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wmj_1_2019_WEB<\/a><\/p>\n

WMA General Assembly
\nvol. 65
\nMedical
\nWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 1, May 2019
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t1
\nThe WMA Medical Ethics Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t2
\nCustomer Satisfaction and Medical Scheme Complaints in South Africa . . . . . . . . . . . . . . . . \t4
\nPath to Universal Health Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t12
\nInterview with Otmar Kloiber, Secretary General of the World Medical Association . . . . . . \t13
\nInterview with Leonid Eidelman, President of the World Medical Association . . . . . . . . . . . \t16
\nReport of the President on Presidential Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t18
\nInterview with Miguel Roberto Jorge President-Elect of the World Medical
\nAssociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t20
\nInterview with Ardis D. Hoven WMA Chairperson of Council American Medical
\nAssociation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t23
\nInterview with Frank Ulrich Montgomery Vice-Chairperson of Council of WMA . . . . . . . . \t24
\nEuropean Doctors Towards the European Elections 2019. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t26
\n10 Questions for SEEMF\u2019s President, prof.\u00a0Andrey Kehayov, MD . . . . . . . . . . . . . . . . . . . . . . \t27
\nGeorgian Medical Association Turns 30 years old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t29
\nActivities of the Belarusian Medical Association in the Modern Period . . . . . . . . . . . . . . . . . . \t32
\nA Medical Voice Is Needed at the Human Rights Council in Geneva . . . . . . . . . . . . . . . . . . . . \t33
\nEuthanasia and Physician-Assisted Suicide are Unethical Acts . . . . . . . . . . . . . . . . . . . . . . . . . \t34
\nThe Defensive Medicine isn\u2019t the Best Way to Avoid Mistakes. . . . . . . . . . . . . . . . . . . . . . . . . . \t37
\nCPME Position Paper on Defensive Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t39
\nWMA General Assembly
\nWMA General Assembly
\nEditor in Chief
\nDr. P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nThe Latvian Medical Association, \u201cLatvijas \u0100rstu biedr\u012bba\u201d,
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr. Leonid EIDELMAN
\nWMA President
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.,
\nP.O. Box 3566
\n52136 Ramat-Gan
\nIsrael
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nDr. Jung Yul PARK
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\nSamgu B\/D 7F 8F 40 Cheongpa-ro,
\nYongsan-gu
\n04373 Seoul
\nKorea, Rep.
\nDr. Miguel Roberto JORGE
\nWMA President-Elect,
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Mari MICHINAGA
\nWMA Vice-Chairperson of Council
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,Tokyo
\nJapan
\nDr. Osahon ENABULELE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nNigerian Medical Association
\n8 Benghazi Street, Off Addis Ababa
\nCrescent Wuse Zone 4, FCT,
\nPO Box 8829 Wuse
\nAbuja
\nNigeria
\nDr. Yoshitake YOKOKURA
\nWMA Immediate Past-President
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,
\nTokyo, Japan
\nDr. Ravindra Sitaram
\nWANKHEDKAR
\nWMA Treasurer
\nIndian Medical Association
\nIndraprastha Marg
\n110 002 New Delhi
\nIndia
\nDr. Joseph HEYMAN
\nWMA Chairperson of the Associate
\nMembers
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nChairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr Andreas RUDKJ\u00d8BING
\nWMA Chairperson of the Medical
\nEthics Committee
\nDanish Medical Association
\nKristianiagade 12
\n2100 Copenhagen 0
\nDenmark
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of The World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nEditorial
\nEditorial
\nIn recent years the documents, declarations and priority setting of
\nthe World Medical Association have increasingly focused on the
\nfuture.The WMA policy is largely determined by its leaders \u2013 Presi-
\ndent, Council members and chairs, Secretary-General. The WMJ
\nalso pursues this idea, and the Journal more and more often pub-
\nlishes articles that not only describes the current situation or reflects
\ncurrent realities,but at the same time also seeks to predict the devel-
\nopment of global medicine \u2013 socio-medical affairs, environmental
\nhealth, social determinants, public health, universal coverage. The
\nforecast is needed for the WMA to act really as the world medical
\nleader.
\nIncreasingly, we use the concepts of personalized medicine, preci-
\nsion medicine, stratified medicine, individualized medicine. Each
\nof them includes a slightly different set of concepts, but overall,
\nit is the way we see global health care and medicine moving. Per-
\nsonalized medicine is an adaptation of medical care to the indi-
\nvidual peculiarities of each patient. In fact, personalized medicine
\nis the reverse thinking for global business that dreams of selling
\none contraceptive pill every day to every woman in the world, to
\nevery elderly person one ibuprofen tablet in the morning and one
\nsleeping pill in the evening. The new thinking advocates that for
\neach person there are only definite drugs in appropriate doses that
\nhelp to maintain health, ensure quality of life, treat the disease and
\nextend survival.
\nThe adjustment of treatment to patients has already been known
\nat the time of Hippocrates. A holistic approach to a patient is not
\nnew either; by the way, various Eastern medical techniques largely
\nhave sought to treat a patient holistically. However, in the current
\nunderstanding of personalized medicine, we can talk about the phe-
\nnomenon of the 21st
\ncentury as this approach to a particular patient
\nas a whole has expanded through the development of diagnostics
\nand information processing, which provides an understanding of
\nthe molecular basis of the disease.The new diagnostic and informa-
\ntion processing techniques provide a clear evidence base to stratify
\nor group specific patients. Each person has a unique variation of the
\nhuman genome. The health of an individual is determined by this
\ngenetic variation in combination with behaviour and environmental
\nimpacts, although most of the differences in the genome do not
\ndirectly affect the individual\u2019s health. Each person\u2019s unique genetic
\nprofile and unique molecule arrangements make them more sensi-
\ntive or less sensitive to individual diseases and chemicals (drugs).
\nHowever, globally, the ZIP Code affects human life expectancy
\nmore than the genetic code. Social determinants continue to prove
\nconvincingly that a wealthy person with a good education resid-
\ning in a democratic country lives a considerably longer life than the
\npoor without education, but particularly when living in a country
\nwithout social guarantees. The World Medical Association today
\nfaces two major challenges: universal coverage and the need to
\nprovide available doctors assistance to every citizen of the planet,
\nrather than the assistance of poorly educated health professionals.
\nOur goal for the coming years will be focusing on how to combine
\nuniversal coverage for every citizen of the planet with personalized
\nmedicine and the possibility of each individual person be treated for
\na particular disease and diagnosed by applying genetic mapping. At
\nthe same time, we uphold prescribing only appropriate medicines at
\nthe appropriate dosage and duration. It will bring to the fore issues
\nrelating to medical treatments, patients and relatives, ethics, data
\nsecurity, science ethics, computerization and the big social networks
\nand Internet companies worming their way into medicine.
\nDr. med. h. c. Peteris Apinis,
\nEditor-in-Chief of the World Medical Journal
\nBACK TO CONTENTS
\n2
\nMedical Ethics
\nThe Icelandic Medical
\nAssociation (IcMA)
\nLaeknafelag Islands (The Icelandic Medical
\nAssociation, IcMA) was founded in 1918
\nby only 39 physicians. A local association
\nin the capital preceded it, but IcMA was
\nthe first national association of doctors.The
\nmembership slowly increased and the to-
\ntal number of active physicians is currently
\naround 1000 while the population has qua-
\ndrupled from 90 000 to 360 000.Tradition-
\nally, Icelandic physicians seek abroad for
\nspecialisation and, therefore, have always
\nbeen in good contact with international
\ntrends of the profession. The leaders of the
\nassociation followed closely the foundation
\nof WMA after World War II. A represen-
\ntative of IcMA was present at the prepara-
\ntory meeting in London in 1946 and two
\nrepresentatives attended the first GA of
\nWMA in Paris in September 1947 ensuring
\nthat IcMA became one of the 27 founding
\nmembers.Increasingly,the leaders of the as-
\nsociation have had an ambition to partici-
\npate in the work of the WMA and to attend
\nits constituent meetings. Small work group
\nmeetings of the WMA have been held in
\nIceland, but four years ago, IcMA sought to
\norganize a General Assembly for the first
\ntime, a request well received by the WMA
\nCouncil.
\nGeneral Assembly in
\nReykjavik, October 2018
\nThe Assembly was organized in a tradition-
\nal manner with the exception of the science
\nday as discussed later. As the venue was in
\nthe northernmost capital of the world, there
\nwere some concerns regarding the weather.
\nUnsurprisingly, the weather changed more
\nthan once a day as is customary in Iceland
\nat this time of the year and the delegates
\nexperienced intermittently strong wind
\nwith rain, strong and cold wind without
\nrain and calm and cool weather during the
\nfour days of the Assembly. All of this was
\nforgotten when the northern lights became
\nvisible at the night tour outside the capital.
\nAs customary, the local hosts organized the
\nsocial events apart from the Assembly din-
\nner. A tour was organized to Thingvellir,
\nwhere the oldest parliament in the world
\nwas established in 930, functioning until
\nour times except for 45 years in the first
\nhalf of the 17th
\ncentury. The delegates and
\nguests walked through the area in a brisk
\nand cold wind and got hopefully an impres-
\nsion of what this was like in old times. The
\ntour ended by a dinner in a restaurant in a
\nViking style.
\nIn its ceremonial session, Dr. Gudni Johan-
\nnesson, President of Iceland, gave an ad-
\ndress that was very well received.
\nHowever, the Assembly will surely be re-
\nmembered for the unexpected events
\nleading to the immediate termination of
\nmembership of the Canadian Medical As-
\nsociation and subsequently of the Royal
\nDutch Medical Association some weeks
\nlater. These have been among the most ac-
\ntive members of the WMA for years and,
\nhopefully, this will be a time-limited deci-
\nsion.
\nThe Medical Ethics Conference
\nThe traditional science day was extended to
\na two and a half day conference on medical
\nethics.The idea was presented early and the
\nWMA Secretariat gave a very valuable sup-
\nport but it was informed of the idea as soon
\nas it came up.
\nThe main purposes of the conference were
\nthreefold:
\n\u2022\t To allow delegates and WMA guests
\nto discuss more thoroughly the various
\nmedical issues central to the associa-
\ntion.
\n\u2022\t To involve in discussions those physi-
\ncians not familiar with the work of WMA
\nand thereby increase the visibility of the
\nassociation.
\n\u2022\t To allow for the possibility for WMA
\nworkgroups to present their work and to
\nget feedback from those interested but
\nnot involved otherwise in the work.
\nIt is fair to say that all of these aims were
\nreached and the presentations and discus-
\nsions facilitated the work on the various
\nissues. It is worth mentioning examples.
\nThe Work Group on the revision on Ge-
\nnetic Medicine had a fruitful open meeting
\nwhere several ideas were presented.This was
\nvery helpful and has a positive effect on the
\nwork. It was extremely gratifying for us in
\nthe local association that the Medical Eth-
\nics Committee subsequently proposed and
\nthe Council agreed that even though the
\nThe WMA Medical Ethics Conference
\nReykjavik, Iceland, October 2018
\nJon Snaedal
\nBACK TO CONTENTS
\n3
\nMedical Ethics
\nwork on this policy was not finalized, it was
\ndecided to name it \u201cThe Reykjavik Declara-
\ntion on Genetic Medicine\u201d.
\nAnother example is the session on the
\ncentral ethical policies for physicians, the
\npledge of Declaration of Geneva (DoG) and
\nthe International Code of Medical Ethics
\n(ICME).The former had been revised thor-
\noughly a year earlier and has since been in-
\ncreasingly visible for physicians, both those
\nactive inside the WMA as well as others. It
\nwas a moving moment when the pledge was
\nread out in at the Assembly session, first in
\nIcelandic by Gu\u00f0r\u00fan \u00c1sa Bj\u00f6rnsd\u00f3ttir, the
\nchair of the Young Doctors Association in
\nIceland, and subsequently, line by line and
\nsimultaneously,in the three official languag-
\nes of the WMA by all delegates.
\nIt was decided to start a revision process
\nof the ICME with an open consultation
\nmethod in the same manner as for other
\nmajor revisions in the last years.
\nThe most heated debate was on end of life
\nissues, primarily on euthanasia, and phy-
\nsician-assisted suicide where the opinion
\ndiffers vastly. However, it must be kept in
\nmind that active end of life actions are only
\nallowed in very few countries represented in
\nthe WMA and hardly any since the CMA
\nand RDMA withdrawal from the Associa-
\ntion.
\nProminent professionals were invited to
\ngive talks on some of the central issues.
\nDr. Ruth Mcklin, Professor Emeritus in
\nBioethics at the Albert Einstein College
\nin New York, gave her views on research
\nethics with special consideration to the
\nDeclaration of Helsinki. She argued for
\nsome changes of the Declaration and these
\nwill surely be considered during the next
\nrevision most likely to take place some-
\ntimes in the coming decade. Dr. Bartha
\nKnoppers, Professor at McGill University
\nin Toronto, Canada, gave an overview of
\nthe ethical challenges in genetic medicine
\nand so did also Kari Stefansson, the CEO
\nof the Reykjavik based research company
\nDeCode Genetics. Dr. Kristi Boyd from
\nEdinburgh, Scotland, gave a lecture on
\npalliative medicine and Baroness Ilora
\nFinley from the UK on ethical aspects on
\nphysician-assisted suicide and euthanasia
\nfor which she is a fierce opponent.
\nMany other issues were discussed in differ-
\nent sessions such as \u201cHard Choices in Med-
\nicine\u201d, Dual Loyalty of Physicians\u201d, \u201cFuture
\nChallenges in Genetic Medicine\u201d,\u201cThe Use
\nof Artificial Intelligence in Medical Care\u201d,
\n\u201cHealth Care of Undocumented Immi-
\ngrants\u201d, \u201cEthical Use of Health Data\u201d and
\n\u201cPerson Centered Medicine\u201d. The scientific
\ncommittee organized all of these symposia
\nbut in addition, the Nordic Bioethics Com-
\nmittee organized a symposium on \u201cPrenatal
\nTesting\u201d and the International Federation
\nof Pharmaceutical Physicians another one
\non \u201cEthics in Education for Medicines De-
\nvelopment\u201d.
\nAddresses at the opening ceremony were
\ngiven by Mrs. Svandis Svavarsdottir, the
\nMinister of Health, and the President of
\nWMA Dr. Yokokura from Japan.
\nGenerally, there is a great competition in
\ngetting physicians to attend conferences,
\nat least those that do not have a long tra-
\ndition. The WMA has, however, a very
\ngood name and is well connected to both
\nvarious National Member Association
\nand many different collaborators and that
\nhelped. The attendance to the conference
\nwas relatively good with 215 registered
\nparticipants when WMA meetings were
\nin session and 380 participants on the last
\nday when all the delegates were able to
\nattend.
\nThe local organizers had meetings with
\nrepresentatives from some of the NMAs
\nbefore the event and that was very help-
\nful.The WMA Secretariat was very instru-
\nmental in realizing the event, both before
\nand during the days of the conference and
\nthe local organisers are very grateful for
\nthat.
\nIn summary, these are the main take home
\nmessages from the conference.
\nOn the positive side:
\n\u2022\t The content was generally very well re-
\nceived and ethical issues are very suitable
\nfor dialogues.
\n\u2022\t Ethical issues central to the WMA were
\nwell covered.
\n\u2022\t An open session for a WMA work group
\nwas well attended and many valuable
\ncomments were presented.
\n\u2022\t The work of WMA became more visible
\nto physicians that generally are not very
\nwell aware of the work of the associa-
\ntion
\nOn the negative side
\n\u2022\t A part of the conference was parallel with
\nmeetings of the WMA and this has been
\ncriticised. To avoid this, the organizers
\nhad discussed to hold the conference ei-
\nther before the GA or right after but that
\nwas found too risky for attendance.
\n\u2022\t Most of the time, there were two and
\neven three parallel sessions and many
\ncomplained of the difficulty of choosing.
\nHowever, the central issues to physicians
\nare many and thus difficult to choose
\nwhich to leave out.
\n\u2022\t The event faced a financial risk that had
\nto be carried by the local host.
\nLessons to learn
\n\u2022\t To organize a conference on core issues
\nof the WMA is definitely recommend-
\nable, as so many outside the organization
\nwill learn about the important work of the
\nWMA.
\n\u2022\t As the experience of an open WG meet-
\ning was very good, this practice could be
\nused to a greater extent.
\nJon Snaedal, Professor in Geriatric Medicine
\nPresident of the World Medical
\nAssociation 2007-2008
\nE-mail: jsn@mmedia.is
\nBACK TO CONTENTS
\n4
\nSocial Medical Affairs
\nIntroduction
\nCustomer service is viewed as one of the
\nmost fundamental concepts that deal with
\ncustomer loyalty and sustainability in busi-
\nness. It is known that customers who are not
\nhappy with the products offered to them are
\nlikely to switch to products that meet their
\nneeds or their expectations. Prior studies
\nhave found that higher levels of dissatisfac-
\ntion with a company are associated with in-
\ncreased brand switching behaviour and exit
\nintentions [18,7].Thus, customer service is a
\nnecessary component for the success of most
\nbusinesses across all sectors, particularly in
\nhealth care. The health sector has typically
\nbeen slow or reluctant to adopt practices
\nthat place a substantial effort into customer
\nsatisfaction. There is, however, some empiri-
\ncal evidence that shows a growing interest in
\nfocusing on patient and customer satisfaction
\nsurveys [1,14].Studies [11,20,16] show that
\nindustry leaders have been focusing their at-
\ntention on improving patient and customer
\nsatisfaction through various initiatives.How-
\never,despite their many efforts and successes,
\nevidence shows that more work in this area is
\nstill needed [12, 3, 13, 21].
\nA few entities assess medical scheme satis-
\nfaction surveys in South Africa. These enti-
\nties conduct surveys on an annual basis and
\nthey do attempt to provide some insight.
\nHowever, various methodologies employed
\nhave their own shortcomings. One of the
\nshortcomings is that the survey results are
\nnot publicly available other than reported
\nat the aggregate level, thus the true level of
\ncustomer satisfaction is unknown.The other
\nlimitation is that such surveys are mainly
\nconducted for commercial gain. There are
\nalsomethodological issues such as the sam-
\nple size, the sample size used in some of the
\ncustomer satisfaction surveys might not be
\nrepresentative of the medical schemes in-
\ndustry due to small sample size. A GTC
\n(formerly Grant Thornton Capital) study
\nadmits that their annual medical scheme
\nsurvey does not necessarily provide a full
\npicture of medical schemes, as compared
\nwith other similar types of surveys [8].
\nThe medical schemes industry in South Af-
\nrica has been stagnant for the past ten years,
\nhovering at 16% of population covered by
\nmedical schemes. Many social economic fac-
\ntors may have contributed to the slow growth
\nof the industry. One of the possible key fac-
\ntors that have not been explored in detail is
\nthe effect of customer satisfaction and com-
\nplaints on the industry growth. The purpose
\nof the current article is the customer satis-
\nfaction and complaints analysis pertaining
\nto medical scheme members. The objective
\nof the study is to depict both secondary data
\nsourced from various service providers as well
\nas primary complaints data that are collected
\nby the Council for Medical Schemes (CMS).
\nA strong correlation exists between cus-
\ntomer satisfaction, complaints and the value
\nthe customer derives from the products they
\npurchase.Figure 1 below shows the key com-
\nponents of customer satisfaction and the key
\nfactors of perceived quality and customer
\nexpectation and complaints [26, 27]. The
\nACSI model uses survey data as input to the
\ncause-and-effect econometric model which
\nestimates customer satisfaction as the result
\nof the survey-measured inputs of expecta-
\ntions and perceptions of the quality services
\noffered. The ACSI model links satisfaction
\nwith the survey-measured outcome of com-
\nplaints [26,27].Thus,if customer satisfaction
\nis not viewed as a function of perceived value,
\nperceived quality and customer expectation
\nas depicted in Figure 1, then there is a high
\nlikelihood of these resulting in complaints.
\nMedical scheme members often complain
\nwhen a claim for services rendered is not
\nhonoured or paid in full as expected. Mem-
\nbers often feel that they do not receive the
\ncover and the benefits they expect from
\ntheir medical scheme. A study [10] showed
\nthat customer expectation has a significant
\npositive effect on the customer. Another
\nstudy revealed that service quality seems to
\nlead to positive word-of-mouth, and there-
\nfore the lessening of complaint [22]. There
\nis empirical evidence on the correlation be-
\ntween perceived value,perceived quality and
\ncorporate image that have a significant pos-
\nitive influence on customer satisfaction [2].
\nThere are investigations on how the sellers\u2019
\nresponse to complaints affects complain-
\nants\u2019 satisfaction, perceptions of fairness,
\netc. [23]. Furthermore, a study [24] found
\nthat patients who register medical aid com-
\nplaints are four and a half times more likely
\nto voluntarily exit the Health Maintenance
\nOrganization.
\nOther studies have also shown that there
\nis a statistically significant impact of the
\nCustomer Satisfaction and Medical Scheme Complaints
\nin South Africa
\nMichael Mncedisi Willie
\nSOUTH AFRICA
\nBACK TO CONTENTS
\n5
\nSocial Medical Affairs
\noverall dimensions of complaints handling
\n(service recovery, service quality, switching
\ncost, service failure, service guarantee, and
\nperceived value) on customer satisfaction
\n[25]. Thus, customer satisfaction goes be-
\nyond normal service delivery and further
\ntaps into meeting the needs of the customer.
\nIn many cases customer complaints arise
\nbecause their expectations or their needs are
\nnot met by the service provider and that is
\nwhen the perceived value is not realised. A
\nstudy [17] discussed a framework focused
\non a firm\u2019s pre-emptive value offering (also
\nknown as a customer value proposition).
\nFurthermore, [19] proposed a comprehen-
\nsive customer-value creation framework
\nthat identifies four main types of value that
\ncan be created by organisations:
\n\u2022\t Functional\/instrumental value: the at-
\ntributes of the product itself; the extent
\nto which a product is useful and fulfils a
\ncustomer\u2019s desired goals.
\n\u2022\t Experiential\/hedonic value: the extent
\nto which a product creates appropriate
\nexperiences, feelings, and emotions in the
\ncustomer.
\n\u2022\t Symbolic\/expressive value: the extent to
\nwhich customers attach or associate psy-
\nchological meaning to a product.
\n\u2022\t Cost\/sacrifice value: the cost or sacrifice
\nthat would be associated with the use of
\nthe product.
\nIn terms of general business practices, com-
\nplaints might be a result of basic business
\npractices not being carried out as expected
\nby the member, and thus the product does
\nnot meet the customer\u2019s desired goals.Typi-
\ncally, a member of a medical aid scheme
\nexpects a claim to be paid but, due to ad-
\nministratively related issues, a claim is not
\npaid or a benefit is not paid in full. This is
\nnot explained to the member. A rise in the
\nnumber of complaints is also due to admin-
\nistrative inefficiencies by third parties con-
\ntracted to the scheme, which ultimately af-
\nfect the members negatively. This is evident
\nin the two most complained about schemes
\nover the review period.
\nThe Resolution Health Medical Scheme
\nand the Spectramed Medical Scheme are
\nopen schemes that have reported the high-
\nest number of complaints. The schemes
\nhave reported 2.6 and 4.4 complaints per
\n1000 beneficiaries respectively in 2017, and
\nthis is considerably higher when compared
\nwith other schemes. The trend has contin-
\nued during the past three years.
\nThe table below shows the number of mem-
\nbers and valid complaints about Spectramed
\nand Resolution between 2015 and 2017.
\nThe schemes consistently reported more
\ncomplaints, and this possibly contributed to
\na decline in the membership of more than
\n30% for both schemes.
\nThe other contributing factor to the rise in
\ncomplaints is the complexity of the product
\nsold. The more complex the product is the
\nhigher the risk of it not being fully under-
\nstood by the purchasers. During 2017 there
\nwere 278 registered benefit options operat-
\ning in 81 medical schemes, thus choosing a
\nbenefit option became even more confusing
\nto customers. A study [9] depicts that the
\nnumber of benefit options available in the
\nmedical scheme market creates a complex
\nenvironment impacting decision making.
\nFigure 1: ACSI Unique Benchmarking Model [28]
\nSource:ACSI Unique Benchmarking.The American Customer Satisfaction Index,the nation\u203as only cross-
\nindustry measure of customer satisfaction, gives businesses science-based insights across the complete arc of
\nthe customer experience.
