Geneva Health Forum Archive

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

Public Private Partnership in the Management of Primary Health Centers in India.

Author(s): Samal Sarangahdar1
Affiliation(s): 1National Youth Service Action and Social Development Research Institute, Bhubaneswar, India
1st country of focus: India
Relevant to the conference theme: Redesigning health services
Summary: In the PPP model, the skills, assets, risks, and rewards of delivering a service or facility are shared between public agencies and private sector entities through a contractual agreement. This innovative model of healthcare delivery has been successfully piloted over five years for two local community health centers in Orissa, India and is now being scaled up to other areas of the state and the country, with scope for it to be replicated in similar underserved rural settings around the globe.
What challenges does your project address and why is it of importance?: The public health sector in India is unable to provide basic services to the marginalized segments of the population due low investment (3% of GDP), poor infrastructure, inadequate management, physician shortages, lack of patient education or awareness, and shortage of resources in terms of manpower, medication, and supplies. In the state of Orissa, 90% of the 1166 government-run primary health centers (PHCs) are irregularly functioning or defunct. On the other hand, the private health sector has the capacity to provide high quality, efficient, accountable, and patient-centered care but cannot be accessed by poor, rural communities. There is thus a disconnect where the private sector has resources, knowledge, and skills that the public sector has never tapped into.
How have you addressed these challenges? Do you see a solution?: Based on the philosophy that synergy leads to better health outcomes, we introduced the PPP model in which public and private development organizations complement and supplement each other in a combined effort to reach joint goals. To rehabilitate two local defunct PHCs (Khankira GP, Dhenkanal district and Atta GP, Jajpur district), our NGO, NYSASDRI, partnered with the government at the local and state level. To ensure success, we ascertained that several key requirements of the partnership were met: commitment from the top by political leadership, the selection of the right private partner, active involvement of the public sector throughout the process, a well-thought out contract with clearly defined responsibilities and methods of dispute resolution, a dedicated income stream, the judicious use of resources, and collaboration with stakeholders in the local community.
How do you know whether you have made a difference?: Performance was measured through the routine monitoring and evaluation of outcomes by all parties involved. Categories assessed include quantity of services provided or advanced, percentage of the populationwho  receiving specified services, quality of service provided (e.g. waiting time), hospital care parameters (e.g. length of stay, cost per admission, patient turnout, facilities utilization), and the health status of the population (e.g. nutrition markers, health awareness). Qualitative analysis was done through patient feedback surveys and quantitative analysis was done via the comparison of predefined health indicators with both baseline and benchmark values.
Have you or the project mobilized others and if so, who, why and how?: To make management more participatory and ensure local ownership of the PHC, a hospital management committee (HMC) was formed with representatives of Panchayati Raj Institutions (a local system of governance), government health department officials, NGO representatives, women’s self help groups (SHGs), Kishori clubs (adolescent girls clubs), and other important villagers of the area. These participants were mobilized by holding multiple local and state level meetings for needs assessment, discussion, and negotiation. The HMC looks after the day-to-day operation of the PHC, customizing decisions to local priorities regarding which services will be rendered and the process of implementation.
When your donor funding runs out how will your idea continue to live?: In the two villages which conducted our pilot project, building renovations, the installation of basic facilities (electricity, telephone connectivity, medical equipment), and appointed staff members (doctors, attendants, pharmacists, sweepers) will remain permanent assets of the PHC under the oversight of the government and HMC even after the partnership ends. Meanwhile, the capacity building facilitated by our project has not only empowered the members of the local community organizations to act as advocates for their village’s healthcare, but inspired neighboring communities to do the same. Finally, on a larger scale, the success of our venture has paved the way for other private players to play a role in strengthening the rural healthcare systems in Orissa. Our political advocacy efforts brought about the necessary policy level changes to allow other NGOs and corporate institutions to partner with the government in the revival of other dysfunctional PHCs throughout the state. The PPP model has thus emerged as an important strategy for health care reform in the state of Orissa.

