Geneva Health Forum Archive

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Dr. Dominick Mboya

PS03_Mboya_squareDr. Dominick Mboya

Dominick Mboya has over 25 years experience as medical practice and teaching, currently employed as a research scientist at Ifakara Health Institute in Tanzania, responsible for coordinating Health System Quality Improvement initiatives implemented by Ifakara Health Institute through Initiative to Strengthen Affordability and Quality of Health Care (ISAQH). The initiative is funded by Novartis Foundation for Sustainable Development. Apart from that he is the Intervention coordinator for the Connect project designed to test the model of trained and paid Community Health Workers to accelerate achievement of MDG 4 & 5, the project is funded by Doris Duke Foundation and Comic Relief.

He has extensive clinical and teaching experience, prior to joining Ifakara Health Institute, Dominick was employed by Tanzania Ministry of Health and Social Welfare, as medical doctor and tutor in clinical officers training institutions from 1987 to 2008 where he served as Dean of studies. In collaboration with the National Tuberculosis and Leprosy Control Programme, he coordinated and facilitated capacity building trainings to health care providers on Tuberculosis and Leprosy and TB/HIV. He is a national trainer for Regional and District Health Management Teams, Integrated Management of Childhood Illness (IMCI) both conventional and Computerized Adaptation Training Tool (ICATT), Community based health insurance scheme at district levels. He is a founding member and board chair of LUPA a non- governmental no-profit organization promoting quality education in remote districts, member of the district education board and member of medical and public association of Tanzania. His interest are in area of health system strengthening and quality of health care

GHF2014 – PS05 – Health Services Integration and Disease Control Programmes

PS05 TUESDAY, 15 APRIL 2014 ROOM: 13 ICON_Fishbowl
Health Services Integration and Disease Control Programmes
Marianne Pirard, MD
Educational Coordinator of the Public Health department, Institute of Tropical Medicine, Antwerp, Belgium
Amina Essolbi, MD, MPH,
Senior lecturer Ecole Nationale de Santé Publique, Rabat, Morocco
Basile Keugoung, MD, MPH, PhD student,
Ministry of Public Health, Yaounde, Cameroon
Raoul Bermejo, MD, MPH, PhD student,
Researcher, Department of Clinical Epidemiology, University of the Philippines College of Medicine, Philippines
There is currently a broad consensus in the global community on the need for Health Systems Strengthening (HSS) to make further progress toward the Millennium Development Goals. The recent momentum around UHC, a likely post-MDG goal, is another example of this. However, there is still divergence on how HSS should be framed and how it should be done in practice.In this session we will present three frameworks to guide HSS with applied examples from different countries. We intend to discuss the relevance of these HSS frameworks and exchange experiences in HSS with a diverse audience bringing the perspective from actors such as first line health workers, health system and disease control programme managers, decision makers, international organisations and donors working in diverse settings (LICs & MICs, different continents).

Marianne Pirard
Marianne Pirard
is a medical doctor with an MPH from the Institute of Tropical Medicine (ITM), Antwerp. She currently is the Educational Coordinator of the Public Health department of ITM and is in charge of the organization of an international MPH with a track in Health Systems & Policy and a track in Disease Control.Before joining ITM in 2002, she worked for 5 years as a clinician in a rural district in Zimbabwe in a period its health system based on PHC principles was an example for the region (1986-91). She also spent 8 years in Bolivia as a Public Health physician, strengthening the National Centre for Tropical Diseases in its operational research and surveillance activities. (1994-2002)She believes that stronger synergies between health service managers and disease control programme managers can make health systems stronger.


Amina Essolbi

Amina Essolbi is a medical doctor with an MPH from Boston University.
She has worked for 5 years as medical officer before being recruited by USAID-Morocco as health care specialist (1994-98).
Thereafter, she joined the National School of Public Health (ENSP) in Morocco where she is a lecturer. She also teaches in different national and international short courses (VIH-AIDS, Ipact, continuing education) on matters related to strategic planning, project management, epidemiology and disease surveillance.

Her current domain of research is related to the role of home caregivers, the effects of free health care policies on the local health system and the conditions and mechanisms of success or failure of policy implementation.


Basile Keugoung

Basile Keugoung is a medical doctor, with a Master in Public Health in Health system management and policy from the Institute of Tropical Medicine, Antwerp-Belgium. He is registered as a PhD candidate at the Louvain Catholic University, Brussels-Belgium since 2010. He has a 10-year experience of working as a district medical officer in Cameroon. He is also co-facilitator of the Community of Practice Health Service Delivery (, and one of the Editors of the Newsletter ‘Politiques Internationales de Santé ( His field of research is the interface between vertical programmes and the general health system. The aim is to find avenues for optimizing the interface between vertical programmes and the recipient health system.


Raoul Bermejo

Raoul Bermejo III, MD, MPH

Researcher, Department of Clinical Epidemiology, University of the Philippines College of Medicine.

PhD Student at the Institute of Tropical Medicine, Antwerp, Belgium.

He is a medical doctor with experience in managing Reproductive, Maternal, and Child Health and Nutrition Programs in the Philippines. He also worked as a consultant for the Philippine Health Insurance Corporation. His current research work is focused on understanding how health systems in low and middle income countries are adapting to the rise in the burden of non-communicable diseases. He is also interested in global and local discussions on UHC.

When he is not thinking about global health problems, he dives and restores traditional Ifugao houses.

