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wmj31<\/a><\/p>\n

UNITED STATES
\nvol. 57
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 1, February 2011
\n\u2022 Medical Ethics and Personal vs. Public Conscience
\n\u2022 Tobacco-Free World in Twenty Years\u2019Time!
\n\u2022 Czech Medical Chambers\u2019 Experience to Make an Agreement
\nwmj 1 2011 5CS.indd I 21.02.2011 16:27:19
\nCover picture from Korea
\nii
\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
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by P\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas\u00a0apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nThis picture is produced by prof.Tae-Sub
\nCHUNG of Dept. of Diagnostic Radiology,
\nYonsei University, Korea.
\nProf. Chung is creating pictures using X-ray art.
\nIn this picture titled \u201cIt\u2019s delicious\u201d,
\nX-ray image of tiny granule on tangerine peel
\nmeets with bone and skin of a woman\u2019s
\nhands bringing fresh and delicious atmosphere.
\nPublisher
\nThe World Medical Association, Inc. BP 63
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\nPublishing House
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\nSubscription fee \u20ac 22,80 per annum (incl.
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\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
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\nISSN: 0049-8122
\nDr. Wonchat SUBHACHATURAS
\nWMA President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
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\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
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\nWilliamstown, VIC 3016
\nAustralia
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\nWMA Immediate Past-President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nProf. Dr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
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\n10623 Berlin
\nGermany
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\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
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\nGOMES DO AMARAL
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\nMedical-Affairs Committee
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\nNorway
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\n28209 Bremen
\nGermany
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\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
\nwmj 1 2011 5CS.indd Sec1:ii 21.02.2011 16:27:44
\n1
\nFor over 60 Years the World Medical
\nAssociation has been the global platform
\nfor medical ethics, physician affairs and
\ninternational medicine. It has been and is
\nbeing driven by the national medical asso-
\nciations being the constituents of the or-
\nganization. Outstanding physicians have
\nbeen and are until today its leaders. With
\ncurrently more than 90 nations in our
\nAssociation we are a truly global medical
\nvoice representing more than 9\u00a0 million
\nphysicians worldwide.
\nAmong the achievements of the World
\nMedical Association are landmark docu-
\nments like the first International Code of
\nMedical Ethics (1948), the Declaration
\nof Geneva often referred to as the mod-
\nern Hippocratic Oath (1949), or the most
\nfamous of our declarations the Declaration of Helsinki\u00a0\u2013 Ethi-
\ncal Principles for Medical Research Involving Human Subjects
\n(1964)\u00a0\u2013 to mention just 3 out of more than 100 policies on medi-
\ncal ethics, human rights and socio-medical affairs. All of them are
\nliving documents, up-to date, not trendy, but value- and reality-
\nbased. They guide physicians all over the world in difficult ethical
\nsituations, from the bedside at hospitals to the battlefields of this
\nworld. Our policies have proven value and receive the highest re-
\nspect.
\nThe World Medical Association is the voice of the physicians at
\nthe international organization like the United Nations, the World
\nHealth Organization, the International Labour Organization,
\nUNESCO and many others.
\nAnd although many physicians know WMA
\npolicies and hopefully many more know the
\nWMA, only a few are aware that individual
\nphysicians can be Associate Members of the
\nAssociation. With a very affordable rate the
\nmembership in the WMA is not a matter of
\nmoney, but of engagement. Our Associate
\nMembers stand for an independent medical
\nprofession.Together we strive to achieve the
\nhighest possible standards of medical care,
\nethics, education and health-related human
\nrights for all people.
\nAssociate Members have access to all work-
\ning documents of the Association and
\nthey are invited to voice their opinion on
\nour policy making either by writing or by
\nparticipating in the Association Members\u2019
\nMeeting. The yearly Associate Members\u2019
\nMeeting can even send its own policy proposals to the General As-
\nsembly for consideration. Membership benefits also include a sub-
\nscription to the World Medical Journal and significant discounts
\non our registration fees for the WMA General Assembly and the
\ninterim Council Session.
\nMore information and the possibility to sign up can be found on
\nour website www.wma.net.
\nFor the people of this world health is bridge to peace and a better living.
\nWe are building it. Please join us.
\nDr. Otmar Kloiber,
\nWMA Secretary General
\nInterested in Global Health? Join the World Medical
\nAssociation\u00a0\u2013 Become an Associate Member
\nOtmar Kloiber
\nwmj 1 2011 5CS.indd 1 21.02.2011 16:27:45
\n2
\nSome time ago, New York Times colum-
\nnist Professor Stanley Fish (NY Times 12
\nApril 2009) [1] wrote about \u201cConscience
\nvs. Conscience\u201d, where he discussed the
\nconundrum about how people in general
\nand physicians in particular, under different
\ncircumstances should or shouldn\u2019t abide by
\ntheir own conscience.
\nThe contending issue was that physicians
\nshould not refuse treatment or procedures
\nbasedontheirownpersonalmoralorreligious
\ngrounds. Professor Fish argued that there
\nis such a thing as a collective \u201cpublic con-
\nscience\u201dwhich should supersede that of one\u2019s
\npersonal conscience and value systems, no
\nmatter how entrenched these may have been.
\nDuring the Bush administration, the culpa-
\nble clause, called the Provider Refusal Rule,
\nallows health care providers to refuse to par-
\nticipate in procedures they find objection-
\nable for moral or religious reasons.The main
\nbone of contention was of course regarding
\nfreedom to choose abortion, pro-choice, or
\nconversely, pro-life.
\nIn Fish\u2019s article, he underscored an earlier
\nstatement by Mike Leavitt, Bush\u2019s Secre-
\ntary of Health and Human Services, who
\nhad said that, \u201cDoctors and other health
\nproviders should not be forced to choose
\nbetween good professional standing and
\nviolating their conscience.\u201d The direction
\nof the Bush doctrine was of course to urge
\nthe conservative right against unfettered
\nabortion on demand, which continues to
\ndivide the American people.
\nProfessor Fish reviewed the etymology of
\n\u201cconscience\u201d as ascribed to English phi-
\nlosopher Thomas Hobbes. Here one of the
\nearliest definitions of conscience, referred to
\nthose occasions \u201cwhen two or more men know
\nof one and the same fact … which is as much
\nto know it together,\u201d and where, violation of
\nconscience meant that knowing together,
\nmen prefer their \u201csecret thoughts\u201d to what
\nhas been publicly established.
\nFish acknowledged that Hobbes understood
\nthat many consider conscience to be the name
\nof the private arbiter of right and wrong.
\nBut Hobbes regards this as a corrupted us-
\nage invented by those who wished to elevate
\n\u201ctheir own …opinions\u201dto the status of reliable
\nknowledge and try to do so by giving \u201ctheir
\nopinions … that reverenced name of Conscience.\u201d
\nHobbes\u2019s main argument is that if one can
\nprefer one\u2019s own internal judgments to the
\njudgments of authorized external bodies
\n(legislatures, courts, professional associa-
\ntions), the result will be the undermining
\nof public order and the substitution of per-
\nsonal whim for general decorum: \u201c… because
\nthe Law is the public Conscience … in such di-
\nversity as there is of private Consciences, which
\nare but private opinions, the Commonwealth
\nmust needs be distracted, and no man dare to
\nobey the Sovereign Power farther than it shall
\nseem good in his own eyes.\u201d
\nFollowing his article, Fish was roundly
\ncriticized for being half-right in his inter-
\npretation of conflicting conscience, but in-
\ntellectual disagreement continues to divide
\nmostly implacable and partisan ethicists.
\nNancy Berlinger in an ensuing Hastings
\nCenter Report [2] has this to say: \u2018Stanley
\nFish\u2026 recognizes that defining \u201cconscience\u201d
\nmore loosely\u00a0 \u2013 as \u201cmoral intuition,\u201d or those
\n\u201csecret thoughts\u201d\u2026 does not solve our contem-
\nporary problem. When medical professionals be-
\nlieve that they are being forced to do harm or are
\nprevented from doing good, the ethical solution
\nmay not always be the conscience-clause remedy
\nof stepping away from troubling situations.\u2019
\nWhere does this leave the medical pro-
\nfessional when it comes to ethical under-
\npinnings of doing what\u2019s right or wrong?
\nWould our personal conscience suffice? Or,
\nshould we subsume to the greater wisdom
\nof our collective professional voice (e.g.
\nnational medical associations, professional
\nbodies, world medical association, medi-
\ncal councils, etc.), which through the long
\narduous passage of time and historical ex-
\nperiences, would have honed a burnished
\nif straitjacketed version of what\u2019s generally
\naccepted as \u201cethically and publicly correct\u201d?
\nBe that as it may, does this mean that the
\nmedical professional would then have no
\nneed to rely on his own personal conscience
\nand moral standing? No, but surely if these
\nare diametrically opposed to the greater
\nwisdom of peers, then one has to justify
\none\u2019s personal convictions all the more!
\nAgain, this cannot be taken out of context
\nof the prevailing society and sociopolitical
\nsituation. This becomes extremely relevant
\nin societies such as in Malaysia and other
\nquasi-democratic nations, where govern-
\nments tend to be paternalistic, even ar-
\nrogant or worse [3]. The instruments and
\ninstitutions of power are often abused to
\nforcefully interpret laws or even medical
\nfindings in a slanted manner, which severely
\ntest the mettle and autonomy of physicians
\nunder their charge.
\nDavid KL Quek
\nMALAYSIAMedical Ethics
\nMedical Ethics and Personal vs.
\nPublic Conscience: a Malaysian Context
\nwmj 1 2011 5CS.indd 2 21.02.2011 16:27:48
\n3
\nMedical EthicsMALAYSIA
\nIn certain authoritative or political circum-
\nstances, the medical professional is called
\nupon to exercise extreme judgment calls,
\nwhich can be sorely tested by either threats
\nfrom or fears of authority (e.g. police, su-
\nperior officers, military, even political pow-
\ners) or worse, direct or indirect \u201crewards\u201dfor
\npassive compliance!
\nThe 1st
\ncentury AD Hindu code, Charaka
\nSamhita [4], exhorts doctors to \u201cendeavor
\nfor the relief of patients with all thy heart
\nand soul; thou shall not desert or injure thy
\npatient for the sake of thy life or living\u201d,
\nwhich have been restated in many codes
\nof professional conduct including our own.
\nYet,these are often pushed to the backburn-
\ner, when conflicts of duties, arise.
\nRecent in Malaysia, public spats on medical
\ntestimonials and reports have arguably cast
\nlong shadows as to the so-called impartial-
\nity, ethics or professionalism of some of our
\nmedical colleagues [5]. Forensic pathologists
\nare facing some intense scrutiny of late,due to
\nquestionable lapses, incoherent practices and
\nperhaps even perceived selective memories,
\nand slipshod standards of duty of care [6].
\nOther physicians making medical reports
\nare also put under the microscope for their
\nperceived biasness or slant of their reports,
\none way or the other, until the truthfulness
\nof one vs. the other, appears difficult or im-
\npossible to discover [7]!
\nSuch ambiguous if disingenuous medical
\nfindings or reports cast a dismal if disap-
\npointing view on our profession [8].While
\nsome of these appear coerced, some might
\nconceivably be simply venal, just as if medi-
\ncal veracity can be made to sway according
\nto the purchasing power of the most damn-
\ning and powerful!
\nPhysicians must be reminded that for that
\npatient (deceased or detainee) under his\/her
\ncharge, there is frequently no other person
\nwhose interests can be represented, except
\nfrom the physician\u2019s unbiased assessment\u2026
\nSadly some of these dubious practices place
\nus at odds with the perceived wisdom and
\nconventions of some greater external collec-
\ntive conscience. These conventions although
\nseemingly unenforceable, have long been
\narticulated by world authorities such as the
\nWorld Medical Association and even the
\nUnited Nations Human Rights Commission.
\nThe UN High Commission for Human
\nRights Istanbul Protocol [9] is categorical in
\nstating that:
\n\u201cDilemmas arising from these dual obligations
\nare particularly acute for health professionals
\nworking with the police, military, other securi-
\nty services or in the prison system. The interests
\nof their employer and their non-medical col-
\nleagues may be in conflict with the best interests
\nof the detainee patients. Such health profes-
\nsionals with dual obligations, owe a primary
\nduty to the patient to promote that person\u2019s best
\ninterests and a general duty to society to ensure
\nthat justice is done and violations of human
\nrights prevented. Whatever the circumstances
\nof their employment, all health professionals
\nowe a fundamental duty to care for the people
\nthey are asked to examine or treat. They cannot
\nbe obliged by contractual or other considerations
\nto compromise their professional independence.
\nThey must make an unbiased assessment of the
\npatient\u2019s health interests and act accordingly.\u201d
\nUnfortunately, this protection by conven-
\ntion appears so remote to the lonely phy-
\nsician standing in the grips of perceived
\nauthoritarian powers, whose influence are
\nimaginably all-powerful!
\nSeen in this context, society must exert its
\nmoral imperative of the public good on a
\nuniversal basis, and demand the application
\nof such universal conventions, to protect the
\nhapless physician at the centre of such po-
\nlitical or partisan storms, lest such pressure
\nlead to further erosion of already debilitated
\ninstitutions.
\nSimilarly, the onus is on members of the
\nmedical profession to remain steadfast to
\nthe doctrine of public conscience and uni-
\nversal principles rather than personal ones,
\nwhen carrying out our duties, including
\nwhen making judgment or pronouncement
\non some of our possibly errant colleagues.
\nSectarian perceptions whether religious or
\npolitical, clearly must take a back seat, and
\nshould not be allowed to color our thinking
\nor decision making.
\nPersonal bias or experience or even con-
\nviction should yield to the more nuanced,
\nperhaps more balanced decision based on
\nstrict interpretations of statutes, codes of
\nprofessional conduct, and perhaps legal
\nprecedents.
\nThe US Supreme Court [10] has ruled that
\nwhen the personal imperatives of one\u2019s re-
\nligion or morality lead to actions in viola-
\ntion of generally applicable laws\u00a0\u2013 laws not
\npromulgated with the intention of affront-
\ning anyone\u2019s conscience\u00a0\u2013 the violations will
\nnot be allowed and will certainly not be cel-
\nebrated; because: \u201cTo permit this would be to
\nmake the professed doctrines of religious belief
\nsuperior to the law of the land, and in effect
\nto permit every citizen to become a law unto
\nhimself.\u201d Therefore,we must be quite clear to
\ndissect conscionably our dilemma of which
\nis the superior right.
\nSimilarly, in the context of political or au-
\nthoritarian pressure, especially where dem-
\nocratic institutions are weak, and where
\nrisk to the individual may seem likely, it
\nbehooves the professional to be reminded
\nabout the World Medical Association\u2019s Dec-
\nlaration of Geneva [11], which is a modern
\nrestatement of the Hippocratic values, as
\nwell as to be cognizant of UN Conventions
\nsuch as the Istanbul Protocol. Doctors are
\nreminded that the health of their patients
\nis their primary consideration and that we
\nmust devote ourselves to the service of hu-
\nmanity with conscience and dignity.
\nWe must learn and adhere to our historical
\nmemories, that which are collectively ac-
\nknowledged as \u201ccorrect\u201d and first and fore-
\nwmj 1 2011 5CS.indd 3 21.02.2011 16:27:49
\n4
\nE-health AUSTRALIA
\nmost for our patients\u2019interests. Certainly, in
\nthis context, every professional should not
\nlet religious, political or sectarian reasons
\nfrom influencing our decision-making.
\nBut does this mean that these are fixtures
\nwhich cannot or should not be modified
\nwith the passage of time and perhaps move
\nin tandem with the \u201cfashion\u201d or faddism of
\ncurrent perceptions or even societal move-
\nment or direction?
\nClearly this will depend on the circum-
\nstances and the human aspects of all pa-
\ntient-physician interactions. Although eth-
\nics these days are not as immovable or as
\npermanently cast in stone, societal views do
\nevolve. Like sometimes shifting tides, ethi-
\ncal perceptions may very gradually ebb and
\nflow, but often with the anchored moorings
\nand underpinnings of moral public good
\nand greater and greater foundation of uni-
\nversal values.
\nSo changes may occur, but again these must
\nbe based on contextual interpretation which
\nshould be carefully justified so that the
\nnewer interpretation can withstand scrutiny
\nand\/or rigorous re-examination, by an in-
\ncreasingly knowledgeable public and also by
\neven more discerning generations of similar
\nprofessionals.
\nThus, personal conscience and public con-
\nscience must be employed together to shape
\nour moral compass when we are dealing
\nwith ethics and medical professionalism. It
\nhelps when we all undertake to reexamine
\nour own values and learn more and more as
\nto how these ethical dilemmas and ques-
\ntions are evolving in this day and age. We
\nmust not be cowed into a mindset of conve-
\nnient way out or of callous expediency\u00a0[12].
\nReferences
\n1. Fish S.Opinionator.Conscience vs.Conscience.
\nThe New York Times. The Opinion pages. 12
\nApril, 2009. http:\/\/opinionator.blogs.nytimes.
\ncom\/2009\/04\/12\/conscience-vs-conscience.
\n2. Berlinger N. Conscience: We\u2019re not donne yet.
\nBioethics forum. The Hastings center report. 7
\nMay 2009. http:\/\/www.thehastingscenter.org\/
\nBioethicsforum\/Post.aspx?id=3404&blogid
\n=140.
\n3. Quek D.K.L. Unbiased treatment for all.
\nMalaysiakini,March23,2010.http:\/\/myhealth-
\nmatters.blogspot.com\/search?q=ethics+
\nconscience.
\n4. Roy P, Gupta H. Charaka Samhita. A scien-
\ntific synopsis. 2nd ed., Indian National Science
\nAcademy, New Delhi, India, 1980.
\n5. Quek DKL. Kugan\u2019s Autopsy Findings & In-
\nquiry: Unsettling Questions remain. Malaysia-
\nkini, April 8, 2009. http:\/\/myhealth-matters.
\nblogspot.com\/2009\/04\/kugans-autopsy-find-
\nings-inquiry.html.
\n6. Quek DKL. Ethics, medical confidentiality vs.
\npolitical pressures. Malaysiakini, July 31, 2008.
\nhttp:\/\/dq-liberte.blogspot.com\/2008\/07\/eth-
\nics-medical-confidentiality-vs.html
\n7. Chong D. Teoh family disappointed with Brit-
\nish pathologist\u2019s report. Malaysian Insider 26
\nApril 2010. http:\/\/www.themalaysianinsider.
\ncom\/index.php\/malaysia\/61368-teoh-family-
\ndisappointed-with-british-pathologists-report.
\n8. Quek DKL. Physicians must be more vigilant.
\nMalaysiakini,March 11,2009.http:\/\/myhealth-
\nmatters.blogspot.com\/2009\/03\/doctors-must-
\nbe-vigilant-when-dealing.html.
\n9. Istanbul Protocol. Manual on the effective in-
\nvestigation and documentation of torture and
\nother cruel, inhuman or degrading treatment or
\npunishment. Office of the United Nations high
\ncommissioner for human rights. United Na-
\ntions, Geneva, 1999.
\n10. Scalia J. Opinion of the Court. Supreme Court
\nof the United States; 494 U.S.872.Employment
\nDivision, Department of Human Resources of
\nOregon v. Smith. Certiorari to the Supreme
\nCourt of Oregon No. 88\u20131213 Argued: Nov. 6,
\n1989; Decided: April 17, 1990.
\n11. WMA Declaration of Geneva. Revised 173rd
\nCouncilSession,Divonne-les-Bains,France,May
\n2006. https:\/\/www.wma.net\/en\/30publications\/
\n10policies\/g1\/index.html.
\n12. Quek DKL. A New Malaysia still possible.
\nMalaysiakini, March 9, 2010. http:\/\/dq-liberte.
\nblogspot.com\/2010\/03\/malaysiakini-new-malay-
\nsia-still.html.
\nDr. David KL Quek, President,
\nMalaysian Medical Association
\nThe promise of e-health has been on the
\nhorizon for many years.
\nWhile the full potential of that promise is
\nyet to be delivered, it feels like we are just a
\nlittle bit closer to making e-health a reality.
\nThe very fact that we are here today discuss-
\ning the practical steps we need to develop
\nthe personally controlled electronic health
\nrecord shows how close we really are.I would
\nlike to acknowledge the efforts of Dr.Muke-
\nsh Haikerwal in pushing the e-health agen-
\nda. In his charming way, he has been tireless
\nand determined in bringing together all of
\nthe relevant players over the last few years.
\nHis involvement has had a significant im-
\npact on the e-health agenda and its progress.
\nClinicians Driving Change:
\nSupporting Patient Care
\nSpeech at the E-health conference 2010, Melbourne, 30th November 2010
\nSteve Hambleton
\nwmj 1 2011 5CS.indd 4 21.02.2011 16:27:54
\n5
\nAUSTRALIA E-health
\nDoctors are excited about the prospect of
\nsharing patient information electronically
\nwith each other and with other health care
\nproviders to improve patient safety and the
\nquality of care we provide.
\nMany GPs now hold accurate and compre-
\nhensive information about their patients
\nthat has been progressively built up over
\nmore than a decade.
\nBut at present the only way we can share it
\nis by printing it.Even then, it may or may
\nnot be with the patient when he or she ar-
\nrives at the next doctor\u00a0\u2013 and even then, at
\nbest it is subject to transcription errors.
\nToday I am going to talk about what my
\nmedical colleagues think must be done to
\nget the first stages of the electronic health
\nrecord up and running, and ensure that it is
\ndone in a way that will best assist doctors in
\ncaring for their patients.
\nWe need to strike a balance between clini-
\ncal safety and consumer expectations in the
\ndesign and use of the electronic health re-
\ncord. To succeed, the e-health record must
\nbe easy to use, support what doctors already
\ndo, and not disturb time-honoured clinical
\nmethods.We doctors talk to our patients,
\ntake a history, perform a medical examina-
\ntion, assess supporting information, order
\ninvestigations if needed, then make a diag-
\nnosis for the patient and decide on a treat-
\nment plan.
\nThat is the hard part about what we do. It
\ntakes years to learn and even longer to get
\ngood at it. If doctors can rapidly access rel-
\nevant data via the electronic health record,it
\nwill support this process. But irrelevant data
\nwill get in the way.
\nDuring my consultations with my patients,
\nI find that most of them have a reasonable
\nunderstanding of their health circumstanc-
\nes\u00a0\u2013 and they are usually very honest with
\nme about what\u2019s going on with them. But
\ncommonly\u00a0\u2013 despite our best intentions\u00a0\u2013
\ndoctors don\u2019t always have all the clinical in-
\nformation that we need to provide the saf-
\nest, most clinically appropriate care.
\nThis is where information obtained by other
\nhealth practitioners in relation to my pa-
\ntient during other episodes of health care
\ncould ensure that I don\u2019t miss the critical
\nissues that could impact on my treatment
\ndecisions.
\nHere is a \u201clive\u201dexample from one of my pa-
\ntients last week.John told me that he had
\na number of times called an ambulance to
\nhis home because he had severe abdominal
\npain\u00a0\u2013 RUQ 10\/10.On the first two occa-
\nsions,his pain had gone by the time the am-
\nbulance arrived, and he was not transported.
\nHe had a health summary from me with him
\ndetailing his cardiac history,his diabetes,his
\nAAA, his past history of cholecystectomy.
\nHe also had retained gallstones in the bile
\nduct after the above surgery and needed
\nan ERCP and sphincterotomy to solve the
\nproblem.The next three times he was taken
\nto Royal Brisbane Hospital Emergency
\nDepartment where, once again, they were
\nin possession of his paper history. The pain
\ninvariably went away within a few hours of
\narriving at hospital.His diabetes and vascu-
\nlar disease were proving to be a distraction.
\nThe CT Abdomen showed nothing more
\nthan his AAA, and the US of the liver was
\nnormal.This information trickled in to me
\nsome days after his hospital visits.The first
\ndischarge letter contained the blood results,
\nwhich showed a rise in his liver function
\ntests that were consistent with obstruction
\nof the bile duct.The second and third letters
\nfrom A&E did not include the above but,
\nwhen I asked for them to be faxed, it was
\nclear that on each occasion that there was
\nacute pain the liver enzymes rose.
\nFor the non-doctors in the room, it was
\nclear evidence of bile duct obstruction.This
\nwas enough evidence to convince another
\ngastroenterologist that he needed another
\nERCP and, sure enough, there were two
\nmore gallstones.There were five blood tests
\non three different pathology computers. A
\nCT scan of the abdomen and an ultrasound
\nof the abdomen were also needed to make
\nthe diagnosis.The patient had no way of
\nrecalling the sort of detail that I needed to
\nmake the diagnosis, or even of being sure
\nwhat tests had been done.
\nFor example, the negative cardiac enzyme
\ntests were just as important. I was the only
\none who had all of the information avail-
\nable. The diagnosis would have been made
\nmuch more quickly if we all had all the de-
\ntail in \u201creal time\u201d. It was time consuming
\nfor me and inconvenient for the patient\u00a0\u2013
\nmaybe even life threatening.
\nThis is just one example where the sharing
\nof a patient\u2019s information between health
\ncare providers could make a real difference
\nto the quality, safety, and cost of the health
\ncare that I could deliver.
\nAt the most basic level, doctors should be
\nable to access from electronic health records
\nimportant information such as:
\n\u2022 pathology results;
\n\u2022 diagnostic imaging results;
\n\u2022 discharge summaries; and
\n\u2022 current medications and adverse events.
\nThis is basic information, yet critical to pa-
\ntient care.
\nWhen I talk to doctors, and when I think
\nabout my own practice, I am struck again
\nand again by what a difference it would
\nmake\u00a0\u2013 even in the case I have mentioned\u00a0\u2013
\nif we had an electronic health record.
\nThe record could facilitate the sharing of
\nthis most basic yet critical patient infor-
\nmation between treating doctors and other
\nhealth providers.
\nIt would deliver a very loud bang for the
\nbuck. Clearly, I am talking about a very
\nsmall but fundamental part of the much
\ngrander plan for a personally controlled
\nelectronic health record.
\nwmj 1 2011 5CS.indd 5 21.02.2011 16:27:55
\n6
\nAUSTRALIAE-health
\nLet\u2019s start with the basics and get it up
\nand running. Let\u2019s start with electronically
\nshared patient summary information that
\ncannot be altered by the patient, and which
\nis accessible to all doctors.
\nI am not suggesting that the personally
\ncontrolled aspects of the electronic health
\nrecord are not important. The point I am
\nmaking is that, if we are to get take-up of
\nthe electronic health record by doctors, the
\ndoctors need to be able to trust the reliabil-
\nity and accuracy of the information the re-
\ncord contains so that they can act on it.