A Chronic Disease Surveillance System: Bangladesh

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Author(s): Sheikh Mohammed Shariful Islam1, Dewan Shamsul Alam1
Affiliation(s): 1Center for Chronic Diseases,Dhaka, Bangladesh
1st country of focus: Bangladesh
Additional countries of focus: India
Relevant to the conference theme: Non-communicable chronic diseases
Summary: Chronic diseases have emerged as a major public health threat globally and for the developing countries. There is a need for comprehensive nationally representative chronic disease surveillance system in many South East Asian countries. ICDDR, B in collaboration with LSHTM and SANCD initiated a project in Bangladesh for conducting chronic disease surveillance by using WHO STEPS 3 approach.  The project will test the feasibility of integrating a chronic disease component in the well established Matlab health and demographic cohort and using electronic data capture for socio demographic information, anthropometric measurement, blood pressure, lung function and vision tests and biological sample analysis.
What challenges does your project address and why is it of importance?: This project will provide a measure of burden of chronic non-communicable diseases and their risk factors, and help understanding the wider consequences of chronic diseases. An important component of this study will be the ability to link data collected on chronic diseases and their risk factors with historical data on these participants from the ongoing health and demographic surveillance system (HDSS) in Matlab.   Through this study, we will assess the feasibility, scalability and efficiency of conducting this field-work in rural households, including children (aged 2 years and above) and adults.  We will test the reliability and applicability of chronic-disease questionnaires and techniques using standardized tools and an electronic data capture system. This study will include interviewer-administered questionnaires (on diet, physical activity, socio-economic position, quality of life, disability and functioning) along with physiological measures (blood pressure, body weight, height, leg length, lung function) and blood measures for people above 12 years of age (fasting glucose, lipids and cotinine levels) and 24-hour urine (salt excretion).
How have you addressed these challenges? Do you see a solution?: We have linked historical data from Matlab HDSS through Census, Socio Economic Survey and regular bi-monthly updates with the participant information in the electronic data capture system developed for the project. In addition RKS (Record Keeping System) data from the Matlab Hospital and Hospital Surveillance System data was explored for incidences of diarrhea, pneumonia, breastfeeding history and immunization among others. Data regarding hospitalization of any participant of the study was also linked with the electronic data capture system used by the project.  Using notebook computers with specialized software data was collected from all members of the rural households and physical measurements, blood pressure, lung function and vision tests performed at the household levels by field workers supervised by a medical doctor and project manager. A nurse was engaged to collect fasting blood from the participants at the household levels and transporting the samples for analysis and storage for future genetic analysis at the Matlab laboratory.
How do you know whether you have made a difference?: This project attempts to assess the acceptability, feasibility and reliability of a surveillance system for chronic diseases and its risk factors in the developing countries where nationally represented surveillance for chronic diseases has not yet been established. The project used electronic data capture system for data collection in the field-work which has reduced the use of paper based questionnaire and data entry for routine surveillance. The project has also incorporated new chronic disease events as part of the regular surveillance for demographic data conducted every 2 months in Matlab. It has demonstrated the feasibility of home based collection of blood for bio assays and DNA extraction for future genetic and epigenetic studies and the feasibility of linking historical data collected on study participants from the existing Matlab demographic and health database.
Have you or the project mobilized others and if so, who, why and how?: This project is a role model for establishing a chronic disease surveillance system in a developing country with the need for minimum resources and collecting entire data from the household levels. Following the initiatives of this project at Matlab, Bangladesh, two other similar project was initiated by South Asia Network for Chronic Diseases in Goa and Chennai of India in collaboration with NGOs using similar protocols, methodologies and guidelines prepared by this project.
When your donor funding runs out how will your idea continue to live?: The project has established linkage with the Matlab Demographic and Health Surveillance System database and created a set of questionnaires to be included in the routine surveillance using existing infrastructure and human resources. So, without any external donor assistance and additional funds the chronic disease risk factor project will continue to live and provide valuable information for research and strategies for detection, prevention, treatment and management of chronic conditions.

