Geneva Health Forum Archive

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PATHS to Well-Being: An Inter-Sectoral Approach to Health

Author(s): D. L. Bratt1
Affiliation(s): 1Work and Income, Ministry of Social Development, Wellington, New Zealand

Health interventions, welfare beneficiaries, social inequalities, inter-sectoral collaboration, social determinants of health


In the context of increasing demands on the health budget many minor health interventions are now required to be privately funded. This creates a significant inequity of access for social welfare beneficiaries. A recent survey of Sickness Beneficiaries showed that 40% would like to be working if the right intervention and support could be provided. This has led the Ministry of Social Development to collaborate with the Ministry of Health in an initiative to jointly fund access to some health services.


Providing Access to Health Solutions (or PATHS) is a programme developed jointly by the Health and Welfare sectors of the Public Service. PATHS is based on an understanding that health is more than just medical interventions and that income, housing, education and employment are all equally significant. PATHS uses a tripartite approach with a welfare coordinator, health coordinator and community services coordinator. This has allowed the diverse and complex factors which often surround beneficiaries to be holistically addressed.


The programme was been rolled out slowly in partnership with District Health Boards. The first two programmes have been running over 5 years and it is now planned to roll it out across the country through as many of the 21 District health Boards wish to participate. The programme has exceeded expectations with 60% of participants being engaged in employment or study on exit from the programme.

Lessons learned:

While collaboration is often held up as a core requirement for government departments, it is not easily achieved and requires continuing effort to maintain it.

Making the Right to health a Reality in the Context of Social Inequalities and Rapid Economic Change in Brazil

Author(s): V. S. P. Coelho*1, A. Shankland2
Affiliation(s): 1Citizenship and Development Group, Brazilian Centre of Analysis and Planning, Sao Paulo, Brazil, 2IDS, Falmer, United Kingdom

SUS, the brazilian public health system; rights; social excluded groups; decentralization; PSF Family Health Program; health councils, accountability


In the two decades since Brazil recognised access to healthcare as a Constitutional right, the country has undergone wide-ranging transformations that have left their mark on the profile of the population and on the country’s health system. Initially, a brief overview of the changes that have taken place in recent years in the socio-demographic and epidemiologic profile of the Brazilian population is presented, showing the challenges facing the healthcare system. We go on to present a brief overview of the system, which includes both the publicly-funded services provided by the SUS (Unified Healthcare System) and those financed and provided by the private sector. Our analysis concentrates on the public sector, which is the sole source of healthcare for approximately 70% of the country’s population.


We outline the chief mechanisms – programs, financing and management – that have ensured the SUS’s capacity to respond to the challenges pointed out previously. We argue that two of the key mechanisms are the establishment of transparent financing mechanisms for promoting universal coverage within a highly decentralised health system where most service delivery responsibilities lie at the municipal level, and the innovative approaches to democratic accountability.
Some 32% of Brazil’s population of 184 million people are considered to be living in poverty. Despite a recent decline in overall income inequality, indicators show expressive inequalities in both income and life expectancy between rural and urban populations, and between the population as a whole and minority ethnic populations, in particular Afro-descendent and indigenous groups. It should also be noted that 85% of Brazil’s population lives in cities, with metropolitan areas expanding rapidly throughout the country. In this context, a key challenge is to overcome urban bias in health system organisation and healthcare models, ensuring the realisation of the universal right to healthcare among minority populations living in remote rural areas where municipal service delivery capacity is weakest.


Since it was established in the late 1980s as a public health system with universal and unconditional coverage, the SUS has achieved a rapid expansion in access to services. A key driver of this expansion has been the system of direct central government transfers to the municipal level, tied to the delivery of priority packages such as the Family Health Program or PSF (Programa Saúde da Família). The statutory participation and accountability institutions, known as Health Councils (Conselhos de Saúde) have facilitated coordination between health system managers, service providers and civil society groups. However, both the transfer system and the accountability institutions have been less successful in guaranteeing service quality, and in particular in ensuring that service provision models such as the PSF are adapted to address the specific health needs of the most marginalised and vulnerable population groups. In this presentation we focus on the ways in which the SUS is dealing with these challenges, and the innovative approaches emerging from ongoing change processes such as the reforms in health service provision for indigenous peoples.