\nMost patients would recognise the need for
\ntreating doctors to be confident about the
\ninformation that they have before them.
\nI can\u2019t think of any of my patients who
\nwould object to me being able to have ac-
\ncess to information about where they have
\nrecently been hospitalised, or when they
\nneeded to see another doctor. In fact, many
\nare surprised when I don\u2019t have that kind
\nof information at my fingertips already.
\nHow many patients have turned up at their
\nGP before the specialist\u2019s letter or before
\nthe discharge summary has arrived?In fact,
\nthe Menzies-Nous Australian Health Sur-
\nvey published last week found that: \u201cMost
\npeople believed their doctor and all the people
\ntreating them should have direct access to their
\nhealth record.\u201d
\nThe AMA has thought very hard about how
\ndoctors will integrate the personally con-
\ntrolled electronic health record into the way
\nthey practise medicine. At the AMA, we
\nare talking about the sharing of summary
\npatient information electronically between
\ntreating doctors.
\nWe don\u2019t talk about sharing all of our pa-
\ntient information\u00a0 \u2013 just the key informa-
\ntion that other doctors need to provide safe,
\nquality patient care.And that is what we
\ndo already\u00a0\u2013 when I refer my patient to a
\nspecialist, I don\u2019t send their entire file. I just
\nsend the key information that I think the
\nspecialist needs.
\nThe AMA supports the premise that the
\nsharing of accurate summary patient infor-
\nmation between treating doctors is critical
\nto the success of e-health.
\nThis is information that sits beside a per-
\nsonally controlled record. It is essential that
\nthis record contains reliable and relevant
\nmedical information about individuals.
\nIt is important that it aligns with clinical
\nworkflows. It must integrate with existing
\nmedical practice software.Otherwise we are
\nfaced once again with the transcription er-
\nrors I spoke of earlier. It is also very impor-
\ntant that the personally controlled record
\nhas appropriate security measures to protect
\npatient privacy.
\nWe believe that if the system is to be truly
\nnational and consistent, it must be governed
\nby a single national entity.
\nWe believe governments must fund the sys-
\ntem and support its take-up with appropri-
\nate incentives, education and training.
\nProgress in these areas would provide bene-
\nfits to patients through efficient and accurate
\ncommunication between GPs,other special-
\nists, hospitals, and other health providers.
\nOver time, once the initial capability to
\nshare the summary patient information
\nacross healthcare settings is rolled out, there
\nis significantly more information that could
\ngo on the summary.
\nIt could include information such as pros-
\ntheses, implants, ECGs, referrals, advance
\ncare directives, health care plans, and team
\ncare arrangements to name but a few.
\nClearly, as the information on the record
\nstarts to get more complex, patients will
\ninevitably and very reasonably want more
\nrules around who can access all that extra
\ninformation.
\nPrivacy of and access to those parts of the
\nrecord will be very important.
\nThis is also the point at which I think the
\npersonally controlled aspect of the record
\nis very relevant. A personally controlled
\nrecord that patients would operate along-
\nside the summary information shared by
\ndoctors could prove to be a great motivator
\nfor many patients to become more involved
\nin their own health care. In my experience,
\nwhen my patients take responsibility for
\ntheir health and work with me, we usually
\nget the best outcomes. Most doctors don\u2019t
\nlike \u201cDr Google\u201dand there are good reasons
\nfor that. But it is undeniable that the advent
\nof the Internet has produced patients who
\nare more informed and perhaps a bit more
\nprepared when they come to see me.
\nI actually prefer it when patients with ongo-
\ning health concerns take an active interest
\nin informing themselves about their con-
\nditions and in actively engaging with me
\nabout the steps they can take to manage
\ntheir condition better.
\nI think there are generational issues here
\nwith some patients older than me who are
\nreluctant to use the web all that much.I find
\nthat patients about my age are quite will-
\ning to go after information and to inform
\nthemselves.
\nNow there are young people who can\u2019t
\nstop pulling down information. The chal-
\nlenge with them is to direct their gaze to
\nuseful locations and to stop them getting
\nsidetracked. I think that the personally con-
\ntrolled record will encourage and empower
\npatients to take more responsibility for as-
\npects of their health care. The opportunity
\nto create their own record about how they
\nare managing their health will help patients
\nto keep track of their conditions and medi-
\ncal history. This should dovetail into home
\nmonitoring for things like diabetes and
\nblood pressure.
\nThis, in turn, will lead to patients being able
\nto truly engage with their health care pro-
\nvider to provide better management of their
\nhealth.
\nwmj 1 2011 5CS.indd 6 21.02.2011 16:27:57
\n7
\nAUSTRALIA E-health
\nHowever, we need to strike the right bal-
\nance here between the health care provider\u2019s
\nneed to provide safe patient care and con-
\nsumer expectations about the role of the in-
\nformation they control in the record when
\nhealth care is delivered to them.
\nIt is not realistic to expect that doctors will
\nturn to information put in the personally
\ncontrolled record by the patient as the de-
\nfinitive source of information on which to
\nbase clinical decisions. Doctors will always
\ntake a history, do an examination, and
\nmake an assessment and diagnosis putting
\ndifferent weights on different types of in-
\nformation. We cannot just rely on what is
\nin the personally controlled record. Often,
\ndiagnoses or previous conclusions need to
\nbe challenged. Just like my patient I men-
\ntioned earlier. I have never ever seen a pa-
\ntient with retained gallstones after ERCP
\nand sphincterotomy, but that is what the
\nevidence said. To get it right we need all
\nthe evidence though. Even now, doctors
\nhave concerns that patients might be re-
\nluctant to share some information with
\nthem. Patients may think that once in-
\nformation is on the record\u00a0\u2013 somewhere,
\nsometime\u00a0\u2013 that information might be ac-
\ncessed inappropriately. Patients are already
\nconcerned about how treatment decisions
\nmight affect them in other aspects of their
\nlives.
\nI recently saw a patient who wasn\u2019t sure
\nwhether he wanted to be prescribed anti-
\ndepressant medication for fear that some-
\nhow down the line it could \u201cget out\u201d and
\naffect his employment as a teacher. These
\nkinds of concerns will become even more
\nimportant to patients when diagnoses,
\ntreatment decisions, and medications are
\nshared electronically.
\nSo, if we look at a world where there is a
\npersonally controlled electronic health re-
\ncord\u00a0\u2013 where information may be in \u201cThe
\nCloud\u201d and therefore truly accessible\u00a0\u2013 it is
\nentirely understandable that those concerns
\nfor patients will intensify.
\nUnfortunately, if patients have the ability to
\nremove or \u201cmake private\u201d facts that are part
\nof their summary information, they might
\ndo so\u00a0\u2013 for all kinds of reasons. And if they
\nchoose to do so, then the record may be-
\ncomes useless to a doctor because the doctor
\ncould never rely on it.
\nFor example, when prescribing medication,
\nif the anti-depressant was hidden, the real
\npossibility of a serious adverse medication
\ninteraction could exist. If Tramadol is pre-
\nscribed, then it could precipitate a serotonin
\nsyndrome if the patient was taking an SSRI
\n(Selective serotonin reuptake inhibitor).
\nOnce the personally controlled record is
\nup and running, if there is just one serious
\nadverse medication event like this, then e-
\nhealth will not have delivered on its promise.
\nIf the summary information was not avail-
\nable to the treating doctor, then the whole
\nventure will have failed.
\nFailed the patient. Failed the doctor. Failed
\nthe health system.
\nThe summary patient information needs to
\nbe accessible to all doctors.
\nIt should only be able to be changed by
\ndoctors who understand the implication of
\nwhat is recorded\u00a0\u2013 and this can certainly be
\ndone in consultation with the patient.
\nConversely, the addition of some informa-
\ntion into the electronic record by a patient
\ncould also pose a clinical risk\u00a0\u2013 if the doctor
\nwere to rely upon it.
\nFor instance, many patients believe they
\nhave allergies to drugs, but they are simply
\nside effects. While they are important, they
\ndo not have the same clinical impact. For
\nexample, Augmentin nausea, muscle aches
\nwith statins.
\nIf we think about these examples, it is clear-
\nly not true that the personally controlled
\nelectronic health record will entirely remove
\nthe need for patients to tell their history to
\nevery new health professional they see. But
\nit will streamline it.
\nDoctors and other health providers who are
\ncommitted to safe, quality patient care will
\nneed to have that conversation and practise
\ntheir craft, no matter what is in the record.
\nAs I said earlier, it is essential that doctors
\ncan rely on the summary information in-
\ncluding:
\n\u2022 pathology results;
\n\u2022 diagnostic imaging results;
\n\u2022 discharge summaries; and
\n\u2022 current medications and adverse events.
\nAs we develop the personally controlled
\nelectronic health record, we need to con-
\nsider that e-health in primary care will
\ndrive most of the health system benefits.
\nThose benefits will be most apparent in
\nthe acute care setting. Most of the costs,
\nhowever, will be incurred in the primary
\ncare setting.
\nWith this in mind, the Government must
\ninvest in e-health at the primary care level
\nor the momentum will stall. The right ap-
\nproach, the right information, and the right
\ninvestment in e-health can deliver real ben-
\nefits to patient care and to the efficiency of
\nthe health care system.
\nThe AMA and the medical profession stand
\nready to get behind e-health and make it
\nthe reality that the Australian health system
\nneeds.
\nDr. Steve Hambleton, Australian
\nMedical Association, Vice President
\nwmj 1 2011 5CS.indd 7 21.02.2011 16:27:58
\n8
\nUNITED STATESMedical ethics
\nLately I\u2019ve been thinking about bridges.
\nOne bridge in particular has been in my
\nmind: the so-called Bridge of No Return
\nbetween North and South Korea.
\nHere\u2019s the story. More than 40 years ago,
\nas a young naval medical officer, I was part
\nof the team that examined crew members
\nof the USS Pueblo after they were released
\nfrom captivity in North Korea. The Pueblo,
\na U.S. communications monitoring ship,
\nhad been in international waters-legally\u00a0 \u2013
\nwhen it was surrounded and fired upon by a
\nNorth Korean warship.
\nOne crewman was killed and 10 others were
\nwounded before Cmdr. Lloyd \u201cPete\u201d Bucher
\nsurrendered the ship. Had he not surren-
\ndered, the superior firepower of the North
\nKorean ships would have prevailed and many
\nmore of his men would have been killed.
\nBucher and his crew\u00a0\u2013 82 in all\u00a0\u2013 were held
\nin captivity in North Korea for 11 long
\nmonths, during which time they were beat-
\nen, tortured, starved and humiliated on a
\ndaily basis. When they were finally released,
\nthey walked to freedom across that Bridge
\nof No Return.
\nOverall, the Pueblo\u2019s commander and crew
\nwere in pretty bad shape physically. All had
\nlost weight, and there were skin diseases,
\njaundice, pneumonia, infections, contu-
\nsions, abrasions and broken bones. Despite
\ntheir ill health and having been tortured,
\nthe Pueblo crew walked across that bridge
\nunited,loyal and upbeat.None had been co-
\nopted by the North Koreans. They had not
\nturned on one another.
\nIn their forced confession they had man-
\naged to send a message of their own to the
\nAmerican authorities. Their spirit could
\nhave been destroyed, but it was not. Today,
\nthe behavior of the Pueblo crew during that
\ncaptivity is held up as model of prisoner-of-
\nwar resistance.
\nI have always felt privileged\u00a0 \u2013 and sad-
\ndened\u00a0\u2013 that I was on hand to meet these
\nmen and their commander after they came
\nacross that bridge and were brought to the
\nBalboa Naval Hospital in San Diego. It is
\na time I shall never forget. And a time that
\nremains with me in lessons learned.
\nAs a former naval medical officer, I am
\nkeenly aware of how much my civilian
\nmedical practice owes to military medicine.
\nEmergency and disaster medicine,in partic-
\nular, are the offspring of battlefield medical
\nexperience. So is public health.
\nHere are a few examples:
\n\u2022 During the Seminole Wars in the early
\n1800s, Army physicians discovered that
\nquinine was effective in treating people
\nwith malaria
\n\u2022 Following the Spanish-American War
\nin 1898, military physician, Walter Reed,
\nheaded a commission that proved the link
\nbetween yellow fever and mosquitoes
\n\u2022 The North African battlefields of World
\nWar II were also a battleground that
\nproved the miracle of antibiotics
\n\u2022 During World War II, the work of Navy
\nCaptain, Robert Phillips, broke new
\nground in the treatment of cholera
\nTrauma and disaster medicine also have
\nmilitary roots:
\n\u2022 Medical triage first took place on Napole-
\non\u2019s battlefields, offering a way to deal
\nwith casualties and save lives in an orderly
\nway
\n\u2022 In the late 1940s, military physicians did
\npioneering work in the treatment of burn
\nvictims
\n\u2022 As a result of casualties in the Middle
\nEastern conflicts we have seen new treat-
\nments for amputees and advances in pros-
\nthetic technologies
\n\u2022 Out of Vietnam came an understanding
\nof the importance of the \u201cgolden hour\u201d
\nand the need for early, even pre-hospital,
\ntreatment. Our civilian EMT and mede-
\nvac systems are a direct result
\n\u2022 The Vietnam War and more recent mili-
\ntary conflicts in the Middle East taught
\nthe value of a systems approach to han-
\ndling mass casualties\u00a0 \u2013 a lesson civilian
\nmedical teams applied after the 9\/11 at-
\ntacks, the 2004 tsunami, Hurricane Ka-
\ntrina and the earthquake that hit Haiti
\nearly this year
\n\u2022 Today the military is a leader in telemedi-
\ncine, sending patient information from
\nthe battlefield and receiving expert advice
\nback from around the world to physicians
\nwho are on the front lines.This is technol-
\nogy that ultimately may be as important
\nto a physician and patient in remote rural
\nareas as it is to those on the battlefield.
\n\u2022 All of this is a reminder of the impor-
\ntance of learning from one another, of
\nbeing united, of facing obstacles together.
\nThat is my message for physicians today.
\nCecil B. Wilson, MD, President,
\nAmerican Medical Association
\nHumbled by Those Who Crossed
\nBridge of No Return
\nCecil B. Wilson
\nwmj 1 2011 5CS.indd 8 21.02.2011 16:27:59
\n9
\nEffective regulatory framework is the key
\nto delivery systems that create a well func-
\ntioning healthcare environment, this arti-
\ncle provides an analysis of the regulatory
\nframework of private health insurance as it
\nrelates to the protection of beneficiaries and
\nthe public within South Africa context. The
\nCouncil for Medical schemes (CMS) which
\nis the statutory body established in terms
\nof the Medical Schemes Act 131 of 1998 to
\nprovide regulatory oversight to the medi-
\ncal schemes industry in a manner that is
\ncomplementary with national health policy.
\nMedical schemes that are regulated by the
\nCMS are insurance institutions that cover
\nmedical expenses and provide health care
\ninsurance in the private sector in South Af-
\nrica. Medical schemes reimburse their\u00a0mem-
\nbers for actual expenditure on health. A
\nregulatory framework must protect the in-
\nterests of Beneficiaries, thus CMS contin-
\nues to effectively engage on regulatory and
\npolicy developments in the health and in-
\nsurance industries to ensure that the rights
\nof South African Beneficiaries are protected
\nat all times.
\nIntroduction
\nAn effective regulatory framework is critical
\nto delivering system reform and to creating
\na well-functioning healthcare market\u00a0[13].
\nThis paper presents such a framework with-
\nin the South African context; we give an
\noutline of goals that a regulation should ad-
\ndress. It is important to note that the South
\nAfrica\u2019s health system consists of a large
\npublic sector and a smaller private sector.
\nThe public sector is under-resourced and
\nover-used, while the private sector caters to
\nmiddle- and high-income earners who tend
\nto be members of medical schemes (16% of
\nthe population in 2009,not significantly dif-
\nferent to the 15% cover by medical schemes
\nin 2000). The demographic structure of
\nmedical schemes implies a differently struc-
\ntured health system to that of the general
\npopulation. This is a worrying factor on the
\nresulting efficiency of the health system as a
\nwhole, given the substantial resource alloca-
\ntion bias in favour of the medical scheme
\nmarket. In 1994, the National Depart-
\nment of Health (DoH) allowed medical
\nschemes, which are primary to paying for
\nprivate health care, to be regulated\u00a0[16].The
\nMedical Schemes Act 131 of 1998 gives
\nthe Council for Medical Schemes (CMS)
\npower over medical schemes; the CMS
\nregulates not only medical schemes,but also
\nhealth insurance brokers, medical scheme
\nadministrators and managed care organi-
\nsations\u00a0[12]. It also imposes much stricter
\ncontrols upon medical schemes themselves
\nin terms of corporate governance, financial
\nand membership requirements, and provi-
\nsion of benefits.The Act states the functions
\nof the Council in a far more purposeful and
\nconsumer-oriented terms, with a defined
\nfocus on the protection of the interests of
\nmedical scheme members.
\nTo achieve its regulatory goals, the office
\nof the Registrar participates in the con-
\nsultative process which aims to demarcate
\nmedical schemes from health insurance be-
\ncause it is the case that the encroachment
\nof risk-rated health insurance products into
\nthe business of medical schemes results in
\ncream-skimming the young and healthy,
\nunfair discrimination against the old and
\nsickly, and a risk to the sustainability of
\nthe medical schemes industry\u00a0[7]. Another
\ncritical element of regulating the private
\nhealth care sector is to, on an ongoing basis,
\nrevise benefit and contribution structures
\nto protect community rating, which is the
\nprinciple that all beneficiaries on the same
\nbenefit option pay the same contribution,
\nand that contributions may vary based only
\non an individual\u2019s income, number of de-
\npendants, or both\u00a0 [12]. The regulator of
\nmedical schemes is in support of the initia-
\ntion of a proper consultative and research
\nprocess towards the development of a regu-
\nlatory framework for collective bargaining
\nbetween healthcare providers and funders
\n(including the review of the National
\nHealth Amendment Bill).
\nThe Bill was published for comments in
\n2006 with the final comments at the end of
\nFebruary in 2007. The new draft of the Bill
\nwas submitted to the Minister of Health in
\nMonwabisi Gantsho Michael Mncedisi Willie
\nSOUTH AFRICA Healthcare insurance industry
\nThe Regulatory Framework in the Healthcare
\nInsurance Industry:
\nIn the Interest of Beneficiaries and Public
\nwmj 1 2011 5CS.indd 9 21.02.2011 16:28:00
\n10
\nHealthcare insurance industry SOUTH AFRICA
\nJuly 2007, and is awaiting discussion and
\nsignature of the State President in Parlia-
\nment.The Bill seeks to address among other
\nkey topics the governance issues for medical
\nschemes, including the fit and proper status
\nof trustees.The Bill also seeks to change the
\nmanner in which benefits are designed,so as
\nto improve transparency and further reduce
\nincentives for unfair discrimination.
\nGoals of regulation
\nThe role of market regulation is to facilitate
\nthe delivery of overarching policy objectives
\nthrough economic regulation and consumer
\nprotection\u00a0[13]. The objective of this arti-
\ncle is to assess the regulatory framework as
\nit relates to the protection of beneficiaries,
\nthus we focus on the following goals of reg-
\nulations, the regulatory framework\u00a0[3].
\n\u2022 Ensuring services (and goods) are safe
\nand of high quality.
\n\u2022 Ensuring fair access to services and
\n(where relevant) also ensure choice of
\nprovision.
\n\u2022 Ensuring financial solvency of medical
\nschemes.
\n\u2022 Ensuring transparency and fairness in
\nthe contractual relationship between the
\nmedical scheme and beneficiary.
\n\u2022 Ensuring that health insurance packages
\nprovide adequate financial protection.
\n\u2022 Managing key externalities and by-prod-
\nucts of service provision.
\n\u2022 Governance of medical schemes.
\nRegulation in advanced
\nmarket economies
\nThe regulatory framework of private health
\ncare insurance industries is administered
\nby a government agency or agencies that
\nimplement statutory requirements, usually
\nwith the authority to establish administra-
\ntive rules and procedures\u00a0[9]. This section
\ndiscuses the some of the regulated activities
\nwithin the health sector and core functions
\nof such regulating entities.
\nLicensing of medical schemes,
\nadministrators, managed
\ncare entities and brokers
\nA major reason for having regulation is to
\nprotect regulated industries from instability
\nand lack of consumer confidence caused by
\npoor administration and trading systems.
\nSetting up minimum registration and ac-
\ncreditation rules and regulations ensures the
\nefficient functioning of market mechanisms.
\nEstablishing minimum standards and ac-
\ncreditation rules reduces additional costs of
\noverhead spreads created by artificial mar-
\nket signals that are driven by health insur-
\nance administration functions. The Medi-
\ncal Scheme Act gives the CMS regulatory
\npowers over medical schemes,managed care
\nentities, brokers, and administrators. The
\nfunctions of the CMS are included in Sec-
\ntion 7 of the Act. For the purpose of this re-
\nport, the regulatory functions are expanded
\nusing literature on regulatory theory\u00a0 [7];
\nthey are listed are as follows:
\nSupervising the conduct of registered in-
\ntermediaries by the Council\u2019s line and staff
\nfunctions, through the implementation of
\nrules-based bureaucratic style of carrying
\nout Council\u2019s governance function:
\n\u2022 A managerial approach to the regulator\u2019s
\nfunction of stewardship, controlling con-
\nduct by means of quantitative benchmarks
\nand\/or qualitative scorecards, monitoring
\nobservance to preset specification and
\nperformance standards by registered in-
\ntermediaries
\n\u2022 A collaborative governance approach
\nwhich allows for a joint learning process
\nin developing health insurance regulatory
\npolicy by:
\n– configuring formal cooperative
\ninterfaces between the regulator\u2019s
\ninternal operational line functions
\nand staff function (specialist ad-
\nvisors) channels, for the benefit
\nof strengthening the responsive-
\nness of benchmark or peer review
\npolicy tools, economic incentives
\nand reducing market uncertainties
\n(market stability and institutional
\nsustainability);
\n– Increasing the scope of regulatory
\ntransparency and democratizing
\nadministrative justice processes by
\nmaking the Registrar\u2019s Office and
\nmarket information more accessible
\nto medical scheme members
\nPolicing registered institutions in terms
\nof their observance of rules for minimum
\ncompliance and mandatory standards inter-
\nmediaries, such as the observance of:
\n\u2022 Rules of minimum compliance and ap-
\nproval requirements for the registration
\nof medical schemes and other institutions
\nwithin the regulator\u2019s jurisdictional regu-
\nlatory environment.
\n\u2022 Mandatory compliance standards.
\n\u2022 The regulatory function of: Legal en-
\nforcement of provisions emanating from
\nthe Act and other forms of precedence,
\nsuch as behavioural incentives legitimat-
\ned by enabling rules and guidance notices.
\n\u2022 The regulatory function of: Adjudicat-
\ning over grievance applications made by
\nmedical scheme enrolees.
\n\u2022 The regulatory function of: Educating
\n& Communication of the regulator\u2019s fi-
\nduciary duty to medical scheme enrolees
\nand, the strengthening of the governance
\nfunction\u2019s role of demonstrating account-
\nability over regulated stakeholder and
\nmedical scheme members.
\n\u2022 The regulatory function of: Sanctioning
\nthe business of medical schemes and the
\nadministration of health insurance busi-
\nness functions.
\n\u2022 The regulatory function of: Observing
\nFiduciary Obligations arising from Prin-
\ncipal-Agent market relationships by, gov-
\nerned schemes and other registered inter-
\nmediaries and,the Regulatory Body itself.
\nSolvency Regulation
\nSolvency regulation includes solvency mon-
\nitoring, capital requirements, other controls
\non medical scheme behavior (for example,
\nwmj 1 2011 5CS.indd 10 21.02.2011 16:28:02
\n11
\nHealthcare insurance industrySOUTH AFRICA
\ninvestment regulations) and, in many cas-
\nes, establishment of beneficiary protection
\nschemes to pay specified claims against in-
\nsolvent medical schemes\u00a0 [9]. Beneficiaries
\npay contributions towards medical schemes
\nfor future health care spending and the fi-
\nnancial capacity for the scheme to respond
\nto claims\/ pay for healthcare spending is de-
\npendent on the schemes viability and finan-
\ncial soundness. It is of note that the claims
\ncan potentially exceed the sum of the total
\npremiums\/ contributions received and this
\nis critical to the viability of the scheme.
\nWith solvency regulation, beneficiaries del-
\negate responsibility for monitoring solvency
\nto regulators, as this is also the case in South
\nAfrica. Regulatory monitoring might detect
\nmedical scheme financial problems early
\nenough to prevent insolvency.In other cases,
\nmonitoring can help regulators intervene
\nbefore the deficit between an insolvent med-
\nical scheme\u2019s assets and liabilities becomes
\nlarge. Some degree of regulatory restrictions
\non medical scheme risk taking (for example,
\ninvestment limitations and capital require-
\nments) could be efficient for this reason.
\nSolvency is measured in terms of Regulation
\n29 of the Act. The net assets, after deduct-
\ning assets set aside for the specific purpose
\nof and unrealized non distributable reserves,
\nare also referred to as \u201cAccumulated Funds\u201d.
\nRegulation 29 prescribes the \u201cMinimum ac-
\ncumulated funds\u201d expressed as a percentage
\nof \u201cGross annual contributions\u201dis referred to
\nas a solvency level.
\nThe Medical Schemes Act requires schemes
\nto maintain a solvency of at least 25%\u00a0[12].
\nIn the same breath, a solvency level below
\n25% does not necessarily mean that the
\nscheme is experiencing financial difficulties.
