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wmj40<\/a><\/p>\n

COUNTRY
\n\u2022 Medical Association of Thailand
\n\u2022 Regulation of Health Professions
\n\u2022 Protesting a System. Turkey
\nvol. 58
\nMedicalWorld
\nJournalJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 4, September 2012
\nCover picture from Japan
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nJapanese doctor examining patient. Created by
\nNeuville after Japanese painting by unknown
\nauthor, published on Le Tour Du Monde, Ed.
\nHachette, Paris, 1867
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 Cologne\/Germany
\nPhone (0 22 34) 70 11-0
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\nAdvertising rates available on request
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl. 7%
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website
\nwww.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA President
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP Brazil
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O.Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Wonchat SUBHACHATURAS
\nWMA Immediate Past-President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Cecil B. WILSON
\nWMA President-Elect
\nAmerican Medical Association
\n515 North State Street
\n60654 Chicago, Illinois
\nUnited States
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O. Box 1152 sentrum
\n0107 Oslo
\nNorway
\nDr.Frank Ulrich MONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\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
\n121
\nClinical, Legal and Political Issues in UK Clinical
\n& General Practice; Personal Observations
\nRetired does not mean tired again, it means experienced. I am re-
\ntired from the National Health Service but I do locum GP work
\nbecause I cannot do gardening at home. From the time one is born
\nuntil the time one dies, everyone has to fill time. I was lucky to
\nbe born as a positive thinker and to remain so. I believe that even
\nGod only helps those who help themselves. In addition to Locum
\nGP work, I wear many hats including being an Expert Witness in
\nCultural, Religious & Ethnic Issues in Litigation and also in GP
\nNegligence. Before saying anything, I check three things: Do I have
\nsomething new to say? (which I always have). Is there anyone will-
\ning to listen to me? How much should I say now and say later?
\nSome people listen to me like a Samaritan but, unlike them, take
\nno notice; others find it thought provoking. Criticism is a positive
\nactivity to learn in science and politics. I enjoy knowing that I am a
\nBritish citizen. Britain is a democracy.
\nI am aware that in a democracy everyone but everyone has a right
\nto be heard before being ignored. The chairman decides. He\/she
\nmay ask for a vote if the committee agrees, otherwise the item is
\ntaken on board. Only a leader is often elected but their appointees
\nare selected. For me, to live and let live is the best policy, as everyone
\nhas their own way.
\nI enjoy whatever I do, including Locum GP work. The perk in GP
\nwork is that nothing can happen without my signatures.I have to be
\nskilful, careful, tactful, alert and helpful, without taking any risk to
\nmyself. Locum work is a matter of supply and demand.The Princi-
\npals would try before they buy. It is a good business and there is no
\nreason to cry. I respect idealists, follow realists but listen carefully to
\nboth and take balanced steps.
\nA locum\u2019s job is as good as his\/her last performance. You can
\noften win but not always. One must remember that eventually
\nwe are all answerable about what we do. One of my GP trainers
\nused to say \u201cAs a GP, do right and fear no man; do not write and
\nfear no woman\u201d. In golden old days, GPs wrote in patient\u2019s notes,
\nsometime illegible even to themselves as there were no solicitors
\nor judges to read their notes. Now it is an era of computers, au-
\ndits and litigation. Everything changes in this world except this
\nprinciple.
\nMy suggestions to Clinical Consultants and General Practitioners,
\nin Britain, are:
\n1. Politics, economics and law have as much to do with \u201cPatient
\ncare\u201d as medicine.
\n2. Academics and Politicians, very rarely respect each other. GPs
\nneed them both.
\n3. Never say \u201cnever or always\u201d as anything can really happen in
\ngeneral practice.
\n4. A GP knows and is expected to know \u201csomething about every-
\nthing\u201d.
\n5. A Specialist knows and is expected to know \u201ceverything about
\nsomething\u201d.
\n6. A GP should deal what is possible and must refer to a Specialist
\nwhat is not.
\n7. Hospital doctors can only see patients referred by GPs. Let
\nthem see, if needed.
\n8. Patients\u2019 confidentiality laws must be followed in Britain. Write
\nnotes clearly.
\n9. Remember, these notes may be read by patients, lawyers, wit-
\nnesses and judges.
\n10. No one is immune from law. Idealists get trapped in breeches
\nmore than realists.
\n11. A GP is akin to a bus driver or a pilot, check everything and
\ndrive safely.
\nPlease beware;
\nA. Do not become totally subjective.There is no such thing as \u201cmy
\npatient\u201d.
\nB. You only need one patient to complain against you and your life
\nwould change.
\nPlease remember;
\nA. Do every thing objectively and professionally. Write notes wise-
\nly and medicolegally.
\nB. Listen to Patients and Academics but remain a Realist. Change
\nwith changing rules.
\nDr. Bashir Qureshi FRCGP, FRCPCH,
\nFFSRH-RCOG, AFOM-RCP
\nGP Locum & Expert Witness in Clinical GP Negligence.
\nAuthor of Transcultural Medicine.
\nExpert Witness in Cultural, Religious
\n& Ethnic Issues in Litigation
\nInstead of Editorial
\n122
\nTHAILANDRegional and NMA news
\nAs the host of the WMA GA 2012 and
\n192nd
\n& 193rd
\nCouncil Sessions in Bang-
\nkok, Thailand, October 10\u201313, 2012, the
\nMedical Association of Thailand would
\nlike to introduce itself for your back-
\nground information of the organization.
\nInception of the Organization
\nThe Medical Association of Thailand under
\nthe Royal Patronage symbolizes the collab-
\noration and cooperation of every physician
\nto intertwine their contribution into \u2018one-
\nness\u2019 in order to carry out the constructive
\nactivities that surveillance all physicians to
\npractice under the ethical code.
\nThe Medical Association of Thailand under
\nthe Royal Patronage has been functioning
\nto promote and develop issues concerning
\nmedical studies, researches, including pro-
\nmoting moral and medical ethics among
\nthe member physicians.Moreover,this body
\nhas also a close collaboration with public
\nsectors and medical organizations nation-
\nally and internationally. This is to scale up
\nmedical knowledge and practices of the
\nmembers to international standard at pres-
\nent and in the future.
\nThe Medical Association of Siam was first
\ninitiated on 25 October, 1921 by being reg-
\nistered as an association. The temporary
\noffice of the organization at that time was
\nlocated at the Administration Building of
\nChulalongkorn Hospital Bangkok, Thai-
\nland. There were 10 senior physicians in-
\nvolved in the setting up of the Association.
\nTheir names were as follows:
\n1. Naval Colonel M.\u00a0J.\u00a0Thavornmongkon-
\nwong Chaiyata: Senior Naval Medical
\nOfficer, who became a Naval General
\nlater on;
\n2. Colonel Phrayavibul-Ayuravej: Senior
\nArmy Medical Officer; his name before
\nroyal appointment was Sekh Thamsa-
\nroch;
\n3. Colonel PhraSakda Pholrak: Director
\nof Chulalongkorn Hospital; his name
\nbefore royal appointment was Chuen
\nPhutiphat, later on, becoming an Army
\nGeneral,he was Phraya Damrong
\nPhatta Phattayakhun by royal appoint-
\nment;
\n4. Ammart Tho Luang Ayurapatpises:
\nDirector of Siriraj Hospital; his name
\nbefore royal appointment was Sai Kho-
\njaseni;
\n5. Ammart Thri Luang Upphantraphath-
\npisan: his name before royal appoint-
\nment was Kamchon Bhalangkool, later
\nby royal appointment he was Phra Up-
\nphantraphathpisan;
\n6. Ammart Thri Luang Vaitayesarangkool:
\nhis name before royal appointment was
\nCheuch Israngkool Na Ayuthaya;
\n7. Dr.\u00a0M.E. Barns;
\n8. Ammart Ek Phraya Vechsithpilas:
\nDean of the Faculty of Medicine, Chul-
\nalongkorn University;
\n9. Colonel M.J. Wallapakorn Worawan;
\n10. Dr.\u00a0Leopold Roberte.
\nThe working committee of the Association
\nhad asked Field Marshall Prince Nakorn-
\nsawan Worapinis, Vice President and Di-
\nrector of the Siam Red Cross at that time,
\nfor the name of the Association which he
\nnamed \u201cMedical Association of Siam\u201d, and
\nlater on it was changed to \u201cMedical As-
\nsociation of Thailand\u201d (MAT). The change
\naffected only the spelling of the name to
\nmake it up-to-date.
\nIn 1930 Phrabath Somdej PhraPoramin-
\ntaramahaprachathipok Phrapokklaocha-
\noyuhoa, the 7th
\nKing, graciously accepted
\nthis society under his royal patronage. The
\nwords \u201cunder Royal Patronage\u201d have ever
\nsince been added to the name of the As-
\nsociation.
\nAt the beginning the Association had
\nits temporary office at Chulalongkorn
\nHospital. The first meeting of the As-
\nsociation was held on 9 January, 1922,
\nwith 64 members attending. Field Mar-
\nshall Prince Nakornsawan Worapinis,
\nVice President and Director of the Siam
\nRed Cross and Maha Ammarttho Prince
\nChainatnarenthorn, Director General of
\nthe Department of Public Health, also
\ngraciously participated at the meeting.
\nThe temporary office of the Association at
\nChulalongkorn Hospital was used until 4
\nAugust, 1932, when the office was moved
\nto Bamrung Muang Road, next to the
\nKasatseuk Bridge; the land belonged to
\nthe Red Cross.
\nIn 1923 the Association started using
\nits own emblem, developed by Prince
\nNarisaranuwattiwong. The emblem bears
\na picture of the naga or King of Snake
\nsnake and the trident, encompassed by the
\ninscription \u201cMedical Association of Siam\u201d
\nthat was changed later on to \u201cMedical
\nAssociation of Thailand\u201d. The trident is
\na weapon used by God Isuan or Shiva in
\nHinduism.
\nProfile of the Medical Association
\nof Thailand (MAT)
\nWonchat Subhachaturas
\n123
\nTHAILAND Regional and NMA news
\nOne of the important issues in the work
\nof the Association was the launch of the
\nmedical journal, which since then is being
\nused as a network to communicate with the
\ncurrent members, including dissemination
\nof knowledge and information as well as
\ncurrent medical research. At the beginning
\nof the establishment of the Association,
\nthere was no official journal produced by
\nthe society, however, the Association pur-
\nchased the Red Cross Bulletins, issued in
\nthe early period of the establishment of the
\nAssociation, to distribute to all its members.
\nOn 17August, 1925 there was a transfer
\nof administration of the journal from the
\nRed Cross to the Association, and the jour-
\nnal was renamed \u201cMedical Bulletin of the
\nMedical Association of Siam\u201d.
\nDuring 1926\u20131927 there were no concrete
\nactivities provided by the Medical Asso-
\nciation of Siam to sensitize the members.
\nThe existing journal did not gain much in-
\nterest from the members. Moreover, only
\na few copies of the journal were sent out
\nto the members (3 editions annually). The
\nscientific meeting was also rarely held.
\nAll members who lived in different areas
\nhardly met one another. Two leading per-
\nsons\u00a0 \u2013 Dr.\u00a0 Luang Chalermcampeeravej
\nand Dr.\u00a0Luang Chetthawaitayakarn\u00a0\u2013 tried
\nhard to take an initiative in developing the
\nMedical Union Club at Chulalongkorn
\nUniversity.
\nThe Club was legitimately registered on 15
\nMarch, 1927 with the temporary office at
\nSiriraj Hospital. The Medical Union Club
\nwas dealing with scientific matters, but
\nthere was no definite building to house the
\nactivities of the members. In the meantime
\nthe Department of Public Health, the Min-
\nistry of the Interior had built the Bangrak
\nhealth center for the purpose of treating the
\nvenereal diseases. It was a 2-storey build-
\ning adjacent to Silom Road. Within the
\ncompound of this hospital building there
\nwas a large wooden high-level house where
\nDr.\u00a0Hays had run his clinic and had already
\nclosed his business. The Department of
\nPublic Health allowed the Medical Union
\nClub to house there for the purpose of the
\nmember meetings.
\nThe objectives were as follows:
\n1. to foster athletics;
\n2. to be the place where the new and se-
\nnior students could mix; and
\n3. to enrich knowledge and to create con-
\ntacts between students and schools.
\nThe Medical Union Club organized the first
\nscientific meeting on 1 April, 1928. There-
\nafter, there was held a regular annual meet-
\ning.After each scientific meeting there were
\npublished papers a copy of which was dis-
\ntributed to the members every two months.
\nThe first scientific paper was issued in No-
\nvember, 1929, under the title \u201cReport of the
\nMeeting of the Medical Union Club\u201d.
\nThe other newsletter that was published by
\nthe Medical Union Club was named \u2018Physi-
\ncians\u2019 News\u201d which was issued in 1928 with
\nthe aim to educate general public about dis-
\neases and illnesses. It was sold for 25 stang
\nper copy and it was issued on a monthly ba-
\nsis. In 1942 this newsletter was closed due
\nto World War II.
\nThe aim of the Medical Association of Siam
\nfocused on scientific matters, whereas the
\npurpose of the Medical Union Club con-
\ncentrated on both scientific and social is-
\nsues.Thus, it seemed that the work of the
\nMedical Union Club was more interesting
\nthan that of the Medical Association of
\nSiam. It was because the membership grew
\nas graduates from medical schools enrolled
\nas new members in the Medical Union
\nClub. Only very few of the new graduates
\nregistered as new members of the Medical
\nAssociation of Siam. This seemed to make
\nthe latter more inferior. However, the im-
\nportant point that had never been revealed
\nwas that the current members of the Medi-
\ncal Association of Siam at that time had
\nalso registered as members of the Medical
\nUnion Club when this club came into ex-
\nistence.
\nThey had to pay membership fees to both
\nsocieties, which meant that those who were
\nmembers of the two societies had to pay the
\nmembership fees twice compared to those
\nwho were members of either society. More-
\nover, the economic situation in the country
\nat that time was weak. There was an idea
\nof combining the two societies together in
\norder to make a stronger body, and at the
\nsame time running only one organization
\nwould be more economial. However, this
\nidea failed. Until in 1933 Dr.\u00a0Phrayabori-
\nrakvechchakarn was elected President of
\nthe Medical Association of Siam as well as
\nPresident of the Medical Union Club. The
\nmerge of the two societies was approved by
\nthe members of the societies.
\nThe strategic solution to this combination
\nwas that those members who had already
\npaid their membership fees to the Medi-
\ncal Association of Siam were exempted
\nfrom the fees of the Medical Union Club.
\nThe combined activities included finances,
\nthe library, medical bulletins and the an-
\nnual meeting. The offices of both societies
\nwere asked to be in the same premises or
\nin a place nearby, if possible. Both societ-
\nies had a joint agenda for the first time on
\n2 February, 1933, which was announced as
\nthe annual meeting of the Medical Associa-
\ntion of Siam and Medical Union Club un-
\nder the name \u201cMedical Association of Siam
\nand Medical Union Club of Chulalongkorn
\nUniversity\u201d. At the beginning each society
\nhad a separate working committee.
\nIn 1936 the Medical Union Club moved
\nto the Bangrak Health Center, the same
\nplace where the office of the Medical As-
\nsociation of Siam was located, in Bamrung
\nMuang Road.The two working committees
\nwere united into one.The office in Bamrung
\nMuang Road was considered a convenient
\nplace in terms of public transport, as well
\nas being close to some offices of the De-
\npartment of Public Health located in Yodse
\nRoad. As a consequence, more members
\nfrequented the Association. The Associa-
\ntion had acquired two billiard tables and
\n124
\nRegional and NMA news
\nthree tennis courts. This had been consid-
\nered as \u2018very advanced\u2019 facilities provided
\nto the members. Besides physicians there
\nwere some visiting civil servants who were
\nnot registered as members, but they utilized
\nthe facilities at the society and considered it
\nto be a convenient meeting and recreation
\nplace.
\nThe Medical Association and the Medi-
\ncal Club continued working successfully
\nuntil Thailand entered World War II on 8
\nDecember 1941, when the Japanese troop
\noccupied several places in Bangkok. Apart
\nfrom the effects of the war, in 1982, there
\nwas a big flood, the biggest in the Thai his-
\ntory which lasted almost for one month.
\nMost of the roads in Bangkok were under
\ndeep water and resembled canals; in some
\nparts of Bangkok cars were not accessible.
\nDuring the war and after the flood the Club
\nwas on decline due to difficulties to access it,
\nbut soon after the war ended and gasoline
\nwas available the club started functioning
\nagain, but the space was so limited. During
\n1940\u20131942, Naval Rear Admiral Sa-nguan
\nRujirapa, the then President of the Asso-
\nciation, tried to find a new bigger place. He
\nwas a member of the revolution party,there-
\nfore, found it easier to communicate with
\nthe country governing people, nevertheless
\nit took a very long time.When Dr.\u00a0Chalerm
\nPrommas was elected President of the As-
\nsociation the project turned out successful
\nas the Royal Property Estate Office agreed
\nto let the \u201cBaan Saladaeng\u201d which used to
\nbe the residence of Chao Phaya Yommarat
\nand was situated opposite to Chulalongkorn
\nHospital at the intersection of Rama 4 road
\nand Rachadamri and Sirom roads or the lo-
\ncation of the Dusit Thani Hotel at present.
\nThe reason why the negotiations took so
\nlong was because a residence of high rank-
\ning officials and the Old European Students
\nAssociation were located in the area and,
\nbesides, we tried to get the possibly cheap-
\nest rent. More than that, when the members
\nlearned that we were moving to Saladaeng,
\nthere were some disagreement and com-
\nplaints that it was too far, however, it was
\nnot that far when we got acquainted with
\nthe location.
\n\u201cBaan Saladaeng\u201d
\nThe extensive renovation of the new site
\nneeded a lot of money, more than tens of
\nthousands of Baht. Those expenses were
\nshared with the Dentist Association and the
\nPharmacist Association.Therefore, after the
\nrenovation was completed the three Asso-
\nciations united and worked together at the
\nsame place.The Medical Association moved
\nto \u201cBaan Saladaeng\u201don 4 May, 1948 during
\nthe presidency of Dr.\u00a0Chalerm Prommas.
\nIn 1949, the Nurses Association asked to
\njoin in. Thus, Baan Saladaeng housed four
\nAssociations\u00a0\u2013 the Medical, the Dentist, the
\nPharmacist, and the Nurses and the abbre-
\nviation of the building was M.D.P.N. Of-
\nfice.
\n\u201cBaan Saladaeng\u201d consisted of a big build-
\ning and possessed an area of more than
\nTHAILAND
\n125
\nRegional and NMA news
\neight rais. The Association set a wooden
\nhouse near the big building as a club and a
\nsection of the Medical Association acquired
\ntwo billiard tables, several bridge tables and
\nthree tennis courts in the rear, a glass court
\nin the front and a residential house. It was
\nbigger and more comfortable than the pre-
\nvious one and more members could be ac-
\ncommodated even though it might seem far
\naway for someone.
\nThe four Associations worked together until
\n1966 when the Royal Estate Office notified
\nabout the termination of the rental permit
\nas it wanted the land to be developed as a
\nmodern commercial arcade and was willing
\nto pay 2.5 million Baht to the Association.
\nThe negotiations ended in the payment of
\n5 million Baht. Half of the sum was given
\nto the three Associations and the remaining
\n2.5 million Baht were spent to purchase a
\npiece of land (3 rais, 2 ngarns and 92 square
\nwahs) from the Kheha Pattana Estate
\nCompany at Soi Soonvijai, 300 metres away
\nfrom New Petchburi Road, and 45 square
\nwahs more for the entrance to the Associa-
\ntion. The construction of the new Associa-
\ntion building was started in May, 1967 with
\nthe budget of 1.3 million Baht.
\nNew Home at Soi Soonvijai,
\nNew Petchburi Road
\nThus, the Medical Association of Thailand
\nunder Royal Patronage acquired a new and
\npermanent Office. But before the processes
\nof land purchasing and the construction
\nfinished, it had to be temporarily moved to
\nthe Tuberculosis Eradication Association. It
\nmoved permanently to Soi Soonvijai on 13
\nJanuary, 1968.
\nThe Medical Association of Thailand un-
\nder the Royal Patronage and all the medi-
\ncal professions were greatly honoured when
\nHis Majesty the King and Her Majesty the
\nQueen graciously presided over the opening
\nceremony of the Association building on 1
\nFebruary, 1968
\nToday at the Royal Golden Jubilee
\n(Chalermprabarami Anniversary)
\nSince the number of the Royal Colleges and
\ntheir activities have been increasing together
\nwith the number of college students grow-
\ning there have been no permanent offices for
\nthose colleges due to being non-profit orga-
\nnizations and lacking the government sup-
\nport.The colleges have been providing train-
\ning for specialists under the supervision of
\nthe Medical Council for more than 20 years
\non voluntary basis as they are not included
\nin the government development plan. Most
\nof the functions, therefore, were absorbed by
\nthe institutes where the Chairs or the Secre-
\ntary General of the College associated.Then
\nthe plan of having fixed or permanent offices
\nfor each Royal College was initiated.
\nProfessor Dr.\u00a0 Arun PAUSAWASDI, the
\nthen Secretary General of the Royal Col-
\nlege of Surgeons, sent out invitations to all
\nthe Presidents and the Secretary Generals of
\nthe Royal Colleges to meet and discuss the
\nissue of permanent offices. Representatives
\nfrom 9 out of 11 Royal Colleges attended
\nthe meeting and decided on finding suitable
\nplaces for the permanent offices that might
\nbe at the Ministry of Health or at the Medi-
\ncal Association or to find their own places.
\nSeveral senior members had looked for the
\nsite for these permanent offices at the Srith-
\nanya hospital, the Department of Medical
\nServices, or even at the construction site
\nof the new Ministry of Public Health, but
\nnothing seemed acceptable. On 23 Decem-
\nber, 1993, at the meeting of the Medical
\nCouncil at the Ambassador Hotel Pattaya,
\nProfessor Dr.\u00a0 Arun Pausawasdi, President
\nof the Royal College of Surgeons, called a
\nspecial meeting to revise the project and at
\nthis important meeting Rear Admiral Air
\nMarshal Dr.\u00a0 Kitti Yensudchai, the then
\nPresident of the Medical Association, pro-
\nposed that the construction of the special-
\nist consortium should be at the site where
\nthe Medical Association was located. The
\nproposal was approved and a committee of
\neight members was appointed to continue
\nwith the project.
\nThe Consortium of the Medical Specialty
\nTraining Institute was afterwards estab-
\nlished to strengthen and consolidate the ac-
\ntivities of the colleges and invited his Royal
\nHighness, the Crown Prince of Thailand,
\nto be the Chair of the construction proj-
\nect to celebrate the Golden Jubilee of the
\nKing\u2019s Accession to the throne in 1996.
\nThe building was planned to accommo-
\ndate the Medical Association of Thailand,
\nthe Royal Colleges and Medical Societies.
\nAt the beginning the Ministry of Public
\nHealth had coordinated with the Govern-
\nment Bureau of Lottery and other charity
\nfoundations for the seed money to construct
\na 12-storey building with the working space
\nof 32,000 square metres to accommodate
\n11 Royal Colleges, 23 Medical Societies
\nand the Medical Council. The construction
\nwas budgeted at 440 million Baht and built
\non the land which belongs to the Medical
\nAssociation. The budget was administered
\nin the form of foundation that was later
\nnamed \u201cVajiravej-vitayalai Chalermprakiert
\nFoundation under the Royal Patronage of
\nHis Royal Highness Crown Prince Maha
\nVajiralongkorn\u201d.
\nThe building itself was graciously named by
\nthe King as the \u201cGolden Jubilee Building\u201d.
\nOn 18 March, 1997, His Royal Highness,
\nthe Crown Prince Maha Vajiralongkorn
\nwas assigned by the King to preside over
\nthe opening of the Golden Jubilee Building
\non his behalf.The event was of great honour
\nand brought much delight to all the medi-
\ncal professions of the Kingdom of Thailand.
\nThe Medical Association
\nof Thailand
\nAt Present 2012\u20132014
\nThe Executive Committee of The Medical
\nAssociation of Thailand under his Majesty
\nTHAILAND
\n126
\nRegional and NMA news
\nthe King\u2019s Patronage (according to the con-
\nstitution and bylaws) composed of 40 mem-
\nbers, they are
\n11 Elective members
\n– President
\n– President Elect
\n– Vice President
\n– Secretary General
\n– Treasurer
\n– House Master
\n– Publication
\n– Welfare
\n– Scientific
\n– Medical Education
\n– Ethics
\n29 Appointed members
\n– Chair of the Medical Council
\n– Presidents of the Royal Colleges of
\nSpecialty
\n52 Advisors
\n18 Representatives from national geo-
\ngraphical medical regions
\nAdministration
\nThe Meetings of the Executive Board and
\nAdvisors convene every Wednesday of the
\n4th
\nweek of the month.
