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Geneva Health Forum 2014 – Conclusions of Day 2

Highlight_of_the_Day Highlights of the Day

  • For integration of health to become a reality the following are needed:
    • Enlightened politicians
    • Multiple sectors and actors involved in health (but being careful of any conflicts of interest)
    • Adequate funding and resources and appropriate use of these
    • Research and production of knowledge

Lesson_of_the_day Lessons of the Day

  • How does the global governance structure help ensure integration of health and the health system by:
    • Leading at a global level, but taking into account local conditions
    • Define the roles and responsibilities of different actors
    • Ensure coherent allocation of resources
    • Make health the priority and entry point for sustainable future

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

“ Stop talking about health systems and start talking about systems for health” - D. De Savigny, Head, Health Systems Interventions Research Unit, Department of Public Health and Epidemiology, Swiss Tropical and Public Health Institute, Switzerland

Feedback Feedback

  • Integration seems to mean different things to different people
  • This brings things I have read and learnt to life
  • Amazing panel with Prof. Ilona Kickbush, Prof. Ronald Labonté, Dr. Mira Shiva, Mr. Pascal Lamy and Mr. Bart Peterson – such a wealth of information
  • All the speakers are so approachable and open to further discussion and debate after their presentations

Unanswered_Question Unanswered Question

  • Day 1 looked at the “what” of integration and Day 2 more about the “how” so the unanswered questions are:
    • Who will lead the integration agenda?
    • What role for the WHO in the changing global health environment?
    • What role for the private sector in integration?

Lesson  Expectations for Tomorrow

  • Looking at issues beyond health, e.g. food, innovation, sustainability
  • How can integrating other sectors and perspectives benefit health
  • More interesting and thought provoking sessions

Download here the PDF version for CONCLUSIONS of DAY 2

 

 

 

GHF2014 – PL05 – Integrating Health, Wellbeing and Sustainability

08:45
10:15
PL05 THURSDAY, 17 APRIL 2014 ROOM: 2 ICON_QA
INTEGRATING HEALTH, WELLBEING AND SUSTAINABILITY
MODERATOR:
Dr. Carlos Dora
Department of Public Health and Environment, World Health Organization, Switzerland
PANEL:
H.E. Ambassador Michael Gerber 
Ambassador and Special Representative for Global Sustainable Development Post-2015, Swiss Agency for Development and Cooperation (SDC), Switzerland
Mrs. Pam Warhurst 
Founder and Chair, Incredible Edible Tordmorden, United Kingdom
Mrs. Meenakshi Raman
Third World Network, Malaysia
Mr. Rick Bell
Executive Director, American Institute of Architects New York Chapter, Center for Architecture, United States
AIM:
Discuss how to better integrate the three dimensions of sustainable development and embed health into the post 2015 new development agenda.
OUTLINE:
The Millennium Declaration adopted by the heads of State at the Millennium Summit in 2000 has constituted the dominant development paradigm and organizing framework of the last decade. The Millenium Development Goals have substantially contributed to focus development co-operation efforts, strengthened the accountability requirement and mobilized support. With the Millennium Development Goals scheduled to come to an end in 2015, the international community is now taking stock of the substantial advances made as well as the unevenness and gaps in achievement. As we approach the 2015 deadline, unrelenting efforts are required to accelerate progress across all the goals but debates and global consultations about what will replace the MDGs have already taken place. In June  2012, on  the  occasion of the Rio+20 Conference on  Sustainable Development, another mandate  with  similar  aspirations  was  born:  the  Sustainable  Development  Goals  (SDGs). Whilst the MDGs primarily focused on social issues such as poverty, hunger, health and education in developing countries, SDGs will seek to strike a balance between all three dimensions of sustainable development, namely the economic, environmental and the social, and will be applicable for all countries.Health as a component of social progress is a key aspect of the debates, and is being framed as a precondition for, an outcome and a possible indicator of sustainable development.The position health might take into this new framework is still subject to various narrative exercises and a lot of uncertainty still remains of what will be the next development framework by 2015.Moving away from global statements and declarations, the session will convey a diverse panel of actors involved in development, urban planning and community mobilization to discuss the enabling environment needed at a global and local level to build healthier societies and preserve our environment.Some of the questions to be discussed include:

  • What kind of systemic global reforms would be required to secure an accommodating international environment for sustainable development in both developed and developing countries?
  • How can health serve as an indicator to measure sustainable development policies progress, achievement and impact?
  • How can local communities, people’s movements and citizens contribute in shaping healthier and more inclusive societies/cities?
  • How can urban design influence behavioral changes and promote healthy living?
PROFILES:

Carlos Dora_squareDr. Carlos Dora

Carlos Dora, is a coordinator at the WHO HQ Public Health and Environment Department, leading work on health impacts of sector policies (energy, transport, housing and extractive industry), health impact assessment and co-benefits from green economy/climate change policies. He previously worked at the London School of Hygiene and Tropical Medicine (LSHTM), at the WHO Regional Office for Europe, at the World Bank, and with primary care systems in Brazil after practicing medicine. He serves in many science and policy committees, has an MSc and PhD from the LSHTM.  His publications cover health impact of sector and sustainable development policies, HIA and health risk communication.

 

Michael Gerber Jan. 2013H.E. Ambassador Michael Gerber

Perspective: Switzerland’s position on the new Sustainable Development Framework

Member of the Swiss Agency for Development and Cooperation (SDC), Mr Gerber was the Head of the SDC Analysis and Policy Section before being appointed Special Representative for Global Sustainable Development Post-2015 by the Federal Council with the rank of ambassador. In this position, he has been given the task of formulating Switzerland’s position on a Framework for Sustainable Development Post-2015 . Ambassador Gerber is also representing Switzerland in the Open Working Group on SDGs (Switzerland shares with France and Germany).

 

PL05_Pam_WarhurstMrs. Pam Warhurst

Perspective: How to empower ordinary people to take control of their communities through active civic engagement.

Pam Warhurst is a British community leader, activist and environment worker best known for co-founding the community initiative, Incredible Edible, in Todmorden, West Yorkshire.

