Geneva Health Forum Archive

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Geneva Health Forum 2014 – Conclusions of Day 1

Highlight_of_the_Day Highlights of the Day

  • Integration from the point of view of health is needed at multiple levels
    • Global: different agendas (Universal Health Coverage, Primary Healthcare, MDGs, post-MDGs, Noncommunicable diseases, etc.)
    • National: political agendas, capacity and financial resources
    • Health system: capacity to respond to political agenda in parallel to responding to the needs of the population
    • Patient: driver of the health system

Lesson_of_the_day Lessons of the Day

  • Will the push be top-down and driven by resource and financial constraints
  • Or will it be bottom-up with consumers/patients driving the agenda
  • Importance of a clear understanding of the context where integration is taking place
    • How does the context shape the response

Quote of the day1 Quote of the day2 Quote of the Day

“In order for integration to happen cultural change is necessary, but it requires politicalsupport” – B. Levrat, CEO, Geneva University Hospitals

Feedback Feedback

  • Interesting discussions
  • Practice that explains the theory
  • Lively discussion
  • Different perspectives

Unanswered_Question Unanswered Question

  • Who will drive the “integration” agenda?
  • How to empower users of the health system to truly “drive” change?
  • How can medical education play a role in improving integration of the health system and patient perspectives?

Lesson Expectations for Tomorrow

  • More lively discussions
  • Answers to some of the questions about the role of the health systems
  • How do health systems fit into the larger picture of health on a national and global level

Download here the PDF version for CONCLUSIONS of DAY1




Making profession of family doctors attractive for future doctors: Kyrgyzstan

Author(s) Salima Sydykova1, Nurlan Brimkulov2.
Affiliation(s) 1Hospitral Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan, 2Department of Hospital Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan.
Country - ies of focus Kyrgyzstan
Relevant to the conference tracks Education and Research
Summary One of the main current healthcare problems is a shortage of family doctors/general practitioners, especially in rural areas. Medical students are not motivated to choose the specialty of family medicine because they don't find it prestigious. The community also has disrespectful and discriminating feelings about this specialty.
The Kyrgyz State Medical Academy has the very challenging task of re-orienting the training in order to find a training approach that would change this situation. This abstract is about one of the new teaching modules, “Human, Society and Health”. Its primary goal is to set a positive “pro-family medicine” attitude from the beginning of the undergraduate training.
What challenges does your project address and why is it of importance? The burning problem of health education and the healthcare system is a dramatic lack of general practitioners/family doctors in the field, particularly in rural areas. Many villages do not have even a single medical professional however it is considered that  the number of medical students in Kyrgyzstan is sufficient. Another figure is the low number of students who have their post-graduate education in family medicine as opposed to the giant number of residents who do their post-graduate education in the field of surgery, gynecology, cardiology and other narrow specialties. The major reason why students are not motivated to become a general practitioner/family doctor is a negative and disrespectful image of this specialty in the eyes of the community as undertrained and poorly qualified doctors.
Kyrgyz traditional health education system, both at undergraduate and post-graduate levels, is based on a curriculum with longitudinal disciplines that are taught separately and in isolation. The teachers of different departments are used to focusing on the narrow competencies of their discipline without knowing the general goal of the curriculum.
How have you addressed these challenges? Do you see a solution? KSMA is the largest medical educational institution that provides undergraduate and post-graduate and continuous medical education. To meet the needs of the healthcare system and to help to overcome the crisis in family medicine, the KSMA started working actively to change the curriculum and to change the whole approach to teaching the curriculum. The working groups of KSMA realized that the current curriculum needs one main goal that would connect and link all teaching units. The main task and challenge was to introduce the integration principle, so called vertical and horizontal integration, and build the curriculum around the core competencies to provide the country with well-prepared and motivated general practitioners.
After setting the main teaching goal as producing well-prepared General Practitioners/Family Doctors, the Department of the training, organizational and methodic work (DTOMW) has assigned working groups consisting of the representatives of each teaching Department/Chair to revise the existing modules and training programs.
Current modules were revised and some new integrated modules were developed in place of the longitudinal isolated disciplines.