Tuberculosis Pilot Active Mass Screening Programme: Lao PDR


Author(s): Thongleck Xiong1, Montira Inkochasan1, Chiara Frattini1
Affiliation(s): 1International Organization for Migration, Ventiane, Laos,
1st country of focus: Laos
Relevant to the conference theme: Vulnerable groups
Summary: The International Organization for Migration (IOM) is working in collaboration with the National Tuberculosis Centre (NTC) to address bottlenecks to tuberculosis (TB) screening and diagnosis in the Lao People’s Democratic Republic (Lao PDR) through active case finding strategies.  The project targets the two provinces of Champasak and Savannakhet which are characterized by highest prevalence of TB in the country, strong presence of ethnic groups and high population mobility through the borders with Thailand, Vietnam and Cambodia.  The Pilot Active Mass Screening helped to identify an efficient, cost effective and sustainable method to implement full scale mass screening activities in ten selected districts.
What challenges does your project address and why is it of importance?: Lao PDR has one of the lowest GDPs in the region.  Up to 80% of the population lives in rural areas with limited or no access to basic infrastructure and services.  Health facilities lack funding, adequate human resources and equipment.  The target areas are located  in southern border provinces.  In these areas, low population density, long distances and bad road conditions affect the financing and provision of health services.  In addition, economic, social and cultural barriers, health seeking behaviours of ethnic minorities and migrants further limit their access to health services and represent a major challenge for passive TB case detection, including facility based direct observation and drug adherence.  It is the first time that active TB case finding is conducted in the Lao PDR.  Through the implementation of this new methodology, IOM’s project seeks to support national health partners to find a solution to overcome these barriers.  Through the innovative strategy the contact between hard to reach populations and health services will be fostered and this will lead to an increase of symptomatic patients referred to health services for diagnosis and treatment.
How have you addressed these challenges? Do you see a solution?: IOM has implemented an active TB case finding strategy using existing government health and administrative networks for TB case detection and treatment, bringing the mass screening activities to the villages.  The strategy entails conducting interviews in the target areas to all villagers aged six years old and older. The Pilot Active Mass Screening targeted two villages out of four in each province, which are located in particularly remote areas.  In collaboration with the NTC, IOM developed tools to conduct the mass screening activities.  With the support of the District TB Managers (DTMs), village leaders and village health volunteers (VHVs) were convened to the districts for a meeting before the start of the activities to inform them about the project and advocate for their commitment and participation.  Subsequently, IOM conducted training in each of the four villages on mass screening and interview methods, symptoms scoring, sputum collection and delivery, questionnaire follow up processes and reporting.  A total of 70 people participated in the training, including: DTMs, health centre (HC) staff, VHVs, village leaders and unit heads that were in charge of a certain amount of village households.  After the training, VHVs and unit heads went out to their communities and conducted the interviews and in two months screened 3,584 individuals out of the total population of 4,849.  The HC staff checked the questionnaires and identified suspect cases using symptomatic scoring system.  VHVs were then deployed to collect sputum from all 315 suspect cases and delivered it to the HC that handed it over to the district hospital for acid-fast-bacilli (AFB) smear examinations.  Only the laboratories of the district hospitals can officially perform the AFB examinations.  The results of the examinations were reported to the DTMs, who then referred them to the IOM team.  Out of all cases, none were identified as sputum smear positive.  A random quality check of the 50 slides was later conducted by the IOM laboratory in Bangkok and results were confirmed.  Despite the fact that no sputum smear positive case was found, the Pilot Active Mass Screening represented an extremely valuable exercise in terms of testing the methodology and tools and learning lessons to apply for the full scale implementation of the mass screening activities.  Health partners at all levels demonstrated enthusiasm in pioneering the methodology and provided full support to the project.
How do you know whether you have made a difference?: The Pilot Active Mass Screening was the first attempt of active TB case finding using the symptomatic survey and sputum smear approach in Lao PDR. This methodology enabled the screening of a high number of people within a short period of time.  The direct involvement of VHVs and unit heads rendered it possible to reach and communicate with isolated communities living in remote areas, to detect TB cases and to raise awareness of the disease among the population.  In fact, VHVs and unit heads are in a position to easily gain trust of the villagers as they share the same language and cultural value and are known by the community members.  Lessons learned from the pilot enabled the project team and stakeholders to revise TB case detection tools and methodology, to identify challenges such as gaps in capacity, equipment and supplies of health structures, difficulties in reaching remote areas, difficulties in working with villagers that may not have a high literacy level and may not see TB as a priority over conducting livelihood activities.  The pilot also represented an opportunity to strengthen the network of national stakeholders working in the health sectors and to promote their closer collaboration for health issues of concern, such as TB.  For HC staff and VHVs in particular, participation in the training was a valuable occasion to strengthen their technical and reporting skills and to deepen or acquire knowledge on TB.
Have you or the project mobilized others and if so, who, why and how?: The pilot, as part of the bigger project, was implemented in close collaboration with government counterparts working on TB to support the Government of Lao PDR’s efforts for TB detection and treatment.  Their involvement was essential to the project implementation. They provided data and information on population TB profile and suggestions on selection of target provinces, districts and villages and facilitated project coordination and implementation.  The following national stakeholders were mobilized: NTC, Provincial Tuberculosis Division, District Tuberculosis Division and HCs.  In addition, to ensure access to the villages and to be able to conduct activities in an effective manner at the village level, the project engaged with existing institutions such as village leaders, unit heads and VHVs. The NTC was involved from the very first stage of tools and methodology development and contributed to the overall supervision of activities conducted by health authorities and the provincial, district and village levels. Provincial TB Coordinators worked as links and coordinators between the national and the district level and District TB Managers as links and coordinators between the province and the HCs.  The district hospitals provided the facilities, personnel and equipment for sputum smear examination.  The HCs worked as links and coordinators between the district and the village level and contributed to check and deliver questionnaires and sputum samples to district hospitals.  And finally, VHVs conducted interviews and data collection activities.  Technical guidance and assistance to ensure the quality of the sputum smear examinations for AFB was also provided by IOM Bangkok through the facilitation of the IOM Regional Laboratory Coordinator.
When your donor funding runs out how will your idea continue to live?: IOM has advocated to relevant health authorities at all levels on the importance and effectiveness of active TB case finding.  The pilot has created a model and a precedent that will be further adjusted and improved during the implementation of the project.  At the conclusion of the project the mass screening strategy can be scaled up in other provinces or at the national level.  The National, Provincial, and District TB staff have been trained to train other VHVs. A network of trained VHVs will remain embedded in the target areas and can be integrated into existing public health infrastructure and utilized in future government-led TB control interventions.  If the active case finding in the project target areas is adopted as a National TB Control Strategy, the NTC has the opportunity to conduct this activity regularly, on an annual basis.  This will not only reduce the stigma of TB but will also encourage the community to cooperate and participate in the health screening activities. As mentioned, health care structures and services in the country suffer from lack of funding.  However, TB is an issue of concern for the Government of Lao PDR as the prevalence is still high.  The creation and testing of this model was highly appreciated by all relevant TB institutions and their participation in the pilot is seen as part of the effort the country is making in order to achieve the MDGs.


An Evaluation of the Lime Tree Project: The Creation of a New Village Centre and an Intergenerational Living Space: Geneva, Switzerland