Pam studied Economics at the University of Manchester. She has previously served as a member of the Board of Natural England, where she was the lead non-executive board member working on the Countryside & Rights of Way Bill. She is a Fellow of the Royal Society of Arts & Manufacturing, and chairs Pennine Prospects, a regeneration company for the South Pennines, and Incredible Edible Todmorden, a local food partnership. Pam has also been Deputy Chair and Acting Chair of the Countryside Agency, leader of Calderdale Council, a board member of Yorkshire Forward, and chair of the National Countryside Access Forum and Calderdale NHS Trust. Pam was awarded Commander of the Order of the British Empire award (CBE) in 2005 for services to the environment.

PL05_Meenakshi_Raman_squareMrs. Meenakshi Raman

Perspective: How to tackle the growing environment crises factoring international equity in the equation?

Mrs Raman is Legal Advisor and Senior Researcher at Third World Network (TWN) and is based in Geneva. She is also a Member of the Board of Friends of the Earth International and Honorary Secretary to Friends of the Earth Malaysia (Sahabat Alam). As Legal Advisor to the Consumers’ Association of Penang in Malaysia, she currently heads its Community Mobilization Section, which works with farmers and fisher folk. She has served as Chair of Friends of the Earth International (2004-2008), an international organization with 77 member groups. At Third World Network, Meenakshi currently coordinates the Climate Change Programme and has actively been involved in the intergovernmental climate negotiations, from Bali to Cancun. She has been monitoring and reporting on the negotiations and providing analysis and support both to developing country governments as well as to civil society participants. Upon graduation in 1982, Meenakshi and a colleague set up the first public interest law firm in Malaysia, which launched her legal practice assisting consumers. In the past 25 years, she has represented the organizations she works with at numerous conferences and presented papers on issues ranging from environmental and consumer protection, to climate change, agriculture and fisheries, and globalization and trade.

PS25_Rick Bell_squareMr. Rick Bell

I became an architect because of the inspirational oratory of professors including Vincent Scully and the physical example of buildings seen while attempting, at the age of 19, to hitchhike from Paris to Dakar. As an architect I've had three careers, first in the private sector, then at a public agency, and, most recently, in the not-for-profit domain. As a private architect, I mostly designed schools and libraries in a NYC-based firm that also did hotel projects worldwide. In the public sector, I served as chief architect and assistant commissioner of New York City’s public works department, responsible for 700 projects annually. And for the last twelve years I’ve led the New York Chapter of the American Institute of Architects and created its storefront Center for Architecture.

GHF2014 – PL03 – Global Health Governance: Integrating Competing World Views

14:00
15:30
PL03 WEDNESDAY, 16 APRIL 2014 ROOM: 2 ICON_QA
GLOBAL HEALTH GOVERNANCE: INTEGRATING COMPETING WORLD VIEWS
MODERATOR:
Dr. Sunoor Verma
Executive Director, Geneva Health Forum, Switzerland
TENTATIVE PANEL:
Prof. Ilona Kickbush
Director, Global Health Programme, the Graduate Institute of International and Development Studies, Switzerland
Prof. Ronald Labonté
Professor, Canada Research Chair, Globalization/Health Equity, Faculty of Medicine, Institute of Population Health, University of Ottawa, Canada
Dr. Mira Shiva 
Chairperson, Health Action International Asia –Pacific, India
Mr. Pascal Lamy 
Honorary President, Notre Europe, Jacques Delors Institute, France
Mr. Bart Peterson
Honorary President, Senior Vice President, Corporate Affairs and Communications, Eli Lilly and Company, United States
AIM:
Drawing on the personal journeys of a politician, an activist and two academic experts in the field of global health governance and diplomacy, this session will aim to illustrate how effective global health advocacy not only lies in the institutional and technical assets of GHG actors but among other things in their ability to strategically frame policy issues, in order to appeal to different audiences within specific contexts and timeframes.
OUTLINE:
Many of the most pressing global challenges facing the world today are intertwined with the complex dynamics of globalization, and require policy solutions that see national and international institutions acting in concert and the need for health communities across countries to cooperate more closely, and across a wider range of issues. The question, of how we should collectively protect and promote health in an increasingly globalized world, has opened up the policy space known as global health governance (GHG).The starting point of this session is the recognition that GHG space is inherently a political space, not limited to technical solutions based on 'best practice', cost effectiveness or evidence, but  a political arena characterized by competing frames, each with its own logic, language and preferred policy pathways. This creates a complex and contested policy space where different frames (with the worldviews and interests they represent) compete.
PROFILES:

Sunoor -130Dr. Sunoor Verma

Dr. Sunoor Verma is the Executive Director Geneva Health Forum.As a senior development expert, Sunoor Verma has worked in emergency, conflict and post-conflict situations. He has led the establishment of complex partnerships and coalitions by negotiating strategic agreements and their implementation plans. He has set up programs across sectors, including, Education, Health, Protection, Injuries, Sanitation, HIV/AIDS, Harm Reduction, Conflict Resolution, Refugees, Internally Displaced Persons, Environment, Culture, Gender, Minority issues etc. He has worked in various locations, including Western Europe, South East Europe, South Asia, South East Asia, North Africa and Australia. Among others, he consulted and worked with UNHCR, UNICEF, and the European Centre for Minority Issues, Cambridge University and the Australian Society of Plastic Surgeons. Sunoor Vema has been the principal consultant of the strategy consulting practice ‘ProCube’ and is the founder of www.csrforchildren.org.

He is a seasoned speaker on the topics of strategy, partnerships and leadership. He is also sought after for his skills as an effective moderator on high-voltage panels. In a previous avatar, Sunoor Verma was a practicing cardiothoracic surgeon.

 

PascalLamyMr. Pascal Lamy

Perspective: How to engage in dialogue with various actors who have differing interests and power positions while safeguarding public good interests?