GHF2014 – PS18 – Improving Health Information Systems for Better Decision Making

Improving Health Information Systems for Better Decision Making
Mr. Hazim Timimi
Data Manager, Tuberculosis Monitoring and Evaluation, World Health OrganizationSwitzerland
Best Practices for Building an Integrated National Health Information System: Rwanda
Dr. Caricia Catalani
Senior Researcher, Innovative Support to Emergency, Disease, & Disaster (InSTEDD) & University of California, Berkeley, School of Public Health, United States
Prof. Don De Savigny
Head, Health Systems Interventions Research Unit, Department of Public Health and Epidemiology, Swiss Tropical and Public Health Institute, Switzerland

PS18_Catalani_squareDr. Caricia Catalani

I am a researcher, focusing on digital innovations for health.  I started working in the health field at age 16, as a physician’s assistant in our family-run urgent care clinic in the rainy Pacific Northwest of the United States. Since then, I’ve worked in an emergency room in a tough neighborhood in New York City, a sex workers’ union in the Dominican Republic, devastated neighborhoods in New Orleans after hurricane Katrina, US government health departments across the coasts, a cigar factory in Cuba, one of the world’s biggest private health insurance companies, a women’s health advocacy powerhouse in Washington, DC, a milky-eyed shamanic healer’s hut on the border of Cameroon, a teen health and empowerment center in San Francisco low-income housing, and clinics with mud floors and tin roofs throughout the African continent.  These days, I spend most of my time as a research consultant to eHealth, mHealth, and digital innovation projects at ministries of health, hospitals, and non-governmental organizations around the world (especially in Rwanda, Cambodia, Kenya, India, Canada, and the USA). I am faculty at the University of California, Berkeley, where I teach courses on digital innovations for health.  Awesome comedy improv and freestyle rap give me a lot of joy.  I spend countless hours learning from my four-month old and three-year old daughters, as we grow up together in the San Francisco Bay Area.

Don de Savigny_squareProf. Don de Savigny

Professor de Savigny is an epidemiologist and public health specialist and currently Head of the Health Systems Research Unit in the Department of Epidemiology and Public Health at the Swiss Tropical and Public Health Institute, University of Basel.  He has extensive experience in conducting and facilitating health research in developing countries and has lived and worked for many years in Africa.  He chairs or is a member of a number of WHO, RBM, Global Fund, and TDR advisory committees and networks such as COHRED, the Health Metrics Network and the INDEPTH Network.  His current research focuses on interventions to strengthen health systems in developing countries, and on the health system effects of Global Health Initiatives for scaling up access.

GHF2014 – PS16 – Unpacking Health Systems Through System Thinking

Unpacking Health Systems Through System Thinking
Dr. Taghreed Adam, MD, Alliance for Health Policy and Systems Research (HSR), Health Systems and Innovation (HIS), World Health Organization, Switzerland
Evaluating Systems-Thinking for District Managers : Ghana
Ms. Aku Kwamie, Researcher, Health Policy, Planning and Management, University of Ghana School of Public Health, Ghana
Understanding the Growing Complexity of Governing Immunization Services in Kerala, India
Dr. Joe Varghese, Post Doctoral Research Fellow, NCD Lifespan Training Program, Centre for Chronic Diseases Control
Dual Practice in Uganda: the Evolution and Management of a Complex Phenomenon
Dr. Ligia Paina Bergman, Department of International Health, Johns Hopkins University School of Public Health, United States
Exploring Primary Care: System Dynamics in USA and Romania
Mrs. Andrada Tomoaia-Cotisel, PhD Candidate, Health Services Research & Policy, London School of Hygiene and Tropical Medicine, United States
Learning from Evidence: Advice-Seeking Behaviour Among Primary Health Care Physicians in Pakistan
Dr. Asmat Malik, Director Research and Development, Department of Research and Development, Integrated Health Services, Pakistan

PS16_Taghreed_AdamDr. Taghreed Adam

Taghreed Adam is a Pediatrician and Health Economist. Having joined WHO in 1999, she focused on methodological and analytical developments in the areas of costing and the economic evaluation of health interventions. Her main research contributions include the multi-country evaluation of IMCI and the WHO-CHOICE project on cost-effectiveness analysis.  Dr Adam joined the Alliance for Health Policy and Systems Research in February 2008. She leads various projects, notably research to advance the methods and application of “systems thinking” concepts in strengthening health systems of low-income and middle-income countries; and the Alliance’ portfolio on capacity strengthening of health policy and systems researchers. Before joining WHO, she worked with the Egyptian Ministry of Health in their Health Sector Reform Project, particularly in the development of a universal health insurance package for the Egyptian population.

AkuKwamieMs. Aku Kwamie

Aku Kwamie is a health systems researcher based at the University of Ghana School of Public Health. Her current area of research is district level governance. Ms Kwamie also has research interests in management and leadership, accountability, decentralisation, complexity science, and maternal and newborn health. She has worked internationally in community health settings in Ghana, Nigeria, Togo, Lesotho, and Canada. Ms Kwamie holds degrees from the University of Toronto and King's College London. She is currently completing her doctoral thesis.

PS16_Joe_VargheseDr. Joe Varghese

I am a NIH D43 Research Fellow associated with Centre for Chronic Disease Control, New Delhi and Rollin School of Public Health, Emory University, Atlanta. I have master and doctoral degree in public health from Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram and currently, undergoing MSc in Global Health Policy (Distance Learning), London School of Hygiene and Tropical Medicine, University of London. I have over 12 years of involvement in public health at the national level as a health system researcher, policy expert and program manager.  I am associated with Jan Swasthya Abhiyan, the Indian affiliate of People’s Health Movement. My research and publications are related to Panchayat Raj Institutions and health sector, sex ratio at birth of Delhi hospitals, public health ethics, analytical frameworks for public health policies & programs and immunization & health governance. My current interest and researches are in the area of policy priorities for NCD prevention and control, population level behaviour change interventions, complexity of public health governance and in the development and application of System Thinking frameworks for public health.