One of the new modules was module “Human, Society and Health” for the 1st year of medical study. It involves the following disciplines: public health, psychology, philosophy, anatomy and physiology, biology and physics and clinical component. The revolutionary piece of the module is bringing the students to a real clinical environment, in the setting of a family medicine at a primary health organization. The module has a dual goal: the first is technical and the second is “ideological”. All the disciplines of the module built their teaching around these two goals. The first goal is to introduce a new medical student into the specialty of General Practice/Family Medicine, to orient medical students towards the specialty of general practice/family medicine and make them comfortable and aware about the goals of the undergraduate training. The second goal is to set a positive attitude towards the specialty of family medicine and help students understand the challenges and advantages of this specialty. The module explains the most important yet challenging role of the family doctors especially in neglected rural areas and the key role of primary health professionals in sustaining the health of the nation.
How do you know whether you have made a difference? Students are trained in the module “Human, Society and Health” in the beginning of their 1st year of study. To test the effectiveness of the module and our success in achieving our “ideological” goal each student was asked to make a visual presentation in any format to describe his vision and feelings about being a family doctor. Different formats were proposed: Power Point presentation, video, illustrated personal story, poster. Students were encouraged to work in groups. The idea behind the group work was to facilitate discussions and enhance creativity.
At the end of the module we conducted an anonymous survey among the students to assess the organizational and methodological aspects of the new module.
The students worked really hard on their projects and created motivational presentations and videos describing the challenging but fascinating work of a family doctor. All of them acknowledged that it is one of the most difficult jobs and admitted that their vision about the image and perspectives of a family doctor has been changed in the process of the training.
The anonymous survey of 221 first year medical students showed that 96% of the students found visiting doctor’s office interesting and helpful. 88% of the students found it the most interesting and motivational part of the training which allowed them to understand this profession better.
At the first meeting with students, each student was informally asked about future career plans and very few students had plans to become a family doctor, which was very shocking. A question about the choice of the profession was included into the survey.
25% of students responded that they “would like to work as family doctors in future”, 48% - “don’t know yet”, 27% - “would not like to work as family doctor” (explaining that they would like to become narrow specialists such as neurosurgeons, cardiologists, gynecologists, etc.).
48% of students who don’t know yet whether they would become a family doctor illustrates the possibility of using the 6-year training process to further encourage family doctor as a career choice. All the teachers of the KSMA have to be dedicated to the idea behind all the teaching units which is to build a positive and respectful attitude towards family medicine in our future doctors.
Our module allows us to understand the feelings and career plans of our future doctors, orient them into family medicine, and form positive attitudes to the primary healthcare professions.
Have you or the project mobilized others and if so, who, why and how? The disciplines were mobilized to form the working group and elaborate the training plan for the module “Human, Society and Health”. The most difficult part of the work was to re-orient the teaching staff into the integration mode. Traditionally every department would teach the discipline in isolation with its own competencies not being linked with the core global competencies of the whole master curriculum. Teachers of various departments had difficulty discussing the general training plan of the module and finding links to their discipline. They would tend to develop their part of the module without considering integration and interrelation with the other parts of the module. The coordinator of the module (the author of this abstract) took over the role of ensuring the integrity of the module and interconnection of the various disciplines and maintaining regular communication between the departments.
Now that the module is developed it is important to motivate the departments to continue collaboration and monitor the effectiveness of the new module in order to provide dynamic development and yearly improvement of the module.
If considered successful by the Main Training and Methodic Committee of KSMA, this module will be recommended to other medical schools in Kyrgyzstan.
When your donor funding runs out how will your idea continue to live? Our activity is not funded externally or internally. It is an internal initiative within the frames of the current health education reform which was started several years ago to meet the needs of the Kyrgyz health care system. To help with the revisions of the overall health education strategy and re-shaping the curriculum the KSMA has been granted funding for technical support by the health education experts of the Faculty of Medicine of Geneva University. They have provided field trainings for the KSMA leaders and faculty about the integration principles, competencies-based teaching and teamwork.
The reform at the KSMA is impeded by the lack of motivation of the faculty staff because their extra work is not funded and the only motivation to change is professional interest.
We need to discover other opportunities to motivate the faculty staff to improve their performance, to be engaged actively in this challenging but fascinating process in order to improve the training of future doctors!