\n15 subcommittees are appointed to work
\non various fields of interest
\n1. Funding subcommittee
\n2. Scientific meeting subcommittee
\n3. Land asset and Welfare Subcommittee
\n4. Membership Relations subcommittee
\n5. Medical Journal Editorial Board
\n6. Subcommittee for Health Professional
\nSecurity Support Acts
\n7. Subcommittee on
\n8. Subcommittee on fund Raising Golf
\nTournament
\n9. Subcommittee for WMA General As-
\nsembly 2012
\n10. Subcommittee for Social Medias Ac-
\ntivities
\n11. Subcommittee for
\n12. Subcommittee to follow the Medical
\nCompensation Acts
\n13. Subcommittee to provide help to flood
\nVictims (health Professionals)
\n14. Subcommittee for
\n15. Subcommittee for the \u201cRoyal Kathin
\nOfferings\u201d
\nWhat \u2018s Done:
\n1. Promotion and maintaining the stan-
\ndards of Professional Ethics
\n2. Promotion of the professional solidarity
\n3. Promotion of medical education, re-
\nsearch and medical services
\n4. Promotion of member welfare
\n5. Cooperation and collaboration with
\ngovernmental and private organizations
\nfor improving and maintaining medi-
\ncal services at the level of International
\nStandard
\n6. Advocating medical and health educa-
\ntion to public to improve the social de-
\nterminants of health
\n7. Collaboration with international orga-
\nnizations to leverage the global health
\ncare
\nWhat\u2019s Next
\n1. Expanding the network by appointing
\nrepresentatives from 18 National Medi-
\ncal Geographical Regions to the Execu-
\ntive Board
\n2. Support the professional Security Acts
\n3. Training of the risk management in
\nmedicine twice a year
\n4. Cooperate Social Responsibility (CSR)
\nPromotion of Medical Profession
\nand Medical Ethics
\n1. The Medical Association of Thailand
\n(MAT) has initiated the laws consul-
\ntation session within MAT to provide
\nconsultations to members 24 hours a day
\n2. Promotion of the member relationships
\nthrough
\n2.1. Publication of the monthly medi-
\ncal journal
\n2.2. Publication of the monthly medi-
\ncal association news letters
\n3. Professional Risk Management Project.
\nPromotion and support the Health Pro-
\nfessional Security Acts.
\n4. Medical Professions Guidelines Project.
\nAdvisory and guidelines lectures to the
\nnew graduates from 10\u201314 institutes
\nevery year under the support of Pfizer
\nFoundation since 2004
\n5. Member Visit Project. MAT pays visits
\nto members working in upcountry from
\ntime to time
\n6. Promotion of Professional Ethics Proj-
\nect. MAT gives lectures on medical eth-
\nics to both the public and private hospi-
\ntal staff and institutes
\nPromotion of Education,
\nTraining and Research
\nThe Journal of the Medical Association
\nof Thailand has a long history of publica-
\ntion and it is the only Medical Journal of
\nthe country which is included in the Index
\nMedicus. Today it has been developed and
\nimproved to meet the needs of the members
\nat monthly distribution.
\nThe Medical Association of Thailand with
\nthe collaboration of Takeda Science Foun-
\ndation has granted funds for its members
\nto continue their education in Japan. The
\nfunds are granted in 3 groups: 3 months for
\nthree, 6 months for two, and 1\u20132 years for
\none grant-holder. Up to now, the funds had
\nbeen granted to 155 recipients.
\nThree more separate funds have been grant-
\ned to members of the Medical Association
\nof Thailand, \u201cDr.\u00a0Prasert Prasartthong-oso-
\nth Fund\u201d Dr.\u00a0Prasert Prasartthong-osoth is
\na member of the association who graciously
\ndonated a sum of 1,000,000 (one million)
\nThai Baht to the association every year to
\nTHAILAND
\n127
\nRegional and NMA news
\npromote the research for the benefit of the
\nThai Medicine and to create innovations to
\nserve the health care of the national and in-
\nternational level. Up to now, 37 researchers
\nworking on 40 projects had been beneficia-
\nries.
\nThe Medical Association of Thailand itself
\nalso provides a grant for the research on de-
\nvelopment of the primary health care and
\ndevelopment of health care provision.
\nPromotion of the \u201cBest Performance\u201d
\nto Doctors Who Had Dedicated
\nThemselves to the Communities
\n\u201cSomdej Prawanarat\u201d Award goes to the
\ndoctor, selected by the committee, for dis-
\ntinguished performance.
\nThe Awards from the Medical Association
\ngo to the doctor for the best performance in
\nthe upcountry hospitals.
\nScientific Medical Meetings
\nTwo scientific meetings are routinely con-
\nvened, one in the periphery and one in
\nBangkok together with the administrative
\nmeetings.
\nInternational meetings on various subjects
\nhave also been called from time to time both
\nin the Medical Associations in the ASEAN
\ncountries (MASEAN) and the Confedera-
\ntion of the Medical Associations in Asia
\nand Oceania (CMAAO) communities.
\nOrganization Efficiency
\nDevelopment Plan
\nSince 2005, under MAT the Thai Health
\nProfessional Alliance against Tobacco Net-
\nwork has been established,composed of 21
\nprofessional organizations. The Network\u2019s
\nactivities are supported by the Bureau of
\nHealth Promotion. The efficiency of the
\nNetwork has been well accepted both in the
\ncountry and internationally.
\nThe Medical Professional Network for To-
\nbacco Control has also been established
\nconsisting of 32 executive members to en-
\nhance the research work in controlling to-
\nbacco consumption. More than 50 projects
\nhad been granted.
\nInternational Contacts
\nThe Medical Association of Thailand has
\nbeen working in collaboration with the
\ninternational medical and health organi-
\nzations both in the regions and globally.
\nRepresentatives from MAT hold several
\nadministrative posts in international medi-
\ncal organizations:
\nDr.\u00a0 Songkram Supcharoen: President of
\nCMAAO: 1987\u20131989,
\nDr.\u00a0 Kachit Choopanya: the President of
\nMASEAN and CMAAO: 1997\u20131999
\nProf. Somsri Pausawasdi: President of
\nCMAAO: 2007\u20132009
\nDr.\u00a0 Wonchat Subhachaturas: Secretary
\nGeneral of CMAAO: 1997\u20131999, Chair
\nof CMAAO Council: 2007\u20132011, Advisor
\nto CMAAO: 2011-Present, 61st
\nPresident
\nof the World Medical Association: 2010\u2013
\n2011
\nand many other roles at the conferences and
\nAssemblies.
\nService Efficiency Project
\nPublic Relation and Newsletters for mem-
\nbers
\nHealth Club Programme on television
\nchannel 9 is aired every Monday\u2013Friday at
\n09.00\u201309.30 am with a good rating.
\nImprovement of membership registration
\nAt present the membership has increased
\nup to 24,381 for the life members and
\n5,330 for the Junior members Development
\nof the modern website 20 new systems
\nhave been developed to meet the needs of
\nthe members. The address of the website of
\nthe Medical Association of Thailand had
\nbeen changed from www.medassocthai.org
\nto www.mat.or.th. The content is adjusted
\ntwice daily. This website includes the elec-
\ntronic form of the Journal of Medical Asso-
\nciation of Thailand that can be traced back
\nand is directly publishable in the PubMed
\neducational column, activities, announce-
\nments and etc. with more than 10,000 visi-
\ntors each month.
\nSocial Welfare to Members
\nFor 12 years the Medical Association of
\nThailand has been organizing annual trips
\nto observe the Primary Health care abroad,
\ne.g. in such countries as Laos, Cambodia,
\nMalaysia, China, Myanmar, Brunei Darus-
\nsalam, Japan, Nepal, Jordan, Kazakhstan,
\nFinland a.o.
\nAssociation Club
\nMAT offers 6 furnished accommodation
\nspaces on the 12th
\nfloor of the Association
\nbuilding for the members to stay.
\nThe progress and success of the Medi-
\ncal Association of Thailand are based on
\nthe fruitful and sustainable performance
\nof our predecessors who had dedicated
\nthemselves to development and facilita-
\ntion to all members during the past 90
\nyears for the dignity of our Medical Pro-
\nfession and all members, to be accepted
\nand respected by the local and interna-
\ntional communities. We will all follow
\nthe teaching of the King\u2019s Father, Prince
\nMahidol Adulyadej, the father of the
\nmodern Thai Medicine and the solidarity
\nof our Association.
\nDr.\u00a0Wonchat Subhachaturas
\nPresident of The Medical
\nAssociation of Thailand
\nTHAILAND
\n128
\nRegulation of Health Professions
\nRegulation of health professions serves nu-
\nmerous purposes and is associated with im-
\nproved quality of care. Globalization of
\nhealth care has prompted discussions of har-
\nmonization of systems of regulation within
\nvarious health professions. To inform global
\ndiscussion of this issue, the authors developed
\nan online survey on regulatory environ-
\nments.
\nThe survey consisted of queries about respon-
\ndents\u2019 location and profession, followed by
\nspecific questions related to regulation. We
\nsynthesized the survey responses to produce
\na final data set consisting of one answer per
\ncountry and per profession.
\nThe aggregated data includes 197 responses
\nfrom 78 countries representing 22 systems
\nof regulation for dentists, 38 for doctors of
\nmedicine, 45 systems for nurses, 37 for phar-
\nmacists, and 36 for physiotherapists. Varia-
\ntions include the type of regulatory bodies,
\ncomplexity of systems, the entities that set
\nrules, and scope of regulation. Collaboration
\nbetween governmental bodies and profes-
\nsional organizations becomes more prevalent
\nas the number of functions ensured through
\nthe system of regulation increases.
\nThere is significant international diversity
\nin the systems of regulation for health profes-
\nsionals. Our data describe more differences
\nthan similarities for systems of regulation
\nacross countries, and illustrate the challenges
\nof a global movement toward harmoniza-
\ntion.
\n\u201cIt has been said that arguing against glo-
\nbalization is like arguing against the laws of
\ngravity.\u201d Kofi Annan.
\nBackground
\nRegulation of health professions serves
\nnumerous purposes, including defining the
\nscope of competence, ensuring high stan-
\ndards for entry and practice, and promot-
\ning and maintaining professionalism and
\nethics. Regulation has also been associated
\nwith better quality of care and improved
\npatient outcomes in a variety of settings
\n[1\u20133].
\nGlobalization of health care has prompted
\ndiscussions of harmonization of standards
\nand systems of regulation within profes-
\nsions.To advance the discussion about these
\nissues, the World Health Professions Al-
\nliance (WHPA), which gathers the global
\nassociations of dentists (World Dental Fed-
\neration\u00a0\u2013 FDI), doctors of medicine (World
\nMedical Association \u2013 WMA), nurses
\n(International Council of Nurses \u2013 ICN),
\npharmacists (International Pharmaceuti-
\ncal Federation \u2013 FIP), and physiotherapists
\n(World Confederation for Physical Thera-
\npy\u00a0\u2013 WCPT), organized the Second World
\nHealth Professions Conference on Regula-
\ntion (WHPCR 2010) in Geneva on Febru-
\nary 18\u201319, 2010.
\nThe aim of WHPCR 2010 was to shape
\nthe future of health professional regulation
\nwithin the context of global health sys-
\ntems\u2019 redesign and evolving roles, keeping
\nin mind that public protection should be
\nLuc Jean Ren\u00e9 Besan\u00e7on
\nRegulation of Health Professions: Disparate Worldwide Approaches
\nare a Challenge to Harmonization
\nPaul Rockey Marta van Zanten
\n129
\nRegulation of Health Professions
\nthe primary objective of health professional
\nregulation. Specific objectives of WHPCR
\n2010 were to:
\n\u2022 Debate future control and direction of
\nhealth professionals\u2019 regulation within
\nthe context of changing scopes of prac-
\ntice
\n\u2022 Examine regulatory and professional is-
\nsues related to international migration of
\nhealth professionals
\n\u2022 Critically evaluate the relationship be-
\ntween health professional education, reg-
\nulation and standards of practice
\nThe WHPCR 2010 organizers envisioned
\nthat an overview on the current regula-
\ntion of these five professions would be a
\ngood starting point for debating the future
\nof regulation (as mentioned in Objective
\nOne). However, we noted that there is a
\ngeneral lack of knowledge about the sys-
\ntems of regulation in which health profes-
\nsions must operate. A few regional or global
\ncomparisons of systems of regulation for
\nspecific health professions have been con-
\nducted over the past decade in the fields
\nof medicine [4\u20136] and nursing [7], but
\nlittle published data were found describ-
\ning or comparing systems of regulation in
\nthe fields of dentistry, pharmacy or physio-
\ntherapy. In addition, no study was identified
\nthat had simultaneously collected such data
\nfrom multiple countries for these five health
\nprofessions. Therefore, to provide a global
\noverview of the regulation of healthcare
\nprofessionals, an online survey was devel-
\noped in conjunction with the conference to
\ncollect data on the regulatory environment
\nof health professions throughout the world.
\nThis study was exploratory; we had no prior
\nhypotheses regarding the outcomes of the
\ndata.
\nMethods
\nThe online survey consisted of queries
\nabout respondents\u2019 location and profes-
\nsion, followed by specific questions related
\nto regulation in five health care professions:
\ndentistry, medicine, nursing, pharmacy and
\nphysiotherapy.When respondents indicated
\nknowledge of regulation of one or more of
\nthe five professions for a particular country
\nthey were asked a series of detailed ques-
\ntions pertaining to the affiliation (e.g., gov-
\nernmental or professional) of the regulating
\nbody, the level of regulation (e.g., supra-na-
\ntional, national, sub-national), and the con-
\ntact information of the regulator.The survey
\nprompted consideration of at least eight
\npotential regulatory activities: 1) accredita-
\ntion of initial education, 2) registration (or
\nlicensure), 3) investigation, 4) discipline
\n(or sanction), 5) specialization, 6) re-cer-
\ntification, 7) accreditation of continuing
\neducation, and 8) practice guidelines. The
\nsurvey also queried whether a regulatory
\nactivity was predominantly the responsibil-
\nity of the profession (self-regulation), the
\ngovernment, or was shared. If respondents
\nmentioned more than one body involved
\nin regulation, descriptive questions were
\nrepeated for each additional organization.
\nWe also asked about the entity that sets the
\nrules used by the regulator, the scope and
\njurisdiction of the regulating body, and any
\nadditional activities of the regulator. Finally,
\nfree text fields were provided to describe
\nany unique circumstances in a respondent\u2019s
\ncountry or profession.
\nThe survey was available on the WHPCR
\nwebsite from October 15, 2009 to March
\n1, 2010, and all WHPCR 2010 registrants
\nwere prompted to complete the survey.
\nIn addition, the five WHPA organiza-
\ntions encouraged their members and other
\nknowledgeable individuals to complete the
\nsurvey.
\nWe synthesized responses to form a data
\nset consisting of one answer per country
\nand per profession according to the follow-
\ning schema: If more than one individual
\nfrom a particular country and profession
\ncompleted the survey, for each question
\nwe retained only the answer that was pro-
\nvided by the majority of respondents. If
\nrespondents provided an equal number of
\ndisparate answers, we retained the answer
\ngiven by the respondent employed by the
\norganization with the broadest jurisdic-
\ntion. Therefore the final aggregated data
\nset consisted of just one set of answers to
\nthe survey questions per country and per
\nprofession.
\nRole of the Funding Source
\nNo outside funding was used in this study.
\nResults
\nAltogether, there were 292 unique survey
\nrespondents from 78 countries providing
\nsufficient data for analysis. The final data
\nset consisted of 197 aggregated responses.
\nWhen a specific country has at least one
\nregulator in place for one profession, we
\nindentified this as a \u201csystem of regulation\u201d.
\nExisting systems of regulation were report-
\ned by 178 (91%) of the aggregated respon-
\ndents,and nine (5%) indicated that a system
\nof regulation was about to be implemented.
\nNo regulation was reported by seven (3%)
\nof the aggregated respondents, and three
\n(1%) did not know.The aggregated data in-
\ncluded reports on 22 systems of regulation
\nfor dentists, 38 for doctors of medicine, 45
\nfor nurses, 37 for pharmacists, and 36 for
\nphysiotherapists.
\nIncome Level
\nCountries or states represented in the
\nsurvey1
\nwere classified by income level ac-
\ncording to the World Bank Atlas Method
\n(as described on World Bank website:
\nhttp:\/\/go.worldbank.org\/QEIMY0ALJ0).
\nThe countries were divided according
\nto the 2008 GNI per capita as follows:
\n<$975 (low income); $976 \u2013 $3,855 (lower\n1 GDP data was not available for Bermuda, Koso-\nvo and (China-) Taiwan. These countries and\nstates were excluded from income-level analyses.\n130\nmiddle income); $3,856 \u2013 $11,905 (upper\nmiddle income); >$11,906 (high income).
\nFigure\u00a0 1 displays the regulation systems
\nby profession and income level per capita.
\nThe distribution of systems of regulation
\nby country income level was similar among
\nall five professions, and the majority of the
\nsystems of regulation included in this study
\nare located in high and upper-middle in-
\ncome countries. The presence of a system
\nof regulation (all professions combined)
\nis similar by income level of the country.
\nFor low income, lower middle income, and
\nupper middle income countries, the aggre-
\ngated responses indicating that a system of
\nregulation exists ranged from 83% to 86%.
\nAll of the aggregated responses represent-
\ning high income countries indicated the
\nexistence of a system of regulation.
\nCharacteristics of Systems of
\nRegulation
\nModels for systems of professional regu-
\nlation vary around the world. Regulatory
\nschemes can be developed and administered
\nby governmental bodies, such as Ministries
\nof Health or other governmental agencies,
\nprofessional organizations (whose gover-
\nnance is mainly ensured by elected members
\nof the profession), or a combination of enti-
\nties. For the five professions combined, 52%
\n(n= 95) of the systems of regulation are gov-
\nernment-based, 25% (n= 45) are conducted
\nby non-governmental professional bodies,
\n20% (n= 37) by a combination of govern-
\nment and professional bodies, and 2% (n=4)
\nunclassified. The types of regulatory bodies
\npresent for the five professions are displayed
\nseparately in Table 1.Across the professions,
\nthere is little variation of the type (govern-
\nment, professional body, combination) of
\nthe regulatory bodies. Government-related
\nregulators ranged from 47% of systems for
\nnurses to 59% for dentists and physiothera-
\npists. The frequency of professional bodies
\nadministering the regulation system ranged
\nfrom 14% for physiotherapists to 33% for
\nnurses.
\n18% 20%
\n28%
\n18% 18% 20%
\n18% 15%
\n14%
\n18%
\n11%
\n15%
\n14% 17%
\n20%
\n21%
\n16%
\n18%
\n50% 44%
\n37% 44%
\n48%
\n45%
\n0%
\n10%
\n20%
\n30%
\n40%
\n50%
\n60%
\n70%
\n80%
\n90%
\n100%
\nDentists
\nDoctors
\nof medicine
\nNurses Pharmacists
\nPhysio-
\ntherapists
\nTotal
\nNo classi cation
\nHigh income (OECD and
\nnon OECD)
\nUpper middle income
\nLower middle income
\nLow income
\nFigure 1. Aggregated respondents by profession and country income level
\nTable 1. Government vs. professional self regulation within each system of regulation across the
\nfive professions
\nDentists
\nDoctors of
\nMedicine
\nNurses
\nPharma-
\ncists
\nPhysio-
\ntherapists
\nTotal
\nGovernment-related
\nregulators
\n59%
\n(n=13)
\n51%
\n(n=20)
\n47%
\n(n=21)
\n50%
\n(n=19)
\n59%
\n(n=22)
\n52%
\n(n=95)
\nA combination
\n9%
\n(n=2)
\n21%
\n(n=8)
\n20%
\n(n=9)
\n29%
\n(n=11)
\n19%
\n(n=7)
\n20%
\n(n=37)
\n(A) professional
\nbody(ies)
\n27%
\n(n=6)
\n28%
\n(n=11)
\n33%
\n(n=15)
\n21%
\n(n=8)
\n14%
\n(n=5)
\n25%
\n(n=45)
\nUnknown
\n5%
\n(n=1)
\n0%
\n(n=0)
\n0%
\n(n=0)
\n0%
\n(n=0)
\n8%
\n(n=3)
\n2%
\n(n=4)
\nNumber of systems 22 39 45 38 37 181
\nTable 2. Government vs. professional self regulation by WHO-based geographic region
\nAFRO EMRO EURO PAHO SEAR WPO Total
\nGovernment- regulators
\n52%
\n(n=15)
\n80%
\n(n=12)
\n56%
\n(n=38)
\n24%
\n(n=6)
\n40%
\n(n=4)
\n59%
\n(n=17)
\n52%
\n(n=95)
\nA combination
\n10%
\n(n=3)
\n0%
\n(n=0)
\n20%
\n(n=13)
\n28%
\n(n=7)
\n10%
\n(n=1)
\n38%
\n(n=12)
\n20%
\n(n=37)
\n(A) professional body(ies)
\n34%
\n(n=10)
\n20%
\n(n=3)
\n20%
\n(n=14)
\n48%
\n(n=11)
\n50%
\n(n=5)
\n3%
\n(n=1)
\n25%
\n(n=45)
\nUnknown
\n3%
\n(n=1)
\n0%
\n(n=0)
\n4%
\n(n=3)
\n0%
\n(n=0)
\n0%
\n(n=0)
\n0%
\n(n=0)
\n2%
\n(n=4)
\nNumber of systems 29 15 68 24 10 30 181
\nAfrican region (AFRO); Eastern Mediterranean region (EMRO); European region (EURO);
\nRegion of the Americas (PAHO); South-East Asia region (SEAR); Western Pacific region (WPO)
\nRegulation of Health Professions
\n131
\nOur preliminary analysis of systems of
\nregulation showed much greater differences
\namong countries than among the five pro-
\nfessions within a country. In fact, we ob-
\nserved strong similarities and concordance
\nof system of regulation for any of the five
\nprofessions within an individual country.
\nTherefore, we made several analyses using
\ncountries as the unit of analysis.
\nTo see if there were major regional dif-
\nferences (based on geography and cul-
\nture) among the administration of systems
\nof regulation, we grouped the countries
\nbased on the World Health Organization
\n(WHO) geographic regions. Table 2 dem-
\nonstrates that there is significant variation
\nworldwide in the control of systems of reg-
\nulation based on these geographic regions.
\nGovernment administration of systems of
\nregulation ranges from 25% in the Americas
\nto 80% in the Eastern Mediterranean, and
\nprofessional organization-affiliation ranges
\nfrom 3% in the Western Pacific to 50% in
\nthe South East Asian region.
\nIn contrast, country income level appears
\nto have only a moderate relationship with
\nthe affiliation of the regulatory bodies
\n(Table\u00a03). Governmental regulation ranged
\nfrom 37% in upper middle income coun-
\ntries to 52% in lower middle income coun-
\ntries. Professional administration of regu-
\nlation ranged from 15% in lower middle
\nincome countries to 37% in upper middle
\nincome countries.
\nComplexity of Systems of Regulation
\nWorldwide, there is wide variability in how
\nindividual countries organize health care
\nprofessions regulation systems, and differ-
\nences in the overall complexity of particu-
\nlar systems. In some countries, there is one
\ncentralized system that controls and man-
\nages a specific profession (or more than one
\nprofession); in other countries, numerous
\nregulators have authority within one sys-
\ntem.To investigate the relationship between
\norganization of a country\u2019s government and
\nthe complexity of systems of regulation,
\nwe compared the number of regulators,
\nthe number of regulation systems, and the
\nnumber of regulators per system for federal
\nversus non-federal countries. We defined
\na federal country as a sovereign country
\ncharacterized by a union of partially self-
\ngoverning political entities (regions, states,
\nprovinces) united by a central (federal)
\ngovernment. Countries that are considered
\nfederal are indicated with an (*) in the Ap-
\npendix.
\nAcross all five professions and countries,
\nthere is an average of 3.92 regulators per
\nregulation system.In federal countries com-
\nbined, there is an average of 10.83 regula-
\ntors per regulation system, compared to an
\naverage of 1.13 regulators per system in all
\nnon-federal countries.
\nIn addition to the relationship between the
\nnumber of regulators and the type of po-
\nlitical organization of a country, we also
\ninvestigated the influence of country in-
\ncome level on the complexity of systems of
\nregulation. The numbers of regulators were
\ncompared against World Bank country in-
\ncome level (Table 4), demonstrating that
\ncomplexity increases appreciably in coun-
\ntries with higher income levels.