Ligia Paina 2014Dr. Ligia Paina Bergman

Ligia Paina is an Assistant Scientist in the International Health Department of the Johns Hopkins University Bloomberg School of Public Health (JHSPH). Her research interests include health workforce policy, complex adaptive systems, and research and organizational capacity development in low and middle income countries.

Ligia's experience in global health is focused on health systems strengthening and health systems research.  As a Research Assistant at Johns Hopkins University, she has contributed to the design, management, and analysis of qualitative, quantitative, and mixed methods research studies. Prior to joining Johns Hopkins, Ligia worked as a Health System Advisor in the Office of Health, Infectious Diseases, and Nutrition at the U. S. Agency for International Development.

Ligia holds a PhD and a MHS in International Health - Health Systems from the Johns Hopkins University Bloomberg School of Public Health.

PS16_Andrada_Tomoaia_CotiselMrs. Andrada Tomoaia-Cotisel

My long-term career goal is to improve population health via improving health systems (HS).  My PhD dissertation explores the impact of primary care structures on patients’ risk of hospitalization.  The purpose of my research is to make a robust assessment of the dynamic interactions of these health system components and resulting outcomes.  My first job in public health (PH) was studying the effect of exertional heat illness on Marine Corps recruits with Sickle Cell trait.  I saw the importance of PH in identifying and protecting vulnerable populations. As an undergraduate intern at the World Health Organization in Geneva, I observed the complex interactions between NGOs and national health ministries that characterize effective health systems. I observed the paramount role HS plays in PH. After graduation, as an unpaid, uninsured, USAID intern, I got sick.  I sought care from a local community health center. Grateful for their help, I soon found myself working at one such organization.  There, I witnessed up close how changes in the local health service delivery system, such as interdisciplinary preventive care, could result in higher quality care for patients and improve cost-effectiveness. I saw how HS improvement happens and made it my long term goal to participate, whether my career takes me in research, policy or practice – hopefully all of the above!

AsmatMalikDr. Asmat Malik

Dr. Asmat Ullah Malik, a medical doctor and health policy and systems analyst has an extensive experience of working in health system in Pakistan. He is currently heading the Research and Development Division of Integrated Health Services, Islamabad, Pakistan. His key research interests are in health policy, its translation into national health systems and programs and testing innovative strategies for strengthening health service delivery. He was awarded Rockefeller Foundation Bursary Award for his research work presented at Health Systems in Asia Conference held in Singapore in 2013. He was also awarded an Australian Development Scholarship by the Government of Australia for PhD in Health Policy and Systems (2007-2013). He was winner of ‘Emerging Voices’ essay competition organized by Institute of Tropical Medicine (ITM), Antwerp, Belgium in 2010.


Recep Akdag

RecepAkdagSquareRecep Akdag

Minister of Health of Turkey 2002 - 2013

Recep Akdag was born in Erzurum, Turkey in 1960. As a pediatrician, he has been holding a professor title from the Ataturk University School of Medicine since 1999. During his career as a medical specialist and academician, he had been involved in a number of administrative tasks. Between 1994 and 1998, he worked as the Deputy Chief Medical Director, Chairman of the Procurement Commission and Deputy Editor of the Medical Bulletin in the Research Hospital of the Medical Faculty of Ataturk University. He also co-founded the Biotechnology Research Center of the University and served as the Deputy Head of the Center from 1997 to 2000.

After being elected as a Member of Parliament from the Province of Erzurum, he had served as the Minister of Health of Turkey between 2002 and 2013. During his tenure, he has been the key figure for the implementation of the influential Health Transformation Program (HTP) in Turkey. This comprehensive program brought a people-oriented approach to healthcare service delivery and strengthened the health system with successful implementation of universal health coverage. Major aspects of this health system reform included integration of public hospitals, increased patient access to medical services and prescription drugs, invigorated primary healthcare delivery with the implementation of family medicine, improved maternal and childhood healthcare services, better quality and reach of emergency services, and establishment of a national medical rescue team.

HTP generated high access rate for essential services thru the adequate healthcare supply and universal health insurance covering the poorest. Infant mortality rate, maternal mortality ratio and catastrophic health expenditures decreased dramatically. Public satisfaction with health services increased from 39% in 2002 to 75% in 2012. Apart from leading this influential program, Prof. Akdag has edited a number of reports and contributed/co-authored academic articles about HTP. He has addressed, directed and moderated in many international conferences including of those the WHO and UNICEF. He has received the WHO’s “World No Tobacco Day” Award as a recognition of his efforts in the fight against the global tobacco epidemic and in the promotion of tobacco control initiatives and policies. He has been an advisory board member of the Ministerial Leadership in Health (MLIH) Program at Harvard University since 2012.

Prof. Akdag still serves as an MP in the Grand National Assembly of Turkey for his third consecutive term. He also is a Richard L. and Ronay A. Menschel Senior Leadership Fellow, Harvard School of Public Health.


Case Management in Mental Health Settings in Bosnia and Herzegovina.