New Challenges for Government, Civil Society and the Private Sector in India’s highly Marketized Health System

Author(s): B. Kanjilal1
Affiliation(s): 1Indian Institute of Health Management Research, Jaipur, India
Keywords: Liberalization, health market, India

Indian health care market is under rapid transition. The economic liberalization process started in early 1990s unleashed enormous potential for economic advancement. Simultaneously, it also triggered a fast growth of private players in the health sector leading to a significant expansion of consumers’ choice set for medical care. However, there is also a growing concern that liberalization has brought forth a new set of vulnerabilities, inequalities, and insecurities especially when people seek curative care. The response of public and voluntary sector to this transition has been grossly inadequate and often misguided so far. The study highlights the need for a change in paradigm of traditional public financing and state governance in health care in the context of unchained markets in health care of India.

Methods: The present study is based primarily on secondary data sourced from various rounds of national level health surveys, such as NFHS and NSSO, conducted since 1990. A set of primary data on households’ health care utilization, collected from three districts of West Bengal, India was used to supplement the findings. Simple descriptive statistics and an extensive review of literature were used to highlight the key issues.

The share of private sector in Indian inpatient care market has increased from 40 percent to 60 percent during the last two decades. The rural outpatient care market, on the other hand, has been consistently dominated by unqualified private practitioners. The drug industry has experienced an unprecedented growth – nearly six times - during the same period. However, the rapid marketisation process has also triggered catastrophic out of pocket payments which accounts for more than 75 percent of total health spend in India and led to increase in poverty by 3.6 percent and 2.9 percent respectively for rural and urban areas. The government and other non-profit agencies, therefore, require restructuring their roles in this transition. Specifically, the public sector needs to provide (1) a safety net to protect people from poverty induced by health care, (2) an equity-based public financing mechanism to reduce sharp inequalities in health care utilization, and (3) an effective regulatory framework to internalize the growth of private sector and realign its direction to national health policy targets.

Childhood Cancer: A Prospective Roadmap to Healthcare

Author(s): R. P. Menon*1, R. K. Marwaha2
Affiliation(s): 1Pediatrics, Government TD Medical College, Alappuzha, 2Pediatrics, PGIMER, Chandigarh, India
Keywords: Childhood hematological malignancies, risk category, referral patterns, resource-poor setting

Estimated number of new cancers diagnosed in India every year is: 700 -900,000.The geographic, socioeconomic, educational,health system inequalities in cancer treatment, in children, have only now begun to be addressed. This study was designed to assess referral patterns of children with hematological malignancies (HM) in Northern India.


In the period between the months of Oct 2001 and Nov 2002, based on a predesigned performa, parents/guardians of children with HM were interviewed, at presentation to a tertiary cancer care facility for children in North India. Details from previous prescriptions and referrals, if available, and details of diagnosis (staging and risk categorization) were recorded. Hematological malignancies (HM) included acute leukemia [lymphocytic (ALL), myeloid (AML), undifferentiated (AUL)] and non-Hodgkin’s lymphoma (NHL). Risk stratification of disease category at presentation (into high risk disease and standard risk disease) was done. Patient delay (symptom-contact interval); Health system delay (contact-diagnosis interval); Total delay (symptom-diagnosis interval) and number of contacts were recorded and compared between high risk and standard risk disease group using descriptive analysis.


Of the 79 children (55 boys; 69.6%) with HM, the total number in high-risk category was 40(50.6%), rest were of the standard risk group. The mean age was 5.9 ± 3.2years. The median patient delay of care seeking for children with high risk HM was 2 (95% CI: 1.27, 3) days and for children with standard risk HM was 3 (95% CI: 1, 4.22) days (P=0.42). The median system delay of care providing for children with high risk HM was 27 days and for children with standard risk HM was 40 days (P=0.19). The median symptom to diagnosis interval for children with high risk HM was 29 days and for children with standard risk HM was 45 days. (P=0.09). In the standard risk group, 19 (48.7%) had >3 contact whilst in the high-risk category, only11 (27.7%) had >3 contacts (P=0.043). The private sector was similarly approached in both risk groups for medical care. In the study group, the risk category had a significant association with the total delay (spearman correlation coefficient=-0.276, p=0.01) and the system delay (Spearman correlation coefficient= -0.262, p=0.02).Sensitizing the private sector practitioners about the possibility of hematological malignancy in symptomatic children (pallor, bleeding, fever) may be the most effective step in resource poor settings, for an early referral.