\nTo further investigate the impact of a
\ncountry\u2019s governmental structure on regu-
\nlation of health professionals, the survey
\nincluded a question regarding the level of
\nregulation (e.g., supranational, national,
\nTable 3. Government vs. professional self regulation across all professions by country income level
\nRegulator
\nLow
\nincome
\nLower
\nmiddle
\nincome
\nUpper
\nmiddle
\nincome
\nHigh income
\n(OECD and
\nnon OECD)
\nNo
\nclassifi-
\ncation
\nTotal
\nGovernment-
\nrelated regulators
\n50%
\n(n=17)
\n62%
\n(n=16)
\n37%
\n(n=11)
\n56%
\n(n=48)
\n60%
\n(n=3)
\n52%
\n(n=95)
\nA combination
\n15%
\n(n=5)
\n23%
\n(n=6)
\n17%
\n(n=5)
\n23%
\n(n=20)
\n20%
\n(n=1)
\n20%
\n(n=37)
\n(A) professional
\nbody(ies)
\n35%
\n(n=12)
\n15%
\n(n=4)
\n37%
\n(n=11)
\n20%
\n(n=17)
\n20%
\n(n=1)
\n25%
\n(n=45)
\nUnknown
\n0%
\n(n=0)
\n0%
\n(n=0)
\n10%
\n(n=3)
\n1%
\n(n=1)
\n0%
\n(n=0)
\n2%
\n(n=4)
\nNumber of
\nsystems
\n34 26 30 86 5 181
\nTable 4. Numbers of regulatory bodies across all professions by country income level
\nNumber of
\nregulatory
\nbodies
\nNumber of
\nsystems of
\nregulation
\nNumber of regulatory
\nbodies per system of
\nregulation
\nLow income 110 34 3.24
\nLower middle income 94 26 3.62
\nUpper middle income 19 30 0.63
\nHigh income (OECD
\nand non OECD)
\n482 86 5.60
\nNo classification 4 5 0.80
\nTotal 709 181 3.92
\nRegulation of Health Professions
\n132
\nor sub-national levels). We compared the
\nlevels of the systems of regulation between
\nfederal and non-federal countries (Figure
\n2). Non-federal countries were more likely
\nto have systems of regulation conducted
\nat the national level compared to federal
\ncountries. In contrast, a large segment of
\nsystems of regulation in federal countries
\nare conducted at the state or provincial
\nlevel, or a combination of sub-national and
\nnational levels.
\nWho Sets the Rules?
\nThe survey also included a question on the
\nentities that determine the rules that are
\nsubsequently implemented and enforced
\nby the regulatory bodies. Results of the
\nsurvey demonstrate that even in settings
\nwhere systems of regulation are ensured by
\nprofessional bodies, the entities that set the
\nrules are frequently governmental, such as
\nthe Ministries of Health, other government
\nagencies, or the Parliament. In fact, in 41%
\nof these systems the rules or laws are actu-
\nally solely determined by governmental leg-
\nislation or Ministry decrees. Only 35% of
\nprofessional body-affiliated regulators set
\ntheir own rules, and 24% use a combination
\nof self-determined and governmental rules.
\nScope of Regulation and Hierarchy
\nof Regulatory Activities
\nThe final section of the survey included
\nseveral questions related to the various
\nactivities conducted by regulatory bodies.
\nParticipants were then given a list of po-
\ntential functions and requested to indicate
\nwhich of these activities were conducted by
\nthe regulatory body. Across all five profes-
\nsions , 96% of the aggregated respondents
\nindicated that regulators were involved
\nwith the activity of registration, 81% in-
\ndicated discipline, 72% investigation, 70%
\nrecertification, 61% practice guidelines,
\n53% specialization, 45% accreditation of
\ninitial education, and 43% accreditation of
\ncontinuing education.
\nFigure 3 displays the specific functions car-
\nried out by systems or regulation according
\nto the number of functions engaged by each
\nsystem. This figure shows a hierarchy of
\nfunctions, indicating that across systems of
\nregulation for all professions, there is a clear
\npattern of the specific functions engaged in
\nby regulators based on the number of func-
\ntions in their scope. For example, almost
\nall regulatory bodies, even those that only
\nengage in one or two functions, handle reg-
\nistration. As systems of regulation broaden
\ntheir scope and undertake additional func-
\ntions, these responsibilities are generally
\nincreased in a hierarchical manner (e.g.,
\ndiscipline is the next most common func-
\nNational
\nlevel
\n85%
\nBoth at
\nnational
\nand
\nsubnatio
\nnal level
\n6%
\nSub-
\nnational
\n2%
\nSupranati
\nonal
\n2%
\nI don’t
\nknow
\n5%
\nNon Federal countries
\nNational
\nlevel
\n40%
\nBoth at
\nnational
\nand
\nsubnatio
\nnal level
\n35%
\nSub-
\nnational
\n23%
\nI don’t
\nknow
\n2%
\nFederal countries
\nFigure 2. Level of systems of regulation by Non-Federal versus Federal countries
\n0%
\n10%
\n20%
\n30%
\n40%
\n50%
\n60%
\n70%
\n80%
\n90%
\n100%
\n1\u20132 7\u201385\u201363\u20134
\nFigure 3. Specific function by number of functions engaged by regulatory bodies
\nRegulation of Health Professions
\n133
\ntion, followed by investigation and recerti-
\nfication). Only those regulatory bodies that
\nengage in seven or eight functions are likely
\nto do accreditation of continuing education
\nand regulation of practice guidelines.
\nFigure 4 demonstrates that as systems of
\nregulation engage in an increasing number
\nof functions, the system is more likely to
\ninvolve professional organizations. Specifi-
\ncally, if the system of regulation is perform-
\ning only one or two functions, professional
\norganizations are involved in the process in
\nonly 4% of countries and share responsibil-
\nity in another 17%. However, if a system in-
\ncludes seven or eight functions, professional
\nbodies are primarily responsible for 36% of
\nthe systems of regulation and share respon-
\nsibility in another 22%.
\nBased on the survey results, the specific
\nfunctions carried out by systems of regula-
\ntion vary depending on the type of regula-
\ntors. For example, certain functions, such
\nas discipline, investigation, recertification,
\npractice guidelines, and specialization, ap-
\npear to be more frequently conducted if
\nthe regulatory body includes a professional
\norganization. Table 5 displays the functions
\ncarried out by various systems of regulation
\nstratified by the type of regulator.
\nDiscussion
\nGlobalization is increasing in all areas of
\nhuman endeavor, including health care.
\nWith international migration, advances
\nin technology, instantaneous communica-
\ntion and improved transportation these
\ntrends will accelerate. Within the context
\nof movements towards harmonization of
\nhealth professions regulation, our survey
\nresults support several conclusions regard-
\ning regulation worldwide. Systems of regu-
\nlation are highly variable across countries
\nwhile being generally similar among the
\nfive professions within a given country, and
\nthe number and type of regulators in sys-
\ntems of regulation are a reflection of type
\nof government, wealth of nation, and region
\nof the world. Systems of regulation appear
\nto have a hierarchy of functions, with ba-
\nsic systems almost always including regis-
\ntration (licensure) and discipline, and only
\nmore complex systems including roles such
\nas accreditation of initial or continuing pro-
\nfessional education and regulation of prac-
\ntice guidelines. Also, as systems of regula-
\ntion become more complex (e.g., administer
\nseven, eight or more functions) the level of
\ncollaboration between governmental and
\nprofessional regulators increases. Also, even
\nin systems described as self-regulated by the
\nprofession, governmental organizations fre-
\nquently determine the rules that are in turn
\nimplemented by the professional body.
\nSeveral challenges to potential harmoniza-
\ntion efforts are evident based on our results.
\nFor example, although elements of regula-
\ntion may be transportable from one nation
\nto another (e.g., tests used for initial licen-
\nsure or examinations used to certify knowl-
\nedge within a professional specialty), regu-
\nlators should consider how such elements
\n43% 41%
\n33%
\n17%
\n30%
\n26%
\n16%
\n25%
\n17%
\n19%
\n29%
\n22%
\n4%
\n11%
\n22%
\n36%
\n4% 4%
\n0%
\n10%
\n20%
\n30%
\n40%
\n50%
\n60%
\n70%
\n80%
\n90%
\n100%
\n1\u20132 Functions 3\u20134 Functions 5\u20136 Functions 7\u20138 Functions
\nUnknown
\nProfessional body
\nCombination
\nGovernmental
\nagency
\nMinistry of Health
\nFigure 4. The regulators involved in a system of regulation by the number of regulatory functions
\nTable 5. The regulators involved in a system of regulation by the number of regulatory functions
\nGovernment based Combination Professional body
\nFunctions % % %
\nRegistration 96% 97% 97%
\nDiscipline 80% 78% 95%
\nInvestigation 66% 81% 84%
\nRecertification 68% 72% 84%
\nPractice Guidelines 49% 69% 86%
\nSpecialization 46% 61% 68%
\nAccreditation Initial
\nEducation
\n41% 56% 49%
\nAccreditation Continuing
\nEducation
\n41% 36% 54%
\nRegulation of Health Professions
\n134
\nwill be introduced and integrated with the
\nexisting system of regulation. Standardized
\n\u201crecognition of qualifications\u201d may make it
\neasier to achieve harmonization for basic
\nfunctions such as licensure\/registration.
\nDifferences among countries between
\nscopes of practice may also complicate com-
\npetence measures within professions. Varia-
\ntions in levels of access to technology and
\nexpensive therapies will affect measures of
\nprofessional competence, the creation and
\nimplementation of clinical guidelines and
\nthe content of specialty examinations. For
\nexample, treatment of chronic diseases such
\nas those related to obesity (diabetes, hyper-
\ntension, hyperlipidemia) prevail in affluent
\ncountries whereas developing countries face
\nmore often widespread infectious and para-
\nsitic diseases.
\nHarmonization of regulation has often fo-
\ncused on the cross-border recognition of
\nprofessional qualification (diplomas, spe-
\ncialties, etc.,) both in Europe and North-
\nern America, with some systems imple-
\nmented to ensure such recognition [7, 8].
\nHowever, to date little attention has been
\ngiven to studying the competent authori-
\nties (regulators) and their diversity (e.g., in
\nnumbers, in tasks, in governance) and the
\nincreased importance of investigating the
\npractical feasibility of expanding systems
\nof recognition in regions with different
\nmodels of regulation. For instance, in the
\n27 member states of the European Union
\nand for medical doctors, pharmacists, nurs-
\nes, midwives and dentists, it is estimated
\nthat there are at least 900 regulators, while
\nat the same time, there is no common Eu-
\nropean definition of a regulator nor an of-
\nficial register of these regulators [9]. Such
\ndiversity, complexity, and potential redun-
\ndancy in tasks will likely lead to difficulties
\nwhen authorities need to work together to
\nensure validation of the data provided by
\nhealthcare professionals.
\nIn addition, variability in the implementa-
\ntion of disciplinary sanctions can complicate
\nAppendix
\nCountry Number
\nAnswers
\nfor Den-
\ntists
\nAnswers for
\nDoctors of
\nMedicine
\nAnswers
\nfor
\nNurses
\nAnswers
\nfor Phar-
\nmacists
\nAnswers for
\nPhysio-
\ntherapists
\nLow income 40 4 8 14 7 8
\nAfghanistan 2 \u00d7 \u00d7
\nBangladesh 3 \u00d7 \u00d7 \u00d7
\nBurundi 1 \u00d7
\nEthiopia* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nGhana 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nMalawi 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nMali 1 \u00d7
\nNepal 3 \u00d7 \u00d7 \u00d7
\nNigeria* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nPakistan* 1 \u00d7
\nRwanda 4 \u00d7 \u00d7 \u00d7 \u00d7
\nSenegal 1 \u00d7
\nTanzania 2 \u00d7 \u00d7
\nViet Nam 2 \u00d7 \u00d7
\nZimbabwe 1 \u00d7
\nLower middle income 29 4 6 7 7 5
\nAlbania 1 \u00d7
\nChina 1 \u00d7
\nEl Salvador 1 \u00d7
\nGeorgia 1 \u00d7
\nIndia* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nIraq* 1 \u00d7
\nJordan 1 \u00d7
\nMacedonia 2 \u00d7 \u00d7
\nMarshall Islands 1 \u00d7
\nMongolia 1 \u00d7
\nPhilippines 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nSamoa 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nSudan* 1 \u00d7
\nSwaziland 1 \u00d7
\nSyria 2 \u00d7 \u00d7
\nUpper middle income 35 3 7 10 8 7
\nArgentina* 2 \u00d7 \u00d7
\nBelarus 1 \u00d7
\nBotswana 2 \u00d7 \u00d7
\nBrazil* 2 \u00d7 \u00d7
\nCosta Rica 1 \u00d7
\nCroatia 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nFiji 3 \u00d7 \u00d7 \u00d7
\nJamaica 1 \u00d7
\nLibyan Arab Jamahiriya 1 \u00d7
\nMexico* 2 \u00d7 \u00d7
\nRussian Federation* 1 \u00d7
\nSerbia 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nRegulation of Health Professions
\n135
\nefforts towards harmonization, as the capa-
\nbility of a regulator to transmit information
\nto a foreign authority is limited by regula-
\ntor protocols and the national law on pri-
\nvacy. While some countries would expect
\nto receive the complete disciplinary file
\nof a migrating healthcare professional, in
\nmany countries only current sanctions can
\nbe transmitted. The inclusion as part of the
\nhealth professionals\u2019official record past sanc-
\ntions that have been completed varies across
\nregulators. Similarly, regulators are limited in
\ntheir capability to share cases under current
\ninvestigation and\/or appeal.
\nWhile we strived to collect valid informa-
\ntion on the regulation of health care profes-
\nsions from a worldwide representative sam-
\nple across five professions, there are several
\nlimitations to these survey data. We did not
\nverify the accuracy of the answers provided
\nby survey respondents. This was mitigated
\nsomewhat by our method of data synthesis
\n(e.g., retaining only the answers provided
\nby the majority of multiple respondents),
\nbut we did not independently validate the
\ndata or adjudicate discrepancies. The survey
\ninstructions did not provide definitions of
\nvarious terms, and therefore the same term
\ncould have different meanings across coun-
\ntries. For example, in Northern Europe and
\nthe United States, \u201cregistration\u201d of pharma-
\ncists documents fulfillment of educational
\nand competence requirements and a phar-
\nmacist\u2019s capability to practice pharmacy
\nlegally. In contrast, in Southern Europe,
\npharmacists can only \u201cregister\u201d if, in addi-
\ntion to the educational and competence re-
\nquirements, they actually practice pharmacy
\nin an authorized pharmaceutical outlet; if
\nthey stop practice they are removed from
\nthe registry and cannot be re-registered un-
\ntil they resume a professional activity.
\nWe received survey responses from 78
\ncountries and do not know if these results
\nare representative of all countries. It is pos-
\nsible that countries with more effective sys-
\ntems of regulation are over-represented.The
\nsurvey was provided only in English, per-
\nCountry Number
\nAnswers
\nfor Den-
\ntists
\nAnswers for
\nDoctors of
\nMedicine
\nAnswers
\nfor
\nNurses
\nAnswers
\nfor Phar-
\nmacists
\nAnswers for
\nPhysio-
\ntherapists
\nSouth Africa 2 \u00d7 \u00d7
\nTurkey 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nUruguay 2 \u00d7 \u00d7
\nHigh income: non
\nOECD
\n23 3 5 6 3 6
\nBahamas 3 \u00d7 \u00d7 \u00d7
\nBahrain 4 \u00d7 \u00d7 \u00d7 \u00d7
\nCyprus 1 \u00d7
\nIsrael 4 \u00d7 \u00d7 \u00d7 \u00d7
\nKuwait 1 \u00d7
\nMalta 1 \u00d7
\nQatar 1 \u00d7
\nSaudi Arabia 1 \u00d7
\nSingapore 4 \u00d7 \u00d7 \u00d7 \u00d7
\nSlovenia 1 \u00d7
\nTrinidad and Tobago 2 \u00d7 \u00d7
\nHigh income: OECD 65 8 13 13 14 15
\nAustralia* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nBelgium* 1 \u00d7
\nCanada* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nDenmark 4 \u00d7 \u00d7 \u00d7 \u00d7
\nFinland 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nFrance 2 \u00d7 \u00d7
\nGermany* 1 \u00d7
\nIreland 2 \u00d7 \u00d7
\nItaly 3 \u00d7 \u00d7 \u00d7
\nJapan 1 \u00d7
\nNetherlands 4 \u00d7 \u00d7 \u00d7 \u00d7
\nNew Zealand 4 \u00d7 \u00d7 \u00d7 \u00d7
\nNorway 3 \u00d7 \u00d7 \u00d7
\nPortugal 4 \u00d7 \u00d7 \u00d7 \u00d7
\nSpain 1 \u00d7
\nSweden 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nSwitzerland* 3 \u00d7 \u00d7 \u00d7
\nUK* 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nUSA*\u2020 5 \u00d7 \u00d7 \u00d7 \u00d7 \u00d7
\nNo Classification from
\nWorld Bank
\n5 0 2 1 0 3
\nBermuda 1 \u00d7
\n(China-)Taiwan 2 \u00d7 \u00d7
\nKosovo 3 \u00d7 \u00d7 \u00d7
\nGrand Total 197 22 41 51 39 44
\n* Federal country
\n\u2020 The term \u2018Doctors of Medicine\u2019 for the United States applies to both allopathic and os-
\nteopathic physicians, who have equal practice rights.
\nRegulation of Health Professions
\n136
\nhaps deterring responses from non-English
\nspeaking countries. In addition, based on
\nseveral instances of incongruity within the
\nsurvey results, it appears that respondents
\nin several countries and professions do not
\nalways have a clear understanding of the
\ncomposition, affiliations, and roles of the
\nregulatory bodies governing their profes-
\nsion.
\nOur point of analysis was at the country
\nlevel, but systems of regulation can vary
\nsubstantially within countries and across
\nvarious states\/provinces. Collapsing data at
\nthe country level may have obscured some
\ndifferences. Finally, we only reported on the
\nexistence of systems of regulation and vari-
\nous functions thought to be implemented
\nby the regulators. The scope of the survey
\ndid not include gathering information on
\nthe actual execution, efficiency, or success
\nof the various activities associated with the
\nregulatory bodies.
\nOver time, each of these five health profes-
\nsions has delegated multiple tasks to assis-
\ntants with lesser training. Such allied health
\nworkers are developing systems of regula-
\ntion as well. This study provides no infor-
\nmation about the regulation of such allied
\nhealth workers or their systems of regula-
\ntion, a needed area of further research.
\nConclusions
\nOur data describes the significant differenc-
\nes among countries in the systems of regula-
\ntion for health professionals. Although glo-
\nbalization is rapidly advancing in all spheres
\nof human endeavor, the regulatory systems
\ncontrolling the health professions are very
\ndisparate and may not be amenable to rapid
\nharmonization. These efforts should take
\ninto account the diversity of current system
\nof regulations to evaluate the feasibility of
\nharmonization, as similar concepts may
\nbe understood differently throughout the
\nworld and regulation systems vary in orga-
\nnization and roles.
\nCompeting Interests
\nThe authors declare that they have no com-
\npeting interests.
\nAuthor Contributions
\nLB led in the development of the question-
\nnaire, ensured the collection of data (via an
\nonline tool),collaborated in the analysis and
\ninterpretation of data, and assisted in draft-
\ning and reviewing the manuscript. PR col-
\nlaborated in the design of the initial survey,
\nanalysis and synthesis of the data,and draft-
\ning and reviewing the manuscript. MvZ as-
\nsisted in data synthesis and drafting and
\nreviewing the manuscript.
\nReferences
\n1. Holmboe ES, Wang Y, Meehan TP, Tate JP,
\nHo SY, Starkey KS et al.: Association between
\nmaintenance of certification examination scores
\nand quality of care for medicare beneficiaries.
\nArch Intern Med 2008; 168(13):1396-1403.
\n2. Pringle M.: Regulation and revalidation of doc-
\ntors. BMJ 2006; 333(7560):161-162.
\n3. Flook DM.: The professional nurse and regula-
\ntion. J Perianesth Nurs 2003; 18(3):160-167.
\n4. Rowe A, Garcia-Barbero M.: Regulation and
\nLicensing of Physicians in the WHO European
\nRegion. 2005. Copenhagen, Denmark, World
\nHealth Organization.
\n5. de Vries H, Sanderson P, Janta B, Rabinovich
\nL, Archontakis F, Ismail S et al.: International
\ncomparison of ten medical regulatory systems.
\nRand Corporation, editor. 2009. Cambridge,
\nUK, Rand Europe.
\n6. Shaw K, Cassel CK, Black C, Levinson W:
\nShared medical regulation in a time of increasing
\ncalls for accountability and transparency: com-
\nparison of recertification in the United States,
\nCanada, and the United Kingdom. JAMA 2009;
\n302(18):2008-2014.
\n7. International Council of Nurses. The Role and
\nIdentity of the Regulator: An International
\nComparative Study. Benton DC, Morrison A,
\neditors. 2009. Geneva, Switzerland, Internation-
\nal Council of Nurses.
\n8. Young A, Chaudhry HJ, Rhyne J, Dugan M:\u00a0
\nA\u00a0Census of Actively Licensed Physicians in the
\nUnited States, 2010. Journal of Medical Regula-
\ntion\u00a02011;96(4):10-20.
\n9. Hawkins RE, Weiss KB. Commentary: Build-
\ning the evidence base in support of the Ameri-
\ncan Board of Medical Specialties maintenance
\nof certification program. Academic Medicine
\n2011:86(1):6-7.
\n10. HPROCard. Workpackage 1: Identification
\nof the competent authorities and the author-
\nized organisations in charge of issuing con-
\ntinuing education and training for healthcare
\nprofessionals in the European Union Member
\nStates\u00a0 \u2013 Deliverable 1: List of competent au-
\nthorities for healthcare professionals in each Eu-
\nropean Union Member State. Report published
\nin 2009. Available at: http:\/\/www.hprocard.eu\/
\nimages\/20091012-hpc-wp1-deliverable1.pdf
\n[latest access on 2011 Oct 11].
\nLuc Jean Ren\u00e9 Besan\u00e7on,
\nInternational Pharmaceutical
\nFederation (FIP)
\nAndries Bickerweg 52517 JP
\nThe Hague The Netherlands
\nE-mail: luc@fip.org
\nPaul Rockey,
\nAmerican Medical Association (AMA)
\n515 N. State Street Chicago, IL 60654
\nUnited States of America
\nE-mail: Paul.Rockey@ama-assn.org
\nMarta van Zanten (Corresponding author)
\nFoundation for Advancement of International
\nMedical Education and Research (FAIMER)
\n3624 Market Street
\nPhiladelphia, PA 19104
\nUnited States of America
\nE-mail: mvanzanten@faimer.org
\nRegulation of Health Professions
\n137
\nSOUTH AFRICA Healthcare Reform
\nOver three decades ago, signatories to the Al-
\nma-Ata Declaration noted that Health for All
\nwould contribute not only to a better quality of
\nlife but also to global peace and security. They
\ngave recognition to the fact that promoting and
\nprotecting health is essential not only for hu-
\nman welfare but also for sustained economic
\nand social development [1]. In 1996 the Con-
\nstitution of the Republic of South Africa, in its
\npreamble, established its constitutional impera-
\ntive to improve the quality of life for all citizens
\nand to free the potential of each person. Section
\n27 of the Bill of Rights of the Constitution af-
\nfirms that everyone has the right to have access
\nto health care services, including reproductive
\nhealth care. Section 27 places an obligation
\non the state to take reasonable legislative and
\nother measures within its available resources
\nto achieve the progressive realisation of this
\nright [2]. In 2004, the National Health Act
\n[3] was promulgated to provide a framework
\nfor a structured and uniform health system that
\ntook into account the obligations imposed by
\nthe Constitution. The Act identifies in its pre-
\namble inter alia the socio-economic injustices,
\nimbalances and inequities of health services of
\nthe past, the need to establish a society based on
\nsocial justice and fundamental human rights,
\nand the need to improve the quality of life for
\nall in the country as the background context for
\nits enactment. Section 3 of the Act places the re-
\nsponsibility for the provision of health care onto
\nthe shoulders of the Minister of Health. One of
\nthe objectives of the Act is the provision of the
\nbest possible health services that available re-
\nsources can afford in an equitable manner for
\nthe population of South Africa.
\nIn its 2000 Report, the World Health Or-
\nganization (WHO) stated that the govern-
\nment carried the ultimate responsibility for
\nthe overall performance of a country\u2019s health
\nsystem and that all sectors in society should
\nbe involved in working towards positive out-
\ncomes under the government\u2019s stewardship.