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Author(s): Sandrine Motamed1, Susan B Rifkin2, André C Rougemont1, the community from Meinier
Affiliation(s): 1Institute of Social and Preventive Medicine, Geneva University Hospital, Geneva Switzerland, Colorado School of Public Health, Aurora, United States,
Name your project or intiative: An evaluation of the Lime Tree Project: the creation of a new village center and an intergenerational living space near Geneva, Switzerland.
1st country of focus: Switzerland
Relevant to the conference theme: Equity and empowerment
Summary: To examine a case study in Geneva - the Lime Tree, a community participation project  and to examine how equity and empowerment improve health outcomes using an analytical framework called CHOICE (Capacity building, Human Rights, Organizational Sustainability, Institutional Accountability, Contribution, Enabling Environment).   The Lime Tree Project is a community, university and local authority partnership in its tenth year. Its aim was to help the residents to identify and express their own health needs and to meet the challenges that were mainly of socio-economic and psycho-social in nature.  The inhabitants drew together to develop a more just society which over the years, resulted in a novel concept about how healthy living emerges.  Ref: Rifkin SB. A framework linking community empowerment and health equity: it is  a matter of CHOICE. J Health Popul Nutr. 2003 Sep;21(3):168-80.
What challenges does your project address and why is it of importance?: The Commission on the Social Determinant of Health has identified equity and empowerment as key to the improvement of health outcomes, especially for the poor.  In the case of our project the learning and experience gained in terms of community participation and of behavioral and social health determinants has been very important for all concerned. Old people felt isolated and wished to remain in the village, even when they lost their autonomy, rather than enter a nursing home elsewhere. Young families could not get established because of a lack of available housing, the cost of living and nonexistent day care facilities for children. Social links between people had diminished, especially between the generations. Further difficulties arose from poor mobility, both for work and leisure.  The challenge was to improve health (defined by WHO as mental, physical and social well being of the individual) outcomes.
How have you addressed these challenges? Do you see a solution?: The project address the challenges through participation and involving a comprehensive life style approach to a situation which threatened to lead to deterioration of the good physical and mental health of the community. CHOICE is a framework that identifies six areas that are critical to examine as they influence the empowerment and equity of health outcomes. By modifying the questions to describe each domain it is possible to create an assessment tool to link equity and empowerment to the good health outcomes that we are seeing in our project.  We describe these links by answering the following questions.  Capacity building: Can local people obtain and act upon new skills and/or knowledge to improve their health?  Human Rights: By exercising their rights, can the communities influence the circumstances that change their poor health conditions? Organizational Sustainability: Can organizations be developed and maintained to ensure sustainability of health gains for the poor? Institutional Accountability: Can mechanisms be developed to ensure resource allocation and decisions that benefit those most in need? Contribution: How does the contribution of a program’s intended beneficiaries reflect its development? Enabling environment: What is the contribution of the existing environment to pursuing equity and empowerment for health improvements?
How do you know whether you have made a difference?: A vision of health living in the commune has been drawn up. One prominent aspect of the reality of the project is the creation of a new village center, with its sheltered housing for the elderly, affordable accommodation for young families, child day care, a games library, shops and a restaurant as well as an intergenerational park and living space. By analyzing the data in the 6 domains of CHOICE we describe how equity and empowerment lead to better health outcomes. Capacity building: One can mention the numerous thematic evenings that have been organized. Themes as varied as the importance of mealtimes to family life, the connection between architecture and health or how to prepare for and draw up an advance directive have been tackled. The project's newsletter, entitled “Tilleul”, ran for two years. There have been communal events aimed at getting the inhabitants to know one another (such as a photographic exhibition). Events and lectures by people from the villages, demonstrating their special skills, were highly successful.  Human Rights: The governance of the project is the community. We have respected the country's quasi-direct democratic system. We asked the population to proceed in the direction negotiated during the twice-yearly general meetings (about 400 people, out of 2000 residents, took part). A multidisciplinary group worked on this and, when it thought it had reached the end of a phase, presented it to the community, for a wide ranging discussion of all options. When the agreed specifications were finished a budget for the building work was presented to the citizens by local authorities and was voted through.  Organizational Sustainability: Our organization strategy is a “community-campus-authorities partnership” which is a process of community participation. The university has a role of emulating the competences of the community. In addition it brings its learning and know-how which mesh with those of the community and the local authorities, in our case, with those of the other partners (architects, etc.). Everything depends on each one's capacity and willingness to exchange experiences and ideas and to meld all this into one integrated cooperating whole.  By continuing to support the factors identified by the CHOICE framework, the project will find sustainability by involving communities and supporting their efforts.  Institutional Accountability: The community consists of all residents of the commune (village, electoral district). It was imperative that there was “something for everyone” in this project and essential that none of the various subpopulations seized the reins guiding the project's principal orientation. We have taken care that everyone can have their say adding to our meetings a newsletter and/or a website, so that information can be passed around. Furthermore, an appeal mechanism called a referendum can be called for by the community to recall actions not in accordance with agreed directions. Contribution:  The university was the facilitator that brought together community residents to shape a program meeting the articulated needs of the community.   The local authorities contributed the management for different service providers to work together to meet these needs. Finally, community residents contributed their skills and time to create the center that became the focal point of the project.  All these groups were brought together in a multidisciplinary group that was created to ensure these contributions were debated, shared and coordinated. Enabling environment: Community participation is created. Healthy  Partners including professional and community people worked together toward the goal of creating a project to address improved health in a most comprehensive context.  Good health is a result of social, political and economic factors and medical interventions. The partnership's success is due to a conjunction of personalities and the respect of the democratic process.
Have you or the project mobilized others and if so, who, why and how?: Our Institute has been contacted by other local authorities (Geneva State) to know more about community participation process. An international symposium has been organized by the authors in Washington D.C. to share on experiences from developed and developing countries around implementation of health democracy in national health policies. A book has been recently published based on those experiences. New collaborations between universities have followed.
When your donor funding runs out how will your idea continue to live?: The financing of the number of consultants working in partnership, including the architects and from time to time the university, came from public funding, i.e. from tax revenue. The fiscal agent is the village's administration. There was never an overall budget provision nor an external sponsor; the commune's elected representatives voted on the finance necessary for each of the project's phases. The key to sustainability is the ownership of the community.