Mr. Pascal Lamy has served two terms as Director-General of the World Trade Organization (WTO) from September 2005 to September 2013. He holds degrees from the Paris based Ecole des Hautes Etudes Commerciales (HEC), from the Institut d’Etudes Politiques (IEP) and from the Ecole Nationale d’Administration (ENA). He began his career in the French civil service at the Inspection Générale des finances and at the Treasury. He then became an advisor to the Finance Minister Jacques Delors, and subsequently to Prime Minister Pierre Mauroy. In Brussels from 1985 to 1994, he was Chief of Staff for the President of the European Commission, Jacques Delors, and his representative as Sherpa in the G7. In November 1994, he joined the team in charge of rescuing Crédit Lyonnais, and later became CEO of the bank until its privatisation in 1999. Between 1999 and 2004, he was Commissioner for Trade at the European Commission under Romano Prodi. After his tenure in Brussels, he spent a short sabbatical period as President of “Notre Europe”, a think tank working on European integration, as associate Professor at the l’Institut d’Etudes Politiques in Paris and as advisor to Poul Nyrup Rasmussen (President of the European Socialist Party). More recently, Pascal Lamy was the chair of the Oxford Martin Commission for Future Generations, a commission that brought together highly experienced leaders from government, business and society to examine the current gridlock in international and national attempts to deal with key global problems. The Commission has issued recommendations in a report entitled “Now for the Long Term” made public in October 2013.

 

Ronald_LabontéProf. Ronald Labonté

Perspective: How global health as a foreign policy issue is conceptualized, framed? And why is it important to study it?

Prof. Labonté is Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and Professor in the Faculty of Medicine, University of Ottawa. His current research interests include globalization as a ‘determinant of determinants’ (he chaired the Globalization Knowledge Network for the WHO Commission on Social Determinants of Health); ethics, human rights and global health development; global migration of health workers; revitalization of comprehensive primary health care; global health diplomacy.

He recently reviewed the various policy frames (security, development, global public goods, trade, human rights and ethical/moral reasoning) for health in foreign policy that inform global health diplomacy.

 

Ilona KickbushProf. Ilona Kickbusch, Switzerland

Perspective: What is global health diplomacy and why is it important to build capacity in this domain?

Ilona Kickbusch is the Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva. She advises organisations, government agencies and the private sector on policies and strategies to promote health at the national, European and international level. She has published widely and is a member of a number of advisory boards in both the academic and the health policy arena. She has received many awards and served as the Adelaide Thinker in Residence at the invitation of the Premier of South Australia. She has recently launched a think-tank initiative “Global Health Europe: A Platform for European Engagement in Global Health” and the “Consortium for Global Health Diplomacy”.

Her key areas of interest are global health governance, global health diplomacy, health in all policies, the health society and health literacy. She has had a distinguished career with the World Health Organization, at both the regional and global level, where she initiated the Ottawa Charter for Health Promotion and a range of “settings projects” including Healthy Cities. From 1998 – 2003 she joined Yale University as the head of the global health division, where she contributed to shaping the field of global health and headed a major Fulbright programme. She is a political scientist with a PhD from the University of Konstanz, Germany.

 

MiraShiva200x150Dr. Mira Shiva, India

Perspective: Mobilizing local communities and raising the voices of the women.

Dr. Mira Shiva is a physician and health activist (MBBS, MD Medicine, Christian Medical College, Ludhiana, India). She has been working on issues related to public health, women’s health, reproductive health & gender concerns, women ecology & health, food & nutritional security, health rights rooted in social justice & gender justice.

She is the Coordinator, Initiative for Health & Equity in Society/Third World Network, Founder Member & Steering Committee member of Diverse Women for Diversity, Peoples’ Health Movement, Health Action International-Asia Pacific, South Asian Focal Point-International Peoples’ Health Council.

She is member working Group Regulation of Food & Drugs by Planning Commission for 12th 5 year plan.She was member Central Council for Health, and  Chairperson of the Consumer Education Taskforce on Safety of Food & Medicine, Ministry of Health. She has been Member Health Committee National Human Rights Commission, Member, Central Social Welfare Board, Member-Advisory Committee, Gender and Communication Programme for Vigyan Prasar-Department of Science and Technology.

She was Director-Women & Health, Rational Drug Policy Head Public Policy in VHAI, Founder Coordinator All India Drug Action Network. She is steering Committee Member of Indian alliance of Child Righs & National alliance for Maternal Health & Human Rights, Right To Food Campaign, Doctors for Food & Biosafety.

She was involved in relief work following the Bhopal gas Tragedy 1984, was member of Supreme Court of India and member of the Commission that  investigated the causes of a cholera outbreak trans Jamuna, part of Delhi in 1988.

 

BartPetersonSMMr. Bart Peterson, United States

Mr. Bart Peterson joined Eli Lilly and Company in June 2009 as senior vice president of corporate affairs and communications. He is a member of the company’s executive committee.

Peterson received a bachelor’s degree from Purdue University in 1980 and earned his law degree at the University of Michigan in 1983.Prior to joining Lilly, Peterson was Managing Director at Strategic Capital Partners, LLC from June2008 to June 2009. During spring 2008, Peterson was a fellow with the Institute of Politics of Harvard University’s Kennedy School of Government. During the 2008-2009 school year, Peterson was a Distinguished Visiting Professor of Public Policy at Ball State University. He continues as a fellow with the University’s Bowen Center for Public Affairs.

From 2000 to 2007, Peterson served two terms as Mayor of Indianapolis, the nation’s 12th largest city. He also served as President of the National League of Cities in 2007. As mayor, Peterson led a transformation of public education in Indianapolis as the only mayor in America with the authority to create new schools by issuing charters. He was responsible for 16 charter schools and won Harvard University’s prestigious Innovations in American Government Award for the initiative in 2006. He was also instrumental in the business expansions of FedEx, Rolls Royce, and WellPoint in Indianapolis, and the construction and development of major projects such as Lucas Oil Stadium, the Conrad Indianapolis, Simon Property Group’s world headquarters, the new Indianapolis International Airport’s Col. H. Weir Cook terminal building, and the future Indiana Convention Center expansion and J.W. Marriott Hotel.

Along with Indiana University, Purdue University, Lilly, and the Central Indiana Corporate

Partnership, he created BioCrossroads, a focused effort to push Indianapolis to the forefront   as a life sciences capital. Peterson was honored by the National Association of Clean Water Agencies with their city government leader of the year award for his efforts in cleaning up the Indianapolis waterways.