\nFigure 2: Spectramed and Resolution Health Medical Schemes complaints related issues
\nSource: [4,5]
\nSOUTH AFRICA
\nBACK TO CONTENTS
\n6
\nIt is not an easy task to accurately assess the
\nimpact of customer satisfaction in health
\ncare, particularly when medical scheme
\nbeneficiaries view it with antipathy. Mem-
\nbers feel that there is nothing intrinsically
\nsatisfying about spending money on medi-
\ncal risk mitigation [15]. They view it as a
\nmust have, and there is no denying that in
\nthe event of a major medical emergency,
\nmedical aid membership is an absolute ne-
\ncessity.
\nCustomer Satisfaction Scores
\nA number of customer satisfaction surveys
\nhave been conducted. The recent data show
\na declining trend in this regard. The South
\nAfrican Customer Satisfaction Index (the
\nSA-csi) for Medical Schemes survey was
\ndone on a sample of schemes, and shows
\na declining trend in customer satisfaction
\nlevels, which dropped from 74.2% in 2017
\nto 72.7% in 2018.The main factors contrib-
\nuting to the declining scores are increasing
\npremiums, shrinking benefits and lack of
\nvalue for money. A survey published by the
\ncompetition commissioner revealed that for
\nrespondents whose family members were
\nnot members of a medical scheme the rea-
\nsons for it were the following:
\n\u2022\t no longer able to afford the contribu-
\ntions\u00a0\u2013 15%;
\n\u2022\t no longer a dependant child and could
\nnot afford it\u00a0\u2013 14%.
\nA survey conducted by one of the larg-
\nest restricted schemes in 2018 revealed
\nthat affordability of the premiums, co-
\npayment, shrinking benefits or benefits
\nexhausting quickly were some of the fac-
\ntors contributing to lower customer sat-
\nisfaction scores. Table 2 below presents
\nthe SA-csi customer satisfaction scores,
\nexposure, and demographic information
\nof the five schemes considered. The list of
\nschemes depicted in the table below ac-
\ncounts for 65% of all schemes, 81% of all
\nopen schemes and 46% overall, in terms of
\nbeneficiaries in 2017.
\nOf the five large medical schemes surveyed,
\nonly two had an improved index score. This
\nwas an open scheme which had slightly
\nabove 200 000 beneficiaries and a higher
\nsolvency level, compared with the other five
\nschemes which rose from 72.6% last year to
\n75.1% this year. GEMS, which is the larg-
\nest restricted scheme (employer medical
\nscheme), also saw an increase in customer
\nsatisfaction level, improving from 64.3% to
\n68.8% in 2017.The Discovery Health Med-
\nical Scheme dropped from 74.8% to 73.1%,
\nwhile the Bonitas Medical Scheme\u00a0\u2013 from
\n73.1% to 70.2% over the period.
\nThe Momentum Health remained within the
\nrange of 72.0%.Only one of the five schemes
\nis self-administered. Others are adminis-
\ntered by third party, which further discloses
\nthe impact of the operating model upon the
\ntypes of services offered. Simplicity of prod-
\nucts plays a role.Table 2 shows the number of
\nbenefits offered by these schemes that offered
\na range between 5 and 17 benefit options.
\nSurvey Limitations
\nWhile the data give an insight into the cus-
\ntomer satisfaction survey, it is of importance
\nto note the following limitations: Only one
\nrestricted scheme was considered, which
\nrepresents less than half of the restricted
\nschemes. There are also considerable differ-
\nences in the scheme considered in terms of
\ndemographics and the number of benefit
\noptions offered, which is similar to the op-
\nerating model.
\nThe other limitation of the survey is that it
\nconsiders a random sample of 1757 medical
\naid members. A bigger sample size across
\nother scheme types could certainly improve
\nthe findings of the study. The present num-
\nber accounts for less than a percent (<1%
\nof the overall membership) of the overall
\npopulation coverage by medical schemes.
\nTable 1:
\nMembership and valid complaints data for Spectramed and Resolution Health
\nMedical Schemes
\nCategory
\nSpectramed medical
\nscheme
\nResolution health
\nmedical scheme
\nNumber of complaints
\n2017 81 70
\n2016 102 100
\n2015 167 123
\nNumber of beneficiaries
\n2017 22,777 28,839
\n2016 27,599 37,546
\n2015 33,062 45,575
\nTable 2: Customer satisfaction scores for five selected medical schemes
\nScheme Name
\nScheme
\nType
\nBeneficia-
\nries
\nNumber of
\nOptions*
\nSolvency,
\n%
\nSA-csi Score,
\n% (2016)
\nDiscovery health
\nmedical scheme
\nOpen 2,777,946 17 27.4 73.1 (74.8)
\nMEDIHELP Open 200,487 7 29.6 75.1 (72.6)
\nMomentum health Open 293,787 6 25.7 72.0 (72.2)
\nBONITAS Open 728,943 11 24.5 70.2 (73.1)
\nGEMS Restricted 1,807,538 5 15.2 68.8 (64.3)
\nSource: [15, 4, 5], * Excluded Efficiency Discount Options\/Sub-options
\nSocial Medical Affairs SOUTH AFRICA
\nBACK TO CONTENTS
\n7
\nComplaints Trend Analysis
\nTable 4 below reveals the trend data of valid
\ncomplaints logged between 2015 and 2018,
\nthe complaints ratio (valid complaints per
\n1000 beneficiaries) was slightly higher for
\nopen schemes, compared with restricted
\nschemes. There was an increasing trend in
\nrestricted schemes between 2015 and 2016;
\nhowever, a notable trend was noted in 2017
\nin both sectors.
\nThere were more complaints in medical
\nschemes in 2017 compared with previous
\nyears where an increase of more than 10%
\nwas noted.
\nOver the period, the number of com-
\nplaints and complaint resolution time have
\nconsistently increased. Open schemes
\nhave reported more complaints than re-
\nstricted schemes. The data show an in-
\ncreasing trend in the average complaint
\nresolution time within the range of two
\nto six months, in both open and restricted
\nschemes. It is seen that it took longer to
\nresolve complaints in 2017. This might be
\nattributed to the complexity of the com-
\nplaints received.
\nTypes of Complaints Over
\nthe Reviewed Period
\nThe figure below presents a grouping of
\ncomplaints by the complaint type over the
\nperiod of three years. Complaints relating
\nto benefit payments accounted for a third
\nof the complaints, short payments\u00a0\u2013 for just
\nunder a quarter, pre-authorisations\u00a0 \u2013 for
\n10%, and no-payments\u00a0\u2013 for 9%.
\nTrends in complaint type
\nFigure 4 below reveals that the payment
\nof benefits accounted for \u2153 of complaints
\nin 2016 and 2017, and short payments\u00a0\u2013
\nfor under a quarter of the complaints
\nand dropping to 24% of the complaints
\nin 2017. Complaints relating to pre-au-
\nthorisations were wthinin the range of 9
\nto 10%. Non-payments accounted for 8 to
\n9% of all complaints. A similar trend was
\nnoted for complaints relating to customer
\nservice.The data show that in 2015, short-
\npayment complaints had a large share;
\nhowever, this was improved in subsequent
\nyears.
\nMedian time to resolve
\ncomplaints by complaint
\ntype
\nFigure 5 below shows the median time
\nto resolve complaints within the period
\n2015-2017 stratified by the complaint cat-
\negory. Other types of complaints such as
\nTable 3: Demographic Information of SA-csi surveyed schemes
\nScheme Name
\nName of the admin-
\nistrator
\nAverage
\nAge
\nPensioner
\nratio
\nNo. of de-
\npendents per
\nmember
\nNo of
\nTrustees
\nDHMS
\nDiscovery Health
\n(Pty) Ltd
\n34.6 9.3 1.1 8
\nMEDIHELP Self-Administered 37 14.1 1.2 8
\nMomentum
\nhealth
\nMMI Health (Pty)
\nLtd
\n32.8 8.1 0.9 8
\nBONITAS
\nMedscheme Hold-
\nings (Pty) Ltd
\n33.3 8.3 1.2 11
\nGEMS
\nMetropolitan Health
\nCorporate (Pty) Ltd
\n30.5 6 1.6 11
\nSource: [4]
\nTable 4 Complaints ratio\u00a0\u2013 Industry\/100 beneficiaries
\nYear All Open Restricted
\n2017 0.47 0.50 0.43
\n2016 0.42 0.46 0.38
\n2015 0.42 0.47 0.36
\nSource: Author computations, extrapolated from the CMS reports [4,5,6]
\nTable 5: Median time to resolve complaints
\nCategory
\nNumber of Valid
\nComplaints
\nMedian Time to resolve complaints
\nDays Months
\nOpen
\n2017 2 500 169 6
\n2016 2 348 122 4
\n2015 2 353 91 3
\nRestricted
\n2017 1 690 143 5
\n2016 1 498 85 3
\n2015 1 400 63 2
\nSocial Medical Affairs
\nSOUTH AFRICA
\nBACK TO CONTENTS
\n8
\n\u00ad
\ngovernance related complaints, late joiner
\npenalties and waiting periods were excluded
\ndue to the smaller sample size within the
\ngroups. In 2015, the median time to resolve
\ncomplaints ranged around three months and
\nthis increased to six months in 2017.Notable
\nchanges affected complaints related to non-
\npayment of claims, membership status, and
\npre-authorisations that showed a significant
\nshift. Complaints related to payment of ben-
\nefits, contributions and medical savings ac-
\ncounts increased from two to four months.
\nDiscussion
\nThe current report describes a decrease in
\ncustomer satisfaction scores, although the
\nsample used to assess these scores has its
\nown limitations. However, the data reveal
\nsome valuable facts. One of the key findings
\nthe surveys depict is declining of customer
\nsatisfaction scores. The medical schemes
\ncustomer satisfaction score for a select list
\nof schemes surveyed in 2018 was less than
\n75%. This was substantially lower than that
\nmeasured in other financial service indus-
\ntries ranging from 77% to 79% for financial
\nservices and life insurance industries, respec-
\ntively. Due to the complexity that exists in
\nthe private health sector, the low customer
\nsatisfaction scores might be an indication to
\nmembers\u2019feeling about the quality of services
\nin medical schemes sector. One of the un-
\nderlying factors that drives the complexity is
\ninformation asymmetry, namely, the types of
\nproducts sold to members. There were over
\n270 benefit options that are also coupled
\nwith complex rules and various treatment
\nprotocols.There are, however, studies that do
\nnot reflect the complexity of products offered
\nby medical schemes.A recent survey released
\nby the competition commissioner showed
\nthat the 1 507 medical schemes surveyed
\nwere about their knowledge of cost implica-
\ntions and benefits provided by the various
\noptions across medical schemes.
\nThe GTC annual survey conducted in 2017
\ndepicted that consumers were unsure of
\ntheir own medical scheme details and ben-
\nefits they were entitled to [8]. Seventy-six
\npercent (76%) of respondents stated that
\nthey made sure that they understood the
\ncost implications and the benefits of options
\nprovided across a medical scheme before se-
\nlecting it. At the same time certain partici-
\npants admitted that they had poor knowl-
\nedge of the cost and benefit implications
\nof the various medical scheme options. The
\nhealth market inquiry report published in
\n2018 made recommendations to standardise
\nbenefit packages offered by medical schemes
\nto be able to allow members make better-
\ninformed choices based on value-for-money.
\nIn response to such challenges, the CMS
\nis currently working on the benefit op-
\ntions standardisation process, which will
\nultimately assess the possible simplification
\nof benefit options and meeting members\u2019
\nneeds. Another aspect contributing to the
\ndeclining scores is the affordability of pre-
\nmiums that have consistently risen above
\nthe annual inflation rate and, as a result,
\nhealthcare is becoming more unaffordable.
\nPayment of benefits
\nShort payment
\nPre-authorisation
\nNon-payment
\nGeneral customer service
\nMembership status
\nMedical Savings Account
\nContributions
\nWaiting periods
\nLate joiner penalties
\nBenefit Option changes
\nGovernance
\nRejection of membership application
\nBroker conduct
\n0% 5% 10% 15% 20% 25% 30% 35%
\nFigure 3: Median time to resolve complaints by nature of the complaint, %
\n0
\n5
\n10
\n15
\n20
\n25
\n30
\n35
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\n%
\nof
\ncomplaints
\n2015 2016 2017
\nFigure 4: Median time to resolve complaints by nature of complaint, trend data
\nSocial Medical Affairs SOUTH AFRICA
\nBACK TO CONTENTS
\n9
\nPremiums between 2015 and 2017 have in-
\ncreased within the range from 6% to 14%,
\nwhich is higher than inflation. A study
\nconducted by the GTC also revealed that
\nincrease in medical aid premiums continues
\nto outstrip salary increase. Since 2010, the
\nCMS embarked on a process of a stringent
\nreview of medical schemes [4].
\nThe data presented in the current report
\nshow a correlation between complaints
\nand loss of membership, as revealed by the
\nResolution Medical Scheme and Spec-
\ntramed case studies. A noticeable trend
\nwas the increase in valid complaints dur-
\ning the period under review, and this trend
\nwas evident in both open and restricted
\nschemes. One of the key features revealing
\nthe increasing trend was complaints relat-
\ning to the benefit payment that accounted
\nfor more than a third of all valid complaints
\nin the review period. Coupled to this was
\nthe median complaint resolution time that
\nincreased twice between 2015 and 2017,
\ni.e. from three months to six months. This
\nmight be the result of an increase in the
\ncomplexity of complaint types or the result
\nof increased operational inefficiencies in the
\nindustry over the period. Industries, such
\nas the short-term industry, report a lower
\nresolution time with an average resolution
\ntime of 131 days,which is equivalent to four
\nmonths.This shows the unique features and
\ncomplexity of the medical scheme industry.
\nRecommendations
\nThe complexity of the medical schemes
\nindustry with respect to the number of
\nproducts offered and the various operating
\nmodel used needs to be carefully consid-
\nered when comparing customer satisfaction
\nscores. Considering methodological issues
\nsuch as smaller sample size and other key
\nfeatures, e.g. the demographics, balance in
\nscheme types used in the survey, corporate
\ngovernance structures, third-party arrange-
\nments, and the financial performance of the
\nscheme over time, could certainly add value
\nto annual customer satisfaction surveys.
\nThe results presented, indeed, highlight the
\ncomplexity of the sector and the number
\nof components where a competing inter-
\nest may have possibly contributed to lower
\nsatisfaction scores. One of the main issues
\nconsistently evident in most of the com-
\nplaints relate to the effect of third parties
\non complaints. There needs to be a clearer
\nseparation of duties, responsibilities and ac-
\ncountability between the scheme and con-
\ntracted parties.
\nThe increase in the number of valid com-
\nplaints received by the regulator provides an
\nindication that the complaint department
\nneeds to be properly resourced to be able to
\nimpact positively on the turnaround times.
\nThere is also a need to review the overall
\ncomplaint resolution time and this needs to
\nbe consistent with the nature of complaints
\nand should reflect modern challenges that
\nthe schemes are facing. The overall com-
\nplaints process needs to be aligned with the
\nregulatory tools in order to be more effective
\nand such a process should outline proactive
\nmeasures as opposed to a reactive approach
\nto complaint resolution. One of the key
\nrecommendations in this regard is to invest
\nin data analytics as well as in research and
\ndevelopment to assist in developing mod-
\nels that will provide insight and ultimately
\nidentify systematic issues that need urgent
\nattention from a regulatory perspective.
\nThe current study revealed that more than
\na half of the valid complaints are related to
\nthe payment of benefits. In many cases the
\nscheme does not honour claims and pays only
\nup to a certain threshold. It is recommended
\nthat medical schemes need to be proactive,
\nand they must effectively communicate to
\nmembers what benefits are covered. Fur-
\nthermore, in instances where a claim is not
\ncovered in full, this should be communicated
\nto the members. Schemes are encouraged to
\nprovide feedback to the members on benefits
\npaid.Training and member education on the
\nproducts offered by medical schemes could
\ngo a long way towards changing the percep-
\ntion of medical schemes. The latter also ap-
\nplies to third parties who are contracted to a
\nscheme that,in its turn,affects the delivery of
\nservice to the members.The operating model
\nof the scheme, particularly where third par-
\nties are involved,needs to take accountability
\nfor service failures.
\nReferences
\n1.\t Al-Abri R, Al-Balushi A. Patient satisfaction
\nsurvey as a tool towards quality improvement.
\nOman Med J, 2014, 29 (1), 3\u20137.
\n2.\t Ali, Rizwan, Leifu, Gao, Rafiq, Muhammad
\nYasir & Hassan, Mudassar. Role of Perceived
\nValue, Customer Expectation, Corporate Im-
\nage and Perceived Service Quality on Customer
\nSatisfaction. The Journal of Applied Business
\nResearch, 2015, 31 (4), 1425\u20131436.
\n3.\t Bleich S. How does satisfaction with the
\nhealth-care system relate to patient experience?
\n0
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\nMonths
\nComplaint category
\n2015 2017
\nFigure 5: Median time to resolve complaints by nature of complaint, trend data
\nSocial Medical Affairs
\nSOUTH AFRICA
\nBACK TO CONTENTS
\n10
\nAnnexure A1: Complaint Categories\u00a0\u2013 descriptions
\nComplaint
\ncategory
\nShort description
\nContribu-
\ntions
\nComplaints related to contributions\/ premiums: These complaints relate to premium increases, incorrect contributions
\nraised to the member.
\nPayment of
\nbenefits
\nComplaints related to payments of benefits: This is the largest category of complaints and has at least 19 subcategories,
\nthe range of complaints transmit to payment on incorrect benefits, claims paid in error, sublimit on options, benefits
\nexhausted, incorrect information on accounts.
\nShort pay-
\nment
\nComplaints where a scheme does not pay in full: This is where the claim in not paid in full due to incorrect diagnosis
\nICD-10.
\nNon-pay-
\nment
\nComplaints where a scheme does not pay a benefit: This is where the claim in not paid due to incorrect diagnosis ICD-
\n10.
\nMembership
\nstatus
\nComplaints related to the membership status: This category includes suspension and\/or termination of membership.This
\nusually occurs when the membership status is terminated by the scheme due premiums not paid, material non-disclosure,
\nfraudulent conduct by the member.
\nPre-authori-
\nsation
\nComplaints related to pre-authorisation: These types of complaints are the result of an authorization not granted by the
\nscheme due to benefits that are excluded, protocols, waiting periods, pending outstanding information and non-disclo-
\nsure.
\nLate joiner
\npenalties
\nThese types of complaints are the result of late joiner penalties or waiting periods being imposed by a scheme to a
\nmember. A \u201clate joiner\u201d refers to an applicant or an adult dependant of an applicant who, at the date of application for
\nmembership or admission as a dependant, is 35 years of age or older and who was not a member of one or more medical
\nschemes as from a date preceding 1 April 2001,without a break in coverage exceeding 3 consecutive months since 1 april
\n2001. A waiting period is a time when a person cannot claim benefits as set out in the Medical Schemes Act. It aims to
\nprotect current members of a medical scheme by ensuring that people do not just join a scheme, make a large claim and
\nthen cancel their membership.
\nWaiting
\nperiods
\nGeneral cus-
\ntomer service
\nComplaints related to customer service: Complaints relating to the service offered, these types of complaints arise where
\na brochure is not received by a member, schemes failure to provide feedback to the member, where the scheme sends
\nincorrect information to the member,
\nMedical Sav-
\nings Account
\n(MSA)
\nComplaints related to medical savings account and would typically include a clawback of funds, refunds or received by
\nthe member and self-payment gap. MSA is usually a percentage of their premiums that get put into a separate account,
\nfrom which certain benefits are paid, such as doctors\u2019 visits and acute medication, etc.
\nBenefit Op-
\ntion changes
\nComplaints related to benefit option changes and typically instances where benefits are excluded or limited when a
\nmember moves from one benefit option to another.
\nRejection of
\nmembership
\napplication
\nComplaints related to membership application where a scheme depict that a dependant is not eligible or due to discrimi-
\nnation.
\nBroker con-
\nduct
\nComplaints due to the broker\u2019s conduct, this may entail issues related to broker fees or incorrect advice by a broker.
\nMedical Schemes Act and Medical Schemes
\nMedical schemes are legal bodies registered in terms of the Medical Schemes Act for defraying medical expenses of its members.
\nThere are two kinds of schemes\u00a0\u2013 open and closed schemes. Any person can join an open scheme, but closed schemes are for specific
\nemployer groups.
\nSocial Medical Affairs SOUTH AFRICA
\nBACK TO CONTENTS
\n11
\nBull World Health Organ, 2009, 87(27), 1\u20138,
\nhttps:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/
\nPMC2672587\/, accessed February 2019.
\n4.\t Council for Medical Schemes. CMS Annual
\nReport 2017-2018, 2018, www.medicalschemes.
\ncom\/Publications.aspx, accesed February 2019.
\n5.\t Council for Medical Schemes. CMS Annual
\nReport 2016-2017, 2017, www.medicalschemes.
\ncom\/Publications.aspx, accessed February 2019.
\n6.\t Council for Medical Schemes. CMS Annual
\nReport 2015-2016, 2016, www.medicalschemes.
\ncom\/Publications.aspx, accessed February 2019.
\n7.\t Curtis T, Abratt R, Rhoades D, & Dion P. Store
\nloyalty repurchase and satisfaction : a meta-an-
\nalytical review. Dissatisfaction & Complaining
\nBehaviour, 2011, 24, 1\u201326.
\n8.\t GTC (formerly Grant Thornton Capital). The
\nGTC Medical Aid Survey. Benet and cost com-
\nparisons\u20132018. The Wanderers Office Park,52
\nCorlett Drive, Illovo, 2196, 2018, http:\/\/www.
\ngtc.co.za, accessed February 2019.
\n9.\t Kaplan J. & Ranchod S. Analysing the structure
\nand nature of medical scheme benefit design
\nin South Africa. In: South African Health Re-
\nview. Eds. Padarath A, King J, English R, 2015,
\nHealth Systems Trust, Durban, 2015.
\n10.\tKattra HS., Weheba E. & Ahmed O.The impact
\nof employee behaviour on customers\u2019service qual-
\nity perceptions and overall satisfaction. Tourism
\nand Hospitality Research, 2008, 8 (4), 309\u2013323.
\n11.\tKennedy DM. Creating an Excellent Patient
\nExperience Through Service Education. J Pa-
\ntient Exp, 2017, 4 (4), 156\u201361, https:\/\/www.
\nncbi.nlm.nih.gov\/pmc\/articles\/PMC5734521,
\naccessed February 2019.
\n12.\tIlioudi S, Lazakidou A & Tsironi M. Impor-
\ntance of patient satisfaction measurement and
\nelectronic surveys: methodology and potential
\nbene\ufb01ts. Int J Health Res Innov, 2013, 1, 67\u201387.
\n13.\tMorris BJ., Jahangir AA. & Sethi MK. Patient
\nsatisfaction: an emerging health policy issue.Am
\nAcad Orthop Surg, 2013, 9, 29.
\n14.\tPrakash B. Patient satisfaction. J Cutan Aesthet
\nSurg, 2010, 3, 151\u2013155.
\n15.\tSAcsi\u2013Consulta.South African Customer Satis-
\nfaction Index (SAcsi) for medical schemes.Con-
\nsulta Pty Ltd. Central Park Building 1 Highveld
\nTechno Park, Cnr Witch Hazel Avenue & Es-
\ndoring Street, Centurion, 0157, 2018, https:\/\/
\nconsulta.co.za, accessed February 2019.
\n16.\tSaeed R,Ghafoor MO,Sarwar B,Lodhi RN,Ar-
\nshad M & Ahmad M.Factors Affecting Custom-
\ner Satisfaction in Health Care Services in Paki-
\nstan.J.Basic.Appl.Sci.Res,2013,3 (5),947\u2013952.
\n17.\tShanker A. A Customer Value Creation Frame-
\nwork for Businesses That Generate Revenue
\nwith Open Source Software. Technology Inno-
\nvation Management Review. 2012, 2 (3), 18\u201322.
\n18.\tShukla P. Effect of product usage, satisfaction
\nand involvement on brand switching behaviour.
\nAsia Pac. J. Mark. Log, 2004, 16 (4), 82\u2013104.
\n19.\tSmith JB & Colgate M. Journal of Marketing
\nTheory and Practice, 2007, 15, 7\u201323.
\n20.\tTorpie K. Customer service vs. Patient care. Pa-
\ntient Experience Journal, 2014, 1 (2), 5\u20138.