Author(s) Darko Paranos1, Biljana Lakić2, Tatjana Popović3, Dženita Hrelja Hasečić 4.
Affiliation(s) 1Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina, 2Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 3Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 4Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Chronic Diseases
Summary Within scope of the Mental Health Project in Bosnia and Herzegovina (BIH) the Case Management in Mental Health was introduced across the country with the aim of improving the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs. In order to achieve planned objectives an integrated set of activities was conducted compromising of teaching materials development, continuous education activities targeting Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives and (Peer) Support to Mental Health institutions in applying Case Management. Initial findings indicate the significant increase in the number of CMHCs which successfully started with the application of the Case Management in their institutions.
Background Activities were conducted within the scope of the Mental Health Project (MHP) in Bosnia and Herzegovina (BIH). The Mental Health Project in BIH is a result of continuous commitment of the health ministries to continue the mental health reform in BIH. The mental health reform was launched in 1996 focusing on community-based care as a contrast to the traditional model that was mainly oriented towards hospital treatment of persons with mental disorders. The overall goal of the Mental Health Project in BIH, in the period June 2010 - December 2013, was to improve the general mental health of the population and enhance the capacities of policy makers and competent institutions for complying with European standards in mental health care in BIH. Since 2011 the Mental Health Project in Bosnia and Herzegovina was involved in trainings of Community Mental Health Centres staff in the field of Case Management with the aim to improve the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs.
Objectives The objectives of the Mental Health in BiH Project in the period June 2010 to December 2013 were as follows: 1. Improved administrative and legislative frameworks to enable efficient operations and processes in mental health care in both BiH entities, Federation of Bosnia and Herzegovina and Republika Srpska.
2. Persons with mental problems to have access to improved and better quality services of mental health care at the community level.
3. Provision of high-quality mental health services at the community level is supported as a priority of the reform process by the management structures in Community Health Centres.
4. Capacities to fight against stigmatisation and discrimination related to mental disorders are strengthened. Within the objective 2, the specific objectives include: a) Competencies and skills of the multidisciplinary teams of the Community Centres for Mental Health to be enhanced, b) Independence and responsibility of the nurses in provision of the mental health services and direct work with clients to be enhanced.In order to achieve planned objectives the integrated set of activities were conducted:
• Teaching materials development -
o The Case Management continuing education Curriculum and Manual development
• The continuous education -
o A Training of Trainers (ToT) course in Case Management
o The health professionals continuous education of Community Mental Health Centres multidisciplinary teams and
psychiatric hospitals/clinics/departments representatives
• (Peer) Support to Mental Health institutions in applying Case Management -
o Mentoring and support to Community Mental Health Centres and psychiatric
hospitals/clinics/departments in applying Case Management.
Methodology The case management is a collaborative process which connects users with services and available resources aimed at ensuring provision of optimal care. The approach involves the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders, and often reluctant to come into contact with mental health services. It is activated by establishing contact with customers in the community, a comprehensive needs assessment, developing individual "tailored" packages of care and effective coordination of services and treatments in a variety of services which increases the user's potential for recovery. The process of introducing the Case Management principles across Mental Health Settings in Bosnia and Herzegovina is based on a set of integrated activities. The Development of Teaching materials sets the fundamentals for the continuous education of multidisciplinary teams employed by Community Mental Health Centres and psychiatric hospitals/clinics/departments representatives. The core materials are the Case Management in Mental Health Curriculum and Manual which are organised into seven modules: I - Introduction to Case Management - concepts, principles, practices and theories; II – User Involvement and needs assessment; III - Assessment and Risk Management; IV - Planning of care, implementation of treatment and use of resources in the community; V - The Case Management at the first psychotic episode, early intervention and prevention of relapse; VI - Team Approach to Mental Health; VII - Gender and Mental Health. The Mental Health Professional continuous education was organised in two phases. The first step was to identify, recruit and train group of mental health professionals as a part of Case Management Training of Trainers course. The next step was to deploy trainers in training of Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives.Applying the Care Coordination model across the country began after the completion of the trainings. The Peer support to Mental Health Institutions across the country is organised Systematic (peer) support to application principles in Mental Health Settings will be conducted in between September- December 2013 with aim of ensuring increased access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs is secured.
Results The Mental Health Case Management Curriculum and Manual were developed setting the basis for continuous education of Mental Health Professionals in Bosnia and Herzegovina. Training for trainers was completed in 4 training cycles with total duration of 9 days. As an education result, 21 mental health professionals have been certificated and formally appointed as future trainers by entity MoHs. Training of CMHC multidisciplinary teams was organised involving 625 mental health professionals from 67 CMHCs and 15 psychiatric hospitals/clinics/departments. 565 professionals (or 90%) passed the final exam, and successfully completed the training. After completion of the trainings the application of Case Management across the Mental Health care institutions started. Initial findings indicate that the 54% CMHCs (37 out of 69) successfully started the application of the Case Management in their institutions. As such this data indicates the significant increase in number of institutions applying the Case Management compared with 4 CMHCs from the baseline conducted in 2008. (Peer) Support to Mental Health institutions will provide not only support to the institutions in applying Case Management in standardised manner, but will provide insight in terms of effectiveness in changing the practice of those institutions. The key indicators to measure success of the process (in the short term) are the percentage of CMHCs appointing the Case Managers, number of appointed Case managers per CMHC (segregated by profession, particular focus on nurses) and percentage of service users involved in care plan development. A particular focus will be on measuring the service users involved in Case Management satisfaction.
Conclusion CMHCs capacities to involve the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders are improved when compared to the initial survey. The significant increase in the number of CMHCs applying Case Management in their institutions is observed. The Case Management is recognised by the revised service nomenclature, an organised and officially recognised classification/ registry of the health services endorsed by entity/cantonal Health Insurance Funds. As only those services officially recognised in the nomenclature can be performed by health institutions and charged to HIFs, a long term sustainability of Case Management is supported. Initial findings emphasise the issues of a large number of patients covered by the coordinated care, lack of staff and other resources required for adequate Case Management application in their institutions. In addition, another obstacle in the implementation of the Case Management observed is weak cooperation among agencies and institutions involved in the Case Management process.