GHF2014 – PS27 – Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies

10:45
12:15
PS27 THURSDAY, 17 APRIL 2014 ROOM: 13
ICON_Fishbowl
Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies
MODERATORS:
Dr. Carlos Dora
Department of Public Health and Environment, World Health Organization, Switzerland
SPEAKERS:
Prof. Ilona Kickbush
Director, Global Health Programme, The Graduate Institute of International and Development Studies, Switzerland
Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies
Ms. Natalie Mrak
Student, Masters of Development Studies, The Graduate Institute for International and Development Studies, Switzerland
Mr. Callum Brindley
Student, Masters of Development Studies, The Graduate Institute for International and Development Studies, Switzerland
Dr. Ralph Chapman, Environmental Studies Director, Victoria University, Wellington, New Zealand
Dr. Philippa Howden-Chapman, Professor of Public Health, University of Otago, and Director of the New Zealand Centre for Sustainable Cities, New Zealand
OUTLINE:
This session will begin with a comprehensive overview of the expansive literature, encompassing more than 20 years, on how health indicators can serve as measures of sustainable development and the presentation of a tool that has been developed which essentially combines all of this literature on indicators into one space. This will then set the stage for discussion on how this literature can essentially be placed into action. The session will entail perspectives from local, national and global levels as well as academic circles in order to provide a more comprehensive overview of the progress that has been made in incorporating health into sustainable development objectives as well as the challenges and the bottlenecks which still remain. The aim is to stimulate creative thinking and discussion around innovative ways through which health can become more embedded in the sustainable development agenda.This discussion is crucial particularly as the post-2015 development agenda talks continue. While the first set of Millennium Development Goals (MDGs) were a momentous endeavor to tackle crucial issues affecting the most vulnerable, they did not provide a comprehensive and integrated approach to tackling these challenges. Health was a dominant theme in the first set of MDGs, composing 3 of 8 goals but as 2015 approaches it is apparent that these goals do not comprehensively address the major health challenges of the 21st century for both developed and developing countries alike. While barriers to overcoming communicable diseases, maternal and child health still exist, issues such as tropical diseases (NTDs) and non-communicable diseases (NCDs) are posing challenges to existing approaches to health. A horizontal integrative approach is crucial to overcoming these new health challenges. For instance, good water and sanitation could prevent the infection from the majority of  NTDs while changes in daily routines, such as the substitution of motor transport for public or active transport, could reduce the incidence of NCDs.While recent literature has called for the inclusion of health in the post-2015 sustainable development agenda, there has not been a substantial discussion on how it could fit into this agenda and what exactly this health goal would look like as well as its feasibility at all levels of government from global to national to local.
PROFILES:

Carlos Dora_squareDr. Carlos Dora

Carlos Dora, is a coordinator at the WHO HQ Public Health and Environment Department, leading work on health impacts of sector policies (energy, transport, housing and extractive industry), health impact assessment and co-benefits from green economy/climate change policies. He previously worked at the London School of Hygiene and Tropical Medicine (LSHTM), at the WHO Regional Office for Europe, at the World Bank, and with primary care systems in Brazil after practicing medicine. He serves in many science and policy committees, has an MSc and PhD from the LSHTM.  His publications cover health impact of sector and sustainable development policies, HIA and health risk communication.

Ilona KickbushProf. Ilona Kickbush

Ilona Kickbusch is the Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva. She advises organisations, government agencies and the private sector on policies and strategies to promote health at the national, European and international level. She has published widely and is a member of a number of advisory boards in both the academic and the health policy arena. She has received many awards and served as the Adelaide Thinker in Residence at the invitation of the Premier of South Australia. She has recently launched a think-tank initiative “Global Health Europe: A Platform for European Engagement in Global Health” and the “Consortium for Global Health Diplomacy”.

Her key areas of interest are global health governance, global health diplomacy, health in all policies, the health society and health literacy. She has had a distinguished career with the World Health Organization, at both the regional and global level, where she initiated the Ottawa Charter for Health Promotion and a range of “settings projects” including Healthy Cities. From 1998 – 2003 she joined Yale University as the head of the global health division, where she contributed to shaping the field of global health and headed a major Fulbright programme. She is a political scientist with a PhD from the University of Konstanz, Germany.

PS27_Natalie_MrakMs. Natalie Mrak

Natalie   Mrak is a Global  Health  Project Coordinator with the Access to Health (A2H) team. In  parallel, she is also pursuing a Master´s in Development Studies, with a concentration on Human, Financial and Economic Development, at the Graduate Institute for International and  Development Studies (IHEID).  At  the  Institute,  she  is  focusing  on  global health issues. including  health  and  sustainable  development  as  well  as  the role of emerging  economies  in  global  health  governance and diplomacy. While in Geneva,   Natalie   has   interned  for  Otsuka  Pharmaceuticals  in  their communications  division  and in the community mobilization unit at UNAIDS. Prior  to  her  arrival in Geneva, Natalie worked at UNICEF headquarters in New York for 4 years as the Executive Assistant to the Chief of the HIV and AIDS  programme. In addition, she has a Master´s in International Relations from  the  City College of the City University of New York (CCNY) where she focused  on  gender  and  development  issues  in  Eastern  Europe. Natalie received  her  Bachelor´s  degree  from Kenyon College where she received a dual degree in History, with honors distinction, and Spanish Studies as well as Magna Cum Laude and Phi Beta Kappa honors.

PS27_Callum_BrindleyMr. Callum Brindley

Callum Brindley is studying a Masters of Development Studies at the Graduate Institute for International and Development Studies in Geneva. He is also a part-time researcher with the Global Health Programme and has co-authored two WHO publications on Health in All Policies and health in the post-2015 development agenda. Prior to his post-graduate studies, Callum worked for three years with the Australian Agency for International Development.

Ralph Chapman (aug06) VUW photoDr. Ralph Chapman

Ralph directs the Graduate Programme in Environmental Studies at Victoria University. An environmental economist, he’s worked on energy, transport, urban design and climate change. He’s also worked with the New Zealand Ministry for the Environment, the NZ Treasury; the British Treasury in Whitehall; the OECD, in the Beehive, and as a negotiator for New Zealand of the Kyoto Protocol. Ralph has a first in engineering, a Masters in public policy, and a PhD in economics.