The perception of Family Medicine by Medical Student and Clinical Teaching Staff: Tajikistan

Author(s) Dilrabo Kadirova1, Jura Inomzoda2, Sabine Kiefer3, Erik van Twillert 4, Kaspar Wyss 5
Affiliation(s) 1Chair of Family Medicine Nb. 1, Tajik State Medical University, Dushanbe, Tajikistan, 2Chair of Family Medicine Nb. 2, Tajik State Medical University, Dushanbe, Tajikistan, 33Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 4Medical Education Project, Swiss Tropical and Public Health Institute, Dushanbe, Tajikistan, 53Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tajikistan
Relevant to the conference tracks Health Workforce
Summary The Tajik government is committed to promoting a family medicine model for Tajikistan. However, recent trends show that family medicine remains an unpopular choice among medical students. The study explores, in a cross-sectional survey, the perception of students as well as teaching staff on family medicine. Results show that several steps can be taken by the university to improve the perception of family medicine among students and staff (e.g. orientation events, early exposure to family medicine training). However, extrinsic incentives are perceived as the most promising drivers for changing students’ perception of family medicine.
Background The Tajik government is, in its National Strategy 2010–2020, committed to a family medicine model by which affordable primary health care should be introduced throughout the country. To successfully implement the strategy, reforming medical education to increase the number of family doctors is therefore a priority. The Swiss Agency for Development and Cooperation is assisting these efforts through the Medical Education Project (MEP) being implemented by the Swiss Tropical and Public Health Institute.Though the changes are on-going, it is being observed that many students and health workers find family medicine still unattractive. The number of interns registering for family medicine has, similar to other Central Asian Countries, decreased strongly over the last years.It is assumed that several factors during undergraduate studies influence the choice of specialisation. Among these factors are the mediated perception of family medicine through medical teaching staff as well as the students own perception. To increase the number of family doctors, it is essential to understand the perception of family medicine at different stages of a students’ lifecycle at university and the possible positive or negative influences of these through teaching staffs’ own perception of family medicine.
Objectives The objective of the study was to generate insight into the prevailing perceptions of family medicine among medical undergraduate students and teaching staff. Possible determinants including the influence of socio-demographic aspects and clinical teaching. The changes to students' perception over the course of study were also investigated.
Methodology In 2013 a cross sectional survey among 1st, 4th and 6th year students as well as all clinical teaching staff at the Tajik State Medical University (TSMU) was carried out by the chairs of family medicine. Perception of respondents towards family medicine was assessed through a set of items relating to family medicine. Respondents were asked to rate them on a 5-point Likert scale.
In total more than 2’500 students and more than 350 staff of TSMU were included in the study. The ratings were analysed through factor analysis to identify underlying dimensions in the perception items. Each factor was combined in a composite score to compare opinions of different groups using statistical tests for independent samples and outcome variables to investigate the influence of socio-demographics.
Results Students were mostly interested in working in specialities other than family medicine, most prominently surgery and obstetrics and gynaecology. In their speciality choice, students rated the possibility to work in Dushanbe and/or abroad, as well as prestige and salary very highly. Teaching staff reinforced these aspects as main drivers for students’ choices but also added that career opportunities/professional possibilities would play an important role. Overall students and staff of all three cohorts agreed that working as a family doctor is currently not very attractive in Tajikistan.
There was also large agreement that most students, as well as teaching staff, do not actually know what family medicine is really about. Moreover, students were convinced that society and other medical professionals have a low opinion and perception of family medicine.
Nevertheless, students showed themselves to be open to family medicine. Students and teaching staff both agreed that everyone should receive training in family medicine, no matter what specialty they choose later. Students supported the idea that family medicine should have the same prestige as any other speciality. This was seen differently by some teaching staff. However, students and teaching staff did not agree that family doctors should receive higher salaries than narrow specialists or that the access to specialists should be controlled by family doctors.
The majority of students did not recall any comments by teaching staff about family medicine. Of those who had heard about family medicine, many reported that the statements were neutral or positive.
More in-depth results are currently being analysed and will be presented at the Geneva Health Forum 2014.
Conclusion The study provides insight into Tajik medical undergraduate students’ perception of family medicine and indicates that targeted interventions are necessary to increase the interest and commitment of students to become family doctors.
Several steps can be taken in conjunction with the university, the chairs of family medicine and through the medical education curriculum to improve students and staff perception of family medicine.
Given the low level of knowledge of family medicine, it is concerning that students and staff have a rather bad perception of family medicine. The majority of teaching staff and students were unfamiliar with family medicine. Once students enter university orientation and information events are essential. Contents of family medicine lectures, as well as career pathways, should be presented to the students. Similarly, information and promotion activities for the teaching staff would lead to a better perception of family medicine. Adapting the curriculum to provide an earlier and intensified exposure to family medicine training is required. Attractiveness and participation in practical trainings in family medicine should also be incentivised.A higher appreciation of family doctors, through extrinsic incentives, would positively change student perceptions. The most important aspects for students choosing a speciality were those which currently cannot be offered by family medicine positions in Tajikistan, specifically the placement in the Dushanbe or the higher prestige of a speciality. These aspects need reforms and continuous efforts from the Tajik Ministry of Health to better the conditions for family doctors and provide incentives for students to take up family medicine. Incentives for students need to be well-designed and structured to ensure that they truly raise students’ interest in family medicine. Beside higher salaries for the family doctors compared to other narrow specialities, this could include mandatory internships in family medicine.Based on the Tajik national health sector strategy, a strong political commitment from the government outlining the possible career pathways and opportunities for family doctors would clearly enhance the perception, value and popularity of family medicine.

Self-Efficacy of Nurses in the Performance of Counselling-Related Tasks: Eldoret, Kenya.