\nManaging the well-being of the population
\ncarefully and responsibly is the very essence
\nof good government. The best and fairest
\nhealth systems possible with the available re-
\nsources need to be established.\u2018The health of
\nthe people is always a national priority: gov-
\nernment responsibility for it is continuous
\nand permanent. Ministries of health must
\ntherefore take on a large part of the steward-
\nship of health systems\u00a0[4].\u2019
\nIn August 2011, the Green Paper on the
\nNational Health Insurance (NHI) [1] was
\nreleased for debate and comment by all in
\nthe country.The proposed NHI is a step to-
\nwards health care reform as espoused in the
\nConstitution and the National Health Act
\nand a move towards the Alma-Ata\u2019s Health
\nfor All. The seven principles of the NHI,
\ni.e. the right to access, social solidarity, ef-
\nfectiveness, appropriateness, equity, afford-
\nability and efficiency, could be interpreted
\nas the value assumptions of the proposed
\nreforms.The objectives of the NHI are:
\n1. To improve access to quality health ser-
\nvices for all
\n2. To pool risks and funds in order to
\nachieve equity and social solidarity
\n3. To procure services on behalf of the en-
\ntire population and to efficiently mobilise
\nand control key financial resources, and
\n4. To strengthen the public health sector
\nso as to improve health systems perfor-
\nmance.
\nMajor reform in health financing is required
\nif these objectives are to be realised.In 2005,
\nmember States of the WHO committed to
\ndevelop their health financing systems so
\nthat the goals of universal coverage would
\nbe achieved m [1]. The WHO identified
\nthree fundamental, inter-related problems
\nthat restrict countries from moving closer
\nto universal coverage. The first was the
\navailability of resources. Even the richest
\nof countries have not been able to ensure
\nthat everyone has immediate access to every
\ntechnology and intervention that may im-
\nprove their health. Over-reliance on direct
\npayments at the time that people need care
\nwas another barrier to universal coverage.
\nEven where some form of health insur-
\nance is available, patients may still need to
\ncontribute, e.g. in the form of co-payments
\nor deductibles. Many are prevented from
\nreceiving health care because of the need
\nfor direct payments. Others are driven into
\npoverty and financial ruin because of this.
\nInefficient and inequitable use of resources
\nwas the third obstacle impeding the passage
\ntowards universal coverage. A conservative
\nestimate placed the wastage of health care
\nresources at 20\u201340% [1]. Corruption could
\nbe added to this list as a fourth hurdle, as is
\nthe case in South Africa. Corruption erodes
\n10% of all health expenditure in South Af-
\nrica, and within the private sector this is es-
\ntimated to be between R5 and R15 billion
\nyearly [6]. At the recent National Health
\nInsurance Conference: Lessons for South
\nAfrica (National Consultative Health Fo-
\nrum), [7] views expressed by members
\nof the World Bank, the WHO and lead-
\ning health economists in the country were
\nthat the financing of universal coverage is
\nnot beyond the reach of South Africa, as
\nHealthcare Reform in South Africa:
\na Step in the Direction of Social Justice
\nAmes Dhai
\n138
\nSOUTH AFRICAHealthcare Reform
\ncurrently funds are available within the sys-
\ntem. However, what is urgently required is
\nthe efficient management and use of the
\nfunds coupled with the elimination of cor-
\nruption. In addition, employment taxation
\ntogether with other innovative methods of
\nrevenue collection will be necessary.
\nReforming the healthcare financing system
\nin South Africa dates back as early as 1928
\nwhen a Commission on Old Age Pension
\nand National Insurance recommended the
\nestablishment of a health insurance scheme
\nto cover medical, maternity and funeral
\nbenefits for all low-income formal sector
\nemployees in urban areas. In 1935, similar
\nproposals were recommended by the Com-
\nmittee of Enquiry into National Health
\nInsurance. Between 1942 and 1944, the
\nNational Health Service Commission (also
\nknown as the Gluckman Commission) was
\nset up.It recommended the implementation
\nof a National Health Tax that would allow
\nfor the provision of free health services at
\nthe point of delivery for all South Africans.
\nHealth centres providing primary care ser-
\nvices were to be core to the health system.
\nSome of the recommendations were imple-
\nmented, but gains from these were reversed
\nafter the National Party government was
\nelected in 1948. The Health Care Finance
\nCommittee of 1994 recommended that all
\nformally employed individuals and their
\nimmediate dependants initially form the
\ncore membership of social health insurance
\narrangements, which would be expanded to
\ncover other groups over time.More work on
\nthis was done by the Committee of Enquiry
\non National Health Insurance (1995), the
\nSocial Health Insurance Working Group
\n(1997), the Committee of Enquiry into a
\nComprehensive Social Security for South
\nAfrica (2002) and the Ministerial Task
\nTeam on Social Health Insurance (2002).
\nIn 2009, the Ministerial Advisory Com-
\nmittee on National Health Insurance was
\nestablished with the objective of providing
\nrecommendations on relevant health sys-
\ntems reforms and matters relating to the
\ndesign and roll-out of a National Health
\nInsurance as per Resolution 53 passed at
\nthe ANC\u2019s conference in Polokwane in De-
\ncember 2007.5 While several committees,
\ncommissions and working groups have been
\nestablished since 1994 to work towards a
\nway forward for universal coverage, display-
\ning positive political will in this direction,
\nit has only been under the stewardship of
\nthe current Minister of Health that posi-
\ntive political commitment towards Health
\nfor All has materialised.The two areas to be
\nworked on as a priority, as articulated by the
\nMinister, are improving the quality of care
\nin the public sector and decreasing the cost
\nof private health care [7].
\nWhile we embark on the journey towards
\nuniversal coverage, it is important to re-
\nmember that there are also other barriers
\nto accessing health services. Proper financ-
\ning will help poor people obtain care, but
\nwill not guarantee it. Lack of transport and
\ntransport costs would also pose an impedi-
\nment to access. In addition, other social de-
\nterminants are a prerequisite for ensuring
\nthe attainment of health,e.g.food and clean
\nwater. Because health is so dependent on
\nits social determinants, it cannot be viewed
\nas a silo. It will be imperative for the other
\nministries to come on board, and perhaps
\nthe comprehensive package to be offered
\nby NHI should include some of the social
\ndeterminants. In addition, while we have so
\nmany highly skilled and dedicated people
\nworking at all levels to improve the health
\nof our people, we also have the harsh reali-
\nties of severe shortages of human resources
\nand health care workers with poor attitudes,
\nin part because of the conditions that they
\nfind themselves in.
\nThe Green Paper, which outlines broad
\npolicy proposals for the implementation of
\nNHI,is currently undergoing a consultation
\nprocess where public comment and engage-
\nment with the broad principles are encour-
\naged. This will be followed by the policy
\ndocument or the White Paper. Thereafter
\ndraft legislation will be developed and pub-
\nlished for public engagement before being
\nfinalised and submitted to Parliament for
\nconsideration as a Bill. Health reform as
\nproposed by NHI is history in the making,
\nand it is vital that we as citizens of South
\nAfrica engage with and interrogate the
\ndocument and all the subsequent processes
\nthat follow. There are a number of positive
\naspects to the Green Paper. There are also a
\nnumber of concerns and insufficient clarity
\non some extremely important issues.
\nThe indicator of success of NHI will be the
\nachievement of universal coverage. Under
\ndiscussion at the moment is not whether
\nNHI should be implemented, but how this
\nshould be done and what method of financ-
\ning would be the most fair. Trade-offs will
\nbe inevitable.This is the experience in coun-
\ntries that have achieved universal coverage
\nand financial security for their people. The
\ntrajectory is going to be long and challeng-
\ning, but worth it for the future of our coun-
\ntry and its people.
\nReferences
\n1. The World Health Report 2010. Health Sys-
\ntems Financing. The path to universal cover-
\nage. http:\/\/www.who.int\/whosis\/whostat\/EN_
\nWHS10_Full.pdf (accessed 1 December 2011).
\n2. The Constitution of the Republic of South Africa.
\n3. The National Health Act No 61 of 2003.
\n4. The World Health Report 2000. Health Sys-
\ntems: Improving Performance. https:\/\/apps.
\nwho.int\/whr\/2000\/en\/report.htm (accessed 1
\nDecember 2011).
\n5. Green Paper: National Health Insurance in
\nSouth Africa. http:\/\/www.hst.org.za\/publica-
\ntions\/green-paper-national-health-insurance-
\nsouth-africa (accessed 1 December 2011).
\n6. Haywood M. Civil Society Perspectives on NHI
\nand Innovative Funding. Paper delivered at the
\nNational Health Insurance Conference: Lessons
\nfor South Africa. National Consultative Health
\nForum (NCHF). Gallagher Conference Centre,
\n7\u20138 December 2011.
\n7. The National Health Insurance Conference:
\nLessons for South Africa. National Consultative
\nHealth Forum (NCHF). Gallagher Conference
\nCentre: 7\u20138 December 2011.
\nAmes Dhai
\nEditor of SAJBL
\nDecember 2011, Vol. 4, No. 2.
\n139
\nRegional and NMA newsTURKEY
\nBackground Information
\nPhysicians are having a hard time all
\nover the world. They lose their job secu-
\nrity while their salaries are decreasing, and
\nthe social status of the profession is being
\neroded gradually. Violence against health-
\ncare workers is so common that it is now
\nconsidered normal to hear about a new
\nincident nearly every day. On the other
\nhand, the conditions are not any better on
\npatients\u2019 side. While their rights have been
\npromoted and enforced by legal regulations
\nsignificantly in the last decades, paradoxi-
\ncally their access to the services they need
\nis decreasing. What is happening? What is
\nbeing changed in this period, what are the
\ndynamics behind this widespread turmoil?
\nThe short answer to the big question is the
\ncommercialization of healthcare services,
\nand Turkey is no exception.
\nThe last 30 years passed witnessing the
\nstructural crisis of capitalism, and neo-
\nliberal policies recommended by the In-
\nternational Monetary Fund (IMF,) the
\nWorld Bank (WB) and the World Trade
\nOrganization (WTO) were introduced as a
\nglobal solution. Neo-liberal theory is based
\non the idea of maximizing the size and the
\nfrequency of market mobility and as such it
\ntries to include all human activities in the
\nefficiency area of the market [8]. Through
\nthe Washington Consensus between IMF
\nand WB, the structural adaptation pro-
\ngrams of IMF, and WTO agreements such
\nas GATS and TRIPS, public services were
\nreorganized according to market economy,
\nwhile nation-states withdraw from their
\npublic responsibilities. Mass privatization
\nof public properties and services is the main
\ncharacteristic of this period.
\nLike other services such as education,
\ncommunication, energy, and transporta-
\ntion, healthcare services were affected tre-
\nmendously by commercialization policies.
\nA \u201creform\u201dproject of the World Bank was
\nimplemented in Turkey under the name
\nof \u201cTransformation in Health\u201d. The proj-
\nect aims to transform the organization, fi-
\nnancing and provision of healthcare from
\na public to a private model. The coverage
\nof accessible health care provided by the
\nsocial insurance system became narrower
\nand health is no more considered as a right
\nof citizens. Centers for primary health-
\ncare were transformed into family physi-
\ncians\u2019 private clinics, and public hospitals
\nhave become autonomous institutions that
\nare administrated by professional execu-
\ntive boards. The private sector is financially
\nsupported by public funds, and public ser-
\nvices are increasingly provided according
\nto demand and the ability to pay rather
\nthan the need. Competition, performance,
\nproductivity, and cost effectiveness have
\nbecome the leading factors that determine
\nthe amount and quality of services provided.
\nReimbursement policies are also based on
\ncost effectiveness rather than quality. Man-
\nagers of public healthcare institutions must
\nnow learn to buy, sell and compete with
\nthe private sector and to prioritize cost ef-
\nfectiveness over their patients\u2019 best interests
\n[6].
\nOn the other hand, working conditions of
\nhealthcare workers have changed funda-
\nmentally. In a very broad spectrum from
\nproduction relations to modes of employ-
\nment, they have lost many of their rights.
\nHealth workforce was treated as an ordi-
\nnary commodity in the market; and through
\nflexible working, job insecurity and subcon-
\ntracting exploitation of the workforce be-
\ncame more evident. The effectiveness, effi-
\nciency, profit making criteria are used as a
\ntool of control, and if these criteria are not
\nmet the contracts of health workers would
\nnot be renewed. Physicians are compelled
\nProtesting a System which \u201cEvaluates the Price
\nof Everything, but cannot Appreciate the Value
\nof Them\u201d
\nFeride Aksu Tan\u0131k Murat Civaner
\n140
\nRegional and NMA news TURKEY
\nto work on the basis of performance-based
\nincentives, which shorten the examining
\ntime per patient and increase the number
\nof working hours in a day. Health workers
\nhave accepted longer working hours and
\nheavier workload for lower salaries under
\nthe threat of losing their job and becoming
\nunemployed.This proves that, in fact, health
\nworkers are compelled to act like that. [12].
\nIn the end, the working life in health sector
\nhas been transformed from independency
\nto dependency, from qualified and highly
\nprestigious roles to lesser prestigious roles,
\nand from economic prosperity to poverty
\n[12].
\nAnother effect of the commercialization
\nprocess on physician\u2019s working condi-
\ntions is that their professional autonomy
\nwas severely compromised. As the cost-
\neffectiveness became the central measure,
\nreimbursement policies solely based on
\ncosts were implemented through treatment
\nprotocols, diagnosis related groups, restric-
\ntions on prescriptions, global budgeting for
\nhealthcare, and narrowing the coverage of
\ninsurance packages. This was clearly an as-
\nsault to the clinical autonomy of physicians,
\nsimultaneously violating the right of access
\nto healthcare. The art of medicine which
\nbrings together the knowledge and expe-
\nrience of the physician, the possibilities
\nof medicine and the needs of the patient,
\nstarted to disappear, and the profession has
\nbeen transformed from a kind of craft into
\na business entrepreneurship [1].A few phy-
\nsicians have become capitalists, but many
\nof them are under the control of capital
\nand became proletarian [12]. This internal
\npolarization process differentiated physi-
\ncians, dissolved them and they fell apart
\nfrom solidarity. Physicians are squeezed be-
\ntween their personal benefits, social rights
\nand professional values. The team solidar-
\nity broken by the performance based pay-
\nment made physicians rival one another,
\nmade them strangers, even enemies to
\nother health workers. It destroyed human
\nrelationships in health team. Healthcare
\nworkers have been alienated from each
\nother, from their work, and from patients.
\nIn a way, they have been atomized and iso-
\nlated [1].
\nTMA and \u201cMany Voices \u2013
\nOne Heart Campaign\u201d
\nThe Turkish Medical Association (TMA) is
\nthe country-wide professional organization
\nof physicians in Turkey. It was set up by a
\nlaw dated 1953, which gives it the author-
\nity of regulating the profession. At present
\n90,000 of 120,000 physicians are mem-
\nbers, although compulsory membership
\nwas lifted except for physicians who work
\nin the private sector, after the military coup
\nin 1980.TMA is interested in all health re-
\nlated problems and carries out its activities
\nwith its members working on voluntary ba-
\nsis [2]. The mission of the Association is to
\nensure that the profession is practiced so as
\nto promote the benefit of public in general
\nas well as each individual, and to protect the
\nrights of physicians.
\nParticularly after 2003, TMA paid more
\nattention to defending professional rights,
\nas the system which \u201cevaluates the price of
\neverything, but cannot appreciate the value of
\nthem\u201d was increasingly becoming a major
\nthreat to the profession as well as public
\nhealth. Its struggle against the dominant
\npolicies that devalue the labour of physi-
\ncians was well-accepted by physicians, and
\nmarked in the official statements of the
\nMinistry of Health as \u201cTMA\u2019s intensive and
\nnoisy opposition\u201d. In addition to presenting
\ndraft laws and opinion on personal rights
\nand benefits of health workforce,TMA also
\norganizes demonstrations and other actions
\nincluding stopping working temporarily.
\nIn spite of this struggle, the government
\ncontinued its policy of commercializing
\nhealthcare. The government decreased the
\naccess to health care by minimum health
\npackages and increasing co-payments, com-
\nmercialized the public hospitals through
\nfinancial interventions, manipulated the
\nmodes of working,destroyed peace in work-
\ning relations by performance based payment
\nand flexible working, seized the university
\nhospitals through financial constraints, in-
\ncreased the numbers of students of the
\nmedical schools at the expense of decreasing
\nthe quality of medical education.
\nAfter all these policies and regulations
\npassed through the National Assembly and
\nbecame the new legal enforcements for all,
\nTMA decided to carry out a massive cam-
\npaign called \u201cMany Voices, One Heart\u201d.
\nThe campaign was basically demanding
\nceasing privatization policies in order to be
\nable to practice our profession respectfully
\naccording to professional values (or \u201cgood
\ndoctoring\u201d), and to be able to provide good
\nquality healthcare services by respecting the
\nright to healthcare.These demands were not
\nnew; TMA has been carrying out its strug-
\ngle on the basis of defending the right to
\nhealth and professional rights for decades.
\nSo the main themes of the campaign were
\ndefined as democratization, peace, the right
\nto health and professional rights [1].
\nA holistic analysis of actual conditions has
\nbeen made together with a vision for the
\nfuture. Today, physicians are fragmented,
\nisolated and turned into strangers to one
\nanother. For this reason, the campaign is
\nbased on different components and stages
\nin order to understand the subjective needs
\nof physicians and to put them on the agen-
\nda. In meetings organized in 44 cities, phy-
\nsicians came together and discussed their
\nproblems.
\nThe campaign started on the day when
\nthe National Assembly was discussing the
\nhealth budget. \u201cBudget for health, not for
\nthe capital\u201dwas TMA\u2019s main statement.The
\ncampaign brought to the foreground the
\nfollowing: the economic constraint on med-
\nical faculties, commercialization of primary
\ncare, the problems of specialization training
\nand problems of contractual working in the
\nprivate sector, violence against health work-
\ners, and the policies diminishing access to
\n141
\nRegional and NMA newsTURKEY
\nthe services needed. The conceptual frame-
\nwork of the campaign was based on five de-
\nmands. These were job security, income as-
\nsurance, safety of life in terms of protection
\nfrom violence against health workers, pro-
\nfessional autonomy and the right to health.
\nThe first four demands were the basic con-
\ncepts that physicians otherwise fragmented
\nwould agree on. The demand \u201cthe right to
\nhealth\u201d was the key word to bring health-
\ncare workers and the people together.TMA
\nmade a call to 65 Chambers of Medicine
\nand 97 Specialty Associations with a view
\nto involve them in this struggle. While this
\nstruggle was building up in TMA, several
\nmeetings have been carried out with other
\nhealth workers\u2019 unions and associations in
\norder to enhance unity and solidarity. In-
\nstead of limiting the demands to physicians\u2019
\nneeds, the campaign invited all healthcare
\nworkers, including the cleaning workers,
\nnurses, dentists, pharmacists, laboratory
\ntechnicians, social workers, to struggle to-
\ngether with the physicians [1].
\nOrganization of the
\nMass Meeting
\nAfter arranging several local meetings in
\n44 cities, it was decided to organize a mass
\ndemonstration in front of the Ministry of
\nHealth building in Ankara. The date was
\nchosen March 13,as March 14 has been cel-
\nebrated as Medicine Day all over the coun-
\ntry for a hundred years and this is the day
\nthat media show interest in the problems of
\nphysicians.Seventeen trade unions and pro-
\nfessional associations urged their members
\nto participate. Also, different instruments of
\nthe media were used to spread the call. In
\naddition to classical methods such as print-
\ned materials, e-mail and web announce-
\nments, invitation to the mass meeting was
\nmade through a collective singing process.
\nA professional agency prepared a project of
\ncollective singing, in which a famous song
\n\u201cI can\u2019t take my words back\u201d was chosen as
\nthe symbol of the invitation and message to
\nthe people. First, individual physicians or
\ngroups of healthcare workers sang the song
\nand recorded it. Then, all over the country
\nthousands of healthcare workers, medical
\nstudents, and physicians sent their record-
\nings to TMA, and those records were ed-
\nited to build up a video clip. This video clip
\nhas been clicked on tremendously and had
\na very positive effect on people in the sense
\nthat they felt themselves a part of the move-
\nment. Collective singing and recording was
\na way to bring people together (the clip is
\naccessible through: tinyurl.com\/canttake-
\nmywordsback).
\nThe demonstration on March 13, 2011 was
\na great success, with the participation of
\nmore than 30,000 healthcare workers. Or-
\nganised by the Turkish Medical Associa-
\ntion, the demonstration was the biggest in
\nthe Republic\u2019s history on the part of health
\nworkers, and the most enthusiastic and par-
\nticipative meeting ever (for a short video:
\ntinyurl.com\/13march). Healthcare workers
\nprotested in the streets of Ankara against
\nthe privatisation policies of the Ministry
\nof Health which transform physicians into
\nsmall entrepreneurs, patients into custom-
\ners, and healthcare services into a commod-
\nity [6].
\nOver 30, 000 healthcare workers declared
\ntheir demands, and if their demands were
\nnot to be met by the authorities, they de-
\nclared that they would use their power de-
\nrived from production.
\nBut, unfortunately, the media coverage was
\nlower than expected, creating intense disap-
\npointment among physicians. Mainstream
\nmedia did not cover the protesting at all,
\nor showed it on screen for a few seconds.
\nAlso, there was nearly no reaction from
\nthe government except the comments of
\nthe Minister of Health, stating that only
\na few participated in the demonstration
\nand they were nothing but \u201cold-fashioned
\nhardliners\u201d. These developments made the
\ncampaign pass to another phase. TMA to-
\ngether with ten unions and associations of
\nhealthcare workers announced that they
\nhad aggreed on a two-day general strike in
\nthe country on April 19\u201320.
\nDuring the preparation of the strike, we
\nwitnessed the rising movement of research
\nassistants.Their urgent demands focused on
\nthe time allocated for training,and the right
\nto have a day-off after their night duties.
\nTheir slogan was \u201cresearch assistants are not
\nslaves\u201d.They were also refusing performance
\nbased payment. This rising movement re-
\nsulted in many local warning strikes before
\nthe April strike in several provinces. Some
\nof their demands were met,including a day-
\noff after night duties.
\nPreparation of the Strike
\nWhile preparing the 19\u201320 April strike,
\nTMA made a declaration to the press in or-
\nder to explain the conditions and problems
\nlying at the basis of the strike.The rationale
\nof the strike was explained as:
\n\u201cThe worsening working conditions, enforce-
\nment of insecure modes of working, disrespect-
\nful manner and discourse of the politicians, the
\nnew laws and the regulations which propose
\nimperceptible future in the field of health, com-
\nmodification and commercialization of health
\ncare.\u201d
\nThe demands have been defined as follows:
\n\u201cWe have common demands with other people
\nwhich are to live a decent life. We don\u2019t want to
\nbe the \u201cactor\u201d of a commercialized health care;
\nwe don\u2019t want to become the \u201cemployee\u201d of the
\nlow-waged, unsecured, flexible working. As
\nthe honorable members of a profession which
\nis dedicated to society, we want to do our job
\nwithout concerns for the future.
\nBy accepting the right to health, we demand
\nhealth for all and secure future. We demand
\njob security, income assurance, and safety of life
\nwhich means protection from violence against
\nhealth workers, professional autonomy, and the
\nright to health.\u201d
\n142
\nRegional and NMA news TURKEY
\nThus, the urgent demands were formulated
\nas fifteen items given below:
\n\u2022 Performance based payment which cre-
\nates rivalry instead of solidarity and
\ntransform our patients into bonus score
\nshould be terminated.
\n\u2022 All co-payments, out-of-pocket pay-
\nments which commodificates health care
\nshould be eliminated.
\n\u2022 Minimum health package which narrows
\nthe coverage of social insurance and in-
\nterferes with the professional autonomy
\nof physicians must be abandoned.
\n\u2022 Medical faculties should maintain their
\nautonomy.
\n\u2022 Day-off after night duties should be given
\nto all physicians and the weekly working
\ntime should not exceed 56 hours.
\n\u2022 All healthcare workers should be em-
\nployed in secure employment modes.
\n\u2022 TMA should be a party in the contracts
\nof private physicians working on contrac-
\ntual basis.
\n\u2022 TMA should have authority in assign-
\nment and wage determination of occupa-
\ntional health physicians.
\n\u2022 Income inequality should be ended
\namong primary care physicians and they
\nshould be employed securely.
\n\u2022 Necessary arrangements should be made
\nin healthcare institutions in order to es-
\ntablish life security, diminish violence
\nagainst health care staff and legal regula-
\ntions should be made urgently.
