Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Public-Private Partnerships: Beneficial or Undermining?

Author(s): Louis J. Currat1
Affiliation(s): 1Former Executive Secretary, Global Forum for Health Research, Geneva, Switzerland
Key issues: Many infectious diseases affecting the developing world are potentially treatable in the longer term. However, economic disincentives have resulted in underinvestment in medical research for new vaccines and medicines targeted at these diseases. Thus, of the more than 1200 drugs that reached the global market in the past three decades, only an estimated two to three per cent were for tropical infectious diseases that primarily affect the poor. Worse yet, three million children die each year from diseases that could have been prevented with existing vaccines (for example vaccines against hepatitis B and Haemophilus influenzae type b), underlining the huge economic, social and cultural obstacles existing between the availability of products and their accessibility by poor populations. The main reasons for this situation are that, on the one hand, high costs and inadequate commercial returns have resulted in the withdrawal of the private commercial sector from investments in tropical disease research and commercialization of health products for the poor populations of developing countries. On the other hand, the public sector has concentrated its financing on basic health research and generally lacks the expertise, mechanisms and resources to discover, develop, register and commercialize new products. In other words, there is a disconnection (or several) in the pipeline for producing, developing, and delivering health products to the poor between the public and private commercial sectors and these disconnections may be different for different diseases.
Meeting challenges: How to reconnect and/or reinforce this pipeline? The solution has to come from joint undertakings of the public and private sectors. In many cases, the initiative to launch a public/private partnership is likely to come from the public sector, as the sector is ultimately responsible for ensuring that the poor have access to health products. It may also come from civil society organizations, pursuing a global health objective with private resources. Examples also exist where the initiative was taken by the private commercial sector.
Conclusion (max 400 words): When are PPPs needed? In short, one could say that the larger the disconnection in the product discovery/delivery pipeline between the public sector and the private commercial sector, the higher the rationale for launching a PPP. Are PPPs the only strategy to reconnect and reinforce the discovery/delivery pipeline? No, the public sector may decide to use push and pull interventions to help correct the structural problem of under-investment in the diseases of developing countries. If the disconnection is particularly large, it may choose to use push and pull interventions together with support to specific PPPs in order to speed up the impact on the health of poor populations. Do PPPs always work and are they always cost effective? With good management, the benefit/cost ratio of PPPs may be very high, i.e. the benefits of joint action may be much larger than what each institution could obtain separately for the same amount of time and resources invested. In cases where the overall estimated benefits become limited, while the costs remain high, it is justified to stop the investment in the partnership. To illustrate these points, the presentation will draw upon a few examples of actual PPPs.

Public Responsibility in Research and Development Partnerships

Author(s): Bernard Pécoul1
Affiliation(s): 1Executive Director, Drugs for Neglected Diseases Initiative, Geneva, Switzerland
Key issues: A fatal imbalance exists in the investment in new drugs for neglected diseases, such as sleeping sickness and leishmaniasis, versus diseases prevalent in wealthy countries. From 1975 to 2004, of the 1,556 new drugs marketed only 21 just over one percent were for infectious tropical diseases and tuberculosis, in spite of the huge need. So, not only are the poor in developing countries disproportionately suffering from curable diseases, but their needs are woefully unmet by the existing model of drug development.
Meeting challenges: This disparity is now widely acknowledged and is being addressed by new research as well as new initiatives. Several research initiatives have been set up in the last 5 years to address this issue, e.g., the Drugs for Neglected Diseases Initiative (DNDi), Medicines for Malaria Venture, and TB Alliance. The challenge here lies in procuring full financial and political support from governments so that the initiatives can achieve their goals of developing and delivering desperately needed, new, effective, needs-oriented medicines to neglected patients. Currently, only 16% of funding for these initiatives comes from governments, while almost 80% comes from philanthropic organisations. This is unsustainable. The importance of public responsibility in providing equitable access to these health tools is an essential part of DNDi’s message as a not-for-profit research organisation that works in close collaboration with public and private partners in both developing and developed countries. The need for increased public support of essential innovation for neglected diseases is a growing global concern. Governments are being urged to lose no more time in supporting new funding mechanisms for neglected disease research and development and to create a favourable environment to stimulate R&D. A handful of Innovative Developing Countries such as India, South Africa, Brazil, etc. are becoming more proactive in the field of drug R&D. Yet innovation in drug discovery for neglected diseases remains a critical gap.
Conclusion (max 400 words): This message has recently gained ground at the WHA 2006, which voted to adopt a resolution to establish a global strategy and a plan of action directed at public health, innovation and essential health research. These are positive steps towards addressing the greater problem of R&D for neglected diseases. Much more remains to be done.