Role of Future Family Physician in Rwandan Health Sector

First: Anaclet
Last: Mugali
1st country of focus: Rwanda
Relevant to the conference theme: New roles and responsibilities of health personnel
Summary: In 1963 the Rwandan government implemented its first University,  National University of Rwanda, which had many faculties including a Faculty of Medicine.  Since that time however, the Faculty of Medicine has produced only undergraduates (6 years for generalist Medical Doctors). In 1997 National University of Rwanda Staff decided to introduce a Master’s in Medicine: Postgraduate specialty training. In 2004 supported by the MInister of Health the first batch commenced with the 4 main disciplines: Surgery, Internal medicine, Ob/Gyn, and pediatrics. Anesthesiology was added in 2005. In 2008 the Family medicine and community (FAMCO) program started with 7 residents for 4 years of training.  The first Rwandan family physicians are expected to graduate in August 2012. According to this four year curriculum family physicians will be able to: coordinate and be involved in clinical activities within institutions, manage clinical programs such as palliative care; non-communicable diseases, communicable diseases, provide integrated clinical care within the scope of training experience and according to Family Medicine principles, coordinate community health care team activities and research, develop the community primary health care capacity at the health center level, collaborate with public health care authorities in the planning and implementation of preventive health care and health promotion activities, train all levels of health professionals i.e. medical students, post-graduate students (family medicine), nurses, Community Health Workers. Within our national health system structure we are looking at how family physicians can improve our communities primary health care.  Key words: Family physician, performance, Rwandan health system. Objectives: To improve our health sector structure by including family physician staff.  Setting: National University of Rwanda / Family Medicine Department / Minister of Health. Subjects: Family physicians in Rwandan health sector structure. .
What challenges does your project address and why is it of importance?: Within our national health sector structure, we are looking for strategies that encourage the family physician to constructively contribute to the the improvement of our health care services in general.
How have you addressed these challenges? Do you see a solution?: In terms of challenges we would like to do more advocacy by faciliating workshops with broad discussions with the Rwanda health program key leaders, districts hospital directors, medical doctors’ representatives, health providers at the district level and in the communities. These workshops, via a detailed explanation of the role of the family physician,  will illustrate how the accumulated knowledge  of the family physician can be delivered to the community.
How do you know whether you have made a difference?: Our future family physicians have not yet graduated and the emergence of this new form of professional staff will be in August 2012 after graduation.  After a certain period the evaluation of these new specialists contribution will be revealed by the evaluation criteria in our health sector policy report.
Have you or the project mobilized others and if so, who, why and how?: No.
When your donor funding runs out how will your idea continue to live?: There is no external funding.

Is Assessing Diabetic Distress An Efficient Pathway To Tailor More Effective Intervention Programs?

Author(s): Davoud Shojaeezadeh1, Azar Tol2, Golamreza Sharifirad2, Ahmadali Eslami2
Affiliation(s): 1Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Iran, 2Department of Education and promotion, School of Public Health, Isfahan University of Medical Sciences
1st country of focus: Iran
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Type 2 diabetes is one of the most important health concerns worldwide. Many studies revealed that distress can significantly affect diabetes-related health outcomes, especially patients’ self-management. It is necessary that health experts and professionals take steps to better understand the nature of diabetes distress and its effects on health outcomes. Distress and its manner of management are powerful predictors of adopting self-management behaviors and affect the achievement rate of diabetes control. This study aims to assess the diabetes distress score and its related factors among patients with diabetes. The study can help decision- makers tailor appropriate and timely interventions.
Background (max 200 words): This study was performed to assess diabetes distress score and its related factors among type 2 diabetic patients. Considering the fact that different variables affect diabetes control in diabetic patients, this study tried to determine and analyze related effective variables. Identification and focusing of the modifiable determinants of diabetes distress plays a key role in appropriate intervention planning programs to achieve the best possible outcomes.
Objectives (max 100 words): The purpose of this study was to assess the diabetes distress score and its related factors among type 2 diabetic patients in order to tailor more effective intervention planning.
Methodology (max 400 words): A descriptive – correlation study was conducted for a period of six months in 2011. The study population was type 2 diabetic patients referring to Omolbanin, an outpatient diabetic center in Isfahan. 140 diabetic patients met the inclusion criteria and all participated in the study. A patient's diabetes distress was measured by DDS( Diabetes Distress Scale ) self-report scale with subscales reflecting four domains including Emotional Burden (5 items), Physician Distress (4 items) ,Regimen Distress (5 items) and Interpersonal Distress(3 items). Collected data was analyzed by using SPSS software version 11.5.
Results (max 400 words): The response rate was 100%. Participants were between the ages of 37 and 75 with a mean of 53.23 years (SD=7.82).  54.3% were female, 97.1% were married, and 57.1% had education levels  lower than diploma. Mean of duration of diabetes was 7.1 (SD=5.63) years. 69.3% of participants had borderline metabolic control according to World Health Organization criteria (Table 1).  The average score of total diabetes distress was 2.96 ± 0.83. The average score of each domain was (3.40 ± 1.18), (2.57 ± 0.88), (2.97 ± 0.90), (2.76 ± 0.91) respectively. ‘Emotional Burden’ was considered as the most important domain in measuring diabetes distress. Total diabetes distress revealed a significant relationship between variables such as age (p=0.02), duration of diabetes (p<0.001), marital status, comorbidity, and complications (p<0.001), and history of diabetes (p=0.01). The relationship between each domains and sociodemographic and health related factors has been shown in Table 2. With the intention of tailoring more effective intervention planning, we decided to distinguish which item in each domain had more weight on the score. Table 3 revealed the domains and more frequent response rate in each domain. Furthermore, the Pearson correlation coefficient also revealed that diabetes distress of type 2 diabetic patients had a direct relationship with HgbAlc (r = 0.63, p<0.001). This means that by increasing diabetes distress score, HgbAlc is increased and diabetes control becomes worse.
Conclusion (max 400 words): As outlined in our research it seems some keywords have a pivotal role in diabetes distress, such as emotional support, communication with patient and physician, self-efficacy and social support. All of these points are achievable through an empowerment approach to a diabetes care plan