Author(s) Carolyne Chakua1.
Affiliation(s) 1Educational Psychology, Moi University, Eldoret, Kenya.
Country - ies of focus Kenya
Relevant to the conference tracks Health Workforce
Summary This study investigated the self-efficacy of nurses at Moi Teaching and Referral Hospital in the performance of counselling-related tasks. A self-efficacy questionnaire was used to assess the nurses’ self-efficacy in the performance of counselling tasks. The findings revealed that whereas age, experience and additional training in nursing had a significant influence on nurses’ self-efficacy in performing counselling tasks, gender and level of training had a non-significant influence. These findings pose significant implications for managers and trainers of healthcare professionals in ensuring an enabling environment for the practicing and training of professionals in counselling tasks.
Background Counselling as a fundamental element of nursing has been acknowledged repeatedly. Nursing is recognized as being the art and science of caring. The artistic part of nursing demands ability in the creative use of nursing actions. The scientific part involves an analytical, systematic process to solve clinical nursing problems. Irrespective of which approach nurses take, the need for counselling-related skills is inherent in nursing tasks. Despite numerous opportunities for nurses to utilize counselling skills, their ability to effectively provide these services using the knowledge and skills gained during their training is an issue of concern. For a long time now, concern has grown that nurses may often be ineffective counsellors, and that deficiencies exist in training for counselling-related skills in nursing. It is against this background that the study investigated the perceptions of nurses regarding their performance in counselling-related tasks. This was achieved through the measurement of nurses’ self-efficacy. Self-efficacy measures were identified through statements identifying counselling tasks, where the participants were required to indicate their level of confidence in performing these activities.
Objectives 1. To investigate the relationship between age and self-efficacy of nurses at Moi Teaching and Referral Hospital (MTRH) in performing counselling tasks.
2. To investigate the relationship between gender and self-efficacy of nurses at MTRH in performing counselling tasks.
3. To investigate the influence of level of training in nursing on the self-efficacy of nurses at MTRH in performing counselling tasks.
4. To investigate the effect of experience in nursing on the self-efficacy of nurses at MTRH in performing counselling tasks.
5. To investigate the influence of additional training in counselling skills on the self-efficacy of nurses at MTRH in performing counselling tasks.
Methodology The study employed a causal comparative research design, a type of descriptive research that describes conditions that already exist, with an attempt to determine reasons, or causes, for preexisting differences in groups of individuals. This study adopted simple random and stratified sampling as probability techniques to select participants involved in the collection of the data. At the very outset of this research process, stratified sampling was used to select practicing nurses based on the departments they worked in. From each stratum, simple random sampling technique was then employed to select participants from each department. This was achieved through computer generation of random numbers from the list of nurses in each department to come up with a total of 212 nurses. The Self-Efficacy Questionnaire was used as a close-ended questionnaire with 30 statements describing counselling-related tasks. The respondents were required to answer on a 5 point likert scale, where 1 = Not true; 2 = Hardly true; 3 = Not Sure; 4= Moderately true and 5 = Very true. T-test for independent samples was used to compare the difference in mean self-efficacy scores for the categorical variables in this study that had only 2 groups: gender (male and female) and additional training (yes and no). One-way ANOVA was used to compare mean difference in self-efficacy along the variables of age-group, level of training and length of experience in nursing, and variables that had more than two groups. All tests were considered significant at 95% confidence level.
Results 1. Relationship between age and self-efficacy in performing counselling-related tasks: The results indicated that there was a statistically significant difference in mean efficacy score by age of nurses, F(192 ) = 1.52, p = .03. From these results, it was then concluded that age does influence self-efficacy of nurses in the performance of counselling. The older the nurses, the more efficacious they are in performing counselling tasks.
2. Relationship between gender and self-efficacy in performing counselling-related tasks: The result of the analysis indicated that there was a non-significant difference, t(193) = -.50, p = .619. It was then concluded that gender had no significant influence on the self-effcacy of nurses at MTRH in performing counselling tasks.
3. Relationship between level of training in nursing and self-efficacy in performing counselling-related tasks: The results indicated that there was a statistically non-significant difference, F(190) = 2.0, p = .117. The interpretation thereof was that the level of training in nursing, whether certificate, diploma or undergraduate degree, did not exert any significant influence on nurses’ self-efficacy in performing counselling tasks.
4. Relationship between length of nursing experience and self-efficacy in performing counselling-related tasks: The results obtained indicated that there was a significant difference among the mean scores, F(191) = 3.12, p = .046. Therefore, nurses with longer experience had a higher self-efficacy in performing counselling tasks than those who had less work experience.
5. Do nurses who have received additional training in counselling skills and those who have not differ in self-efficacy in performing counselling-related tasks? Nurses with additional training in counselling skills were defined as those nurses who have undertaken additional training in counselling, outside of their regular nursing training programme. The result of the analysis indicated that there was a statistically significant difference between the mean scores, t(192) = 2.51, p = .013. Consequently, it was concluded that nurses with additional training in counselling were more self-efficacious in performing counselling tasks than those without additional training.
Conclusion Self-efficacy of nurses in performance of counselling tasks was investigated along various variables namely age, gender, level of training, experience in nursing and additional training in counselling skills. Of these variables, the study found out that gender and level of training do not significantly influence the self-efficacy of nurses in performing counselling tasks. On the other hand, this study revealed that additional training, age and experience in nursing positively influence self-efficacy of nurses in performing counselling tasks. Bandura (1977) asserts that self-efficacy is enhanced by interventions. In the case of nurses at MTRH, their self-efficacy in performing counselling was enhanced by additional training in counselling, advance in age and increase in experience. All these three factors are external interventions that positively impacted performance of nurses. In essence, the self-efficacy of nurses in performing counselling tasks had everything to do with external interventions as opposed to personal attributes. Furthermore, these interventions enabled exposure to specific activities in a deliberate manner. This could explain why the level of training in nursing, though an intervention, had a non-significant effect on self-efficacy as the nursing training in itself does not deliberately address preparation in task specific counselling activities. These findings provide insights for all stakeholders in the field of medical education on the relevant areas of emphasis in training healthcare workers. This in turn will translate to competent professionals and high levels of patient satisfaction.