How well do we know the “users” of health interventions? The example of (non-)enrolment in voluntary community-based health insurance schemes in Mali.

Author(s) Alexander Schulze1.
Affiliation(s) 1Global Health, Novartis Foundation for Sustainable Development, Basel, Switzerland.
Country - ies of focus Mali
Relevant to the conference tracks Social Determinants and Human Rights
Summary For health interventions to be successful, not only the health system needs to be considered, but also the patients understood. However, often in health research this understanding is reduced to their socio-economic status.
The present empirical study, focusing on the reasons for (non-) enrolment in voluntary health insurance schemes in rural Mali, expands the analysis of household characteristics to sociocultural orientations and intra-familial structures, including decision-making patterns.
The results reveal that the socio-economic status of households does not explain membership in a health insurance scheme, whereas the attitudes heads and family decision making patterns clearly do.
Background Systematic, quantitative evidence on user characteristics of health interventions is mostly limited to socio-demographic features and economic status. Yet, as research in medical anthropology has revealed, the acceptance of health related innovations is not only dependent on these factors.The example of (non-)enrolment in voluntary health community-based insurance schemes in sub-Saharan Africa mirrors this research gap. These schemes are characterized by modest enrolments rates and do not tap their potential in an already limited catchment area. In order to increase their coverage, the reasons for (non-)enrolment need to be better understood.However, to date, research has focused on the supply side, i.e. features of the insurance schemes and their contracted providers. On the demand side, comparative studies of enrolled and non-enrolled households have mainly concentrated on their socioeconomic status.Three research gaps remain which are not unique to the analysis of community-based health insurance: 1) sociocultural features are not analyzed in a quantifiable manner as socio-economic characteristics are. 2) household and family structures and their decision making patterns are not considered. Thirdly, significant factors are not explained and related to each other.
Objectives The present empirical study aims to fill the following research gaps:1) to expand the analysis of household characteristics beyond households’ socio-economic status by also taking account of their sociocultural orientations and intra-familial structures, including decision-making patterns. The main hypothesis underlying this approach is that socio-economic differences have been overestimated regarding their importance in determining the uptake of innovations, i.e. in the presented case membership in health insurance schemes, whereas attitudes and values, such as openness to or mistrust of social innovations, have been underestimated.2) A further goal is to systematically bring together and interrelate influencing factors that are meaningful beyond statistical significance, in order to ultimately reveal different lifestyle patterns associated with membership in, or refusal to join, a health insurance scheme.3) A further aim of this study is to present an analytical framework that links the socio-economic characteristics of households with their sociocultural orientations as well as with household and family structures.
Methodology A mixed methods approach, with different instruments employed sequentially, was developed. The central rationale behind a mixed-methods approach of this type was the idea to use qualitative methods of data collection not only in the exploratory phase but also at a later stage, to enhance interpretation of results from quantitative statistical data analysis and to develop explanatory patterns.The core element of the mixed methods approach chosen was household surveys on lifestyle patterns and social protection strategies. A total of 600 heads of households were interviewed in two localities. Of these, in each locality 200 had no insurance, while 100 did have insurance. In a second survey round, half of these household heads were again interviewed about their social protection strategies. In each study area this round covered 100 households with insurance and 50 households with no insurance.Households were the focus of research for two reasons: on the one hand, they are the unit of membership in the community-based health insurance schemes being studied. On the other hand, households are important repositories of lifestyle patterns within society and have a great degree of influence on the activities of their members. This is manifested, for example, in the transmission of values between generations and in the sharing of resources. Moreover, households are units of decision-making in different areas of life.Comparison of two rural areas in Mali had been considered useful insofar as community-based health insurance schemes are being advocated for peasant populations, primarily in French-speaking Africa. Furthermore, the two localities differ in terms of climate and in socio-economic and sociocultural terms but have a very similar health insurance scheme. Comparison of two areas also made it possible to examine to what extent social differences exist in rural Mali.

The household surveys were preceded by an exploratory phase including group and individual discussions, which primarily served to identify locally relevant categories of social differentiation. Following the household surveys, preliminary results were presented to representatives from the municipalities. These discussions brought out new points of view that were of use in further data collection and analysis. Following this, 20 group discussions and 24 individuals from selected families were interviewed in order to obtain insights into household and family decision-making patterns.

Results The results reveal that the socio-economic status of households does not explain membership in a community-based health insurance scheme, whereas the attitudes of household heads and family decision-making patterns clearly do. For instance, households of the lower socioeconomic tercile were even slightly more likely to be members than those of the middle tercile (p-value: 0.669; CI: .63-2.02; OR: 1.13).Households that are single households or are not part of a large family have greater freedom in decision-making. Moreover, heads of households with insurance appreciate different social changes (e.g. existence of new, formal organizations including community-based health insurance schemes), take on responsible roles in their communities and plan in a manner where the benefit is unsure or not immediately given, significantly more often than heads of uninsured households. For instance, those heads of household who only utter negative social changes are significantly less likely to be insured than those who also mention positive changes (p-value: 0.000; CI: .21-.57; OR: .35).Based on the results, a typology of households and their lifestyle patterns was empirically determined in both study areas. Each of the two study areas, two different household types were identified that are distinct not by their socio-economic status but by family structure and sociocultural orientation. The existence of different household types in both areas underscores the clear social differences that exist in rural Mali.
Conclusion The findings from this research on the reasons for (non-)enrolment of households in community-based health insurance schemes in rural Mali reveal that limiting the "users" of health interventions to their socio-economic status in many circumstances does not sufficiently explain why people "lack access to" or do not take up the services offered through health interventions.In order to better target potential users of health interventions and increase coverage, a more comprehensive but systematic analysis of their characteristics must be done. This includes socio-cultural features such as attitudes towards social innovations and change, leading values, consumption priorities as well as decision making patterns at household and family level.In other words, for health interventions to be successful, not only the heath system and its actors need to be considered, but also the patients. However, they must not be reduced to people living in poverty. Rather research must acknowledge that they are characterised by different livelihood patterns that expand beyond the issue of poverty.