\n21.\tUrden LD. Patient satisfaction measurement:
\ncurrent issues and implications. Lippincotts
\nCase Management, 2002, 7, 194\u2013200.
\n22.\tWhite CJ. The impact of emotions on service
\nquality, satisfaction, and positive word-of-mouth
\nintentions over time. Journal of Marketing
\nManagement, 2010, 26, 5\u20136, 381\u2013394.
\n23.\tYamamoto APDGT. Understanding customer
\nvalue concept: Key to success. Istanbul: Maltepe
\nUniversity, 2007, http:\/\/www.opf.slu.cz\/vvr\/
\nakce\/turecko\/pdf\/Yamamoto.pdf, accessed Feb-
\nruary 2019.
\n24.\tBolton RN, Bronkhurst TM . The relationship
\nbetween customer complaints to the firm and
\nsubsequent exit behaviour. Advances Consum.
\nRes.,1995, 22(1): 92-100.
\n25.\tShammout M. and Haddad S. The Impact of
\nComplaints\u2019 Handling on Customers\u2019 Satisfac-
\ntion: Empirical Study on Commercial Banks\u2019
\nClients in Jordan. International Business Re-
\nsearch, 2014, 7, No. 11
\n26.\tAngelova B & Zeqiri J. Measuring Customer
\nSatisfaction with Service Quality Using Ameri-
\ncan Customer Satisfaction Model (ACSI Mod-
\nel). International Journal of Academic Research
\nin Business and Social Sciences. 2011, 1, 10.
\n27.\tSun Kyung-A & Kim Dae-Young. Does cus-
\ntomer satisfaction increase firm performance?
\nAn application of American Customer Satis-
\nfaction Index (ACSI). International Journal of
\nHospitality Management, 2013, 35. 68-77. 10.
\n28.\tAmerican Customer Satisfaction Index
\n(ACSI). The Science of Customer Satisfaction.
\nACSI LLC 625 Avis Drive. Ann Arbor, MI
\n48108 , 2019, https:\/\/www.theacsi.org\/about-
\nacsi\/the-science-of-customer-satisfaction, ac-
\ncessed February 2019.
\nMichael Mncedisi Willie,
\nGeneral Manager Research & Monitoring,
\nCouncil for Medical Schemes, South Africa
\nE-mail: m.willie@medicalschemes.com
\nAnnexure A2: Complaint categories and sub categories
\nSocial Medical Affairs
\nSOUTH AFRICA
\nBACK TO CONTENTS
\n12
\nRegional Medical Affairs
\nSince time immemorial regardless of race,
\nregardless of era, health has been a primary
\nconcern of human beings throughout his-
\ntory. Life expectancy that has kept on im-
\nproving in the past centuries serves as a
\nproof to this.
\nGovernments from all over the world
\nstarted its interventions on health care,
\nfirst in Germany in 1883, with the Sick-
\nness Insurance Law. Employers were re-
\nquired to provide injury and illness insur-
\nance for their low-wage workers, and the
\nsystem was funded and administered by
\nemployees and employers through \u201csick
\nfunds\u201d, which were drawn from deductions
\nin workers\u2019wages and from employers\u2019con-
\ntributions. This was later followed by the
\nUnited Kingdom, the National Insurance
\nAct 1911 provided coverage for primary
\ncare (but not specialist or hospital care) for
\nwage earners, covering about one third of
\nthe population. The Russian Empire es-
\ntablished a similar system in 1912. In New
\nZealand, a universal health care system was
\ncreated in a series of steps, from 1939 to
\n1941.
\nFollowing World War II, universal health
\ncare systems began to be set up around the
\nworld. On July 5, 1948, the United King-
\ndom launched its universal National Health
\nService. Universal health care was next in-
\ntroduced in the Nordic countries of Swe-
\nden (1955), Iceland (1956), Norway (1956),
\nDenmark (1961), and Finland (1964). Uni-
\nversal health insurance was then introduced
\nin Asia in Japan (1961), and in Canada in
\n1962 to 1972.
\nAs a result, life expectancy has kept on im-
\nproving in the past decades. By 2025, as
\nforecasted by the World Health Organiza-
\ntion, it will reach 73 years and it claims that
\nby then no country will have a life expec-
\ntancy of less than 50 years.
\n\u2022\t 1955: 48 years
\n\u2022\t 1995: 65 years
\n\u2022\t 2025: 73 years
\nIn February 2019, Margaret Chan, WHO
\nDirector-General,described universal health-
\ncare as a powerful tool to fight inequality.
\nAccording to the WHO, a lack of univer-
\nsal healthcare pushes 100 million people a
\nyear below the poverty line because of pay-
\ning for the services they need, while coun-
\ntries such as the United States and China
\ngrapple with how to provide coverage to all
\ntheir citizens. \u201cUniversal health coverage is
\none of the most powerful social equalizers
\namong all policy options. It is the ultimate
\nexpression of fairness,\u201d WHO\u2019s Margaret
\nChan said.
\nThe path to implementing Universal Health
\nCare in the Philippines, having a high pov-
\nerty incidence with 25% of Filipinos earning
\n$5.21\/day, is really tough. The 1987 Philip-
\npine Constitution mandates that \u201cHealth
\nis a right of every Filipino citizen and the
\nState is duty-bound to ensure that all Filipi-
\nnos have equitable access to effective health
\ncare services\u201d. But with a $3,580 (2016) per
\ncapita income inclusively implementing the
\nUHC makes it more challenging.
\nOn February 20, 2019, President Duterte
\nsigned the UHC Act into law. The newly-
\nsigned law is groundbreaking as it replaces
\nthe previous universal healthcare policies
\ninto a definite, coherent government man-
\ndate.The Universal Health Care Act expands
\ncoverage from just hospitalization to preven-
\ntive, promotive, curative, and rehabilitative
\nhealthcare services.The Act is commendable.
\nThis Act is more inclusive because only 6 out
\nof 10 Filipinos have any form of PhilHealth
\ninsurance. Based on the 2017 National De-
\nmographic and Health Survey and govern-
\nment data, a little more than half (54.5%)
\nof all healthcare spending was financed by
\nhouseholds\u2019 out-of-pocket payments.
\nThere are just some limitations in the im-
\nplementation of the 2019 UHC Act. The
\ndelivery of such healthcare services is also
\nseverely constrained by the perennial short-
\nage of health human resources.
\nDoctors and nurses and caregivers and oth-
\ner healthcare professionals continue to leave
\nthe country in droves (especially when va-
\ncancies suddenly crop up abroad),and with-
\nout enough of them, service delivery will
\nsurely be compromised. Healthcare in the
\nPhilippines suffers from a dire shortage of
\nhuman medical resources,especially doctors.
\nThis makes the system run slower and less
\nefficiently. Only 30% of health profession-
\nals employed by the government address the
\nPath to Universal Health Coverage
\n\u201cThe usual reason given for not attempting to provide universal healthcare in a country is poverty.\u201d
\n\t\t \/Amartya Sen, Nobel Prize Laureate for Economics\/
\nJose P. Santiago
\nPHILIPPINES
\nBACK TO CONTENTS
\n13
\nWMA Health Policy
\nhealth needs of the majority. Healthcare in
\nthe Philippines suffers because the remain-
\ning 70% of health professionals work in the
\nmore expensive privately-run sectors.
\nIn 2016, under the Duterte Administra-
\ntion, the Philippines hopes to adopt the
\nCuban health system but it needs to ad-
\ndress the shortage of doctors. The present
\ndoctor-population ratio of 1:33,000 is a far
\ncry from the 1:1,000 in Cuba, majority of
\nwhom are primary care physicians.
\nThe Philippine Medical Association report-
\ned that there are 140,000 licensed physicians
\nin the country, but only 80,000 are active in
\nthe profession. A good number have actually
\nturned to nursing and work as nurses over-
\nseas. Only 2,300 doctors are produced annu-
\nally. Only 30-40% passes the medical board
\nexam every year.It is common to residents in
\nfar-flung villages of the Philippines never to
\nhave seen a doctor from birth to death.
\nAnother hurdle is the shortfall on its bud-
\nget. The 2019 General Appropriations Act
\nallocated only P217B ($4.14B) for the
\nimplementation of UHC. The Universal
\nHealth Care would require P257 billion this
\nyear. It has a deficit of P40B ($765.40M).
\nThis would limit the intended inclusivity of
\nthe coverage of the 2019 UHC Act.
\nFor many Filipinos, especially the poor, get-
\nting sick is not an option. Each hour spent
\nin bed or in hospital is an hour not spent
\nearning money for one\u2019s own family or one-
\nself. Moreover, serious illnesses continue to
\npush more Filipinos to poverty. This merely
\naffirms what the WHO said about Univer-
\nsal Health Care.
\nThe challenge to implement the laudable
\nUniversal Health Care of 2019 is how to
\naddress its hurdles systemically. Govern-
\nment, the health care industry and the third
\nsector should put their acts together to do
\nthis.This would be a giant stride toward im-
\nproving the lives of the Filipinos in terms
\nof health and wellbeing. This is also aligned
\nwith the vision that the Philippines will be
\namong the healthiest peoples in the South-
\neast Asia by the year 2022.
\nJose P. Santiago, Jr., M.D.
\nPresident, Philippine
\nMedical Association
\nApinis: Dr Kloiber, I would like to ask you
\nsome questions about the Alma\u2013Ata and the
\nAstana conferences on Primary Health Care.
\nThe former took place forty years ago in Alma-
\nAta, which at the time in 1978 was the capital
\nof the Kazakh Soviet Socialist Republic. The
\nlatter conference took place last September in
\nAstana, the new capital of the now sovereign
\ncountry of Kazakhstan. At both conferences,
\nsignificant declarations on primary health care,
\nnamed after the cities in which the meetings
\ntook place, were adopted.
\nAt the time the first declaration, the Dec-
\nlaration of Alma-Ata, was adopted I was
\nliving in the Soviet Union and you in the
\nFederal Republic of Germany. There was
\npractically no exchange of information be-
\ntween our countries. In the Soviet Union
\nthis Declaration was recognised as the most
\nimportant document on the subject globally.
\nWhat was the view of the Declaration in
\nGermany?
\nKloiber: To be truthful, I didn\u2018t hear about
\nthe Alma-Ata Declaration until I was active
\nin organized medicine. The reception of this
\ndocument in Germany was probably restrict-
\ned to those who had a very specific interest in
\nprimary care or international health. I would
\nnot be able to say that the health commu-
\nnity in general really took notice of it. In our
\ndefence: at that time Germany already had
\na pretty well-established, high level primary
\ncare system with fairly equitable access and
\nhigh performance. Certainly not perfect, but
\npretty good on the global scale.
\nApinis: This Declaration largely established
\nthe principle that the point of entry into the
\nhealth care system is the family doctor. In the
\nSoviet Union they were called \u201cprecinct thera-
\npists\u201d. These specialists saw patients in large
\noutpatient clinics called \u201cpolyclinics\u201d.These clin-
\nics were built in cities throughout the USSR.
\nOther socialist countries and many develop-
\ning countries followed this example. The real-
\nity of the Declaration was that buildings were
\nerected, not that more family physicians were
\neducated.
\nKloiber: We as physicians would, of course,
\nargue that each patient in primary care
\nshould be seen by a primary care physician,
\nbut not everybody interpreted the Alma-
\nAta Declaration in this way. As you said:
\nsome thought you could fulfil the pledge
\nof primary care\u00a0\u2013 and that was the essence
\nof the Declaration\u00a0 \u2013 by constructing new
\nbuildings.Others thought bare-foot doctors
\nwould be enough and, especially at WHO,
\nthere was a move, at least by some, to see
\nnurses as \u201cprimary care providers\u201d. They
\nThe Astana Conference on Primary Health Care. Interview with
\nOtmar Kloiber, Secretary General of the World Medical Association
\nby WMJ Editor Peteris Apinis
\nBACK TO CONTENTS
\n14
\nthought that family physicians would be a
\nkind of luxury add-on.
\nAnd yes, you are right: in many places the
\ninvestment in educating and retaining phy-
\nsicians did not take place.
\nApinis: So, the Alma-Ata Declaration did
\nnot only bring about positive change, it had
\nnegative aspects too. Did the Declaration of
\nAlma-Ata mean some poorer countries stopped
\neducating specialists and sought only doctors
\nwith the lowest possible level of general medical
\neducation?
\nKloiber: Well there were reports from coun-
\ntries in Europe as well as in Africa that for
\nsome time after Alma-Ata the education of
\nspecialists was significantly reduced. In some
\nplaces this was a decision taken by the gov-
\nernments themselves, in other places donors
\ntold the countries to focus on primary care
\nphysicians. At that time, this meant ending
\neducation after the basic medical degree.
\nApinis: The Declaration of Alma-Ata got very
\nspecial attention from the leaders of socialistic
\nCuba. They started to train doctors in a very
\nshort space of time and export these barely
\ntrained people to countries in Africa and Latin
\nAmerica.
\nKloiber: There have been export pro-
\ngrammes of Cuban doctors to African and
\nLatin American countries with very ques-
\ntionable methods and success. One new
\nprogramme started just last year in Kenya.
\nWe see these programmes very critically for
\nvarious reasons. Most importantly: the Cu-
\nban doctors are not subjected to the same
\nstandards of checking of their qualifications
\nand abilities as everybody else, secondly,
\nthey are not paid properly and the money
\nthat the host countries pay goes to the Cu-
\nban government. Finally, we have seen plac-
\nes where local physicians were pushed out
\nof their jobs, only to be replaced by Cuban
\ndoctors.
\nApinis:Could you mention other examples
\nwhere the Alma-Ata Declaration was trans-
\nlated inappropriately in practice?
\nKloiber: After Alma-Ata, donors discussed
\nhow to best fulfil the pledges of primary
\ncare. In the end, UNICEF decided to go for
\na very minimalist approach.The idea was to
\nsave as many as possible children with the
\nfunds they had. In my opinion, this did not
\nreally lead to a sustainable development. In
\nmany cases, I would be inclined to judge the
\ndevelopment that followed as a deteriora-
\ntion. Primary care is not a minimalist con-
\ncept. A good primary care structure should
\nbe at the core of a comprehensive health
\ncare system.There is no room for short cuts.
\nApinis: Did the Alma-Ata Declaration
\ncompletely ignore the Social Determinants of
\nHealth? Although the theory of social determi-
\nnants was not yet popular, medics already knew
\nthat health was affected by social conditions.
\nKloiber: No, I wouldn\u2019t say that the Alma-
\nAta Declaration ignored the Social Deter-
\nminants of Health. The Declaration itself is
\nnot bad, it\u2019s only that politicians and donors
\ndid not live up to it.Although not expressed
\nverbatim, there is a strong sense of the So-
\ncial Determinants of Health in the docu-
\nment. What many governments and donors
\nmade out of the document was somehow
\ncontrary to the intention: instead of build-
\ning solid health care systems with quality
\nprimary care systems at their core, they took
\nit as an excuse for minimalist approaches.
\nApinis: Did the Alma Ata conference hinder
\nglobal medical and health care development in
\nthe end? Did the financiers and politicians use
\nthe resulting Declaration as an excuse not to
\nallocate enough funds to medicine and health-
\ncare?
\nKloiber: It is not a black and white picture.
\nSome countries understood the value of pri-
\nmary care. In the following years, solid evi-
\ndence was produced showing that proper pri-
\nmary care structures do significantly improve
\nthe efficiency of a health care system. Other
\ncountries, as I said, went the opposite way.
\nApinis: Did the Alma Ata conference trigger
\nthe global migration of doctors and medical
\nworkers? In some poorer countries there are
\nvery few health professionals left because most
\nof them have left for rich countries?
\nKloiber:The Alma-Ata conference and Dec-
\nlaration were certainly not the cause of the
\nbrain drain from poorer to richer countries.
\nThis migration existed before Alma-Ata.The
\nWorld Medical Association addressed brain-
\ndrain in 1971 already, in a resolution which
\ndemanded that richer countries educate
\nmedical students from poorer countries, but
\nthen send them back to their home countries
\nafter receiving their degree. Germany, for in-
\nstance, did this and sent young doctors back
\nto their countries. After Alma-Ata, when
\ndonors started to use minimalist approaches,
\nthese young doctors wouldn\u2019t find any op-
\nportunities for post-graduate education in
\ntheir home countries. Post-graduate educa-
\ntion was no longer supported because prima-
\nry care was enough. These young physicians
\nfinally left for other, richer countries, which
\nwere happy to hire them.
\nNot the Alma-Ata Declaration, but rather
\nits misinterpretation aggravated the prob-
\nlem.
\nOtmar Kloiber
\nWMA Health Policy
\nBACK TO CONTENTS
\n15
\nApinis: You took part in the Astana conference
\nmarking the 40th
\nanniversary of the Alma-Ata
\nconference. Was there a sense of celebration?
\nPlease describe the atmosphere at the Astana
\nconference in a few words.
\nKloiber: Let me first pay a great compli-
\nment to the government of Kazakhstan and
\nall the officials and volunteers who made
\nthis a truly celebratory event. But it was not
\njust a big party: I had the impression from
\nour colleagues at the WHO that they took a
\nvery serious approach to it.Ten years previ-
\nously, the WHO carried out a critical analy-
\nsis of the developments after Alma-Ata in
\nthe 2008 World Health Report \u201cPrimary
\nCare\u00a0\u2013 now more than ever\u201d.
\nThe fact is that the WHO cannot realize
\nprimary care itself, it is the role of the do-
\nnors to do that: governments, the global fi-
\nnancing mechanisms like the Global Fund,
\nGAVI, UNICEF and private relief founda-
\ntions, to name just a few.
\nApinis: WHO documents state that universal
\nhealth coverage means that all people and com-
\nmunities can use the promotive, preventive,
\ncurative, rehabilitative and palliative health
\nservices they need, of sufficient quality to be ef-
\nfective, while also ensuring that the use of these
\nservices does not expose the user to financial
\nhardship.
\nWas the main discussion in Astana not around
\nthis\u00a0\u2013 primary care as a step towards universal
\nhealth coverage?
\nKloiber: Yes, definitely. In contrast to the
\npast, the WHO has brought primary care
\ninto the global picture of universal health
\ncoverage. Primary care is not an end in it-
\nself, not a cheap substitute for real health
\ncare. Primary care is an important invest-
\nment in building a real and efficient health
\ncare system. Maybe the most important
\npart, alongside action on the Social Deter-
\nminants of Health. It should certainly be
\nthe first step, but it cannot be the last if uni-
\nversal health coverage is the aim.
\nApinis: Please tell me, how do you understand
\nuniversal health coverage and the difference be-
\ntween how financiers and bankers understand
\nit?
\nKloiber: I cannot tell you how bankers and
\nfinanciers define universal health coverage
\n(UHC). Personally, I go with the WHO
\ndefinition. In brief, \u201cUHC means that all
\nindividuals and communities receive the
\nhealth services they need without suffer-
\ning financial hardship.\u201d If I may take off
\nmy physician hat for a moment and argue
\nfrom an economic perspective, I would de-
\nfine investment in universal health cover-
\nage as an important investment into the
\nmost productive part of any service-based
\neconomy. In other words: in most service-
\nbased economies the health care sector is by
\nfar the biggest part: highest turn-over, most
\njobs, great return on investment.
\nApinis: Isn\u2019t it true that politicians, finan-
\nciers and bankers would prefer a low-educated
\nhealth worker who is able to measure blood
\npressure, detect blood sugar and cholesterol lev-
\nels, and dress a wound, over a universal or spe-
\ncialised doctor educated for ten or more years at
\ngreat expense?
\nKloiber: Do you know of any politician, fi-
\nnancier or banker who would prefer to be
\ntreated by a community health worker in-
\nstead of a physician? Those who think ahead,
\nthose who care for their people, will accept
\ncommunity health workers in their auxiliary
\nroles, but only in their auxiliary roles. We
\nmay all sometimes have to accept second best
\nsolutions where physicians are not available,
\nbut in the end I hope everyone would agree
\nthat all people who need to be seen by a phy-
\nsician should be seen by a physician.
\nApinis: To what extent are global financial
\ncustodians and donors nowadays interested in
\nreplacing doctors with health workers, espe-
\ncially in poorer countries?
\nKloiber: Unfortunately, we are seeing the
\nsame tendencies as after Alma-Ata. Again,
\nthere seems to be a strong appetite for quick
\nfixes. There is not enough focus on sustain-
\nable development and long-term planning.
\nApinis: Will the lessons from the Astana con-
\nference not become a new incentive for doctors
\nto migrate from poorer countries to wealthier
\nones?
\nKloiber: Again, like with the Alma-Ata
\nDeclaration, the Astana Declaration is not
\nthe problem. It is what we make out of it.
\nApinis: Could the Astana conference not be-
\ncome a reason for inequalities among doctors in
\nterms of work and pay, even though it stated
\nthe exact opposite?
\nKloiber:There are leaders who believe medi-
\ncine is a technical service, who believe a con-
\ntrol and command approach is all they need.
\nWell, as George Santayana said: \u201cThose who
\ncannot remember the past are condemned to
\nrepeat it.\u201dThis is such a case.If we don\u2019t learn
\nto build good workplaces in health care and
\ndecent living conditions in poor countries,
\nthe drama will just continue
\nApinis: What are the main ideas and actions
\nof the World Medical Association for univer-
\nsal health coverage and the global development
\nof primary health care? What new ideas is the
\nWMA preparing for the WMA Conference
\non Universal Health Coverage in Tokyo this
\nJune?
\nKloiber: For us, the biggest insight of the
\nlast two decades has been that without tak-
\ning action on the social and environmental
\ndeterminants of health, anything else will
\nonly produce second rate results. To this
\nextent I think we are in perfect sync with
\nWHO: that universal health coverage is
\nthe number one priority in health systems
\npolicy. We will do what we can to convince
\npeople, politicians, economists and our col-
\nleagues to go with us on this.
\nApinis: Dr Kloiber, thank you very much for
\nyour time.
\nWMA Health Policy
\nBACK TO CONTENTS
\n16
\nApinis: Mr. Eidelman! Half of your presi-
\ndency period has elapsed. Time goes by very
\nfast. You have represented the WMA at vari-
\nous global conferences and events. What do you
\nconsider to be the most important part of your
\nglobal activities?
\nEidelman: As Ppresident of the WMA,
\nI\u00a0stated that I would like to devote my ten-
\nure towards evaluating future challenges
\nfaced by physicians throughout the world
\nas well as promoting preparedness. Dur-
\ning the first half of my presidency, in order
\nto represent the WMA and fulfil my mis-
\nsion, I took an active part in the following
\nconferences and meetings: Global Confer-
\nence on Primary Health Care (October
\n25-26, 2018) in Astana, Kazakhstan; Ja-
\npan Medical Association Ceremony and
\nMedical Congress, (November 1, 2018) in
\nTokyo, Japan; WHO GCM\/NCD Gen-
\neral Meeting (November 5, 2018) in Ge-
\nneva, Switzerland; Unveiling Ceremony of
\nthe German Medical Profession Marking
\nthe Withdrawal of the Medical Licenses
\nof Jewish German Doctors (hosted by the
\nNational Association of Statutory Health
\nInsurance Physicians) (November 8, 2018)
\nin Berlin, Germany; CPME General As-
\nsembly (November 9-10, 2018) in Geneva,
\nSwitzerland; Swedish Medical Association
\nAnnual Meeting (November 21-22, 2018)
\nin Stockholm, Sweden; UNESCO Chair
\nin Bioethics 13th
\nWorld Conference (No-
\nvember 27\u201329, 2018) in Jerusalem, Israel;
\nUniversal Health Care International Con-
\nference (December 1, 2018) Taipei,Taiwan;
\nInternational Conclave on Zero Tolerance
\nTo Violence Against Doctors and Hospi-
\ntals (February 8-9, 2019) in Mumbai, India;
\nMeeting at the American Medical Associa-
\ntion Headquarters (February 18-20, 2019)
\nin Chicago, Illinois, and 12th
\nGeneva Con-
\nference on Person-Centered Medicine,Pro-
\nmoting Wellbeing and Overcoming Burn-
\nout (March 25-27, 2019).