Would you Terminate a Pregnancy Affected by Sickle Cell Disease? Views of Doctors, Parents and Patients in Cameroon.

Author(s) Ambroise Wonkam1, Jantina de Vries2, Charmaine Royal3, Dora MBanya 4, Jeanne Ngongang 5, Fru Angrafo III6
Affiliation(s) 1Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, 2Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Institute for Genome Sciences & Policy, Duke University, Durham, United States, 4Department of Medicine, Faculty University of Yaoundé I, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon, Biochemestry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon, Surgery, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary We studied the views of 110 doctors, 130 parents with one living child with SCD (Sickle Cell Disease), and 89 adults patients suffering from SCD, regarding prenatal genetic diagnosis and termination of a SCD-affected pregnancy.
The majority accepted the principle of prenatal genetic diagnosis for SCD (78.7%, 89.8% and 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%) as opposed to doctors and patients where this group were in the minority (36.1%, and 40.9 %). Parents and patients who rejected termination of pregnancies claimed ethical reasons (69.1 and 78.1%) while those who accepted it feared having another SCD-affected child (98.1 and 88.9%) with a poor quality of life (92.6% and 81.5%).
Background Patients with Sickle Cell Disease (SCD) can suffer from anemia, painful episodes, susceptibility to infection, stroke, and chronic organ damage (kidneys, lungs, heart, brain). There is currently no cure available for SCD, but the condition can be managed using a variety of therapies. When the condition is not managed patients tend to die in early childhood as occurs in many African countries.
In Cameroon it is possible to test for sickle cell homozygosity before birth, and in fact Prenatal Genetic Diagnosis (PND) represents one type of preventive strategy, as it is offered as a reproductive option to at-risk parents. PND provides parents with a reproductive option to test at-risk pregnancies and make decisions regarding medical abortion.
However, legal bans on abortion exist in virtually all African countries and when allowed medical abortion is often restricted to direct threats to maternal health. This raises important ethical questions regarding the desirability of terminating affected pregnancies.
Many parents currently caring for a child with SCD opt to abort a fetus that is also suffering from SCD. What has not yet been investigated is the comparative views of parents to those of health care providers and patients living with SCD.
Objectives We examined the attitudes of a sample of Cameroonian medical doctors, parents with at least one SCD-affected child, adult SCD patients towards PND and TAP. There were two major research questions: (1) their agreement with prenatal genetic diagnosis and pregnancy termination in general (2) their agreement with prenatal genetic diagnosis for SCD, and pregnancy termination for SCD, and the reasons for their attitudes.
Methodology Design
This research was a quantitative social science study administered by structured questionnaires.
Sample Population and Eligibility Criteria.
The sampling methods used included both purposeful and convenience sampling.
Medical doctors were recruited from a National Medical Conference for continue medical education. In an attempt to ensure inclusion of parents and adult SCD-affected patients and incorporate the entire spectrum of this illness, we issued a call for participation using the national Cameroonian media. We also approached two SCD Patients’ Associations in Cameroon. Participants needed to be at least 18 years old with a diagnosis of SCD that was confirmed by a laboratory documentation of their hemoglobin electrophoresis.
Questionnaire Format.
The data were collected by means of a structured questionnaire consisting of three sections of closed-ended questions. These were (1) Socio-demographic characteristics; (2) Attitudes towards SCD screening policies; and (3) Attitudes about principles of SCD- prenatal diagnosis and termination of an affected pregnancy if the participant’s unborn child were proven to be affected. Response options were “Yes,” “No” or “Undecided”.
Research Setting and Data Collection.
The study was conducted at the Yaoundé Central Hospital where face-to-face questionnaires interviews were conducted. Informed consent was also obtained at this stage. In addition to the introductory explanation, each patient was given full non-directive genetic counseling with neutral information concerning PND and its reproductive options. Images were used to explain the obstetric procedure of PND and risks (specifically 1% induced miscarriages). Information on the available therapeutic options and follow up for patients with SCD was reviewed and the participants were given an opportunity to ask questions. The information provided during this counseling session was equivalent to the information that prospective parents would have received had they been seeking PND for SCD.
Data Analysis.
Data were analyzed using SPSS (Statistical Package for Social Sciences, Chicago). A comparison between two or more variables was evaluated by non-parametric tests (H test of Kruskal-Wallis or Z test of Kolmogorov-Smirnov, when applicable). The p values were considered significant if they reached 95%.
Results The majority of parents participants lived in urban areas (89%), were female (80%), Christian (93%), married (60.2%) in monogamous households (81.1%), were employed (61.7%), and had at least a secondary or tertiary education (82%). Similarly, the majority of the patient participants were urban dwellers (84.3%), female (57.3%), Christian (95.5%), single (90.9%), with a secondary/tertiary education (79.5%).
The clinical profile of participant children and patient participants indicated that they suffered from (relatively) severe forms of SCD. The majority of research participants received poor treatment for their SCD. Only 4.4% of participants received hydroxyurea treatment, the only treatment currently available to manage SCD. Nearly 90% (89.7%) had received traditional medicine for their conditions on at least one occasion in the past.
The majority accepted the principle of prenatal genetic diagnosis for SCD (doctors: 78.7%; parents: 89.8% and patients: 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%), but doctors and adults patients were less comfortable with this principle (36.1%, and 40.9 % acceptance, respectively). The acceptance of the principle of medical termination for SCD increased with unemployment status. (missing data here)
Conclusion Differential views regarding medical abortion for SCD in Cameroon could lead to societal, ethical and legal conflicts. Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon.
The patient participants in this study indicated a surprisingly high (40.9%) rate of acceptability of TAP. This is surprising as one could argue that a decision to terminate a pregnancy where the future child would suffer from the same condition that is affecting the parent seems to imply a value judgment about the individuals’ quality of life. Patients who participated in this study presented with severe forms of SCD. We wonder whether our results mean that approximately 4 out of 10 of the patients included in this study did not find their quality of life worth living and did not want to allow a child to experience it. This is a disturbing finding that requires the further attention of policy makers and medical professionals in Cameroon.
Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon. For instance, the average late diagnosis of the condition in our participants leads to greater clinical severity. In addition, the very low number of people who receive adequate medical care to manage their condition, as well as the large number of people who received traditional medicine, may also indicate the failure of medical professionals in Cameroon to adequately manage SCD. Many patients with SCD require the expertise of specialized centers. Lifelong medical care and surveillance are not yet available in Cameroon where provision of healthcare services is hampered by major economic, organizational and infrastructural difficulties.These differential views of patients, physicians and parents also indicate potential ethical conflicts between various components of the Cameroonian society regarding TAP for SCD. Additional studies among various groups may provide detailed insight into the range of moral, legal and social perspectives held by the public and the healthcare community regarding genetic technology and prenatal diagnosis in Cameroon.