\n\u2022 The humiliating discourses and attitudes
\ntowards healthcare staff before the media
\nshould be ceased.
\n\u2022 The salaries of physicians should be re-
\nconsidered and they should be sufficient
\nto ensure them decent living and provide
\nassurance regarding the future.
\n\u2022 Physicians should have the right to self-
\nemployment.
\n\u2022 There must be a workplace health unit in
\nhealth care institutions.
\nHealth and social workers, radiologic tech-
\nnologists, subcontracted workers in health
\ncare, laboratory technicians, dentists, nurses,
\npharmacists and their professional organiza-
\ntions joined in this call along with TMA. A
\ncall was made to the public by saying \u2013 please,
\nsupport this justified struggle by not admit-
\nting patients to hospitals on April 19\u201320. At
\nthe same time the public was informed about
\nthe action that emergencies will be taken
\ncare of as usual; health services will be pro-
\nvided as it has been done during the holidays.
\nThe Law Office of TMA prepared an evalu-
\nation on the legal issues of the strike. They
\ndeclared that blaming the participants of a
\nstrike is against the legal arrangements of
\nthe country as well as the European Con-
\nvention on Human Rights. TMA as a con-
\nstitutional organization has the resposibility
\nto share the problems physicians are facing
\nand make society aware of the health care
\nproblems. They informed the physicians on
\npossible disciplinary proceedings, second-
\nment, temporary assignments and litiga-
\ntions. The Law Office of TMA declared
\nthat they will be defending the rights of
\nthe physicians who would face problems
\nbecause of the strike actions. In addition to
\nthe Law Office\u2019s statement, TMA declared
\nthat \u201cany single investigation about a physi-
\ncian will be the basis of stronger solidarity.\u201d
\nEthical Dimension
\nThe Minister of Health announced that be-
\ning on strike endangers patients\u2019 health and
\nlives, and therefore it would be \u201cimmoral\u201d,
\nlet alone its illegality. In fact, there is no in-
\nternational consensus whether physicians\u2019
\nstrike is compatible with their professional
\nduties. There are different points of view
\nthat either support or decline strikes in the
\nhealth sector due to different reasons (At
\nthis point, we would like to state that there is a
\nreal need of WMA Declaration on this issue, as
\nphysicians all over the world need guidance ur-
\ngently in this process of commercialization and
\nviolation of rights). However, TMA takes
\nthe position that strikes would be morally
\njustifiable under certain circumstances, as it
\nwas stated in its Declaration on Physicians\u2019
\nStrikes, adopted in 2008 (see Box). Two
\nrationales, namely, defending the right to
\nhealth and protecting professional rights,
\nmay allow physicians to go on strike. On
\nthese grounds, physicians should first try
\nother ways to make a change, and a strike
\nshould be the last option. Moreover, the
\npublic should be informed in advance about
\nthe reasons of this action and the availability
\nof services. And providing services should
\nnot be interrupted to certain groups of pa-
\ntients, i.e. pregnant women, those in need
\nof urgent care, dialysis patients, persons
\nwith cancer, intensive care patients and in-
\npatients. When all these preconditions are
\nmet, then TMA confirms the strike to be
\nin conformity with professional ethics. And
\nbeyond that, under these circumstances de-
\nfending the right to health and protecting
\nprofessional rights that are directly linked
\nto the right to health, constitute a profes-
\nsional duty based on social responsibility.
\nThat is why TMA is naming the word strike
\nas \u201cg(\u00f6)rev\u201d (duty), instead of \u201cgrev\u201d (strike).
\nThe April 19\u201320 strike was very-well justi-
\nfied in this context. The decision on strike
\nwas shared with the public by announc-
\ning that \u201cservices will be provided just like on
\nholidays\u201d. Emergency patients, in-patients
\na.o. were taken care of without any disrup-
\ntion in services,and society mostly supported
\nthe action. The only real problem was some
\nout-patients for whom the date of the visit
\nto the clinic had been fixed weeks in advance
\nand not being informed about the strike,they
\ncame from a long distance to be examined,
\nbut couldn\u2019t get the service. This is an issue
\nto be carefully handled in similar situations
\nso as to protect patients as much as possible.
\nEvaluation of the Strike
\nThe slogan of the mass meeting of 13
\nMarch was \u201cI can\u2019t take my words back\u201d. In
\naccordance with this slogan and in spite of
\npressures made by the Ministry of Health
\nphysicians and health workers kept their
\npromise and this very promising participa-
\ntion encouraged all of us.
\n143
\nRegional and NMA newsTURKEY
\nThe two-day strike took place in most prov-
\ninces, totally embracing 87.5 % of the phy-
\nsicians (yellow colored provinces). In some
\nprovinces where 7.2% of the physicians work,
\nsupportive press declarations were made (red
\ncolored provinces), and in the remaining
\nprovinces (white colored) with 5.3% of the
\nphysicians no strike action occured.
\nTents were set up in the hospital gardens.
\nInformative leaflets were distributed to
\nthe people. Meetings and demonstrations
\nwere arranged. University hospitals and
\nstate hospitals lively participated. In many
\nprovinces there were difficulties in partici-
\npation of employees of private hospitals
\nbecause of intimidating with dismissals.
\nIn each province press declarations were
\nmade. Some conflicts occurred between
\nthe health personnel and the security staff
\nof the hospitals. The media provided in-
\nformation about the strike by stating that
\n\u201con 19\u201320 of April the hospitals will not
\nprovide health care except for emergen-
\ncies\u201d. In the cities which participated
\nin the strike, people supported it by not
\nasking admission to hospitals. Although
\nthe Minister of Health made provocative
\nspeeches against the strike, not any single
\nconfrontation between the patients and
\nthe health care staff occurred. TMA ap-
\npreciates the common sense and tolerance
\nof our people.
\nTurkish Medical Association
\nDeclaration on Physicians\u2019 Strikes
\nAdopted in\u201cEthics Declarations Workshop\u201d held in Ankara on 4\u20135 April
\n2008, with the participation of representatives from 33 medical specialty
\nsocieties, Society of Turkish Nurses, Istanbul and Ankara Bars, and acade-
\nmicians from Departments of Medical Ethics in universities.
\nIn the \u201cProfessional Ethics Rules of Physicians\u201d adopted by the
\nTurkish Medical Association, a holistic approach to health is
\nconsidered as the responsibility of individual physicians and it is
\nfurther stated that self-development by human beings is possible
\nonly in healthy living conditions:
\n\u201cPhysicians are aware that the profession of medicine cannot be ab-
\nstracted from social and cultural circumstances surrounding the profes-
\nsion and that the most fundamental precondition for developing and
\nrealizing human potential is the state of physical and mental health.\u201d
\nAnother fundamental responsibility is stated as protecting human
\nlife and health:
\n\u201cThe primary task of the physician is to protect human life and health
\nby preventing diseases and curing patients through fulfilling scientific
\nrequirements. It is also among the paramount duties of the physician to
\nrespect human dignity while performing his profession.\u201d
\nThese responsibilities make it necessary to take into account also
\nsocial circumstances under which service delivery takes place.Sci-
\nentific evidence shows that the health status of individuals and
\nsocieties are determined not only by services provided but also
\nby many other factors including social class, level of education,
\ngenetics, nutrition, sheltering, working and environmental condi-
\ntions.
\nThe Turkish Medical Association declares that, in the context
\nof responsibilities mentioned above, the action of strike is con-
\nsistent with professional ethics on the basis of following two
\ngrounds:
\n\u2022 Policies currently pursued may limit or hinder individuals\u2019access
\nto healthcare services they need. Furthermore, there may also be
\nproblems related to the other determinants of health status in-
\ncluding social inequalities,human rights violations,environmen-
\ntal health problems, unhealthy sheltering, unfavourable working
\nenvironments and unemployment. Since all these factors and
\nconditions affect the health status of individuals and society and
\nare in contrast with the requirements of the right to health, it is
\nalso among the social responsibilities of physicians to warn pol-
\nicy makers and the executive and to build awareness in public at
\nlarge. In this context, physicians may talk issues with authorities
\nthrough their professional organization, make press statements,
\norganize marches,engage in training and extension activities and,
\nwhen necessary,make strike.An action of strike in this sense is in
\nconformity with professional ethics given that service delivery to
\npregnant women, those in need of urgent care, dialysis patients,
\npersons with cancer, under intensive care and in-patients is not
\ninterrupted and the right to health is properly defended.
\n\u2022 Another fact which justifies the action of strike is the losses that
\nphysicians suffer in their professional rights. It runs parallel to
\nthe realization of the right to health. It is because health work-
\ners themselves can be healthy in conditions of decent life and
\ncan provide their services better in case they get a fair return to
\ntheir efforts and work in safe and secure conditions. Yet, poli-
\ncies geared to establishing rivalry instead of solidarity among
\nhealth workers, to introducing cheap and insecure employment
\nthrough privatizations and on-contract recruitment will inevi-
\ntably undermine the health of health workers and society and
\nfurther deepen existing inequalities.
\nWhen strike decision is taken, the public should have been in-
\nformed in advance and the reasons for this action should be clear-
\nly stated and shared with the public.
\n144
\nRegional and NMA news TURKEY
\nThe Ministry of Health has conducted dis-
\nciplinary proceedings, secondment, tempo-
\nrary assignments and litigations.Some pres-
\nidents of medical chambers, some members
\nof the Board of Directors,even one member
\nof the Central Council of TMA have faced
\ndisciplinary proceedings and litigations.The
\nLaw Office of TMA has provided a sample
\nof petition to physicians who have been ex-
\nposed to any kind of pressure.The lawyers of
\nTMA have provided legal assistance. In the
\nend all arbitrary actions of the Ministry of
\nHealth were legally halted.
\nHowever,on June 6,2012,47 students from
\nmedical, dental and health sciences schools
\nwere detained, and after the prosecution
\nand court inquiries 13 of them were arrest-
\ned. 11 of these students are from schools
\nof medicine and they are also members of
\nthe Student Branch of the Turkish Medi-
\ncal Association. Without being accused
\nof anything, these students were asked by
\nthe Prosecutor and the Court about their
\nparticipation in legal activities organized
\nby the Turkish Medical Association. Due
\nto their prolonged detention the students
\ncould not attend to their internship duties,
\ncould not take their regular tests; there are
\neven some among them who would have
\ngraduated if not detained. Meanwhile, all
\nthese events also \u201ccriminalize\u201d the Turkish
\nMedical Association as a constitutional
\nbody. The idea is to \u201ccriminalize\u201d involve-
\nment of medical students in public health
\nissues and health policies in order to deter
\nother students from such activities. This is
\nnothing less than restricting the freedom of
\nexpression and association in a state under
\nthe rule of law.The process that the Turkish
\nMedical Association has experienced upon
\nthe Decree Law No. 663 is clearly articu-
\nlated in the Editorial by the WMA Sec-
\nretary General Dr. Otman Kloiber in the
\nfirst issue of WMJ in 2102; the article by
\nDr. Eri\u015f Bilalo\u011flu who was then the Presi-
\ndent of TMA and the council decision ad-
\nopted by WMA in April 2012 in relation
\nto TMA. It is considered that the arrest of
\nour students is a part and extension of the
\nsame process.
\nLessons Learned and
\na Call From TMA
\nIt was very risky to organize a strike of this
\nscale,as there were serious doubts about phy-
\nsicians\u2019 participation. Most of the physicians
\nwere unhappy and hopeless during the meet-
\nings organized all over the country before
\nthe strike. But in terms of participation, the
\nstrike was successful. Physicians massively
\ntook part in the action. On the other hand,
\nin terms of the results or positive gain, it is
\nnot possible to claim that it was a success in
\nthe short run; the Ministry of Health and
\npolicy makers didn\u2019t care about the rightful
\ndemands of healthcare workers, instead they
\nfocused on decrying the action in the public
\neye.Nevertheless,it would be unfair to recog-
\nnize an action of this scale as a failure.On the
\ncontrary, TMA and the other organizations
\nhave made a very clear signal to the Ministry
\nof Health and to society by this strike. Also
\nhealthcare workers have learnt and gathered
\nexperience that they have enough power to
\nbe heard and to negotiate when they are
\nunited under a common platform and act-
\ning together.This point is so critical that the
\nWorld Bank\u2019s expert recommends another
\napproach in the book titled \u201cGetting Health
\nReform Right\u201d[11]:
\n\u201cOn the negative side, it is important to consid-
\ner how to divide or undermine coalitions that
\nare opposing you. Suppose that the medical as-
\nsociation has decided to oppose a new insurance
\nscheme because it will limit reimbursement for
\nhigh cost procedures, which would negatively
\naffect the income of some physicians. It may be
\npossible to persuade doctors who provide pri-
\nmary care to switch sides and support the plan,
\nand thereby divide the medical association, if
\nprimary-care doctors can be persuaded to see
\ntheir interests in a different light.\u201d
\nThis book was translated into Turkish under
\nthe editorialship of the Minister of Health
\nhimself, and this is one of their main guides
\nin policy-making, besides the World Bank
\nproject \u201cTransformation of Health\u201d (for a
\ndetailed information, please, visit the related
\nproject site of WB: tinyurl.com\/WB-Trans-
\nformationinHealth. It is possible to follow the
\npast, current and future policies of the Ministry
\nof Health in a timeline until July 31, 2013). It
\nis crystal clear that national medical asso-
\nciations are direct targets of these commer-
\ncialization policies, and standing together is
\nvital.
\nIt is also clear that the rights of patients
\nand society in general are not to be sepa-
\nProvinces going on strike
\nProvinces making supportive press declaration
\nProvinces not participating
\n145
\nHealthcare
\nrated from healthcare workers; they will
\nbe either exercised or violated all together.
\nThat is why, we, physicians, always need
\nto claim our rights together with those of
\npatients and society. We always need to
\ndefend the right to health, emphasize that
\nhealth care should be financed from gen-
\neral taxes and should be provided by the
\npublic sector according to needs. Health
\ncare should be equal, accessible, of good
\nquality and free for every one. Otherwise,
\nstruggles focused only on professional
\nrights are doomed to fail, as it is not pos-
\nsible to protect professional rights and in-
\nterests without opposing commercializa-
\ntion policies.
\nWe would like to finish with a call from
\nTMA to all NMAs: It is important to share
\nthe experience, as we need to know our
\nshortcomings and gaps, and improve our
\nmethods wisely. In this context we would
\nlike to propose that WMA would establish
\na database for physicians struggle all around
\nthe world. What were their motives? What
\nwere the actions and consequences? What
\ncan be improved and how? What was soci-
\nety\u2019s reaction? What would they change for
\nthe next time? Every NMA might send in-
\nformation about such actions during the last
\ndecade. We believe it to be a very precious
\nresource for all of us.
\nReferences
\n1. Aksu Tan\u0131k, Feride. (2011) \u201cMany Voices-One
\nHeart\u201d Struggle Campaign for Good Medicine,
\nGood Quality of Health Care and Health Right
\nCrisis of Capitalism and Health XVI. Confer-
\nence of International Association of Health
\nPolicy in Europe, http:\/\/www.ttb.org.tr\/kutu-
\nphane\/kapitalizm.pdf ISBN 978-605-5867-50-
\n8, p.162-165
\n2. Bilalo\u011flu, E. (2012) Turkish Medical As-
\nsociation (TTB). World Medical Journal,
\n2012;58(1):27-9.
\n3. Boratav, K. (2011) Hak M\u00fccadeleleri ve
\nEkonomill Kuramsal ve Tarihsel Boyutlar\u0131yla
\nHak M\u00fccadeleleri cilt I, s.153-164, Nota Bene
\nYay\u0131nlar\u0131. (Struggle for Rights and Economy:
\nStruggle for Rights with Theoretical and His-
\ntorical Dimensions)
\n4. Braverman, (2008) Emek ve Tekelci Sermaye,
\n\u0130stanbul: Kalkedon. (Labour and Monopoly
\nCapital)
\n5. Civaner M. Sale strategies of pharmaceuti-
\ncal companies in a \u201cpharmerging\u201d country: the
\nproblems will not improve if the gaps remain.
\nHealth Policy, 2012; 106(3):225-32.
\n6. Civaner M. \u201cTransforming\u201d our health by
\nprivatisation. British Medical Journal, 2011;
\n342:d1959.
\n7. \u00c7\u0131daml\u0131,\u00c7.(2011) \u2013 Kamusal Alan\u0131n D\u00f6n\u00fc\u015f\u00fcm\u00fc
\nSorunu Devrimci Bir Sorundur Kuramsal ve
\nTarihsel Boyutlar\u0131yla Hak M\u00fccadeleleri cilt I,
\ns.241-252, Ankara: NotaBene Yay\u0131nlar\u0131. (The
\nProblem of the Transformation of Public Sphere
\nis a Revolutionary One: Struggle for Rights with
\nTheoretical and Historical Dimensions)
\n8. Harvey, D. (2007) A Brief History of Neo-liber-
\nalism. Oxford: Oxford University Press.
\n9. Karahano\u011fullar\u0131,O.(2004),Kamu Hizmeti,An-
\nkara: Turhan. (Public Services)
\n10. \u00d6zu\u011furlu, M. (2003) \u2013 Sosyal Politikan\u0131n
\nD\u00f6n\u00fc\u015f\u00fcm\u00fc ya da S\u0131fat\u0131n Suretten Kopu\u015fu, M\u00fcl-
\nkiye Dergisi, C.27, S.239, s.59-75. (Transforma-
\ntion of Social Policy or Rupture of Atrribute
\nfrom Appearance)
\n11. Roberts M. et al. Getting Health Reform Right:
\nA Guide to Improving Performance and Equity.
\nOxford University Press, USA; 2004. p.80
\n12. \u00dcnl\u00fct\u00fcrk Uluta\u015f, \u00c7. (2011) T\u00fcrkiye\u2018de Sa\u011fl\u0131k
\nEmek S\u00fcrecinin D\u00f6n\u00fc\u015f\u00fcm\u00fc, Ankara: NotaBene
\nYay\u0131nlar\u0131 (Transfromation of Health Labour
\nProcess in Turkey)
\nFeride Aksu Tan\u0131k,
\nFormer Secretary General, Turkish
\nMedical Association,
\nProfessor of Public health
\nAnkara University School of Medicine,
\nE-mail: ferideaksu59@gmail.com
\nMurat Civaner,
\nFormer Secretary of Turkish Medical
\nAssociation Ethics Committee,
\nAssoc.Professor, Department
\nof Medical Ethics,
\nUludag University School of Medicine,
\nE-mail: mcivaner@gmail.com
\nToday, our country and many others around
\nthe world are faced with the epidemics of ar-
\nthritis, hypertension, obesity, diabetes, heart
\ndisease, stroke, and cancer. Obviously, our
\nhealth prevention strategy of more than half
\na century has failed in our race and battle
\nagainst these diseases. While the world has
\nsucceeded significantly in the area of infec-
\ntious diseases, eliminating the killer small
\npox, and to a great extent, polio, we are still
\nlagging far behind in the race against those
\nseven common illnesses enumerated above.
\nDuring the past six decades,medical science
\nand technology have made mind-boggling
\ndiagnostic and therapeutic advances. Both
\npharmaceutical and surgical treatments
\nof diseases have progressed significantly.
\nMore effective antibiotics and medications
\nfor various illnesses have been developed.
\nOpen heart surgery, angioplasty, brain and
\njoint surgeries,conventional and endoscopic
\n(minimally invasive techniques) have come
\nto the forefront, saving and making lives
\nmore comfortable. This cutting-edge thera-
\npies include new and more effective chemo-
\ntherapies with lesser side-effects, albeit still
\nfar from ideal.
\nIn essence, the world\u2019s state-of-the-art
\nknowledge and ability to diagnose diseases
\nand manage many of those illnesses are
\ngreat strides we have gained during the post
\nWorld War II period to the present.
\nBut the stark reality today glaringly points
\nto our massive failure as a global society in
\nthe vital area of disease prevention. Testa-
\nment to this are the escalating statistics\u00a0\u2013
\nthe worsening incidence of those major
\nOur Failed Health Strategy
\n146
\nHealthcare
\ndiseases, their morbidity, complications, and
\ndeath tolls. We have barely put a dent on
\nthem. Evidently, our conventional preven-
\ntive strategy has not worked and diseases
\nare way ahead of us in the race.
\nIs medical science to blame? Don\u2019t we have
\nenough scientific data in this exploding in-
\nformational age to help guide us to the right
\npath to health and longevity?
\nLifestyle diseases (self-induced or self-in-
\nflicted illnesses) are the major killer diseases
\ntoday. In general, except in impoverished
\nnations who deserve our compassion and
\nhelp, we abuse ourselves with our abun-
\ndance and blessings.We eat the wrong food,
\nwe overeat and simply loosen our belt, we
\nneglect physical and exercises, we indulge in
\nunhealthy behaviour and vices, like smok-
\ning, undisciplined alcohol intake, and even
\nunsafe sex.
\nWorse than what majority of us are doing to
\nourselves are the bad examples we are setting
\nfor our children, as pointed out in the 800-
\npage coffee-table health guide, entitled Let\u2019s
\nStop \u201cKilling\u201d Our Children, which is avail-
\nable at PhilipSchua.com, xlibris.com, ama-
\nzon.com, and barnesandnobel.com. Anyone
\nnot positively contributing to the health and
\nwell-being of children under our care, for
\nwhatever reason, including love, is literally
\ncutting short the life span of these young-
\nsters and shortchanging them unfairly.
\nUnfortunately, the negative impact of our
\nbad examples as parents is so subtle and
\nshows up late\u00a0\u2013 when our children are al-
\nready in their middle-age, where all these
\ninfirmities start bothering them, like ar-
\nthritis, high blood pressure, diabetes, heart
\ndisease, stroke, and cancer \u2013 that the deadly
\neffects of our unhealthy behaviour on our
\nchildren before they are born and as they are
\ngrowing up are not immediately apparent.
\nMany of us shrug this off and rationalize
\n\u201cWhen they grow up,they will develop their
\nown habits, behaviour, and preferences.\u201d
\nBut we do not realize, as science has clearly
\nshown, that the first five years in the life of
\nchildren are the formative years, where \u201cthe
\ndye is almost cast,\u201d where their mindset,
\nas influenced by what they learn from us,
\ntheir parents and guardians, has taken roots,
\nand has become a permanent part of their
\nthinking, behaviour, and choices in life. So,
\nif we waited for them to grow up, it would
\nbe a bit too late to iron out the kinks they
\nlearned from us, adults.
\nThe proper timing for gifting our children
\nhealthy lifestyle starts before they are con-
\nceived, when they are in the womb, when
\nthey get in the crib, and at least during their
\nfirst five years and teen years. Doing this
\nwill ensure that we maximize the protection
\nof their DNA and immune system, start-
\ning healthy lifestyle from the cellular level,
\nor from what I call \u201cGround Zero\u201d in my
\nnew book, to effectively reduce their risk for
\nacquiring arthritis, hypertension, diabetes,
\nheart diseases, stroke and even cancer when
\nthey reach their middle age and beyond.
\nUnfortunately, many seemed to have dis-
\ncounted convincing scientific evidences
\nshowing we can chart the course of our
\nown health destiny to a significant extent.
\nAs a consequence, they have surrendered to
\ntheir \u201cfate\u201d(que sera,sera),which they feel is
\nbeyond their control. In essence, they have
\nunwittingly programmed their mindset to
\na casual, careless, self-destruct, slow-suicide
\nmode.They simply accept whatever happens
\nand seek treatment of the diseases when
\nthey occur, instead of preventing them in
\nthe first place.
\nThe incidence, complications, and death
\nrates from obesity, diabetes, cardiovascular
\ndiseases, cancer and other illnesses are es-
\ncalating to epidemic proportion. And this
\nis unfortunate, because, to a great extent,
\nthese diseases are, believe it or not, mostly
\npreventable!
\nTrite and corny, perhaps, but the adage
\nby Ben Franklin, \u201can ounce of prevention
\nis worth a pound of cure,\u201d rings truer and
\nlouder when it comes to health, and well-
\nbeing, and illnesses, especially those that
\nkill. Indeed, no medical treatment is more
\neffective than prevention of diseases.
\nHowever,I would like to underscore the fact
\nthat the timing of prevention is of utmost
\nimportance, which I propose to be at the
\ncellular, DNA level, during infancy in order
\nto be truly effective, and not later.
\nOur past and current strategy has failed
\nmiserably as present day medical statistics
\nshow. Common sense tells us we, as a soci-
\nety and as individuals, are doing something
\nwrong in our race against diseases. We are
\nJohnny-come-lately in this battle. We have
\nbeen joining the race a bit late, when the
\nintegrity of our DNAs have already been
\ndamaged after years of self-abuse. The race
\nbegins at the starting line and not in the
\nmiddle.