\nApinis: You participated at the conference in
\nAstana (now Norsultan) which focused on the
\nissues of primary care and universal coverage
\nin order to provide medical treatment to ev-
\nery citizen of our planet. This WHO conference
\nwas dedicated to the 40th
\nanniversary of the
\nAlmaAta Declaration. When it was endorsed
\nyou were still in Riga\u00a0\u2013 the WHO meeting was
\nheld in Riga in 1986 and was dedicated to the
\n10th
\nanniversary of the AlmaAta declaration.
\nWhat are your impressions of the Astana con-
\nference?
\nEidelman: The goal of the meeting was to
\nrenew a commitment to primary health care
\nto achieve universal health coverage and the
\nSustainable Development Goals which
\nis part of the UN agenda for 2030. The
\nConference was co-hosted by the Govern-
\nment of Kazakhstan, WHO and UNICEF.
\nThis was the second meeting on Primary
\nHealthcare, the first one was held 40 years
\nprior in Almaty, Kazakhstan, during which
\nthe Declaration of Alma-Ata was endorsed.
\nStrengthening of primary health care
\n(PHC) is essential for Universal Health
\nCoverage (UHC) which is one the major
\ntheme of WMA, particularly promoted by
\nDr. Yokokura during his presidency the last
\nyear.The role of physicians is crucial in PHC
\nfrom education to prevention and acute and
\nchronic care. High quality, evidence-based
\nPHC provided by a trained team led by a
\nphysician is probably the best foundation of
\nfuture medicine. However during the meet-
\ning,it was noticeable that many participants
\ndidn\u2019t think the PHC model should have
\nthe physician at the helm of leadership.The
\nconference focused on other health care
\nproviders, traditional (nurses, pharmacists
\nand social workers) and new ones (com-
\nmunity health workers and healthcare as-
\nsistants).
\nApinis: Universal coverage is a global theme
\nnowadays. You have already discussed this in
\nTaiwan and we are looking forward to the
\nTokyo conference. In June, the World Medi-
\ncal Association (WMA) in Tokyo is hosting
\nthe conference HEALTH PROFESSIONAL
\nMEETING (H20) 2019\u00a0 \u2013 THE ROAD
\nTO UNIVERSAL HEALTH COVERAGE.
\nCould you comment on the evolving discussions
\non universal coverage in Taiwan and Tokyo
\nand on the upcoming Tokyo conference?
\nEidelman: Yes, I attended the confer-
\nence Universal Health Care International
\nConference in Taipei. The International
\nSymposium on Universal Health Cover-
\nage featured an interesting array of panels
\nincluding presentations on disease pre-
\nvention, end-of-life care and quantity and
\nquality of UHC. I had the opportunity
\nto meet Dr. Shih-Chung Chen, Taiwan\u2019s
\nInterview with Leonid Eidelman, President of the World Medical
\nAssociation by WMJ Editor Peteris Apinis
\nLeonid Eidelman
\nWMA Health Policy
\nBACK TO CONTENTS
\n17
\nMinister of Health. Dr. David Barbe,
\nPast President of the AMA, and I were
\non a joint panel moderated by Dr. Otmar
\nKloiber. Dr. Barbe presented on Ensuring
\nAccess to Healthcare in the United States
\nand I presented on Medical Education in a
\nPost-modern Era. We had fruitful discus-
\nsions with Dr. Tai-Yuan Chiu, President
\nof the Taiwan Medical Association, about
\nhow Taiwan achieved UHC in a relatively
\nshort period of time. Until approximately
\n20 years ago, Taiwan had limited health
\ncare accessibility.
\nIn addition, I also participated at a very im-
\nportant event in Japan\u00a0\u2013 the Japan Medical
\nAssociation Ceremony and Medical Con-
\ngress. The JMA is one of the most active
\nmembers of the WMA.The meeting mark-
\ning the JMA\u2019s 71st
\nanniversary was attended
\nby many international guests and stressed
\nthe involvement of JMA and support to
\nNMAs in Asia and throughout the world.
\nDuring the meeting UHC was a topic of
\ndiscussion as well as the role of the JMA in
\nthe international healthcare arena.
\nI\u2019m sure,that the Tokyo Health Professional
\nmeeting (H20) results will be ambitious and
\ncourageous. I hope that we (WMA) will be
\nheard after the Tokyo meeting by politicians
\nand financiers gathering at the G20 sum-
\nmit.
\nApinis: Aggression and violence against doc-
\ntors and medical professionals grow in the
\nworld. A conference on the issue was held in
\nMumbai, India. What did you learn at this
\nconference and what did you emphasize on
\nviolence against doctors as the WMA Presi-
\ndent?
\nEidelman: Violence against doctors has in-
\ncreased significantly in India. To this end,
\nthe Indian Medical Association and the
\nWorld Medical Association came together
\non February 8-9 in Mumbai to discuss the
\nissue of increasing violence against doctors.
\nAccording to the IMA, nearly 72% of In-
\ndian doctors have suffered physical or verbal
\nabuse in their career. During his remarks,
\nDr. Otmar Kloiber gave an international
\nperspective. The speakers described causes
\nof violence and ways to withstand it; they
\nurged all doctors to report all forms of vio-
\nlence, big or small.
\nI presented the statement of the WMA
\non violence against physicians and stressed
\nthat this kind of violence not only has de-
\nstructive social effect but impairs a quality
\nof healthcare that is provided to innocent
\npatients as well. In addition, I emphasized a
\nrole of physician burnout in this intolerable
\nphenomenon.
\nApinis: We know you as a person who has al-
\nways been interested in the future of medicine,
\nabout the direction it will develop. Do you have
\nenough time to work on this?
\nEidelman: On the subject\u00a0\u2013 the future of
\nmedicine\u00a0\u2013 I attended an event in Chicago
\nthat was very important and instructive\u00a0\u2013
\nthe Meeting at the American Medical
\nAssociation Headquarters. This two-day
\nmeeting organized by Ms. Robin Menes
\nfocused on the future of medicine and
\ntrends. We discussed augmented intel-
\nligence, environmental intelligence, what
\nphysicians want to know about technology,
\nhealthcare economy and what is on the ho-
\nrizon. There were many discussions about
\nthe importance of NMAs learning from
\none another in order to ensure prepared-
\nness for the future.
\nApinis: In Tel Aviv you are currently pre-
\nparing one of the most interesting conferences
\never held by the World Medical Association
\nPHYSICIAN\u00ad2030: THE FUTURE IS
\nAROUND THE CORNER\u00a0 \u2013 BE PRE-
\nPARED. Please could you tell me about the
\nideas and objectives of this conference?
\nEidelman: During the half year period,
\nI\u00a0allocated a great deal of time preparing the
\nWMA and IMA \u201cPhysician 2030\u201d meeting
\nwhich will be held in Herzliya, Israel, May
\n13-15. The conference will serve as a plat-
\nform for discussions in multiple areas and
\ndimensions of physician activity that is ex-
\npected to be a subject of significant change
\nin the near future and which require special
\npreparations by physicians and the health-
\ncare system.
\nWorld-renowned speakers: the Nobel prize
\nwinner Yisrael Aumann, Kira Radinsky
\nfrom eBay, Daniel Kraft from the Singular-
\nity University along with representatives of
\nNMAs from Africa, Europe, Asia, North
\nand Latin America will address the issues
\nof the validity of models and predictors in
\nhealth system, healthcare models and medi-
\ncal workplace in 2030, patient-physician re-
\nlationship,medical education-how it should
\nbe changed and technology- where it can
\ntake us.
\nI call upon NMAs to participate at this
\nunique conference and contribute their
\nknowledge, aspirations and experience in
\norder to understand the future, which is just
\naround the corner, and ultimately improve
\nour preparedness.
\nApinis: One of the topics of modern medicine
\nis the burnout in doctors. You discussed this is-
\nsue and reported on it at the Geneva conference.
\nEidelman: This year the International
\nCollege of Person-centered Medicine
\n(\u00ad
\nICPCM) convened the 12th
\nGeneva Con-
\nference on Person-centered Medicine Pro-
\nmoting Wellbeing and Overcoming Burnout
\ndedicated to physician burnout that is one
\nof the most acute challenges of the con-
\ntemporary medicine and endangers physi-
\ncians as well as the quality of healthcare.
\nShortage of physicians that aggravates in
\nmost countries of the world will have a
\nnegative effect on physician wellbeing and
\nthe society at large. Much research has
\nbeen conducted on the crisis of burnout,
\nits causes and manifestations. Currently,
\nthere is a need for studying preventive and
\ntreatment solutions. The WMA statement
\non physician wellbeing was a part of my
\npresentation. The ICPCM has decided to
\nWMA Health Policy
\nBACK TO CONTENTS
\n18
\norganize meetings on physician burnout
\nand wellbeing every year.
\nApinis: Each year you organise a global con-
\nference on medical ethics, and you are one of the
\nkeynote speakers. Please tell me about the con-
\nference in Jerusalem?
\nEidelman: Physicians and leading health
\nprofessionals from around the globe attend-
\ned the UNESCO Chair at the 13th
\nWorld
\nConference on Bioethics in Jerusalem, Isra-
\nel. I had the privilege of delivering remarks
\non behalf of the WMA.
\nThere were over 100 parallel sessions with
\nmore than 1000 participants from over
\n70\u00a0countries including a sizable contingent
\nof WMA members: Dr. Otmar Kloiber,
\nSecretary General of the World Medical
\nAssociation, Dr. Yokokura, President of the
\nJapan Medical Association, Yuji Noto, in-
\nternational relations of the JMA, Dr. Selma
\nG\u00fcng\u00f6r, Board member of the Turkish
\nMedical Association, Dr. Jacques de Haller,
\noutgoing president of the CPME (Standing
\nCommittee of European Doctors), Annabel
\nSeebohm, Secretary General of the CPME,
\nSarada Das, Deputy Secretary General of
\nthe CPME, Thomas Hedmark, policy ana-
\nlyst at the Swedish Medical Association,
\nProfessor Ravi Wankhedkar, President of
\nthe Indian Medical Association, Dr. R.N.
\nTandon, honorary Secretary General of
\nthe Indian Medical Association, Profes-
\nsor Thomas Linden, Board member at the
\nSwedish Medical Association and Jeppe
\nBerggreen H\u00f8j from the Danish Medical
\nAssociation.
\nApinis: Time goes by too fast. The best medi-
\ncal texts and documents become outdated not
\nwithin decades, but by years. Don\u2019t you think
\nabout auditing, reviewing and updating any
\nof the WMA declarations of vital role?
\nEidelman: The WMA declarations primar-
\nily focus on medical ethics and are revised
\nevery decade. Unlike the rapidly changing
\nmedical advancements, the issues, outlined
\nin the declarations, focus on existential
\nrights and our moral obligations as physi-
\ncians. These are long term and don\u2019t change
\nwith the same speed. Moreover, NMA\u2019s are
\ninvited to submit statements to the WMA
\nannually concerning current medical dilem-
\nmas, technology and developments.
\nApinis: We are currently going to the WMA
\nCouncil Session in Santiago, Chile. What are
\nyour priorities at this meeting? What documents
\ndo you consider to be the priority? What will we
\nachieve with our discussions in Santiago?
\nEidelman: During the meeting there will
\nbe elections for new leadership including
\nthe Council chair and Treasurer, both key
\npositions. I look forward to joining my col-
\nleagues in reviewing the plethora of state-
\nments and promoting the WMA mission to
\nserve humanity by endeavouring to achieve
\nthe highest international standards in Med-
\nical Education, Medical Science, Medical
\nArt and Medical Ethics, and Health Care
\nfor all people in the world.
\nReport of the President on Presidential Activities
\nOctober 2018\u00a0\u2013 April 2019
\nAs president of the WMA, I stated that
\nI would like to devote my tenure towards
\nevaluating future challenges faced by physi-
\ncians throughout the world as well as pro-
\nmoting preparedness. During the first half
\nof my presidency, in order to represent the
\nWMA and fulfil my mission, I took an ac-
\ntive part in the following conferences and
\nmeetings.
\nGlobal Conference on Primary
\nHealth Care, October 25-26,
\n2018; Astana, Kazakhstan:
\nThe goal of the meeting was to renew a
\ncommitment to primary health care to
\nachieve universal health coverage and the
\nSustainable Development Goals which
\nis part of the UN\u2019s agenda for 2030. The
\nConference was co-hosted by the Govern-
\nment of Kazakhstan, WHO and UNICEF.
\nThis was the second meeting on Primary
\nHealthcare, the first one was held 40 years
\nprior in Almaty, Kazakhstan during which
\nthe Declaration of Alma-Ata was endorsed.
\nStrengthening of primary health care
\n(PHC) is essential for Universal Health
\nCoverage (UHC) which is one the major
\ntheme of WMA, particularly promoted by
\nDr. Yokokura during his presidency the last
\nyear.The role of physicians is crucial in PHC
\nfrom education to prevention and acute and
\nchronic care. High quality, evidence-based
\nPHC provided by a trained team leaded by
\na physician is probably the best foundation
\nof future medicine. However during the
\nmeeting, it was noticeable that many partic-
\nipants didn\u2019t think the PHC model should
\nhave the physician at the helm of leadership.
\nThe conference focused on other health care
\nproviders, traditional (nurses, pharmacists
\nand social workers) and new ones (com-
\nmunity health workers and healthcare as-
\nsistants).
\nJapan Medical Association
\nCeremony and Medical Congress,
\nNovember 1, 2018; Tokyo, Japan
\nThe JMA is one of the most active mem-
\nbers of the WMA. The meeting marking
\nWMA Health Policy
\nBACK TO CONTENTS
\n19
\nthe JMA\u2019s 71st
\nanniversary was attended by
\nmany international guests and stressed the
\ninvolvement of JMA and support to NMAs
\nin Asia and throughout the world. During
\nthe meeting UHC was a topic of discussion
\nas well as the role of the JMA in the inter-
\nnational healthcare arena.
\nWHO GCM\/NCD General
\nMeeting, November 5, 2018;
\nGeneva, Switzerland
\nThe General Meeting of the Global Co-
\nordination Mechanism on the Prevention
\nand Control of Noncommunicable Dis-
\neases (GCM\/NCD) provided an opportu-
\nnity to increase coordination of activities
\namong participants which were comprised
\nof NGOs, the UN and Governments. The
\nprevalence of NCD is one of the leading
\nchallenges physicians currently face and can
\nincrease in the future. I had the privilege of
\nparticipating in a plenary entitled \u201cCollec-
\ntive leadership: Multisectoral engagement
\nand policy coherence as key enablers of ac-
\ntion to address NCD and their underlying
\ndeterminants\u201d.
\nUnveiling Ceremony of the
\nGerman Medical Profession
\nMarking the Withdrawal of the
\nMedical Licenses of Jewish German
\nDoctors (hosted by the National
\nAssociation of Statutory Health
\nInsurance Physicians), November
\n8, 2018; Berlin, Germany
\nOn November 8, 2018, the eve of Kristall-
\nnacht, the National Association of Statuto-
\nry Health Insurance Physicians in Germany
\norganized an unveiling ceremony marking
\nthe withdrawal of the medical licenses of
\nJewish German doctors 80 years ago.
\nMy remarks concentrated on physician\u2019s
\nmoral responsibility and made mention of
\nthe WMA\u2019s Declaration of Geneva,recently
\nupdated due to the immense contribution
\nof the German Medical Association, which
\nstates that physicians must never use their
\nmedical knowledge to violate human rights
\nand civil liberties, even under threat.
\nCPME General Assembly, November
\n9-10, 2018; Geneva, Switzerland
\nThe Standing Committee of European
\nDoctors (CPME) General Assembly and
\nWorking Groups meetings took place on
\nNovember 9-10 2018, in Geneva. During
\nthe Assembly Prof. Dr Frank Ulrich Mont-
\ngomery was elected president. There were
\nan array of working groups focusing on diet,
\nnutrition and physical activity, e-health,
\nhealthcare for refugees and undocumented
\nmigrants, pharmaceuticals and professional
\npractice. One of the central themes of the
\nconference was Healthcare in Danger. I de-
\nlivered a presentation about Healthcare in
\nConflict Settings which featured key state-
\nments of the WMA and position papers
\ndeveloped by NMAs. I stressed the impor-
\ntance of the physician\u2019s professional obliga-
\ntion to the patient and the highest ethical
\nstandards.
\nSwedish Medical Association
\nAnnual Meeting, November 21-
\n22, 2018; Stockholm, Sweden
\nThe SMA designed a special program for
\ninternational guests. One of the day\u2019s high-
\nlights was a meeting at the Swedish Agency
\nfor Health Technology Assessment. There
\nwas a fruitful discussion led by Sophie
\nVerk\u00f6, the agency\u2019s president, on global
\nsolutions enabling the implementation of
\nevidence into evidence-informed policies
\nand practices within healthcare. At my stay
\nin Stockholm, it was important to learn
\nabout how Swedish physicians tackle with
\nlanguage limitations and cultural differ-
\nences while taking care of the large number
\nof refugees during the last years. Dr. Heidi
\nStensmyren was re-elected president of the
\nSMA.
\nUNESCO Chair in Bioethics 13th
\nWorld Conference, November
\n27-29, 2018; Jerusalem, Israel
\nPhysicians and leading health professionals
\nfrom around the globe attended this con-
\nference. I had the privilege of delivering re-
\nmarks on behalf of the WMA.
\nThere were over 100 parallel sessions with
\nmore than 1000 participants from over 70
\ncountries including a sizable contingency
\nof WMA members: Dr. Otmar Kloiber,
\nsecretary-general of the World Medical
\nAssociation, Dr. Yokokura, president of the
\nJapan Medical Association, Yuji Noto, in-
\nternational relations of the JMA, Dr. Sel-
\nma G\u00fcng\u00f6r, board member of the Turkish
\nMedical Association, Dr. Jacques de Haller,
\noutgoing president of the CPME (The
\nStanding Committee of European Doc-
\ntors). Annabel Seebohm, secretary-general
\nof the CPME, Sarada Das, deputy secre-
\ntary-general of the CPME, Thomas Hed-
\nmark,policy analyst at the Swedish Medical
\nAssociation, Professor Ravi Wankhedkar,
\nPresident of the Indian Medical Associa-
\ntion, Dr. R.N. Tandon, honorary secretary-
\ngeneral of the Indian Medical Association,
\nProfessor Thomas Linden, a board mem-
\nber at the Swedish Medical Association
\nand Jeppe Berggreen H\u00f8j from the Danish
\nMedical Association.
\nUniversal Health Care International
\nConference, December 1,
\n2018; Taipei, Taiwan
\nThe International Symposium on Univer-
\nsal Health Coverage featured an interest-
\ning array of panels including presentations
\non disease prevention, end-of-life care and
\nquantity and quality of UHC. I had the op-
\nportunity to meet Dr. Shih-Chung Chen,
\nTaiwan\u2019s health minister. Dr. David Barbe,
\nthe past-president of the AMA, and I were
\non a joint panel moderated by Dr. Otmar
\nKloiber. Dr. Barbe presented on Ensuring
\nAccess to Healthcare in the United States
\nWMA Health Policy
\nBACK TO CONTENTS
\n20
\nInterview with Miguel Roberto Jorge President-Elect of the World
\nMedical Association by WMJ Editor Peteris Apinis
\nApinis: Presidents of the World Medical
\nAssociation represent countries of the entire
\nworld. ALL of them are highly qualified
\nspecialists in different fields. Xavier Deau
\nis a family doctor, Sir Michael Marmot\u00a0\u2013
\na scientist in social determinants, Ketan
\nDesai\u00a0 \u2013 urologist, Yoshitake Yokokura\u00a0 \u2013 a
\nsurgeon, Leonid Eidelman\u00a0 \u2013 an anesthe-
\nsiologist. You are a psychiatrist. Perhaps it
\nis time for the World Medical Association
\nto look at health care from a position of a
\npsychiatrist.
\nJorge: I am sure that the WMA does not
\ntake into consideration the speciality of its
\nand I presented on Medical Education in a
\nPost-modern Era. We had fruitful discus-
\nsions with Dr. Tai-Yuan Chiu, president of
\nthe Taiwan Medical Association,about how
\nTaiwan achieved UHC in a relatively short
\nperiod of time.Until approximately 20 years
\nago, Taiwan had limited health care acces-
\nsibility.
\nInternational Conclave on Zero
\nTolerance To Violence Against
\nDoctors and Hospitals, February
\n8-9, 2019; Mumbai, India
\nViolence against doctors has increased sig-
\nnificantly in India. To this end, The Indian
\nMedical Association and the World Medi-
\ncal Association came together to discuss the
\nissue of increasing violence against doctors.
\nAccording to the IMA, nearly 72% of In-
\ndian doctors have suffered physical or verbal
\nabuse in their career. During his remarks,
\nDr. Otmar Kloiber gave an international
\nperspective. The speakers described causes
\nof violence and ways to withstand it, they
\nurged all doctors to report all forms of vio-
\nlence, big or small.
\nI presented the statement of the WMA
\non violence against physicians and stressed
\nthat this kind of violence not only has de-
\nstructive social effect but impairs a quality
\nof healthcare that is provided to innocent
\npatients as well. In addition, I emphasized a
\nrole of physician burnout in this intolerable
\nphenomenon.
\nMeeting at the American Medical
\nAssociation Headquarters, February
\n18-20, 2019; Chicago, Illinois
\nThis two-day meeting organized by Ms.
\nRobin Menes focused on the future of med-
\nicine and trends. We discussed augmented
\nintelligence, environmental intelligence,
\nwhat physicians want to know about tech-
\nnology, healthcare economy and what is on
\nthe horizon. There were many discussions
\nabout the importance of NMAs learning
\nfrom one another in order to ensure pre-
\nparedness for the future.
\n12th
\nGeneva Conference on Person-
\nCentred Medicine, Promoting
\nWellbeing and Overcoming
\nBurnout, March 25-27, 2019
\nThis year conference of The International
\nCollege of Person-centred Medicine (ICP-
\nCM) was dedicated to physician burnout
\nwhich is one of the most acute challenges of
\nthe contemporary medicine and endangers
\nphysicians as well as a quality of health-
\ncare. Shortage of physicians that aggravates
\nin most countries of the world will have a
\nnegative effect on physician wellbeing and
\nthe society at large. Much research has
\nbeen conducted on the crisis of burnout, its
\ncauses and manifestations. Currently, there
\nis a need for studying preventive and treat-
\nment solutions. The WMA statement on
\nphysician wellbeing was a part of my pre-
\nsentation. The ICPCM has decided to or-
\nganize meetings on physician burnout and
\nwellbeing every year.
\nDuring the reported half year period, I al-
\nlocated a great deal of time preparing the
\nWMA and IMA \u201cPhysician 2030\u201d meeting
\nwhich will be held in Herzliya, Israel, May
\n13-15. The conference will serve as a plat-
\nform for discussions in multiple areas and
\ndimensions of physicians\u2019activity that is ex-
\npected to be a subject of significant change
\nin the near future and which require special
\npreparations by physicians and the health-
\ncare system.
\nWorld-renowned speakers: Nobel prize
\nwinner Israel Aumann, Kira Radinsky from
\nEbay, Daniel Kraft from the Singular-
\nity University along with representatives of
\nNMAs from Africa, Europe, Asia, North
\nand Latin America will address the issues
\nof the validity of models and predictors in
\nhealth system, healthcare models and medi-
\ncal workplace in 2030, patient-physician re-
\nlationship,medical education-how it should
\nbe changed and technology- where it can
\ntake us.
\nI call upon NMAs to participate in this
\nunique conference and contribute their
\nknowledge, aspirations and experience in
\norder to understand the future, which is just
\naround the corner, and ultimately improve
\nour preparedness.
\nLeonid Eidelman, President of the
\nWorld Medical Association
\nWMA Health Policy
\nBACK TO CONTENTS
\n21
\nmembers when electing them as officers of
\nthe Association, including for the position
\nof President. But, considering the speciali-
\nties of our Presidents and other officers in
\nthe last few years, it is possible to recog-
\nnize the diversity represented in the WMA
\nExecutive Committee. This adds value to
\nthe business conduct by the Association
\nand\u00a0\u2013 in times when mental health prob-
\nlems increase significantly in all regions
\nof the world and are very frequent among
\npatients in primary care services\u00a0 \u2013 I be-
\nlieve that being a psychiatrist allows me to
\nemphasize the need of general physicians
\nto attend carefully to their patients\u2019 overall
\nneeds.