Determinants of Child Health Services Utilization in a Developing Country

Author(s): S. R. Joshi*1, B. Joshi2
Affiliation(s): 1Community Health, Community Health and Environmental Society Nepal, 2Sociology, Trivuwan University, ktm, Nepal
Keywords: Health service utilization, child health, health inequality, Nepal

High child mortality and morbidity in developing countries are highly associated with limited access to and poor quality of health care. Utilization of health services for children plays an important role towards achieving the Millennium Development Goal in the reduction of child mortality. In Nepal, several studies reveal disparities in child health outcomes across socio-economic levels and regions of the country. Health inequalities found in the relationship between socio-demographic determinants and the utilization of child health services has not been under rigorous examination. The primary goal of the study is to examine empirical evidence of the socio-demographic determinants of child health services utilization, such as geographical access, household income, and mother’s age and education level.


Using 1996 and 2001 Nepal Demographic and Health Survey (NDHS) data, both cross-sectional and fixed-effects logit models are used to analyze the effect of the determinants health services utilization for children suffering from diarrhea and/or respiratory illness.


Results show inequalities in child health utilization by sex of the child, maternal education, and across household income quintiles. Overall, health use increased over time and income; however, a smaller increase is observed for the top two income quintiles. Male health service utilization improved over time across all income groups; female health use also improved with the exception of the top quintile. Conclusions: In order to improve child survival, it is important to understand the determinants of healthcare use so that appropriate policies can be developed to maximize health services utilization. This study undertakes such an analysis to understand determinants of health services utilization for children in Nepal. This study demonstrates that sex of the child, household income, mother’s education, partner’s employment, and distance to health provider play a role in determining health services utilization for children under-5 years in Nepal. An important health equity implication of the association is the design of health policies and programs that reach children most at risk by increasing coverage to ensure including or targeting programs towards them. The analysis highlights the usefulness of the NDHS 1996 and 2001 data as tools to conduct health services research, and in developing policies to address health inequalities and improve access to underutilized health services.

GHF2006 – PS20 – Gender, Sexual & Reproductive Health: Access Issues

Session outline

Parallel session 20, Friday, September 1 2006, 14:00-15:30
Chair(s): Mary Anne Burke, Switzerland, Priscilla Daniel, India
Microfinance and Health Intermediation 
K. Narendar, Chief Executive, DHAN Foundation, Madurai, India
Micro-credit Financing and Impact on Female Genital Mutilation
Berhane Ras-Work, NGO, Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, Geneva, Switzerland
Mainstreaming Gender-Based Analysis of the Women's Hospital of Costa Rica
Zully Moreno Chacón, Hospital of Costa Rica, San José, Costa Rica

Session Report

submitted by: Anne May (ICVolunteers)
Sudan, Garsila, Western Darfur. Preparations for a distribution of basic household items with support from Sudanese Red Crescent volunteers. Image: © ICRC/ T. Gassmann / 2004

The session addressed the various manners in which gender and social inequalities may negatively impact on population health and general wellbeing. It further looked at ways in which women can be empowered to allow them to develop a holistic approach to their specific health and other related needs. Examples showed that implementing gender-based analysis can produce profound changes in the treatment of women's specific problems.

Mr. K. Narendar, Chief Executive of the Development of Humane Action Foundation (DHAN), Madurai, India, presented the activities of his organization, which promotes improved health outcomes through microfinance intervention. To put his foundation's work into perspective, Mr. Narendar first reminded the audience that population health is strongly correlated with poverty. Microfinance programmes have emerged as one of the significant mechanisms to address the deep-rooted causes of poverty. There is a growing body of evidence showing that access to microfinance services is positively correlated with factors that have a positive impact on health, such as nutritional intake or contraceptive usage, he said.

The microfinance programme of the DHAN, through savings, credit and insurance, is aimed at developing appropriate savings that can be devoted to health care. Specifically targeted at women, it enables poor women to increase expenditure on the well-being of themselves and their children, which ultimately affects the health outcome at the family level. Mr. Narendar cautioned that such schemes are not appropriate to address higher health care needs, for which social security measures such as health insurance must be in place.

Mrs. Berhane Ras-Work, from the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) addressed the problem of female genital mutilation (FGM) in Africa. FGM is a widespread problem on the continent, affecting at least 28 countries. It is rooted in and nurtured by tradition, culture, religion, far-reaching misconceptions and socio-economic circumstances. All members of the community are participants in the continuation of this most brutal form of violence and governments tend to be silent, thereby justifying this violation of Human Rights, she said.