\nThere is a serious need for world society
\nas a whole to re-evaluate our failed strat-
\negy and put emphasis on early prevention
\nby being pro-active and pre-emptive in the
\nway we deal with health and longevity, oth-
\nerwise the future generations are doomed
\nas we are.
\nWhile it is never too late for any of us, at
\nany age, to start disease prevention or ame-
\nlioration through healthier lifestyle, we can
\nsave our young children and grandchildren,
\nand theirs, from the ravages of preventable
\nillnesses we ourselves have acquired through
\nnegligence and carelessness, by implement-
\ning the timely intervention before con-
\nception of the child, when in the crib, all
\nthrough its teenage years, and beyond.
\nI strongly propose we start at \u201cGround
\nZero.\u201d
\nPhilip S. Chua, MD, FACS, FPCS
\nCardiac Surgeon, Northwest Indiana
\nAuthor, Let\u2019s Stop \u201cKilling\u201d Our Children
\nE-mail: scalpelpen@gmail.com
\n147
\nRegional and NMA news
\n\u2018Spend not more, but smarter!\u2019 \u2013 this idea is
\nthe driving force behind the \u201cInternational
\nResearch on Financing Quality in Health-
\ncare (InterQuality)\u201d. Co-financed by the
\nEuropean Commission\u2019s Framework Pro-
\ngramme 7,InterQuality is led by the Medical
\nUniversity of Warsaw.Its consortium is com-
\nposed of the Universities of Hannover (DE),
\nSyddansk (DK), Catania (IT), York (UK), as
\nwell as the think tank \u201cThe Urban Institute\u201d
\n(US), a Polish research and education-ori-
\nented SME specialised in the pharmaceuti-
\ncal sector, Sopharm Sp z.o.o. (PL) and the
\nEuropean Patients\u2019 Forum (EPF) as well as
\nthe Standing Committee of European Doc-
\ntors (CPME). The CPME President Dr.
\nKonstanty Radziwill sees the project\u2019s objec-
\ntive as an attempt to resolve a fundamental
\nchallenge: \u201cThe problem of how to pay for medi-
\ncal services probably already arose thousands
\nof years ago. It is said that ancient Sumerian
\nkings paid their doctors until they regained their
\nhealth. Today the idea of paying for healthcare
\noutcomes rather than for procedures is still viv-
\nid.\u201d While Europe\u2019s healthcare systems vary
\nsignificantly in structure, economic pressure
\non budgets is a unifying reason to review
\nfinancing systems. \u201cThe problem still exists \u2013
\nhow much to pay for efforts and how much for
\nresults, how much for procedures performed and
\nhow much for availability, presence and care\u201d,
\nstates the CPME President.
\nLaunched in 2010, InterQuality strives to
\naddress these questions by concentrating
\non four models of care and their respec-
\ntive financing systems, i.e. hospital care,
\noutpatient care, pharmaceutical care, and
\nintegrated care. In these focal areas, Inter-
\nQuality works towards establishing a com-
\nmon understanding of the terminology and
\nconcepts used to describe different financ-
\ning system and identify payment systems\u2019
\nincentives, as well as indicators suitable
\nto assessing quality of care. On this basis,
\nthe focal areas will be examined in-depth,
\nwith a view to assessing good practices and
\nprocessing these findings in guidelines for
\npolicy-makers. \u201cThere are many solutions in
\nthe world; most of them of mixed nature. The
\nquestion is how to pay in a just and effective
\nway. These questions are addressed by the In-
\nterQuality project which is designed to at least
\nget us closer to answering the dilemma: how to
\nfulfil growing patient demand in\u00a0 shrinking
\neconomic possibilities?\u201d
\nDr. Radziwill explains that \u201cwhile this is
\ndefinitely a task for the economists, the medi-
\ncal profession is also necessary in this research.
\nThis is why CPME decided to take part in In-
\nterQuality.\u201d CPME will be contributing to
\nseveral project deliverables to share the doc-
\ntor\u2019s perspective on the impact of financing
\nsystems on quality of care. As one of the
\nprimary stakeholders in the implementation
\nof healthcare financing reforms, CPME
\nshall also be looking at communication
\nstrategies which support reform cycles to
\nestablish how governments can best ensure
\nthat stakeholders\u2019 views are considered and
\nprocessed. CPME shall be carrying out this
\nwork in close collaboration with the Euro-
\npean Patients\u2019 Forum (EPF), who is leading
\nthe project\u2019s communication activities.
\nThe project is currently entering into its
\nempirical phase in which the four selected
\nmodels of care will be studied. Results are
\nexpected for mid-2013. In the meantime,
\nthe consortium will be presenting interim
\nfindings at conferences and other events, an
\nup-to-date list of which can be found on the
\nproject\u2019s website www.interqualityproject.eu.
\nThe questions InterQuality seeks to answer
\nwill increase in relevance as public budgets
\ndeal with the mid- and long-term impact of
\nthe economic crisis. However, the consor-
\ntium hopes to show that quality need not
\nbe compromised. As the project leader, Prof.
\nDr. Hab. Tomasz Hermanowski, concludes,
\n\u201cthe good news is that we can realign payment
\nincentives to drive quality improvement and
\nfoster better use of our health care resources. To
\nget to better quality, we don\u2019t need to pay more:
\nwe need to pay smarter.\u201d
\nDr. Konstanty Radziwill,
\nCPME President;
\nMs Sarada Das,
\nCPME EU Policy Advisor\u2019
\nFinancing Quality in Healthcare \u2013 the
\nInterQuality Project Takes on the Challenge
\nKonstanty Radziwill Sarada Das
\n148
\nGERMANYAlternative Medicine
\nProblems of Defining Alternative
\nMedicine and Possible Solutions
\nWhat is alternative medicine? Unfortunate-
\nly,there is no clear definition.In general it is
\ngrouped with complementary medicine or
\nintegrative medicine. In the literature there
\nare basically two definitions:
\nAlternative medicine is considered to sum-
\nmarize treatments which are outside of con-
\nventional medicine
\n1. which are used instead of conventional
\nmedicine to treat a disease or
\n2. which are used to directly treat a disease.
\nAccordingly, complementary medicine is
\nconsidered to cover treatments
\n1. which are used parallel to conventional
\ntreatments in order to improve their ef-
\nficacy or to decrease side effects or
\n2. which are used to treat the symptoms of
\na disease.
\nFrom the view point of conventional medi-
\ncine there may be no need to distinguish
\nbetween alternative and complementary
\nmedicine. Clearly, both are not generally ac-
\ncepted by conventional medicine, which led
\nto them being grouped together. However,
\nit seems that the distinction is important.In
\ncontrast to the protagonists of complemen-
\ntary medicine who accept the conventional
\nmedicine\u2019s underlying concepts of disease
\netiology, pathogeneses and treatment, the
\nprotagonists of alternative medicine often
\nhave developed their own disease concepts,
\nwhich often are of esoteric nature and con-
\nflicting with the concepts of conventional
\nmedicine. Thus, protagonists of comple-
\nmentary medicine disclaim the concepts of
\nalternative medicine and do not feel com-
\nfortable when grouped with followers of
\nalternative medicine.
\nIn order to write about alternative medicine
\nit seems important to have a clear defini-
\ntion. A possible solution to the problem
\ncould be an approach comparable to the use
\nof crosstabulation with the question of ac-
\nceptance of conventional medicine\u2019s disease
\nconcepts on one side and the question of a
\ndirect treatment approach versus a focus on
\nthe treatment effects on the other. Figure
\ndepicts the result of such a combined defi-
\nnition and gives some examples on where
\nvarious treatments could be grouped to.
\nHowever, such a solution allows defining 3
\nsubsets of alternative medicine:
\nA \u2013 Approaches directly against the disease
\nwhich are not consistent with scientific con-
\ncepts;
\nB \u2013 Approaches directly against the disease
\nand consistent with scientific concepts but
\nwithout scientific proof of efficacy;
\nC \u2013 Supportive approaches directly which
\nare not consistent with scientific concepts.
\nIn the following part, the evidence of vari-
\nous methods will be summarized based on
\nthe referred grouping.
\nScientific Evidence of
\nApproaches Directly against the
\nDisease,which are not Consistent
\nwith Scientific Concepts (Group
\nA \u2013 alternative medicine)
\nHamer\u2018s German New Medicine
\nIn brief, Hamer\u2018s German New Medicine
\nconsiders every cancer or cancer-like disease
\nto originate with a Dirk Hamer Syndrome
\n(\u2018DHS\u2019) which is a very difficult,highly acute,
\ndramatic and isolating shock, which affects
\nthe psyche,the brain and the organ.Basically,
\nthe resolution of the underlying problem is
\nbelieved to induce the cure of the disease.
\nAccording to the followers of Dr.Hamer,the
\nmethod is supposed to work well. Unfortu-
\nnately, the so-called successes have not been
\nreviewed by independent scientists; howev-
\ner, there are several reports on the internet
\nwhich show that 149, perhaps another 500
\ndeaths of cancer patients are due to the fact
\nthat cancer patients are not allowed to accept
\nany part of conventional medicine, not even
\npain medication (http:\/\/www.deathsect.com\/;
\nhttp:\/\/www.ariplex.com\/ama\/ama_ham2.
\nhtm; accessed on August 26th
\n, 2012).
\nAlternative Medicine in Oncology
\nKarsten M\u00fcnstedt Thomas Karl Riepen
\n149
\nFaith Healing
\nFaith healing is healing through spiritual
\nmeans. It is believed that healing of a per-
\nson can be brought about by religious faith
\nthrough prayer and\/or rituals, which again
\nwould stimulate a divine presence and power
\ntoward correcting the disease and disability.
\nA recent analysis shows that it is widely used
\nin pediatrics [1].Detailed analyses on efficacy
\nare lacking; however, some reports show that
\ncancer cure is out of the scope of faith heal-
\ning [2]. A meta-summary has confirmed the
\nfundamental importance of spirituality at
\nthe end of life and highlighted the shifts in
\nspiritual health that are possible when a ter-
\nminally ill person is able to do the necessary
\nspiritual work; however, in cancer survivors
\npraying for one\u2019s own health was inversely as-
\nsociated with good or better health status [3].
\nHomeopathy
\nHomeopathy is based on the idea that the
\ndilution of a substance that causes the symp-
\ntoms of a disease in healthy people will cure
\nthat disease in sick people. This dilution is
\ncalled \u201cpotentization\u201d. Some protagonists of
\nhomeopathy,like Dr.Wurster from Germany,
\nclaim that cancer may be cured by homeo-
\npathic means. In his book, Wurster describes
\nseveral cases which he believed to have been
\ncured by this method [4].There has not been
\nany independent proof for these claims.
\nDr. Hulda Clark\u2018s Therapy
\nDr. Hulda Regehr Clark (1928\u20132009)
\nclaimed that all human diseases were related
\nto parasitic infections, which she claimed to
\nbe able to cure by destroying the parasites by
\n\u201czapping\u201dthem with electrical devices which
\nshe marketed.So far there are no studies that
\ncould provide evidence for these claims.
\nAnthroposophical Medicine
\nAnthroposophical medicine mainly seeks to
\nextend, not replace, conventional medicine.
\nEspecially, the use of mistletoe extracts in
\nthe treatment of cancer has become quite
\npopular after it was first proposed by Rudolf
\nSteiner and anthroposophical researchers.
\nHowever, the anthroposophical concepts
\nare not founded on the phytotherapeutic
\neffects of mistletoe extracts, but the merely
\nbelieved similarity between the mistletoe,
\nwhich is a hemi-parasitic plant in a tree and
\na cancer in an organism. There have been
\nseveral trials which were designed to sup-
\nport the use of mistletoe in oncology. So far,
\nthe evidence to support the view that the
\napplication of mistletoe extracts has impact
\non survival is weak [5]. Even protagonists
\nof mistletoe therapy acknowledge that the
\nsurvival benefit that has been shown is
\nnot beyond critique [6]. Positive evidence
\ncomes from non-randomized, prospective,
\ncontrolled cohort studies in matched pair
\ndesign, or retrolective studies. Prospective,
\nrandomized controlled trials failed to show
\npositive effects [7,8].
\nApproaches Directly against the
\nDisease and Consistent with
\nScientific Concepts, but without
\nScientific Proof of Efficacy
\n(Group B \u2013 alternative medicine)
\nGalvanotherapy
\nGalvanotherapy, also called electrotherapy,
\nuses direct electric current especially to
\ntreat superficial tumors. Recently, modern
\nimaging techniques allowed positioning of
\ngalvanotherapy wires into tumors in deeper
\nparts of the body (e.g. magnetic resonance
\nimaging-guided galvanotherapy). So far,
\nthere has been only one trial on galvano-
\ntherapy, which is more or less a feasibility
\nstudy. It shows that there are some partial
\nremissions, some stable diseases and few
\nprogressive diseases in patients with pros-
\ntate cancer. However, the lack of a control
\narm and long-term results does not allow
\nany conclusions on whether this method
\nAlternative MedicineGERMANY
\nAcceptance of conventional medicine\u2018s disease concepts
\nIntendedtherapeuticgoal
\nYesNo
\ndirectlyagainstdiseasesupportiveonly
\nGalvanotherapy
\nDi Bella Multitherapy
\nHigh-dose vitamins;
\nDr. Rath\u2018s Vitamines
\nInsulin Potentiated erapy
\nGalavit
\nLaetrile
\nEnzyme erapy
\nDr. Coy\u2018s Diet
\nUkrain
\nHamer\u2018s German New Medicine
\nFaith healing
\nHomeopathy
\nDr. Hulda Clark\u2018s erapy
\nAnthroposophical Medicine
\nHomeopathy
\nAnthroposophical Medicine
\nComplementary
\nmedicine
\nA B
\nC
\n150
\ncould be recommended to patients with
\nprostate cancer or other cancer diseases [9].
\nDi Bella Multitherapy
\nDi Bella Multitherapy is based on the the-
\nory that growth hormones and prolactin are
\ninvolved in neoplastic growth.The treatment
\ncomprised a multidrug, custom-made medi-
\ncal treatment developed by Luigi Di Bella,
\nan Italian physician, who claimed effective-
\nness in blocking, if not curing altogether,
\nmost cancers. Because of his claims the Ital-
\nian government initiated trials which clearly
\nfailed to show that the treatment was effec-
\ntive [10,11].In spite of these results,relatives
\nof Luigi Di Bella are again promoting this
\nmethod and claiming higher survival rates
\nfor patients with metastatic breast cancer
\ncompared to the literature [12].
\nDr. Rath\u2018s Vitamins, High-
\ndose Vitamins
\nAccording to Dr.Rath,all diseases are caused
\nby a lack of lysine and vitamin C (http:\/\/
\nwww.quackwatch.org\/11Ind\/rath.html; ac-
\ncessed August 26th
\n, 2012). In the past, Dr.
\nRath claimed to have cured patients from
\ncancer.However,in his publications he pres-
\nents only evidence from preclinical studies.
\nSo far, there have been only few trials which
\nhave addressed the effects of high-dose vi-
\ntamins. Probably the most important study
\nconcluded that high-dose vitamin C therapy
\nis not effective against advanced malignant
\ndisease regardless of whether the patient has
\nhad any prior chemotherapy [13].
\nInsulin Potentiated Therapy
\nThis is a cancer treatment where insulin is
\nused in order to bring chemotherapeutic
\ndrugs selectively into cancer cells. It was
\ndeveloped by Donato Perez Garcia in the
\n1930s. Due to the combination of insulin
\nand chemotherapy it is believed that only
\n10-15 % of a standard dose is required [14].
\nJust recently, a study on this study was re-
\nported. However, it does not allow any con-
\nclusion on the possible importance of Insu-
\nlin Potentiated Therapy because all patients
\nwith prostate cancer received conventional
\nhormone therapy in conjunction with low-
\ndose chemotherapy and Insulin Potentiated
\nTherapy [15].
\nGalavit
\nThis is a Russian drug with an immunomod-
\nulatory potential. In 1999 and 2000 it was
\nrecommended as an anticancer drug. About
\n170 cancer patients mainly with advanced
\ndiseases were treated with galavit. However,
\nalmost all patients died from cancer dis-
\nease, although they were told that cure rates
\nwere expected to range around 70% (http:\/\/
\nde.wikipedia.org\/wiki\/Galavit).
\nLaetrile (vitamin B 17)
\nLaetrile has been promoted as a cancer cure
\nsince the early 1950s. In spite of the name,
\nit is not a vitamin in any sense.A recent sys-
\ntematic review found no evidence for ben-
\neficial effects for cancer, but a considerable
\nrisk of serious adverse effects from cyanide
\npoisoning [16].
\nEnzyme Therapy
\nGenerally, enzyme therapy is mainly used
\nas a complementary treatment in combina-
\ntion with conventional treatment. However,
\nin the early years it has also been promoted
\nas an anticancer treatment by the Scottish
\nphysician John Beard and later by Freund
\nand Kaminer in Vienna. Recently, the re-
\nsults of a randomized, phase III, controlled
\ntrial of proteolytic enzyme therapy versus
\nchemotherapy in pancreatic cancer was
\npublished, which showed that conventional
\ntreatment was clearly superior to enzyme
\ntherapy [17].
\nUkrain
\nUkrain is a combination product of ex-
\ntracts of the plant Chelidonium and thio-
\ntepa. A\u00a0recent systematic review concluded
\nUkrain to have potential as an anticancer
\ndrug, but this positive conclusion cannot
\nclearly been drawn because of the need for
\nindependent rigorous studies [18].
\nSupportive Treatments
\nInconsistent with Scientific
\nConcepts (Group C \u2013
\nalternative medicine)
\nHomeopathy
\nHomeopathy has been investigated in the
\nsupportive setting as well.Two independent
\nsystematic reviews have shown that there is
\nno convincing evidence for the efficacy of
\nhomeopathic medicines for other adverse
\neffects of cancer treatments [19,20]. There
\nis some evidence favoring topical calendula
\nfor prophylaxis of acute dermatitis during
\nradiotherapy and Traumeel S mouthwash
\nin the treatment of chemotherapy-induced
\nstomatitis; however, these trials need repli-
\ncating.
\nAnthroposophical Medicine
\nAnthroposophical medicine may possibly
\nimprove patients\u2019 wellbeing. A recent meta-
\nanalysis concludes that the methodological
\nquality of most studies was poor, but that
\nthe analyzed studies give some evidence
\nthat anthroposophical mistletoe treatment
\nmight have beneficial short-time effects on
\nquality-of-life-associated dimensions [21].
\nDealing with Alternative
\nMedicine
\nAs demonstrated above there is lacking
\nor insufficient evidence for all type A ap-
\nGERMANYAlternative Medicine
\n151
\nproaches. Furthermore, there is no proof for
\nany concept of alternative medicine which is
\nnot consistent with scientific concepts.Since
\nanalyses have shown that prognosis of pa-
\ntients who give themselves over to alterna-
\ntive medicine of this type is clearly inferior
\nto patients undergoing conventional thera-
\npies, these methods cannot be recommend-
\ned to patients, with no exceptions [22,23].
\nFor type B alternative treatments there
\nis some evidence for some of the named
\nmethods. Clearly, they cannot be recom-
\nmended in general, but there may be certain
\nsituations in which some may be considered
\nafter conventional treatments have failed.
\nIn this group of treatments, some deserve
\nfurther investigation and may eventually
\nbecome part of conventional treatment one
\nday.
\nWhen alternative medicine is used in a sup-
\nportive context, it may be used if patients
\nhave the desire to try this approach. This
\nconclusion is mainly due to the fact that the
\nmethods named here do not interfere with
\nthe use of conventional medicine. Since
\nevidence regarding these methods is low, it
\nseems important that new studies are con-
\nducted.
\nIn general, it is important to know how
\nto deal with alternative medicine. In 1983,
\nKlimm endeavored to address these issues
\nby devising 10 \u201cgolden\u201d rules which should
\ngovern CAM use in relation to convention-
\nal medicine [24]. Although these rules are
\nalmost 30 years old, they still seem appro-
\npriate today.These rules state:
\n1. Conventional medicine is the founda-
\ntion of a physician\u2019s work.
\n2. Practitioners of conventional medicine
\nmust recognize that CAM beliefs and
\nmethods exist and are being widely
\npracticed. Ignoring CAM\u2019s existence is
\nunwise.
\n3. Misjudgment of CAM represents igno-
\nrance and arrogance \u2013 gathering infor-
\nmation about CAM represents increas-
\ning knowledge.
\n4. The necessity of educating patients
\nabout medical facts is self-evident; edu-
\ncating them about CAM is essential,
\ntoo.
\n5. Practitioners of conventional medicine
\nmust keep themselves informed about
\nCAM.
\n6. CAM methods should be clearly reject-
\ned where conventional treatments have
\nproven benefits.
\n7. CAM methods can be allowed where
\nreasonable conventional treatment is
\nnot compromised.
\n8. Harmless CAM methods may be al-
\nlowed when conventional methods are
\nunlikely to be successful.
\n9. CAM practitioners and their methods
\nmust be critically observed.
\n10. Physicians who only practice CAM
\nshould be censured unless they are able
\nto prove the efficacy of their methods.
\nIf these rules are followed, physicians
\nshould be able to cope with dubious practi-
\ntioners and their offerings. Physicians must
\nbe aware that dubious practitioners of al-
\nternative medicine are very good at setting
\nup the concept of an enemy, namely con-
\nventional medicine. In contrast they pres-
\nent themselves as true advocates of patients\u2019
\nrights and well-being, overemphasizing the
\nside effects of conventional medicine and
\nsupporting their conclusions with selective
\ncitations.Rhetorically,they are well-educat-
\ned and very good at alienating patients by
\nvarious means.For example,they often omit
\nfacts which contradict their claims, cite only
\nthose which support their ideas and cre-
\nate pseudoscientific technical terms, which
\nsuggest competence. One major problem is
\nthe fact that critics of alternative medicine
\nare often the subject of personal attacks and
\ndiscreditation.
\nWhat Should Be Done?
\nPatients must be protected against dubi-
\nous practitioners of alternative medicine.
\nSince many of them are well organized, it
\nseems virtually impossible to achieve this
\ngoal without support from governmental
\nauthorities. It is suggested that it should be
\nruled that all alternative methods should
\nonly be used within clinical studies or under
\nclearly defined circumstances. An institu-
\ntion comparable to the European Medi-
\ncines Agency (EMEA) could be useful in
\norder to define such situations and decide
\nabout the mechanisms that could lead to ac-
\nceptance of the methods. In contrast, meth-
\nods with clearly proven inefficacy should
\nbe forbidden. On the other hand concepts
\nfor the scientific investigation of reasonable
\nmethods should be developed.
\nReferences
\n1. Baverstock A, Finlay F. Faith healing in paedi-
\natrics: what do we know about its relevance to
\nclinical practice? Child Care Health Dev. 2012
\nMay;38(3):316-20.
\n2. Blazer DG,Cohen HJ,George LK,Koenig HG,
\nVerhey A. Why John wasn\u2019t healed by prayer:
\nperspectives across disciplines. Int J Psychiatry
\nMed. 2011;42(4):377-91.
\n3. Ross LE, Hall IJ, Fairley TL, Taylor YJ, How-
\nard DL. Prayer and self-reported health among
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\nplement Med. 2008 Oct;14(8):931-8.
\n4. Wurster J. Die hom\u00f6opathische Behandlung
\nund Heilung von Krebs und metastasierter Kar-
\nzinome. Buchendorf (Irl) 2012.
\n5. Horneber MA, Bueschel G, Huber R, Linde
\nK, Rostock M. Mistletoe therapy in oncol-
\nogy. Cochrane Database Syst Rev. 2008 Apr
\n16;(2):CD003297
\n6. Kienle GS, Kiene H. Complementary cancer
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\ncal trials on anthroposophic mistletoe extracts.
\nEur J Med Res. 2007 Mar 26;12(3):103-19.
\n7. Kleeberg UR, Suciu S, Br\u00f6cker EB, Ruiter DJ,
\nChartier C, Li\u00e9nard D, Marsden J, Schadendorf
\nD, Eggermont AM; EORTC Melanoma Group
\nin cooperation with the German Cancer Soci-
\nety (DKG). Final results of the EORTC 18871\/
\nDKG 80-1 randomised phase III trial. rIFN-
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\n8. Steuer-Vogt MK, Bonkowsky V, Ambrosch P,
\nScholz M, Neiss A, Strutz J, Hennig M, Lenarz
\nT, Arnold W.The effect of an adjuvant mistletoe
\nAlternative MedicineGERMANY
\n152
\nWMA news
\nThe Fifth Geneva Conference on Person-
\ncentered Medicine was held on April 28th
\nMay 2nd
\n, 2012, the latest in the series of
\nannual Geneva Conferences on this per-
\nspective since May 2008 [1-4].The gradual
\nbuilding of this conceptual and method-
\nological perspective [5-8] has proceeded
\nthrough collaboration with major global
\nmedical and health organizations, aca-
\ndemic institutions, and an expanding com-
\nmunity of committed international experts
\nall engaged in an International Network
\n[9], now International College of Person-
\ncentered Medicine [10].