\nApinis: You have worked for global psychia-
\ntrist organizations, such as the World Federa-
\ntion of Mental Health, the World Psychiatric
\nAssociation, you have been a member of the
\nWorld Health Organization Panel of Experts
\non Psychiatry, Mental Health and Substance
\nAbuse. You have a great knowledge and experi-
\nence. What\u2019s going on in mental health glob-
\nally?
\nJorge:There are many different aspects to be
\nconsidered but, briefly, we can say that the
\nmost important problems related to mental
\nhealth identified in different regions of the
\nworld involve a high prevalence of mental
\ndisorders (around 30% of people experi-
\nence a mental disorder during their lives).
\nMental disorders are a major contributor
\nto people\u2019s disability (around 22% of total
\ndisabilities are due to mental disorders).
\nThere is an important treatment gap (more
\nthan 50% of people with mental disorders
\ndo not receive treatment). Moreover, child
\nand adolescent mental health problems are
\nnot considered enough by health care sys-
\ntems,and the flourishing urbanization (now
\naround 54% of the world population lives
\nin towns) is a risk factor for a considerable
\npart of population to develop mental health
\nproblems.
\nApinis: The world\u2019s population is ageing. Isn\u2019t
\nthe main psychiatric problem the increasing
\nage related dementia? What is your vision of
\nthe role, opportunities and development of psy-
\nchiatry in a situation where 20% of the world
\npopulation will be old people with different
\nage-related brain problems?
\nJorge: The epidemiological transition in
\nthe world population started some time
\nago and, with the growing increase of the
\nrepresentation of older people, it affects the
\nhealth sector. Cognitive impairment and
\neven dementia is just one of the problems
\nthat physicians face when treating patients.
\nIn the mental area, depression in the elderly
\nis also an important issue to be taken into
\nconsideration. And, in general, comorbid
\ndiseases and over medication are serious
\nproblems sometimes neglected in everyday
\npractice.
\nApinis: More than half of the people affected
\nby mental health burden have common mental
\ndisorders such as major depression, generalized
\nanxiety disorder, and substance use disorders.
\nThese patients are not well cared for in general.
\nIs it possible to treat these patients only by a
\npsychiatrist alone? Primary care professionals
\nare involved in this process, too. Psychiatry is
\nnot a priority of big specialized hospitals only.
\nCould you comment on global transforma-
\ntions in psychiatry? How does the integration
\nof Common Mental Disorders treatment take
\nplace in primary care?
\nJorge: We do not have enough psychiatrists
\nto treat people with a mental illness. And
\nthere are many mental illnesses that can be
\ntreated by general practitioners, family doc-
\ntors and other medical specialists. I believe
\nit is not the nature of the mental illness, but
\nmainly its severity that requires specialized
\ncare. The most common mental illnesses
\nare depression and anxiety disorders and
\nusually non-psychiatrists can efficiently
\nmanage most of them if they are aware of
\nmental health problems and have received
\nappropriate training. Unfortunately, men-
\ntal health is not yet given enough attention
\nin medical school curricula and physicians
\nwho are specialists in a particular area of
\nmedicine usually do not pay any or enough
\nattention to other health areas of their pa-
\ntients.
\nApinis: Could you comment on stigmatisa-
\ntion in psychiatry? In my opinion, in the whole
\nworld stigma is attached not only to sick pa-
\ntients, but also to psychiatry in general. Adverse
\neffects of medical treatment are caused by a low
\nlevel of knowledge regarding mental illnesses
\nand prejudice and discrimination against peo-
\nple with a mental illness.
\nJorge: Stigma and discrimination against
\npatients with mental illnesses is just \u201cthe
\ntip of the iceberg\u201d. There are lots of evi-
\ndence that stigma also reaches patient
\nfamilies, psychiatrists, psychiatric services
\n(particularly hospitals), psychiatric treat-
\nments (e.g., use of psychiatric medication,
\nelectroconvulsive therapy), some particular
\nmental illnesses (e.g., drug dependence,
\nschizophrenia) and even the occurrence of
\nself stigma. The result is that people suffer-
\ning from a mental illness are double penal-
\nized\u00a0\u2013 by the illness itself and by the stigma
\nagainst them.Early diagnosis and interven-
\ntion is of importance to improve response
\nand prognosis, but stigma is an important
\nfactor of long delays in seeking for mental
\nhealth care.
\nMiguel Roberto Jorge
\nWMA Health Policy
\nBACK TO CONTENTS
\n22
\nApinis: Prevention of mental diseases is a
\nglobal challenge. Is it important to develop
\nPrevention of Child Mental Health as part
\nof Mental Disorders globally? It seems there
\nis a great stigmatisation in this area. What do
\nyou think about the necessity to review WMA
\ndocuments to draw doctors\u2019 attention to the pre-
\nvention of mental diseases, especially to mental
\ndisorders in children?
\nJorge: Prevention of mental disorders and
\nchild and adolescent mental health are two
\npriorities of today. Some of the problems
\nidentified in the mental health arena for
\nadults are even greater when considering
\nthe situation among children and adoles-
\ncents. Research has shown that experiences
\nbuild brain architecture and toxic stress de-
\nrails healthy development. Mental health
\nproblems affect 10 to 20% of children and
\nadolescents worldwide and there is a need
\nto propose well developed strategies to take
\ncare of our future adults.
\nApinis: As WMA President you agreed to pro-
\nmote solving the needs of each physician and the
\nworld\u2019s most vulnerable people, to represent a
\nstrong voice of physicians from low and middle
\nincome countries. Could you describe what\u2019s go-
\ning on in psychiatry and health care in general
\nin the countries of Latin America and the Ca-
\nribbean Region?
\nJorge: There are many studies showing that
\nthe prevalence rates of mental disorders are
\neven higher in low and middle income coun-
\ntries such as those located in Latin America
\nand the Caribbean. Besides facing greater
\nprevalence, access to care is more difficult
\nand there is a scarcity of mental health ser-
\nvices and professionals, in addition to their
\nuneven distribution.The work conditions of
\nphysicians represent a challenge for provid-
\ning sometimes minimal care and, moreover,
\na good quality medical care. In those coun-
\ntries, there are isles of excellence in terms of
\nthe care provided to those who can pay by
\nthemselves for good medical services. This
\nsituation is not the same found in high in-
\ncome countries but even there it is possible
\nto observe differences in services provided
\nto people in better or worse socio-economic
\nconditions.
\nApinis: You come from S\u00e3o Paulo, a city
\nwhere eight times more people than in my
\ncountry live. Is overpopulation, the over-
\ncrowding in cities a reason for increasing
\nmental health problems, too? What do you
\nthink about mental health problems in the
\nworld\u2019s megalopolis?
\nJorge: There are data from the United
\nNations informing that the world had
\n28\u00a0 megacities (those with more than
\n10\u00a0million inhabitants) in 2015.Many other
\nstudies show that mental health problems
\nare more common in urban than in rural
\nareas, and there are many factors related to
\nurbanism that contribute to the difference.
\nOne of the most important ones is trauma
\nexperienced particularly through different
\nforms of violence when associated with sig-
\nnificant social inequalities and being part of
\na minority group. Other factors that deserve
\nto be mentioned are a competitive environ-
\nment and individual loneliness.
\nApinis: There is mass migration in the world.
\nTravelling from one country to another, from
\none continent to another usually causes over-
\ncrowding, stress, depression, ignorance. What is
\nyour view on how to take care of mental health
\nissues among refugees and migrants? But is it
\na problem at all, maybe it is a myth created in
\nsocial networks?
\nThere are some aspects related to be a refu-
\ngee and\/or a migrant that can be a risk fac-
\ntor to develop mental illnesses such as to be
\npart of a minority group, to live in a diverse
\ncultural environment, to be deprived of
\nbasic human needs (decent housing, food,
\nwork, health care access) and to suffer stig-
\nma and discrimination among other factors.
\nSo, refugees and\/or migrants are considered
\na particularly vulnerable population to de-
\nvelop mental illnesses and unfortunately
\nthis is a reality in our world of fake news.
\nNo myth concerning this fact.
\nApinis: I promised to ask you not more than
\nten questions. I know you\u2019re not only a psy-
\nchiatrist, but also a psychotherapist. In which
\ndirection does the world go: psychotherapy or
\nmedical treatment?
\nJorge: As my training as a medical student
\nand a psychiatrist was mostly between 1975
\nand 1986 in Brazil, at that time it was not
\nconceivable to separate those approaches.
\nOur patients, with a mental illness or any
\nother illnesses, need to be treated by physi-
\ncians that take into consideration the bio-
\nlogic nature of their illnesses, their person-
\nality characteristics and emotional impact of
\nthe illness they present,and also their family
\nand social environment. We know that all
\nthose aspects are of importance in plan-
\nning, discussing different alternatives and
\nadopting treatments. Without an excellent
\ndoctor-patient\/family relationship no treat-
\nment will work well enough. And I do not
\nthink that be a medical doctor is just a mat-
\nter of prescribing a medication even when
\nfor some particular illness the medication
\nwill be crucial to the desired outcome. That
\nis the way I work in my private practice and
\nwhat I will emphasize during my presidency
\nterm.
\nWMA Health Policy
\nBACK TO CONTENTS
\n23
\nApinis: You have chaired the WMA Coun-
\ncil since 2015 and were the most influential
\ndoctor in our global organization. You were
\nnamed one of Top 25 Women in Healthcare
\nof the World, in addition to its list of the 100
\nMost Influential People in Healthcare, and its
\n50 Most Influential Physician Executives and
\nLeaders. Whatever you do, it is accompanied
\nwith smile and optimism. What makes you so
\npositive?
\nHoven: I have had the opportunity over
\nmany years to work with a variety of or-
\nganizations and in doing so, I recognized
\nthe value of a team and collaborative ef-
\nforts. As a leader when you recognize that
\nseated around the table are your partners
\nand colleagues, it makes being positive
\nand supportive so much easier. Building
\ntrust and sharing values are equally im-
\nportant.
\nApinis: In your time, the Council meetings
\nand the General Assembly have been held in
\nOslo (Norway), Moscow (Russia), Buenos
\nAires (Argentina), Taipei (Taiwan), Living-
\nstone (Zambia), Chicago (USA), Riga (Lat-
\nvia), Reykjavik (Iceland). Very different cities,
\ndifferent countries, different continents. Are the
\nWMA statements, settings and policies affected
\nby the continent and country we come together?
\nHoven: Perhaps by a small amount, but
\noverall I would say that they represent all
\nwho attend and are seated at the table. It
\nis the job of leadership to make sure that
\nall voices are heard, and that the minority
\nopinion is recognized and valued.
\nApinis: Under your leadership, the Council
\nmeetings and the General Assemblies became
\nshorter and more specific. The discussions were
\nmore geared to working groups and commis-
\nsions. Consequently, at major events, people
\nworked quickly and constructively. Is that at
\nthe basis of your leadership?
\nHoven: I have tried throughout my years in
\nleadership to learn from mentors and un-
\nderstanding \u201cbest practices\u201d. Small groups
\nare definitely better than large ones when
\nattempting to come to consensus and de-
\ntermining a policy or statement for debate.
\nApinis: The leaders of the national medical
\nassociations are leaders because they are ambi-
\ntious, charismatic and energetic. At the WMA
\nCouncil meetings, the global leaders sit friendly
\nand in good humor at the table. How did you
\nmake a team out of these brilliant leaders? Isn\u2019t
\nit the way the conductor runs an all-star or-
\nchestra?
\nHoven: Doing our work well at the Coun-
\ncil meetings and those of the General As-
\nsembly, requires all at the table to know that
\nwhat they say is important and respected.
\nNo one\u2019s voice should be diminished.I\u00a0think
\nbecause of this, individuals feel more com-
\nfortable. By the way, a bit of humour goes a
\nlong way in easing any tensions that might
\ndevelop around the table.
\nApinis: Is it true that the chairperson of the
\nWMA Council has a key job on the phone or
\nat Internet conferences because all Board mem-
\nbers need to reconcile the nuances in documents
\nand strategies? How many hours a day did you
\nhave to talk to world medical leaders?
\nHoven: Yes, the role of Chair of Council
\nrequires making important phone calls and
\ncommunicating on a regular basis with the
\nmembers of the Executive Committee and
\nany other groups as needed. I honestly have
\nnot kept track of the time spent.
\nApinis: The main issues of the Council are
\nnevertheless dealt with by the Committees.
\nCould you describe the leaders and performance
\nof the Medical Ethics Committee, Finance and
\nPlanning Committee, Socio-Medical Affairs
\nCommittee?
\nHoven:(I am not quite sure about this ques-
\ntion). During my tenure as Chair, I\u00a0 have
\nbeen very fortunate to have had elected
\nchairs of the committees who are commit-
\nted to high quality work, strong leadership
\nskills, and the willingness to work on behalf
\nof WMA. As we have seen during recent
\nsessions, when the work of the Committee
\nis done well,it makes the work of the Coun-
\ncil so much easier and efficient.
\nApinis: What are the main WMA documents
\nadopted under your leadership, and of which
\nare you proud to have adopted?
\nHoven: I am going to have to go back and
\nreview a lot of materials on this one. Several
\nDeclarations in particular come to mind.
\nI\u00a0will need to get back to you on this.
\nInterview with Ardis D. Hoven WMA Chairperson of Council
\nAmerican Medical Association by WMJ Editor Peteris Apinis
\nArdis D. Hoven
\nWMA Health Policy
\nBACK TO CONTENTS
\n24
\nApinis: Elections to the European Parliament
\nare approaching. The new Parliament will face
\nserious challenges in different areas, and we are
\ninterested in issues related to public health, a
\nhealthy environment, social determinants and
\nmedicine, particularly in universal coverage
\nand access to medicine. How will CPME try
\nto ensure that these issues are always on the
\nagenda of the European Union?
\nMontgomery: Health in all policies is a
\nfundamental demand of CPME in the
\nwork of the European Commission, the
\nEU Parliament and the Council of Member
\nStates. We hope that the next Commission
\nwill be more interested in the wellbeing of
\ncitizens and good health than in industry
\nand commerce and we will constantly re-
\nmind the three large players of European
\npolitics of their obligations and responsi-
\nbilities in these subjects.
\nApinis: There is a lack of clarity in Europe on
\nthe relationship between the United Kingdom
\nand the European Union after Brexit. Could
\nyou comment on what the European Union
\nexpects with restricting doctor mobility and, to
\na large extent, narrowing of cooperation? Are
\nthere opportunities to minimise Brexit\u2019s nega-
\ntive impact on the health of European patients
\nand the work of medical professionals? Will
\nCPME make concrete proposals to the Euro-
\npean Parliament on post-Brexit medical de-
\nvelopment, including receiving of cross-border
\nmedical services on the island of Ireland?
\nMontgomery: \u201cBritish medicine is Europe-
\nan medicine\u201d\u00a0\u2013 This is the core message of
\nCPME on Brexit.At present nobody knows
\nwhat the exact results of Brexit will be but it
\ncertainly demands changes in legislation on
\nboth sides of the Channel. It is obvious that
\nwe are fighting for maintaining free mobil-
\nity of health care professionals. But there is
\nmore to Brexit: Shortages of drugs both in
\nmainland Europe and the UK can be fore-
\nseen, liability questions arise when licenses
\nfrom the UK are no longer valid in Europe.
\nAll this has to be dealt with and CPME is
\nprepared to take over responsibilities.
\nInterview with Frank Ulrich Montgomery Vice-Chairperson of
\nCouncil of WMA by WMJ Editor Peteris Apinis
\nFrank Ulrich Montgomery
\nApinis: During these four years you had to
\nwork with six WMA presidents: Xavier Deau
\n(France), Sir Michael Marmot (UK), Ketan
\nDesai (India), Yoshitake Yokokura (Japan),
\nLeonid Eidelman (Israel), Miguel R. Jorge
\n(Brasil). They all are great doctors. Could you
\ndescribe each of them and their contribution to
\nthe world community of doctors?
\nHoven: All of these gentlemen, during
\ntheir years of service have represented the
\nWMA well. Although they may have dif-
\nferent styles of leadership, each one was
\nable to project their ideas and concerns gra-
\nciously and knowledgably to those listen-
\ning to them. I learned that they each have a
\nspecial side to them be it a sense of humour,
\ngentleness, charisma, or a passion in life and
\nhealth care that brought them to the WMA.
\nApinis: Opportunities to familiarise them-
\nselves with culture, medicine and nature of dif-
\nferent countries of the world, tours and parties
\nplay an important role in all General Assem-
\nblies, Council meetings and conferences. What
\ndo you remember most about our events?
\nHoven: The opportunity to travel around
\nthe world, and see amazing sites along with
\nhaving the opportunity to experience new
\ncultures, environments, and food has been
\nextraordinary. Perhaps what I have learned
\nthe most, is that no matter where I have
\ntravelled, the people of that country have
\nbeen wonderful and kind. Each country
\nhas demonstrated great pride and we all
\nhave been the recipients of graciousness and
\nkindness. I particularly am fond of learning
\nmore about the culture and art of a country
\nand in my travels,I have learned a great deal.
\nIt has been an extraordinary experience.
\nApinis: The achievements and success of WMA
\nare also based on the precise and qualitative
\nwork of the Secretary General and the Secre-
\ntariat. Could you comment on the role of the
\nSecretariat and your cooperation with the Sec-
\nretariat?
\nHoven: Words cannot adequately express
\nmy appreciation to Dr. Kloiber and the Sec-
\nretariat for all that they have accomplished
\nover the past four years. Guidance, encour-
\nagement and education have always been
\nplentiful and so valued. The WMA is very
\nfortunate to have individuals so committed
\nto the work of the WMA and working dili-
\ngently to make all of us look good!
\nWMA Health Policy
\nBACK TO CONTENTS
\n25
\nApinis: How could CPME at European level
\ninfluence vaccination attitudes, increase vac-
\ncine coverage, strengthen immunisation pro-
\ngrammes while reducing unnecessary antibiotic
\nuse in Europe and active action against anti-
\nmicrobial resistance?
\nMontgomery: Vaccination needs informa-
\ntion and awareness. It is sad that not only
\nthe public but even European legislators are
\nbadly informed on the values of vaccina-
\ntions. And AMR is another subject where
\ninformation is pivotal. Not only do we talk
\nto the other health care professions but
\nwe also accompany campaigns by the G7-
\nStates and the EU.
\nApinis: How can we increase the safety of Eu-
\nropean patient data while allowing these data
\nto be used for medical science and pharmaceuti-
\ncal development? What perspective do you see
\nin introducing personalized medicine that re-
\nlies heavily on patient genome data and large
\namounts of data processing?
\nMontgomery: Though difficult to handle
\non an individual level, the General Data
\nProtection Regulation (GDPR) guarantees
\na high level of data-security. In the context
\nof co-creation of health, personalized medi-
\ncine relies on the information and consent
\nof patients and data processing must not
\nend up in \u201cdata mining\u201d. CPME and its
\nExecutive Council closely cover the devel-
\nopment in the European arena and keep
\nclose watch not only on legislators but also
\non member states\u00a0\u2013 in the best interest of
\npatients and physicians.
\nApinis: Globally, the main issue of the planet\u2019s
\nfuture existence is climate control. The Europe-
\nan Parliament has done much to make Europe
\nsignificantly reduce greenhouse gas emissions.
\nWe hope and believe that the next European
\nParliament will be even more active in this
\narea. However, the turnout of Parliament is
\ninfluenced by stakeholders and in the field of
\ncontrolling and reducing climate change doc-
\ntors\u2019 opinion has a very large role to play. What
\nwill the CPME policy be, in cooperation with
\nthe new EU leadership and Commissions, spe-
\ncifically in the field of climate control?
\nMontgomery: Climate control is an obliga-
\ntion of all citizens\u00a0\u2013 not of physicians and
\ntheir organizations alone.Within this range
\nCPME takes part in international activities
\nto reduce greenhouse gases and enhance cli-
\nmate control.
\nApinis: What are the main CPME priorities
\nconcerning prevention? Can we achieve that
\nthe provision that is already in force in some
\nEuropean countries is incorporated in EU leg-
\nislation, namely that use of tobacco products
\nin the presence of children is violence against
\nchildren? And the fact that non-smokers have
\na right to clean air and that right is always a
\npriority over a smoker\u2019s right to smoke close to
\nothers?
\nMontgomery: CPME stands for a strong
\nanti-smoking policy. We need a strict ban
\non tobacco advertisements and we fight for
\nprotection of children. It is absurd that in
\nsome countries the taxes levied on tobacco
\nand alcohol by far exceed the investments in
\nprevention.
\nApinis: How can we affect the European
\nUnion to promote healthy living across Europe,
\nreduce alcohol consumption, take care of healthy
\ndiets and increase sporting activities for every
\nEuropean citizen?
\nMontgomery: Alcohol and food labelling
\nare important aspects of providing infor-
\nmation to citizens. But the \u201chealth in all
\npolicies\u201d strategy entails more than that.
\nHealthy living has to become part of all in-
\ndustrial relations, of city planning and the
\ndevelopment of industry.
\nApinis: Education of future physicians is an
\nimportant topic for Europe. The Professional
\nQualifications Directive (PQR) was a mile-
\nstone on the implementation of a common
\ntraining regime in Europe.What is the CPME
\nposition on the PQR?
\nMontgomery: CPME has always been
\nheavily involved in all issues of basic profes-
\nsional training and specialization of physi-
\ncians. We are deeply concerned about the
\nintroduction of new training schemes by
\nprivate institutions that have a clear finan-
\ncial interest. Medical training courses on an
\nIT basis are an important tool to achieve
\nbasic knowledge but a medical training
\ncourse has to contain large quantities of
\npractical training. It has to be on a scientific
\nbasis delivered by a university and it has to
\ncontain at least 5500 training hours in five
\nyears to comply with the PQR.
\nApinis: Everyone talks of digitization. What
\nis the CPME position?
\nMontgomery: Digitization of medicine is
\none of the most important topics of the fu-
\nture. But it must be seen as a tool to assist
\nphysicians and patients in the co-creation
\nprocess of health.We not only have to defend
\nthe rights of patients but also of physicians to
\ndata security and we have to fight data cor-
\nruption. But we must also be open to new
\ntechnologies that are designed to help us!
\nWMA Health Policy
\nBACK TO CONTENTS
\n26
\nCPME Health Policy
\nThe Standing Committee of Europe-
\nan Doctors (CPME) has launched its
\nHealth Check 2019 ahead of the upcoming
\nEuropean elections. The European doctors
\ncall on EU decision-makers to: put health
\nhigh on the EU agenda, support skilled
\ndoctors and safe conditions, enable healthy
\nliving, invest in health security, foster trust
\nin the sharing of health data and guarantee
\naccess to medicines.
\nFuture of Health
\nThe CPME Health Check 2019 puts
\nemphasis on the future of health. Although
\nthe need to respect budgetary restraints is
\nrecognised, it is equally important to as-
\nsess the impact that any budgetary plan
\nmay have upon health policy. Health is an
\nessential element of the European social
\nmodel and contributes to social cohesion,
\ninclusive growth and nurtures a sound eco-
\nnomic environment which is a prerequisite
\nfor investment.
\nThe future newly-elected European Parlia-
\nment and European Commission will have
\nthe power to make concrete contributions
\nto the creation of a healthier European
\nUnion and to keep health policy on the EU
\nagenda. Therefore, CPME considers it es-
\nsential that the political groups within the
\nEuropean Parliament, national representa-
\ntives in EU Member States and the new
\nCommission commit to health priority on
\ntheir working agenda.
\nSkilled doctors, safe conditions
\nEnsuring the best possible conditions for
\ndoctors\u2019 education and professional prac-
\ntice remains a priority of CPME. There-
\nfore, the European medical community asks
\nthat safe and attractive working conditions
\nfor doctors be ensured across Europe, even
\nmore so with Brexit changing the paradigm
\nof medical migration and education and
\ntraining. Brexit will bring many changes
\nwithin the EU membership and within
\nEU institutions. For the European medical
\nprofession, the impact of Brexit on mobility
\nis a great concern. Doctor mobility in fact
\ntakes many forms: students cross borders
\nto attend medical schools in other Member
\nStates, junior doctors seek specialist train-
\ning in another country, and professionals
\ntake the chance to develop their capacities
\nby accepting posts abroad, be it temporary
\nor long-term. European doctors will there-
\nfore continue to advocate for a solution
\nthat safeguards quality of care and a con-
\ntinued knowledge transfer in the profession
\nthroughout Europe.