\nSimilarly, extremely high solvency levels are
\nnot an indication that a scheme is in \u201cper-
\nfect\u201d financial position. Figure 1 shows the
\nnumber of schemes stratified by the (>25%)
\nand (\u226525%) stratum. The phasing in of the
\nstatutory solvency reserve requirements was
\nfrom 2000 to 2004, and upward trend in the
\nnumber of schemes in the \u226525% stratum
\nis seen until 2004, from 2005 a downward
\ntrend is observed and the number of schemes
\nin \u226525% stratum declined significantly by
\n21% from 111 to 88 medical schemes. The
\ndeclining trend also correlates to the con-
\nsolidation in the medical schemes environ-
\nment. There were no significant declines in
\n<25% stratum from 2004 to 2009. Solvency\nratio is one indicator used as a benchmark to\nmeasure the \u201cfinancial health\u201dof the scheme\nand a noteworthy feature of the ratio is that\nit triggers interventions on the financials\nof the medical scheme. Thus the regulator\nof medical schemes consistently monitors\nsolvency levels of medical schemes together\nwith other ratios,such as investment income,\nnon-health expenditure, and membership\nprofile. In ensuring the consumers\u2019 willing-\nness to pay contributions for private health\ninsurance, effective regulation requires that\nschemes are financially sound such that they\nare able to reimburse their members for the\nactual expenditure on health.\nBenefit option packages, Scheme\nRules, Pricing and Risk Selection\nMany governments significantly restrict\nprivate health insurance pricing and risk se-\nlection (underwriting), including imposing\nlimits on rate differentials among different\nbuyers, guaranteed-issue requirements, and\nguaranteed-renewability rules. Some gov-\nernments require medical schemes to ob-\ntain prior regulatory approval of certain rate\nchanges\u00a0 [9]. In South Africa, the Council\nis mandated through the Medical Schemes\nAct 131 of 1998 [12] to approve all the rules\nbefore they are implemented by the schemes\n(s31).The Council also has to ensure that all\nproposed new benefit options, restructured\noptions, and new schemes, are assessed fully\nfor viability before they are registered in\nterms of section 33(2). The most important\ncomponents of section 33 of the Act include\nthe following. A medical scheme:\n\u2022 May apply for the registration of more\nthan one benefit option.\n\u2022 Shall be self-supporting in terms of\nmembership and financial performance.\n\u2022 Is financially sound.\n\u2022 Will not jeopardize the financial sound-\nness of any existing benefit option within\nthe medical scheme.\nRegulation 4 of the Act states that medi-\ncal scheme rules may provide members of\ndependants a right to participate in only\none benefit option at a time. The referred\nregulation that scheme rules may provide\nthat members may change options at the\nbeginning of the month of January each\nyear, and by giving written notice of at least\nthree months before such a change is made.\nIt is also stated that a medical scheme must\nnot in its rules, or in any other manner,\nstructure any benefit option in such a man-\nner that creates a preferred dispensation for\none or more specific groups of members\nor provides for the creation of ring-fenced\nnet assets by means of such benefit option.\nThe CMS also approves the amendments\nof rules to scheme rules and evaluate these\nin accordance to the required standards;\nthese include mid-year contribution and\nbenefit changes, new options, and the ef-\nficiency discounted options for a number of\nschemes.\nFigure2illustratesstructuraldifferencesthat\nexist between open and restricted schemes\nin terms of benefit options. The 2009 data\nshowed that 40% of restricted schemes,\ncompared to the 3% of open schemes, con-\nsisted only of one benefit option. A similar\ndistribution exists in schemes with two ben-\nefit options. However this trend is reversed\non schemes with four or more benefit op-\ntions. There are many options in the open\nschemes environment and this is worrying\nas each represents a distinct package of ben-\nefits, thus members find it difficult to com-\npare products to see which offers the best\nvalue for money. Also, as a general rule, the\ngreater the number of benefit options, the\ngreater the costs of providing these benefits.\nThe CMS continues monitor the registra-\ntion of benefit options, ensuring that they\nwmj 1 2011 5CS.indd 11 21.02.2011 16:28:03\n12\nHealthcare insurance industry SOUTH AFRICA\nare self sustainable, affordable to enrollees,\nand, indeed, do offer value for money.\nAccess to minimal level of care\nMany governments regulate most language\nby requiring certain contract provisions\nand prohibiting others. Some governments\nmandate minimum coverage provisions\u00a0[9].\nThe concept of a minimum level of care is\ncentral to the facilitation and achievement\nof a more equitable and efficient qual-\nity health care system in South Africa. The\nPrescribed Minimum Benefits (PMBs), as\nprovided for by the Medical Schemes Act,\nhave had the greatest importance. PMBs\nare minimum benefits which, by law, must\nbe provided to all medical scheme mem-\nbers and include the provision of diagnosis,\ntreatment and care costs for:\n\u2022 any emergency medical condition;\n\u2022 a range of conditions as specified in An-\nnexure A of the Regulations to the Medi-\ncal Schemes Act\u00a0[12], subject to limita-\ntions specified in Annexure A; included\nin this list of conditions are chronic con-\nditions.\nPMBs were introduced to avoid inci-\ndents where individuals lose their medical\nscheme cover in the event of serious illness\nand are put at serious financial risk due to\nunfunded utilization of medical services.\nThey also aim to encourage improved ef-\nficiency in the allocation of private and\npublic health care resources. PMBs are not\nonly legislated, but they are the envisaged\nplatform for the national health insurance\npackage, which defines the entitlement for\nany person contributing towards such in-\nsurance. As a consequence, a package of\nPMBs with a focus on catastrophic care\nwas developed as Annexure A in the Regu-\nlations to the new Act in 2000. In terms of\nthe Regulations, the PMB package was to\nbe reviewed every two years by the DoH.\nThis review must involve the Council for\nMedical Schemes (CMS), stakeholders,\nprovincial departments of health and con-\nsumer representatives.\nA review process of PMBs was begun by\nthe Council for Medical Schemes in 2008\n[4]. Comments from the stakeholders on\nthe document were taken into account and\npublication of the third draft of the re-\nport in that process was published on the\nCMS webpage. This process was finalized\nin 2009\/10 and the final draft regulation\nwas submitted to the Minister of Health for\nconsideration for possible publication in the\ngovernment gazette for public comments.\nThere are, however, challenges with the im-\nplementation of the Act and Regulations\nrelating to PMBs. In this regard the CMS\ncontinues to engage with the provisions of\nPMB regulations, including the \u201cpayment\nin full\u201d provisions contained in regulation 8\nof the Medical Schemes Act.\nMarket conduct and unfair\ntrade practices\nInsurance regulators often enforce legisla-\ntion dealing with market conduct and unfair\ntrade practices, such as provisions related to\nunfair claim settlement practices and po-\ntentially deceptive sales practices by medi-\ncal schemes and administrators [9]. The\nregulator of the medical schemes in South\nAfrica actively participates in the consulta-\ntive process which aims to demarcate medi-\ncal schemes from health insurance. The of-\nfice of the Registrar is acutely aware that the\nencroachment of risk-rated health insur-\nance products into the business of medical\nschemes results in cream-skimming, unfair\ndiscrimination,and a risk to the sustainabil-\nity of the medical schemes industry.\nEffective regulation of medical schemes\u00a0 \u2013\nand the protection of beneficiaries\u00a0\u2013 is criti-\ncally dependent on all entities and products\nbeing subjected to the rigorous oversight\nand strict protections are contained in the\nMedical Schemes Act. A serious threat\nis posed to the sustainability of medical\nscheme risk pools by the recent prolifera-\ntion of insurance products which seek to en-\ncroach on the preserve of medical schemes.\nThus, the CMS continues to participate in\nthe demarcation work group established by\nNational Treasury to draft regulations in\nsupport of certain amendments effected to\nthe Long- and Short-Term Insurance Acts\nFigure 1. Industry solvency trends for all schemes (2000\u20132009)\nSource: [5]\n119\n112 111 109 111 108\n102 97 92 88\n30 30 31 26 22 21 22 25 22 22\n0\n20\n40\n60\n80\n100\n120\n140\n2000 2001 2002 2003 2004 2005 2006 2007 2008 2009\nyear\n< 25% \u226525%\nNumberofschemes\nFigure 2. Distribution of benefit options across medical schemes (2009)\nSource: [21]\nwmj 1 2011 5CS.indd 12 21.02.2011 16:28:04\n13\nHealthcare insurance industrySOUTH AFRICA\nof 1998 by the Insurance Laws Amendment\nAct (Act 27 of 2008).The work group com-\nprises stakeholders from industry, govern-\nment, and regulatory authorities, and has as\nits purpose consideration of the underlying\nprinciples required to inform the drafting of\nregulations to ensure that a clear delineation\nof products is achieved so that the purpose\nof the Medical Schemes Act is not under-\nmined. The differences between the Medi-\ncal Schemes and Insurance Products is out-\nlined in table 1.\nThe Medical Schemes Act also states that\nit is not a good practice to market, adver-\ntise or in any other way promote a medi-\ncal scheme in a manner likely to create the\nimpression that membership of such medi-\ncal scheme is conditional upon an applicant\npurchasing or participating in any product,\nbenefit or service provided by a person other\nthan the medical scheme. Thus, it is an of-\nfense to conduct practices that are not in\nline with the scheme rules, and the CMS\nsecures adequate protection for beneficiaries\nby approving the manner in which medical\nschemes carry out business, including the\nproducts offered by medical schemes and\nschemes\u2019 compliance with Section 21A.\nInformation disclosure and\nconsumer complaints\nMany governments make available con-\nsumer buying guides and other information\nabout medical schemes contracts. In the\nUnited States, many jurisdictions provide\ncontribution rate comparisons, and some\npublish counts of consumer complaints\nagainst medical schemes. Section 48 and 49\nof the Medical Schemes Act provide that\nthe Council has authority to resolve com-\nplaints between medical schemes and their\nmembers. This process requires that com-\nplaints to be made in writing to the Reg-\nistrar, who must then pass on the details of\nthe complainant to the party that is subject\nto the complaint. The party against whom\nthe complaint is made has 30 days in which\nto respond to the Registrar.The Registrar is\nrequired to resolve the dispute or submit it\nto Council, which is expected to take neces-\nsary steps to resolve the complaint. The fol-\nlowing are key problem areas in the medical\nschemes industry, according to an analysis\nof complaints data in 2010\u00a0[6].\n\u2022 Intermediary behaviour and the func-\ntional dimensions of the registered en-\ntities were identified as one of the key\nproblem areas that need to be addressed\nand monitored closely.\n\u2022 Lack of product quality and standardiza-\ntion is a policy problem is caused by exter-\nnal factors, related to capitalizing on op-\nportunities to take advantage of un-priced\nrisk positions by market participants.\n\u2022 Fiduciary duties of intermediaries, duty\nto disclose and\/or unilateral mistake vs.\nmoral hazard and risk-selection are com-\nplaints are largely related to non-clinically\nrelated entitlements.Undesirable conduct\nis due to incomplete markets and char-\nacteristics of such markets creating bar-\nriers to accessing healthcare. These were\nidentified as one of the biggest changes\nthat threaten the systematic sustainability\nin the industry.\n\u2022 Conduct inducing market uncertainty is\none of the contributing factors that relate\nto systematic sustainability in the indus-\ntry.These complaints relate to the restruc-\nturing of financial & operating capital\nand contingencies impacting risk hazards\nin market environment.\n\u2022 Clinical treatment, formularies and pro-\ntocols were also identified as one of the\nkey problem areas dealing with the sys-\ntematic sustainability in the medical\nschemes industry. Section 29(1) & An-\nnexure A of the regulation of the Medical\nSchemes Act 131 of 2008 is to be used\nas a base or control measure for clinical\ntreatment, formularies and protocols re-\nlated types of complaints.\nThe data analyzed by the CMS showed\nthat social regulation, which also relates to\nTable 1. Differences between Medical Schemes and Insurance Products\nSource [16]\nMedical Schemes Insurance Products\nMedical Schemes Act 1998 Long Term Insurance Act 1998 and Short Term\nInsurance Act 1998\nGoverned by the Council for Medical\nSchemes\nGoverned by the Financial Services Board\nMay not refuse to admit prospective\nmembers\nHave the right to refuse to insure an individual on\nthe grounds of carrying too high risk\nMay not make profit Insures are listed companies which aim to make a\nprofit for their shareholders\nSeek to match premiums and benefits\npaid over the period of a year\nRely on underwriting and actuarial skills to predict\nfuture claims experience for given categories of\ninsured persons over long-term\nMedical scheme reimburse members\nfor the actual medical expenses\nInsurance companies pay policy holders a pre-\nagreed fixed rate in the event of a claim\nCan be paid directly to the provider of\nthe service, a doctor or hospital\nMust be paid to the policy holder, not the provider\nof the service\nRegistered medical schemes have to\nprovide certain benefits and may not\ncharge a member contributions based\non your\nInsurance policies may refuse to sell a policy to\nan individual or may weight premiums according\nto perceived extra risk. Insurance companies are\nallowed to evaluate an individual\u2019s life style and\ngeneral state of health before selling a policy for\n\u2018dread diseases cover\/for example\nwmj 1 2011 5CS.indd 13 21.02.2011 16:28:06\n14\nLaws, Rules, and Norms & Conventions of\nRegulatory Institutions (456\/469, 97.2%), is\nmost dominant in the medical schemes en-\nvironment. Social Regulation [14] typically\nfocuses on policy levers that enhance con-\nsumer welfare interventions within specific\npolicy environments, thus the paternalistic\nand normative values of regulatory philoso-\nphy inform how regulators protect the inter-\nests of consumers. There was a significantly\na small number of complaints that relate to\nEconomic Regulation\u00a0\u2013 Institutional School\n(1\/469, 0.2%) and Economic regulation\u00a0 \u2013\nneoclassical school (12\/469, 2.6%).\nIn keeping with the Act\u2019s emphasis on\ncomplaints, in 2009, the Council embarked\non a process of revamping the complaints\nsystem that captures complaints. This was\nto ensure an efficient and accessible, com-\nplaints processing system that will be an\ninstrumental tool of health system policy\nanalysis through strengthening the respon-\nsiveness of policy levers to consumer needs\nand the advocacy of consumer interests.\nThe Governance of\nHealth Insurance\nThe Medical Schemes Act imposes strict\ncontrols upon medical schemes themselves\nin terms of corporate governance in en-\nsuring the protection of beneficiaries. The\nframework for medi-\ncal scheme corporate\ngovernance is derived\nfrom the common\nlaw, King II and the\nMedical Schemes\nAct of 1998. A ma-\njor challenge facing\nall trustees, including\nmedical aid trustees,is\nto act \u201cwith due care,\ndiligence and the ut-\nmost good faith\u201d.Sec-\ntion 29 of the Act sets\nout certain minimum\nrequirements to be\ncontained in the rules of a medical scheme,\nwith a view to protecting the interests of\nmembers and also providing a framework\nfor good governance. In terms of section\n24(2) of the Medical Schemes Act\u00a0[12], no\nmedical scheme shall be registered unless\nthe Council is satisfied that members of the\nboard of trustees and the principal officer\nof the proposed medical scheme are fit and\nproper persons to hold the office concerned.\nThe statutory duties of the board of trustees\nof a medical scheme, however, derive pri-\nmarily from the provisions of section 57 of\nthe Act. These include: appointment of the\nprincipal officer; accountability for opera-\ntions of the scheme and resolutions passed\nby the board; ensuring that proper control\nsystems are in place; communication to\nmembers on rights, benefits, contributions,\nand duties in terms of rules of the scheme;\nensuring timely payment of contributions\nto the scheme; procuring professional in-\ndemnity insurance and fidelity guarantee\ninsurance; obtaining expert advice on legal,\naccounting, and business matters as re-\nquired; ensuring compliance with the Act;\nand protecting the confidentiality of mem-\nber information. Ongoing governance fail-\nures among medical schemes prompted the\nCouncil for Medical Schemes to undertake\na project to review their governance prac-\ntices and to identify the key determinants\nof governance failures.The findings and rec-\nommendations of the Council\u2019s \u201cGovern-\nance Theme Project\u201d were released in mid\n2006, to recommend additional strategies\nto improve medical scheme governance and\nto mitigate the risk of governance failure.\nOut-of-pocket payments\nOut-of-pocket health expenditures rep-\nresent a significant burden on households\nglobally. Most private health expenditure\ncomprises out-of-pocket payments for\nhealth care, and this includes user fees or\nco-payments for insurance covered services,\npayments for health service not covered by\nthe insurance and informal payments to\nproviders. Private health expenditure ac-\ncounted for 40% of total health spending\nin the EAC countries compared to the 27%\nin countries that are members of the Or-\nganization for Economic Cooperation and\nDevelopment (OECD). In Latvia, out-of-\npocket expenditure for health care repre-\nsented 4.7% of household expenditure\u00a0[20].\nHealth services funded by medical schemes\nonly benefit the 15% of the population who\nwere members of these schemes in 2000;\nthis figured moved slightly to 16% in 2009.\nMedical schemes cover 16% of the popula-\ntion; this population uses the private sec-\ntor on an out-of-pocket basis for primary\ncare but is almost entirely dependent on the\npublic sector for hospital care\u00a0[11]. The to-\ntal household expenditure in South Africa\nin 2007 was R148.5 billion. 19% of this was\nthe out-of-pocket payments, which means\nthat the spending over and above the medi-\ncal schemes contributions was R28 bil-\nlion\u00a0[16].The figures presented in the figure\n4 below show South Africa as the second\nlowest out-of-pocket expenditure with ref-\nerence to other countries.\nThe Medical Schemes Act lays down the\nminimum benefits beneficiaries should re-\nceive from their medical scheme; these are\nbenefits that schemes must by law pay for\nin \u201cfull\u201d. Earlier in 2009, a task team on the\nHealthcare insurance industry SOUTH AFRICA\nFigure 3. Nature of regulation classification\nSource: [6]\nAsapercentageoftheselctedsample(%)\n97.2 0.2 2.6\n0\n20\n40\n60\n80\n100\n120\nSocila Regula\u019fon-Lawas,\nRules, Norms, &\nConven\u019fons of regula\u019fon\nEconomic regula\u019fon-\nneoclassical School\nEconomic Regula\u019fon-\nIns\u019ftu\u019fonal School\nNature of regula\u019fon\nwmj 1 2011 5CS.indd 14 21.02.2011 16:28:07\n15\nPMBs was set up by the Registrar com-\nposed of the Council for Medical Schemes,\nmedical schemes, healthcare providers and\npatient rights groups, who are working on\nclarifying how the PMBs are defined and (at\nthe time of writing this article) this process\nwas still in progress. The outcome of this\nprocess could result in schemes becoming\nliable for more healthcare costs; the success-\nful implementation of PMB could possibly\noffer members the potential to save on out-\nof-pocket expenses and contribution costs.\nContribution increases\nIncreases in excess of the CPI create an af-\nfordability challenge for beneficiaries because\nmedical scheme contributions comprise a\nlarger proportion of household expenditure.\nWhen the pricing of benefit options in-\ncreases it is often followed by a downward\nmigration of beneficiaries to cheaper benefits\noptions. Contribution increases are moni-\ntored by the CMS on annual basis to ensure\nthe affordability of premiums by beneficiar-\nies.The average increase in contributions per\noption is compared to a benchmark of CPIX\n+ 3%. Options that reflect increases greater\nthan this benchmark are requested to provide\nfurther justification for their increase.This is\nused as a guideline by the office to ensure\nthat contribution increases are justified and\nfall within a reasonable range.\nThe nominal increase in average risk con-\ntributions per average beneficiary (as per\nscheme financials) from 2006\/2007 was\n9.9% and the comparing figure for period\n2009\/2010 was 11.6% for the open schemes\nmarket, which was slightly higher than the\nrestricted schemes. The average increase for\nrestricted scheme in gross contribution per\naverage beneficiary per month was 3.9%\nfor 2006\/7 and the comparing figure for\n2009\/10 was 11.6%. The contribution in-\ncreases proposed by the schemes in 2009\/10\nwere 15.7% (a deviation of 4.1% from the\nactual) for the open schemes and 12.7%\nfor the restricted schemes (a deviation of 1,\n1% from the actual). The considerable dif-\nference between these estimated contribu-\ntion increases and the actual increase in the\naverage contribution income of schemes\nindicates that some beneficiaries bought\ndown from more comprehensive options\nto cheaper options, with the consequent\ndampening effect on contributions. This\nphenomenon is more pronounced in open\nschemes than the restricted schemes. The\nCMS vigorously investigates the contribu-\ntion increases and also monitors the afford-\nability and access to healthcare within the\nmedical schemes industry, which is done\nthrough the cost containing strategies.\nNon-healthcare costs and\ncontribution increases\nAccredited entities, including medical\nschemes, administrators, brokers and man-\naged care entities do not always act in the\nbest interests of scheme members and the\npublic at large. \u201cMany schemes and admin-\nistrators attempt to influence brokers to\nHealthcare insurance industrySOUTH AFRICA\nPercentageofTotal\n0\n10\n20\n30\n40\n50\n60\n70\n80\nOut-of-pocket\nPrivate insurance\nSocial sicurity\nGeneral government\nSouth\nAfrica\nVietnamColumbiaTaiwanMexicoSouth\nKorea\nThailandJapan\nFigure 4. Out-of-pocket payments (Country comparisons)\nSources: [22]\nFigure 5. Contribution rate changes (2001\u20132008)\nSource: [5]\nwmj 1 2011 5CS.indd 15 21.02.2011 16:28:08\n16\nadvise clients to choose a particular scheme\nby bidding up broker commissions.This was\nwhat largely necessitated the regulated cap-\nping of broker fees from 2004.However,the\nregulatory regime still has loopholes allow-\ning conflicts of interest to exist by permitting\nschemes to pay the fees in respect of advice\nto members. The conflicts substantially re-\nduce the quality of advice in the market and\npermit schemes to avoid being wholly re-\nsponsive to members and beneficiaries\u201d,\u00a0[4].\nFigure 6 illustrates the increase in broker\nfees relative to membership of schemes that\npay brokers. Broker service fees have been\nrising sharply over the past few years,result-\ning in rates of increase now far exceeding\nthe increases in number of members. For\nthose schemes that paid brokers, broker\nservice fees PAMPM (per average mem-\nber per month) increased by 169.6% since\n2000 compared with an 81.6% net increase\nin the average number of members. The\nsubstantial increases in broker service fees\nare not proportional to the increase in new\nmembers in the medical schemes environ-\nment\u00a0[5], and this poses questions whether\nthe brokers are indeed adding value to the\nmedical schemes.The CMS has started ini-\ntiate consultative processes to propose the\nrevision of the regulatory framework for the\nremuneration of healthcare brokers.\nExpanding coverage and\nhealth work force\nRegulated private insurance coupled with\nvarious social health insurance options and\ngovernment subsidies represent the mid-\ndle-income country route toward build-\ning a universal system. There has been a\nlot discussion about introducing National\nHealth Insurance (NHI) in South Africa.\n\u201cThe first phase of the project will be rolled\nout in 2012, and will focus primarily on\nbringing services to areas with little or no\naccess to quality healthcare and thereafter\nbe extended to other areas of the country.\nProviding universal coverage for all South\nAfricans, irrespective of whether they are\nemployed or not should aim to ensure eq-\nuity and solidarity among the population\nthrough the pooling of risks and funds.\nThe NHI calls for mandatory membership\nfor all South Africans through mandatory\ncontributions and social solidarity, it is up\nto the general public to continue with ad-\nditional voluntary cover with the medical\nschemes after they have contributed to the\nNHI Fund\u201d\u00a0 [1]. Private health insurance\nplays a large and increasing role around\nthe world and it is envisaged that even in\nSouth Africa the medical schemes could\nbe an important component of achieving\nuniversal coverage. One possibility is envis-\naged in which medical schemes continue to\noperate in an NHI setting and function as\na supplementary cover; this is, of course,\nwith reference to the international experi-\nences and is also dependent on definition\nof the NHI package. A word of caution is\nto learn from the international experiences,\nso as to mitigate the shortcomings of es-\ntablishing such a fund and also to be aware\nof the different characteristics between\ncountries.