\nAs for all previous Geneva Conferences, the
\nmain venue of the Fifth one was the Mar-
\ncel Jenny Auditorium and auxiliary halls of
\nthe Geneva University Hospital. Within
\nthe framework of growing institutional col-
\nlaboration (from 27 entities in the previ-
\nous to 33 in the latest), the Fifth Geneva
\nConference on Person-centered Medicine
\nwas organized by the International College
\nof Person-centered Medicine (ICPCM) in
\ncollaboration with the World Medical As-
\nsociation (WMA), the World Health Or-
\nganization (WHO), the International Alli-
\nance of Patients\u2019Organizations (IAPO),the
\nInternational Council of Nurses ICN), the
\nInternational Federation of Social Workers
\n(IFSW), the International Pharmaceutical
\nFederation (FIP), the World Organization
\nof Family Doctors (WONCA), the World
\nFederation for Mental Health (WFMH),
\nthe World Federation of Neurology
\n(WFN),the Council for International Or-
\nganizations of Medical Sciences (CIOMS),
\nthe International College of Surgeons
\n(ICS), the International Federation of
\nGynecology and Obstetrics (FIGO), the
\nMedical Women\u2019s International Associa-
\ntion (MWIA), the International Federation
\nof Ageing (IFA), the World Association
\nfor Sexual Health (WAS), the European
\nFederation of Associations of Families of
\nPeople with Mental Illness (EUFAMI), the
\nWorld Federation for Medical Education
\ntreatment programme in resected head and neck
\ncancer patients: a randomised controlled clinical
\ntrial. Eur J Cancer. 2001 Jan;37(1):23-31.
\n9. Vogl TJ, Mayer HP, Zangos S, Selby JB Jr, Ack-
\nermann H, Mayer FB. Prostate cancer: MR
\nimaging-guided galvanotherapy–technical de-
\nvelopment and first clinical results. Radiology.
\n2007 Dec;245(3):895-902.
\n10. Italian Study Group for the Di Bella Multith-
\nerapy Trials. Evaluation of an unconventional
\ncancer treatment (the Di Bella multitherapy):
\nresults of phase II trials in Italy. BMJ. 1999 Jan
\n23;318(7178):224-8.
\n11. 11. Buiatti E, Arniani S, Verdecchia A, Tomatis
\nL.Results from a historical survey of the survival
\nof cancer patients given Di Bella multitherapy.
\nCancer. 1999 Nov 15;86(10):2143-9.
\n12. Di Bella G. The Di Bella Method (DBM) im-
\nproved survival, objective response and perfor-
\nmance status in a retrospective observational
\nclinical study on 122 cases of breast cancer. Neu-
\nro Endocrinol Lett. 2011;32(6):751-62.
\n13. Moertel CG, Fleming TR, Creagan ET, Ru-
\nbin J, O\u2019Connell MJ, Ames MM. High-dose
\nvitamin C versus placebo in the treatment of
\npatients with advanced cancer who have had
\nno prior chemotherapy. A randomized double-
\nblind comparison. N Engl J Med. 1985 Jan
\n17;312(3):137-41.
\n14. Ayre SG, Perez Garcia y Bellon D, Perez Garcia
\nD Jr.Insulin potentiation therapy: a new concept
\nin the management of chronic degenerative dis-
\nease. Med Hypotheses. 1986 Jun;20(2):199-210.
\n15. Damyanov C, Gerasimova D, Maslev I,
\nGavrilov V. Low-dose chemotherapy with in-
\nsulin (insulin potentiation therapy) in combi-
\nnation with hormone therapy for treatment of
\ncastration-resistant prostate cancer. ISRN Urol.
\n2012;2012:140182.
\n16. Milazzo S, Ernst E, Lejeune S, Boehm K,
\nHorneber M. Laetrile treatment for can-
\ncer. Cochrane Database Syst Rev. 2011 Nov
\n9;(11):CD005476.
\n17. Chabot JA,Tsai WY, Fine RL, Chen C, Kumah
\nCK, Antman KA, Grann VR. Pancreatic pro-
\nteolytic enzyme therapy compared with gem-
\ncitabine-based chemotherapy for the treatment
\nof pancreatic cancer. J Clin Oncol. 2010 Apr
\n20;28(12):2058-63.
\n18. Ernst E, Schmidt K. Ukrain \u2013 a new cancer
\ncure? A systematic review of randomised clinical
\ntrials. BMC Cancer. 2005 Jul 1;5:69.
\n19. Kassab S, Cummings M, Berkovitz S, van Hase-
\nlen R, Fisher P. Homeopathic medicines for
\nadverse effects of cancer treatments. Cochrane
\nDatabase Syst Rev. 2009 Apr 15;(2):CD004845.
\n20. Milazzo S, Russell N, Ernst E. Efficacy of ho-
\nmeopathic therapy in cancer treatment. Eur J
\nCancer. 2006 Feb;42(3):282-9.
\n21. B\u00fcssing A, Raak C, Ostermann T. Quality of
\nlife and related dimensions in cancer patients
\ntreated with mistletoe extract (iscador): a meta-
\nanalysis. Evid Based Complement Altern Med.
\n2012;2012:219402.
\n22. Bagenal FS, Easton DF, Harris E, Chilvers CE,
\nMcElwain TJ. Survival of patients with breast
\ncancer attending Bristol Cancer Help Centre.
\nLancet. 1990 Sep 8;336(8715):606-10.
\n23. Han E, Johnson N, DelaMelena T, Glissmeyer
\nM, Steinbock K. Alternative therapy used as
\nprimary treatment for breast cancer negatively
\nimpacts outcomes. Ann Surg Oncol. 2011
\nApr;18(4):912-6.
\n24. Klimm HD. Der Krebskranke und sein Arzt
\nim Spannungsfeld medizinischer und paramed-
\nizinischer Behandlungsmethoden. Kassenarzt
\n1983; 9: 40\u20134.
\nKarsten M\u00fcnstedt,
\nThomas Karl Riepen
\nDepartment of Obstetrics
\nand Gynecology,
\nJustus-Liebig-University
\nCorresponding author:
\nProf. Dr. med. Karsten M\u00fcnstedt
\nKlinikstra\u00dfe 33
\nD-35392 Giessen, Deutschland
\nTel.: +49 641 985-45120
\nFax.: +49 641 1313443
\nE-mail: karsten.muenstedt@
\ngyn.med.uni-giessen.de
\nThe Fifth Geneva Conference on
\nPerson-centered Medicine
\n153
\nWMA news
\n(WFME), the International Association
\nof Medical Colleges (IAOMC), the Paul
\nTournier Association, the World Associa-
\ntion for Dynamic Psychiatry (WADP), the
\nEuropean Association for Communication
\nin Health Care (EACH), the WHO Col-
\nlaborating Center for Public Health Edu-
\ncation and Training at Imperial College
\nLondon, the International Federation of
\nMedical Students\u2019 Associations (IFMSA),
\nthe Zagreb University Medical School,
\nthe University of Gothenburg Centre for
\nPerson-Centred Care, the George Wash-
\nington University Institute on Spirituality
\nand Health, the Peruvian University Cay-
\netano Heredia, the Universita degli studi di
\nMilano, the Medical University of Plovdiv,
\nand the Buckingham University Press, and
\nwith the auspices of the Geneva University
\nMedical School and Hospitals.
\nWith the overall theme of Chronic Diseases:
\nPerson- and People-centered Perspectives, the
\nFifth Geneva Conference on Person-cen-
\ntered Medicine encompassed a number of
\nsessions larger than ever before and com-
\nprised plenary symposia, workshops, brief
\noral presentations, and posters, all having
\nan international framework. Additionally,
\ninstitutional work meetings were held fo-
\ncusing on the guiding principles for person-
\ncentered clinical care,person-centered diag-
\nnosis, an organizational informational base,
\nand special institutional projects.
\nThe Conference Core Organizing Com-
\nmittee was composed of Juan E. Mezzich
\n(President,International College of Person-
\nCentered Medicine), Jon Snaedal (World
\nMedical Association,President 2007-2008),
\nChris van Weel (World Organization of
\nFamily Doctors,President 2007-2010),Mi-
\nchel Botbol (World Psychiatric Association
\nPsychoanalysis in Psychiatry Section),Ihsan
\nSalloum (World Psychiatric Association
\nClassification Section), Tesfamicael Ghe-
\nbrehiwet (International Council of Nurses),
\nShanthi Mendis (WHO Chronic Diseases
\nDepartment), and Ruben Torres (PAHO\/
\nWHO Health Systems Area).
\nFinancial or in-kind support for the Con-
\nference was provided by 1) the International
\nCollege of Person-centered Medicine (core
\nfunding),2) the University of Geneva Med-
\nical School (auditorium services and coffee
\nbreaks), 3) the Paul Tournier Association
\n(conference dinner), and 4) Participants\u2019
\nregistration fees.
\nPre-conference Work Meetings
\n– The first Work Meeting on April 28,
\n2012 focused on activities and projects
\nrelated to the organizational and infor-
\nmational framework of ICPCM.
\n– The International Journal of Person
\nCentered Medicine was launched at the
\nFourth Geneva Conference on Person
\nCentered Medicine in 2011. As the
\nofficial journal of the International
\nCollege of Person Centered Medicine
\n(ICPCM) and created in partnership
\nwith the Buckingham University Press,
\nthe Journal is advancing the global
\ncommunication of scholarship and
\nresearch for personalized healthcare
\n[11]. As it was reported and discussed,
\nthe full first volume of quarterly issues
\nhas been completed. The first issue of
\nthe second volume was presented at
\nthe Conference. In this short time,
\nthe journal has achieved considerable
\nstrength and prestige and is attracting
\na continuous stream of quality manu-
\nscripts from all regions of the world.
\nA productive meeting of the Journal\u2019s
\nEditorial Board took place at the end
\nof the first day.
\n– Upgrading of College and Journal web-
\nsites. The main institutional website for
\nthe initiative on person-centered medi-
\ncine was established early in the course
\nof the Geneva Conferences process
\nand has been upgraded regularly [11].
\nAdvanced videos and interactive capa-
\nbilities are being planned. The website
\nof the International Journal of Person
\nCentered Medicine was launched along
\nwith the Journal itself and is serving as
\nan increasingly effective instrument to
\naccess the Journal as well as acquiring
\nand managing subscriptions.
\n– Use of Social Media in the Promotion of
\nPerson-centered Medicine. Within the
\nframework of the Internet and the
\nWorld Wide Web (WWW), there
\nis a popular trend to engage in Social
\nNetworking Sites. The potential use of
\nthese resources to promote person-cen-
\ntered medicine activities was discussed
\nalong with concerns and limitations.
\n– International Conference and Publica-
\ntion Series. Dealing primarily with per-
\nLogos of the institutions collaborating on the organization of the Fifth Geneva Conference on
\nPerson-centered Medicine.
\n154
\nWMA news
\nson-centered care for specific clinical
\nconditions, this project is due to start
\nin the second half of 2012. Its general
\nplan was outlined during the initial
\nwork meetings and it was the subject of
\na panel discussion during the course of
\nthe core conference.
\n– Person Centered Medicine Book Projects.
\nMonographs have a distinct place in the
\ndevelopment of the field,and in person-
\ncentered medicine there are early prec-
\nedents such as Paul Tournier\u2019s Medicine
\nde la Personne in Switzerland [13], as
\nwell as recent contributions appearing
\nin Croatia [14] and France [15]. Future
\nprojects were outlined for major text-
\nbooks with systematic presentations of
\nthe status quo in the field, as well as on
\nbroad specialty and discipline areas.
\nThe second ICPCM Work Meeting focused
\non Person-centered Integrative Diagnosis
\n(PID) and Related Diagnostic Projects.The
\nwork is predicated on the understanding
\nthat one of the key aspects of clinical care
\nis comprehensive diagnosis as fundamental
\nbasis for treatment planning and care. This
\nrenders person-centered diagnosis as crucial
\nfor the implementation of person-centered
\nmedicine.The first session focused on mov-
\ning forward the PID development process
\nfrom a theoretical model to practical guide,
\nstarted in psychiatry and mental health.The
\nconceptual base and structure of the model
\nwere published in the Canadian Journal of
\nPsychiatry [16] and more recently a concep-
\ntual appraisal was conducted and published
\n[17].The presentations in this initial session
\ndealt with general development strategies,
\nthe heuristic value of ontological analysis,
\nthe instrumentation of the various domains
\nand levels of the PID, the utilization of
\ndescriptive categories, dimensions and nar-
\nratives, and the establishment of common
\nground among clinicians, patients and fam-
\nilies towards the formulation of a compre-
\nhensive diagnosis and a plan of care.
\nAn ensuing session on Related Diagnostic
\nProjects discussed first the ongoing revision
\nof the Latin American Guide for Psychiatric
\nDiagnosis (Gu\u00eda Latinoamericana de Diag-
\nn\u00f3stico Psiqui\u00e1trico) (GLADP) [18-19],
\nan official Priority Program of the Latin
\nAmerican Psychiatric Association, and its
\nnext steps leading to the publication of the
\nrevised version towards the end of 2012.
\nOther presentations presented updates on
\nthe French Diagnostic Project, the World
\nFederation for Mental Health Assessment
\nProject, a pediatric diagnostic plan, and the
\ngrounds towards an internal and family
\nmedicine diagnostic effort.
\nThe third ICPCM Work Meeting was
\ndedicated to the ongoing development of
\nPerson-centered Clinical Care Guiding
\nPrinciples. Earlier work on this project was
\nsummarized and placed in perspective as
\nan orientation to the next steps. It was fol-
\nlowed by several brief presentations made
\nby members of the respective workgroup,
\nparticularly those representing geriatric, pe-
\ndiatric, family medicine and mental health
\nperspectives.
\nAn extended 3-hour working luncheon
\ntook place on the second pre-core-con-
\nference day to further discussions in vari-
\nous ICPCM workgroups, each meeting
\nseparately. The group participants included
\nthose who had made earlier initial presenta-
\ntions as summarized above, and those deal-
\ning with person-centered partnership and
\nperson-centered young health professionals
\n(the Janus Group).This extended session fa-
\ncilitated the formulation of conclusions and
\nthe delineation of next steps. The conclu-
\nsions were briefly presented in the plenary
\nsession.
\nComplementing the scientific program,
\ntwo major ICPCM institutional meetings
\ntook place during the Fifth Geneva Con-
\nference. One was a face-to-face meeting
\nof the Board, which regularly manages the
\norganization through monthly teleconfer-
\nences. The other was the General Assembly
\nwhich heard a report from the Board, re-
\nviewed prospective activities (the Sixth Ge-
\nneva Conference and other events, ongoing
\nadvancement of the International Journal
\nand other publications, continued work of
\nresearch groups and projects, and further
\ndevelopment of the ICPCM institutional
\nstructure and governance), and discussed a
\ndraft of the Geneva Declaration on Person-
\ncentered Care for Chronic Diseases, an ef-
\nfort for the first time to extend on public
\npolicy an impact of the main Conference
\nideas.
\nCore Conference
\nThe Core Conference was opened on April
\n30 by Prof. Panteleimon Giannakopoulos,
\nVice-Dean of the Geneva University Medi-
\ncal School, and Dr. Manuel Dayrit, Direc-
\ntor, World Health Organization. They were
\njoined in the presidium by the members of
\nthe Board of the International College of
\nPerson Centered Medicine.
\nThe opening address was delivered by the
\nICPCM president, who presented the
\nprogress report, ranking as the most im-
\nportant the consolidation of the Interna-
\ntional College of Person-centered Medicine
\nwhich emerged from the International Net-
\nwork and the Geneva Conferences [9, 10].
\nAmong the vital activities is the engage-
\nment of a growing number (33 at present)
\nof international medical and health bodies
\n(including WHO for the third time) as
\nco-sponsors of the Fifth Geneva Confer-
\nence, the strengthening of the International
\nJournal of Person Centered Medicine as a joint
\nventure with the University of Bucking-
\nham Press [11], activities of the workgroups
\nparticularly those on Person-centered Care
\nGuiding Principles and Person-centered
\nIntegrative Diagnosis (the latter reflected
\nin several journal publications and books)
\n[16-19], WHO supported path-opening
\nresearch activities initiated towards the sys-
\ntematic conceptualization and measurement
\nof person-centered care, and collaboration
\nin the anticipated launching of an Interna-
\ntional Conference and Publication Series
\n155
\nWMA news
\naddressing specific clinical conditions. The
\npreparation for the first time of a Geneva
\nDeclaration focused on the Conference\u2019s
\nmain theme (chronic diseases) promises to
\nextend substantially the impact of our flag-
\nship event [20].
\nThe first scientific session of the Core
\nConference was the Symposium on the
\nEffectiveness of Person-centered Care for
\nChronic Diseases. It started with apprais-
\ning the contextualized approach to endur-
\ning clinical complexity. After affirming the
\ncrucial role of relationships and trust in per-
\nson-centered care, it unfolded the principal
\naspects of context in terms of family, social
\nnetwork, physical (including left and right
\nbrain integration), financial, occupational,
\nspiritual and health literacy concerns. Next,
\nwhen focusing on well-being and work on
\npersonality development it was recognized
\nas highly important, particularly for dealing
\nwith people\u2019s chronic diseases. Finally, there
\nwas addressed the issue of the critical role
\nthat the patient can and should play in the
\ncases of chronic diseases, identifying specif-
\nic approaches for ensuring that the patient\u2019s
\nvoice is heard in clinical and public health
\nsettings.
\nThe Workshop on Person-centered Care for
\nOncological Diseases started with a review
\nof informational procedures to support the
\npatient\u2019s decision making in cancer care.
\nThis was followed by a discussion on cancer
\npain which is currently acquiring a strong
\nperson-centered framework. This involves
\nthe need for a comprehensive evaluation of
\nthe situation and of the patient\u2019s attitudes
\nand preferences, paying considerable at-
\ntention to good clinical communication,
\nthe patient engagement, and participation
\nin decision making. Next, the interface be-
\ntween cancer and sexual health was focused
\non. Substantial numbers of cancer patients
\nexperience long-term sexual dysfunctions,
\nand these need to be addressed emphasizing
\nexchange of information and fluent com-
\nmunication between clinicians and patients.
\nConcluding the session, person-centered
\ncare at the end of life was discussed. This
\nencompassed ensuring empathy, family en-
\ngagement,advance planning,symptom con-
\ntrol, fluid management, place of death, and
\nspiritual support.
\nThe Workshop on Person-centered Care for
\nChronic Psychiatric & Neurological Dis-
\neases, addressed the first two of the most
\ncommon psychiatric disorders, depression
\nand substance abuse, that tend to be chronic
\nand rank among the top human disease
\nburdens. The benefits of employing a holis-
\ntic theoretical framework, attending to the
\npatient\u2019s experience, the range of contribut-
\ning factors, and the integration of care were
\nemphasized. The personal integrity to be
\nconsidered when treating the patient with
\ndementia was discussed next. This would
\ninclude a comprehensive examination of
\nthe patient\u2019s clinical condition as well as full
\nconsideration of his\/her needs and prefer-
\nences. Concerning child and adolescent
\nchronic psychiatric condition, emphasis was
\nplaced on attending to the specific objec-
\ntive and subjective dimensions of the child\u2019s
\nillness and health. Finally, a comparative
\nanalysis was presented of recovery-oriented
\nand person-centered models of care, not-
\ning that the former developed and remains
\nprincipally in the mental health field, while
\nthe latter has broader origins and presence
\nin general medicine and comprehensive
\nhealth. Both largely coincide in theoreti-
\ncal perspectives, ethical commitment, and
\nclinical procedures.
\nThe Poster Session was held during lunch
\ntime on the first day of the Core Conference.
\nThe presentations reviewed the relations
\nof person-centered care and, respectively,
\nEastern Orthodox psychotherapy, reduction
\nof self-report uncertainty in chronic heart
\nfailure, care experiences among hospitalized
\nSwedish patients, experiences of \u201cbroken
\nheart\u201d syndrome patients, culture-specific
\npatient education in Bulgaria, adherence
\nand self-management in hypertension, and
\ncontextualization of functional symptoms
\nin primary health care.
\nThe Workshop on Person-centered Care
\nfor Chronic Circulatory and Respiratory
\nConditions started with a presentation on
\nexperiences of patients with acute coro-
\nnary syndromes. These challenging situa-
\ntions emphasize the importance of indi-
\nvidual treatment plans and person-centered
\nPart of the collaborating organizations\u2019 leaders, speakers and participants at the Fifth Geneva Conference 2012
\n156
\nWMA news
\ncare in order to help patients return to the
\nactivities of regular life. Next, the outcome
\nstudies on person-centered cardiovascu-
\nlar care were reviewed. Recommendations
\nwere offered to design such studies from the
\npatients\u2019 perspectives and samples of such
\ndesigns were presented. It was followed by
\na presentation on person-centeredness in
\nintensive care medicine. It was noted that
\nphysiological circumstances often lead to
\nlimit the patients\u2019 choices in intensive care
\nunits. Therefore clinicians have a high de-
\ngree of responsibility to ensure that care is
\nindividualized and the patients\u2019 individual-
\nity is respected.
\nThe Workshop on Self-Care and Integra-
\ntive Approaches to Non-communicable
\nDiseases began with a WHO review on the
\nevidence of self care for non-communicable
\ndiseases, and ended with a review of educa-
\ntional efforts needed in this field. It noted
\nthat today\u2019s chronic and non-communi-
\ncable diseases (NCDs) are the main cause
\nof morbidity and mortality in almost all
\ncountries around the world. It addressed
\napproaches needed within our health and
\neducational systems to increase awareness,
\nknowledge and skills to prevent and man-
\nage cardiovascular disease, cancer, diabetes
\nand chronic lung disease. It also pointed out
\nthat most NCDs are preventable and that
\nmost risks factors (smoking, obesity, lack of
\nphysical activity,hypertension,and excessive
\nuse of alcohol) can be managed if identified
\nearly. It emphasized that all approaches to
\ncontrol NCDs must be person-centered and
\nthat continuity of care is crucial for achiev-
\ning better health outcomes at individual and
\npopulation levels.
\nThe Symposium on Person-centered Care
\nand Modern Clinical Practice started with
\na presentation on ethics and social deter-
\nminants of health. Next it addressed case-
\nbased models of practice, arguing that these
\nare more relevant than evidence-based ones
\nfor clinical decision-making in person-
\ncentered medicine. The casuistic approach
\nseeks warrants from clinical research,
\npathophysiologic rationales, personal expe-
\nrience, patient\u2019s goals and preferences, and
\nsystem features, which all must be weighed
\nand negotiated by the clinician and the pa-
\ntient to arrive at reasonable decisions. The
\nfollowing presentation discussed Bayes-
\nian statistical procedures for systematically
\ntaking into consideration local factors and
\nthe results of large multi-center trials lead-
\ning to more accurate estimations of inter-
\nvention effects than in case each factor is
\nconsidered separately, and potentially con-
\ntributing to the coalescence of evidence-
\nbased and person-centered models. Finally,
\nremarks were offered stimulated by the
\nabove presentations and an ongoing review
\nof the literature towards an integrated clin-
\nical care model.
\nThe Symposium on Transformative Edu-
\ncation for Person- and People- centered
\nCare started with a presentation of the
\nWHO Transformative Education Initia-
\ntive. It pointed out that the World Health
\nReport of 2006 documented the severe
\nshortages of health professionals around
\nthe globe and their poor preparation for
\nthe needs of health service delivery. There-
\nfore, an adequate transformation of health
\nprofessional education should put popu-
\nlation health needs and expectations at
\nthe centre and should be directed by the
\nreality of health service delivery. Next an
\noutline was given on the Health Improve-
\nment Card being developed by the World
\nHealth Professional Alliance to help pre-
\nvent chronic diseases.The Card would seek
\nto assess lifestyle and biometric risk factors
\nto enable individuals and their health pro-
\nfessionals to take preventive actions. Then
\nprofessional training to optimize team
\nwork for person-centered care was dis-
\ncussed. It noted that in addition to short-
\nage of health professionals there are severe
\nlimitations in opportunities for health pro-
\nfessional students of different disciplines
\nto learn together and interact adequately
\nduring their training. It caused innovative
\nand strategic responses to this challenge.