Needs of Female Medical Students concerning Reproductive Health Education

Author(s): H. Gharaie1
Affiliation(s): 1Women Affairs Office, Ministry of Health and Medical Education, Tehran, Iran
Keywords: Reproductive health, education, focus group discussion

Reproductive health is a state of complete physical, mental and social well-being, in all matters relating to the reproductive system and to its function. Improvement of the women’s health status requires not only good health services, but also their cooperation. Information about the importance and details of healthcare are necessary to ensure the best individual cooperation. Thus education is one of the most important factors of reproductive health.


In order to plan an appropriate educational programme assessment of information, insights and behaviours of the target group are needed. In this project that was implemented thorough focus group discussion insights of female medical students about reproductive health have been evaluated. A questionnaire was designed about reproductive health, and its questions were discussed by the 12 selected female medical students.


We concluded that although the students’ insight about reducing uncontrolled population was accepted but their information about family planning, sexually transmitted diseases and HIV were not significant. Most of them believed that today reproductive health education is neither enough nor appropriate, so they could not be good messengers of reproductive health in their society .In addition, theoretical, microbiological and demographic bases are more attended in these educational university programmes and unfortunately operational aspects of reproductive health, family planning, sexually transmitted diseases and their ways of transmissions and prophylactic methods are less considered. Many of the students believed that 20-25 and 24-28 years are the most suitable ages for marriage for the girls and boys, respectively. Most of them suggested beginning reproductive health education in school. Unfortunately, sometimes inappropriate nutritional behaviours are seen among students.

Lessons learned:

In view of the fact that marriage is delayed and because of our cultural background, today we need some plans of action for answering to young people’s needs. Also for planning the best such actions, there is a need for discussions and recommendation of specialists and exports, in addition to find   strategies to facilitating marriage by the government.

Access to Reproductive Health Services in Rural Haryana, India: Pertinent Issues and Concerns

Author(s): A. K. Aggarwal1
Affiliation(s): 1School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Keywords: Reproductive health, access, quality of care, community survey

Better access to healthcare is a global challenge. Increased amounts of funds are allocated nationally and internationally to improve access. Therefore, understanding access at local levels helps to focus the policies and strategies.


To study utilization of pubic health facilities for reproductive healthcare. 2) To identify important access issues from community’s perspectives.