\nAs South Africa prepares for the imple-\nmentation of the NHI, one of the key chal-\nlenges that needs to be addressed relates to\nthe health work force. \u201cThere is a massive\nglobal shortage of health workers and these\nare most intensely in developing countries,\nthe reasons for shortage in health workforce\nare multitude including underproduction,\nmisdistribution of health workforce, health\nworkforce exit and increase in demand of\nhealth care. Many countries in the world\nwith acute shortage of health workforce\nface a lack of medical schools. For an in-\nstance, two thirds of sub-Saharan African\ncountries have only one medical school\nand some have none\u201d\u00a0[17]. The number of\nnurses in South Africa, as estimated by the\nWHO, is 18000 and these professionals are\nserving a population of nearly 49 million.\nThis translates to 3.8 per 1000 patients\u00a0\u2013\nsignificantly smaller than the 9.4 and 7.7\nper 100 patients in the US and Canada\nrespectively\u00a0[16]. The national shortage of\nhealth care workers is critical to the imple-\nmentation of the NHI and key areas of at-\ntention for the initial roll-out of the NHI\nare being discussed.These include investing\nand rebuilding the country\u2019s public health\ninfrastructure, developing human resources\nprograms to fill the national shortage of\nqualified health workers, and establish-\ning a national health fund that would be\nensconced in the Ministry of Health but\noperate autonomously. The CMS\u2019 expertise\nand 10 years of experience can also play a\nvital role in making NHI Fund work effi-\nciently.\nHealthcare insurance industry SOUTH AFRICA\nFigure 6. Broker fees and scheme membership\nSource [5]\n230\n289\n354\n581\n704\n848\n903\n980\n1107 1125\n1.3\n1.5\n1.8\n1.9 1.9\n2\n2.1\n2.2 2.2\n2.3\n0\n200\n400\n600\n800\n1000\n1200\n2000 2001 2002 2003 2004 2005 2006 2007 2008 2009\n0\n0.5\n1\n1.5\n2\n2.5\nMillion(R)\nmembers(millions)\nBroker fees Average members\nwmj 1 2011 5CS.indd 16 21.02.2011 16:28:09\n17\nHealthcare insurance industrySOUTH AFRICA\nConclusions\nThe ultimate responsibility for the overall\nperformance of a country\u2019s health system\nlies with government,which,in turn,should\ninvolve all sectors of society, promoting\nthe spirit of cooperation and partnerships\namong private and public health profes-\nsionals.A government has the responsibility\nfor establishing the best and fairest health\nsystem possible with available resources and\nthe oversight and regulation of private sec-\ntors, which must form part of the overall\ngovernment response, must be high on the\npolicy agenda.\nRegulation of private health insurance\nshould not only provide oversight to private\nhealth insurance companies but it should\nalso focus on encouraging demand for cov-\nerage and otherwise facilitating the entry\nand expansion of access to health care. This\nwill then result in an environment where\na greater proportion of the citizens of the\ncountry have access to good quality health-\ncare. In the South African context, the pri-\nvate sector is critical to the implementation\nof the NHI fund, and policy makers need to\nconfront the role that private health insur-\nance will play. Regulatory approaches and\npolicies can structure private health insur-\nance markets in ways that mobilize resourc-\nes for health care, promote financial risk\nprotection, protect consumers, and reduce\ninequities. Regulatory frameworks for pri-\nvate health insurance need to be structured\nin such a way that they regulate the sector\nappropriately so that it serves public goals\nof universal coverage and equity\nEffective regulation ensures the protection\nof beneficiaries and includes a critical re-\nsponsibility to ensure financial solvency of\nthe schemes. This is achieved by establish-\ning risk-based solvency and minimum capi-\ntal standards to mitigate risk for the insured\npopulation and employers.The rationale for\nan effective regulation framework should\nmandate disclosure requirements for poli-\ncies and costs requiring that their content\nis understandable to consumers and that\nthe consumers are informed of their rights.\nPromoting equity involves ensuring access\nto health care by all income strata of the\npopulation, and minimizing risk skimming\nand adverse selection, which distort health\ninsurance markets, and this is also a key\npolicy goal for effective regulation. Govern-\nment policy needs to provide a framework\nthat result in coverage for a minimum level\nof essential services, irrespective of whether\nit is provided in the public or the private\nsectors. Given the existence of perverse in-\ncentives in unregulated markets for health\ncare, any regulation must pay careful atten-\ntion to the incentives generated. The use of\nmixed systems for covering and providing\nhealth care, combined with the correct ele-\nments of choice, is the best approach to bal-\nancing health care objectives with the need\nfor operational efficiency.\nReferences\n1. ANC Task Team NHI Proposal to NEC, 13\nJuly 2009. Also available on www.health-e.org.\nza\/news\/article\n2. Baldwin R, Cave, M. 1999. Understanding\nRegulation: Theory, Strategy and Practice, Ox-\nford: Oxford University Press.\n3. Bermuda Health Council (BHeC). 2010. En-\nhancing the Regulatory Framework for Health\nInsurers. Also available on www.bhec.bm\n4. Council for Medical Schemes. 2008, CMS\nPress Release 3 Of 2008: Medical Schemes\nCost Increases April 2010. Available on http:\/\/\nwww.medicalschemes.com.\n5. Council for Medical Schemes. 2009, Annual\nReports of the Registrar of Medical Schemes\n2009\/2010. Available on http:\/\/www.medicals-\nchemes.com\n6. Council for Medical Schemes. Research and\nMonitoring Unit. 2010b. Key Complaints Ar-\neas for Compliance Action, (unpublished re-\nport), 2010\n7. Council for Medical Schemes. 2010a. CMS\nPress Release Template 2009: Regulator of\nMedical Schemes turns April 2010. Available\non http:\/\/www.medicalschemes.com.\n8. Georgetown University Health Policy Institute.\n2004. \u201cSummary of Key Consumer Protections\nin Individual Health Insurance Markets.\u201d www.\nHealthInsurance.org.\n9. Harrington, S.E. 2007. Facilitating and Safe-\nguarding Regulation in Advanced Market\nEconomies,The World Bank.\n10. King Committee on Corporate Governance.\nThe King Report on Corporate Governance for\nSouth Africa. 2002.\n11. McIntyre D, Thiede M, Nkosi M, Mutyam-\nbizi V, Castillo-Riquelme M, Gilson L, et al. A\nCritical Analysis of the Current South African\nHealth System. Cape Town: Health Economics\nUnit, University of Cape Town and Centre for\nHealth Policy, University of the Witwatersrand;\n2007.\n12 Medical Schemes Act, 1998 (Act No. 131 of\n1998). Also available on www.doh.gov.za\/docs\/\nbills\/msr.pdf\n13. Monitor, Independent Regulator of NHS\nFoundation Trust, \u201cDeveloping an effective\nmarket Regulatory Framework in Healthcare\u201d,\n2010. Available on www.monitor-nhsft.gov.uk\n14. Ogus; A. (2002). Regulatory Institutions and\nStructures. Annals of Public and Cooperative\nEconomics, Vol. 73, Issue 4, pp. 627\u2013648.\n15. Pearmain, D. 2000. Impact of Changes to the\nMedical Schemes Act. South African Health\nReview\n16. Still, L. 2008. Health Care in South Africa.\nAvailable on www.profile.co.za\n17. V. Bhatt, S. Giri & S. Koirala: Health Work-\nforce Shortage: A Global Crisis. The Internet\nJournal of World Health and Societal Politics.\n2010 Volume 7 Number 1\n18. Van den Heever, A. & Brijlal, V. 1997. Health\ncare financing. South African Health Review,\n(8), 81\u201389.\n19. Van Rensberg,H.C.J.2004.Health and Health-\ncare in South Africa. First edition. Pretoria: Van\nSchaik Publishers.\n20. Xu, K et al. (2009), Access to Health Care and\nthe Fiancial Burden of Out-of-Pocket Health\nPayments in Latvia\n21. Willie, MM & Nkomo, P. 2010. Intraclass cor-\nrelation and multilevel modelling of contribu-\ntions data. First Global Symposium on Health\nSystems Research, 16\u201319 November 2010,\nMontreux, Switzerland\n22. World health organisation (2004), Discussion\npaper number 3: Private health insurance: im-\nplications for developing countries\nDr. Monwabisi Gantsho,\nMr. Michael Mncedisi Willie\nCouncil for Medical Schemes, South Africa\nEmail: m.gantsho@medicalschemes.com\nwmj 1 2011 5CS.indd 17 21.02.2011 16:28:11\n18\nOn the threshold of the year 2011 I would\nlike WMA to pay its attention to the dam-\nage caused by tobacco smoking and espe-\ncially to the disastrous consequences of\nsmoking in the presence of infants, young\nchildren and pregnant women. Our task is\nto eliminate this malady forever. This year\nis favourable for its implementation as our\nfriends in Monte Video have set as the main\ntask for the General Assembly the recogni-\ntion of the extreme harmfulness of tobacco\nsmoking. The Latvian Medical Association\npoints out that our goal is not restriction of\ntobacco smoking but total elimination of\nthis disaster. This is not an easily achievable\ngoal as a long and persistent effort is re-\nquired here; however, it is possible to reach\nin a twenty-year period.\nFrom today\u2019s point of view the most alarm-\ning fact is that the Tobacco industry that\nhas been continuously defeated in Europe,\nAustralia and North America, has shifted\nits business to the Third World countries,\nincreasing the number of smokers among\nchildren and young people, especially young\ngirls.The Third World countries do not pos-\nsess enough resources to fight the Tobacco\nindustry as they lack means to provide their\npopulation with food and drinking water\nand many of these countries suffer from\nhigh rate of unemployment. These hard\nconditions are still worsened by Tobacco\nstepping in and attracting the scarce re-\nsources.\nThere is a principle that applies to a cer-\ntain group of countries in the world\u00a0\u2013 the\namount of finances spent on smoking equals\nthat spent on healthcare as a whole.The old\nEuropean countries have imposed high ex-\ncise duties and VATs on Tobacco, which re-\ndirects a significant part of these taxes to the\nstate budget. In the developing countries all\nmoney made on tobacco sales flows directly\ninto the greedy arms of producers and mer-\nchants. Bread and water get exchanged for\nTobacco. Even starving children smoke. So\nthe Tobacco manufacturers kill people not\nonly by means of nicotin, tar and carcino-\ngens but also economically.\nToday the World Medical Association has\nto undertake leadership in the campaign\nagainstTobacco on a global scale.The World\nMedical Association cannot be bribed and\nits leaders will not take up any discussion or\ndeal with the Tobacco industry.\nThe World Medical Association has to use\nits authority and powers, the knowledge\nbased on evidence and to declare world-\nwide:\n1. Smoking in the presence of a child is vio-\nlence against a child.\n2. Smoking in the presence of a pregnant\nwoman is a crime against humanity.\n3. What we can do is protect children and\npregnant women worlwide from passive\nsmoking within family, in public, in prmises,\ncars, hotels, hospitals, at sports events, train\nstations and anywhere else.\n4. Those selling tobacco to young people and\nchildren and those involving children into\nsmoking must be considered murderers.\nThese four messages must become our slo-\ngan that we should bring to the WHO and\ngovernments of all countries thus obliging\nthem to include these messages into their\nlegislation and to declare smoking in the\npresence of children and pregnant women\na crime to be prosecuted. Only WMA is\nable to act zealously and forcefully because\nthere is no threat of friendly co-operation\nbetween it and the Tobacco industry.WMA\nshould take the initiative of fighting the\nTobacco industry in its hands, and espe-\ncially the tendency that forces children and\nyoung women in the developing countries\nto smoke.\nAlmost all governments and politicians\ntend to be close to Tobacco manufacturing\nand merchandising companies, even receiv-\ning direct or indirect support from them.\nMembers of the World Medical Associa-\ntion are able to persuade their governments\nthat flirting with the Tobacco industry is a\ndangerous game that puts the health and\nlives of their people at stake.\nPassive smoking is a significant\ncause of illnesses and deaths\nEnvironmental tobacco smoke (ETS) that\nis also called \u201csecond hand smoke\u201d or \u201cpas-\nsive smoking\u201d is a widespread cause of ex-\ncessive morbidity and mortality worldwide,\nwhich results in significant costs paid by the\nwhole world community. ETS is composed\nof more than 4.000 chemicals including\nmore than 50 presently known carcinogens\nand a lot of toxic substances.\nThe US Department of Health and Hu-\nman Services has classified ETS as human-\ngenerated carcinogen and toxic pollutant.\nHarm of tobacco LATVIA\nP\u0113teris Apinis\nTobacco-Free World in Twenty Years\u2019 Time!\nwmj 1 2011 5CS.indd 18 21.02.2011 16:28:12\n19\nHarm of tobaccoLATVIA\nIt has been repeatedly proven that passive\nsmoking causes serious damage to human\nhealth and life. Continuous passive smok-\ning induces the same diseases that are pro-\nvoked by active smoking including lung\ncancer, coronary heart disease and infantile\ndiseases.\nA WHO survey states that non-smokers\nliving together with smokers are by 20\u201330%\nmore exposed to lung cancer. The risk of\nbecoming ill with lung cancer is estimated\nas 12\u201319% for those working in a smoking\nenvironment. Passive smoking is connected\nwith respiratory diseases and it causes exac-\nerbation of asthma,allergy and chronic lung\ndisease that results in excluding from the\nsocial and working environment.\nLiving together with a smoker increases the\nrisk of cardiovascular diseases by 25\u201330%,\nwhile working in a smoking environment\nincreases it by 15\u201318%. Besides, the con-\nnection between doses and the response is\nnot a linear one. Passive smoking relates to\nheart diseases and the probability is about\nhalf of that resulted from 20 cigarettes a day.\nEven a small amount of tobacco smoke can\nhave an immediate effect on blood clotting\nas well as a long-term influence on athero-\nsclerosis, which make the most significant\nheart disease factors.\nAccording to the European Respiratory\nSociety, Cancer Research UK and Insti-\ntut National du Cancer, more than 79.000\nadults in 25 member countries of the EU\ndie annually from passive smoking. Home\nand work are the two main environments\nwhere tobacco smoke acts intensively and\nchronically.\nThese estimations include deaths from\nheart diseases, stroke, lung cancer and dif-\nferent respiratory diseases caused by passive\nsmoking. These numbers do not include\nadult deaths caused by other conditions\nconnected with ETS (such as pneumonia),\nearly death or both serious acute and chron-\nic diseases caused by passive smoking.\n\u201cSecond hand smoke\u201d is particularly\ndangerous for young children and in-\nfants. Smoking in the presence of a child\nis an act of violence that threatens child\u2019s\nhealth and life. Smoking in the presence\nof a pregnant woman is an act of vio-\nlence against her and the unborn child,\nconsequently\u00a0\u2013 a crime against the state\n\u201cSecond hand smoke\u201d is particularly dan-\ngerous for young children and infants, it is\nrelated to sudden death, pneumonia, bron-\nchitis, asthma and respiratory symptoms as\nwell as tympanitis. ETS can also result in\ndecreased birth weight, prenatal death or\npremature birth.\nSmoking in the presence of a child can\ncause addiction that in turn makes the child\nan early smoker. Parents\u2019 smoking becomes\na kind of brand that is followed in the future\nlife. After seeing a camel or brave horsemen\nin a prairie in their young years, people con-\nsider the image being a positive one in their\nadulthood.\nThe WHO Framework Convention on\nTobacco Control (FCTC) has recognized\nthat there is scientific evidence of the fact\nthat tobacco smoke causes death, diseases\nand disability. The convention obliges the\nmember countries to prevent \u201csecond hand\nsmoke\u201d risks.\nAccording to FCCT article 8, every mem-\nber is bound to \u201cadopt and implement ef-\nfective legislative, executive, administrative\nand\/or other measures, providing for pro-\ntection from exposure to tobacco smoke in\nindoor workplaces, public transport, indoor\npublic places and,as appropriate,other pub-\nlic places.\u201d\nSmoking is an economic burden\nAt the moment when country after coun-\ntry has been stricken by the economic crisis,\ntobacco consumption imposes one of the\nheaviest burdens on the economy. However,\npoliticians often pretend not seeing this\nthreat.\nAt first this burden includes the increased\ndirect costs of health care determined by\ndeseases caused by tobacco smoking. This\nburden is different in different countries,\nbut in the EU it is considered that at least\none quarter (24\u201332%) of health care costs\nare related to diseases caused directly by al-\ncohol and tobacco consumption.\nAnother economic stroke coming from\nsmoking is indirect costs, which occur be-\ncause smokers fall ill more often than non-\nsmokers, they do not work and do not pro-\nduce any added value during these periods\nand thus they decrease the health and social\nbudget. The same is also true for \u201cpassive\nsmokers\u201d. Their productivity is lower than\nthat of non-smokers\u00a0\u2013 oxygenation in the\nlungs becomes slower during smoking and\nsmoker\u2019s blood oxygen saturation decreases,\nwhich results in rapid tiredness and lack of\nattention. Smokers also tend to take breaks,\nso no work is being done during these pe-\nriods.\nOne more aspect\u00a0 \u2013 smoking quite often\ncauses domestic, industrial and forest fires.\nSmoking while driving has been the reason\nfor thousands of road accidents in the whole\nworld. The policy of the Tobacco industry\nthat supports tobacco manufacturing in\nthe developing countries and a differenti-\nated excise duty policy has facilitated turn-\ning of the tobacco goods into a contraband\nthat involves thousands of people traffick-\ning tobacco produced in China, India, the\nUkraine or Russia illegally into the EU or\nthe USA.\nAn essential task is to promote the stand-\npoint that smoking is a calamity and it is\n\u201cnormal\u201d not to smoke. One of the first\ntasks is to achieve the situation that medi-\ncal people do not smoke. Smoking by a\nphysician is one of the most negative ex-\namples possible.\nwmj 1 2011 5CS.indd 19 21.02.2011 16:28:13\n20\nHarm of tobacoo LATVIA\nSixty years of fighting smoking.\nSixty years of randomized research\nIn this article I would like to give some in-\nsight into the history of fighting smoking and\ngive evidence of the significant work done by\ndoctors. In 1951 Austin Bradford Hill dis-\ncovered that smoking causes lung cancer.For\nthe time being it was a sensational discov-\nery as after WW II most of male Europeans\nwere smokers. During the war tobacco acted\nas a tranquillizer in entrenchments; even if\nit did not give relief, it kept one busy. It was\nnot an easy task to prove this correlation\nbecause both healthy and unhealthy people\nused to smoke. So statistics was the only\ntool. The 1950\u2019s were the time of paradigm\nshift in medicine because lung cancer came\nforward instead of tuberculosis. In England\nthe number of lethal outcomes from lung\ncancer in 1950 exceeded those from tubercu-\nlosis. In 1947 Austin Bradford Hill, Ernest\nKennaway from St Bartholomew\u2019s Hospital\nand Percy Stocks, chief government medical\nstatistician, were asked to find out whether\nsmoking could cause the shocking 15-fold\nincrease in lung cancer deaths during the\nprevious 25 years. They were accompanied\nby Dr Richard Doll. From April 1948 every\nsuspected lung cancer case in 20 London\nhospitals was reported to Doll.In turn,a lady\nalmoner was sent to interview a patient and\ntwo more patients from the control group\u00a0\u2013\none with a stomach or colon cancer and the\nother one from any other therapy or surgery\ndepartment.The research proved the correla-\ntion concerning smokers and non-smokers,\nas well as the number of cigarettes smoked\na day. A control research was carried out\noutside London. The results were undoubt-\nable. At the same time similar results were\nobtained in the USA.\nHowever, this was not enough to persuade\nthe world that smoking is harmful. Brad-\nford Hill was looking for more evidence\nand he invented a new method of research.\nThe previous method was a retrospective\none, but to make it absolutely veritable,\nsimilar data had to be obtained in future\nperspective. So a large number of men\nand women were questioned, finding out\nabout their habits, including smoking and\nthey were observed for several years. So\nthis prospective or cohort research gave\nthe answer to the question why smokers\ndie. Bradford Hill chose 60.000 physicians\nfrom the Medical Registry, who were reli-\nable for his research. There was no better\nway to promote this discovery than spread-\ning it in the medical environment.The doc-\ntors passed the message about the harm\nof smoking over to their patients. In 1951\nBradford Hill sent a letter to the British\nMedical Journal, asking: \u201cDo you smoke?\u201d\nIn the short period of two years, Bradford\nHill got his response. Out of 40.000 re-\nspondents, 789 were dead, 36 of them of\nlung cancer.When the results were put into\ntables, a correlation between doses showed\nout. The more cigarettes were smoked, the\nmore death cases occurred.\nThus in 1951 Bradford Hill started the sta-\ntistical methods that are used by thousands\nof scientists and physicians in the whole\nworld today. The randomized controlled re-\nsearch came as a substitute for clinical ob-\nservation.\nThese findings of 1951 empowered physi-\ncians in the whole world to start the battle\nagainst tobacco. Smoking doctors disap-\npeared from packages, and some time lat-\ner\u00a0\u2013 from posters that recommended ciga-\nrettes of a certain brand. Today at least in\nLatvia any advertising of tobacco is banned,\nand all legally sold packages have visible\nand serious warnings about the hazards of\nsmoking\u00a0\u2013 cancer, heart disease, impotency\nor at least bad teeth. In Northern Europe\nthere is no smoking in clubs, bars and\npublic places. In some countries no indoor\nsmoking is allowed, because passive smoke\nis harmful not only for those standing next\nto the smoker but for smokers themselves\nas they are more exposed to cancer (and at\nthe same time financial losses to the state\nhealth budget). A lot is achieved, still a lot\nis to be done.\nThe Latvian Medical Association is pro-\nmoting an anti-smoking legislation in\nLatvia and we are inviting the world to\njoin us\nWe are supplementing the Children\u2019s\nRights Defence Law with a thesis that no\nchild must be exposed to tobacco smoke\nand nobody is allowed to smoke in the\npresence of a child, to ensure a smoke-free\nenvironment for children. The same law\nstates that physical violence against a child\nis a conscious application of power when\napproaching a child or a situation when\na child is exposed to harmful factors (air\npollution, tobacco smoke, etc.). So smok-\ning in the presence of a child, including an\nunborn one, is considered physical violence\nagainst a child and makes it suffer physi-\ncally.\nLatvian lawmakers today are forced to con-\nsider whether real imprisonment (5\u201315 days\nand work) should be imposed on those sell-\ning cigarettes to minors or \u201ckind uncles\u201d\nbuying those for minors. We propose that\nthose who smoke in the presence of children\nand women should be naturally imprisoned.\nLet us join our forces in 2011 to protect\nchildren in the whole world against direct\nand indirect effects of tobacco smoking!\nReferences\n1. Barnoya J, Glantz SA. Cardiovascular effects of\nsecondhand smoke: nearly as large as smoking.\nCirculation. 2005 May 24;111(20):2684-98. Re-\nview.\n2. Boldo E, Medina S, Oberg M, Puklov\u00e1 V, Mekel\nO. Health impact assessment of environmental\ntobacco smoke in European children: sudden in-\nfant death syndrome and asthma episodes.Public\nHealth Rep. 2010 May-Jun;125(3):478-87.\n3. Cardiovascular effects of secondhand smoke:\nnearly as large as smoking. Circulation. 2005;\n111(20): 2684-2698\n4. Commision of the European Communities. Gre-\nen paper: Towards a Europe free from Tobacco\nsmoke: policy options at EU level. Available\nat: http:\/\/eur-lex.europa.eu\/LexUriServ\/site\/en\/\ncom\/2007\/com2007_0027en01.pdf.\nwmj 1 2011 5CS.indd 20 21.02.2011 16:28:14\n21\nClimate ChangeAUSTRALIA\nWhile many people and groups have ex-\npressed disappointment with the outcomes\nor lack of outcomes from the Copenhagen\nclimate talks, it remains undeniable that cli-\nmate change poses serious threats to human\nhealth globally.\nThe world\u2019s climate\u00a0\u2013 our life-support sys-\ntem\u00a0\u2013 is being altered in ways that are likely\nto pose significant direct and indirect chal-\nlenges to health.\nWhile climate change can be due to natu-\nral forces or human activity, there is now\nsubstantial evidence to indicate that human\nactivity\u00a0\u2013 and specifically increased green-\nhouse gas emissions\u00a0\u2013 is a key factor in the\npace and extent of global temperature in-\ncreases.\nPotential health impacts of\nclimate change in Australia\nIn Australia, consequences of climatic ex-\ntremes and changes to food and water\nsupplies are predicted to have particular\nimpacts on rural, regional, and some re-\nmote Indigenous communities, with some\ncoastal communities facing relocation due\nto storms and flooding.\nSignificant numbers of Australians are vul-\nnerable to severe storms and to increases in\nsea level.\nThere is a consensus that the more vul-\nnerable members of the community\u00a0\u2013 the\nelderly, the young and those whose health\nis already compromised\u00a0\u2013 will be most af-\nfected by climate-related illnesses.\nChildren\u2019s exposure to climate change-re-\nlated exposures and social stresses has been\nhighlighted as a particular concern.\nBy 2056, there will also be a much higher\nproportion of Australians over the age of 65,\nas well as a rapid increase in the number of\npeople aged 85 and over.\nBy 2020, it is expected that Australian doc-\ntors and other health professionals will be\nseeing patients with illnesses and conditions\nrelated to both short-term and longer-term\neffects of climate change.\n5. Doll R, Hill AB. Mortality in Relation to\nSmoking: Ten Years\u2019 Observations of Bri-\ntish Doctors. Br Med J. 1964 June 6; 1(5396):\n1460\u20131467.