Strengthening health systems to achieve access to essential medicines

Author(s) Alessandra Ferrario1, Rita Seicas2, Nina Sautenkova3, Jarno Habicht4
Affiliation(s) 1LSE Health, London School of Economics and Political Science, London, United Kingdom, 2Centre for Health Policies and Studies, Chisinau, Moldova, 3World Health Organization, Regional Office for Europe, Copenhagen, 4World Health Organization, Country Office, Republic of Moldova
Country - ies of focus Moldova
Relevant to the conference tracks Health systems
Summary This presentation aims to generate debate on issues affecting access to medicines in low- and middle income countries, discuss how they can be tackled through a coordinated health system response by proposing simple and actionable recommendations and to encourage participants to share their own countries’ experience.
Background Despite continuous scientific progress and the existence of several life-saving medicines, one third of the world’s population still lacks of access to essential medicines.
Achieving access to essential medicines requires much more than an increase in funding for medicines reimbursement. As outlined by the World Health Organization (WHO) in 2004, access to medicines encompasses rational selection and use, affordability, sustainable financing and reliable health and supply systems. Although the WHO health system building blocks model depicts medicines almost as an independent component of the health system, improving access to essential medicines is dependent on the strengthening of all other building blocks. Trained human resources are necessary to develop a national essential medicines list and treatment guidelines, to educate patients on how to take their medications and follow them up to ensure compliance. Facilities equipped with the necessary diagnostic tools are needed to diagnose patients. Policies need to be in place to promote price competition and use of generics. Efforts to achieve universal health coverage need to be sustained and quality of medicines needs to be ensured through a reliable and efficient regulatory system.
Objectives To show the need for integrated action across different health systems dimensions to improve access to medicines using as an example the recent reforms introduced in the pharmaceutical sector in the Republic of Moldova.
Methodology Analysis of expenditure, use and reimbursement data together with a review of policy documents in Moldova.
Results Between 2005 and 2012, reimbursement for outpatient medicines increased from Lei 7,404 thousands (Euro 434 thousands) to Lei 166,244 thousands (Euro 10,490 thousands). The increased budget translated in a greater number of medicines reimbursed over time, from 8 medicines (with different active ingredient) in 2005 to 81 medicines in 2013. In parallel, the number of reimbursed prescriptions and the proportion of total prescription value reimbursed have also increased.
A similar pattern was highlighted for inpatient medicines whose spending increased from Lei 94,234 thousands (Euro 5,550 thousands) in 2007 to Lei 357,766 thousands (Euro 22,575 thousands) in 2012 and was accompanied by an increase in the number of medicines available.
Another positive development was the inclusion of insulin in the 2013 reimbursement list. Before insulin used to be procured through a vertical programme and although patients could access insulin for free, stock-outs problems were reported due to gaps in the distribution system and the lack of accurate data on the number of insulin patients.
After a previous attempt to introduce generic prescribing, in October 2012, thanks to Government support, it was finally possible to introduce generic prescribing. This is expected to reduce spending for both the national insurance company and for patients.
Until 2013 compliance with good manufacturing practices (GMP) was not enforced. With release of the new reimbursement list medicines registered in either the European Union, the US, Canada, Australia, or Japan and therefore compliant with GMP are given preferred supplier status. This is expected to provide a strong incentive, particularly to the local manufacturing industry, to improve their manufacturing practices according to international accepted standards of good quality.
Areas were more efforts are needed include covering the insured population, expanding the breadth and depth of medicines coverage while promoting rational selection and use of medicines, strengthening post-marketing quality control and pharmacovigilance activities.
Conclusion Although presented as a building block on its own, achieving access to essential medicines requires integrated action across all health systems building blocks.
In Moldova, increased coverage of medicines was possible due to increased funding. Political support enabled to overcome initial resistance and to introduce generic prescribing. However, several challenges remain to achieve universal access to quality essential medicines. These include, but are not limited to, achieving universal health coverage, obtaining better prices for medicine, reduce waste by promoting rational selection and use of essential medicines, strengthening post-marketing quality control systems and pharmacovigilance.

The Effectiveness of Holistic Care Unit by Using Rate of Patients Revisiting Emergency Department within 3 Days in Taiwan