Inequity in Utilizing of Healthcare Services by Infertile Patients in Nigeria

Author(s): T. M. Ola1
Affiliation(s): 1Research and Documentation, Centre for Population and Health Research, Ado-Ekiti, Nigeria
Keywords: Infertility, healthcare systems, health inequity
Background:

Health inequity refers to health inequalities that are unjust according to some theories of social justice and is represented by inequalities in health status, healthcare utilization and healthcare financing. Infertility is a stigmatized health condition which has been relatively neglected as both a health problem and a subject for social science research. Few studies have been done to assess socio – economic inequities in health in Nigeria.

Summary/Objectives:

The purpose of the study was to assess socio-economic inequities in infertility management services in the three healthcare systems in Nigeria (that is traditional, orthodox and spiritual healthcare systems). The study employed a triangulation method of data collection. 152 infertile patients male and female were interviewed at the various healthcare systems where they were currently receiving treatment. Information was sought on their socio-economic and demographic status and use of the 3 healthcare systems in the management of their infertility. Analysis was done using the Statistical Package for Social Sciences (SPSS) version 11. Information collected through focus group discussions and in-depth interviews were transcribed verbatim.

Results:

About 90.1% and 9.9% were females and males respectively. Majority of the respondents (41.4%) were currently receiving treatment from the faith healing healthcare system followed by 22.4% currently utilizing orthodox healthcare system. However, majority of the respondents (37.5%) first chose orthodox medicine for the management of the infertility. They later opted out for reasons ranging from the quality of care, financial and physical accessibility, unfavourable outcomes, and efficacy of services provided by the different treatment providers. The Assisted Reproductive Technology comes at a cost which makes it non-affordable to majority of the respondents with irreversible form of infertility.

Lessons learned:

In Nigeria, inequity exists in the management of infertility. Equity or fairness involves a focus on the distributive impact of health policies and programmes on different individuals and families. Such evidence for health inequities in the management of infertility should inform such programmes aimed at making infertility treatment affordable and accessible so that they include strategic components aimed specifically at keeping inequality to a minimum.

Economic Evaluation of Emergency and Surgical Disease in Developing Countries

Author(s): R. Y. Hsia*1, J. Razzak2, A. C. Tsai3
Affiliation(s): 1Department of Emergency Medicine, San Francisco General Hospital, University of California at San Francisco, USA, 2Emergency Medicine, Aga Khan University, Karachi, Pakistan, 3Department of Psychiatry, University of California at San Francisco, USA
Keywords: Burden of disease; emergency care; cost-effectiveness analysis; economic evaluation
Background:

Because public health has traditionally focused on prevention and primary care, emergency and surgical care has often been conceptualized as peripheral, costlier services that only well-developed and well-funded health systems are able to offer. However, there is emerging data showing that there are numerous treatable conditions within emergency and surgical care, such as road traffic injury that can significantly decrease morbidity and mortality of those in developing countries. Unfortunately, research activity correlates poorly with the injury burden in developing countries.

Summary/Objectives:

Because of the lack of work in this area, there are considerable methodological challenges specific to the evaluation of emergency and surgical services and interventions. Our research focuses on the definition of emergency and surgical care, as well as methodological advances in quantifying these conditions.