\n6. Doll R,Hill AB. Smoking and carcinoma of the\nlung: preliminary report.Br Med J. 1950 Sep\n30;2(4682):739-48.\n7. Doll R, Hill AB. Study of the Aetiology of\nCarcinoma of the Lung. Br Med J. 1952 Dec\n13;2(4797):1271-86.\n8. Flouris AD. Acute health effects of passive\nsmoking. Inflamm Allergy Drug Targets. 2009\nDec;8(5):319-20.\n9. Gehrman CA, Hovell MF;Centre for Reviews\nand Dissemination. Protecting children from\nenvironmental tobacco smoke (ETS) exposure:\na critical review. Cochrane Database of Ab-\nstracts of Reviews of Effects, 2003.\n10. Glantz SA, Parmley WW. Even a little second-\nhand smoke is dangerous. JAMA. 2001 Jul 25;\n286(4):462-3.\n11. Hopkins DP, Briss PA, Ricard CJ, Husten CG,\nCarande-Kulis VG; Centre for Reviews and\nDissemination. Reviews of evidence regarding\ninterventions to reduce tobacco use and exposure\nto environmental tobacco smoke. Cochrane Da-\ntabase of Abstracts of Reviews of Effects , 2001.\n12. Lin S, Fonteno S, Weng JH, Talbot P. Com-\nparison of the toxicity of smoke from con-\nventional and harm reduction cigarettes using\nhuman embryonic stem cells.Toxicol Sci. 2010\nNov;118(1):202-12.\n13. Oberg M, Jaakkola MS, Woodward A, Peruga\nA,Pr\u00fcss-Ust\u00fcn A.Worldwide burden of disease\nfrom exposure to second-hand smoke: a retro-\nspective analysis of data from 192 countries.\nLancet. 2011 Jan 8;377(9760):139-46.\n14. Prevalence and Incidence of Smoking.Available\nat:http:\/\/www.wrongdiagnosis.com\/s\/smoking\/\nprevalence.htm\n15. Priest N,Roseby R,Waters E,Polnay A,Camp-\nbell R. Family and carer smoking control pro-\ngrammes for reducing children\u2019s exposure to\nenvironmental tobacco smoke. Cochrane Da-\ntabase of Systematic Reviews, 2008, October.\n16. Reh DD, Lin SY, Clipp SL, Irani L, Alberg AJ,\nNavas-Acien A. Secondhand tobacco smoke\nexposure and chronic rhinosinusitis: a popula-\ntion-based case-control study.Am J Rhinol Al-\nlergy. 2009 Nov-Dec;23(6):562-7.\n17. Wdowiak A, Wiktor H, Wdowiak L. Ma-\nternal passive smoking during pregnancy and\nneonatal health. Ann Agric Environ Med. 2009\nDec;16(2):309-12.\n18. Wipfli HL, Samet JM. Second-hand\nsmoke\u2019s worldwide disease toll.Lancet.2011 Jan\n8;377(9760):101-2.\n19. World Health Organization.WHO Report\non the GlobalTobacco Epidemic,Implementing\nsmoke-free environments. 2009\nP\u0113teris Apinis,\nPresident, Latvian Medical Association\nClimate Change\u00a0\u2013 a Serious Threat\nto Human Health\nAndrew Pesce\nwmj 1 2011 5CS.indd 21 21.02.2011 16:28:15\n22\nClimate Change AUSTRALIA\nHigher temperatures\nHeatwaves, especially in cities, can increase\nthe rates of death and illness,primarily from\nheart and respiratory illnesses.\nAustralia\u2019s ageing population, increasing\noccurrence of chronic disease and co-mor-\nbidities and high levels of urbanisation all\nserve to increase susceptibility to the impact\nof heatwaves.\nIf NSW were to experience a heatwave\nsimilar to one that occurred in Europe in\n2003, calculations suggest that an extra 647\ndeaths would occur over a two-week period.\nStudies suggest that, over time, levels and\npatterns of airborne pollens and pollutants,\nwhich have significant effects on respiratory\nhealth, can be affected by higher tempera-\ntures and humidity resulting from climate\nchange.\nWhile the links between ozone and atmo-\nspheric warming are complex,elevated levels\nof ambient ozone have been found to lead to\nmore frequent asthma attacks and hospitali-\nsations and greater morbidity and mortality\nin patients with pre-existing pulmonary or\ncardiovascular disease. Investigations of the\npotential impact of climate change on ambi-\nent ozone concentrations suggest that a con-\ntinuation of current trends over the next 10\nyears could result in asthma-related deaths\nrising by almost 20 per cent.\nVector-borne diseases\nThe potential for the resurgence of old dis-\neases, the redistribution of others, and the\nemergence of new diseases have all been\nlinked to altered climate and changing eco-\nlogical balances.\nChanges in climate can significantly alter\nthe ecology and epidemiology of viruses\nand their potential to cause outbreaks of\nhuman disease. The transmission of cer-\ntain arboviruses (transmitted to humans\nthrough mosquito bites) is particularly sus-\nceptible to environmental conditions that\nenable breeding and survival\u00a0\u2013 rainfall,tides,\nsea level, temperature, humidity and wind\nall play a part.\nClimate change is expected to particularly\naffect the spread of diseases such as malaria\nand dengue fever.\nThe arboviruses of greatest concern in\nAustralia are Ross River, Barmah Forest,\nMurray Valley encephalitis, Kunjin virus,\ndengue and Japanese encephalitis virus.\nThe spread of other mosquito-borne diseas-\nes such as Chikungunya virus may also be\naffected, as there is evidence that the virus,\npreviously thought to be limited to particu-\nlar species of mosquitoes, is capable of be-\ning transmitted by species distributed more\nwidely in Queensland and in other areas\nthroughout Australia.\nIt is believed that global warming will result\nin tropical conditions in Australia spreading\nsouth, as will disease vectors such as mos-\nquitoes.\nFood and water-borne diseases\nHeavy rain, flooding and increased temper-\natures are factors that influence water-borne\ninfections.\nAs the temperature of the environment\nincreases, the quality and the quantity of\ndrinking water could decrease through\ndrought.\nIn Australia, there are already water restric-\ntions in many States for the first time in 20\nyears.\nIt is expected that health disorders related\nto environmental and water contamination\nby bacteria, viruses, protozoa and parasites\nwill increase as the quality of water de-\ncreases. This contamination also occurs at\nthe other extreme as heavy rainfall and run-\noff influence the transport of microbial and\ntoxic agents from agricultural fields, human\nseptic systems and toxic dumps.\nWarmer temperatures also encourage food-\nborne infections.\nThe incidence of bacterial food-borne dis-\neases (and amoebic diseases) increases dur-\ning the summer months and is worse in the\nnorthern regions of Australia, due primarily\nto the increased bacterial replication where\nambient temperatures are higher.\nIf average temperatures continue to rise,\nrates of food-borne diseases are also pre-\ndicted to rise. However, actual health im-\npacts will depend on factors such as food\nhygiene practices and contributions of dif-\nferent pathogens.\nThe combination of water shortages and\nlack of fresh food suggests the potential for\nsignificant harm to both the environment\nand human health in isolated Australian\ncommunities.\nChanges in the amount and distribution of\nwildlife, fish and vegetation could also have\nhealth consequences for people in remote\nIndigenous communities who follow a tra-\nditional diet.\nMental health\nBoth extreme events and gradual climate-\nrelated changes, such as drought, may give\nrise to mental health problems, and these\nmay continue for a significant period, and\neven be delayed.\nPopulations exposed to climate-related ex-\ntreme weather events or disasters experience\nsocial, physical and material conditions that\nadversely affect mental health. Post-trau-\nmatic stress disorder,depression and anxiety\nmay all result. Because of increasing num-\nwmj 1 2011 5CS.indd 22 21.02.2011 16:28:17\n23\nAUSTRALIA Climate Change\nbers of extreme weather events, the impact\nof natural disasters on mental health is a\ngrowing concern.\nStudies have found that mental health is-\nsues remain for a considerable time after the\nevent and that, while post-disaster morbid-\nity is likely to decline over time, the effects\nof exposure to the initial disaster and losses\nare likely to persist.\nA number of Australian studies have shown\nthat bushfires increase psychological mor-\nbidity among individuals and communities\nexperiencing loss.\nThese effects can be chronic and delayed\nand may require ongoing intervention, al-\nthough relatively few individuals develop\nserious long-term problems.\nDiagnosis of post-traumatic stress disorder\nrequires a clinical evaluation of symptoms.\nOther mental health problems occurring in\na post-disaster environment include depres-\nsion, bereavement complications, anxiety\ndisorders, substance abuse and adjustment\ndisorders.\nThree years after Hurricane Katrina in the\nUSA, psychiatrists and other clinicians,\nhospitals,government and non-government\nagencies, schools and community groups\nwere still working to help adults and chil-\ndren overcome persistent mental health\nproblems.\nStudies have found that people recover from\nextreme events in different ways and that a\nrange of support services across the whole\nof the community is required. People who\nhad accessed the services of the ACT Bush-\nfire Recovery Centre after the 2003 Can-\nberra bushfires reported that, after the Re-\ncovery Centre, doctors were the next most\ncommon source of help that they consulted.\nIn addition to the impact of disaster\nevents, coping with and moving away from\nlonger-term effects of climate change may\ncreate mental health problems for some\npeople.\nIn Australia, drought has had a major im-\npact on farm families and communities reli-\nant on agricultural production.\nLevels of depression and suicide in rural\nAustralia have been correlated with pro-\nlonged drought, and there are concerns\nabout the likelihood of mental health prob-\nlems continuing to increase, particularly\namong rural men.\nMany communities, including those famil-\niar with drought, are likely to face the chal-\nlenges of longer-term climate change.\nAction\nClimate change is a real and serious prob-\nlem. The potential health effects are signifi-\ncant, and we need to take steps now to ad-\ndress them. In Australia, we need a national\ncoordinated strategic approach to these\nhealth problems. The AMA advocates that\na National Strategy for Health and Climate\nChange should be developed and imple-\nmented.\nThat strategy should incorporate the fol-\nlowing:\n\u2022 localised disaster management plans for\nspecific geographical regions that model\npotential adverse health outcomes in\nthose areas and incorporate appropriate\nlocalised health and medical response\nmeasures, including for people who have\nbeen evacuated or relocated, temporarily\nor permanently,\n\u2022 strong and active communication link-\nages between hospitals, major medical\ncenter and local weather forecasters and\nemergency response agencies (in at-risk\nlocations) to maximize timely responses\nand efficient use of health resources in ex-\ntreme weather events,\n\u2022 measures targeted to the needs of certain\nvulnerable population groups (older Aus-\ntralians, children, Indigenous communi-\nties, members of remote communities),\n\u2022 measures to address health and medi-\ncal workforce needs in rural and remote\ncommunities, particularly in mental\nhealth services,\n\u2022 enhanced awareness among doctors and\nhealth professionals of the potential con-\nsequences on mental health of extreme\nweather events and disasters,\n\u2022 development of effective interventions to\naddress mental health issues arising from\nextreme events, including those involv-\ning mass casualties,and from longer-term\nchanges, including drought,\n\u2022 programs to improve the education and\nawareness of health professionals about\nthe links between health and climate\nchange, and their understanding of the\nrisks of new vector-borne diseases and\ntheir health impacts,\n\u2022 measures to prevent exotic disease vectors\nfrom becoming established in Australia\nand nationally coordinated surveillance\nfor dangerous arboviruses, with public\neducation programs promoting mosquito\navoidance and measures to prevent mos-\nquito\/arthropod breeding, and\n\u2022 preparedness to deal with the temporary\nand permanent dislocation of people due\nto climate-related physical events and\neconomic conditions.\nDr. Andrew Pesce, President,\nAustralian Medical Association\nwmj 1 2011 5CS.indd 23 21.02.2011 16:28:18\n24\nMore than 170 doctors from around the\nworld gathered in Vancouver in mid-Octo-\nber for a wide-ranging discussion about the\npervasive and profound effects environmen-\ntal factors such as climate change can have\non human health.\nThe occasion was a scientific session orga-\nnized by the CMA as part of the World\nMedical Association\u2019s (WMA) annual\ngeneral assembly. WMA delegates, as well\nas many BC physicians who attended the\nmeeting, were told how health issues re-\nlated to environmental change have become\na policy focus for both the WMA and the\nCMA, thanks in part to the leadership of\na CMA past president, Dr. Ruth Collins-\nNakai.\n\u201cWhy on earth would we be interested\nin environment health?\u201d asked Dr. Maura\nRicketts, director of the CMA\u2019s Office for\nPublic Health, as the scientific session\nbegan. \u201cBecause our members are inte-\nrested.\u201d\nShe said members want and expect the\nCMA to take a strong advocacy stance with\nrespect to issues such as climate change.Be-\ncause they are \u201cextraordinarily well-trusted\nresources for information,\u201d she added, phy-\nsicians can play a key role in making people\naware of environmental issues and their im-\npact on health.\nDr. Alan Abelsohn, assistant professor of\nfamily medicine and community medicine\nat the University of Toronto, said survey\ndata has shown that Canadians consider\nphysicians\u00a0\u2013 especially family physicians\u00a0\u2013\nto be the most credible source of informa-\ntion on the environment and health.\nThe meeting began with a video greeting\nfrom federal Health Minister Leona Ag-\nlukkaq, who advised that every aspect of the\nenvironment can affect human health, and\nthe discussions that followed supported her\ncontention.\nThe session\u2019s keynote speaker,British Medi-\ncal Association President Sir Michael Mar-\nmot, provided an exhaustive global over-\nview of how social and economic inequities,\nas well as inequitable exposure to environ-\nmental risks, affect health.\n\u201cIf we put fairness at the heart of all de-\ncision-making, health would improve and\nhealth inequities would diminish,\u201d said ser\nMarmot.\nHe presented data which proved that com-\nmunities and individuals at the lower end\nof the socioeconomic spectrum also face\ngreater exposure to environment-related\nhealth risks.\nHe was followed by several experts, many of\nwhom work at Canadian centres, who cov-\nered issues ranging from indoor air quality\nin developing nations to mercury toxicity.\nFor instance, thermometers that contain\nmercury remain the largest source of that\ntoxic element within health care settings.\n\u201cThe movement away from mercury ther-\nmometers has been global... and is certainly\npicking up steam,\u201d said Dr. Peter Orris,\nchief of occupational and environmental\nmedicine at the University of Illinois. He\nnoted the number of thermometers broken\nin hospitals remains \u201cquite extraordinary.\u201d\nAll presentations at the WMA meeting\nwere recorded and will be made available on\nwww.cma.ca\nPat Rich, Canadian Medical Association\nWorld\u2019s MDs Discuss Growing Health\nThreats Posed by Environment\nWMA news\nThe World Medical Association has ap-\npealed to the Mexican Government to\nrestore order in the north Mexican city of\nCiudad Juarez where physicians are being\nblackmailed, kidnapped and killed in drug\nrelated violence.\nDr. Federico Marin, the President of the\nMexican Medical Association, has urged\nthe WMA to intervene to help the physi-\ncians in Jurarez. He told the WMA: \u201cDue\nto the escalating violence and now the\nkidnapping of physicians, it has become\nimpossible for the physicians in Juarez\nto provide medical care without threat to\nthemselves. They have had to organise a\nwork stoppage to bring attention to this\nissue.\u201d\nDr. Wonchat Subhachaturas, President\nof the WMA, strongly condemned the\nviolence facing physicians. This year three\nmedical workers have been killed and 11\nkidnapped.\nHe said: \u201cPhysicians have an ethical duty\nto care for their patients and governments\nhave a duty to ensure that appropriate con-\nditions exist to allow physicians to care for\ntheir patients. The situation in Jurarez ap-\npears to be out of control, threatening phy-\nsicians and preventing them from carrying\nout their clinical work.\u201d\nPhysicians Urge Mexican Government to\nRestore Order in Juarez\nwmj 1 2011 5CS.indd 24 21.02.2011 16:28:20\n25\nThe World Organization of Family Doctors\n(WONCA) is the global association of fam-\nily doctors. Its familiar name \u201cWONCA\u201d is\nan acronym taken from the first letters of\nthe first five words of the name used at the\ntime of its formation: the World Organiza-\ntion of National Colleges, Academies, and\nAcademic Associations of General Practi-\ntioners\/Family Physicians. Beginning with\n18 members in 1972, WONCA is now\ncomprised of 122 member organizations in\n102 countries that represent about 300 000\nfamily doctors.\nMission\nWONCA\u2019s mission is to improve the quali-\nty of life of the peoples of the world through\ndefining and promoting its values, and by\nfostering high standards of care in general\npractice\/family medicine by:\n\u2022 promoting personal, comprehensive and\ncontinuing care for the individual in the\ncontext of the family and the community;\n\u2022 encouraging and supporting the develop-\nment of academic organizations of gen-\neral practitioners\/family physicians;\n\u2022 providing a forum for exchange of knowl-\nedge and information between Member\nOrganizations and between general prac-\ntitioners\/family physicians; and\n\u2022 representing the policies and the edu-\ncational, research and service provision\nactivities of general practitioners\/family\nphysicians to other world organizations\nand forums concerned with health and\nmedical care.\nGovernance afnd structure\nWONCA is governed by a World Council\nthat meets once every three years in con-\njunction with the World Conference. Gov-\nernance and oversight between meetings of\nthe Council are provided by an Executive\nCommittee,which consists of the President,\nPresident-Elect, Immediate Past President,\n3 At-Large Members, 7 Regional Presi-\ndents, and the CEO, who serves ex officio\nwithout vote. Terms of office for the mem-\nbers of the Executive are for 3 years, except\nfor the Immediate Past President (1 year)\nand the CEO (under contract). The Secre-\ntariat is located currently in Singapore; the\ncurrent CEO is Dr. Alfred Loh.\nA regional structure has been created to\nfacilitate the development of family medi-\ncine through increased interaction among\nneighboring member organizations within a\nregion. The regions approximate the World\nHealth Organization (WHO) regions: Af-\nrica, Asia-Pacific, Eastern Mediterranean,\nEurope, Iberoamericana (Latin America),\nNorth America, and South Asia. Many, but\nnot all, of the regions convene an annual\nregional conference. A recent development\nhas been the establishment of WONCA re-\ngional organizations for young family doc-\ntors, including the Vasco da Gama Move-\nment (Europe), Rajakumar Movement\n(Asia-Pacific), NaFFDoNA (North Ameri-\nca), and Waynakay (Latin America).\nCommittees, Working Parties,\nSpecial Interest Groups\nMuch of the policy development and ac-\ntivities of WONCA occur through its\nCommittees, Working Parties, and Special\nInterest Groups, which typically consist of\n5\u201315 family doctors selected from around\nthe world who have a particular interest\nand expertise. The 7 Committees are By-\nlaws, Finance, Membership, Nominating\n& Awards, Organizational Equity, Pub-\nlications & Communications, and World\nConference. The 9 Working Parties in-\nclude Classification (WICC), Education,\nEthics, Informatics, Rural Practice, Mental\nHealth, Quality & Safety, Research, and\nWomen and Family Medicine. There are\n5 Special Interest Groups (SIGs): Com-\nplexity, Elderly Care, Environment, Pri-\nmary Care & Cancer Research, and Travel\nMedicine.\nWorld Organization of\nFamily Doctors (WONCA)\nRegional and NMA news\nRichard G. Roberts\n\u201cThe fact that this week thousands of doc-\ntors and health workers in Ciudad Juarez\nwent on a 24-hour strike in protest at the\nhigh number of threats and attacks they are\nsubjected to shows how desperate the situa-\ntion has become.The government\u2019s inability\nto curtail drug-cartel violence is unaccept-\nable.\u201d\nPhysicians in the city are calling for more\nsoldiers and the Mexican federal police to\nbring the violence under control and the\nWMA and its national medical association\nmembers are urging the Mexican Govern-\nment to listen to what physicians are saying.\nNigel Duncan, WMA Public\nRelations Consultant\nwmj 1 2011 5CS.indd 25 21.02.2011 16:28:21\n26\nRegional and NMA news\nAll around Europe the Member States\nare facing common challenges in terms\nof ensuring and maintaining an adequate\nhealth workforce to meet the changing\nand growing health needs of the EU citi-\nzens. Besides, the rapid changes in demo-\ngraphic, the ageing population, the widen-\ning health inequalities and the changing\ndisease patterns place additional chal-\nlenges to the already stretched European\nhealth systems.\u00a0\nTherefore, adequate and sustainable EU\nWorkforce for Health is crucial. Taking\nthis into account, and as a follow-up of the\nMinisterial Conference, held in La Hulpe\non 9\u201310 September 2010, and the Europe-\nan Parliament Written Declaration, signed\nby 182 MEPs, the European Federation of\nNurses Associations (EFN) and the Euro-\npean Public Health Alliance (EPHA) or-\nganised a lunch debate on 27\u00a0October 2010,\nin the European Parliament.\nThe debate, supported by five key MEPs\u00a0\u2013\nOana Elena Antonescu (Romania, EPP),\nJean Lambert (UK,Greens\/EFA),Antonyia\nParvanova (Bulgaria, ALDE), Marc Tara-\nbella (Belgium, S&D) and Marisa Matias\n(Portugal, GUE\/NGL), analysed the extent\nof the EU Members states common chal-\nlenges and showed how the current practice\nof health professionals recruitment, mainly\nnurses and doctors, from some European\ncountries and the developing world to fill\ngaps in the workforce in other areas of Eu-\nrope is unsustainable. Furthermore, speak-\ners and participants pointed out a common\nand urgent need for policy makers to take\naction.\nThe personal testimonies of a Latvian\ndoctor (Mr. Peteris Apinis), a Polish nurse\n(Ms. Paulina Daczkowska), a Belgian nurse\n(Ms. Heidi Ceuppens), and a Bulgarian pa-\ntient (Ms. Evgeniya Adarska), made this\nconcern clear by stressing that issues like\nrecruitment and migration policies, work-\ning and education conditions, attractive-\nness of health professionals, and improve-\nments in the recognition of qualifications,\nare essential for the health profession, and\nthat the key EU solutions are undeniably:\nworkforce planning, implementing recruit-\nment and retention strategies, and develop\na well-educated and motivated workforce\nfor health.\n\u201cRecruitment without retaining nurses\nand doctors is a waste of resources.\u201d (Heidi\nCeuppens, nurse).\nMyria Vassiliadou (EWL) chaired the fol-\nlowing discussions along the debate, high-\nlighting that it is always good to see the\nhuman the human face of the problems.\nDuring the political roundtable she brought\nEU Workforce for Health\u00a0\u2013\nPutting a Human Face to EU Policy-making\nEFN-EPHA Lunch Debate\n27 October 2010\u00a0\u2013 European Parliament\nCollaboration with WHO\nand other world bodies\nWONCA has been involved in a number\nof WHO projects, including the Social\nDeterminants on Health, WHO West-\nern Pacific Region Patient at the Center\nof Care Initiative, Integrating Mental\nHealth Services into Primary Health\nCare, GOLD\u00a0\u2013 Global Initiative for Ob-\nstructive Lung Disease, GARD\u00a0\u2013 Global\nAlliance Against Chronic Respiratory\nDiseases, and the development of the\nthird edition of International Classifica-\ntion in Primary Care (ICPC-3). A number\nof monographs, technical documents, and\neducational programs have resulted from\nthis collaboration. WONCA participates\nin the annual World Health Assembly in\nGeneva.\nAs the global voice for family doctors,\nWONCA is also involved with a number\nof other world organizations, including the\nWorld Medical Association and the Inter-\nnational Federation of Medical Student As-\nsociations (IFMSA). Recently, WONCA\nand IFMSA have begun to collaborate to\npromote family medicine exchange experi-\nences for medical students.\nThe Future: Challenges\nand Opportunities\nIn its 2008 World Health Report \u201cPri-\nmary Care: Now More Than Ever,\u201d WHO\nconcluded that the health systems of the\nworld should be based on primary care.\nAll 194 countries at the 2009 World\nHealth Assembly approved a resolution\nadvocating for countries to train sufficient\nnumbers of primary care workers, includ-\ning family physicians. Reliant on member\norganization dues and conference lev-\nies, World WONCA operates on a very\nmodest budget. To achieve all that is be-\ning asked of family medicine, WONCA\nmust develop a more robust governance\nstructure and garner sufficient resources.\nWONCA\u2019s challenge during the next de-\ncade is to grow from an academic club of\nnational colleges to a global professional\nassociation.\nRichard G. Roberts, MD, JD\nPresident 2010\u20132013\nWorld Organization of Family\nDoctors (WONCA)\nJanuary 2011\nwmj 1 2011 5CS.indd 26 21.02.2011 16:28:22\n27\nRegional and NMA news\nout for further discussions issues such as the\nmobility and the workforce, legal aspects,\nworking and education conditions and fi-\nnancial crisis were addressed but from a\ndifferent approach, taking into account and\nbearing in mind the ones that finally suffer\nfrom these challenges, patients and health-\ncare professionals.\nTalking about recruitment and retention,\nthe MEPs present agreed that several coun-\ntries are putting too much attention on the\nhealth professionals coming from third\ncountries and the ones leaving their own\ncountries are not looked enough. Therefore,\nit is extremely important to understand\nwhat makes the professionals stay or leave.