GHF2014 – PS20 – Harnessing ICTs to Improve Tuberculosis Control

10:45
12:15
PS20 WEDNESDAY, 16 APRIL 2014 ROOM: 16 ICON_Fishbowl
Harnessing ICTs to Improve Tuberculosis Control
MODERATOR:
Dr. Lucicia Ditiu
Executive Secretary, Stop TB Partnership, World Health Organization, Switzerland
SPEAKERS:
Communications Platform for Tuberculosos to Supplement Mainstream Media: India
Ms. Barathi Ghanashyam
Founder Editor, Journalists against TB, India
mTB by Front Line Workers in a Tribal District in India: A Pilot Study
Dr. Archana Trivedi
Union South-East Asia, The Union, India
Using Technology and Community Empowerment to Treat Tuberculosis
Dr. Shelly Batra
President and Co-Founder, Operation ASHA, India
Dr. Alberto Colorado
Patient Advocate, International Public Health Consultant, Advocates for Health International, United States
Mr. Andrew Codlin
Stop TB Partnership, World Health Organization, Switzerland
OUTLINE:
PROFILES:

Ghanashyam Profile PhotoMs. Barathi Ghanashyam

Unconventional choices have shaped my personal and professional life.  Having chosen to eschew formal academics, I pursued the path of learning – learning what I wanted to, in the way I chose to – by reading, absorbing and applying what I learnt to real life situations.  I have also been deeply influenced by the intensive field trips I have undertaken into rural India in the course of my career as a development writer.  Living and interacting with rural communities have taught me to respect their traditional wisdom, the way they cope with lack of choices, the simplicity with which they find solutions to their complex problems and I have often been humbled into emulating their way of life – which is devoid of artifice of any sort.  My writing, because it resonates with field realities, is credible and important for development processes.

PS20_Archana_TrivediDr. Archana Trivedi

Medical Doctor married with two sons, served in Indian Army (Medical Branch) with 21 years of rich and dynamic work experience in the medical field with 7 years of hands on technical experience working in National Health Program on Tuberculosis. Have background of working for 7 years in Global Fund Projects with International Union Against Tuberculosis and Lung Disease, Catholic Bishop Conference of India, Catholic Relief Services and Indian Medical Association.

Have ability to work and liaise effectively with government agencies, civil society organizations, private sector, people affected with diseases and synergize with other stake holders.  Also have persuasive and innovative skills supported by thorough research, to achieve best accruals for health projects. Have ability to conceptualize and lead health projects from front in strict disciplined environment. Adept in program management to include planning, coordination, execution and monitoring & evaluation of project.

At present position in Union South-East Asia The union, implementing project to involve qualified and non-qualified private practioners to promote TB care and control. Developed mobile application to track and trace TB patients. Currently scaling up mobile application under World Bank IDM project and Grand Challenges-TB Care along with Dimagi (USAID funded project).

Batra PhotoDr. Shelly Batra

I started my professional journey as a young surgeon, of which I was dazzled by the glamour, fame and money that was part of being a doctor. Very soon I came to a cross road and decided to take the road not taken. So, on one side there were the dazzling lights, the success and the glamour but the other route was an uphill path; rocky and thorny and all around was the stench of disease and death and all I could hear were the sighs of the sick and dying; that is the road I have chosen.

Mr. Andrew Codlin

I worked along the Texas-Mexico border studying the interaction of diabetes and pulmonary infections (influenza and tuberculosis) for two years.  I then moved to Karachi, Pakistan, where I spent 3 years implementing TB case finding initiatives focused on the private healthcare sector. All of  my programs had a significant mHealth component and I worked with other TB REACH grantees to adapt our successful strategies for other country contexts.

Ilona Kickbush

Ilona KickbushIlona Kickbush

Director of the Global Health Programme at IHEID

Ilona Kickbusch is the Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva. She advises organisations, government agencies and the private sector on policies and strategies to promote health at the national, European and international level. She has published widely and is a member of a number of advisory boards in both the academic and the health policy arena. She has received many awards and served as the Adelaide Thinker in Residence at the invitation of the Premier of South Australia. She has recently launched a think-tank initiative “Global Health Europe: A Platform for European Engagement in Global Health” and the “Consortium for Global Health Diplomacy”.

Her key areas of interest are global health governance, global health diplomacy, health in all policies, the health society and health literacy. She has had a distinguished career with the World Health Organization, at both the regional and global level, where she initiated the Ottawa Charter for Health Promotion and a range of “settings projects” including Healthy Cities. From 1998 – 2003 she joined Yale University as the head of the global health division, where she contributed to shaping the field of global health and headed a major Fulbright programme. She is a political scientist with a PhD from the University of Konstanz, Germany.

Details can be found on her Website: www.ilonakickbusch.com

Learning from evidence: Advice-seeking behaviour among Primary Health Care physicians in Pakistan.