\nInvest in health security
\nThe health status of the population faces
\nchallenges which cannot be contained
\nwithout coordinated and systematic action,
\noften within a very short timeframe. This
\nis the case for the spread of antimicrobial
\nresistance (AMR) and vaccine hesitancy.
\nTherefore, European doctors ask for con-
\nstant efforts to tackle AMR and to increase
\nvaccination coverage. Resistance to antibi-
\notics is progressing at a rapid pace and old,
\nvaccine-preventable diseases are reappear-
\ning. Since these threats may cross national
\nborders, collaboration between Member
\nStates and allocation of resources at Eu-
\nropean level to raise awareness are crucial.
\nPolicies must strengthen doctors and other
\nhealth professionals in playing an active role
\nin the fight against AMR and vaccine hesi-
\ntancy
\nCPME thanks you for your support of the
\nHealth Check 2019 and the work of CPME
\ntowards a safer and better Europe for all its
\ncitizens.
\nMiriam Beatrice Vita D\u2019Ambrosio
\nCommunication and Project Officer
\nStanding Committee of European Doctors
\nEuropean Doctors Towards the
\nEuropean Elections 2019
\nMiriam Beatrice Vita D\u2019Ambrosio
\nBACK TO CONTENTS
\n27
\nRegional Medical Affairs
\nApinis: In 2019 the Southeast European
\nMedical Forum (SEEMF) organizes its Tenth
\nAnniversary International Medical Congress.
\nSEEMF\u2019s congresses take place in different
\nEastern European countries every year. This
\nyear, the Congress will take place in Sofia, Bul-
\ngaria. What are the main goals of the events?
\nWhat are the main topics of this year\u2019s Con-
\ngress?
\nKehayov: The main objectives of SEEMF
\nare to promote partnership between the
\nmedical associations of the member coun-
\ntries; to discuss common problems in the
\nhealthcare systems in the southeastern part
\nof the European continent; to exchange
\nexperience in and develop common ap-
\nproaches towards all fields and activities
\nof the medical organizations; to promote
\ncontinuous medical education; to assist
\nits members in improving their medical
\nand managerial qualifications and skills;
\nto establish contacts and partnership with
\nother international medical organizations.
\nThe scientific program of the Tenth An-
\nniversary Medical Congress of SEEMF is
\ncomprised of variety of topics and will host
\nthe attendance of leading lecturers, promi-
\nnent representatives of medical academia
\nwith recognized academic and practical
\ncompetence.
\n\u2022\t Aging of the population;
\n\u2022\t Cardiovascular diseases and cardiovascular
\nsurgery. Transplantations;
\n\u2022\t Gastroenterology. Transplantations;
\n\u2022\t Neurology, neurosurgery and psychiatry;
\n\u2022\t Nephrology and urology. Transplanta-
\ntions;
\n\u2022\t Sexual medicine and reproductive health;
\n\u2022\t Orthopedics and traumatology. Calamity
\nmedicine;
\n\u2022\t Pharmacotherapy;
\n\u2022\t VARIA.
\nWe hope that during the round table dis-
\ncussion on the topic \u201cChallenges in the
\nHealthcare Systems- 21st
\nCentury. Values
\nand Principles\u201d participants will have the
\nchance to share their views on and aspires
\ntowards the present and the future of the
\nglobal healthcare. The Congress has al-
\nready received the support of the Bulgar-
\nian authorities and the World Medical
\nAssociation. The President of WMA- Dr.
\nLeonid Eidelman has already confirmed
\nhis participation. As usual, the Con-
\ngress will apply for European Accredi-
\ntation Council for Continuous Medical
\nEducation(EACCME) accreditation. The
\nsocial program of the event will be com-
\nprised of several tours- one around Sofia-
\nthe capital of Bulgaria; to the Rila Monas-
\ntery- a historic Christian monument and a
\nvisit to the Cultural Capital of Europe for
\n2019\u00a0\u2013 Plovdiv, the city with a thousand
\nyear old history. I would like to use the op-
\nportunity to appeal to all the members of
\nthe WMA and the readers of the World
\nMedicine Journal and cordially invite all of
\nyou to attend the 10th
\nAnniversary Inter-
\nnational Medical Congress of the SEEMF.
\nAll information about the event\u00a0 \u2013 regis-
\ntration and hotel accommodation is avail-
\nable on the website of the organization:
\nwww.seemfcongress.com.
\nApinis: At present, 18 countries (20\u00a0medical
\norganizations) are members of SEEMF\u2019s so-
\nciety\u00a0\u2013 Albania, Azerbaijan, Belarus, Bosnia
\nand Herzegovina, the Medical Associations of
\nBosnia and Herzegovina and Republika Srp-
\nska, Bulgaria, the Czech Republic, Georgia,
\nGreece, Kazakhstan, Russia, Northern Mace-
\ndonia and Montenegro, Slovenia, Ukraine,
\nUzbekistan, Serbia, Moldova, Croatia, the
\nEuropean Medical Student Organization.
\nDoes SEEMF continue to extend? Do you
\nthink that doctors from other countries will
\njoin your organization?
\nKehayov: Southeast European Medi-
\ncal Forum (SEEMF) was found in 2005
\nby the medical organizations of 4 Balkan
\ncountries\u00a0\u2013 Albania, Bulgaria, Greece and
\nthe Republic of Northern Macedonia as an
\nassociation of doctors\u2019 organizations from
\nSoutheastern Europe- neighbouring coun-
\ntries with similar problems.Today, SEEMF
\nis one of the rapidly developing organiza-
\ntions that unites 20 medical associations.
\nLast year, during the Board Meeting held
\namidst the Ninth International Medi-
\ncal Congress of SEEMF, we approved the
\napplications for membership from Rus-
\nsia, Croatia and Montenegro- our newest
\nmember countries. As you can see every
\nyear, the membership base of the organiza-
\ntion is enriched with new medical experi-
\nence in the face of its new members. From
\n4\u00a0founders of the organization, we became
\n20. SEEMF is expanding naturally as a re-
\nsult of its mission and causes, which are also
\npart of the causes and missions of the world
\nmedical organizations.
\nApinis:Throughout the years, SEEMF\u2019s Con-
\ngresses have been held in countries with politi-
\ncally unstable situations, an example of which
\nis the Congress in Odessa, Ukraine, at a time
\nwhen the military conflict in East Ukraine
\n10 Questions for SEEMF\u2019s President,
\nprof.\u00a0Andrey Kehayov, MD
\nAndrey Kehayov
\nBULGARIA
\nBACK TO CONTENTS
\n28
\nRegional Medical Affairs
\ntook place. Does SEEMF thus show a political
\nstanding?
\nKehayov: SEEMF is an independent orga-
\nnization of physicians and is not under any
\npolitical ward. Our congresses are interdis-
\nciplinary events. We are not only interested
\nin scientific and practical achievements in
\nmedicine, but also in the organizational
\nstructures of the healthcare systems of our
\nmembers. We outline the real labour mar-
\nket; the problems of financial and human
\nresources and aim to provide guidance for
\nrational solutions. Before the institutions
\nthat are involved in shaping the health
\npolicies and before the society, we form
\nour unequivocal and prominent physicians\u2019
\nposition in order to find the adequate bal-
\nance to change the system.These are the real
\nchallenges of the time we live in. Through
\nbrainstorming together,we raise our experts\u2019
\nand specialists\u2019 platforms and display them
\nbefore the various national and internation-
\nal institutions.
\nApinis: The Board meetings of SEEMF are
\noften held on The Island of Kos, Greece, where
\nHippocrates was born. Does this historical ref-
\nerence serve the philosophy of your organiza-
\ntion?
\nKehayov: In accordance with SEEMF\u2019s
\nStatute, SEEMF organizes at least two
\nboard meetings annually.The board consists
\nof 30 individuals, most of whom are heads
\nof the medical associations of the member
\nstates and prominent representatives of the
\nmedical and academic society. The Board
\nmeetings are held in different countries,
\nand this year for a second time we have de-
\ncided to hold our meeting in Kos, Greece\u00a0\u2013
\nThe homeland of the \u201cFather\u201d of modern
\nmedicine\u00a0 \u2013 Hippocrates. The mission of
\nSEEMF, as an organization of physicians
\nfrom different countries, is to transform
\nmoral-ethical behaviour and norms that
\ndistinguish the medical profession from all
\nother professions as a leading one. Parallel
\nto the Board meeting, we have organized an
\nevent with the title \u201cInternational Confer-
\nence on Medical Ethics and Moral. Oath of
\nHippocrates\u00a0\u2013 Symbol of Medicine\u201d. Well-
\nknown lecturers will present various moral
\nand ethical models, practices and standards
\nin medicine.
\nApinis: Most of the countries, represented in
\nSEEMF, are former post-soviet or post-social-
\nist states. Is it not the debate in your Congress
\non the transition from socialistic medicine to
\nEuropean medicine?
\nKehayov: The discussions that participants
\nin SEEMF\u2019s congresses hold are mainly
\nrelated to the socially significant diseases
\nand their prevention. However, the prima-
\nry mission of the doctors and the medical
\nspecialists is to take care of the health of
\ntheir patients and it has nothing in com-
\nmon with the country we come from or
\nlive in. SEEMF\u2019s congresses are multidis-
\nciplinary universities and one of our main
\ngoals is to improve participants\u2019knowledge
\nand professional qualifications with the
\nlatest theoretical and practical achieve-
\nments of the global medicine. Implement-
\ning the established European and global
\nmedical standards and practices with a fo-
\ncus on what quality medical care really is,
\nwe endeavour towards the improvement of
\nthe healthcare systems in the countries of
\nthe region.
\nApinis: A regular topic during SEEMF\u2019s
\nCongresses is the one about the migration of
\ndoctors and medical professionals. Doctors tend
\nto go work in richer European countries and for
\nbetter wages.
\nKehayov: The Migration of the medical
\nprofessionals in the European region has
\nbeen observed since the 1940s. After the
\naccession of Bulgaria to the EU, the most
\nactive amongst the \u201cmigrants\u201d became the
\nmedical specialists with qualifications and
\ndiplomas that are recognised by member
\nstates of the EU.We witness a trend of gen-
\neral migration\u00a0\u2013 Bulgarian doctors migrate,
\nbut specialists from other countries come to
\nBulgaria.This process is two-sided.
\nApinis: Medical tourism plays an increasingly
\nimportant role in EasternEurope. To what
\nextent are Bulgaria and the Balkan countries
\nupdating medical tourism?
\nKehayov: Due to its enormous natural
\nresources Bulgaria has posed a serious re-
\nquest to become one of the biggest health
\ncenters in Europe. Using its endowments
\nand intellectual resources, as well as the
\nhundreds of mineral water springs, heal-
\ning climate, organic farming and services
\npromoting a healthy lifestyle; cultural,
\nwine, seaside and mountain tourism Bul-
\ngaria is turning into a competitive destina-
\ntion for a quality tourism. Bulgaria ranks
\nfirst in Europe according to the availability
\nand diversity of mineral water and spa re-
\nsorts. The Ministry of Tourism in Bulgaria
\nencourages development of medical and
\nhealth tourism and provides legislative
\nchanges to adapt it in accordance with the
\nEuropean standards and European market
\nrequirements through implementation of
\ninnovative practices and quality improving
\nstrategies.
\nApinis: SEEMF is a WMA associate member.
\nHow would you describe the collaboration with
\nWMA?
\nKehayov: The World Medical Associa-
\ntion is a constant supporter of the activi-
\nties and the missions of SEEMF. SEEMF
\nshares strongly WMA\u2019s goals, values \u200b\u200b
\nand
\nstandards. As President of SEEMF, I have
\nthe honour and pleasure to participate in
\nthe annual meetings of WMA- the Gen-
\neral Assemblies and Council Sessions.
\nMany of the declarations and suggestions
\nproposed by our organization on differ-
\nent issues, an example of which are the
\nones on climate change and reduction of
\nemissions in the Mediterranean Sea, were
\naccepted by the WMA and noted by the
\nWorld Medical Journal. What greater rec-
\nognition than the participation of several
\nWMA\u2019s Presidents in the Congresses of
\nSEEMF? I would like to use the opportu-
\nnity to thank Dr. Otmar Kloiber\u00a0\u2013 WMA
\nBULGARIA
\nBACK TO CONTENTS
\n29
\nRegional Medical Affairs
\nSecretary General for his incredible moral
\nsupport and acknowledgment of SEEMF
\nthroughout all the years.
\nApinis: The next WMA General Assembly
\nwill take place in one of SEEMF\u2019s mem-
\nber countries-Georgia. You organised one of
\nSEEMF\u2019s congresses in Georgia with the aim
\nof investigating the extent to which Georgia is
\nprepared for very large medical congresses and
\nevents. What is your impression of the Geor-
\ngian hospitality?
\nKehayov: In 2016, in cooperation with the
\nGeorgian Medical Association we con-
\nducted the Seventh International Medical
\nCongress of SEEMF in Batumi, Georgia.
\nGeorgia acquitted our expectations! The
\nPresident of the Georgian Medical Asso-
\nciation\u00a0\u2013 Prof. Gia Lobzhanidze, professor
\nin surgery at the University of Tbilisi\u00a0\u2013 is
\nalso one of the Vice President of SEEMF.
\nThanks to his exceptional personal and or-
\nganizational potential and with the active
\nsupport of the members of the Georgian
\nMedical Association,SEEMF\u2019s Congress in
\nGeorgia was a significant event with partic-
\nipants from 20 countries. Georgia proved to
\nEurope and the World its scientific,medical
\npotential and incredible skills in conducting
\nlarge-scale international events. The gener-
\nous Georgian hospitality combined with
\nthe mixture of ancient cultural monuments
\nand wonderful nature turned the Congress
\ndays into an impressive collection of shared
\npractices, thoughts and friendship.
\nApinis: One of the subjects you teach as a pro-
\nfessor in a medical university in Bulgaria is
\nethics. What are the challenges of medical ethics
\nin Bulgaria?
\nKehayov: I am an Associated Professor in
\nthe Medical University of Sofia, faculty of
\nPublic health,\u201dHealth policy and manage-
\nment Department\u201d. As a former Presi-
\ndent of the Bulgarian Medical Association
\n(2009-2012), and as a member of the ethi-
\ncal Commission and university professor,
\nI\u00a0worked and continue to work in the field
\nof medical ethics and moral. If we look at
\nthe vision of ethics in public health, in our
\ncountry we witness the same problems that
\neffect the ethical values in most countries,
\nnamely: with reference to availability, fair-
\nness, timeliness and quality of healthcare.
\nIf we take a look in particular at the chal-
\nlenges facing medical and clinical ethics,
\nI believe that the informed consent is es-
\nsential. The form, which the patients sign
\nexpresses their \u201cconsent\u201d only. In practice,
\nthe process of communication that leads to
\nan informed consent, is missing, or is too
\nlimited. The Autonomous model predicts
\nthat the patient receives full and accessible
\ninformation about his disease, diagnostic
\nand therapeutic activities, as well as the
\nprognosis of his illness.This is not necessar-
\nily the case in every situation,but is possible.
\nHowever,patients are increasingly informed
\nand empowered, seeking their rights, and
\nthe physicians\u2019 responsibility is to recog-
\nnize the necessity of the informed consent,
\nwhich is a legitimate mode to protect not
\nonly the patient, but the physician as well.
\nOtherwise, we witness tension and growing
\ndistrust towards the profession. The prob-
\nlems of patients with disabilities who need
\nadditional care and more attention have also
\nbecome widely known. Of course, the issues
\nof confidentiality are also relevant; assisted
\nreproduction- especially against the back-
\nground of the demographic crisis in which
\nour country currently is; donation and
\ntransplantation; clinical trials and medical
\ntourism; ethical issues related to death, in-
\ncluding assisted suicide.
\nGeorgian Medical Association
\nTurns 30 years old
\nThe General Assembly (GA) will be held
\nin Tbilisi, Georgia, in October 2019. This
\nis one of the most strikingly original cities
\nin the world, founded in the 5th
\ncentury by
\nKing Vakhtang I Gorgasali.
\nA legend tells us that once the King hunted
\nin the forests near Mtskheta, the first capital
\nof Georgia.After some time,he saw a pheas-
\nant, shot and killed the bird. The King sent
\nhis falcon to find the prey. The falcon flew
\naway, and after a while, the king lost sight of
\nhim. In search of the birds, Vakhtang Gor-
\ngasali with his hunters came upon a spring
\nand saw that both the falcon and the pheas-
\nant had got into its waters which turned out
\nto be hot.Amazed by this findVakhtang I de-
\ncided to found there a city realizing the great
\nadvantages of the location.In addition to the
\nhot spring, the location had many important
\nother factors for building a city: a protected
\nposition between the mountains, location on
\na trade route, strategically favorable factors.
\nThus, according to the legend, the city of
\nTbilisi was founded. The word \u201ctbili\u201d trans-
\nlated from Georgian means \u201cwarm\u201d.
\nGEORGIA
\nGia Lobzhanidze
\nBACK TO CONTENTS
\n30
\nRegional Medical Affairs
\nHistorically, Tbilisi has been home to peo-
\nple of multiple cultural, ethnic, and religious
\nbackgrounds, though currently it is over-
\nwhelmingly an Eastern Orthodox Chris-
\ntian country. Georgia is the educational and
\ntransportation hub for the Caucasus region.
\nIt has a unique cultural national heritage:
\nsongs, dances, foods and wine. Wine has
\nbeen produced in the country over 8000
\nyears. Georgia\u2019s traditional winemaking
\nmethod of fermenting grapes in earthen-
\nware, egg-shaped vessels \u201cQvevri\u201d has been
\nadded to the UNESCO World Heritage list.
\nFor Georgians \u201cthe guest is a gift from god\u201d.
\nGeorgia is an enjoyable and spectacular
\ncountry. It is a country where many hospi-
\ntable and generous people live. The word for
\nGeorgian meal is supra, which is best trans-
\nlated as \u201cfeast\u201d.
\nThe Georgian language and alphabet are
\nincluded in the UNESCO\u2019s Intangible
\nCultural Heritage List and UNESCO ac-
\nknowledged Georgian polyphonic music as
\n\u201ca masterpiece of the world\u2019s cultural heri-
\ntage\u201d.
\nAutumn is the velvet season in Georgia
\nwhen weather is still pleasant. Temperature
\nrange is between 18-23\u00b0C (64-73\u00b0F).
\nThe hotel Sheraton Grand Tbilisi Metechi
\nPalace will host the GA. There will be a
\ncity tour for the accompanying persons on
\n24\u00a0 october to old Tbilisi and the classi-
\ncal half-day tour for all the participants is
\nscheduled on 25 October to Mtskheta, one
\nof the oldest cities of Georgia, located ap-
\nproximately 20 kilometers (12 miles) north
\nof Tbilisi.
\nAfter the tour, dinner will be served in
\nMtskheta. The guests will be able to taste
\nGeorgian traditional cuisine.
\nOrganizational Committee of Georgian
\nMedical Association from 1988 worked
\nwith Rustaveli Association of Georgia.
\nFrom November of 1988, the mentioned
\norganizational committee separated from
\nRustaveli Association and began indepen-
\ndent functioning. Committee unified as de-
\nserved doctors,so pedagogues,scientists- so,
\nyoung apolitical generation.
\nGeorgian Medical Association (GMA) was
\nofficially founded on May 05, 1989 on the
\nfirst meeting, it is the first non-governmen-
\ntal professional organization in Georgia
\nwhich was registered in the Ministry of Jus-
\ntice of Georgia. GMA:
\n\u2022\t From 1995 is the member of European
\nForum of Medical Associations and
\nWorld Health Organization (EFMA\/
\nWHO);
\n\u2022\t From October 2002 is member of World
\nMedical Association (WMA)
\n\u2022\t From 2011 is the member of South-East
\nEuropean Medical Forum (SEEMF).
\n\u2022\t From 2015 is the observer of European
\nPermanent Committee (CPME).
\nGMA unifies more than 90 professional as-
\nsociations acting in Georgia and cooperates
\nwith multiple organizations and funds as
\ninside the country, so abroad.
\nGeorgian Medical Association (GMA) is
\nan independent, professional union of doc-
\ntors founded for supporting professional
\nand personal needs of doctors working in
\nGeorgia; it unifies doctors of all spheres of
\nmedicine within the whole country; it is
\nvoice of doctors-professionals and medi-
\ncal students before official health struc-
\ntures and administrations of the country,
\nit is interested in active participation of its
\nmembers in formation of issues of strategic
\ndevelopment and health policy of the coun-
\ntry; it aims to active involvement of doc-
\ntors in protection of their civil, professional
\nand social\u00a0\u2013 economical interests; supports
\nimprovement of quality of medical aid of
\npopulation and improvement of health sys-
\ntem of the country.
\nTasks of GMA are: supporting decentral-
\nization of health system, protection of doc-
\ntors\u2019rights,support of professional improve-
\nment of doctors, popularization of scientific
\nachievements, illustration of ecological and
\ndemographic problems, bio-medical ethics,
\nsupporting young doctors, organization and
\nmanagement of educational, scientific and
\npractical actions, licensing-accreditation of
\ndoctors and medical institutions, constant
\nmedical education and constant profes-
\nsional development (CME & CPD); close
\nrelationships with legislative authorities and
\nlobbying of doctors interests.
\nGMA helps doctors and patients and in
\norder to achieve it supports union of doc-
\ntors to work in direction of social health and
\nmost important professional issues.
\nWhat has been done
\nin recent period
\nCooperation with Georgian Parliament:
\nWorking on legislative changes (2001\u2013
\n2008), working in scientific consultation
\nboard of field professional associations at the
\nParliament (2008\u20132012), working in scien-
\ntific \u2013 consultation board for prevention and
\nsupport of health (2017\u20132019), preparation
\nof some initiatives (2008; 2010; 2012);
\nCooperation with the Ministry of Refu-
\ngees from the Occupied Territories of
\nGeorgia, Labor, Health and Social Affairs
\nof Georgia
\n\u2022\t Working in professional boards of the
\nMinistry of Labor, Health and Social Af-
\nfairs of Georgia (1999\u20132009);
\n\u2022\t Health regulation sphere \u2013 preparation of
\nlist of specialties (1999\u20132008); participa-
\nGEORGIA
\nBACK TO CONTENTS
\n31
\nRegional Medical Affairs
\ntion in doctors\u2019 and postgraduates quali-
\nfication exams (commission, members,
\ntranslators, operators) (2002\u20132013);
\n\u2022\t Expertise of medical documentation
\n(2007\u20132010)
\nOther activities:
\n\u2022\t Involvement of Tbilisi State Medical
\nUniversity in international libraries net-
\nwork (2000\u20132008);
\nInternal and international grants
\n\u2022\t Together with organization OPM there
\nwere arranged several workshops for
\noptimisation of calculation of human
\nresources in health sphere. 21 field asso-
\nciation was actively participating in the
\nworkshop (2000\u20132001);
\n\u2022\t Assisting Georgian citizens in foreign
\nand Georgian clinics (Germany, Austria,
\nSwitzerland) (from 1989 to present);
\nSending members of Medical Associations
\nabroad for improvement of qualification
\n(from 1989 to present).
\n\u2022\t By initiative of World Medical Associa-
\ntion joining of Georgian Medical Asso-
\nciation to the project of rehabilitation of
\ntorture victims \u201cIstanbul Protocol\u201d(2002)
\nand realization and implementation of
\nthis project in Transcaucasia together
\nwith Reabilitation Center of Torture Vic-
\ntims \u201cEmpathia\u201d (from 2003 up to pres-
\nent);
\n\u2022\t In November 2008 in Georgian Parlia-
\nment there was conducted a meeting
\nwhich was devoted to medical aspects of
\nAugust events;
\n\u2022\t On October, 2008 there was created a
\nFund for helping families of medical per-
\nsonnel damaged by war;
\nExclusive contract with Georgian Airways
\n(from 2010 to present) (with discount on
\nflight tickets for GMA members).