Results:

Defining what constitutes emergency care is the first task that must be undertaken before any measurements can be made. First, there must be recognition of the variety of presentations that present emergently. Emergency care obviously includes stabilization and treatment of injury-related illness and disease, such as road traffic accidents. Emergency care, however, extends beyond injury-related illness. It should be recognized that many in low-income and middle-income countries often do not seek care until a disease is in its later stages and thus may be prone to more emergent presentations. Consider the treatment of hernia, for example, while an efficient primary care system would, ideally, lessen the proportion of emergent presentations, conditions that require emergency and surgical care will always contribute significantly to a population’s disease burden, especially in countries with a high prevalence of unmet medical need. Treating those who present emergently (such as strangulation or incarceration, which if untreated could lead to severe morbidity and even mortality) would significantly reduce the morbidity and mortality of certain conditions and almost certainly be cost-effective. Clearly, the burden of emergency and surgical need extends beyond disease calculations themselves. Rather than population-based cross-sectional studies of presentations to an emergency ward, or creating a list of these ‘emergent’ entities and deriving calculations of incidence and prevalence, the method we propose consists of using existing burden of disease calculations and determining what percentage of them might present emergently. One could theoretically calculate what percentage of diabetes presents as diabetes ketoacidosis emergently, or malaria as cerebral malaria, or chronic obstructive pulmonary disease or asthma as acute respiratory distress. For example, one could calculate the annual burden of emergency obstetrical care based on knowledge that a minimum of 3-5% of all deliveries need emergency obstetric care to avoid mortality or severe morbidity.

Lessons learned:

We believe emergency and surgical care should be a priority of global health research and initiatives. An emphasis on the role of these services does not detract from current initiatives; indeed, many of Millennium Development Goals – e.g., cutting the maternal mortality ratio by three quarters between 1990 and 2015 – must be met by increasing access to emergency and surgical services. The focus on preventive health programmes in isolation from treating patients with urgent and emergent conditions who either die or live for the remainder of their lives with disabilities that are socially and economically costly to themselves and their families and to society must be revisited to compose a public health strategy that is comprehensive to include an understanding and appreciation of these issues.

Developing Research Ethics Capacity Through Web-Based Dialogue: The Research Ethics Training Project

Author(s): A. Saxena*1, A. Stuckelberger2, R. S. Gutnick3
Affiliation(s): 1Research Policy and Cooperation, World Health Organization, 2Faculty of Medicine, University of Geneva, 3Consultant, University of Geneva and World Health Organization, Geneva, Switzerland
Keywords: Research ethics, capacity building, web-based interactive learning, case studies
Background:

The growing amount and complexity of public health research has been accompanied by increased international attention to ethical issues. At the heart of this concern is the recognition that health-related studies have the potential to benefit the communities and populations involved but can also harm them. This possibility is especially great in settings where research participants are socially and economically vulnerable, poor and illiterate, and where they lack access to healthcare. International guidelines stipulate that all health research with human subjects must undergo ethical review. However, while the infrastructure to promote the ethical conduct of health research with human subjects has evolved significantly over the past decade, in many countries it remains insufficiently supported and developed. As a result, neither the interests of host countries nor research participants are adequately protected.

Summary/Objectives:

The ‘Research Ethics Training Project’ was created to respond to the increasingly expressed need for building and sharing research ethics capacity, particularly in developing countries where increasing amounts of research is conducted. The primary objective of the RETP was to develop, pilot test and evaluate two foundational modules of an interactive, sustainable and low-cost online ethics course, and to develop a companion casebook on research ethics. Importantly, both of these training tools were designed to encourage knowledge building and sharing through dialogue as opposed to a more traditional didactic model of instruction. Thirty participants from eleven countries were chosen to pilot test the course. The discussions were facilitated by ethicists from both developing and developed countries. The case studies used in the course and published in the casebook are largely based on research conducted in developing countries. Upon completion of the e-course modules, the course participants were invited to form a ‘community of practice’ and continue their discussions on the low bandwidth e-platform used for the course.

Results:

The case studies and course content were evaluated to be appropriate and relevant to developing country contexts. The web-based course was accessible and user-friendly. Participants indicated that the dialogue-based aspect of the course enhanced the learning experience. Challenges: (1) From a delivery aspect, the course was more labour intensive than anticipated. (2) The e-platform requires modification to allow for more fluid discussions. (3) While the discussions were dynamic, not all participants were actively engaged throughout.

Lessons learned:

The RETP demonstrated that there is a place for interactive web-based training in research ethics and that participants from different countries and continents are prepared to engage in an online dialogue. Refinement of the e-platform is required to enhance its functionality. The use of developing country-based case studies was crucial in engaging participants and facilitators.

Complex Adaptive Systems Approach to Health Systems: Dose It Change Our Thinking?