Prevalence of Depression among the Elderly Population in Rizal Province Using the Geriatric Depression Scale

Author(s): Cheridine Oro- Josef1, Ma. Cristina dela Cruz1, Teofilo Salandanan Jr.1
Affiliation(s): 1Home Health Care, Quezon City, Philippines
1st country of focus: Philippines
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): The rate of depression (6.6%)  noted in this study was consistent with local studies done by Filipino authors. This prevalence rate among the elderly in the most populated province of the Philippines shows that depression can be present in Filipino healthy communities. However, it is considerable to note that a fourth (26.5%) of the population have scores suggestive of depression. This is a window for early intervention in the community level. Depression has been found to be associated with poorer prognosis, longer recovery times from illness, and increased health care utilization. Screening the elderly population for possible depression is important to decrease health care utilization and increase wellness for this age group. It is necessary for primary care physicians, geriatricians and caregivers to identify symptoms of depression in patients with scores suggestive of depression to avoid the development of outright depression. The Geriatric Depression Scale Short Form 15 has proven itself to be a fast, simple screen to quickly and efficiently identify those elderly who may be depressed.
Background (max 200 words): Depression in the elderly is an important public health concern worldwide. It is a silent disorder that afflicts many in the elderly population. It is the most common psychiatric disorder among the elderly yet unrecognized and under treated because attention is often focused on the physical medical conditions that are apparent during clinic visits. Typical signs and symptoms of depression are usually absent (such as lack of energy, loss of appetite, constipation, no interest in work, poor sleep or loss of weight) and are masked by physical manifestations of co-morbid conditions. In community practice case reports of elderly suffering from depression were regarded as consequences of the aging process. Contrary to this belief depression in the elderly is not physiologic. It is a pathologic condition that is reversible with prompt and appropriate treatment. Failure to recognize and treat depression increases the risk of a prolonged course of depressive illness as well as other conditions like malnutrition, significant metabolic illnesses, and a greater chance of dying.
Objectives (max 100 words): To determine the prevalence of depression and associated socio demographic and clinical conditions among the elderly in Rizal province. SPECIFIC OBJECTIVES: 1. To describe the socio-demographic and clinical conditions of the elderly in Rizal. 2. To detect depression among the elderly population using GDS SF 15. 3. To determine association between depression and socio-demographic and clinical conditions among the elderly
Methodology (max 400 words): A cross-sectional survey of the elderly population (aged 60 yrs old and above) in Rizal province, Philippines was conducted between August to October 2009. Simple random sampling was done to select 3 barangays from 3 municipalities in Rizal. A list of the elderly (60 years and over) was compiled from each of the barangays. All the subjects were contacted for a personal interview. The subjects' socio-demographic, socio- economic and clinical data were gathered during the interview wherein a structured questionnaire was completed. The Geriatric Depression Scale (GDS) SF 15 was used to screen for depression.
Results (max 400 words): The total number of elderly subjects included in this study was 196. There were 122 females and 74 males. Their mean age ± standard deviations was 67 + 6.89  (male 67.7±.6.7; and female 67.7±7) years. Most of the subjects were married, 56% (n=110) while 37.4% (n=73) were widowed. A few were single, (n=8, 4.1%) and separated (n=4, 2.1%). The majority were unemployed (n=173, 88.7%). Their source of financial support mostly came from their children (n=103, 62.8%). They live with either one or two married children (n=78, 40%) or their nuclear family (n=56, 28.7%). Most of the subjects were independent (n=127, 64.8%) and moved around without support (n=167, 86.5%). The top 3 medical conditions were Hypertension (n=75, 37.9%), Arthritis (n=50,25.3%) and other Heart diseases (n=18, 9.1%) . GDS SF scores suggestive of depression were reported in 52 (26.5%) of the subjects, and 13 (6.6%)  were in the almost always indicative of depression score group. Marital status (p= 0.044) and presence of multiple medical condition (p=0.018) correlated strongly with depression. Separated and widowed individuals are more likely to show symptoms of depression (R= 0.159).
Conclusion (max 400 words): Depressive symptoms are common among Filipino elderly in Rizal. Detection and early intervention may be helpful at the community level. A simple instrument such as the Geriatric Depression Scale SF 15 is useful and easily administered.