NGOs have played a key role in giving international recognition to gender inequality and violence. The IAC has initiated action and shown that it is possible to impact positive changes of attitude through the empowerment of women along two lines. First, by offering them micro-credits aimed at curbing their economic vulnerability. Indeed, women accept gender-based violence to ensure the security of their marriage and the survival it provides. Second, by giving them education and information to erase the misconceptions perpetuating the practice of FGM and to develop women's valuation of their bodies and health. In parallel, the IAC has embarked on a micro-credit scheme with excisers themselves, to help their conversion to other income-generating activities. Such schemes have already been successful in persuading excisers to stop their traditional practices.

Mrs. Berhane noted finally that such strategies should be further developed but that their success depended on accompanying, additional measures starting with strong political commitment and investment.

Mr. Manuel Carballo, from the International Centre for Migration and Health, Vernier, Switzerland, focused on the problems faced by migrants, an ever growing population worldwide. The migrant population was officially 195 million in 1995, but certainly amounted to three times that number when illegal migrants were taken into account. The health problems of migrants are a complex issue, combining pre-migration health profiles, diseases and health problems acquired during transit and newer ones acquired in the host country. Hence, care should be specifically tailored to the migrants' health profiles, a course which is undermined in times of increased socio-political resistance to migrants.

The nature of their health problems is only one element in all those undermining migrants' health, Mr. Carballo said. Access to health care for migrants is dependent on the availability of specific services adapted to their different psychosocial, cultural and linguistic backgrounds. The availability of such existing services should be known to the migrants, but this has been shown not to be the case in almost half of those migrants surveyed in Geneva. Such services should also be legally available, for example through a scheme of health insurance, and they should be affordable, taking into consideration the overall low income of migrants.

As migration continues to increase, Mr. Carballo concluded, medical insurance coverage which includes migrants, specific training of health personnel to handle multicultural differences and outreach to the migrant population for health promotion and disease prevention is more critical than ever.

Mrs. Zully Moreno Chacon, from the Hospital of Costa Rica in San José came with a concrete example of how gender-based analysis helped the transformation of the Women's hospital in Costa Rica from a traditional one to one working with women themselves to design tailor-made strategies addressing specific needs. The transformation was a far-reaching process involving strategic planning; revision of physical infrastructure, working processes and administration; space distribution; challenge of management structures; allocation of budgets; new practices and methodologies.

The key to the success of this initiative was to empower women in the process and to develop a holistic approach to their specific health and other related needs. Active participation was fostered by the creation of associations and a health network. Employees' training was carried out to improve the sensitivity of care for women.

Mrs. Moreno noted that implementing gender-based analysis produced profound changes in the treatment of women's specific problems and that female patients demonstrated a real appreciation of the new approaches and resources that were developed.

Reduced Access to Health for People With Disability: An Overview of Causes for an Effective Environmental and Human Rights Approach

Author(s): Patrick Fourgeyrollas1
Affiliation(s): 1Institut de Réadaptation en Déficience Physique de Québec - IRDPQ, Canada
Conclusion (max 400 words):

According to the United Nations, over 600 million people have a disability, 82% of which live in developing countries. They are among the poorest of the poor, not only because the level of income but also because of their bad quality of social participation, non-respect of their dignity and functional differences, inequities of access to health, education, employment, valorised social roles and exclusion or special treatment apart from the mainstream society and services. And this is worse, if that is possible, if you are a woman or a child. In order to have a global understanding of why access to health is significantly reduced for them, it is necessary to know the evolution of disability explanatory models. This issue of causality is at the heart of the problem. Disability can be perceived as an individual or a social pathology depending on whether the responsibility or the problem is focused on the person or on society. Both approaches lead to totally different strategies in how to deal with the problem of disability: a biomedical or functional approach for eliminating or curing disability, or an environmental or human rights approach for eliminating obstacles to social participation and reducing inequalities of human rights. Improving access to health and other care or support services for people with functional limitations urges to clarify what belongs to the domain of individuals and what belongs to the environmental societal factors (health policies and financing, social security systems, training, sensitisation and social attitudes, equalisation of opportunities enforcement, insurance of rights monitoring and strengths of disability rights movement) in the disability prevention or construction process. This systemic interactive process between people with body and functional differences and quality of environmental components of health and social policies and services is an operational tool for defining gaps and goals for equity of access taking into account contextual situations in a cross-disability, mainstreaming and inclusive perspective.