Author(s): N. Keshavarz Mohammadi1
Affiliation(s): 1Gazvin Medical Sciences University, Gazvin, Iran
Keywords: Complex adaptive systems, complexity, diversity, health systems
Background:

The world that we live and work in is changing becoming a more complex environment. Disease and health outcomes occur within a complex socio-ecological context. Globalization, environmental change, demographical movements, advances in information technology, emerging new diseases and interaction networks all create both opportunities for advancement and new types of problems. Consequently, the professional approaches to problems are changing. Reviewing the history of public health in past 60 years indicates significant changes and adaptive developmental shifts in public health focuses and approaches to health have happened. Historical evolutions in public health research have reflected to the advancements in understanding the complex factors contributing to better health. Thus, currently systematic approaches to health problems as well as the solutions are promoted significantly.

Summary/Objectives:

Complex adaptive systems is an emerging new and multidisciplinary theory and/or framework been utilised to study many diverse systems. There are few reports about applications of this theory in healthcare systems but not in a systematic way. This presentation aims to explore systematically the potential applications of the concepts of this new framework in health systems. It examine whether health systems exhibits the characteristics of complex adaptive systems and if so, what new insights are provided for strengthening the health systems and health workforce. An observatory tool for examining complex adaptive systems developed by Keshavarz (2007) in her PhD study is applied to examine schools as complex adaptive systems. This presentation address the key concepts of complex adaptive systems, introduce new tools for observing and analysing the health systems at both level of micro and macro and suggests some new thinking directions to managing health systems to be explored further in future health systems research.

Results:

In light of considering the limitations of any novel approach, it seems reasonable to observe that health systems are complex adaptive systems. This new approach shed lights on our understanding of some of challenges or failures in some of current health systems .It also recommended some new approaches in practice. For example, it is discussed that why context-dependency of health systems as complex adaptive systems and their needs for adaptations should lead us to embracing the diversity of health systems and avoiding unifying health systems in the globalize world.

Lessons learned:

To have effective and sustainable health systems, there is a great need to think in terms of factors that facilitate the adaptations of health systems to their environment. This understanding asks for thoughtful connections and interactions of health systems and health workforce at global and local levels, values the diversity of health systems and sharing the information, knowledge, and experiences.

EPIMECT Project: Epilepsy in Mali, Epidemiological, Clinical and Therapeutical Study

Author(s): G. Farnarier*1, K. Nimaga2, O. Camara2, O. B. Touré3, O. K. Doumbo4
Affiliation(s): 1Service de Neurophysiologie Clinique, Hôpital Nord - Université de La Méditerranée and Santé Sud, Marseille, France, 2RARE, Association des Médecins de Campagne du Mali (AMC), 3Département d’Epidémiologie des Affections Parasitaires (DEAP), Faculté de Médecine - Université du Mali, 4Département d’Epidémiologie des Affections Parasitaires (DEAP), Faculté de Médecine - Université du Mali and Santé Sud, Bamako, Mali
Keywords: Health research, operational research, epilepsy, epidemiology, treatment, Mali
Background:

The prevalence of epilepsy is 3 to 10 fold higher in developing countries, due to the increased impact of infectious, traumatic, neonatal and genetic factors. In tropical African countries, epilepsy is thus a significant problem of public health, with increased social consequences. Knowledge about epilepsy remains scarce and a global approach is mandatory. The EPIMECT project is supported by the IMPACT EPILEPSY programme of Sanofi-Aventis.

Summary/Objectives:

A network of six general practitioners (GPs), each responsible for a given area in Mali, and all members of the Association des Médecins de Campagne du Mali (Association of Countryside Doctors of Mali, AMC), supported by the Santé Sud NGO, gathered to constitute the action-research network on epilepsy (Réseau Action-Recherche sur l’Epilepsie: RARE) in order to diagnose, treat and follow patients with epilepsy in rural areas. To this date, around 1,500 patients have been included in this programme. Significant clinical and social improvement was obtained in more than 2/3 of them. The protocol includes for each patient an initial data sheet and follow-up sheets. The initial sheet includes 93 items: 18 for patient identification, 9 on present status, 18 on disease history, 26 for the description of the last seizure, 6 for previous seizures, 12 for previous anticonvulsant treatment, and 4 for the diagnosis. Patients are followed at 4-month intervals, and on each visit 63 items are collected: 15 for identification, 29 on seizures since the previous visit, and 19 for present therapy. Data are entered twice; a random quality control is performed on 10%. We used software EPI-INFO for collection of the data and SPSS v12 for statistical analysis.