RAFT: Telemedicine in Africa

The RAFT-Network provides telemedicine in African Francophone countries. The main challenge adressed is the de-isolation of care professionals working in remote areas of developing countries. The core activity of RAFT is the webcasting of interactive courses targeted to physicians and other care professionals. Courses are webcast every week, freely available, followed by hunderds of professionals who can interact directly with the teacher.

Project/Initiative Outline:

First Name
Last Name
Name of project or intiative RAFT: de-isolation of care professionals in developing countries
1st country of focus Mali
Additional countries of focus Sub-Saharan Africa and Latin America
Relevant to the conference theme Health information and technologies
Summary Continuing education of healthcare professionals and access to specialized advice are keys to improve the quality, efficiency and accessibility of health system. In developing countries, these activities are usually limited to capitals, and delocalized professionals do not have access to such opportunities, or even to didactic material adapted to their needs. This limits the interest of such professionals to remain active in the periphery, where they are most needed to implement effective strategies for prevention and first-line healthcare.

In order to address these needs, the Geneva University Hospitals have developed a telemedicine network in Africa (the RAFT, Réseau en Afrique Francophone pour la Télémédecine), first in Mali, then in Mauritania, Morocco, Cameroon, and, since 2004, in Burkina-Faso, Senegal, Tunisia, Ivory Coast, Madagascar, Niger, Burundi, Congo-Brazzaville, Algeria, Chad, Benin, Guinea and DRC.
The core activity of the RAFT is the webcasting of interactive courses targeted to physicians and other care professionals, the topics being proposed by the partners of the network. Courses are webcast every week, freely available, and followed by hundreds of professionals who can interact directly with the teacher. 70% of these courses are now produced and webcast by experts in Africa. A bandwidth of 30 kbits/second, the speed of an analog modem, is sufficient, and enables the participation from remote hospitals or even cybercafés.
Other activities of the RAFT network include medical tele-expertise, tele-ultrasonography, and collaborative development of educational on-line material.
The network is currently organized and run by more than 40 national coordinators throughout Africa, and by a coordination team based in Geneva. In each of the partner countries, the RAFT activities are supervised by the focal point, a medical authority (usually a university professor) that links the project to the national governmental bodies (ministry of health, ministry of education). A local medical coordinator (a junior physician) and a technical coordinator take care of the day-to-day operations, including communication with the care professionals, identification of training needs, technical training and support of the various sites within the country.
Key partnerships include the Université Numérique Francophone Mondiale (UNFM) and the World Health Organization (WHO). The RAFT is recognized as an official WHO collaborating center for eHealth and Telemedicine.
The current priority is the large-scale deployment of these telemedicine tools along with IT-enabled diagnostic devices such as portable echography, to the regional and district hospitals in Africa. These infrastructures could also be used to facilitate public health activities including the collection and communication of surveillance and healthcare indicators to the ministries. The usefulness of these tools to support isolated care professionals has been demonstrated, as well as the sustainability of the implementation in large hospitals who can integrate the recurring connection costs in their operational budgets. Given the high costs of satellite connections (about 500 USD per month), which are the only options in remote areas, it has been evaluated that sustainability can currently be achieved down to the district-level hospitals who usually serve populations of 50’000 to 200’000, and operate as the first level of reference for dispensaries and rural hospitals.
In parallel, the network is extending to other linguistic areas: educational sessions have been produced in English since October 2008, and are available to hospitals in English-speaking Africa and the Middle East. Since 2011, the project is being implemented in Latin America.
What challenges does your project address and why is it of importance? The main challenge addressed is the de-isolation of care professionals working in remote areas of developing countries. In most countries, remote areas are understaffed, with a suboptimal use of existing resources, while main cities retain most of the skilled professionals and have overcrowded care facilities.
How have you addressed these challenges? Do you see a solution? The RAFT network provides distance education and tele-expertise services to isolated care professionals, by establishing South-South collaborations between reference hospitals and regional/district hospitals.
How do you know whether you have made a difference? We have many anecdotes showing that these tools are effective both for professional and social de-isolation, and help maintain skilled and motivated professionals in remote areas, thus strengthening thelocal health systems.
Have you or the project mobilized others and if so, who, why and how? The RAFT network has many partnerships in order to provide quality contents and mutualize technical and organizational resources. These include WHO (HUG is a WHO collaborating center for eHealth and telemedicine), UNFM (Université Numérique Francophone Mondiale), AUF (Agence Universitaire de la Francophonie), UNESCO (University of Geneva has a UNESCO chair for distance education), Université Senghor...
When your donor funding runs out how will your idea continue to live? In most countries, the network is supported by the MoH or hospitals within two to three years of the initial deployment in that country.


GHF2006 – Interview with Mary Robinson

September 3, 2006

Submitted by: Viola Krebs (ICVolunteers); Contributors: Jean-Pierre Joly (ICVolunteers)

"With the human rights as a framework... the objective of 'access to health for all' will certainly have made some progress through the conference." Image: Viola Krebs,

Mary Robinson, the first woman President of Ireland (1990-1997) and more recently United Nations High Commissioner for Human Rights (1997-2002) shared with the conference team some of the main challenges at hand when it comes to access to health for all: accountability, financing, the brain drain and the responsibility of those who have the means to make a difference, such as the private sector. She pointed out that the high turnout at the Forum was an indicator of the need for it and the urgency of discussing access to health. Access for all is the concern of all.