GHF2006 – PS12 – Ensuring Access to Health for Migrants

Session Outline

Parallel session PS12, Thursday, August 31 2006, 16:00-17:30
Chair(s): Danielle Grondin, Switzerland, Sandro Cattacin, Switzerland
Global Mobility: Rethinking the Practice of Care
Brian Gushulak, Migration Health Consultants, Vienna, Austria 
Closing the Gap: Migrant-Friendly Health Systems in America
Patricia F. Walker, Department of Internal Medicine, University of Minnesota, St Paul, USA 
Status-Related Access Dilemma: A European Perspective
Francesco Castelli, Infectious and Tropical Diseases, University of Brescia, Italy

Session Documents

[Download not found]
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Session Report

Submitted by: Stephanie Berry (ICVolunteers); Contributors: Hassatou Conde (ICVolunteers)

Image: IOM helping Lebanese refugees in Syria 2006. Photo: Ranjitha Balasubramanyam, 2006.

The fifth largest nation in the world does not have sufficient access to health. Indeed if migrants were seen as a country, they would represent a significant nation in terms of population. How can we explain that so many people do not have access to health care? The focus of this symposium, chaired by Anita Davies from the International Organization of Migration (IOM) and Sandro Cattacin from the University of Geneva, was on the unequal provision of health services for migrants.

Inequalities are caused by problems that we can classify on three different levels:

  • At the patient level: language, culture and social circumstances can inhibit access.
  • At the provider level: the inability to communicate with patients makes physicians reluctant to deal with foreign patients.
  • At the level of the care delivery system: legal restrictions and administrative complexities make it difficult to provide effective service for migrants.

These inequalities are also worsened by adopting a national view. Brian Gushulak, a migrant health specialist, emphasized the importance of a global perspective when dealing with the issue of access to health for migrants. According to this speaker, a national view of the problem at hand would limit the solutions and prevent them from being linked to development, economic and security matters. Indeed, all the participants agreed that migration was part of globalization and that it should be treated from a global point of view. "There are no local diseases and therefore there are no local solutions" Patricia Walker from the Department of Internal Medicine of the University of Minnesota, in the USA, pointed out.

One must not look upon the immigrant community as a homogenous group; its members have different social and cultural backgrounds. In order for the care delivery system to be effective, it has to be culturally competent and knowledgeable about both ethnic and social differences. This is illustrated by the fact that most patients from this community do not dare consult a physician due to language barriers and in turn 78% of the doctors do not like taking care of immigrants due to the complexity of the process.

However, the unequal access to health care was not the only point that was discussed. It was pointed out that providing better health services for migrants is in fact beneficial for host countries. We particularly have to focus on fast intervention because, not only does it prevent diseases like Tuberculosis from spreading, but also reduces the cost of treatments. Indeed, the further the illness is developed, the more complex and expensive it becomes for both patients and health care providers. Focusing on illegal immigrants, Dr. Francesco Castelli from the Infectious and Tropical Diseases Unit of the University of Brescia in Italy, pointed out that more than 70% of HIV infected people are unaware of their condition.

Thus, in order to ensure access to health for migrants, it is important to insist that health should be regarded as a human right and that all citizens, migrants or natives should be entitled to it.

Status-Related Access Dilemma: a European Perspective

Presenter: Francesco Castelli
Author(s): Francesco Castelli1, C. Pezzoli1, A. Matteelli1, I. El Hamad1, S. Geraci2
Affiliation(s): 1Infectious and Tropical Diseases, University of Brescia, Brescia, 2Area Sanitaria, Caritas, Rome, Italy
Key issues: During the 1970s, the labour needs of European States favoured intensive legal migration to sustain growing economic growth. Afterwards, economic recession in Europe caused higher unemployment rates and legal migration into Europe has become increasingly difficult, resulting in a growing number of undocumented migrants from Southern and Eastern countries into Europe.
Meeting challenges: Host European countries are usually reluctant to promote health care programmes for undocumented migrants, fearing to give incentive to further migration flows, yet forgetting the basic human right of every person to access health regardless of his/her legal status. Furthermore, discrimination and internal inequalities in health care for marginalized minorities often have an impact also on the economic, social and health status of the host population, possibly generating public health problems. Some European countries have set up legal systems to offer illegal migrants the right to health care, but wide variations exist among the different countries as to the quality and quantity of access to care according to legal status. Furthermore, even a significant proportion of legal migrants may not have access to health care because of their ignorance of basic rights.
Conclusion (max 400 words): It is our hope that the European and international bodies, including the newly created United Nations Human Rights Council, may soon address the increasingly important issue of guaranteeing every human being the right to access care.

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

[Download not found]

Session Report

Submitted by: Brooke Bishara (ICVolunteers); Contributors: Asta Lim (ICVolunteers)
Image: courtesy of The Public Health Image Library (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.