Results:

1102 initial and 3747 follow-up patient files have been entered into the database. The results concern demographic and epidemiological data (number of patients with epilepsy followed by each GP, prevalence of epilepsy in each area, social/economic statute of patients) ; clinical data (etiology, personal and familial history, seizure and epilepsy type) ; therapeutic data (type and effect of anti-epileptic drug, mostly phenobarbital and valproate, compliance, positive effects, side effects). Comparisons between areas may show local specificities (e. g. risk factors and etiology linked to social and environmental characteristics).

Lessons learned:

Epidemiological studies are often wanting in terms of follow-up. Long-term collection of data in several, distinct areas within a country may produce new knowledge about chronic conditions like epilepsy. Operational research that includes groundwork on comprehensive care and clinical observations allows for meeting such goals. Extension of this research to other developing countries is foreseen.

Clinical Trials and Regulatory Authorities: The Tanzanian Experience

Author(s): A. Fimbo1
Affiliation(s): 1Pharmaco Vigilence and Clinical Trials, Tanzania Food and Drug Authority, Tanzania
Keywords:

Clinical trials, investigational medicinal product dossier, Medicines Regulatory Authorities (MRAs), review of clinical trials, regulatory inspections and Tanzania Food and Drugs Authority (TFDA).

Background:

Clinical trials is part of health research that endeavours to develop instruments (medicinal products, medical devices or medical procedures) for prevention, cure, and relief of effects of diseases. Regulatory authorities assess drug dossiers and decide whether or not the developers have established sufficient evidence for safety and efficacy for their candidate medicinal product to get market authorization. Tanzania Food and Drugs Authority (TFDA) is the regulatory authority in Tanzania which reviews and authorizes clinical trials involving medicines, medical devices and herbal drugs for conduct. It issues clinical trial certificate and also monitors approved trials through regular inspections.
This presentation will cover the following: Definition of a clinical trial/study; Rationale for MRAs to regulate clinical trials; Major phases in drug development; Pre-clinical biomedical research; Phases of a clinical trial; MRAs regulation of clinical trials; Application documents to MRAs; Investigational medicinal product dossier; Review of Clinical Trial Applications; Tanzania clinical trial regulatory instrument; and Regulatory Inspections. It will conclude with identifying the challenges in regulating clinical trials in Tanzania and the measures to overcome the challenges.

Kala Azar Control Program: A Review from 1994-2006

Author(s): G. P. Bhandari*1, S. Rijal2, M. Boelaert3
Affiliation(s): 1Research Section, Nepal Health Research Council, 2Internal Medicine, B.P.Koirala Institute of Health Sciences, Kathmandu, Nepal, 3Public Health, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium
Keywords: Kala azar, Nepal, Visceral leishmaniasis
Background:

The Visceral Leishmaniasis (VL) control program in Nepal started in 1993 including free diagnosis, treatment and indoor residual spraying. After 14 years the disease is far from being controlled. Elimination of VL by 2015 has recently been identified as a regional priority with high level of political commitment. We analyzed the VL control effort in Nepal over the period 1994-2006 and tried to formulate recommendations for the VL elimination initiative.

Methods:

To document performance of the VL control program in Nepal we used literature review and a case study. First, we reviewed articles on VL in Nepal published in medical journals through Pubmed, ISI Web of Science, Google scholar and by hand searching. Secondly, the grey literature, mainly the reports on VL drafted by the Ministry of Health was reviewed for the period 1994-2006. The documents were obtained from key informants and from website of the Nepalese Ministry of Health. Thirdly, a case study is presented to analyze the performance of the VL elimination program in a “pilot district”, where the program was launched in 2006.