Q: Accountability of politicians for decisions affecting human health and dignity is a key issue. If everybody agrees on the principle, the question remains of how to assess their achievements and how to enforce accountability?

I speak more and more about accountability including accountability in the social context. Human rights help greatly. We know what the legal commitments mean for countries. The UN Committee on Economic, Social and Cultural Rights has provided guidance to governments and standards against which they can be held accountable. We have more and more ways to measure their ability to fulfill the right to health. Some of the core obligations such as ensuring that no one is discriminated against in terms of access to basic treatment are to be fulfilled regardless of available resources. The increasing sophistication of civil society groups also enhances social accountability. The Treatment Action Campaign case in South Africa proved that governments can be required to implement comprehensive and coordinated programmes in order to realize the right of access to medical treatment. On 4th September, I will be in London to help Paul Hunt, the UN Special Rapporteur on the Right to Health, to defend his ideas on this matter with the UK Government. It is an important move because we need to keep accountable rich as well as poor countries.

Q: Requesting from developing countries that they finance themselves the access to health for all at a national level seems unrealistic. On the other hand it appears that financing provided by the developed countries for the South has short term effects. Is there a methodology that could be followed to obtain long-term sustainable results?

The current situation is actually shocking. Public health systems in poor countries are broken, in particular in rural areas where many problems surface. We need absolutely to change the approach. It is being recognized that the local parameters have to be far more taken into account. Many errors have been made by the IMF and the World Bank, which actually weakened the ability of countries to take local action. The new trend amongst donors to privilege general budget support since the Paris declaration on aid will put more responsibility on the countries' decision makers. Health ministers will have to be very skilled managers which is not necessarily always the case currently. In quite a number of countries corruption also remains a major issue. Everything should be done to support health ministers and their ministries in order to allow them to manage funding from the GAVI (Global Alliance for Vaccines and Immunization), NGOs, foundations and other donors and to enable them to meet, amongst other things, the Abuja declaration which targets that 15% of national budgets would go to their health systems.

Q: When one thinks of resources, a major one is the human resource. Developing countries suffer from an ongoing brain drain affecting deeply their health systems. How to stop and even reverse this trend?

It is of utmost importance to stop the brain drain. Mid-level workers need to be trained. These middle-skilled personnel are undervalued and invisible. Yet, these health personnel show more sustainability while not being tempted by migration like highly trained health professionals. A good example of this is the use of Tanzania's paramedical personnel to dispense anti-retroviral medication. On 12 September, we will have a high level meeting in New York on migration. The aim is to stimulate more bilateral agreements between countries to avoid permanent migration and to enhance shared training efforts. All countries should share responsibility in this field. In this respect, the pull factor is of importance, meaning that the rich may agree to train more. In the US, where I am currently living, 500,000 nurses and 200,000 doctors are needed by the year 2015. Nurses are being imported. The fact of acquiring them cheaply by not having to educate them is unacceptable. There are many ideas to think about.

Q: The pharmaceutical industry is often criticized. Do you think there is evolution to provide medicine at lower costs? Is there a will within those companies to become socially responsible beyond just a superficial marketing move?

We regard the private sector as an important player either providing good resources or a negative influence. We are keen to see them fully responsible and specific companies have taken this direction. Paul Hunt, the UN Special Rapporteur on Health, is developing guidelines related to the human right to health. The subject is vast and goes from intellectual property to pricing. It is evident that we need a structure and guidelines and pharmaceutical companies, as well as all other stakeholders, have to buy into this.

Q: What are your expectations from the debates during the present Forum and in what way can they influence decision makers?

The Forum comes at the right time. This is proven by the fact that the attendance overshot all expectations. I am convinced that we can initiate change in most of the fields which are on the agenda. The dynamics exist to accelerate a breakthrough in areas such as safer food and water supply, improving educational levels and other social determinants. The Millennium Development Goals have set a 0.7% of GDP level for the aid to be provided by the North to the South. The US Administration is today more willing to commit itself as well. All of this needs to be thought through. The errors of the past often found their origin in the non-coordinated approach of health issues and systems. This Forum gives the opportunity to encompass government representatives, healthcare specialists, donors and NGOs, to strengthen sustainable long-term health systems and to develop common views. With the human rights as a framework it seems that the objective of access to health for all will certainly have made some progress through the conference.

Q: A few weeks ago you attended the World Conference on AIDS in Toronto. What was your overall impression and what conclusions could be drawn from the debates?

My impression was quite similar to the one that prevailed during the previous conference two years ago in Bangkok. A lot of emphasis was put on the progress to be expected from fundamental scientific work. Subjects such as the status of development of microbicides were at the centre point of the majority of the debates, but the use of female condoms got little mention in the context of sub-Saharan Africa. The ability of women and girls to protect themselves from contracting the virus is as important as the process to prepare effective microbicides. The issue of the identification of risk groups did not seem to draw a lot of attention. It appeared as if there was a tendency not to want to address real problems. In a sense it was quite disappointing. Community groups know what they are doing and what they need, but they did not always get enough attention. The focus was more on well known guests than on rallies on women's issues and rights. A number of key issues were not addressed. The planning for the next conference in Mexico needs to put the priorities right.

More Information

For more information about Mary Robinson's current activities and work with Realizing Rights, see