\n\u2022\t Together with foreign partners there
\nwas concluded a contract with insurance
\ncompany \u201cArdi Group\u201d and in 2011 there
\nwas created \u201cGeorgian Insured Medic\u2019s
\nAgency\u201d,the basic functions of which are:
\nsupport of development of culture and
\npractice of professional liability insurance
\nin medical sphere, supporting protection
\nas of medics,so patients\u2019rights; mediation
\nin disputes between medics and patients;
\ndevelopment of strategy and recommen-
\ndations of professional liability insurance
\non the basis of got experience;
\n\u2022\t Together with Ivane Javakhishvili Tbilisi
\nState University and Faculty of Medicine,
\non July 09, 2014 there was executed Co-
\noperation Memorandum between Ivane
\nJavakhishvili Tbilisi State University and
\nGeorgian Medical Association (GMA);
\n\u2022\t In 1999, membership of students of
\nMedical Faculty of TSMU, and in 2010
\nmembership of students of Medical Fac-
\nulty of TSU in EMSA (European Medi-
\ncal Students Association);
\n\u2022\t Celebrating annually with participation
\nof EMSA-TSU official days regulated by
\nWorld Health Organization (WHO);
\n\u2022\t Organization of annual scientific work-
\nshops (autumn, spring) and school-sem-
\ninars (winter, summer) of students;
\n\u2022\t Preparation of official Georgian trans-
\nlation of Geneva declaration of World
\nMedics Association and its update for
\ngraduators of higher schools (oath text)\u00a0\u2013
\nMedical Faculty of Ivane Javakhishvili
\nTbilisi State University, from 2010;
\nEditing activities
\nTranslation and edition of \u201cMedical Eth-
\nics Manual\u201d of World Medical Association;
\ntogether with 3 field professional associa-
\ntions preparation and edition of \u201cRules of
\nProfessional Activity of Doctor\u201d; together
\nwith Medical Faculty of Tbilisi State Uni-
\nversity there was founded electronic scien-
\ntific magazine \u201c Translational and Clinical
\nMedicine\u00a0\u2013 Georgian Medical Journal);
\nInternational forums in Georgia:
\n\u2022\t April, 2015 Tbilisi \u2013 EFMA\/WHO;
\n\u2022\t September 2016 Batumi\u00a0\u2013 SEEMF;
\n\u2022\t September 2017 Tbilisi\u00a0\u2013 First Meeting
\nof Georgian Surgeons;
\n\u2022\t August 2018 Mestia \u2013 Congress of Geor-
\ngian Surgeons
\nFuture plans:
\n\u2022\t 2019\u20132021 \u2013 working on the project of
\nuniversity clinic together with admin-
\nistration of TSU and Dean\u2019s Office of
\nMedical Faculty;
\n\u2022\t 2020\u20132021\u00a0\u2013 Conduction of workshops
\nof GMA Regional Organizations and
\nrenewal registration of GMA members;
\n\u2022\t 18\u201320 September, 2019, Batumi\u00a0\u2013 \u201cNew
\nApproaches of Diagnostics and Treat-
\nment\u201d;
\n\u2022\t 23\u201326 October 2019, Tbilisi \u2013 70th
\nGen-
\neral Assembly of World Medics Associa-
\ntion (WMA).
\nWorking on legislative initiatives
\n\u2022\t Question of certification\u00a0\u2013 recertification
\n(among them restoration of certificate);
\n\u2022\t Postgraduate and continued medical edu-
\ncation;
\n\u2022\t Protection of legal and social rights of
\nmedical personnel.
\nProf. Gia Lobzhanidze \u2013 Chairman
\nof Directors\u2019 Board of GMA
\nMD\/PhD Tinatin Supatashvili-
\nDeputy General Secretary of GMA
\nDavid Lobzhanidze – Deputy
\nGeneral Secretary of GMA
\nGvantsa Modebadze\u00a0\u2013 Head
\nof Legal Office of GMA
\nGEORGIA
\nBACK TO CONTENTS
\n32
\nThe Belarusian Medical Association was
\nfounded in 1992.As of January 2019,its ag-
\ngregate membership is about 25.0% of the
\ntotal number of medical practitioners.
\nThe mission of the Belarusian Medical As-
\nsociation is to promote collaboration, coop-
\neration and mutual understanding on the
\nbasis of professional competence, profes-
\nsional ethics and deontology.
\nThe Belarusian Medical Association is the
\nfounder of the peer-reviewed research jour-
\nnal Medicine; it has its own website www:
\nbeldoc.by, where colleagues can find inter-
\nesting and useful information, learn about
\nthe activities of the association, ask ques-
\ntions and get knowledgeable assistance.The
\nBelarusian Medical Association established
\nthe Ethics Commission chaired by Profes-
\nsor V. P. Krylov. It considers ethical issues in
\nthe relationship between the colleagues and
\nadministration of health care institutions.
\nChairperson of the Belarusian Medical As-
\nsociation is a member of the Supreme At-
\ntestation Commission of the Ministry of
\nHealth of the Republic of Belarus for award-
\ning qualification grades to health officials.
\nThe Belarusian Medical Association has its
\nown regional and sectoral organizational
\nstructures. Our activity is aimed at a broad
\nrepresentation of the Belarusian medical
\ncommunity, including its representation at
\nan international level. We have concluded
\npartnership and cooperation agreements
\nwith international associations: the Lithua-
\nnian Medical Association, Latvian Medical
\nAssociation, Slovak Medical Chamber, and
\nthe National Medical Chamber of Russia.
\nThe Belarusian Medical Association is ad-
\nmitted as a Member of the Southeast Eu-
\nropean Medical Forum (SEEMF), EFMA,
\nand WMA.
\nThe Belarusian Medical Association is cur-
\nrently implementing a skills enhancement
\nand professional development program for
\nBelarusian medical specialists by organiz-
\ning and financing their participation in in-
\nternational academic programs and events.
\nIn close cooperation with sponsors, we send
\nmore than 250 medical specialists a year to
\ninternational symposia and conferences.This
\nmakes it possible for our health profession-
\nals to adopt the best practices and introduce
\nthem into the domestic public health as well
\nas to promote the achievements of the Be-
\nlarusian medical school on the global stage.
\nEvery year the Belarusian Medical Asso-
\nciation organizes and sponsors conferences
\nand forums held in the Republic of Belarus
\nfor medical specialists on diverse subject
\nmatters, involving representatives of the
\nleading world schools.
\nThe Belarusian Medical Association coor-
\ndinates the activities of public associations
\noperating in the health sector and holds
\njoint meetings with the heads of these as-
\nsociations to discuss issues related to coop-
\neration with the Ministry of Health of the
\nRepublic of Belarus.
\nIn June 2018, a working meeting of the top
\nmanagement of the Ministry of Health with
\nthe chairpersons of medical public associa-
\ntions was held, during which they discussed
\nissues concerning the development of legal
\nprotection of medical practitioners, improve-
\nment of furnishing information about risks
\nand particular complications in the process
\nof providing medical treatment to patients.
\nThe Ministry of Health welcomed a broad
\nparticipation of the medical community in
\nrevisions of the clinical protocols for the di-
\nagnosis and treatment as well as participation
\nof members of public associations in the ac-
\ntivities of the Higher Attestation Commis-
\nsions of the Ministry of Health for awarding
\nqualification grades to health officials.Subse-
\nquent to the results of the meeting,a decision
\non joint coordination of activities was made.
\nIn 2018, the Belarusian Medical Associa-
\ntion established the award For Devotion to
\nProfession.The prize is awarded to the health
\nprofessionals who have made a significant
\ncontribution to the development of Belaru-
\nsian medicine, the public health system of
\nthe Republic of Belarus as well as to the de-
\nvelopment of medical science. At its core,
\nthis is recognition of the long-standing self-
\nless service and contribution made by the
\nawardees to preserve and promote life and
\nhealth in the Republic of Belarus.
\nThe Belarusian Medical Association does
\nits best to strengthen the corporate soli-
\ndarity, to protect the honor and dignity of
\ncolleagues, to provide legal protection and
\nassistance in professional and occupational
\ntraining of specialists, to enhance the pres-
\ntige of people in white coats.
\nDmitry Shevtsov, Chairperson of the
\nBelarusian Medical Association
\nDmitry Shevtsov
\nActivities of the Belarusian Medical Association in the Modern Period
\nRegional Medical Affairs BELARUS
\nBACK TO CONTENTS
\n33
\nThe past few months of violence and blood-
\nshed in Sudan alone make a compelling ar-
\ngument that the international medical com-
\nmunity should be more present in Geneva,
\nwhere the United Nations human rights
\nmachinery is centered.
\nSince December 2018, more than 100 doc-
\ntors in Sudan have been arrested, and some
\ntortured, for their peaceful advocacy for
\nthe independence of their profession and
\nthe proper functioning of Sudan\u2019s health
\nsystem. More than seven hospitals have
\nbeen invaded by security forces firing tear
\ngas into the buildings. Doctors have been
\nprevented from treating the sick and the
\nwounded, and at least one was shot dead as
\nhe tried to treat an injured demonstrator.
\nThe Sudan doctors\u2019 union, along with other
\nprofessional groups, has been leading a civil
\nsociety movement to end one of the most
\nbrutal military dictatorships in the world,
\none in which the president and others in
\nhis cabinet are wanted by the International
\nCriminal Court for genocide.Physicians for
\nHuman Rights (PHR)\u2019s April 2019 report
\n\u201cIntimidation and Persecution: Sudan\u2019s At-
\ntacks on Peaceful Protesters and Physicians\u201d
\ndetailed these violations.
\nAnd yet, the medical voice is rarely seen or
\nheard in the corridors of the Human Rights
\nCouncil in Geneva, where delegates from a
\nrotating roster of 47 governments elected
\nfrom each region of the world regularly sit
\nto review human rights reports, evaluate
\ninformation, and make public pronounce-
\nments on violations,pressing for prevention,
\nprotection, and promotion of human rights
\nglobally.
\nNon-governmental organizations (NGOs)
\nlike PHR that have consultative status with
\nthe UN are able to address the Council at
\nits sessions. The messages are live-streamed
\nthrough UN media, so the reach can be sig-
\nnificant and preserved for the international
\nrecord.
\nSince the establishment of the Human
\nRights Council in 2006, PHR has submit-
\nted its reports to this body, spoken at the
\nopen sessions of the Council, distributed
\ninformation to governmental delegates, and
\nparticipated in \u201cside events\u201dto provide med-
\nical evidence of torture and sexual violence
\nand to highlight the devastating erosion of
\nprotection of health facilities and personnel
\nguaranteed in the Geneva Conventions of
\n1949.
\nFollowing the Myanmar government\u2019s 2017
\ncampaign of extreme violence and persecu-
\ntion against the Rohingya Muslim minority,
\nPHR went to Geneva in September 2018
\nto present its medical evidence of atrocities
\nagainst the Rohingya collected during a se-
\nries of population-based surveys and clini-
\ncal evaluation of survivors.
\nPHR and other NGOs also advocated for
\nthe Council to launch an independent in-
\nvestigative body led by prominent experts to
\ninvestigate crimes against the Rohingya; the
\nmechanism was established in 2018. PHR
\ncontinues to press for the body\u2019s operational
\neffectiveness as well as to advocate against
\nthe ongoing crisis of displacement of Myan-
\nmar\u2019s Rohingya and failures in accountabil-
\nity for atrocities committed against them.
\nAt the Human Rights Council\u2019s March
\n2019 session, PHR was once more at the
\ntable, delivering oral statements on the re-
\nlentless attacks on medical personnel and
\nfacilities in the eight-year Syrian conflict
\nand also on the trauma faced by many
\nasylum seekers crossing the US-Mexico
\nborder. \u201cThis is a human rights crisis that
\nis being treated as a security crisis,\u201d PHR
\nSenior Researcher Tamaryn Nelson told
\nthe Council, citing PHR\u2019s documentation
\nof trauma among asylum seekers and call-
\ning upon member states to press for an end
\nto U.S. policies that restrict the right to seek
\nasylum.
\nDr. Craig Torres-Ness, an emergency medi-
\ncine physician at the USC Keck School of
\nMedicine and a member of PHR\u2019s Asylum
\nNetwork, joined the PHR team in Geneva
\nto share his experiences of clinically evalu-
\nating asylum seekers who bear the physical
\nand psychological scars of gang-related and
\ndomestic violence. It was an extraordinary
\nplatform for a medical professional who is
\nusing his skills to advocate for human rights.
\nAnother unique opportunity for human
\nrights organizations and civil society to be
\nheard at the Council is the Universal Peri-
\nodic Review process. Every year, the Coun-
\ncil reviews the human rights record of 42
\ncountries. Governments, UN bodies, and
\nNGOs are able to submit information to
\nthe UN Office of the High Commissioner
\nfor Human Rights for the Council\u2019s country
\nreviews.Issues relevant to medical organiza-
\ntions include: independence of the medical
\nSusannah Sirkin
\nA Medical Voice Is Needed at the Human Rights Council in Geneva
\nMedical Ethics
\nBACK TO CONTENTS
\n34
\nMedical Ethics
\nand scientific communities and the right to
\ninformation about epidemics or outbreaks
\nof disease; persecution of health profession-
\nals for their independent medical or human
\nrights activities; attacks on health facilities
\nand personnel; medical evidence of torture
\nand sexual violence and their severe physi-
\ncal and psychological impacts; reproduc-
\ntive rights and health; collusion of health
\nprofessionals in human rights violations,
\nincluding torture and executions; overt ob-
\nstruction of the right to health; discrimina-
\ntion within health systems; and much more.
\nPHR has submitted documentation to this
\nprocess on human rights violations in Bah-
\nrain, Myanmar, the United States and Zim-
\nbabwe, among other countries.
\nDozens of organizations worldwide regu-
\nlarly send representatives to speak at Hu-
\nman Rights Council meetings on a range of
\nissues. But the credible and influential voice
\nof the medical community in these halls of
\npower is singularly underrepresented. PHR
\nhas been opening a door to these opportu-
\nnities and welcomes company to develop a
\nmore robust presence in Geneva as threats
\nagainst the independence of medical pro-
\nfessionals and the silencing of civil soci-
\nety become ever more pervasive across the
\nglobe.
\nSusannah Sirkin, Director of Policy,
\nPhysicians for Human Rights
\nEwan C Goligher Maria Cigolini Alana Cormier Sin\u00e9ad Donnelly Catherine Ferrier Vladimir A. Gorsh-
\nkov-Cantacuz\u00e8ne
\nSheila Rutledge
\nHarding
\nMark Komrad Edmond Kyrillos Timothy Lau Rene Leiva Renata Leong Sephora Tang John Quinlan
\nEuthanasia and Physician-Assisted Suicide are Unethical Acts
\nThe World Medical Association (WMA),
\nthe voice of the international community
\nof physicians, has always firmly opposed
\neuthanasia and physician-assisted suicide
\n(E&PAS) and considered them unethi-
\ncal practices and contrary to the goals of
\nhealth care and the role of the physi-
\ncian\u00a0[1]. In response to suggested changes
\nto WMA policy on this issue, an exten-
\nsive discussion took place among WMA
\nAssociate Members. We, representing a
\nvoice of many of those involved in this
\ndiscussion, contend that the WMA was
\nright to hold this position in the past and
\nmust continue to maintain that E&PAS
\nare unethical.
\nThe Central Issue Under Debate
\nis the Ethics of E&PAS
\nThe question is whether it is ethical for
\na doctor to intentionally cause a patient\u2019s
\ndeath, even at his or her considered re-
\nquest. The fact that E&PAS has been
\nlegalized in some jurisdictions and that
\nsome member societies support these
\npractices has no bearing on the ethical
\nquestion. What is legal is not necessarily
\nethical.The WMA already recognizes this
\ndistinction, for example, by condemning
\nthe participation of physicians in capital
\npunishment even in jurisdictions where
\nit is legal. The WMA should be consis-
\ntent in this principle also with respect to
\nE&PAS.
\nBACK TO CONTENTS
\n35
\nMedical Ethics
\nE&PAS Fundamentally
\nDevalues the Patient
\nThis devaluation is built into the very
\nlogic of E&PAS. To claim that E&PAS
\nis compassionate is to suggest that a pa-
\ntient\u2019s life is not worth living, that her
\nexistence is no longer of any value. Since
\nthe physician\u2019s most basic tasks and con-
\nsiderations are to \u2018always bear in mind
\nthe obligation to respect human life\u2019 and
\n\u2018the health and well-being of the patient\u2019
\n[2,\u00a03], E&PAS must be opposed. E&PAS
\ndistorts the notion of respect for the pa-
\ntient. On the one hand it claims to help
\nsuffering persons, while on the other hand
\nit eliminates them. This is a profound in-
\nternal contradiction; the ethical priority
\nis to respect the fundamental intrinsic
\nworth of the person as a whole.
\nE&PAS Puts Patients at
\nRisk
\nPatients are autonomous agents but are
\nnot invulnerable to their need for affirma-
\ntion from others, including their physi-
\ncian. Amidst the overwhelming fears of
\nthose who suffer (4, 5), a free autono-
\nmous decision to die is an illusion. Par-
\nticular concern exists for those who may
\nfeel their life has become a burden due
\nto changing perceptions of the dignity
\nand value of human life in all its differ-
\nent stages and conditions, and an explicit
\nor implicit offer of E&PAS by a physi-
\ncian profoundly influences the patient\u2019s
\nown thinking. The troubles of human
\nrelationships within families, the pres-
\nence of depression, and problems of abuse
\nand physician error in an already stressed
\nmedical system, make muddy waters even
\nmore turbulent [6]. Evidence shows that
\nsocieties cannot always defend the most
\nvulnerable from abuse if physicians be-
\ncome life-takers instead of healers [1, 6].
\nThe power of the therapeutic relationship
\ncannot be underestimated in the creation
\nof patient perceptions and choices.
\nE&PAS Totally Lacks
\nEvidence as \u2018Medical
\nTreatment\u2019
\nThe consequences of E&PAS are unknown
\nas both physicians and patients have no
\nknowledge of what it is like to be dead. Ad-
\nvocates of E&PAS place blind faith in their
\nown assumptions about the nature of death
\nand whether or not there is an afterlife
\nwhen arguing that euthanasia is beneficial.
\nE&PAS is therefore a philosophical and
\nquasi-religious intervention, not a medical
\nintervention informed by science. Doctors
\nshould not offer therapy when they have no
\nidea of its effects\u2014to offer E&PAS is to
\noffer an experimental therapy without any
\nplans for follow-up assessment. Therefore,
\nkey elements in any medical intervention
\nsuch as informed consent are simply not
\npossible without knowing what stands on
\nthe other side of death. Rather than a stan-
\ndard medical discussion of alternatives based
\non scientific data or clinical experience, the
\ndiscussion must leave the clinical domain
\nand enter the domain of speculation. This
\nis not an exercise in informed-consent.This
\nis not the accepted medical ethics of medi-
\ncal practice. All this is, in part, why E&PAS
\ncannot be a medical procedure.
\nThese Weighty Moral
\nConsiderations are Supported
\nby the Ethical Intuition of the
\nGlobal Medical Community
\nOnly a small minority of physicians sup-
\nport E&PAS. The vast majority of doctors
\naround the world wish only to foster the
\nwill to live and to cope with illness and suf-
\nfering, not to facilitate acts of suicide or to
\ncreate ambiguity around what constitutes a
\nmedical treatment.We must remember that
\nthe four regional WMA symposia demon-
\nstrated that most doctors would never be
\nwilling to participate in euthanasia. Even
\nthe insistence of E&PAS proponents on (a)
\nusing ambiguous language such as \u2018Medical
\nAssistance in Dying\u2019 to describe their prac-
\ntice and (b) avoiding mention of E&PAS
\non death certificates suggests that they
\nshare to some degree this fundamental ethi-
\ncal intuition about killing patients.
\nAcceptance of E&PAS
\nUndermines Boundaries
\nBetween End-Of-Life Care
\nPractices That do not Intend
\nDeath (palliative care,
\nwithholding\/withdrawing life-
\nsustaining therapy) and Those
\nthat do Intend Death (E&PAS)
\nConfusion is created at a societal level about
\nwhat constitutes \u201cmedical treatment,\u201d espe-
\ncially when language such as \u201cmedical assis-
\ntance in dying\u201dor \u201cvoluntary assisted dying\u201d
\nis used. This renders the reality of such acts
\nand their application unclear. As many pa-
\ntients share our conviction that deliberately
\ncausing death is wrong, a misunderstanding
\nof the distinction between E&PAS and pal-
\nliative care may lead to rejection of palliative
\ncare or insistence on futile life-sustaining
\ntherapies. The availability of E&PAS also
\ndistracts from the priority of providing so-
\ncial services and palliative care to those who
\nare sick and dying [7].
\nThe WMA\u2019s Code of Ethics
\nStrongly Influences Standards
\nfor the Practice of Medicine
\nAround the World and
\nNeutrality on E&PAS by the
\nWMA Would be Interpreted
\nGlobally as Tacit Approval
\nA change in the WMA statement would
\nimply a tacit endorsement of E&PAS and
\nrender the WMA complicit with such prac-
\ntices [8, 9]. Neutrality by professional medi-
\nBACK TO CONTENTS
\n36
\ncal organisations on E&PAS is perceived by
\nsociety, governments and the international
\npro-euthanasia lobby as that organisation\u2019s
\nacceptance of them as medical practice,
\nrather than as a response to a societal\/po-
\nlitical agenda.Those who seek international
\napproval to justify these practices will cre-
\nate a silencing of the majority of the com-
\nmunity, which has real medical, societal and
\nethical concerns around E&PAS and their
\neffects on society internationally.
\nWMA policy on E&PAS reflects that
\nwhich is in place in hundreds of jurisdic-
\ntions with widely divergent legal and politi-
\ncal traditions. While it may be tempting to
\nplacate some member societies so as to avoid
\ndissension, we must not destabilize medical
\nethics around the world. We must continue
\nto characterize E&PAS as unethical even
\nif it conflicts with the demands of the state
\nor influential groups backed by the law. We
\nmust not let imperfect law trump good
\nmedical ethics. Undoubtedly many doctors
\nwho perform E&PAS believe themselves
\nto be acting nobly; but it does not follow
\nthat they should expect others to affirm
\ntheir views or not to oppose them; nor are
\nthey wronged by existing WMA policy.Any
\nsociety that insists on transforming suicide
\nfrom a freedom to a right, should stand up
\na different profession with the duty to fulfil
\nthat new right, as killing does not belong in
\nthe House of Medicine.
\nNeutrality on E&PAS
\nhas Serious Consequences
\nfor Physicians who
\nRefuse to Participate
\nIn jurisdictions where E&PAS is legalized,
\nphysicians who adhere to the long-standing
\nHippocratic ethical tradition are suddenly
\nregarded as outliers, as conscientious objec-
\ntors to be tolerated and ultimately excluded
\nfrom the profession [10]. A neutral stance
\nby the WMA would compromise the po-
\nsition of the many medical practitioners
\naround the world who believe these prac-
\ntices to be unethical and not part of health
\ncare. In some jurisdictions it is illegal not to
\nrefer for these practices, creating a dystopic
\nsituation where the doctor who practises
\nquality end-of-life care needs to conscien-
\ntiously object in order to do so, and may
\nbe coerced to refer for E&PAS. Neutrality
\nfrom the WMA would promote the con-
\ntravention of the rights and ethical practice
\nof these doctors, undermining their ethical
\nmedical position at the behest of a societal
\ndemand that can fluctuate with time.
\nIn sum, the changes currently being de-
\nbated, arising from political, social, and
\neconomic factors, have been rejected time
\nand again and most recently by the over-
\nwhelming consensus of WMA regions. The
\npresent debate represents a crucially im-
\nportant moment for the WMA that must
\nnot be squandered. Given the influence of
\nthe WMA and the profound moral issues
\nat stake, neutrality should not be an option.
\nThe WMA policy must continue to stand
\nas a beacon of clarity to the world, bringing
\ncomfort to patients and support to physi-
\ncians around the globe. The WMA should
\nnot be coerced into promoting euthanasia
\nand assisted suicide by making its stance
\nneutral.
\nReferences
\n1.\t Leiva R, Friessen G, Lau T. Why Euthana-
\nsia is Unethical and Why We Should Name it
\nas Such. WMJ. 2018 Dec; 64 (4) pages 33-37.
\n[Cited 2019 Feb 05]. https:\/\/www.wma.net\/wp-
\ncontent\/uploads\/2019\/01\/wmj_4_2018_WEB.
\npdf
\n2.\t WMA INTERNATIONAL CODE OF
\nMEDICAL ETHICS.WMA [Internet] [cited
\n2019 Feb 05]. https:\/\/www.wma.net\/policies-
\npost\/wma-international-code-of-medical-
\nethics
\n3.\t WMA DECLARATION OF GENEVA.