Author(s) Meng-Chieh Wu1, Li-Sheng Chang2, Hsin-Kai Huang3, Tzu-Chieh Weng 4, Chun-Cheng Zhang 5, Kao-Chang Lin6.
Affiliation(s) 1Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 2Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 3Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 4Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 5Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 6Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan.
Country - ies of focus Taiwan
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for aid and waited for admission through the gate of emergency department. Overcrowding situations affecting the quality of care at Emergency Departments is an important issue in the Taiwan medical system. The overloading pressure induced the shortage of emergency physicians and nurses. A new department, holistic care unit, was established in Chi-Mei Medical Center in Taiwan in August 2012, to bridge ER and wards in order to provide the continuum of patients care and safety. To our knowledge, it is the first approach in Taiwan.
Background The word 'holistic health' was defined in PubMed database as follows: “Health as viewed from the perspective that humans and other organisms function as complete, integrated unit rather than as aggregate of separate parts”. The definition of a holistic view was that all aspects of people's psychological, physical and social needs be taken into account and seen as a whole. The term is sometimes confused with alternative medicine. Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for assistance and waited for admission at emergency departments (ER). In the ER the waiting time was prolonged and more difficult for patients to have beds available. It also influenced the effectiveness of medical treatment. A new department, holistic care unit (HCU), was established in Chi-Mei Medical Center in Taiwan since August 2012, to bridge the gap between ER and wards in order to provide the continuum of patients care and safety.
Objectives Overcrowding situations affect the quality of care at Emergency Departments and is an important issue in  the Taiwan medical system. Many health care workers, including physicians and nurses, are under a lot of working pressure. Many health care workers have retired from emergency department and critical medicine. The shortage of physicians in emergency medicine has significantly decreased the quality of health care. Accordingly, holistic care units were established to improve the quality of medical care. To realize the effectiveness of Holistic Care Units, we evaluated the waiting time for hospitalization and revisits to the Emergency department within 3 days after discharge.
Methodology This Holistic Care Unit was set up close to the Emergency Department to reduce the workload of emergency physicians who were responsible for patients waiting for admission. This newly created unit was composed of seven experienced medical attending staff who would to take care of patients in 8 hours rotations in collaboration with emergency physicians, radiologists, nurses, social workers and cases manager who constituted the team. This team had similar three domains of responsibility: education and training programs, living together in same place, and sharing the medical devices and resources. Each morning there were meetings focused around subspecialties to discuss the constellations with the exception of difficult or surgical cases which ere referred. The case manager followed the condition of post-discharge patients from Holistic Care Unit in order to assure smooth and regular compliance in the transition home without the need for readmittance into the wards. The case manager tracked patients of Holistic Care Unit from January 2013. We used the waiting time period and the rate of revisits to the Emergency Department within 3 days in a proper statistics evaluation of the effectiveness of Holistic Care Unit in our hospital.
Results From February to July 2012 and August to January 2013, before and after the establish of Holistic Care Unit, the rate of waiting period for more than 24 hours for admission at ER declined from 8.55% to 5.4% and from 2.71% to 1.27% for more than 48 hours. The overcrowding conditions at Emergency Departments were largely improved after the establishment of the Holistic Care Unit. The numbers of patients treated at the Emergency Department was 86712 persons from January 2013 to August 2013. The rate of patients revisiting emergency department within 3 days was 3.6% from January 2013 to August 2013. The rate included the patients of Holistic Care Unit. The rate of revisiting Emergency Department within 3 days was 6.1 % among the patients who were discharged from the Holistic Care Unit. The rate of revisiting the Emergency Department within 3 days was 3.2% after eliminating the patients who were discharged against medical advice (DAMA).
Conclusion Overcrowding situations affect the quality of care at Emergency Department and is an important issue in Taiwan medical system. The overloading pressure and the fear of liability has created a shortage of emergency physicians and nurses. A new department, Holistic Care Unit, was established to improve the overcrowding situation and our preliminary results indicate that it has worked effectively. The rate of revisiting emergency department within 3 days is lower if physicians from the Holistic Care Unit suggested early discharge from hospital. However, the overcrowding situation still influences the quality of care. If patients were discharged against medical advice of physicians from the Holistic Care Unit, the rate of revisits to the Emergency Department within 3 days is higher. The major reason for discharges against medical advice is the unavailability of beds and long waiting times for wards. More attention needs to be paid to the long waiting time to admit patients. To our knowledge, this project was the first approach in Taiwan to establish a new department nearby Emergency Department to intervene in the earlier take over patients who waited for admission for advanced and continued care. Beyond above benefits, the mutual interaction bridging Holistic Care Unit and Emergency Department will also cultivate an interdisciplinary teamwork that can achieve the same goals of patients care, education, quality and safety outcomes.