\nFinally, recommendations from academic
\nmedical centers were formulated for devel-
\noping person-centered medical education
\nand training. These include group learn-
\ning with patients and families, shadowing,
\nvideo-recording, and role plays.
\nThe Symposium on Spirituality and
\nHealth started with a presentation on
\nclinical applications towards integrating
\nspirituality into healthcare. It proposed
\nthe recognition of spirituality as a com-
\nponent of health and as an important el-
\nement of compassionate person-centered
\ncare, as well as outlined a procedure for a
\nbio-psycho-social-spiritual assessment and
\nplan. Another presentation discussed that
\nhealing of the body and the spirit is an
\nintegral part of many faith traditions and
\nthe lessons learned by chaplains caring for
\npeople living with AIDS. It was followed
\nby a presentation examining religious and
\nsecular counseling with regard to faith, the
\nneed for science, and the variety of avail-
\nable values. Remarks on personal spiritual
\nexperiences while facing health challenges
\nand a scholarly summary of the presenta-
\ntions completed the symposium.
\nThe Workshop on Conceptualization and
\nMeasurement of Person- and People- cen-
\ntered Care encompassed first the presenta-
\ntion of a literature review on conceptual-
\nizing person- and people-centeredness in
\nprimary health care. It explored the no-
\ntions of person and people within primary
\ncare as defined in the 1978 Alma Ata Dec-
\nlaration and the 2008 World Health Re-
\nport, as well as their relevance to the dis-
\ncussion of equity and social justice, causes
\nof ill health, and the integration of primary
\ncare and public health. This was followed
\nby a set of short papers on the conceptual
\nrefinement and further development of a
\nprototype Person-centered Care Index
\n(PCI) conducted by the International Col-
\nlege of Person-centered Medicine.The ini-
\ntial work engaged broad international pan-
\nels composed of clinicians, public health
\nexperts, patients and family representa-
\ntives, who through Delphi-type consulta-
\n157
\nWMA news
\ntions discussed the results of a review of
\nthe literature and identified key elements
\nof person-centered care, which led to the
\ndesign of a prototype PCI. This was sub-
\njected to an initial evaluation of its content
\nvalidity and general applicability to health
\nsystems. More recently, the prototype PCI
\nwas revised to improve the wording of its
\nitems and rating arrangement and was
\nsubjected to pilot studies of its internal
\nstructure, of its content validity among
\nmental health users in London, and of its
\ninter-rater reliability across various types
\nof health programs in Santa Cruz, Califor-
\nnia and Lucknow, India.
\nThe Workshop on Swedish Clinical Re-
\nsearch on Person-Centered Care encom-
\npassed six papers from a specialized and
\nmultidisciplinary research center at Go-
\nthenburg University, Sweden. It opened
\nwith a review of fundamentals in person-
\ncentered care. Two ensuing papers dealt
\nwith the effects of person-centered care
\nconcerning hip fractures and heart failure.
\nAnother paper discussed patient reported
\noutcomes. The implementation of person-
\ncentered care was the subject of the fifth
\npaper. The last one discussed organization
\nof person-centered care
\nThe Workshop on Person-centered Pain
\nManagement started with an examination
\nof the complexity and challenges imposed
\nby pain in chronic conditions such as can-
\ncer. Maximizing quality of life must be a
\nguiding principle and a multidisciplinary
\nteam approach is usually required. Progress
\nmay be achieved by evaluating systemati-
\ncally treatment options towards enhanc-
\ning health outcomes. When considering
\ninvasive procedures for the management
\nof cancer pain, attending to the patient\u2019s
\nwishes is crucial. Maximizing quality of
\nlife and social integration are important
\noutcomes here. Another presentation pos-
\nited that pain management largely depends
\non bio-psycho-social understanding of
\nthe situation, as well as on analyzing pain
\nmechanisms, patients\u2019 attitudes, and the
\nrole of culture. A presentation on person-
\ncentered pain management in the realm of
\npalliative medicine completed this work-
\nshop.
\nThe Workshop on Shared Care Plan and
\nPersonalized Diagnosis focused on the
\nstructure of a treatment plan with particu-
\nlar attention to the development of whole-
\nhealth objectives. It proposed the integra-
\ntion of general medical, psychological and
\nsocial interventions to promote wellness
\noutcomes.
\nThe Oral Presentations Session on Con-
\nceptual Studies on Person-centered Care
\nbegan with a presentation of neuroscience
\nperspectives towards person-centered care.
\nIt was followed by a presentation on the
\nprospects of personalizing education and
\nmental health through neuroscience and
\nneuroesthetics. Next the Islamic heritage
\nand traditions concerning person-centered
\nmedicine were discussed. Person-centered
\ngynecology and obstetrics was the subject
\nof the following paper. Then a review of
\npersonality concepts and their impact on
\nthe development of Russian psychology
\nand psychiatry was presented. Providing
\nchild-centered hospital care to Serbian chil-
\ndren was reported in the presentation on a
\nrights-based approach. Another paper dealt
\nwith building a person-centered culture in
\nprevention and recovery care service. A role
\nof traditional birth attendants in promoting
\nperson-centered care in Asia was reviewed.
\nFinally, a paradigm in pediatrics to deliver
\nfamily- and child-centered care was dis-
\ncussed.
\nThe other Oral Presentations Session en-
\ncompassed Experimental Studies on Per-
\nson-centered Care. The Project PARIS:
\nParents and Residents in Session is study-
\ning the teaching of person- and family-cen-
\ntered care in a pediatrics residency program
\nin New York. An innovative medical school
\nin Madrid reported on the effects of an ear-
\nly clinical experience program in a medical
\nschool aimed at raising awareness of the re-
\nlational and communicative needs of clini-
\ncal practice and of the structure and perfor-
\nmance of health systems. The UK Program
\non Type 2 Diabetes presented risk assess-
\nment results and their implications for prac-
\ntitioners and patients,as well as a systematic
\nreview of barriers and facilitators in the life
\nstyle modifications for prevention purposes.
\nThere was a Swedish presentation on their
\nresults when analysing the relationship be-
\ntween organizational culture and the imple-
\nmentation of person-centered care. A study
\nfrom Cyprus assessed the implementation
\nof person-centered medicine in treating
\npatients with dementia. Victoria, Australia,
\npresented a review on the importance of in-
\nterdisciplinary support to manage medica-
\ntions in an optimal way when dealing with
\npatients with multiple chronic conditions.
\nA report from Milan focused on reliability
\nand validity evaluation of a person-centered
\nclinical method.
\nThe Workshop on Person-centered Health
\nSystems started with a presentation from
\nWHO on integrated health systems, in-
\ncluding conceptual and empirical elements.
\nThe other presentation from WHO argued
\nthat a person-centered approach is of ut-
\nmost need to attain the state of reproductive
\nhealth. It concluded that the adoption of a
\nperson-centered approach will often pre-
\nclude the need for complicated checklists
\nand contribute greatly to improving qual-
\nity of care and patient satisfaction. A third
\npresentation represented a contribution
\nto the early assessment and prevention of
\nburn-out in the form of a person-centered
\napproach to human resources management
\nin health care. The final presentation dealt
\nwith educational factors in health systems.
\nIt pointed out that human interactions are
\nthe most important aspect of health sys-
\ntems, that learning opportunities are em-
\nbedded in health system facilities, and that
\nan operational linkage between education
\nand health systems needs a clear definition
\nat the different stages of training and prac-
\ntice paying attention to local, national and
\nglobal contexts.
\n158
\nWMA news
\nThe Workshop on Internet and Person-
\ncentered Medicine was based on the pre-
\nsenter\u2019s experience and perspectives on the
\nuse of the internet for health professional
\npurposes. He suggested that the future of
\nscientific professional communication is on
\nthe web, promoting useful and dynamic in-
\nteractions among institutional members, for
\nwhich videos may be quite helpful, and with
\nwebmasters continuously evaluating the of-
\nfered contents.
\nA Scientific Panel was organized to launch
\nan International Conference and Publica-
\ntion Series on Person-centered Healthcare.
\nIt embraced brief presentations on the aims
\nand scope of the series and on their impli-
\ncations as perceived by officers of public
\nhealth, clinical, educational and patient or-
\nganizations.
\nThe Session on Region and Country Ex-
\nperiences on Person- and People- centered
\nCare started with a presentation from Thai-
\nland on the measurement of responsiveness
\nas part of person-centered healthcare. It
\nused a set of questionnaires and vignettes
\nto assess the experience at the intersection
\nbetween person and health system. A pre-
\nsentation from Europe focused on the uti-
\nlization of health ontologies (terminology,
\nnomenclature,taxonomy) to discuss person-
\ncenteredness (as illustrated by the Person-
\ncentered Integrative Diagnosis model) and
\npersonal factors (as defined in WHO\u2019s In-
\nternational Classification of Functioning
\nand Health). It posited that limitations in
\nconceptualization and terminology are key
\nbarriers to scientific progress and the con-
\nsolidation of a new scientific field. Another
\npresentation described a collaborative proj-
\nect to promote person-centered care for
\ndiabetes and depression in South Africa,
\nLesotho, Botswana, Swaziland and Uganda.
\nIt demonstrated that a holistic person-cen-
\ntered approach may help the recognition,
\nmanagement and outcomes of diabetes and
\ndepression. The final presentation discussed
\nAfrican contributions to decision-making
\nin person-centered health practice. It drew
\non indigenous knowledge, such as the isi-
\nZulu term \u201cindaba\u201d that refers to a meeting
\n(such as that between a health professional
\nand a service user) that is so substantive that
\nit is an end in itself, and therefore person-
\ncentered.
\nThe Workshop on Dance Therapy in Per-
\nson-centered Medicine reflected interest in
\nthe field of experiential creative and artistic
\nopportunities aimed at ameliorating illness
\nand enhancing well-being. Initial intro-
\nductions referred to the numerous studies
\ndocumenting the value of dance for health.
\nIt may contribute to self-awareness, expres-
\nsion of feelings, improved communication,
\nand personal development. One presenta-
\ntion focused on expressive psychoanalytic
\ndance therapy; the other on integrative
\ndance\/movement psychotherapy addressed
\nto facilitating the fulfillment of a personal
\nlife project. Each included an experiential
\npracticum.
\nThe Special Session on Stakeholders\u2019 Poli-
\ncies and Contributions for Person- and
\nPeople-centered Care took place with
\nthe participation of major global medical
\nand health institutions co-sponsoring the
\nFifth Geneva Conference. It started with
\nintroductory statements from officers of
\nthe World Health Organization and the
\nInternational College of Person-centered
\nMedicine. They were followed by contribu-
\ntions from the World Medical Association,
\nWONCA, International Alliance for Pa-
\ntients\u2019 Organizations, International Coun-
\ncil of Nurses, International Federation of
\nSocial Workers, International Pharmaceu-
\ntical Federation, Council for International
\nOrganizations of Medical Sciences, World
\nFederation for Mental Health, Internation-
\nal Federation of Gynecology & Obstetrics,
\nInternational Federation of Medical Stu-
\ndents\u2019 Associations, and European Federa-
\ntion of Associations of Families of People
\nwith Mental Illness.
\nConcluding Remarks
\nAs discussed at the Conference\u2019s Closing
\nSession, the Fifth Geneva Conference rep-
\nresented a strong step forward in the process
\nof building person-centered medicine.It was
\nco-sponsored by a record 33 global medi-
\ncal and health organizations, introduced
\nnew presentation formats, documented the
\nadvancement of our International Journal
\nand scientific workgroups, and launched
\nnew initiatives. Furthermore, the inaugural
\nGeneva Declaration on Person-centered Care
\nfor Chronic Diseases was wrapped-up at this
\nsession and was then issued in final form
\nby the ICPCM Board on May 19. Also at
\nthe Closing Session, and earlier than ever
\nbefore, an announcement was made for the
\nSixth Geneva Conference to take place on
\nApril 27-May 1, 2013 with the main theme
\nPerson-centered Health Research.
\nLtoR: Manuel Dayrit, Juan E. Mezzich, Carissa Etienne, and Wim Van Lerberghe, at WHO
\nHeadquarters following the Fifth Geneva Conference.
\n159
\nWMA news
\nAs a colophon to the Fifth Geneva Confer-
\nence, the ICPCM president was invited the
\nnext day to a meeting at the World Health
\nOrganization headquarters with Assistant
\nDirector General Dr. Carissa Etienne and
\nDirectors Drs. Wim van Lerberghe and
\nManuel Dayrit. They expressed congratula-
\ntions for the Conference that had just ended
\nand strong interest for the Sixth Geneva
\nConference and the prospective develop-
\nment of a WHO Guide on Person-centered
\nCare.
\nReferences
\n1. Mezzich JE, Snaedal J, Van Weel C, Heath I.
\nPerson-centered Medicine: A Conceptual Ex-
\nploration. International Journal of Integrated
\nCare, Supplement, 2010.
\n2. Mezzich JE, Snaedal J, van Weel C, Botbol M,
\nSalloum IM: Introduction to Person-centered
\nMedicine: From Concepts to Practice. Journal of
\nEvaluation in Clinical Practice 17: 330-332,2011.
\n3. Mezzich JE, Miles A. The Third Geneva Con-
\nference on Person-centered Medicine: Collabo-
\nration across Specialties, Disciplines and Pro-
\ngrams. International Journal of Person Centered
\nMedicine 1: 6-9, 2011
\n4. Mezzich JE, Miles A, Snaedal J, van Weel C,
\nBotbol M, Salloum IM, Van Lerberghe W: The
\nFourth Geneva Conference on Person-centered
\nMedicine: Articulating Person-centered Medi-
\ncine and People-centered Public Health. Inter-
\nnational Journal of Person Centered Medicine
\n2: 1-5, 2012.
\n5. Heath, I: Promotion of disease and corrosion of
\nmedicine. Canadian Family Physician; 51:1320-
\n22, 2005
\n6. Mezzich J, Snaedal J, van Weel C, Heath I. To-
\nward Person-Centered Medicine: From Disease
\nto Patient to Person. Mount Sinai Journal of
\nMedicine 77: 304-306, 2010.
\n7. Snaedal J: Presidential Address. World Medical
\nJournal 53: 101-102, 2007.
\n8. World Health Organization: Resolution
\nWHA62.12. Primary health care, including
\nhealth system strengthening. In: Sixty-Second
\nWorld Health Assembly, Geneva, 18\u201322 May
\n2009. Resolutions and decisions. Geneva, 2009
\n(WHA62\/2009\/REC\/1), p.16.
\n9. Mezzich JE, Snaedal J, van Weel C, Heath I.
\nThe International Network for Person-centered
\nMedicine: Background and First Steps. World
\nMedical Journal 55: 104-107, 2009.
\n10. Mezzich JE: The construction of person-cen-
\ntered medicine and the launching of an Interna-
\ntional College. International Journal of Person
\nCentered Medicine 2: 6-10, 2012.
\n11. Miles A, Mezzich JE. Advancing the global
\ncommunication of scholarship and research for
\npersonalized health care: the International Jour-
\nnal of Person Centered Medicine. International
\nJournal of Person Centered Medicine 1: 1-5,
\n2011.
\n12. Montenegro RM. Upgrading the ICPCM in-
\nstitutional website and interactions with related
\nones. International Journal of Person Centered
\nMedicine 2: 323-325, 2012.
\n13. Tournier P. Medicine de la Personne. Neuchatel,
\nSwitzerland: Delachaux et Niestle, 1940.
\n14. Dordevic V, Bras M, Milicic D (eds): Person-
\noriented Medicine and Healthcare. Medicinska
\nNaklada, Zagreb, 2012.
\n15. Kipman S-D (ed): Manifest pour une Medicine
\nde la Personne. Doin, Paris, 2012.
\n16. Mezzich JE, Salloum IM, Cloninger CR, Sal-
\nvador-Carulla L, Kirmayer LJ, Banzato CEM,
\nWallcraft J, Botbol M. Person-centered Integra-
\ntive Diagnosis: Conceptual bases and structural
\nmodel. Canadian Journal of Psychiatry 55:701-
\n708, 2010.
\n17. Salloum IM, Mezzich JE: Conceptual appraisal
\nof the Person-centered Integrative Diagnosis
\nModel. International Journal of Person Cen-
\ntered Medicine 1: 39-42, 2011.
\n18. Otero A, Saavedra JE, Mezzich JE, Salloum
\nIM. La Gu\u00eda Latinoamericana de Diagn\u00f3stico
\nPsiqui\u00e1trico y su proceso de revisi\u00f3n. Revista
\nLatinoamericana de Psiquiatria 11:18-25. 2011.
\n19. Saavedra JE, Mezzich JE, Otero A, Salloum IM:
\nThe revision of the Latin American Guide for
\nPsychiatric Diagnosis (GLADP) and an initial
\nsurvey on its utility and prospects. International
\nJournal of Person Centered Medicine 2: 214-
\n221, 2012.
\n20. International College of Person Centered Medi-
\ncine. Geneva Declaration on Person-centered
\nCare for Chronic Diseases.International Journal
\nof Person Centered Medicine 2: 153-154, 2012.
\nJuan E. Mezzich
\n(International College of Person-
\ncentered Medicine President),
\nJon Snaedal (World Medical
\nAssociation President 2007\u20132008),
\nChris van Weel
\n(Wonca\u00a0President\u00a02007\u20132010),
\nMichel Botbol (WPA Psychoanalysis
\nin Psychiatry Section),
\nIhsan Salloum (WPA Classification Section),
\nTesfa Ghebrehiwet (International
\nCouncil of Nurses).
\nAll members of the ICPCM Board and of the
\nFifth Geneva Conference Organizing Com-
\nmittee.
\nWe are writing to you in order to propose to
\njoin forces in co-signing the attached Open
\nLetter on \u201cStandards for medical practice\u201d.
\nWe already had the occasion to raise and
\nshare our concerns with you all regarding
\nthe process that the European Standardisa-
\ntion Committee (CEN \u2013 Centre europ\u00e9en
\nde normalization) has initiated in Aes-
\nthetic Medicine. We have had a report on
\ntheir meeting that was recently organised in
\nDelft and this confirmed our worries.
\nThis invitation to you also provides us with
\nan opportunity to (re)state our position
\nfirmly, i.e. that the UEMS was not at the
\norigin of this initiative, was not actively in-
\nvolved and is strongly opposed to it.
\nWe would be grateful to you for joining
\nthis Open Letter as well as circulating it as
\nwidely as possible within your networks, the
\naim being to get as many co-signatories as
\npossible.
\nUEMS calls to the Presidents of the European Medical
\nOrganisations, National Medical Associations
\n160
\nWMA news
\nWMA General Assembly, Bangkok 2012
\nThis year\u2019s General Assembly will be held
\nfrom 10\u201313 October at the Centara Grand
\nHotel, Bangkok, Thailand. The scientific
\nsession \u201cMegacity \u2013 Megahealth?\u201d will be
\non Thursday, 11 October.
\nWMA Expert Conference: Revision of
\nthe Declaration of Helsinki
\nThe first in a series of expert conferences on
\nthis topic will be hosted by the South Afri-
\ncan Medical Association from 5\u20137 Decem-
\nber, 2012 at the Westin Cape Town, South
\nAfrica. Registration, open to the public on
\nWMA website, closes 5 November 2012
\n194th
\nWMA Council Session, Bali April
\n2013
\nThis meeting will be held from 4\u20136 April
\n2013 at The Laguna, Nusa Dua, Bali, Indo-
\nnesia.
\nWMA General Assembly, Fortaleza Oc-
\ntober 2013
\nThe General Assembly 2013 will be held
\nfrom 16\u201319 October in Fortaleza, Brazil.
\nWMA TB courses rewarded by CDC
\nThe newly launched MDR-TB online
\ncourse was rewarded by US Centers of
\nDisease Control (CDC) as the educational
\nhighlight of the month. Both TB courses
\ndeveloped by WMA have received this
\nCDC recognition.
\nTB Courses at The Union World Con-
\ngress
\nWMA has been accepted to present the
\ndevelopment of the TB refresher course
\nand MDR-TB course at the 43rd
\nUnion
\nWorld Conference on Lung Health in
\nKuala Lumpur, Malaysia, 12\u201317 Novem-
\nber, 2012.
\nForthcoming Events
\nStandards for of Medical Practice
\nOpen Letter
\nBrussels, 14th
\nSeptember 2012
\nThe undersigned European Medical Organisations and National
\nMedical Associations are committed to the achievement of high
\nstandards in healthcare because they recognise the importance of
\nthese for the safety and quality of care for patients.
\nThese Medical Organisations strongly support the considerable
\nwork that has been, and continues to be performed by medical
\nexperts in healthcare in developing standards and guidelines for
\npractice based on their clinical experience and research findings.
\nThese Medical Organisations recognise that standards and guide-
\nlines are best implemented when the doctors who will be imple-
\nmenting them are engaged in their development and in their ap-
\nplication in local healthcare services.
\nAccordingly, these Medical Organisations have profound con-
\ncerns about the attempts by the European Committee on Stan-
\ndardisation (CEN – Centre Europ\u00e9en de Normalisation) to in-
\ntroduce standards based on quality management systems that do
\nnot have a solid evidence-base within the clinical environment of
\nhealthcare systems.
\nThese Medical Organisations further question the rationale for
\nCEN to extend its remit into this area as this would appear to be
\nin breach of core elements of European legislation as applied to
\nhealthcare which is subject to the principle of subsidiarity.
\nThese Medical Organisations consider that the CEN initiative
\nto develop standards derived from the ISO 9000 series and apply
\nthem top down in healthcare systems conflicts with:
\n\u2022 The Treaty of Lisbon, Article 168 (update of Treaty of Amster-
\ndam, Article 152)
\n\u2022 The European Directive on the mutual recognition of profes-
\nsional qualifications (2005\/36\/EC) and in particular the recog-
\nnition of the right of individual Member States to determine
\ntheir own training structure while ensuring compliance with
\ncriteria set out in the Directive.
\n\u2022 National laws and regulations on healthcare systems and pro-
\nfessional practice that are specific to the different healthcare
\nsystems in Europe.
\nThese Medical Organisations have attempted to engage in a con-
\nstructive dialogue with CEN but finds that there is a lack of re-
\nciprocation for a meaningful dialogue.
\nThese Medical Organisations have concluded that CEN does not
\nwish to engage in partnership working with representatives of the
\nmedical profession.
\nThese Medical Organisations therefore call on the European Com-
\nmission and Parliament,the EU Member States and other relevant
\ninstitutions or bodies to challenge the approach being taken by
\nCEN and to question the rationale of its initiative in healthcare.
\nIII
\nThe South African Mail and Guardian has
\nidentified 15 ideas they believe can help
\ntransform Africa. The Speaking Book is
\nhonoured to be recognised as one of the 15
\ninnovative ideas.
\nA range of easy-to-use audio books de-
\nsigned to get potentially life-saving health
\nmessages out to millions of isolated people
\nstruggling with depression and mental
\nhealth problems.
\nIn 2003, Zane Wilson, the founder of the
\nSouth African Depression & Anxiety Group
\n(Sadag), the country\u2019s largest mental health
\ninitiative, was horrified at how suicide rates
\namong young South Africans were spiking.
\nMental health carries a huge social stigma
\nacross Africa and information booklets
\ndesigned to help people with depression
\nor mental health problems simply weren\u2019t
\nworking, especially in remote communi-
\nties with high illiteracy rates. People weren\u2019t
\ngetting the help they needed \u2013 a\u00a02009 study
\nshowed that only a quarter of the 16.5% of
\nSouth Africans suffering from mental health
\nproblems had received any kind of treatment.
\nSpeaking Books created a range of free
\nbooks with simple audio buttons talking the
\nuser through each page. The first Speaking
\nBook, voiced by South African actress and
\ncelebrity Lillian Dube, was called Suicide
\nShouldn\u2019t Be a Secret and focused on how
\ndepression is a real and treatable illness,
\nencouraging people to get help when they
\nneed it.
\nSpeaking Books have now produced 48 ti-
\ntles in 24 different languages and are now
\nused in 20 African countries across the con-
\ntinent. The books now tackle a number of
\ncritical healthcare issues outside of suicide
\nprevention such as HIV and Aids, malaria,
\nmaternal health and clinical trials. Speaking
\nBooks has also expanded to China, India
\nand South America. \u201cThe situation we face
\nin rural South Africa is the same in any other
\nAfrican country \u2013 low literacy compounded
\nby lack of access to services and affordable
\nhealthcare,\u201d says Wilson. \u201cThis means that
\npatients are often not able to get help for
\nmany health problems. We believe that this
\ninteractive, durable, high-quality, hardcover
\nbook engages the user or patient, and allows
\nthem to build self-confidence and skills with
\na simple action plan\u201d. AK<\/p>\n

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