Author(s) Asmat Malik1, Cameron Willis2, Saima Hamid3, Anar Ulikpan 4, Peter Hill 5.
Affiliation(s) 1Department of Research and Development, Integrated Health Services, Islamabad, Pakistan, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Maternal and Reproductive Health, Health Services Academy, Islamabad, Pakistan, 4School of Population Health, The University of Queensland, Brisbane, Australia, 5School of Population Health, The University of Queensland, Brisbane, Australia.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Systems
Summary Access to information is critical for creating and maintaining high performing Primary Health Care (PHC) systems. Among multiple sources of information, advice-seeking from humans possesses significant importance for the physicians in their clinical settings because they are looking for readily available answers to their questions. We used Tuberculosis and measles as a lens for analyzing the advice-seeking behavior of PHC physicians in Pakistan. The study concludes that the heath care providers are falling prey to stagnant system behaviour. There is a need to better understand system behaviors and to identify system principles such as information flows and feedback loops.
Background The available studies provide some insights into how physicians seek information while working in PHC settings. However, as this literature is largely confined to developed countries, there is relatively little known about how physicians in low-middle income countries access or use information when faced with difficult to diagnose conditions. In these settings, where access to electronic information sources is often scarce, understanding advice seeking behaviors from human sources becomes particularly important. Using methods grounded in systems science, this study examines the advice seeking behaviour of PHC physicians in a rural district of Pakistan, analyzes the degree to which the existing PHC system supports their access to advice, and explores ways this system might be strengthened to better meet provider needs.
Objectives Tuberculosis (TB) and measles are currently providing major challenges to PHC physicians in Pakistan. We used these two conditions as a lens for analyzing the advice-seeking behavior of PHC physicans in Pakistan. The specific research questions of this study were:
• To what degree does the existing structure of the PHC system in Pakistan support physicians in accessing advice on difficult to diagnose cases of tuberculosis and measles?
• To what degree are physicians satisfied with their current access to advice on difficult to diagnose cases of tuberculosis and measles?
• What changes, if any, do physicians recommend to improve their access to advice on difficult to diagnose cases of tuberculosis and measles?
In order to answer these research questions, this study has the following specific research objectives:
• To document the flow of information on diagnosing TB and measles cases in the PHC system of Pakistan;
• To describe the advice seeking behaviour of physicians in situations of difficult to diagnose cases of TB and measles;
• To explore physicians’ satisfaction with their access to advice in difficult to diagnose cases of TB and measles;
• To identify and describe possible changes, if any, that physicians recommend to improve their access to advice in difficult to diagnose cases of TB and measles.
Methodology This study was conducted at the district level in Pakistan from January 2013 to August 2013. The organization of health services at a district level is similar across Pakistan. With a cross-sectional study design we employed three research methods comprising:
1. Mapping of formal system of flow of information for diagnosing TB and measles.
Through documentary review and targeted key informant interviews with five district health administrators and line-managers of vertical health programs, we mapped the existing system of the flow of information for assisting physicians in diagnosing TB and measles cases. Illustrations of formal information dissemination systems were developed in the form of flow charts showing the direction of flow of information and roles and responsibilities for providing information/feedback at various hierarchical levels.
2. Survey for social network analysis of physician advice seeking behaviour.
A semi-structured questionnaire was used to conduct a survey for mapping professional networks. The key questions were structured to identify whom each physician had contacted for advice whenever faced a difficult to diagnose cases of TB and measles. Out of the 61 BHUs in district Attock, only those with an appointed physician (n=49) were invited to participate. The compiled data was imported in UCINET software for generating sociograms.
3. Key stakeholder interviews.
Based on the analysis of the findings from Sociograms, the BHU physicians were divided into three groups:
• Physicians who sought advice from a designated person (formally notified by the health department)
• Physicians who sought advice from someone other than a designated person
• Physicians who did not seek advice from any other person
This grouping provided the basis for selecting 11 study respondents for in-depth interviews. All study participants agreed to one-on-one interviews and consented to audio recording. Three separate interview guides were used during these semi-structured in-depth interviews among the three groups of study respondents. The average interview time was 20 minutes. The researchers using an inductive process identified categories, sub-themes and themes. The research team then compared their findings to optimize the data conformity. The final themes were presented after the research team’s consensus on the analysis process.
Results The present configuration of the primary health care system in Pakistan is largely a result of the push for universal health coverage and Health for All under the declaration of Alma Ata Conference on PHC in 1978. Under the influence of this global movement, an extensive network of PHC clinics (5449 Basic Health Units and 579 Rural Health Centers) has been established as the first point of contact for those seeking healthcare across all districts in Pakistan.
Early detection of both TB and measles is critical to decrease morbidity and mortality rates. There are multiple sources of information available to assist physicians in diagnosing cases of TB and measles including clinical guidelines, case definitions and case detection protocols. While these information sources are largely provided through government agencies, the precise channels used for their distribution and the ways in which physicians make use of these channels have not been made explicit. Mostly they use their personal social networks in order to seek guidance in clinical care from their friends, peers, and other disease-specific experts.
With a systems approach, the thematic analysis has been categorized under four key areas. Firstly, the health leadership designs health programs and interventions without placing competent experts and a pathway to seek information on difficult cases (system organizing). Referral systems are not functional and there is no feedback on the patients’ from whom advice is being taken. As a consequence, patients are lost to the private sector. Secondly, PHC clinics do not have functional linkages with tertiary care hospitals (system network). In addition, no needs assessment for refresher trainings is conducted by the health department. Thirdly, the PHC physicians are not provided any feedback on patients sent to higher level centers (system dynamics). There exists no formal system of communication and dissemination through which the latest research or related materials are shared. In addition, there exist no opportunities where PHC physicians can be placed at secondary or tertiary care hospital on a rotation basis. Lastly, the focus of the health managers and administrators is more on administrative running of programs and meeting targets (system knowledge). Consequently, capacity building in clinical management has become a neglected priority.
Conclusion The analysis of the PHC system in Pakistan clearly demonstrates that the problems in the health sector are deeply rooted and complex in nature. The evidence from this study demonstrates that in situations where PHC physicians require further advice in diagnosing potential cases of TB or measles, it is unclear from whom this advice is being sought, or the degree to which the current PHC system enables physicians to seek this advice.
PHC level acts as a driver for healthcare delivery system whereas human resources are the main driving force behind a functional health system because they provide a human link that connects the system building blocks. However, in Pakistan, the heath care providers are falling prey to  stagnant system behaviour. The solutions require a systems’ thinking that views public health problems as a part of a wider and dynamic system, with a focus on in-depth understanding of the linkages, relationships, interactions and behaviors among the sub-system components that characterize the entire system. It is imperative to better understand system behaviors and to identify system principles such as information flows and feedback loops.

Dual practice in Uganda: the evolution and management of a complex phenomenon.