Results/Conclusions:

There are only few studies available on VL in Nepal discussing the epidemiology, diagnosis, treatment, vector bionomics, human behavior and prevention. The review of the grey literature from 1994-2006 revealed that the VL incidence rate remained almost constant since 1993 despite the control efforts. However, these are only the records of patients seeking health care at the public health system. Moreover some indicators and especially the denominators of the indicators were changed during the period so interpretation of these data is difficult. The case study showed that there is a lack of trained human resources, laboratory facilities and treatment guidelines which is hindering the decentralization of the VL elimination program. Strengthening of the health system by training of human resources, availability of appropriate diagnostic tests and treatment with guidelines at district level is necessary for better case management. Active case detection, intersectoral coordination, and improving the surveillance system should contribute to the VL control effort. Research should be encouraged to better understand the disease transmission dynamics, and to monitor control efforts.

GHF2006 – PL06 – Global Access to Health: An Agenda for the Future

Session outline

Plenary session PL06, Friday, September 1 2006, 16:00-17:45
Chair(s): Marcel Tanner, Swiss Tropical Institute, Switzerland
An Agenda for Sustainable Development in Health
Hassan Mshinda, Ifakara Health Research & Development Centre, Tanzania
Partnerships to Promote Global Public Health Security
David L. Heymann, Representative of the Director-General for Polio Eradication, World Health Organization, Switzerland
Access: Opportunities and Challenges
Ruth Dreifuss, Switzerland
Is Health a Commodity?
 Mr. Alok N. Mukhopadhyay,  Voluntary Health Association of India
Role and Responsibility of Academic Institutions
 Bruno Grijseel, Institute of Tropical Medicine, Antwerp, Belgium
Conclusion to the 2006 Edition of the Geneva Health Forum
Marcel Tanner, Swiss Tropical Institute, Switzerland
Closing Remarks
Claude Lecoultre and Louis Loutan, Geneva University Hospitals and Faculty of Medicine, Switzerland

Session Report

Submitted by: Jean-Pierre Joly (ICVolunteers); Contributors: Asta Lim (ICVolunteers)
Image: Jorge Garbino, ICVolunteers.org

The final plenary session of the "Geneva Forum: Towards Global Access to Health" was dedicated to summarizing the key issues which emerged during the three days of discussion and exchange and to formulate suggestions on how to develop these issues in the future. The final plenary was also a moment to thank all the contributors of the Forum for their effort and participation.

The first speaker, Dr. Hassan Mshinda, Head of the Ifakara Health Research & Development Centre in Tanzania, stressed that previous health initiatives have concentrated on aspects such as equity, participation, and multi-sector and comprehensive healthcare. However, Dr. Mshinda urged that as an increasing number of actors are becoming involved, and a greater pressure is put on immediate results.

According to Dr. Mshinda, there is a clear need for an agenda in order to achieve sustainable development of health. The Paris Declaration on Aid Effectiveness set out the principles for doing a better job in delivering and managing aid. Global Health Initiatives have their merits, but it remains indispensable that countries strengthen their national health systems, because this is the key to improving access to health care, said Dr. Mshinda. In any case, such initiatives will eventually have to be absorbed by governments' health systems.

National governments have a key role to play and it is their responsibility to have a long term strategy for sustainable development of health care systems. Long term commitments from partners, as well as monitoring and audit tools could certainly enhance this process. Dr. Mshinda said that the challenge of Global Health Initiatives is to realize their integration at the global, national and regional levels. To create the necessary interaction between those different levels, there is a need to establish even more contractual partnerships.

Dr. David Heymann, Executive Director, Communicable Diseases, of the World Health Organization (WHO), spoke about the role of partnerships in promoting health security, emphasizing the global character of health problems and, more specifically, the security issues related to infectious diseases. He said that while new infectious diseases are appearing, more worrying is that infections such as cholera and yellow fever, which were thought to have been eradicated, are re-emerging. Analysis shows that increased international travel has stimulated the worldwide spread of some diseases, such as SARS and malaria. While malaria is not contagious, it does get transported through mosquitoes to areas where it normally does not occur. As a result, these diseases occur far from their original source.

The spread of numerous infectious diseases is closely linked to animals and insects. The movement of animals to market is a key factor in spreading infectious diseases to other locations, especially when cattle is not vaccinated. Other diseases can be transmitted through international trade in agricultural products as in the case of Creutzfeltd-Jacob disease. Dr. Heymann reminded the audience that there is always a risk of existing viruses mutating and creating new pandemics.

