exist: civil society, vertical programmes, the manpower crisis, the magnitude of economic impediment, increasing privatization and IP issues, among others. Today, PHC needs to address issues that did not exist in 1978.

The issues must be localized, meaning they must address local problems. PHC needs to look at global issues in the context of local issues, in which it must operate and it must be in a position to operate in the given community.

Is compensation really the answer to brain drain? Mr. Bukenya claimed that approximately 10% of HWCs earnings must be given back to the origin country. A compensation mechanism has to be put in place so that HCWs can stay in their 'new' country. The host country must give a proportional remittance back to the country of origin that paid for most of the HCW's primary education. Will paying for professionals to migrate to other countries solve the problem or increase the inequality gap? According to Mr. Gryseels, it is a political responsibility to create feasible working conditions, in order to keep HCWs; individuals cannot be controlled, however, compensation is political.

GHF2008 – PS23 – Patient-centred Health Systems: Good Wishes and Harsh Realities

Session Outline

Parallel session PS23, Monday, May 26 2008, 11:00-12:30, Room 16
Chair(s): Arnaud Perrier, Head, Department of Internal Medicine, University Hospitals of Geneva, Switzerland, Johanna Sommer, Lecturer, Division of Primary Care, Department of Community Medicine and Primary Care, University Hospitals of Geneva, Switzerland
Patient-Centred Healthcare: From Policy to Practice
Jeremiah Mwangi, Senior Policy Officer, International Alliance of Patients’ Organizations, UK
Clean Care is Safer Care: Involving Patients
Didier Pittet, Director, Infection Control Programme, University Hospitals of Geneva, Switzerland 
Doing the Right Things for Patients with Chronic Diseases: Empowerment through Quality of Care Information
Steve Hines, Health Policy, The Lewin Group, Falls Church, United States  
Making Self-Management in Chronic Disease Accessible for All 
Karin Lorvall, Cardio-Pulmonary Physiotherapist and Patient Educator, Hôpital de la Tour, Switzerland 

Session Documents

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Session Report

Contributors: Irene Amodei (ICVolunteers)

A health care system designed and delivered to answer the needs of patients is still far from being achieved, independent of the development level of the country we are considering. Organizations promoting a patient-centered approach, patient empowerment and patient education are working hard to advocate in this direction. Initiatives are on the increase. Evidence is already there. The way forward is clear. The moment has come to take action.

Representing an estimated 365 million patients the International Alliance of Patients' Organisations (IAPO) is a unique global network that aims to advocate on relevant aspects of healthcare policy, with the goal of influencing international, regional and national health agendas. "Health systems need to be reoriented to people and patients rather than diseases" commented Jeremiah Mwangi, Senior Policy Officer from IAPO. The best way to do that is to promote an approach based on strong values of respect, partnership and equity, coping with principles of patient-centred healthcare such as support for the individual patient, access to accurate, relevant and comprehensive information, promotion of patient responsibility and, if possible, patient involvement in health policy-making. Putting patients needs and self-management at the centre of the healthcare system will lead to a number of advantages in terms of cost-effectiveness and quality of care. One caveat only has to be taken into account: health systems should give patients responsibilities they can assume, and not simply what the system cannot do itself.

"Patient education is not just a nice accessory", added Karin Lörvall, Cardio-Pulmonary Physiotherapist and Patient Educator from Hôpital de la Tour, Geneva, illustrating the Chronic Disease Self-Management Program (CDSMP) developed at Stanford University and now implemented in 12 different countries. "Self-management is a process to change health behaviours (physical activity, coping, communication with doctor, interpretation of symptoms) and health status (fatigue, health distress)", pointed out Dr. Lörvall. The pillar stone of this strategy is an active partnership between trained people living with a life-long disease and health professionals. Similar programs (more or less structured but always evidence-based and not disease oriented) adopted in UK, Austria, Sweden and South America demonstrate that increased self-efficiency helps to significantly decrease the number of hospitalisation days.
The importance of patient participation in reducing healthcare-associated infections (HAI) was also underlined by Didier Pittet, Director Infection Control Program at  the University of Geneva Hospitals. Patient involvement in multimodal hand hygiene promotion strategies has a tremendous potential to reduce medical errors and improve patient safety. HAI is a global issue for patient safety: it affects hundreds of millions of individuals worldwide each year. It can complicate patient care and contribute to unexpected deaths. It affects 5 to 15 per 100 hospitalised patients and can lead to complications in 25 to 50% of those admitted to intensive care units. The risk is 2 to 20 fold higher in developing countries. "No hospital, country or healthcare system in the world can claim to have solved the problem", pointed out D. Pittet. The First Global Patient Safety Challenge "Clear Care is Safer Care", launched by WHO World Alliance for Patient Safety in 2005, is aimed at galvanizing global commitment and action to reduce HAI worldwide with hand hygiene promotion as the cornerstone. New Guidelines on Hand Hygiene in Health Care have been developed by experts and a multimodal implementation strategy is proposed to improve hand hygiene in healthcare settings at all levels of development. One of the recommendations explicitly encourages "partnerships between patients, their families and healthcare workers". Dr. Pittet explained that patient involvement is "a process in which patients understand their role, are given the knowledge and skills by their healthcare provider to perform a task in an environment that recognizes community and cultural differences". Patient empowerment programs must be part of a multimodal approach and must include educational tools, motivational tools and role modeling.
The growing awareness of poor and variable quality of care received by persons living with chronic diseases is leading to increasing efforts to provide patients with quality of care information, so empowering them. But the impact of this effort is unclear. Commissioned by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), the Lewin Group assessed the impact of public reporting initiatives in Europe and North America in order to improve the quality and patient-centeredness received by persons with chronic diseases. Steve Hines, from the Lewin Group, presented the major findings of the model used. "Public reporting efforts are expanding" stated Mr. Hines. "More measures, conditions, and provider types are being included and a number of new funding agencies are interested". The impact of information on healthcare depends on different factors: awareness of information, care options, economic incentives to use information, belief that the information is valid, consumer healthcare literacy, and public and private support for change. Raising consumer awareness requires greater emphasis and leveraging common infrastructure for multiple end users is key to financial viability. To succeed, public reporting efforts must better adapt information for their audience and align their efforts with other strategies.