Women tend to consult government and private doctors for the problems associated with use of family planning method. For reproductive tract problems, however, private doctors are preferred over govt. doctors. For institutional deliveries and emergency obstetric care this gap was much more pronounced, with private practitioners taking the lead over govt. health institutions. The major reasons for these as elicited through various focused group discussions were uncaring attitude of health service provider, resulting in delayed initiation of treatment. Other important reasons from community’s perspective were lack of availability of govt. doctors, and insufficient medicines. Lack of faith in public health services drives them to private practitioners that are costlier. Treatment often gets delayed in the process of arranging money. Such delays become fatal for maternal complications, as was evident from maternal mortality enquiry. Health centres were observed for availability of health facilities. Only 56% sub-centres are located in govt. buildings. Approachability of most of the sub-centres was poor especially in rainy season. At community health centre (CHC): first level of health centre where specialists in medicine, surgery, paediatrics and obstetrics should be available, money is charged for routine investigations. This is an important deterrent for many women. Unorganized antenatal care set-up, interpersonal conflicts between service providers, poor management and, co-ordination of services and vested interests reduce access of services to the clients. Only normal vaginal deliveries are conducted at this CHC and for all complications women are referred to district hospital. Ambulance for referral is available but is not accessible to all due to lack of awareness on the part of users, and lack of proactive approach and supervised referral on part of health providers. Treatment at government health facilities consumes more time, and people have to pay money to avail these services. Although cash expenditure is more in private hospitals, but time was considered as more precious than money by most people in this area. For others, even small amount levied upon at government facilities was deterrent. Service environment was found to be very poor at all levels. Our observations indicate that technical incompetence was an important contributor for mismanagement of reproductive problems and maternal complications. Lack of inventory management skills and human resource management skills resulted in frequent vaccine stock-outs and non delivery of services. Technical gaps were also observed through prescription audit. Emergency obstetric care services are practically not available at CHC. All such complicated cases arriving here should have gone directly to district hospital. The information gap exists because of stereotyped thinking in community and among health providers that referral chain from sub-centre to PHC, CHC, and district hospital should be followed irrespective of type of complication and availability of facilities to tackle the complication.

Lessons learned:

Investment on improving management skills, financing mechanisms to cut treatment delay due to immediate non availability of money, putting in place better maintenance structures for building, equipment and supplies, and technical strengthening of health staff may help build faith of community in public health services and improve access.

Why Doctors Strike in Public Health Systems in India: Lessons for Medical Education and Addressing Migration of Healthcare Workforce

Author(s): A. Das1
Affiliation(s): 1Director, Centre for Health and Social Justice, New Delhi, India
Keywords: Medical ethics, health systems, workers rights, training, medical education, health policy, India

India is emerging as a global economic superpower but lags behind many nations in health related MDG indicators. India has a severe shortage of doctors in the public sector and huge public healthcare crisis. The new public health policy in India, the National Rural Health Mission promises an improvement in the public health system and in improvement in basic public health indicators. It is based on the principles of comprehensive primary healthcare. There have been a large number of strikes by young doctors and doctors in training in India over the last couple of years. These have taken place in tertiary teaching hospitals and across many states. The reasons have varied but there are strong links to young doctors wanting privileges and personal opportunities. These include refusal to undergo compulsory rural or public sector posting, or seeking opportunities to go abroad.


The paper is based on newspaper and other secondary reports of a range of strikes across various states in India over the period of the last three years since the National Rural Health Mission was announced. The reasons given for the strikes by young doctors or doctors in trainings, as well as the provocations are examined. The response from the health bureaucracy is examined in the context of the national constitution and health policy guidelines.


The paper provides a short historical summary of the growth of western medical training in the country over the last one hundred and fifty years. The paper examines the changing context of western medicine in providing healthcare to rural and poor citizens in India and the role of the public and private healthcare sector. The paper examines the strikes by young doctors in the context of the growing private sector medical industry and the phenomenon of ‘medical tourism’ that has come up in the country. The paper also examines the validity of strikes by doctors and doctors in training in the context of medical ethics and worker rights.

Lessons learned:

Medical education needs to be guided by a number of factors. While it is necessary to provide up-to-date medical information, and build adequate clinical skills, it is also essential to ground it in the constitutional character of the country and in medical ethics. Doctors are not technical agents in a market place selling healthcare innovations but agents responding to the social and political reality relating to health in the country in which they are trained. The application of these principles in designing medical education curriculum may prevent widespread migration of medical personnel from developing countries.

Global Workforce in Crisis: What Crisis?

Author(s): B. Marchal*1, M. Van Dormael1, G. Kegels1
Affiliation(s): 1Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Keywords: Health workforce, crisis, complexity, context

Human Resources for Health advocates were successful in putting the African health workforce issue on the agenda by framing it as a crisis. The notion of ‘crisis’ usually evokes shortages of staff, and as a consequence, solutions are sought predominantly in the realm of increased manpower production and limitation of brain drain.

Summary/Objectives: We argue that today, there is not one single workforce crisis, and that many African countries do not even face serious shortages. Lumping together all African countries within a single analysis, without taking into consideration the diversity of contexts and the complexity of the problems they face, is likely to lead to inappropriate answers.

1. The challenge of diversity: While some southern African countries have to cope with an undeniable shortage in numbers of health workers (due to HIV/AIDS, brain drain and/or armed conflicts), other sub-Saharan African countries face chronic human resource problems of different kinds: decreased attraction of caring professions, urban/rural misdistribution, skewed skill mix, ineffective regulation mechanisms of health professionals and inadequate (para-)medical education systems. 2. The challenge of performance: Increasing numbers is a necessity in most countries, but will be insufficient on its own to increase performance of health workers. The latter relates to their competencies and their willingness to apply these competencies to the benefit of patient and community. Achievement is the product of three elements: availability of staff, competence and motivation. 3. The challenge of complexity: Management of health workers is dealing with the complexity resulting from the great variety of professional and non-professional cadres, the nature of the work (from very technical tasks to tasks that require strong interpersonal skills), and the diversity of societies to which they belong and of contexts in which they work.