Author(s) Ligia Paina Bergman1, Freddie Ssengooba2, David Peters3.
Affiliation(s) 1Department of International Health, Johns Hopkins University School of Public Health, Washington, United States, 2Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 3Department of International Health, Johns Hopkins University School of Public Health, Baltimore, United States.
Country - ies of focus Uganda
Relevant to the conference tracks Health Systems
Summary Dual practice is widespread in developing countries, yet it is seldom accounted for in health workforce policies. A systems lens guided the development of a qualitative research design to describe how dual practice evolved and how it is currently managed in urban Uganda. We found that dual practice is deeply embedded in the Ugandan health system. In the absence of formal policies, the local, informal management and coping strategies provide learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of dual practice is essential for health workforce policy and planning in countries where this phenomenon occurs.
Background Dual practice, when government health providers also work in the private health sector, is widespread in developing countries, particularly in settings with rapidly developing private sectors. However, it is seldom accounted for in health workforce policy and planning. Uganda has an active private sector and a high proportion of health providers working multiple jobs, particularly in the capital region. An informal, unenforced ban on dual practice in a system where high demand for patient services is constrained by low supply of health professionals creates complexity and unanticipated dynamics over time. Informal management of dual practice, or local responses to complexity, have not been previously documented and could inform health workforce policy and planning in Uganda and similar settings.
Objectives Acknowledging that the health system is a complex adaptive system, this study applied a systems lens to describe how dual practice evolved and how this phenomenon is currently managed in urban Uganda.
Methodology A qualitative research design, supplemented by a review of historical and policy documents was used to develop five case studies of government health facilities, capturing the perspective of both health providers and health managers through semi-structured in-depth interviews. This is one of the few studies examining both doctors and nurses’ perspectives on dual practice. Additionally, interviews with policy stakeholders allowed the exploration of dual practice from multiple angles, from government to private sector. A causal loop diagram was constructed using the qualitative data in order to illustrate the influence of various health system actors, as well as interactions and feedback.
Results Dual practice in Uganda is rooted in the history surrounding the professionalization of medicine, the development of the private sector, and political and economic turmoil. Private practice, and dual practice, started as a privilege for African doctors seeking autonomy and professional status. Feedback from the economic decline and the deterioration of government infrastructure, transformed dual practice into a coping mechanism for health providers who did not migrate. Over time, the government’s skepticism and resistance to dual practice increased, although enforcing a ban has consistently been met with threats from providers leaving. Most respondents believed that the majority of health providers engaged in dual practice informally. Doctors and nurses enter dual practice through a variety of mechanisms – from direct recruitment, to informal networking. Internal labor markets have emerged around major facilities, where parallel institutions conduct well-funded research and service provision, usually related to infectious diseases. Informal management approaches at the facility level vary. In smaller facilities, nurses and doctors self-organize to ensure their shifts are covered. The facility in-charges’ emphasis is on performance and coverage during government hours, although those who had done dual practice in the past apply a personalized approach. In larger facilities, specialists organize their public and private activities depending on the type of service provided, at times in coordination with colleagues and supervisors.
Conclusion The systems lens fostered an approach to capture the perspectives of multiple health system actors, historically and across various levels of the Ugandan health system. The findings confirmed that, in the absence of formal policies, health providers adopt informal approaches to coping with and managing dual practice. Health managers emphasize the government job as a primary duty, while at the same time recognizing the reality that there are advantages to dual practice, from both the individual and the societal perspectives. Doctors and nurses have each developed unique coping mechanisms. The local management and coping strategies are learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of how dual practice evolves and how it is managed in a system is essential for health workforce policy and planning.

Making heathcare affordable to poorest communities through acupuncture: India

Author(s) Walter Fischer1
Affiliation(s) 1Barefoot Acupuncturists, Barefoot Acupuncturists, Mumbai, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary Barefoot Acupuncturists is a non-profit organisation registered in Belgium and founded by acupuncturist Walter Fischer in 2009. We run acupuncture clinics in slums of Mumbai and villages in Tamil Nadu (south of India), and also train local acupuncturists in order to encourage autonomy.Our services have been developed to give the poorest communities access to affordable and efficient healthcare, limited mainly to pathologies for which acupuncture has been recognised and proven (among others by the WHO) to be an effective treatment.
Our range of action covers chronic or acute pain, paralysis and stroke recovery, digestive disorders, fatigue, gynaecological issues and hypertension.
What challenges does your project address and why is it of importance? In India the healthcare sector, which is highly privatised, urged around 39 million people to fall into poverty in 2004-2005 because of out-of-pocket expenditures for their treatments.
India is the country with the largest number of poor people in the world and also has one of the most privatized healthcare systems.
It was estimated in 2010 that in India there was a shortfall of 100.000 doctors and 1000.000 nurses.High absenteeism and corruption amongst health workers discourage the poor to access public facilities. Surveys have pointed out that even when the poor try to seek medical assistance in the public sector, richer people have a greater share of public services.The challenge we are trying to address with Barefoot Acupuncturists is the great disparity between rich and poor, between public and private health systems, in which the poorest:
- choose to be treated in private sector at a high cost that puts them at even higher risk in terms of financial insecurity and social instability.
- often choose low quality publics services with the risk of not being taken care of properly and with the threat of developing more chronic diseases, which in the long term might negatively impact their future.

In both cases, the poor become poorer.

How have you addressed these challenges? Do you see a solution? We have been trying to address that great disparity between rich and poor in healthcare by providing efficient and affordable health services to the poorest through low-cost acupuncture clinics and offering acupuncture training to local communities.
Acupuncture is a unique tool not only for social health practitioners as it is cheap, effective and easy to teach. It treats pain and illness without harmful side effects. A healthcare system provided by local «barefoot doctors» who offer first-line services is a simple solution to ensure much-needed healthcare in slums or rural areas where there is little or sometimes no access to medical facilities.Why is acupuncture a unique tool against poverty:
Acupuncture from an economic perspective:
• Allows treatment at a low cost (acupuncture equipment is cheap).
• Is highly adaptable to different environments due to its simplicity and portability.
• Provides an alternative to expensive and sophisticated treatments.
Acupuncture from a healthcare perspective:
• Offers a proven and effective solution to health related issues.
• Can offer help in cases that have not been successful with conventional medicine.
• Can reduce the excessive use of chemical drugs and their potential side effects.85% of our patients consult for pain related to musculoskeletal disorders.
Coolies, farmers, workers, housewives, drivers, and maids are the majority of people at the lowest economic level who earn their living through physical works. Those are our patients.
Because their body is overused, often misused, and because of poor living conditions, this group will suffer more than others from physical pain. At the same time, they cannot afford to remain inactive without wages. Acupuncture (well known for and particularly effective against pain) allows them to recover faster and better.
The well-known efficiency of acupuncture against pain has not only been an observation through our practice in India, but globally in our acupuncture clinics around the world. In 2002 The World Health Organisation (WHO) issued a detailed report about acupuncture and a list of diseases for which through controlled clinical trails acupuncture has been proven to be an effective treatment.