\nSo, this is not only about recruitment but\nalso about retention policies. Furthermore,\nand as part of the strategy, we should not\nonly focus on the new graduated health\nprofessionals but also at the existing and\nexperienced workforce in keeping them\nmotivated to stay in the nursing profession,\nas the difficult working conditions, mainly\nfor women, and all the new demands of care\nprovisions makes it harder to stay in the\nprofession.\nAs regards migration, the current trends are\nunsustainable, entailing shortages in several\ncountries.\n\u201c\u2026due the economic situation in most\ncountries, especially eastern European\nMember States, and due to the shortage of\nnurses in all national healthcare systems,\nmember states fulfill these gaps by stealing\nnurses from each other\u2026\u201d (Paulina Dac-\nzkowska, nurse).\n\u201c\u2026Today, a widespread and unstop-\npable trend has developed concerning\nthe migration of medical doctors from\npoorer Eastern European countries to\nthe \u201celder European world\u201d especially to\nGreat Britain, Germany, Scandinva-\nvian countries and France\u2026\u201d (Peteris\nApinis, doctor).\nOne of the main causes for nurses to leave\nis the extremely low salary and unpleas-\nant working conditions they have in their\nown countries\/settings. Excessive workload\nand lack of personnel in some shifts make\nnurses feel insecure and in need to find\nnew possibilities for professional develop-\nment. As well, the lack of recognition and\nthe extreme low salaries make the nursing\nprofession unattractive, losing potential\nnew students to come into the nursing\nprofession. Therefore, surrounded in the\nnew increased demands of healthcare, more\nemphasis must be put towards recogni-\ntion of the nurses\u2019 value within the society\nto knock the youth\u2019s minds offering them\nsuccessful opportunities for professional\ndevelopment.\nFurthermore, nurses who migrate to an-\nother country are not always working with\nthe same tasks and responsibilities they\nusually perform in their home country.\nThis situation often leads to a downgrad-\ning of the nursing profession overall, and\nmainly to downgrading the individual as a\nperson and a professional.This is where the\nhuman rights aspect comes into the equa-\ntion. Consequently, the migration of health\nprofessionals is an enriched process that\nshould be done in a transparent and sound\nway.\n\u201c\u2026the process of obtaining the recogni-\ntion of the diploma and beginning to work\nand settling down in another country is\neverything but not easy. It involved me\nenormous and unacceptable administrative\nburdens, and long procedures before the\nfinal approval was achieved. It gave me\nmany moments of stress, of insecurity and\ndoubts, but I resisted\u2026\u201d (Paulina Dacz-\nkowska, nurse).\nAs mentioned by MEP Marc Tarabella, in\norder to encounter that shortage of nurses,\nit is important to recognize the profession-\nals and to improve the mobility started\nwith Bologna. We also need to harmonize\nthe health systems all over Europe in or-\nder to improve the quality and safety of\ncare. Only then, it will be possible to have\nan harmonized highly EU educated work-\nforce guarantying a freedom of movement\nand a safe, updated and sensible process of\nprofessionals\u2019 mobility, taking into account\nthe need to update the minimum training\nrequirements as set out in the Directive, the\nlanguages competences to provide safe care,\nand effective administrative process of mu-\ntual recognition.\nMEP Jean Lamberts took this opportu-\nnity to emphasize the need for a more dy-\nnamic recognition process and boost the\nrole of employers to deal with the language\nrequirements. It is important to take into\naccount both professionals: the ones being\nrecruited from third countries and the ones\nleaving the country. In that sense, a need for\nrecruitment policies is essential, as well as\nthe link between the working conditions\nand the jeopardizing of the quality of care.\nUrgent actions are needed before the health\nworkforce disappears. Therefore, recruit-\nment and retention strategies are key to deal\nwith the EU workforce challenges.\nMEP Oana Elena Antonescu also took\nthis opportunity to mention the difficult\nsituation Romania is living while seeing six\nthousand doctors and four thousand nurses\nleaving the country in the last two years to\nlook for better working conditions. It is true\nthat there are difficulties and differences be-\ntween regions but there is also a common\nshared problem regarding the shortage of\nqualified workforce. There is a need for an\nincrease of the attractiveness of health pro-\nfessions. The EU needs human resources\nstrategies to recruit health professionals,\nand to find strategies to retain them (im-\nproving working conditions), as well as data\ncollection of health professionals.\nParticipating in the meeting, Ms. Katja\nNeubauer (DG SANCO) pointed out\nthat the consultations, with regard to the\nGreen Paper on the EU Health Workforce,\nwmj 1 2011 5CS.indd 27 21.02.2011 16:28:23\n28\nRegional and NMA news\nmade up till now show that people are very\nconcerned by the shortage and that it is\nnecessary to put this topic into the politi-\ncal agenda. The Council Conclusions are\nbeing discussed, and should be adopted in\nDecember 2010, and the Hungarian and\nthe Polish Presidencies are very interested\nin this topic. Finally, it is important to look\nat the workforce planning in a broader way,\ntaking into account what kind of workforce,\nhow many, and with which skills, it will be\nneeded in the future. As it is very difficult\nto recruit and maintain professionals, it is\nessential to look at new strategies (as, for\nexample, what is done in Aalst Hospital\u00a0\u2013\nBelgium) and to make the link between\nHealth Professional and Quality & Safety\nof care. DG Sanco hopes that in 2011 some\nconcrete actions can be put forward.\n\u201c\u2026So together with 3 nurse colleagues,\nall of us working bed-side, we started a\nproject: introducing nursing and promot-\ning our profession to last year students of\nthe secondary school, being 17 to 18 years\nold\u2026\u201d(Heidi Ceuppens, nurse).\nFrom Mr. Arnaud Senn (DG EMPL) per-\nspective, facing the needs of patients is one\nof the main issues to tackle future needs. As\ntopics to go further in we need to highlight:\nthe needs in long-term care,health inequali-\nties and the pressure of health professionals.\nRegarding the current negotiations of the\ncross border directive, it is crucial to look at\nthe consequences of patient and healthcare\nprofessionals\u2019 mobility.\nMr. Fran\u00e7ois Decaillet (WHO Regional\nOffice) stressed that the current challenge\nwith the workforce for health is not only an\nEU problem but a global one, as shortage is\na reality in every country around the world,\nespecially in Africa, and emphasized the\nneed for planning and implementation,next\nto the need for better coordination between\nall the countries, and for social innovation\n(as the project referred by Ms. Heidi Ceup-\npens\u00a0\u2013 Belgium).\nThe EFN Secretary General, Paul de\nRaeve, encouraged the present MEPs to\nbecome champions in EU workforce for\nhealth, as in other initiatives such as the\nsharp injuries success story. The EU work-\nforce for health needs to be treated at the\nhighest political level.\n\u201c\u2026Every health system is unthinkable\nwithout nurses. The politicians should\nunderstand that \u2026\u201d (Evgeniya Adarska,\npatient).\nEPHA President, Mr. Archie Turnbull,\nconcluded that with the bologna process,\nstudies will be globally recognised, allow-\ning guaranty and free movement of people.\nThe question is \u201cHow to support the sec-\ntor and the need for thinking in a broader\nway?\u201d\n\u201cToday I know quite well that people\nwith health problems seek support; seek\nsomeone who offers him hope; someone\nwho will be nearby all the time; some-\none who could give cosiness and security\nat the same time\u201d (Evgeniya Adarska,\npatient).\nListening to the 4 testimonies, the MEPs\npresent were very clear on concrete actions\nand see an opportunity for the three EU\nInstitutions: the Council, the Commission\nand the European Parliament, moving to-\nwards a European and innovative approach.\nFurthermore, synergies should be built be-\ntween the European Institutions and the\nCivil Society.\nMEP Antonyia Parvanova expressed that\nthere are enough arguments to tackle this\nsubject right now. Seen the future shortage\nof 500.000 nurses, we need to decide what\nto do at EU level (European Commission,\nEuropean Parliament and Council). The\ncurrent challenge of the workforce is an EU\nlevel problem, and it is time to start discus-\nsions on these deviations and how it could\nbe done in a more legalised way. Coordina-\ntion and a legal framework to cope with the\nchallenges of the EU workforce for health\nare urgently needed, next to a different ap-\nproach to human resources or employment\nperspectives towards solving the workforce\nissues.\nFinally,the MEPs considered taking further\nthe following actions:\nPutting in place an EU monitoring and\nplanning system to have comparable data\navailable to map to EU health workforce,\nanalysing how many and what kind of\nhealth professionals we will need in the fu-\nture, and what type of policies need to be\ndeveloped to respond to future needs.\nInvesting in human capital by covering re-\ncruitment and retention strategies, evalu-\nating income and working conditions and\nstimulate innovation and entrepreneurship.\nWithin this context the social cohesion\nfunds should be used for health.\nEstablishing an EU Continuous Profes-\nsional Development Framework to main-\ntain a highly skilled and motivated work-\nforce and to educate health professionals\ntowards the new demands and types of\ncare and train for the use of new tech-\nnologies.\nTaking a gender approach to EU workforce\nplanning and valuing the increased partici-\npation of women.\nEFN Report\u00a0\u2013 November 2010\nThe European Federation of\nNurses Associations (EFN)\nEmail: efn@efn.be\nWebsite: www.efnweb.eu\nwmj 1 2011 5CS.indd 28 21.02.2011 16:28:24\n29\nRegional and NMA news\nThe European Federation of Nurses As-\nsociations (EFN) was established in 1971,\nbased on the nursing-education and free-\nmovement Directives being drafted by the\nEuropean Commission at that time. In 40\nyears, the EFN has grown to its present po-\nlitical and professional maturity by becom-\ning the one strong independent voice of the\nnursing profession at pan-European level,\nrepresenting millions of nurses through the\nnational nurses associations of 34 Member\nStates. As such, EFN is a key partner in the\ndesign and re-engineering of the different\nhealth systems within the EU, all aimed at\ndelivering high quality, safe and continuity\nof care to the population.\nAs part of the origin of EFN, the EU Mu-\ntual Recognition of Professional Qualifica-\ntions (Dir2005\/36\/EC) is central in EFN\nlobby strategies towards the European\nCommission, the Council and the Euro-\npean parliament.When re-designing health\nsystems in the EU Member States (taking\ninto account the re-activation of the \u201cLib-\neralisation Act\u201d) a highly educated health\nworkforce, mainly focusing on nurses, mid-\nwives, doctors, pharmacists and dentists,\nremains the cornerstone for each legislative\nredesign. Therefore, the implementation of\nthis Directive, alongside the \u201cAcquis Com-\nmunautaire\u201d compliance process, was anal-\nysed in 2010 by different stakeholders.\nFor EFN, the conclusion represents the\nsame nursing values and principles as advo-\ncated for by nurse leaders in the seventies.\nThe Directive, which sets out the minimum\neducation and training requirements for\nnursing education, substantially impacted\nthe advancement of the nursing profes-\nsion and the status of nurses across Europe\nby positioning of nursing education in the\nHigher Education degree structure, within\nUniversities and Colleges. The minimum\neducation requirements have proven to be\na valuable safeguard of quality and safety in\nhealthcare, since they discourage govern-\nments from downgrading nursing educa-\ntion as means to reduce costs.\nNevertheless, updating the list of required\nsubjects within nursing curricula is seen as\nan opportunity to consider topics such as\npatient safety, quality system thinking and\ne-Health as advancements in nursing edu-\ncation. One of the deliverables of the Eu-\nropean Union Network for Patient Safety\n(EUNETPAS, 2010)\u00a0\u2013 the guidelines for a\ncurriculum on Patient Safety\u00a0\u2013 in which a\nbasic curricula framework for patient safety\nto be simultaneously taught to all healthcare\nprofessions, engaging patients in the design,\ncould help facilitating the paradigm shift:\ncreating a new generation of nurses, doctors\nand pharmacists.\nThe review of the Directive is equally per-\nceived by EFN as a unique opportunity to\nascertain that \u201cfitness to practice\u201d remains a\nprofessional priority.This challenge is linked\nto the European Commission Agenda on\n\u201cNew Skills for New Jobs\u201d,in which a highly\nskilled health workforce is prioritized at the\nsame level as modernising labour markets\nand promoting work through new forms\nof flexibility and security. Interestingly, the\nEU health workforce became an essential\ndriver in the EU health policy domain, with\nnurses\u00a0\u2013 as the largest group of health pro-\nfessionals\u00a0\u2013 playing a central role in pushing\nthe paradigm shift further with the alliances\nconcerned. For EFN, the Council Conclu-\nsions on the EU health workforce provide a\ngood political framework for action to move\nfrom a \u201cGreen\u201d to a \u201cWhite\u201d Paper on EU\nWorkforce for Health\u00a0 \u2013 an initiative that\ndeserves and requires our attention.\nSkill mix,skill matching and extending roles\nand responsibilities for nurses is becoming a\nkey component when re-designing existing\nhealth systems, for both the primary and\nhospital care system (\u201cNurses in Advanced\nRoles\u201d, OECD, July 2010). Consequently,\nthe establishment of an \u201cEU Skills Pan-\norama\u2019 and Sectoral Skills\u201d Councils opens\na policy opportunity for the representative\npan-European nurses organisation to re-\nspond to the societal demands for health\nsystems and their outcomes. The concept\nof \u201cInnovative Partnerships\u201d is a step in the\nright direction to scale up \u201cfrontline initia-\ntives\u201d into an EU added-value for citizens,\npatients and health professionals. The con-\ncept of the \u201clink nurse\u201dis a positive,innovate\nexample, not only in relation to safety and\nquality,but in many other aspects of making\nhealth systems effective and efficient.\nE-health is a tool to decrease the increas-\ning nurses\u2019 workload, standardising activi-\nties such as documentation, patient records,\nreferrals and discharge, including the sur-\nrounding nursing activities such as planning\nhomecare, e-prescribing of medication and\nwound care. Proper e-Health systems must\nhelp nurses to get rid of the excess of admin-\nistrative work providing them more time\nfor direct patient contact.This is part of the\nmanagement paradigm shift: bringing the\nnurse closer to the patient. The condition\nfor success in shifting the paradigm is the\nNurses Impact on the Health System\nParadigm Shift\nPaul De Raeve\nwmj 1 2011 5CS.indd 29 21.02.2011 16:28:25\n30\nRegional and NMA news\nend-users\u2019 engagement in the deployment\nof new innovative e-health solutions, which\nmust be used as a tool to improve the infor-\nmation and communications processes,pro-\nmote the use of standards, indicators, inter-\nprofessional communication channels, and\nencourage continuous professional develop-\nment.The paradigm shift includes therefore\nbringing upfront innovative \u201cfieldwork\u201d in\npatient empowerment, putting gender into\nthe equation, embracing healthy years and\nquality of life, dignity and ability to self-\nmanagement next to emphasising an inte-\ngrated approach of service planning, organ-\nisation of care and financing.\nFrom a political perspective, a paradigm\nshift is only possible if the political insti-\ntutions themselves, governed by govern-\nments, adapt their governance structure\nto move away from the old fashioned and\nwell-known paradigms that are difficult to\nreform. Nevertheless, the policy paradigm\nshift is urgently needed, otherwise Mem-\nber States will continue to produce Coun-\ncil Conclusions and WHO reports for the\nbook shelves and avoid engaging concerned\nstakeholders collectively.\nGood governance in health systems implies\nimplementing an effective stakeholder ap-\nproach, which goes far beyond online con-\nsultations and bilateral partnerships.The key\nprinciples for making the paradigm shift\nwork is to empower transparency, engage a\nrange of concerned stakeholders, build co-\nhesiveness, and make effectiveness measur-\nable to increase responsibility throughout\nthe health system. But these principles re-\nquire trust and effective implementation.\nTherefore, EFN core business is to set the\npolicy agenda pro-actively and design pipe-\nline EU legislation and not to lead EU proj-\nects or work packages. As a successful EU\nlegislative outcome, next to the Directive\n36\/2005\/EC, the EU Directive on preven-\ntion from sharps injuries in the hospital and\nhealthcare sector was adopted by the Euro-\npean Council of Ministers on 11 May 2010.\nEvery year huge numbers of nurses and their\nfamilies face months of uncertainty and emo-\ntional anguish following a needlestick injury,\nnot knowing if the accident will lead to a life-\nthreatening infection. For many years EFN\nadvocated for EU legislation ensuring that\nall healthcare workers (not only nurses) be\nadequately protected from needlestick and\nother medical sharps injuries.\nThe legislative initiative was formally\nlaunched on World AIDS Day in 2004,\nwhen nurses infected by HIV and Hepatitis\nC due to a needle stick injury came to the\nEuropean Parliament to request political at-\ntention and action. National requirements\nwere failing to provide adequate protection\nand an EU added-value legislative initiative\nwas needed.Such serious risks would be con-\nsidered unthinkable in other occupations, so\nwhy should nurses be exposed to life-threat-\nening injuries every day when the majority\nof these can be avoided with better working\npractices, continuous professional develop-\nment, and the use of readily available tech-\nnologies that incorporates needle protection?\nAlthough it has taken considerable politi-\ncal will and policy efforts, great progress has\nbeen made. The EU Directive on preven-\ntion from sharps injuries in the hospital and\nhealthcare sector was published in the Offi-\ncial Journal of the European Union (OJEU)\non 1 June 2010, the same day the European\nBiosafety Network,led by nurses,was estab-\nlished. The network has now the challenge\nmaking sure each EU Member State brings\ninto force national legislation to implement\nthe Directive by 11 May 2013 at the latest.\nTo conclude, EU legislation is a top priority\nfor EFN.Therefore, working towards devel-\noping a strong policy advocacy strategy for\nnurses and nursing at the EU level is central\nto making the paradigm shift possible and\nconsequently, to make progress in society.\nTherefore, EFN will remain focused on the\nfollowing key policy priorities: education,\nworkforce, quality, and safety. Rest assured\nthat EFN will maintain its role as a strong\nadvocate promoting a continuous and col-\nlaborative dialogue among the EU policy-\nmakers and the stakeholders involved in\nre-engineering health systems by putting a\nhuman face to EU policies.\nPaul De Raeve, RGN, MSc,\nMQA, Mphil\/PhD\nSecretary General of the European\nFederation of Nurses Associations\nCZECH REPUBLIC\nDistinguished Colleagues, Dear Friends, al-\nlow me to inform you briefly about the cam-\npaign \u201cThanks, We Are Leaving\u201d, which is\na legitimate expression of dissatisfaction of\nCzech doctors, and at the same time let me\nask you for your help and support for my\ncolleagues.\nCzech Doctors Trade Union, the largest\nand practically the only trade union or-\nganisation of Czech doctors, announced\nin March last year a campaign \u201cThanks,\nWe Are Leaving\u201d, which is now reach-\ning its culminating point. It\u00b4s essence are\nmassive employment termination notices\nof hospital doctors in protest against poor\nworking conditions, low wages and com-\nplete disruption of education system. The\nCzech Medical Chamber supports the\ncampaign, because it is a completely legiti-\nCzech Medical Chamber Request for\nSupport of Hospital Doctors\nwmj 1 2011 5CS.indd 30 21.02.2011 16:28:27\n31\nmate demand of the great majority of its\nmembers. Another reason for the support\nis that The Czech Medical Chamber as a\nsupervisor of the high quality of medical\ncare for the past several years is not able to\nguarantee this care to the citizens, due to\nthe devastation of medical personnel in the\nCzech Republic.The necessary changes are\nnot coming in spite of years-long debates\nand appeals to politicians, who are respon-\nsible for this situation and have the power\nto change it.\nFor twenty years the Czech doctors waited\nin vain for dignified appreciation of their\nwork. And for twenty years politicians were\npromising them to implement reforms, the\nresults of which among others would be an\nimprovement of professional and economic\nconditions of doctors. In reality, however,\nthe situation of most hospital doctors wors-\nened.\nOur health care is chronically underfunded\nas expenditures on health care represent\nonly 7,0 \u20137,5% of GDP.Fair European level\nof the Czech health care and good access\nto health care for the voters (our patients)\nis secured by the politicians at the expense\nof doctors and other health care profession-\nals whose income remain low and working\nconditions poor. As the professional and\nworking conditions are not improving in\nthe Czech Republic, more and more of our\ncolleagues are seeking emigration as solu-\ntion of their economic problems. Gradually,\ndue to that comes to a personnel decompo-\nsition of hospital medical care in the Czech\nRepublic. The gradual devastation of the\nhospital care due to the shortage of medi-\ncal personnel is the consequence of such a\nsituation.\nThe Labour Code and European Work-\ning Time Directive (EWTD) are violated\nin most hospitals, and overworked doctors\nrepresent potential danger to patients. Re-\nports on working hours are falsified and\nthe number of doctors in the statistics is\nincreased against the reality..... A qualified\ndoctor must work monthly about fifty per-\ncent hours over time to obtain the average\nincome of ca. CZK 45.000,\u00a0\u2013 (about 1800\nEuro). Such a salary is indicated in the\nstatistics and it corresponds to less than\ndouble of the average income in the Czech\nRepublic.\nThe doctors demand an increase of their sal-\nary for the basic working time to the level of\n1,5\u20133 times higher than is the average salary\nincome in the country, depending on their\nqualification and length of service. Such a\nsalary level is quite common in countries to\nwhich the doctors from the Czech Republic\nare leaving. This requirement represents an\nincrease in hourly wages of doctors from the\ncurrent 100\u2013200 CZK (about 4\u20138 EUR) to\n200\u2013400 CZK (about 8\u201316 EUR).The ful-\nfilment of this demand requires only 3 bil-\nlion CZK per year, which is approximately\nonly 1% of all the money spent in our health\ncare.\nThe aim of the action \u201cThanks, We Are\nLeaving\u201d is not to drive the doctors into\nexile, but to improve their working condi-\ntions in Czech hospitals and in such a way\nto remove the reasons for their departure\nand the consequent personal devastation\nof Czech health care system. This is the\nmain reason why Czech Medical Chamber\nfully supports the actions of doctor\u2019s trade\nunions. Enclosed I am sending 13 reasons\nthat lead Czech hospital doctors to procla-\nmation of the campaign \u201cThanks, We Are\nLeaving\u201dand that was formulated by Czech\nDoctors Trade Union. These 13 reasons de-\nscribe the motives of doctors and the causes\nof the whole problem.\nIn spite of the fact that employed doctors\nannounced their intention to leave the hos-\npitals in March 2010, political representa-\ntion did nothing to avert their decision. Up\nto the December 31 2010, 3850 doctors\nhanded in their notices of leaving the em-\nployment. Unless the government accepts\ntheir demands, then after the two month\nnotice period these colleagues will not come\nto work on March 1, 2011. Doctors from\nthe whole Czech Republic, from various\nhospitals and departments are involved.\nThe notice of leaving the employment was\nhanded in by the third of the total num-\nber of 12.000 doctors working in hospitals.\nIn some hospitals and in some regions the\nnotice was handed in by more than 80% of\ndoctors, but there are departments where\nthe notice was handed in by all doctors.\nIt is difficult to label the position of Czech\ngovernment by something else than a haz-\nardous play with the health and lives of\ncitizens when instead of constructive ne-\ngotiations with doctors and search for a ra-\ntional solution, government concentrated\non threatening doctors by declaring \u201cemer-\ngency situation\u201d which would allow to or-\nder the doctors to work similarly as is the\ncase during natural catastrophes. Without\ndoctors it is not possible to provide medi-\ncal care and there is nobody who can re-\nplace doctors.\nFor several weeks the Czech Medical\nChamber has very actively negotiated with\nthe representatives of all parliamentary\npolitical parties to find an acceptable so-\nlution to the current situation. Although\nthe Czech health care is chronically un-\nderfunded, only 1% of the funds that flow\ninto the Czech health care are sufficient to\nRegional and NMA news\nMilan Kubek\nCZECH REPUBLIC\nwmj 1 2011 5CS.indd 31 21.02.2011 16:28:28\n32\nmeet the justified demands of hospital doc-\ntors. The money needed can be obtained by\ncontrol of expenditures for the overpriced\npharmaceuticals, by establishing an order\nin the completely chaotic investment policy,\nin the purchases of medical equipment and\nby reducing corruption.The Government of\nthe Czech Republic has \u201cthe fight against\ncorruption\u201d as a main slogan, but in reality\nis rejecting all economic measures proposed\nby the Czech Medical Chamber and is try-\ning to intimidate the protesting doctors.