Lessons learned:

In the light of these challenges, we propose a few guiding principles for health workforce management and policy:
1 – Comprehensive problem analysis: Open systems theory offers powerful tools to examine the root causes of health workforce problems, which are often interlinked and acting on different levels.
2 – Comprehensive solution analysis: In clinical settings, balanced bundles of human resource management (HRM) practices including training, supervision, shared decision-making and teamwork, are more effective in eliciting staff commitment than isolated interventions. Furthermore, not only micro issues at organisational level, but also the external conditions that affect health service managers and their staff (decentralisation, labour market conditions, etc.) need to be taken into account.
3 – Implementation scale matters: Small sized organisations cannot always offer comprehensive interventions on their own, because this requires decisions about external conditions outside their scope of decision making. In such cases, federations, associations and networking make much sense.
4 – Supportive policy environment: policies need to provide health service managers with the autonomy and the means to develop responsive HRM practices. They should institute a solid administrative framework, but also need to provide leeway to managers to develop commitment-eliciting management practices.
Focusing only on the numbers limits the search for solutions to a narrow crisis management perspective. Instead of reactive policies that seek solutions in the short-term, we need to take time to develop pro-active, long-term HR policies. Context-sensitive HRM policies and practices are the key to a more stable and better performing health workforce.

More Healthcare Providers: A Crisis in the Health System

Author(s): G. G. Jerbashian1
Affiliation(s): 1Policy, Knowledge Management Team, Project NOVA, Yerevan, Armenia

Health workforce imbalance, health human resource planning, access to and quality of healthcare


Unlike many developing nations facing huge shortage of health workforce, Armenians experience poor access to healthcare, although the number of physicians is 38.2 per 10,000 inhabitants compared to the average 24.0 in the United States or 34.0 in France (2005), having much better health indicators. Compared to 26.5 in the United States and 17.5 in France, in 2005, the Armenian state medical university alone produced 40.1 medical graduates per 1,000 practicing physicians. Most of these lacking clinical skills freshmen reside and stay to practice medicine in the capital. The Armenian healthcare system is characterized by overstaffed hospitals with low (48%) utilization, inadequate distribution of medical workforce across the country with 76.9 physicians (per 10,000 inhabitants) in the capital vs. 17.6 elsewhere, high level of unmet need for healthcare, and widespread informal payments. The medical workforce has not reduced, despite the hospital beds substantial cutback (49.8%) due to the recent Governmental reforms. Some 95.0% of women paid out-of-pocket money for state-funded pregnancy and delivery care. Despite well developed physical network of health facilities, large number of people eligible to the wide range of state guaranteed free-of-charge services, 39.5% of sick people report not seeking medical assistance because of financial constraints.


1 – Analyse the systemic, structural, and regulatory barriers jeopardizing the efficiency of the healthcare system.
2 – Analyse the extent to which Armenians experience lack of access to healthcare.
3 – Reveal the adverse outcomes of ‘excessive’ healthcare.
4 – Analyse the factors influencing the never-ending increase of prices in healthcare.
5 – Develop policy interventions aiming at increasing access to and quality of healthcare, while improving the efficiency of healthcare system.


Our study identified oversupply of medical workforce as one of the critical factors influencing the interminable increases of prices in healthcare and spread of corruption in the system. On the basis of trends in several national health indicators, adverse outcomes of care are observed in Armenia. Reasons include but are not limited to excessive number and unbalanced distribution of medical workforce in the country. Our analysis indicates steady growth of medical fees and informal payments. Having too many physicians in Armenia does not contribute to better access to and quality of healthcare. The existing healthcare system needs restructuring, specifically as it relates to human resources planning and workforce management. Health system inefficiency in Armenia is stipulated also by low salaries of health providers ‘justifying’ their demand for ‘under-the-table’ payments, and overgrowing number of physicians in the country. Having too many physicians in Armenia does not contribute to the better access to and quality of healthcare. Existing healthcare system needs restructuring, specifically as it relates to the human resources planning and workforce management. Along with customizing the medical workforce skill mix to local health needs, raising public awareness on free-of-charge healthcare services guaranteed by state, introducing proper incentives for retention of health workers in rural areas and regional centres, there is a definite need for strict regulations on medical education and practice, including: solid licensing and (re)-accreditation system, preparation of scientifically sound number of medical cadre and their equitable and balanced distribution across the country.

Lessons learned:

1 – Explain why an excessive number of healthcare providers can actually increase medical fees, induce informal payments while not improving health outcomes, and, hence, be a burden to public health.
2– Formulate policy interventions contributing to the efficiency of the healthcare system and better health outcomes.