Will non-immunized humans serve as an intermediate host in the transmission of diseases? The framework for International Health Regulations has been improved and updated on an ongoing basis since 1947, said Dr. Heymann. The WHO receives inputs from 110 different networks around the world, whose task it is to collect data and to continuously monitor the development of diseases in their region. The WHO reacts to information gathered through the Global Outbreak Alert and Response Network (GOARN).

Distribution of information and education related to infectious diseases still rests on weak ground in developing countries, claimed Dr. Heymann. In this context, it is not surprising that the three diseases with the highest death toll, TB, malaria and HIV/AIDS continue their expansion in sub-Saharan countries. He highlighted the staggering negative economic impact of those diseases by giving one example: GDP in sub-Saharan Africa would have been 100 billion USD higher in 2000 if malaria had been eradicated 35 years ago.

Only systematic partnerships between developed and developing countries will enable significant changes to present trends, stated Dr. Heymann. Those partnerships should focus on four areas: research and development, access to vaccines, prevention, and monitoring. The WHO clearly places health at the centre of development, because it is essential for sustainable economic growth. Although the WHO has a role to play and global partnerships have been expanding, the rolling back of infectious diseases is primarily a matter of high level political commitment in developing countries themselves. The declines in HIV/AIDS in Uganda and of TB in Peru are examples of such commitment.

Ms. Ruth Dreifuss, former President of Switzerland, drew attention to the underlying political issues of the topics discussed during this Forum. These include the interdependence between the North and the South, the search for new medicines, the outcome of the World Trade Organization (WTO) summit at Doha, pandemics, and so on. In this context, she underscored the important role of NGOs in raising public awareness and the necessity of forming partnerships between the public and private sectors, while it should remain the responsibility of governments to provide the engine for the process.

Ms. Dreifuss further stressed the importance of the recommendations and conclusions of the Commission on Intellectual Property Rights, Innovation and Public Health, which she had chaired at the World Health Assembly (WHA) and the report of which has recently been completed. Three concepts surfaced in connection with vaccines and medicines in general: availability, acceptability and accessibility. The commission's major conclusions were that present efforts are not sufficient to assure the continuity of existing programmes; the generosity of the private sector should not be a substitute for the public sector spending; and a global action plan is essential for meeting the public's health needs. In order to stop the current stagnation, the speaker proposed four levels of intervention. First, structuring health care to avoid competition between private and public sectors. Secondly, training health workers and seeking to prevent their exodus to rich countries. Thirdly, focusing on vulnerable and marginalized groups such as children and women. And finally, to seek innovation in the pharmaceutical sector and promote the use of generic drugs.

The next speaker, Mr. Alok N. Mukhopadhyay, C.E.O. of the Voluntary Health Association of India, stressed the interdependence of economy and public health. "Health is not an expense but an investment for governments", he continued. All people want to live healthily and have a basic right to claim the conditions to create and maintain their health. A vital question for the speaker was whether health had to be offered as a commodity in the marketplace. He pointed out that more spirituality was needed. In this context, Mr. Mukhopadhyay quoted Mahatma Gandhi's view that "the world has enough for everyone's needs but not for everyone's greed". He concluded by stressing the lack of dialogue between the different medical and health care systems and the difficulties in attracting workers and experts to public health care.

The final speaker, Professor Bruno Grijseels from the Prince Leopold Institute of Tropical Medicine in Antwerp, highlighted the role and responsibility of academic institutions. Academics and scientists could learn from taking a holistic approach to global health problems instead of focusing on isolated research problems. Access to quality healthcare is a real challenge which can only be won by establishing partnerships, he said. Scientists have the responsibility not to lose sight of reality and to develop systems which can be implemented for the benefit of the public.

In her closing remarks, Professor Le Coultre, Membre of the Forum Organizing Committee and Vice-Dean of the Faculty of Medecine of the University of Geneva, commended the quality of interaction and idea-sharing at the Geneva Forum. She mentioned that this Forum had been a starting point, called for feedback from the participants and promised additional efforts to bring more people from the developing world to the next Global Health Forum.

Dr. Louis Loutan, President of the Forum Organizing Committee and the Geneva University Hospitals, thanked the organizing team, the advisory board, the Forum participants, the sponsors and the volunteers --there were over 60 involved in the conference-- for their contribution to this first edition of the event. He closed the Forum by inviting participants to use the conference web site's feedback form to share their impressions in view of a next edition of the event.