\nWMA [Internet] [cited 2019 Feb 05]. https:\/\/
\nwww.wma.net\/policies-post\/wma-declaration-
\nof-geneva
\n4.\t Zaorsky NG et al. Suicide among cancer pa-
\ntients. Nat Commun. 2019 Jan 14;10 (1):207.
\n[cited 2019 Feb 05]. https:\/\/www.nature.com\/
\narticles\/s41467-018-08170-1
\n5.\t Rodr\u00edguez-Prat A et al. Understanding pa-
\ntients\u2019 experiences of the wish to hasten
\ndeath: an updated and expanded systematic
\nreview and meta-ethnography. BMJ Open.
\n2017 Sep 29;7(9):e016659. [Cited 2019 Feb
\n05].https:\/\/bmjopen.bmj.com\/content\/7\/9\/
\ne016659.long
\n6.\t Miller DG, Kim SYH. Euthanasia and physi-
\ncian-assisted suicide not meeting due care cri-
\nteria in the Netherlands: a qualitative review of
\nreview committee judgements. BMJ Open. 2017
\nOct 25;7(10):e017628. [cited 2019 Feb 05].htt-
\nps:\/\/bmjopen.bmj.com\/content\/7\/10\/e017628.
\nlong
\n7.\t The Canadian Society of Palliative Care Physi-
\ncians -KEY MESSAGES RE HASTENED
\nDEATH [Internet] [cited 2019 Feb 05].https:\/\/
\nwww.cspcp.ca\/wp-content\/uploads\/2015\/10\/
\nCSPCP-Key-Messages-FINAL.pdf
\n8.\t Sulmasy DP, Finlay I, Fitzgerald F, et al. Phy-
\nsician-assisted suicide: why neutrality by organ-
\nized medicine is neither neutral nor appropriate.
\nJ Gen Intern Med 2018; 33: 1394-1399.
\n9.\t Canadian Medical Association softens stand on
\nassisted suicide. Globe and Mail. AUGUST 19,
\n2014 [Internet] [cited 2019 Feb 05]. https:\/\/
\nwww.theglobeandmail.com\/news\/national\/ca-
\nnadian-medical-association-softens-stance-on-
\nassisted-suicide\/article20129000\/
\n10.\tEuthanasia in Canada: A Cautionary Tale.
\nWMJ 2018 Oct; 64 (3), p 17-23. [cited 2019
\nFeb 05].https:\/\/www.wma.net\/wp-content\/up-
\nloads\/2018\/10\/WMJ_3_2018-1.pdf
\n(Institutional affiliations are provided for
\nidentification purposes only and do not im-
\nply endorsement by the institutions.)
\nEwan C Goligher MD PhD
\nAssistant Professor
\nInterdepartmental Division of
\nCritical Care Medicine
\nUniversity of Toronto
\nE-mail: ewangoligher@gmail.com
\nDr Maria Cigolini
\nMBBS(Syd) FRACGP FAChPM
\nGrad.DiPallMed(Melb)
\nClinical Director Palliative Medicine,
\nRoyal Prince Alfred Hospital
\nSenior Clinical Lecturer,
\nUniversity of Sydney
\nNew South Wales, Australia
\nE-mail: Maria.Cigolini@health.nsw.gov.au
\nMedical Ethics
\nBACK TO CONTENTS
\n37
\nAlana Cormier MD CCFP
\nFamily Physician, Twin Oaks
\nMemorial Hospital
\nAssistant Professor, Department of Family
\nMedicine, Faculty of Medicine, Dalhousie
\nUniversity, Nova Scotia, Canada
\nE-mail: alana.cormier@dal.ca
\nSin\u00e9ad Donnelly MD, FRCPI,
\nFRACP, FAChPM
\nConsultant physician Internal
\nMedicine and Palliative Medicine,
\nModule convenor and Clinical lecturer
\nPalliative Medicine, University Otago,
\nWellington, Aotearoa New Zealand
\nE-mail: Sinead.donnelly@ccdhb.org.nz
\nCatherine Ferrier, MD,
\nCCFP (COE), FCFP
\nDivision of Geriatric Medicine,
\nMcGill University Health Centre
\nAssistant Professor of Family
\nMedicine, McGill University
\nE-mail: catherine.t.ferrier@gmail.com
\nVladimir A. Gorshkov-Cantacuz\u00e8ne,
\nBChE, MNeuroSci, MD,
\nDSc(med), TD, JCD
\nDirector, Department of Clinical
\nCardioneurology, American Institute
\nof Clinical Psychotherapists
\nE-mail: hypfoundation@gmail.com
\nSheila Rutledge Harding, MD, MA, FRCPC
\nHematologist, Saskatchewan Health Authority
\nProfessor, College of Medicine,
\nUniversity of Saskatchewan
\nSaskatoon SK Canada
\nE-mail: sheila.harding@me.com
\nMark Komrad MD
\nFaculty of Psychiatry Johns Hopkins,
\nUniversity of Maryland, Tulane
\nEthics Committee, American
\nCollege of Psychiatrists
\nE-mail: Mkomrad@aol.com
\nEdmond Kyrillos, MD, CCFP, B. Eng.
\n(Mechanical), Lecturer, Department
\nof Family Medicine, Faculty of
\nMedicine, University of Ottawa
\nE-mail: edmond.kyrillos@usherbrooke.ca
\nTimothy Lau, MD, FRCPC
\nDistinguished Teacher, Associate
\nProfessor, Faculty of Medicine,
\nDepartment of Psychiatry, Geriatrics,
\nRoyal Ottawa Hospital.
\nE-mail: timlau@sympatico.ca
\nRene Leiva, MD CM, CCFP (Care of
\nthe Elderly\/ Palliative Care); FCFP
\nAssistant Professor
\nDepartment of Family Medicine
\nFaculty of Medicine
\nUniversity of Ottawa
\nE-mail: Rene.leiva@mail.mcgill.ca
\nRenata Leong
\nMDcM, MHSc, CCFP, FCFP
\nAssistant Professor, DFCM,
\nUniversity of Toronto
\nE-mail: leongr@smh.ca
\nSephora Tang, MD, FRCPC
\nStaff Psychiatrist, The Ottawa Hospital
\nLecturer, Faculty of Medicine,
\nDepartment of Psychiatry
\nUniversity of Ottawa
\nE-mail: sephora.md@gmail.com
\nJohn Quinlan MB.BS(Syd)
\nFAFRM MA(ethics)
\nE-mail: jpquinlan@bigpond.com
\nDefensive medical practice represents an
\nincreasing concern in all over the world.
\nThe practice of defensive medicine is main-
\nly associated to the rising number of medi-
\ncal malpractice lawsuits. It negatively affect
\nthe quality of care and waste the limited
\nresources in health sector. The economic
\nburden of defensive medicine on health
\ncare systems should provide an essential
\nstimulus for a prompt review of this situ-
\nation. Defensive medicine in simple words
\nis departing from normal medical practice
\nas a safeguard from litigation. The most
\nfrequent daily practice of defensive medi-
\ncine is performing more unnecessary tests
\nand referring more patients to consultants
\nand hospitalization. Such behavior is an
\nethically wrong and disagrees with deon-
\ntological duties of the doctor. Investigating
\nthe prevalence of defensive medicine in a
\nnumber of international healthcare set-
\ntings, defensive medicine has been found
\nto be highly prevalent in many countries.
\nMajority of physicians across various spe-
\ncialties tends to adopt a defensive profes-
\nsional culture. Daiva Brogiene
\nRegional Medical Affairs
\nThe Defensive Medicine isn\u2019t the Best
\nWay to Avoid Mistakes
\nLITHUANIA
\nBACK TO CONTENTS
\n38
\nThe survey of 2440 physicians manifested
\nbroad spread of the defensive medicine in
\nLithuania. Results show that 86.3% of doc-
\ntors admitted that they refer their patients
\nto other specialists without any true need
\nand solely to protect themselves from po-
\ntential legal challenges. Moreover, 60.7% of
\nthe consulted physicians admitted to hav-
\ning performed unnecessary additional test
\nfor the same reason. Also, 66.6% of the
\nphysicians avoid \u2018risky\u2019 patients, which are
\ndefined as those with a complicated or dan-
\ngerous disease, or those who are prepared
\nto challenge doctors\u2019 decisions. In addition,
\n59.9% of the physicians consulted avoid us-
\ning necessary, but risky procedures. Lastly,
\n40.3% of the physicians indicate that they
\nhave prescribed or used unnecessary medi-
\ncines (Prevalence of defense medicine in
\nLithuania. Liutauras Labanauskas, Viktoras
\nJustickis, Aist\u0117 Sivakovait\u0117. Health policy
\nand management, 2013).
\nWe have to speak up about defensive medi-
\ncine, because it is a low-value care, which
\nhas no benefit neither to the patient and nor
\nto the doctor. Defensive medicine brings
\nenormous prolongation of waiting time for
\nall patients. This causes great harm to pa-
\ntients who should receive the medical care
\nin a proper time, especcialy to the patients
\nwho have the most serious diseases. But a
\nphysician instead of doing his best to help
\nhis patient is concentrated on defending
\nhimself from any legal prosecution in the
\ncase on unsuccessful treatment.
\nDoctors who prescribe unnecessary tests and
\nprocedures out of fear of being sued waste a
\nlot of money each year. Defensive medicine
\npractice is difficult to precisely quantify. Low
\nvalue care \u2013 is a faulty and dangerous phe-
\nnomenon in the healthcare. International
\nprojects analyze opportunities to eliminate
\nwaste and lower value care. But the efforts
\nto rid the nation\u2019s healthcare system of waste
\nand inefficiency faces a defensive medicine.
\nClinical medicine has always been based
\non patient \u2013 physician trust. Unfortunately,
\nthis fundamental trust has been progres-
\nsively eroded by lack of patient face-time.
\nThis is not a picture limited to one country,
\nfor example Lithuania. If this relationship
\nis lost or diminished to unacceptable levels,
\nthen defensive medicine is the logical con-
\nsequence. Time directly spent with patients
\nhas been overtaken by time devoted to elec-
\ntronic health records and other documenta-
\ntion. It is necessary to reestablish the trust
\nbetween doctor and patient. Lithuanian
\nMedical Association demands the govern-
\nment to normalize the worklowds of phy-
\nsicians and allowd them to spend the time
\nthey need with their patients. A doctor who
\nsees patient\u2019s distrust as an expression of his
\nhostility has no other option than to defend
\nand to use defensive medicine methods.
\nIn keeping with the growing trend towards
\nconsidering healthcare as a consumer prod-
\nuct and patients as consumers, patients and
\ntheir families not infrequently demand ac-
\ncess to medical services that, in the consid-
\nered opinion of physicians, are not appro-
\npriate. This problem is especially serious in
\nsituations where resources are limited and
\nproviding \u2018futile\u2019 or \u2018nonbeneficial\u2019 treat-
\nments to some patients means that other
\npatients are left untreated. As a general rule
\na patient should be involved in determining
\nfutulity in his or her case. Overtreatment
\nwith antibiotics is one example of defensive
\nmedicine that endangers everyone. Con-
\ntinuing efforts must be made to educate the
\npublic that information acquired from on-
\nline sources outside of an appropriate clini-
\ncal context is generally inappropriate.
\nThere is no secret that a patient can sue
\nthe doctor, betting on a chance to win a
\nbig award. Such culture of litigation impact
\nboth the medical and legal systems. The
\nlaws and legal systems in each country, as
\nwell as the social traditions and economic
\nconditions are different, but the fundamen-
\ntal principles of litigation culture are similar
\nfor every country. So the adoption of no-
\nfault systems or other extra-judicial me-
\ndiation are shown to be the most effective
\nstrategies to reduce the number of litiga-
\ntions in courts, with consequent economic
\nsavings. In countries where a no-fault sys-
\ntem or a system of conflict mediation is in
\nforce, most of the litigations are disputed
\nout of the court of law. Lithuanian govern-
\nment is also trying to solve this problem and
\nintend currently to enter the no-fault com-
\npensation system without requiring a proof
\nof negligence. Lithuanian Medical Associa-
\ntion speaks up against the increasing crimi-
\nnalization or penal liability.
\nThe physician who has personally been
\nnamed in a lawsuit becomes so called
\n\u2018second victom\u2019. He\/she commited an
\nerror, and are consequently severely af-
\nfected in both their private life and subse-
\nquent practice. They suffer physically and
\npsycho-socially and try to overcome the
\npost-event emotional stress by obtaining
\nemotional support. Psychological support
\nobtained by these physicians in health care
\ninstitutions today is poor and inefficient.
\nThere is a need for effective support to \u2018sec-
\nond victims\u2019, because despite that they will
\ncontinue their defensive medicine in the
\nfuture. \u2018Second victims\u2019 may feel anxiety,
\nfear, guilt or anger and experience social
\nwithdrawal, which may lead to depression.
\nOver the years, this situation may lead to
\ndeterioration in his\/her work and personal
\nlife and, in rare circumstances, may lead to
\npharmaceutical and even alcohol consump-
\ntion. It is no secret, there were the cases
\nwhen the physician have committed sui-
\ncide. But this support is not meant to dis-
\nrupt any correct medical investigation or to
\nstand for a doctor in any way, but rather to
\nallow him\/her to focus on handling stress,
\naccepting the consequences of the mistake,
\nand \ufb01nding out solutions to avoid similar
\nsituations in the future, it means training
\nand learning from mistakes. Lithuanian
\nMedical Association openly and truly
\nprovides the help to the colleagues which
\nneed it. We hope that maintenance of high
\nstandards in daily practice with continu-
\nous training, clear communication and a
\nsigned Patient\u2019s Informed Consent Form
\nRegional Medical Affairs LITHUANIA
\nBACK TO CONTENTS
\n39
\nCPME Position Paper on
\nDefensive Medicine
\nThe Standing Committee of European Doctors (CPME) represents
\nnational medical associations across Europe. We are committed to
\ncontributing the medical profession\u2019s point of view to EU and Eu-
\nropean policy-making through pro-active cooperation on a wide
\nrange of health and healthcare related issues [1].
\nDefinition\/ Background [2]
\nDefensive medicine has seen an increase in both prevalence and im-
\npact over the past years.
\nThe concept of \u2018defensive medicine\u2019 is subject to varying definitions
\nwhich broadly describe the practice of ordering medical tests,proce-
\ndures,or consultations which are not medically indicated or refusing
\nthe treatment of certain patients in order to protect the responsible
\nphysician from malpractice challenges.
\nDefensive medicine consists of two general behaviours. As Stud-
\ndert et al. set out, \u201c[o]ne is assurance behaviour (sometimes called
\n\u201cpositive\u201d defensive medicine), which involves supplying additional
\nservices of marginal or no medical value with the aim of reducing
\nadverse outcomes, deterring patients from filing malpractice claims,
\nor persuading the legal system that the standard of care is met. The
\nother is avoidance behaviour (sometimes called \u201cnegative\u201d defensive
\nmedicine), which refers to physicians\u2019 efforts to distance themselves
\nfrom sources of legal risk\u201d [3].
\nTHE Prevalence of Defensive Medicine
\nin Europe
\nA review of international scientific literature confirms that defen-
\nsive medicine is widespread and occurs in all diagnostic-therapeutic
\nareas, although some medical specialties are affected more often
\nthan others. Various studies have looked at the situation at national
\nlevel, both within the EU and internationally [4\u201313].
\nImpact of Defensive Medicine
\nThe adverse effects of defensive medicine affect healthcare systems
\nworldwide.
\nIt is complicated to calculate or quantify the economic impact of de-
\nfensive medicine due to the many conflicting and overlapping fac-
\ntors [14\u201317]. Nevertheless it is expected that the cost of defensive
\nmedicine is significant.
\nA culture of litigation impacts both the medical and legal systems
\nwith damaging consequences to the patient-physician relationship
\nand the quality of healthcare services even though the national legal
\nframeworks for litigation differ.
\nRecommendations to Prevent and Reduce
\nthe Practice of Defensive Medicine
\nThere is no universal solution for all countries of how to reduce
\nthis phenomenon due to cultural,economic and social differences in
\nthe countries which create the different expectations of the patients,
\ndifferent legal systems and legal procedures. However the common
\nessential directions may be put forward.
\nRecommendations for professionals
\n1. To ensure that healthcare responds appropriately to each indi-
\nvidual patient\u2019s health needs.
\n2. To maintain high standards and evidence-based clinical guide-
\nlines in daily practice. Clinical guidelines require regular revision
\nto ensure they reflect the best available evidence, while allowing for
\nclinical independence to adequately respond to individual patients\u2019
\nneeds and choices.
\n3.To practice more valuable care for every patient through informed
\nchoices and good conversation. With a patient engagement and
\nclear communication promote awareness about appropriate care,
\nunnecessary tests, treatments and procedures.
\n4. To support Continuous professional development (CPD) with
\nthe objective of ensuring that professional practice is up-to-date.
\nMedical Affairs CPME
\nalong with the appropriate documentation
\nof any procedure carried out may provide
\nprofessional safety.
\nSo we are sure,the better care is the best de-
\nfense. The defensive medicine isn\u2019t the best
\nway to avoid mistakes.
\nDr.\u00a0Daiva Brogiene
\nVice-president CPME
\nLithuanian Medical Association
\nBACK TO CONTENTS
\n40
\nThis will contribute to better patient outcomes, quality of care as
\nwell as increasing the public\u2019s confidence in the medical profession.
\n5.To maintain clear,well-documented and detailed medical records.
\nAppropriate documentation of all treatments and procedures con-
\ntributes to quality of care and patient safety.
\nRecommendations for policy-makers
\n6. To build a patient safety culture aimed at transparency, and
\npreventing and learning from errors. Appropriate open disclosure
\npolicies can support both patients and doctors and should be ap-
\npropriately resourced. It has furthermore been established that the
\ndisclosure of adverse events, which may include an apology to the
\npatient affected and their family, lowers the probability of litigation
\nagainst the doctor involved.
\n7. To engage in a debate with the public to contribute to improv-
\ning media literacy on health information in particular in relation
\nto online sources. To inform the public about the consequences of
\ndefensive medicine: reluctance to treat high risk patients, costs and
\ndangers if professionals continue to practice defensive medicine.
\n8.The medical community and administration of health institutions
\nneed to be aware of the \u2018second victim\u2019phenomenon (or the clinical-
\njudicial syndrome) and ensure adequate psychosocial support to
\nboth patients and doctors in the disclosure process.
\n9. To reduce fears of liability proceedings by reforming compensa-
\ntion mechanisms for medical malpractice. Mediation and adminis-
\ntrative compensation systems all hold promise.
\n10. Further development of the liability system is necessary to en-
\nable a reform of tort law focused on balancing the \u2018no blame prin-
\nciple\u2019 with the \u2018accountability principle\u2019. The use of extra-judicial
\nmediation and the adoption of no-fault systems have proven to be
\neffective approaches in reducing both defensive medicine and the
\nwaste of resources it incurs.
\n11. Under-resourcing and under-staffing contribute to clinical error
\nand defensive medicine. Employers and funders have a duty of care
\nto ensure that clinical services are adequately resourced and staffed
\nto deal with appropriate workloads.
\nReferences
\n1.\t CPME is registered in the Transparency Register with the ID number
\n9276943405-41. More information about CPME\u2019s activities can be found
\non www.cpme.eu.
\n2.\t In 2016, CPME carried out a survey mapping the situation of defensive
\nmedicine across Europe (CPME 2016\/008 FINAL). Responses to the
\nCPME survey showed that a majority of National Medical Associations
\nsupport further CPME action concerning defensive medicine, in particular
\nto raise awareness about this problem. The impact of defensive medicine is
\ndiscussed in relation to several policy areas. There are CPME policies relat-
\ning to the liability of doctors which also address the concept of defensive
\nmedicine, in particular the CPME policy on the liability of service providers
\nadopted in 1991 (FR only) and the CPME Proposal for a directive on health
\ncare liability adopted in 2000. Although discussions on doctors\u2019liability were
\nraised both in the context of the Services Directive 2006\/123\/EC,the Cross-
\nBorder Healthcare Directive 2011\/24\/EU and the Professional Qualifica-
\ntions Directive 2005\/36\/EC, there is currently no EU legislation on this is-
\nsue. Awareness of an increasingly defensive medical practice culture and its
\nnegative implications has paved the way for a much-needed political focus,
\nlike the \u2018Choosing Wisely\u00ae\u2019 campaign in the UK launched by the Academy
\nof Medical Royal Colleges. International projects analyse opportunities to
\neliminate waste and lower value care (Netherlands, Alliance of University
\nHospitals and Training centres – NFU programme), the European Collabo-
\nration for Healthcare Optimization (ECHO).
\n3.\t Studdert DM, Mello MM, Sage WM, Des Roches CM, Peugh J, Zapert K,
\net al. Defensive medicine among high-risk specialist physicians in a volatile
\nmalpractice environment. JAMA. 2005;293:2609\u201317.
\n4.\t J Health Serv Res Policy. 2017 Jan, Prevalence and costs of defensive medi-
\ncine: a national survey of Italian physicians. Panella M, Rinaldi, Leigheb F,
\nKnesse S, Donnarumma C, Kul S,Vanhaecht K, Di Stanislao F.
\n5.\t Health Econ Policy Law. 2017 Jul;12(3):363-386. The determinants of de-
\nfensive medicine practices in Belgium. Vandersteegen T, Marneffe W, Cl-
\neemput I, Vandijck D, Vereeck L.
\n6.\t J Eval Clin Pract. 2015 Apr;21(2):278-84. A national survey of defensive
\nmedicine among orthopaedic surgeons, trauma surgeons and radiologists in
\nAustria: evaluation of prevalence and context. Osti M, Steyrer J.
\n7.\t Studdert DM, Mello MM, Sage WM, Des Roches CM, Peugh J, Zapert K,
\net al. Defensive medicine among high-risk specialist physicians in a volatile
\nmalpractice environment. JAMA. 2005;293:2609\u201317.
\n8.\t Hiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al.
\nDefensive medicine practices among gastroenterologists in Japan. World
\nJ\u00a0Gastroenterol. 2006;12:7671\u20135.
\n9.\t Bishop TF, Federman AD, Keyhani S. Physicians\u2019 views on defensive medi-
\ncine: a national survey. Arch Intern Med. 2010;170:1081-1083.
\n10.\tAsher E, Greenberg-Dotan S, Halevy J, Glick S, Reuveni H (2012) Defen-
\nsive Medicine in Israel \u2013 A Nationwide Survey. PLoS ONE 7(8): e42613.
\ndoi:10.1371\/ journal.pone.0042613).
\n11.\tCross-sectional survey on defensive practices and defensive behaviours
\namong Israeli psychiatristsI Reuveni, I Pelov, H Reuveni, O Bonne, and L
\nCanetti. BMJ Open. 2017; 7(3):
\n12.\tPrevalence of defense medicine in Lithuania. Liutauras Labanauskas, Vikto-
\nras Justickis, Aist\u0117 Sivakovait\u0117 . Health policy and management, 2013.
\n13.\tAsher E, Dvir S, Seidman DS, Greenberg-Dotan S, Kedem A, et al. (2013)
\nDefensive Medicine among Obstetricians and Gynecologists in Tertiary
\nHospitals. PLoS ONE 8(3): e57108. doi:10.1371\/journal.pone.0057108.
\n14.\tJ Am Health Policy. 1994 Jul-Aug;4(4):7-15. How much does defensive
\nmedicine cost? Rubin RJ, Mendelson DN.
\n15.\tHermer LD, Brody H. Defensive medicine, cost containment, and reform.
\nJ\u00a0Gen Intern Med. 2010; 25:470-473.
\n16.\tHealth Policy, 119 (2015) 367-374. Tom Vandersteegen and others. The
\nimpact of no-fault compensation on health care expenditures: An empirical
\nstudy of OECD countries.
\n17.\tReschovsky JD, Saiontz-Martinez CB. Malpractice claim fears and the costs
\nof treating medicare patients: a new approach to estimating the costs of de-
\nfensive medicine. Health Serv Res 2017.
\nMedical Affairs CPME
\nBACK TO CONTENTS
\nBACK TO CONTENTS
\nIV
\nWMA General Assembly
\nWMA General Assembly
\nBACK TO CONTENTS<\/p>\n"},"caption":{"rendered":"

wmj_1_2019_WEB WMA General Assembly vol. 65 Medical World Journal Official Journal of The World Medical Association, Inc. ISSN 2256-0580 Nr. 1, May 2019 Contents Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2019\/06\/wmj_1_2019_WEB.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/12759"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=12759"}]}}