Equity and Local Government: Sao Paulo, Brazil

Author(s) Vera Coelho1
Affiliation(s) Citizenship, Health and Development Group , Brazilian Centre of Analysis and Planning , Sao Paulo, Brazil.
Country - ies of focus Brazil
Relevant to the conference tracks Health Systems
Summary Brazil has established a nationwide health system (SUS) aimed at ensuring universal access and has made enormous progress towards this goal over the past two decades. However, a number of studies have shown that certain vulnerable groups often do not have effective access to the services they need. The study analyzes the evolution of the supply and consumption of public healthcare services within the municipality of São Paulo between 2000 and 2011. The results show that there has been equity gains that favored groups living in areas that present the worst socio-economic indices. The paper discusses how municipal health policies and politics helped to guarantee these achievements.
Background During the 1990’s a new governance structure was forged and contracts were initiated between the federal, state and municipal governments, which defined responsibilities and transparent financing rules for the implementation of the national health policy. At that time the effective institutionalization of the health conferences, a national health council, and the health councils in all twenty-six states and in nearly all of the 5,561 municipalities also took place. Today the national government has an important role in regulating and financing health services, while state and municipal governments are responsible for delivering services and allocating supplementary funding. One major challenge facing the SUS is how to increase the system’s equity as the provision of services is still skewed in favor of wealthier regions and citizens. In particular, the study focus on the difficulties posed in tackling internal equity gaps in mega cities as, despite the fact that these are highly unequal areas, the national policy only focuses on inequalities between regions, states and municipalities. The study explores how municipal politics favored the adoption of policies that helped in guaranteeing a more equitable distribution of public health services in the mega city of Sao Paulo.
Objectives The study evaluates the redistributive efficiency of the Sao Paulo municipal policies’ adopted between 2001 and 2011. The period covers three municipal terms. The study: 1) follows the distribution of public health services – equipment and service supply - in all the 31 sub-municipalities between 2001 and 2011; 2) describes the health policies implemented by each of the three administrations and explores the rationale for its adoption; 3) tests the plausibility of the assumption that relates, on one hand, the coupled presence of competitive election for local office and citizen participation and, on the other hand, the adoption of innovations that favored greater equity. The main questions we planned to answer were: Did the gap across areas with the highest and lowest Intra-Municipal Development Index narrow during the period? Can we identify how the different strategies adopted by the municipal government in each term worked to reduce or widen this gap? What was the role played by local politics in favoring the adoption of these strategies?
Methodology The analyses gauge the effect of municipal health policies on indicators of access to public health services. The study was organized in three steps. First, a geographic Information System (GIS) was organized. It contains data from the years 2000 to 2011 on per capita primary appointments of a given submunicipality, the rate of hospital admission per 10.000 residents of a given submunicipality; age, income, and educational level of the submunicipalites’ resident population and the proportion of SUS users and out-of-pocket or private insurance users. The SUS-user is a citizen without a private health insurance, who uses the public health system, which in São Paulo’s case representes 48% of the total population. For primary consultations there is no information to allow for identification of the beneficiary for a given appointment and we assumed a plausible premise that this kind of service tends to be produced in a decentralized fashion and consumed locally. For hospital admissons we worked with the Hospital Admission Authorization (AIH), the means through which healthcare service providers in Brazil are reimbursed. AIH records indicate the zip code of those who used the SUS service which allows for mapping of the consumption of hospitalizations in the sub-municipalities areas. Equity gains have been estimated as the difference between each outcome in the sub-municipalities areas, which are in the highest socioeconomic quartile compared to the lowest quartile. The sources are CENSUS (IBGE) and Data SUS (Ministry of Health).In the second step a structured questionnaire with closed and semi-open questions was applied to health councilors, service providers and municipal public officials. Moreover, we collected data provided to official media for public announcements and mass media. The analysis of these materials helped in understanding the political context and the decisions made by each of the three administrations.In the third step we analyzed the distribution of health units and basic appointments as well as hospital admissions and sought to locate turning points that favored the equity gains identified in the first step. Once we identified these turning points we investigated the relationship between them and the policy decisions made by each of the three administrations, which were identified in the second step.
Results Despite the fact that the SUS population was concentrated in the outskirts, in 2001 in the city of Sao Paulo equipment and services were concentrated in the central and oldest areas of the city of Sao Paulo. This meant that the populations who lived in areas with better socioeconomic indicators were privileged compared to populations living in the outskirts of the city. In this sense, it is important to note that the differences in distribution measured in the present work are between the poor that live in different areas of the city, rather than between poor and non-poor as such. The bias in favor of central areas was partially reversed in more recent years and this was made possible through heavy investment in infrastructure. The average number of basic health units per 20,000 SUS users increased from 0.79 to 1.42, and there was considerable progress in the distribution of these equipments to areas in the outskirts of the city. The implementation of new hospitals has privileged poorer areas, as can be noted by the fact that four out of five new hospitals built in this period were in areas among the 10 sub-municipalities with the lowest Human Development Index (MHDI) in the city. Along with this expansion there was a shift in the distribution of hospital beds: in 2001 the 9 sub-municipalities with the smallest MHDI supplied 5.75% of the public hospital beds in the municipality, while 10 years later this percentage had increased to 13.48%. It should also be noted that, in 2010, hospitalizations were 61.9% higher among SUS users residing in the first quartile (the poorest) and were only 13.8% higher among fourth quartile residents (the richest).The rate of primary appointments increased by 154.7% between 2001 and 2010, with the average rate of basic appointments per SUS user per year going from 1.28 to 3.26. From 2002 to 2006 the standard deviation in the distribution of these appointment between submunicipalities decreased from 0.93 to 0.66.The data collected and analyzed by the study clearly shows that there was significant expansion in the supply as well in the consumption of services in the regions that presented the worst socio-economic and health indicators. An analysis of the distribution of these resources also showed that we now have a more equitable distribution pattern of public health services between locations with a reduction in the geographic inequalities hindering access to the public health system.
Conclusion The results described in the preceding section may seem expected, after all, the distribution of public health services was and still is biased towards wealthier areas and the correction of this situation is the most logical step. However, this is a striking result given how difficult it is to reverse this tendency as attested by the findings of a number of studies in different parts of the world, which indicate that the richest tend to persistently benefit more than the poorest from public spending on health (World Bank 2003; Liu, Hotchkiss and Bose 2007). The guidelines and programs established by the Brazilian Ministry of Health starting in the 1990s guaranteed that new resources reached the municipality. The simple use of these resources, replicating the distributive profile of the pre-existing equipment could, however, have easily led to a deepening of existing inequalities. As seen in the previous section, this was not what happened. From 2001, municipal managers began to take on a major role in proactively coordinating municipal policy and prioritizing those areas with higher populations of SUS users, which are the poorest areas and those with worse health indicators. The analysis suggests that the equity gains reported in the study happened trough cycles of micro and macro politics that reinforced each other. The micro cycles were lead by active local health councils which used political mobilization and contacts to pressure the municipal health secretariat for more resources. The macro cycles involved political projects and efforts by both the Workers' Party (PT), that held municipal office from 2001 until 2004, and the Brazilian Social Democracy Party (PSDB), which entered office in 2005. The equity gains made possible by the macro cycles were assured by the use of technical criteria to make sure that the new resources made available for basic health were distributed in a manner that would serve the population living in the municipality in a more equitable way. As it is described in detail in the study, these two dynamics, fed by political competition between PT and PSDB, allows for an explanation of the adoption of many of the policies that forged the distributive results described in the previous section.