- In 5 years, we have treated more than 3.500 patients, both in slums and villages.
- Today we offer 10.000 treatments every year.
- We are employing a team of 20 local people, including 7 acupuncturists.
- We are preparing to organise acupuncture trainings at a larger scale.

How do you know whether you have made a difference? We are presently making a difference at a very local level, in the slums and the villages where our clinics operate. Our clinics are busy due to our reputation spreading in the community by patients who have been encouraged to consult us by relatives or neighbours who were treated by our barefoot acupuncturists and found relief and solutions to their health problems.
A medical survey and various testimonies have shown and explained the impact and the level of satisfaction among slums dwellers and villagers.
Although our impact is clear upon surrounding poor communities, it is true that we lack scientific data to support our field experience and to quantify that impact.
We plan to hire specialised external skills to enable us to build our practises and communication.In order to expend our impact to other areas, others states in India and later in different countries, Barefoot Acupuncturists is developing an acupuncture training program. This program is aimed at the staff of local NGO’s that will fully manage their own acupuncture clinics, based on their own network and financial resources. This will allow an exponential growth of low-cost clinics, independently of Barefoot Acupuncturists’ human and financial resources. By bringing all the knowledge and tools into the hands of local communities, we hope to create more sustainable growth and functioning.
Have you or the project mobilized others and if so, who, why and how? - Founders: private founders in Europe and India have supported us financially and made it possible for our project to develop during these 6 years.
- Around 30 experienced acupuncturists and medical doctors from all over the world have joined us to work and teach in our Indian clinics.
- In 2012 we signed a collaboration with the "World Federation of Chinese Medicine Societies", an important group of Chinese doctors and professors in Beijing (China) to work on the elaboration of an acupuncture training manual.
- The Foundation Frédéric et Jean Maurice in Switzerland has offered us financial and technical support.
- The association "Humanitarian Acupuncture Project" was created in 2012 in the United-States by American acupuncturists to support our work in India with funding and volunteer acupuncturists.
- Two Indian organisations, UnLtd India and Toolbox, have been advising and coaching us for the year to help us strategise our goals and grow more efficiently.
- Professionals from various fields share their skills continuously with us: graphic designers, photographers, web designers, professional development coaches, accountants, lawyers, film makers…
When your donor funding runs out how will your idea continue to live? Today Barefoot Acupuncturists fully manages and finances all its activities. If funds run out, clinics close and all our patients lose the benefit of our services. This is the main reason (added to the need of a better cost-efficiency ratio) why in the following two years we are preparing to become an organisation offering acupuncture training to local NGO’s and communities, making possible not only an exponential growth but also sustainable structures that will function independently from Barefoot Acupuncturists resources.

Gap between Individual Perception and Expectations and Services Quality in Health Centres of Tehran, Iran.

Author(s) Davoud Shojaeizadeh1, Sima Esmaeili Shahmirzadi2, Monavvar Moradian3, Esmaeil Shojaeizadeh 4.
Affiliation(s) Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, 4 Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran.
Country - ies of focus Iran
Relevant to the conference tracks Health Systems
Summary Services quality is the determining factor of an organisations success in a competitive environment. Evaluation of services is an essential step in the improvement of health programs. The aim of this study was to survey the gap between individual perception and expectations concerning the service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
This research was a descriptive and analytical. The cross-sectional study was performed between 2012-2013 in the health centers under the coverage of Medical and health network of Tehran city. Data gathering was conducted with two questionnaires. The first questionnaire contained four questions on demographic characteristics (gender, age, educational status and marital status).
Background Service quality is the determining factor of an organisations success in a competitive environment. Evaluation of services is an essential step in health program improvement. The aim of this study was to survey the gap between individual perception and expectations concerning service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
Objectives The aim of this study was to survey the gap between individual perception and expectations concerning service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
Methodology This research was a descriptive and analytical. The cross-sectional study was performed between 2013 in the health centers under the coverage of Medical and Health network of Tehran city. Data gathering was conducted with two questionnaires. The first questionnaire contained four questions on demographic characteristics (gender, age, educational status and marital status). The second one consisted of the SERVQUAL questionnaire. The SERVQUAL tool consists of the expectations and perceptions sections. In each section there were 22 statements on five domains: tangibility (4 items), reliability (4 items), responsiveness (4 items), assurance (5 items) and empathy (5 items). The Persian version of SERVQUAL questionnaire has gained necessary validity and Cronbach's alpha was calculated at 0.9. Results were considered significant at conventional p0.05 level. The sample size was 200 people and participants randomly selected from individuals that were referred to health centers affiliated to the Tehran University of medical science in 2012-2013. For data analysis SPSS 18 and Independent T- Test, ANOVA test and Pearson correlation were used.
Results The age average of the subjects was 28.79±7. 41. Among them, 99.5% were female and only 0.5% were male. Also 99.5 percent of the participants (199 persons) were married, and 0.5% (1 person) was single. Gap Average of Individual’s perceptions and expectations were calculated respectively in the domains of tangibility (0.95±0.88), reliability (0.48±0.86), responsiveness (0.53±0.85), assurance (0.49±0.77) and empathy (0.67±0.93) respectively. The total gap between perceptions and expectations of service quality was 0.63±0.73. The gap maximum between perceptions and expectations was in the tangibility domain (0.95±0.88) and the gap minimum was in the reliability (0.48±0.86).
200 participants were in the study. 11% were illiterate, 54.5 percent of the respondents had an elementary educational level, 32% were high school and 2.5 percent had a College education.
Conclusion The large gap between perceptions and expectations of the participants in the tangible indicator suggests that the physical environment and facilities need to be improved in the health centers. Cooperation from the private sector investment in public centers may be effective in reducing the present problems.