\nThe Czech Medical Chamber would be\nhappy to provide you on your request with\nadditional and more detailed information\non the largest protest campaign of doctors\nin the modern history of our country.\nThe prestige and dignity of the whole medi-\ncal profession is involved in the ongoing\nstruggle and therefore we cannot afford\nto lose this battle. The campaign \u201cThanks,\nWe Are Leaving\u201d proclaimed by the Czech\nDoctors Trade Union and supported by\nthe Czech Medical Chamber represents a\nunique,and regretfully even an unrepeatable\nopportunity after 20 years of patiently but\nin vain waiting for a better professional and\neconomic status of all doctors in the Czech\nRepublic. Any defeat, however, would bring\ndisastrous consequences for all doctors.\nNot only on behalf of the Czech Medical\nChamber, but also on behalf of all doctors\nfrom the Czech Republic, I appeal to you\nfor any kind of help, for any kind of state-\nment of support and solidarity.\n13 Reasons for the Exodus\n1. Czech health care has been underfunded on a\nlong-term basis. The share of GDP has oscil-\nlated around 7%, while the average in EU is 10%.\nFrom the monitored OECD countries,behind us\nare only Poland, Mexico and Korea.\n2. The low pay contribution of the state for the\nstate insurant that does not match the volume\nof funding that these \u201cpublic patients\u201d con-\nsume. Absence of commercial insurance. The\ngovernment\u00b4s contribution for citizens without\nincome is much lower than their real spending.\n3. Large reserves in the internal functioning of\nthe health care\u00a0\u2013 the biggest item is the chaotic\ndrug policy, where hundreds millions of Euros\nare wasted.\n4. Strange economy in hospitals\u00a0 \u2013 overpriced\ncontracts (construction, purchase of equipment\nand medicine, etc.). Salaries of health care pro-\nfessionals are the only item for which commis-\nsion cannot be obtained.\n5. Low salaries for doctors which do not corre-\nspond with the intensity of this profession, the\nnecessary education and prestige.\n6. Completely destructed system of education is\none of the reasons for the departure of young\ndoctors abroad.\n7. Departure of doctors abroad due to better\nworking conditions.The remaining doctors are\nburdened with more responsibilities than cor-\nrespond to their qualification. More overtime\nwork is needed.\n8. The Labour Code is not observed, more over\ntime is required from doctors and as a conse-\nquence of it potential medical errors, followed\nby legal proceedings may occur.\n9. In 2013, the exemption from the European Di-\nrective on Overtime Work will no longer apply\nand hospitals will need more doctors.\n10. Due to lack of staff, poor organisation and ir-\nrational use of funds, deterioration of patient\ncare threatens, for which doctors do not want\nto take responsibility.\n11. Unfulfilled promises of politicians\u00a0 \u2013 since\n1989, the doctors have been told that first the\nsystem must change and then their salaries will\nbe improved. So far, this has not happened.\n12. Health care became the object of an ideologi-\ncal war between political parties. The profound\nchanges of the system require an agreement\nacross all political parties, as it happens in other\ncountries.\n13. The Ministry of Health experience among all\nthe ministries the most frequent changes of\nministers, all of them with their own ideas\nhow to change the system. There are constantly\nsome elections taking place, whether they are\nregular or premature. Under such circumstanc-\nes, doctors have no guarantee that the necessary\nchanges will take place.\nDr. Milan Kubek\nPresident of the\nCzech Medical Chamber\nDear Colleagues, Dear Friends, Allow me to express my gratitude\nfor your support of the Czech doctors and the Czech Medical\nChamber. It is my pleasure to announce that today an agreement\nwas signed between doctors and the Czech Republic,represented by\nthe Minister of Health. I believe that the \u201cThank You, We Are Leav-\ning\u201d protest campaign has come after 11 months to a close. Doctors\nthat handed in their notices and were to leave their employment\nin hospitals on 1 March 2011, based on the above agreement will\ncontinue to work in hospitals.\nAgreement between the Ministry of Health and the Doctor\u2019s Trade\nUnions\nMain agreement parameters:\nThe base salaries of all employed physicians in all types of health care\nbed facilities and in the emergency medical service will increase from\n1 March 2011 by 5\u00a0000,- CZK, \u00a06\u00a0500,- CZK and 8\u00a0000,- CZK de-\npending on their qualification.This increase represents a raise in base\nsalaries by 21\u201336 percent.\nRegional and NMA news CZECH REPUBLIC\nAgreement between the Ministry of Health and the Doctor\u2019s Trade Unions\nwmj 1 2011 5CS.indd 32 21.02.2011 16:28:29\n33\nRegional and NMA newsGEORGIA\nThe issue of small countries\u2019 development\nand their integration into the international\nsociety attracts more and more attention of\nthe politicians and academic researchers in\nthe modern world with the tendencies of\nglobalization.\nBecause of its geopolitical location, Geor-\ngia,differently from many other small coun-\ntries, faces specific challenges and threats.\nThe events that developed in August 2008\nhad a great influence not only on Georgia\u2019s\npositioning on the international level, but\nalso on the processes developing inside the\ncountry. With the background of the world\nfinancial crisis, they pushed country\u2019s eco-\nnomic, social, and political processes to a\nnew phase.\nThe state governance, besides the Conflict\nof August 2008,faced the great world finan-\ncial crisis that limited free finance attraction\nprocess, and consequently, the questions of\nstate governance rationality and decrease in\nofficials were highlighted in many countries\nand in Georgia, too.\nIn September 2008, the world econo-\nmy underwent difficulties. The wave of\nbankruptcy covered all the USA. The\nfirst to go bankrupt were the banks, and\nthe investment crisis placed the world in\nfront of big threats. The liquidity-mon-\ney deficit occurred. The companies that\nwere oriented on everyday credits ap-\npeared in a very bad situation. The Index\nof Dow Jones fell, other indexes under-\nwent big attacks too, and the first time,\nafter a long period, the USA entered the\nrecession process.\nAdditional increase by 10 percent, this time of the total salaries of doc-\ntors, will occur from 1.1.2012.\nThe doctors\u2019 incomes will be increased from 1.1.2013 so that the em-\nployed doctors\u2019 average pay would become 1,5\u20133 times higher than the\naverage national salary (currently ca. 25\u00a0000,- CZK) and at the same\ntime with a commitment to cutback the amount of overtime work to a\nmaximum average of 8 hours per week.\nThe government commits itself to work together with the representa-\ntives of doctors, including the Czech Medical Chamber and the Czech\nDoctor\u2019s Trade Union, on the adjustment of the education system of\ndoctors, on anti-corruption measures and on further reform changes\nin health care.\nCMC fully supported the struggle of hospital doctors for the im-\nprovement of working conditions, the implementation of the neces-\nsary order and enforcement of the long overdue changes in medical\ncare.CMC will continue to provide support to its members and will\nsupervise the fulfilment of the agreement. Personally, I consider the\nresult of this protest campaign as a colossal success of Czech doctors\nand hope that in the same way as the doctors also the political repre-\nsentation of the Czech Republic will fulfil all obligations stemming\nfrom this agreement. Allow me to thank you once again for your\nkind help and support.\nYours faithfully,\nDr. Milan Kubek\nPresident of the Czech\nMedical Chamber\nThe Georgian Health Care System during the Conflict\nin August 2008 and World Crisis\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health care\u201d, Riga, September 10-11th 2010\nTamar Lobzhanidze Kakhaber Jakeli Gia Lobzhanidze Zaza Khachiperadze\nwmj 1 2011 5CS.indd 33 21.02.2011 16:28:30\n34\nRegional and NMA news GEORGIA\nSoon the recession overtook Europe; the\neconomy of Great Britain was facing seri-\nous threats. As for Iceland, it almost totally\nwent bankrupt. During this period and as\na result of the situation that developed, the\neconomy of Georgia was also damaged.The\nincome in October 2008 decreased almost 2\ntimes and its GDP reduced 1.9 times.\nAccording to the planned 2009 budget, the\neconomic income was determined as 2%;\nhowever,the world economic crisis resulted in\ndetermining Georgia\u2019s income as 4%.Budget-\nary incomes decreased by 600 million GEL.\nIn 2010 the increase in GDP was planned\nto reach 2%, inflation rate was determined\nas 6%, more than by 1% in comparison with\nthe indicator in 2008.\nThis crisis was very harmful to Georgian\neconomy, but the country\u2019s economy was\nnot as sensitive to this crisis as many other\ncountries\u2019 economies proved to be because\nGeorgia was not as much involved in the\nworld economy. To be more precise, there\nwere no securities on the USA Stock Ex-\nchange, which saved Georgian financial as-\nsets. In fact, our economy was saved by iso-\nlation.The events of August 2008 were soon\nfollowed by economic recession. If, accord-\ning to some sources, Georgia had increased\nits GDP by 9\u201310%, there was no indication\nof improvement in October. In 2009, the\nsigns of large-scale job losses were noticed\namong employees.\nSocial politics is an important part of Geor-\ngian economy. A large part of it is covered\nby health care and pension systems. The\nnumber of pensioners in Georgia reaches\n1\u00a0 million. According to the data of 2009,\nthe problem of nation\u2019s aging prevents the\ndevelopment of effective pension politics.\nThe government accomplishes the issue of\nsatisfying pensioners by a simple model-dis-\ntribution of the pension.The next necessary\nstep to be done is to work out the strategy to\ndirect pensioners\u2019 access to the health care\nsystem and to getting the health care goods\nas it is done in other developed countries.\nThe development of health care system and\nfunctions of strategic nature means system\ninfrastructure rehabilitation through maxi-\nmum objectivity and foreign investment\nby the medical services of private market\nhealth insurance, and voluntary health in-\nsurance stimulation. The health care system\ncovers social and age groups with different\nmechanisms of financing (e.\u00a0 g., refugees,\n0\u20133 years old children, people over 60 years\nof age). The support to all kinds of medi-\ncal services increased by 6% from 2007 to\n2008. The increase reached 3% in 2009, in\ncomparison with 2008. Mostly the increase\nwas determined by ambulance services and\ndoctors\u2019 visits. (Fig. 1.)\nIn 2008 the hospitalization indicator\n(100.000 population) was increased by\n11.2% in comparison with the indicators\nof 2007. And in 2009 the increase reached\n1.2% in comparison with 2008.As for 2007,\nthe increase reached 8.6%. (Fig. 2.)\nThe attracted medical insurance premium\nincreased by 72.4% in 2008, in comparison\nwith 2007, and by 25% in 2009, in compari-\nson with 2008. Private money spending de-\ncreased lightly. (Fig. 3.)\nThe tendency of purchasing public and pri-\nvate sector medical services and supply has\nnot decreased, on the contrary, according\nto some indicators, the tendency of growth\nis noticed. During the crisis the Georgian\nhealth system stability was achieved,first,by\nthe strong support of the state for the medi-\ncal insurance, through which incurrence of\npopulation was managed.\u00a0Secondly, financ-\ning of the system and health care utilization\nwas so small and minimal that the invested\nbudgetary and private sources and the im-\nproved business environment maintained\nthe system functioning.\nThe effectiveness of the functioning of the\nGeorgian health care system in the future\nwill depend on the growth of the state\nshare in health care costs (no more than\n2% per year) and the basic improvement of\nthe process administration.\u00a0It is especially\nimportant to work out the 10-year health\ncare system strategic and human resources\ndevelopment plans.That will be the basis for\nthe education and health care system im-\nprovement and affordability.\nFigure 1\nFigure 2\nFigure 3\nTamar Lobzhanidze, Assistant Professor\nof the University of Georgia\nKakhaber Jakeli, Associate Professor\nof the University of Georgia\nProf. Gia Lobzhanidze, Chairman of\nthe Board of Directors of the Georgian\nMedical Association,\nDr. Zaza Khachiperadze, Deputy Secretary\nof the Georgian Medical Association\nwmj 1 2011 5CS.indd 34 21.02.2011 16:28:32\n35\nThe missions\nThe College of Physicians is a legal entity of\npublic law with civil personality and finan-\ncial authority. This is the highest medical\nprofessional authority. It ensures the main-\ntenance of the principles of morality, quality\nand dedication necessary for the practice of\nmedicine. It also ensures compliance by all\nmembers with the professional duties and\nrules enacted by the code of ethics. It also\nensures the defense of honor and traditions\nof the medical profession. It gives its opin-\nion to the public authorities as regards leg-\nislation and medical regulations in General\non all matters affecting public health and\nmedical course.\nOrganization\nThe National Council\nThe National Council includes:\n\u2022 The eight (8) elected members of sec-\ntion A (medical officers or public services\ncontract,body teacher from the Faculty of\nMedicine).\n\u2022 The eight (8) members elected of section\nB (private doctors).\n\u2022 Three (3) members who are:\n- The dean of the faculty of medicine.\n- The director of public health.\n- The director of health of the armed\nforces.\n\u2022 A legal advisor (head judge).\nThe office\nThe office includes:\n\u2022 A President.\n\u2022 A Vice President, Secretary General.\n\u2022 Two members.\nThe commissions\nThere are five (5) commissions:\n\u2022 The commission of discipline and con-\nflicts.\n\u2022 The administrative and legal commission.\n\u2022 The commission of board qualification\nand specialization.\n\u2022 The social commission.\n\u2022 The cultural and scientific commission.\nThe commission includes a President, a re-\nporter and members.\nThe section councils\nThe A section Council members include:\nThe annual ZEVA Symposium provides a plat-\nform for exchange between physicians\u2019 chambers\nfrom Central and Eastern European countries.\nDuring the symposium, representatives from EU\nand non-EU member states discuss common chal-\nlenges and share experiences in order to find ways\nto improve the working environment of physi-\ncians and the quality of healthcare in the interest\nof all patients.\nThe central focus of the 17th ZEVA Symposium,\nwhich was held in Skopje, Macedonia, was pa-\ntient safety and quality in healthcare. After a\nfruitful discussion, the participating countries\nagreed on the:\n\u2022 Safety is the core element of quality in\nhealthcare.\n\u2022 Physicians have an ethical and professional\nobligation to always strive for continuous\nquality improvement in healthcare and\nmust ensure patient safety during all medi-\ncal decision making.\n\u2022 Physician self-regulation is based on the\ntrust invested in the medical profession.\nPhysicians\u2019 chambers assume this respon-\nsibility and guarantee high standards of\nmedical practice and the ethical provision\nof medical services by physicians. Patient\nsafety and quality in healthcare are core ele-\nments that drive the chambers\u2019 decisions on\npolicy, ethics, education and training.\n\u2022 By being competent advocates for patient\nsafety, physicians prove their credibility in\nthe political arena and to the public. Gov-\nernments should recognize the crucial role\nof physicians and physicians\u2019chambers in all\nmatters relating to patient safety.\n\u2022 Patient safety incidents are often reported\nas errors by individual physicians. However,\nresearch has shown that nearly all incidents\nare actually a result of system failure and\nrarely errors by individuals.\n\u2022 Physicians should take a leading role in\npatient safety and be included in analyzing\ncomplex health information processes that\nlead to errors or create the potential for er-\nrors.\n\u2022 A Critical Incident Reporting System could\nbe a valuable and effective physician-driven\ninstrument. A blame free reporting culture\nis a precondition for this.\n\u2022 Most countries face similar challenges in\nimproving patient safety. These primarily\nconcern the provision of appropriate edu-\ncation and training, ensuring a safe work-\ning environment, building and maintaining\na suitable infrastructure, as well as guaran-\nteeing sufficient financial and human re-\nsources.\n\u2022 Patient safety and quality of care should\ntake particularly high priority when consid-\nering task shifting in the delivery of health\nservices.The role of physicians as the health\nprofessionals with overall responsibility for\ndiagnosis and treatment is crucial in this\nrespect.\n\u2022 Physicians\u2019 chambers should promote poli-\ncies on patient safety to all physicians in\ntheir country and support the development\nof appropriate post-graduate medical edu-\ncation.\n\u2022 Physicians\u2019 chambers in the ZEVA region\nshould continue to share experiences in the\nfield of patient safety and foster more in-\ntense collaboration.\n\u2022 The physicians\u2019 chambers in the ZEVA\nregion fully endorse the World Medical\nAssociation\u2019s \u201cDeclaration on Guidelines\nfor Continuous Quality Improvement in\nHealthcare\u201dand the WMA \u201cDeclaration on\nPatient Safety\u201d.\nRegional and NMA newsSENEGAL\nThe College of Physicians of Senegal\nSkopje Declaration on Patient Safety\nand Quality in Healthcare\nwmj 1 2011 5CS.indd 35 21.02.2011 16:28:33\n36\nRegional and NMA news DEMOCRATIC REP. of CONGO\nThe National Medical Council has been\ncreated by order-law No. 68\/070 of March\n1, 1968, with the load and mission: defense,\nhonor and the independence of the medical\nprofession. It includes:\n\u2022 the National Council (CNOM) and its office;\n\u2022 the provincial Councils (COPROM) and\ntheir offices.\nThe National Council sees:\n\u2022 To the respect and to the maintenance by\nall members of the principles of morality,\nintegrity and devotion.\n\u2022 To the observance by all physicians of\ntheir professional duties and rules of the\nmedical deontology.\n\u2022 To the defense of honor and the indepen-\ndence of the profession.\n\u2022 To the protection of the population\u2019s health.\nThe physician in the Democratic Republic\nof Congo is an actor and sanitary operator\nof a preeminent and important place that\nimposes on him permanent requirements of\nknowledge, ethics, morality, dignity, profes-\nsional independence and sharp sense of re-\nsponsibility.He dedicates his life to the cause\nof humanity and the patient remains his first\nworry. For it, it is necessary that he has the\ncharacter of a perfect honest man. Honor,\ndignity, noble traditions must always come\nwith it when he practices his profession.\nThe Office of the National Council\n(CNOM) was elected at the 4th convention\nof the National Medical Council and took\nits functions on July 28, 2008 for five years.\nIt is constituted by:\nThe Office is the organ of daily manage-\nment of the National Council and as such:\nDr. Mbutuku: National President,\nDr. Kaswa: National Vice-President,\nDr. Sese: National Secretary,\nDr. Ebondo: National Associate Secretary,\nDr. Beya: National Treasurer.\nNational Council and as such:\n\u2022 It elaborates the plan of action and the\nbudget of the National Council.\n\u2022 It executes the decisions of the plenary\nassembly.\n\u2022 It manages the administrative and tech-\nnical staff, the plenary assembly of the\nNational Council.\n\u2022 It coordinates the provincial Council activities.\n\u2022 It raises the yearly and multi-year reports\nsubmitted for the approval of the plenary\nassembly.\n\u2022 It initiates the internal and external au-\ndits for the improvement of its own man-\nagement.\n\u2022 It installs the Office elected from the per-\nmanent Commissions of the CNOM and\nof the COPROM.\nThe National President represents the Na-\ntional Council and all physicians of the\ncountry by the third in the acts of civil life.\nThe National Vice-president helps him and\nreplaces him in case of obstacles. He super-\nvises the general administration, notably\nthe heritage, the bursary, the maintenance\nand the staff. The National Secretary is put\nin charge of the secretariat of the Council\nwith a mission and load:\n\u2022 To look after the good holding and the\nupdating of the Picture of the Council,\nof the cards of identity of the mem-\nbers and in general of all archives of the\nCouncil.\n\u2022 To conduct the correspondence of the\nCouncil that he signs together with the\nPresident.\nThe National Associate Secretary helps the\nlatter and replaces him in case of obstacles.\nThe Treasurer looks after the good holding\nand the updating of the financial affairs and\nthe books necessary for accounting.\nDr. Kaswa, National Vice-President\nNational Medical Council\nof the Democratic Republic of Congo\n\u2022 The eight (8) elected members.\n\u2022 Three (3) representatives of the Ministry\nof Guardianship.\n\u2022 A (1) representative of section B in sec-\ntion A.\nThe section B Council members include:\n\u2022 The eight (8) elected members.\n\u2022 Two (2) representatives of the Ministry of\nGuardianship.\n\u2022 A (1) representative of section A in sec-\ntion B.\nOther agencies\nThe national order of physicians in Senegal\nis a member of the national health research\nEthics Board. This Committee has four (4)\nmissions:\n\u2022 Review of research protocols in health\nin order to ensure the protection of per-\nsons that lend themselves to research and\nscientific quality of collection and data\nanalysis research.\n\u2022 The issuance of ethical and scientific ad-\nvice to the Minister for Health with a\nview to authorization, suspension or pro-\nhibition of the pursuit of a search.\n\u2022 The supervision if there is place for health\nresearch.\n\u2022 The conduct and development of reflec-\ntion on the ethical and legal aspects aris-\ning from the practice of health research.\nConditions to practice\nmedicine in Senegal\n\u2022 Having the Senegalese nationality.\n\u2022 Having the Senegalese diploma of doc-\ntor of medicine or an equivalent foreign\ndegree recognized.\n\u2022 Being entered on the roll of the sections\nof the College of Physicians except for\nthe medical doctors belonging to the ac-\ntive frame of the army medical service\nSenegalese and foreign military physi-\ncians serving as military assistance.\nProfesseur M.L. SOW,\nPr\u00e9sident de l\u2019Ordre\nwmj 1 2011 5CS.indd 36 21.02.2011 16:28:34\n37\nOrder of Physicians of Albania (OPA)\nRr. Dibres. Poliklinika Nr.10, Kati 3\nTirana\nALBANIA\nDr. Din Abazaj, President\nTel\/Fax: (355) 4 2340 458\nE-mail: albmedorder@albmail.com\nWebsite: www.umsh.org\nCol\u2019legi de Metges\nC\/Verge del Pilar 5,\nEdifici Plaza 4t. Despatx 11\n500 Andorra La Vella\nANDORRA\nDr. Manuel Gonz\u00e1lez Belmonte, Presidente\nTel: (376) 823 525\nFax: (376) 860 793\nE-mail: coma@andorra.ad\nWebsite: www.col-legidemetges.ad\nOrdem dos M\u00e9dicos de Angola (OMA)\nRua Amilcar Cabral 151-153\nLuanda\nANGOLA\nDr. Carlos Alberto Pinto de Sousa, President\nTel. (244) 222 39 23 57\nFax (244) 222 39 16 31\nE-mail: secretariatdormed@gmail.com\nWebsite: www.ordemmedicosangola.com\nConfederaci\u00f3n M\u00e9dica de la Rep\u00fablica\nArgentina\nAv. Belgrano 1235\nBuenos Aires 1093\nARGENTINA\nDr. Jorge C. Ja\u00f1ez, Presidente\nTel\/Fax: (54-11) 4381-1548 \/ 4384-5036\nE-mail: comra@confederacionmedica.com.ar\nWebsite: www.comra.health.org.ar\nAustralian Medical Association\nP.O. Box 6090\nKingston, ACT 2604\nAUSTRALIA\nDr. Andrew Pesce, President\nTel: (61-2) 6270 5460\nFax: (61-2) 6270 5499\nE-mail: ama@ama.com.au\nWebsite: www.ama.com.au\nOsterreichische Arztekammer\n(Austrian Medical Chamber)\nWeihburggasse 10-12 - P.O. Box 213\n1010 Wien\nAUSTRIA\nDr. Walter Dorner, President\nTel: (43-1) 514 06 64\nFax: (43-1) 514 06 933\nE-mail: international@aerztekammer.at\nm.reisinger@aerztekammer.at\nWebsite: www.aerztekammer.at\nArmenian Medical Association\nP.O. Box 143\nYerevan 375 010\nREPUBLIC OF ARMENIA\nDr. Parounak Zelvian President\nTel. (3741) 53 58 68\nFax. (3741) 53 48 79\nE-mail: info@armeda.am\nWebsite: www.armeda.am\nAzerbaijan Medical Association\nP.O. Box 16\nAZE 1000, Baku\nREP OF Azerbaijan\nDr. Nariman Safarli, President\nTel.(99 450) 328 18 88\nFax. (99 412) 431 88 66\nE-mail. info@azmed.az\u00a0- azerma@hotmail.com\nWebsite: www.azmed.az\nMedical Association of the Bahamas\nP.O. Box N-3125\nMAB House\u00a0- 6th Terrace Centreville\nNassau\nBAHAMAS\nDr.Timothy Barrett, President\nTel. (242) 328-1858\nFax. (242) 328-1857\nE-mail: medassocbah@gmail.com\nBangladesh Medical Association\nBMA Bhaban 5\/2 Topkhana Road\nDhaka 1000\nBANGLADESH\nProf. Mahmud Hasan, President\nTel. (880) 2-9568714 \/ 9562527\nFax. (880) 2 9566060 \/ 9562527\nE-mail: info@bma.org.bd\nWebsite: www.bma.org.bd\nAssociation Belge des Syndicats\nM\u00e9dicaux\nChauss\u00e9e de Boondael 6, bte 4\n1050 Bruxelles\nBELGIUM\nDr. Roland Lemye, Pr\u00e9sident\nTel: (32-2) 644 12 88\nFax: (32-2) 644 15 27\nE-mail: absym.bvas@euronet.be\nWebsite: www.absym-bvas.be\nColegio M\u00e9dico de Bolivia\nCalle Ayacucho 630\nTarija\nBOLIVIA\nDr. Fernando Arandia Castellanos, President\nFax. (591) 4\u00a0666 3569\nE-mail: colmedbol_tjo@hotmail.com\nWebsite: colegiomedicodebolivia.org.bo\nAssocia\u00e7ao M\u00e9dica Brasileira\nR. Sao Carlos do Pinhal 324\u00a0- Bairro Bela Vista\nSao Paulo SP\u00a0- CEP 01333-903\nBRAZIL\nDr. Jos\u00e9 Luiz Gomes do Amaral, Presidente\nTel. (55-11) 3178 6810\nFax. (55-11) 3178 6830\nE-mail: presidente@amb.org.br\nWebsite: www.amb.org.br\nBulgarian Medical Association\n15, Acad. Ivan Geshov Blvd.\n1431 Sofia\nBULGARIA\nDr. Cvetan Raychinov, President\nTel: (359-2) 954 11 81\nFax: (359-2) 954 11 86\nE-mail: blsus@mail.bg\nWebsite: www.blsbg.com\nCanadian Medical Association\nP.O. Box 8650\n1867 Alta Vista Drive\nOttawa, Ontario K1G 3Y6\nCANADA\nDr. Jeffrey Turnbull, President\nTel: (1-613) 731 8610 ext. 2236\nFax: (1-613) 731 1779\nE-mail: karen.clark@cma.ca\nWebsite: www.cma.ca\nOrdem Dos Medicos du Cabo Verde (OMCV)\nAvenue OUA N\u00b0 6\u00a0- B.P. 421\nAchada Santo Ant\u00f3nio\nCiadade de Praia-Cabo Verde\nCABO VERDE\nDr Luis de Sousa Nobre Leite, President\nTel. (238) 262 2503\nFax (238) 262 3099\nE-mail: omecab@cvtelecom.cv\nWebsite: www.ordemdosmedicos.cv\nColegio M\u00e9dico de Chile\nEsmeralda 678 - Casilla 639\nSantiago\nCHILE\nDr. Pablo Rodr\u00edguez, Presidente\nTel: (56-2) 4277800\nFax: (56-2) 6330940 \/ 6336732\nE-mail: rdelcastillo@colegiomedico.cl\nWebsite: www.colegiomedico.cl\nChinese Medical Association\n42 Dongsi Xidajie\nBeijing 100710\nCHINA\nDr. CHEN Zhu, President\nTel: (86-10) 8515 8136\nFax: (86-10) 8515 8551\nE-mail: zhiliu@cma.org.cn\nWebsite: www.cma.org.cn\nFederaci\u00f3n M\u00e9dica Colombiana\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219\nSantaf\u00e9 de Bogot\u00e1, D.E.\nCOLOMBIA\nDr. Sergio Isaza Villa, Presidente\nTel.\/Fax: (57-1) 8050073\nE-mail: federacionmedicacolombiana@enco-\nlombia.com\nWebsite: www.encolombia.com\nConseil National de l\u2019Ordre des M\u00e9decins du\nRDC\nB.P. 4922\nKinshasa\u00a0- Gombe\nR\u00c9PUBLIQUE D\u00c9MOCRATIQUE DU\nCONGO\nDr. Antoine Mbutuku Mbambili, Pr\u00e9sident\nTel: (243-12) 24589\nFax: (243) 8846574\nE-mail : cnomdrc@yahoo.fr\nUni\u00f3n M\u00e9dica Nacional\nApartado 5920-1000\nSan Jos\u00e9\nCOSTA RICA\nDr. Alexis Castillo Guti\u00e9rrez, Presidente\nTel: (506) 290-5490\nFax: (506) 231 7373\nE-mail: unmedica@racsa.co.cr\nCroatian Medical Association\nSubiceva 9\n10000 Zagreb\nCROATIA Dr. \u017deljko Metelko President\nTel: (385-1) 46 93 300\nFax: (385-1) 46 55 066\nE-mail: tajnistvo@hlz.hr\nWebsite: www.hlk.hr\/default.asp\nColegio M\u00e9dico Cubano Libre\nP.O. Box 141016\nCoral Gables, FL 33114-1016\nUNITED STATES\nDr. Enrique Huertas, Presidente\n717 Ponce de Leon Boulevard\nCoral Gables, FL 33134\nTel: (1-305) 446 9902\/445 1429\nFax: (1-305) 4459310\nCyprus Medical Association (CyMA)\n14 Thasou Street\n1087 Nicosia\nCYPRUS\nDr. Andreas Demetriou, President\nTel. (357) 22 33 16 87\nFax: (357) 22 31 69 37\nE-mail: cyma@cytanet.com.cy\nWMA Directory of Constituent Members\nwmj 1 2011 5CS.indd 37 21.02.2011 16:28:35\n38\nCzech Medical Association\nSokolsk\u00e1 31 - P.O. Box 88\n120 26 Prague 2\nCZECH REPUBLIC\nProf. Jaroslav Blahos, President\nTel: (420) 224 266 201-4\nFax: (420) 224 266 212\nE-mail: czma@cls.cz - Website: www.cls.cz\nDanish Medical Association\nKristianiagade 12,\nDK-2100 Copenhagen\nDENMARK\nDr.Mads Koch Hansen, President\nTel: (45) 35 44 85 00\nFax: (45) 35 44 85 05\nE-mail: er@dadl.dk, cc: clr@dadl.dk\nWebsite: www.laeger.dk\nEgyptian Medical Association\n\u201cDar El Hekmah\u201d\n42, Kasr El-Eini Street\nCairo\nEGYPT\nProf. Ibrahim Badran\nTel: (20-2) 3543406\nE-mail : ganzory@tedata.net.eg\nColegio M\u00e9dico de El Salvador\nFinal Pasaje N\u00b0 10\nColonia Miramonte\nSan Salvador\nEL SALVADOR, C.A.\nDr. Alcides G\u00f3mez Hern\u00e1ndez, Presidente\nTel: (503) 260-1111, 260-1112\nFax: (503) 260-0324\nE-mail: comcolmed@telesal.net marnuca@\nhotmail.com\njuntadirectiva@colegiomedico.org.sv\nEstonian Medical Association (EsMA)\nPepleri 32\n51010 Tartu\nESTONIA\nDr. Andrus M\u00e4esalu, President\nTel: (372) 7 420 429\nFax: (372) 7 420 429\nE-mail: eal@arstideliit.ee\nWebsite: www.arstideliit.ee\nEthiopian Medical Association\nP.O. Box 2179\nAddis Ababa\nETHIOPIA\nDr. Fuad Temam, President\nTel: (251-1) 158174\nFax: (251-1) 533742\nE-mail: ema.emj@ethionet.et\nema@eth.healthnet.org\nFiji Medical Association\n304 Wainamu Road\nG.P.O. Box 1116\nSuva\nFIJI ISLANDS\nDr. Ifereimi Waqainabete, President\nTel. (679) 3315388\nFax. (679) 3315388\nE-mail. fma@unwired.com.fj\nFinnish Medical Association\nP.O. Box 49\n00501 Helsinki\nFINLAND\nDr.Timo Kaukonen, President\nTel: (358-9) 393 091\nFax: (358-9) 393 0794\nE-mail: riikka.sorsa@fimnet.fi\/\n(fma@fimnet.fi)\nWebsite: www.medassoc.fi\nAssociation M\u00e9dicale Fran\u00e7aise\n180, Blvd. Haussmann\n75389 Paris Cedex 08\nFRANCE\nDr. Elie Chow-Chine, President\nTel: (33) 1 53 89 32 41\nFax. (33) 2 99 38 15 57\n(Sylvie Deletoile\u00a0- deletoile.sylvie@cn.medecin.\nfr)\nWebsite: www.assmed.fr\nGeorgian Medical Association\n7 Asatiani Street\n0177 Tbilisi\nGEORGIA\nProf. Gia Lobzhanidze, President\nTel. (995 32) 398686\nFax. (995 32) 396751 \/ 398083\nE-mail. georgianmedicalassociation@gmail.com\nWebsite: www.gma.ge\nBundes\u00e4rztekammer\n(German Medical Association)\nHerbert-Lewin-Platz 1\n10623 Berlin\nGERMANY Prof. Jorg Dietrich Hoppe\nTel: (49-30) 4004 56 360\nFax: (49-30) 4004 56 384\nE-mail: rparsi@baek.de\nWebsite: www.baek.de\nGhana Medical Association\nP.O. Box 1596\nAccra\nGHANA\nDr. Emmanuel Adom Winful, President\nTel. (233-21) 670510 \/ 665458\nFax. (233-21) 670511\nE-mail: gma@dslghana.com\nWebsite: www.ghanamedassn.org\nAssociation M\u00e9dicale Haitienne\n1\u00e8re Av. du Travail #33\u00a0- Bois Verna\nPort-au-Prince\nHAITI, W.I.\nDr. Greta Roy, Pr\u00e9sidente\nTel. (509) 2244 - 32\nFax:(509) 2244 - 50 49\nE-mail: secretariatamh@gmail.com\namh@haitimedical.com\nWebsite: www.amhhaiti.net\nHong Kong Medical Association, China\nDuke of Windsor Social Service Building\n5th Floor\n15 Hennessy Road\nHONG KONG\nDr. Gabriel K. Choi, President\nTel: (852) 2527-8285\nFax: (852) 2865-0943\nE-mail: hkma@hkma.orgoui\nWebsite: www.hkma.org\nAssociation of Hungarian Medical\nSocieties (MOTESZ)\nN\u00e1dor u. 36 - PO.Box 145\n1051 Budapest\nHUNGARY\nDr. Istv\u00e1n Kiss, President\nTel: (36-1) 312 3807\u00a0- 312 0066\nFax: (36-1) 383-7918\nE-mail: szalma.laura@motesz.hu\nWebsite: www.motesz.hu\nIcelandic Medical Association\nHlidasmari 8\n200 K\u00f3pavogur\nICELAND\nDr. Birna Jonsdottir, President\nTel: (354) 864 0478\nFax: (354) 5 644106\nE-mail: icemed@icemed.is\nWebsite: www.icemed.is\nIndian Medical Association\nIndraprastha Marg\nNew Delhi 110 002\nINDIA\nDr. Vinay Agarwal, National President\nTel: (91-11) 23370009\/23378819\/23378680\nFax: (91-11) 23379178\/23379470\nE-mail: imawmaga2009@gmail.com\nWebsite: www.imanational.com\nIndonesian Medical Association\nIkatan Dokter Indonesia\nJl. Samratulangi No. 29\nJakarta 10350\nINDONESIA\nDr. Prijo Sidipratomo, President\nTel: (62-21) 3150679 \/ 3900277\nFax: (62-21) 390 0473\nE-mail: pbidi@idola.net.id\nWebsite:www.idionline.org\nIrish Medical Organisation\n10 Fitzwilliam Place\nDublin 2\nIRELAND\nProf. Se\u00e1n Tierney, President\nTel: (353-1) 6767273\nFax: (353-1) 662758\nE-mail: imo@imo.ie\nccamilleri@imo.ie\nWebsite: www.imo.ie\nIsrael Medical Association\n2 Twin Towers, 35 Jabotinsky St.\nP.O. Box 3566, Ramat-Gan 52136\nISRAEL\nDr. Leonid Eidelman, President\nTel: (972-3) 610 0444\nFax: (972-3) 575 0704\nE-mail michelle@ima.org.il\nWebsite: www.ima.org.il\nOrdre National des M\u00e9decins de la C\u00f4te\nd\u2019Ivoire\n(ONMCI)\nCocody Cit\u00e9 des Arts, B\u00e2t. U1, Esc.D,\nRdC, Porte n\u00b01\nBP 1584\nAbidjan 01\nIVORY COAST\nDr. Aka Kroo Florent Pierre, President\nTel. (225) 22 48 61 53 \/22 44 30 78\/\nTel. (225) 02 02 44 01 \/08 14 55 80\nFax: (225) 22 44 30 78\nE-mail: onmci@yahoo.fr\nWebsite: www.onmci.org\nJapan Medical Association\n2-28-16 Honkomagome, Bunkyo-ku\nTokyo 113-8621\nJAPAN\nDr. Y. Karasawa, President\nTel: (81-3) 3946 2121\/3942 6489\nFax: (81-3) 3946 6295\nE-mail: jmaintl@po.med.or.jp\nWebsite: www.med.or.jp\nNational Medical Association (NMA) of the\nRepublic of Kazakhstan\n117\/1 Kazybek bi St.,\nAlmaty\nKAZAKHSTAN\nDr. Aizhan Sadykova, President\nTel. (7-327 2) 624301 \/ 2629292\nFax. (7-327 2) 623606\nE-mail: doktor_sadykova@mail.ru\nKorean Medical Association\n302-75 Ichon 1-dong, Yongsan-gu\nSeoul 140-721\nREP. OF KOREA\nDr. Man Ho Kyung, President\nTel: (82-2) 794 2474\nFax: (82-2) 793 9190\/795 1345\nE-mail: intl@kma.org\nWebsite: www.kma.org\nwmj 1 2011 5CS.indd 38 21.02.2011 16:28:36\n39\nKuwait Medical Association\nP.O. Box 1202\nSafat 13013\nKUWAIT\nDr. Abdul-Aziz Al-Enezi, President\nTel. (965) 5333278, 5317971\nFax. (965) 5333276\nE-mail. kma@kma.org.kw \/\nalzeabi@hotmail.com\nLatvian Physicians Association\nSkolas Str. 3\nRiga 1010\nLATVIA\nDr. Peteris Apinis, President\nTel: (371) 67287321 \/ 67220661\nFax: (371) 67220657\nE-mail: lma@arstubiedriba.lv\nWebsite: www.arstubiedriba.lv\nLiechtensteinische \u00c4rztekammer\nPostfach 52\n9490 Vaduz\nLIECHTENSTEIN\nDr. Remo Schneider, Secretary LAV\nTel: (423) 231 1690\nFax. (423) 231 1691\nE-mail: office@aerztekammer.li\nWebsite: www.aerzte-net.li\nLithuanian Medical Association\nLiubarto Str. 2\n2004 Vilnius\nLITHUANIA\nDr. Liutauras Labanauskas, President\nTel.\/Fax. (370-5) 2731400\nE-mail: lgs@takas.lt\nWebsite: www.lgs.lt\/\nAssociation des M\u00e9decins et\nM\u00e9decins Dentistes du Grand-\nDuch\u00e9 de Luxembourg (AMMD)\n29, rue de Vianden\n2680 Luxembourg\nLUXEMBOURG\nDr. Jean Uhrig, Pr\u00e9sident\nTel: (352) 44 40 33 1\nFax: (352) 45 83 49\nE-mail: secretariat@ammd.lu\nWebsite: www.ammd.lu\nMacedonian Medical Association\nDame Gruev St. 3\nP.O. Box 174\n91000 Skopje\nMACEDONIA\nProf. Dr. Jovan Tofoski, President\nTel: (389-2) 3162 577\/7027 9630\nFax: (389-91) 232577\nE-mail: mld@unet.com.mk\nWebsite: www.mld.org.mk\nSociety of Medical Doctors of Malawi (SMD)\nPost Dot Net, PO Box 387, Crossroads\nLilongwe Malawi\n30330 Lilongwe\nMALAWI\nDr. Douglas Komani Lungu, President\nE-mail: dlungu@sdnp.org.mw\nWebsite : www.smdmalawi.org\nMalaysian Medical Association\n4th Floor, MMA House\n124 Jalan Pahang\n53000 Kuala Lumpur\nMALAYSIA\nDr. David K.L. Quek, President\nTel: (60-3) 4041 1375\nFax: (60-3) 4041 8187\nE-mail: info@mma.org.my \/ president@mma.\norg.my\nWebsite: www.mma.org.my\nOrdre National des M\u00e9decins du Mali\n(ONMM)\nH\u00f4pital Gabriel Tour\u00e9\nCour du Service d\u2019Hygi\u00e8ne\nBP E 674\nBamako\nMALI\nProf. Alhousse\u00efni AG Mohamed, President\nTel. (223) 223 03 20\/ 222 20 58\/\nE-mail: cnommali@gmail.com\nWebsite: www.keneya.net\/cnommali.com\nMedical Association of Malta\nThe Professional Centre\nSliema Road, Gzira GZR 06\nMALTA\nDr. Steven Fava, President\nTel: (356) 21312888\nFax: (356) 21331713\nE-mail: martix@maltanet.net\nWebsite: www.mam.org.mt\nColegio Medico de Mexico (CMM)\nAdolfo Prieto #812\nCol.Del Valle\nD. Benito Ju\u00e1rez\nMexico 03100\nMEXICO\nDr Federico Marin, Presidente\nTel. 52 55 5543 8989\nFax. 52 55 5543 1422\nE-mail: fenacome@gmail.com\nWebsite: www.colegiomedicodemexico.org\nAssocia\u00e7\u00e3o M\u00e9dica de Mo\u00e7ambique (AMMo)\nAvenida Salvador Allende, n\u00b0 560\n1\u00b0 andar, Maputo\nMOCAMBIQUE\nDr. Rosel Salom\u00e3o, President\nE-mail: associacaomedicamz@gmail.com\nMedical Association of Namibia\n403 Maerua Park\u00a0- POB 3369\nWindhoek\nNAMIBIA\nDr. Reinhardt Sieberhagen, President\nTel. (264) 61 22 4455\nFax. (264) 61 22 4826\nE-mail: man.office@iway.na\nNepal Medical Association\nSiddhi Sadan, Post Box 189\nExhibition Road\nKatmandu\nNEPAL\nDr. Chop Lal Bhusal, President\nTel. (977 1) 4225860, 4231825\nFax. (977 1) 4225300\nE-mail. nma@healthnet.org.np\nRoyal Dutch Medical Association\nP.O. Box 20051\n3502 LB Utrecht\nNETHERLANDS\nProf. A.C.Nieuwenhuijzen Kruseman, President\nTel: (31-30) 282 38 28\nFax: (31-30) 282 33 18\nE-mail: j.bouwman@fed.knmg.nl\nWebsite: www.knmg.nl\nwww.artsennet.nl\nNew Zealand Medical Association\nP.O. Box 156, 26 The Terrace\nWellington 1\nNEW ZEALAND\nDr. Peter Foley, Chairman\nTel: (64-4) 472 4741\nFax: (64-4) 471 0838\nE-mail: lianne@nzma.org.nz\nWebsite: www.nzma.org.nz\nNigerian Medical Association\nNational Secretariat\n8 Benghazi Street, Off Addis Ababa Crescent\nWuse Zone 4, FCT, PO Box 8829 Wuse\nAbuja\nNIGERIA\nDr. Prosper Ikechukwu Igboeli, President\nTel: (234-1) 480 1569, 876 4238\nFax: (234-1) 493 6854\nE-mail: info@nigeriannma.org\nWebsite: www.nigeriannma.org\nNorwegian Medical Association\nP.O.Box 1152 sentrum\n0107 Oslo\nNORWAY\nDr.Torunn Janbu, President\nTel: (47) 23 10 90 00\nFax: (47) 23 10 90 10\nE-mail: ellen.pettersen@legeforeningen.no\nWebsite: www.legeforeningen.no\nAsociaci\u00f3n M\u00e9dica Nacional\nde la Rep\u00fablica de Panam\u00e1\nApartado Postal 2020\nPanam\u00e1 1\nPANAMA\nDr. Rub\u00e8n Chavarria, Presidente\nTel: (507) 263 7622 \/263-7758\nFax: (507) 223 1462\nFax modem: (507) 223-5555\nE-mail: amenalpa@cwpanama.net\nColegio M\u00e9dico del Per\u00fa\nMalec\u00f3n Armend\u00e1riz N\u00b0 791\nMiraflores\nLima\nPERU\nDr. Julio Castro G\u00f3mez, Presidente\nTel: (51-1) 241 75 72\nFax: (51-1) 242 3917\nE-mail: prensanacional@cmp.org.pe\nWebsite: www.cmp.org.pe\nPhilippine Medical Association\n2\/F Administration Bldg.\nPMA Compound, North Avenue\nQuezon City 1105\nPHILIPPINES\nDr. Rey Melchor F. Santos, President\nTel: (63-2) 929-63 66\nFax: (63-2) 929-69 51\nE-mail: philmedas@yahoo.com\nWebsite: www.pma.com.ph\nPolish Chamber of Physicians and Dentists\n(Naczelna Izba Lekarska)\n110 Jana Sobieskiego\n00-764 Warsaw\nPOLAND\nDr. Konstanty Radziwill, President\nTel. (48) 22 55 91 300\/324\nFax: (48) 22 55 91 323\nE-mail: sekretariat@hipokrates.org\nWebsite: www.nil.org.pl\nOrdem dos M\u00e9dicos\nAv. Almirante Gago Coutinho, 151\n1749-084 Lisbon\nPORTUGAL\nDr. Pedro Nunes, President\nTel: (351-21) 842 71 00\/842 71 11\nFax: (351-21) 842 71 99\nE-mail: intl@omcn.pt\nWebsite: www.ordemdosmedicos.pt\nRomanian Medical Association\nStr. Ionel Perlea, nr 10,\nSect. 1, Bucarest\nROMANIA\nProf. Dr. C. Ionescu-Tirgoviste, President\nTel: (40-21) 460 08 30\nFax: (40-21) 312 13 57\nE-mail: amr@itcnet.ro\nWebsite: www.ong.ro\/ong\/amr\/\nwmj 1 2011 5CS.indd 39 21.02.2011 16:28:37\n40\nRussian Medical Society\nUdaltsova Street 85\n119607 Moscow\nRUSSIA\nDr. Mikhail Perelman, President\nTel.\/Fax (7-495) 734-12-12\nTel. (7-495) 734-11-00\/(7-495)734 11 00\nE-mail. info@russmed.ru\nWebsite: www.russmed.ru\/eng\/who.htm\nSamoa Medical Association\nTupua Tamasese Meaole Hospital\nPrivate Bag\u00a0- National Health Services\nApia\nSAMOA\nDr. Viali Lameko, President\nTel. (685) 778 5858\nE-mail: viali1_lameko@yahoo.com\nOrdre National des M\u00e9decins du S\u00e9n\u00e9gal\n(ONMS)\nInstitut d\u2019Hygi\u00e8ne Sociale (Polyclinique)\nBP 27115\nDakar\nSENEGAL\nProf. Lamine Sow, President\nTel. (221) 33 822 29 89\nFax: (221) 33 821 11 61\nWebsite: www.ordremedecins.sn\nLekarska Komora Srbije (LKS)\nSerbian Medical Chamber\nKraljice Natalije 1-3\nBelgrade\nSERBIA\nDr.Tatjana Radosavljevic, General Manager\nE-mail: lekarskakomorasrbije@gmail.com\nSingapore Medical Association (SiMA)\nAlumni Medical Centre, Level 2\n2 College Road\nSingapore 169850\nDr. Chong Yeh Woei, President\nTel. (65) 6223 1264\nFax. (65) 6224 7827\nE-mail. sma@sma.org.sg\nWebsite: www.sma.org.sg\nSlovak Medical Association\nCukrova 3\n813 22 Bratislava 1\nSLOVAK REPUBLIC\nProf. Peter Kri\u0161t\u00fafek, President\nTel. (421) 5292 2020\nFax. (421) 5263 5611\nE-mail: secretarysma@ba.telecom.sk\nWebsite: www.sls.sk\nSlovenian Medical Association\nKomenskega 4\n61001 Ljubljana\nSLOVENIA\nProf. Dr. Pavel Poredos, President\nTel. (386-61) 323 469\nFax: (386-61) 301 955\nSomali Medical Association\n7 Corfe Close\nHayes\nMiddlesex UB4 0XE\nUNITED KINGDOM\nDr. Abdirisak Dalmar Chairman\nE-mail: drdalmar@yahoo.co.uk\nThe South African Medical Association\nP.O. Box 74789, Lynnwood Rydge\n0040 Pretoria\nSOUTH AFRICA\nDr. Norman Mabasa, President\nTel: (27-12) 481 2036\nFax: (27-12) 481 2100\nE-mail: EthelM@samedical.org\nWebsite: www.samedical.org\nConsejo de M\u00e9dicos de Espa\u00f1a\nPlaza de las Cortes 11, 4a\nMadrid 28014\nSPAIN\nDr. Juan Jos\u00e9 Rodriguez-Sendin, Presidente\nTel: (34-91) 431 77 80\nFax: (34-91) 431 96 20\nE-mail: internacional@cgcom.es\nWebsite: www.cgcom.es\nSwedish Medical Association\n(Villagatan 5)\nP.O. Box 5610, Villagatan 5\nSE - 114 86 Stockholm\nSWEDEN\nDr. Eva Nilsson B\u00e5genholm, President\nTel: (46-8) 790 35 01\nFax: (46-8) 10 31 44\nE-mail: info@slf.se\nWebsite: www.slf.se\nF\u00e9d\u00e9ration des M\u00e9decins Suisses (FMH)\nElfenstrasse 18\u00a0- C.P. 170\n3000 Berne 15\nSWITZERLAND\nDr. Jacques de Haller, Pr\u00e9sident\nTel. (41-31) 359 11 11\nFax. (41-31) 359 11 12\nE-mail: info@fmh.ch\nWebsite: www.fmh.ch\nTaiwan Medical Association\n9F, No 29, Sec.1\nAn-Ho Road\nTaipei 10688\nTAIWAN\nDr. Ming-Been Lee, President\nTel: (886-2) 2752-7286\nFax: (886-2) 2771-8392\nE-mail: intl@tma.tw\nWebsite: www.tma.tw\nMedical Association of Thailand\n2 Soi Soonvijai\nNew Petchburi Road, Huaykwang Dist.\nBangkok 10310\nTHAILAND\nPol.Lt.Gen.Dr.Jongjate Aojanpong, President\nTel: (66-2) 314 4333\/318-8170\nFax: (66-2) 314 6305\nE-mail: math@loxinfo.co.th\nConseil National de l\u2019Ordre\ndes M\u00e9decins de Tunisie\n16, rue de Touraine\n1002 Tunis\nTUNISIA\nDr.Taoufik Nacef, Pr\u00e9sident\nTel: (216-71) 792 736\/799 041\nFax: (216-71) 788 729\nE-mail: cnom@planet.tn\nTurkish Medical Association\nGMK Bulvari\n\u015eehit Dani\u015f Tunaligil Sok. N\u00b0 2 Kat 4\nMaltepe 06570\nAnkara\nTURKEY\nDr Eris Bilaloglu, President\nTel: (90-312) 231 31 79\nFax: (90-312) 231 19 52\nE-mail: Ttb@ttb.org.tr\nWebsite: www.ttb.org.tr\nUganda Medical Association\nPlot 8, 41-43 circular rd.\nP.O. Box 29874\nKampala\nUGANDA\nDr. M. Mungherera, President\nTel. +256 772 434 652\nFax. (256) 41 345 597\nE-mail. mmungherera@yahoo.co.uk\nUkrainian Medical Association (UkMA)\n7 Eva Totstoho Street\nPO Box 13\nKyiv 01601\nUKRAINE\nDr. Oleg Musii, President\nTel. (380) 50 355 24 25\nFax: (380) 44 501 23 66\nE-mail: sfult@ukr.net\nWebsite: www.sfult.org.ua\nBritish Medical Association\nBMA House,Tavistock Square\nLondon WC1H 9JP\nUNITED KINGDOM\nSir Michael Marmot, President\nTel: (44-207) 387-4499\nFax: (44-207) 383-6400\nWebsite: www.bma.org.uk\nAmerican Medical Association\n515 North State Street\nChicago, Illinois 60654\nUNITED STATES\nCecil B Wilson, President\nTel: (1-312) 464 5291 \/ 464 5040\nFax: (1-312) 464 5973\nE.mail: ellen.waterman@ama-assn.org\nWebsite: www.ama-assn.org\nSindicato M\u00e9dico del Uruguay\nBulevar Artigas 1515\nCP 11200 Montevideo\nURUGUAY\nDr. Jorge Lorenzo, Presidente\nTel: (598-2) 401 47 01\nFax: (598-2) 409 16 03\nE-mail: secretaria@smu.org.uy\nAssociazione Medica del Vaticano\n00120 Citt\u00e0 del Vaticano\nVATICAN STATE\nProf. Renato Buzzonetti, Pr\u00e9sident\nTel: (39-06) 69879300\nFax: (39-06) 69883328\nE-mail: servizi.sanitari@scv.va\nFederacion MedicaVenezolana\nAv. Orinoco con Avenida Perija\nUrbanizacion Las Mercedes\nCaracas 1060 CP\nVENEZUELA\nDr. Douglas Leon Natera, Presidente\nTel: (58) 2129935227\/3527\nFax: (58) 2129932890\/8139\nWebsite: www.federacionmedicavenezolana.org\nVietnam Medical Association (VGAMP)\n68A Ba Trieu-Street\nHoau Kiem District\nHanoi\nVIETNAM\nDr.Tran Huu Thang,\nSecretary General\nTel: (84) 4 943 9323\nFax: (84) 4 943 9323\nZimbabwe Medical Association\nP.O. Box 3671\nHarare\nZIMBABWE\nDr. Billy Rigawa, President\nTel. (263-4) 791553\nFax. (263-4) 791561\nE-mail: zima@zol.co.zw\nwww.zima.org.zw\nwmj 1 2011 5CS.indd 40 21.02.2011 16:28:38\niii\nRegional and NMA newsLATVIA\nLatvian Medical Association together with\nPublic Institute to arouse extra motivation\nin the minds of the population of Latvia to\nchoose healthy foods and make \u201cunhealthy\nones\u201d less available to the public.\nAn extensive study has been performed\nto determine the main educational and\nmotivational directions that should be in-\ntroduced in Latvia. A special computer\nprogram for the diagnosis of the excess\nweight was developed. The program is able\nto determine the knowledge level concern-\ning theoretical excess weight issues for each\nparticular individual, impact of his or her\npractical actions onto weight fluctuations,\nas well as mark the psychological attitude\nof the individual towards the excess weight\nproblem in general.\nThe user of the program provides answers to\n210 questions.In total 31 topics are covered:\nappetite, breakfast, diet and sports, fats, nu-\ntrition, food shopping, sweets, salt, metabo-\nlism, and other.\nParticipants received individual excess\nweight diagnostics free of charge, based\non the answers they provided. Diagnostics\nincluded not only the above mentioned re-\nsults, but also individually tailored practical\nrecommendations about what should be\nimplemented in their daily routine so that\nthey could control their weight successfully.\nMore than 6000 participants applied for\nthe study within two months. Comparing\nthe number of the participants in the study\nwith the number of inhabitants of Latvia,\nthe proportion was as 800 000 people had\nbeen surveyed in the USA.\nThe general level of knowledge about the\nweight reduction issues in Latvia is very\ngood\u00a0\u2013 on average 76% of all answers to the\ntheoretical questions were correct. The situ-\nation was different with the questions about\npractical actions; here the percentage of cor-\nrect answers reached only 40%. In order to\nmake a comparison on what are the most\nsensitive topics from the point of view of\nknowledge and implementation of knowl-\nedge in everyday life, a term \u201cvoice of con-\nscience ratio\u201d was developed. It determines\nwhat proportion of the knowledge people\npossess they actually use in their daily rou-\ntine. People follow only 1\/2 of what they\nknow about excess weight issues. In the\ntopics on shopping, appetite, consuption of\nhealthy food respondents reval that they fol-\nlow hardly 1\/5 of the information they pos-\nsess.\nThe study results prove that knowledge alone\nis not enough to make people live healthier\nlives. To persuade people to change their\nlifestyle, additional activities for motivation\nshould be sought.\nFind full description of the study in English\nat page www.dietillustrated.com\nInitiative from Latvian Medical Association\nKnowledge and Habits\nEFMA in cooperation with the WHO have\nset up a joint workgroup on antimicrobial\nresistance. We would like to bring this im-\nportant issue to your attention and encour-\nage you to act to promote it to the doctors in\nyour country.\nAntimicrobial resistance is continuing to in-\ncrease throughout the world and has become\na serious threat to public health. Approxi-\nmately 400.000 patients in Europe are annu-\nally reported, to suffer from infections which\nare resistant to antibiotics. It is estimated that\nwithin the EU about 25.000 patients each year\ndie from resistant infections. Such data shows\nthat antibiotic resistance remains a public\nhealth problem across the European Region.\nPrudent use of antibiotics can help stop re-\nsistant bacteria from developing and help\nkeep antibiotics effective for the use of\nfuture generations. We encourage you to\nmake efforts at national level to reduce un-\nnecessary antibiotic use.\nFor more information on this topic, we\nsuggest you look at the ECDC website:\nhttp:\/\/www.ecdc.europa.eu\/en\/eaad\/pages\/\nhome.aspx\nThe ECDC has been working on the issue\nof antibiotic resistance and prepared vari-\nous information documents in coordination\nwith Antibiotics Awareness day. In prepa-\nration for World Health Day, on the 7th\nApril, which will be focused on antimicro-\nbial resistance, we suggest that you start to\nact in the following areas:\n\u2022 Increase awareness of the problem of An-\nti-bacterial resistance\n\u2022 Promote publications in your medical\njournals on this issue\n\u2022 Organise press conferences in your region\non World Health Day\n\u2022 Make contact with experts in the area and\nencourage the development of commit-\ntees to work in the areas of surveillance,\npromotion and protocol.\nI would appreciate it if you would please\nkeep us informed of your actions.\nLeah Wapner\nSecretary General\nEFMA-WHO\nAntimicrobial Resistance\nwmj 1 2011 5CS.indd Sec2:iii 21.02.2011 16:28:39\niv\nContents\nInterested in Global Health? Join the World Medical\nAssociation\u00a0\u2013 Become an Associate Member . . . . . . . . . . . . . . 1\nMedical Ethics and Personal vs. Public Conscience:\na Malaysian Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2\nClinicians Driving Change: Supporting Patient Care . . . . . . . 3\nHumbled by Those Who Crossed\nBridge of No Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8\nThe Regulatory Framework in the Healthcare Insurance\nIndustry: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9\nIn the Interest of Beneficiaries and Public . . . . . . . . . . . . . . . . 9\nTobacco-Free World in Twenty Years\u2019Time! . . . . . . . . . . . . . . 18\nClimate Change\u00a0\u2013 a Serious Threat to Human Health . . . . . . 21\nWorld\u2019s MDs Discuss Growing Health Threats Posed by\nEnvironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24\nPhysicians Urge Mexican Government to Restore Order\nin Juarez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24\nWorld Organization of Family Doctors (WONCA) . . . . . . . 25\nEU Workforce for Health\u00a0\u2013 Putting a Human Face\nto EU Policy-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26\nNurses Impact on the Health System Paradigm Shift . . . . . . . 29\nCzech Medical Chamber Request for Support\nof Hospital Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30\nAgreement between the Ministry of Health\nand the Doctor\u2019s Trade Unions . . . . . . . . . . . . . . . . . . . . . . . . . 32\nThe Georgian Health Care System during the Conflict\nin August 2008 and World Crisis . . . . . . . . . . . . . . . . . . . . . . 33\nSkopje Declaration on Patient Safety and Quality\nin Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35\nThe College of Physicians of Senegal . . . . . . . . . . . . . . . . . . . . 35\nNational Medical Council of the Democratic Republic\nof Congo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36\nWMA Directory of Constituent Members . . . . . . . . . . . . . . . 37\nInitiative from Latvian Medical Association . . . . . . . . . . . . . . iii\nAntimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii\nwmj 1 2011 5CS.indd Sec2:iv 21.02.2011 16:28:40\n\n<\/p>\n"},"caption":{"rendered":"

wmj31 UNITED STATES vol. 57 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 1, February 2011 \u2022 Medical Ethics and Personal vs. Public Conscience \u2022 Tobacco-Free World in Twenty Years\u2019Time! \u2022 Czech Medical Chambers\u2019 Experience to Make an Agreement wmj 1 2011 5CS.indd I 21.02.2011 16:27:19 Cover picture from Korea ii […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj31.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3611"}],"collection":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/comments?post=3611"}]}}