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wmj201402<\/a><\/p>\n

COUNTRY
\n\u2022 The 197th
\nCouncil Meeting
\n\u2022 Market Structure in the South African
\nHealth Care System
\nvol. 60
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 2, May 2014
\nCover picture from LATVIA
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:\u201cBon Appetit\u201d, 1996,
\nby Latvian graphic artist Guntars\u00a0Sieti\u0146\u0161
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
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\nDeutscher-\u00c4rzte Verlag GmbH,
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\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
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\nSubscription fee \u20ac 22,80 per annum (incl. 7%
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website
\nwww.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Margaret MUNGHERERA
\nWMA President
\nUganda Medical Association
\nPlot 8, 41-43 circular rd., P.O. Box
\n29874
\nKampala
\nUganda
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O.Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Cecil B. WILSON
\nWMA Immediate Past-President
\nAmerican Medical Association
\n515 North State Street
\n60654 Chicago, Illinois
\nUnited States
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Xavier DEAU
\nWMA President-Elect
\nConseil National de l\u2019Ordre des
\nM\u00e9decins (CNOM)
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFrance
\nDr. Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFinland
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n2\/174 Millers Road\/PO Box 577
\nAltona North, VIC 3025
\nAustralia
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\n01212 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
\n41
\nWMA News
\nDelegates from more than 30 national
\nmedical associations were welcomed by the
\nDeputy Governor of Tokyo, Tatsumi Ando.
\nHe delivered a brief speech on behalf of the
\nGovernor who was not able to attend, say-
\ning that Japan was experiencing an unprec-
\nedented ageing society. From the year 2020
\nthe population of Japan would start to de-
\ncline and in 2025 one in every four residents
\nin Tokyo would be older than 65. With this
\nageing population, the demand and the
\nneed for health care services would grow.As
\na result Japan had been developing a society
\nwhere everyone could have peace of mind
\nin terms of receiving health care services.
\nMoving forward they would like to develop
\nservices where everyone would secure qual-
\nity care at home.
\nDr. Mukesh Haikerwal, Chair of Council,
\nthanked Mr. Ando and then opened the
\nformal Council proceedings. Dr. Otmar
\nKloiber, Secretary General, gave apolo-
\ngies and introduced two new members of
\nCouncil, Dr. Walter Vorhauer from France
\nand Dr.\u00a0Kenji Matsubara from Japan.
\nDr. Margaret Mungherera, President of
\nthe WMA, presented an interim report on
\nher Presidency, giving details of the many
\nmeetings she had attended and thanking
\nthose NMAs that had hosted her visits. She
\nspoke about progress on her Africa medi-
\ncal initiative to support the role of African
\nnational medical associations by strength-
\nening the health systems in their country.
\nShe reminded delegates that only 21 out of
\nthe 54 African NMAs were members of the
\nWMA.
\nDr. Kloiber presented his detailed written
\nreport of the secretariat\u2019s activities over the
\nyear (see box) and highlighted several issues.
\nHe referred to the comments that
\nDr.\u00a0 Mungherera had made in Uganda at
\nthe time when the Ugandan Government
\nwas introducing legislation stigmatising ho-
\nmosexuals and proposing punishment. He
\nsaid it had taken a lot of courage for her to
\nspeak out on television in Uganda against
\nthis legislation.
\nHe said he had attended a recent conference
\nof the International Association of Patients
\nOrganisations and had spoken on the issue
\nof universal access to health care. The con-
\ncept was still very cloudy and not ambitious
\nenough.What the WMA was asking for was
\nmore than universal health care by looking at
\nthe social determinations of health and it was
\ntime to take this further step.
\nWMJ Council Report
\nThe 197th
\nCouncil meeting of the World Medical Association was held at the Hotel Nikko,
\nTokyo, Japan from April 24 to 26
\n42
\nWMA News
\nHe also spoke about continuing medical ed-
\nucation and continual professional develop-
\nment and the growing dissatisfaction with
\nthe current ways of dealing with these issues
\nin rigid frameworks of recertification. The
\nbureaucracy involved was not welcomed
\nby physicians who wanted something more
\ntangible that led to better outcomes in pa-
\ntient treatment if they had to undergo such
\na bureaucracy.
\nHe then alerted the meeting to a problem
\nthat was approaching on the international
\nnon-proprietary names of medicine, what
\nwere called the generic names of medicine.
\nThis was a consequence of the new classes
\nof medicines that were far more compli-
\ncated than conventional medicines. The
\nstructure of how the names were given,
\ntheir classification and how they were be-
\ning reimbursed were all issues that were
\nlikely to become an important topic in the
\nnear future.
\nDr. Haikerwal gave his interim report as
\nChair and spoke about the WMA\u2019s work to
\nincrease the level of awareness of health as
\na core component of a successful and fair
\nsociety. Health was a wise investment and
\nbrought with it human, political and eco-
\nnomic dividends. Physicians were actually
\npart of the solution in health and health
\ncare research and planning implementa-
\ntion. But too often international organisa-
\ntions chose not to work with physicians.The
\nWMA\u2019s aim was to emphasise the role of
\nphysicians as a solution.
\nMedical Ethics Committee
\nThe Medical Ethics Committee met under
\nthe chairmanship of Dr. Heike P\u00e4lve (Fin-
\nland).
\nPerson Centered Medicine
\nDr. Andr\u00e9 Bernard (Canada), Chair of the
\nWorkgroup on Person Centered Medicine,
\nreported on progress in developing a new
\npolicy document. He said there was still a
\nlack of consensus on this subject and the
\nquestion was whether the definition of per-
\nson centered medicine needed to be broad-
\nened. He suggested that further discussion
\nand debate were needed before proceeding.
\nAfter a brief debate it was decided to rec-
\nommend to Council to authorise the Work-
\ngroup to develop a discussion paper as an
\nexplanatory note with the aim of facilitating
\nconsensus among members.
\nDatabases
\nDr. Kloiber highlighted the importance of
\nrevising WMA policy on health databases
\nand biobanks.The part of the revised Decla-
\nration of Helsinki that related to the second-
\nary use of material information from clinical
\nresearch led to the question of how to deal
\nwith data information and material in health
\ndatabases or in biobanks. This had the po-
\ntential to be one of the key WMA policies.
\nDr. Jon Snaedal (Iceland), Chair of the
\nWorkgroup on Health Databases and Bio-
\nbanks, reported on progress in drafting a
\nDeclaration on Ethical Considerations
\nregarding Health Databases. A successful
\nmeeting had been held in Reykjavik and an-
\nother meeting was planned for August. He
\nalso spoke about the possibility of a wider
\ndiscussion.
\nDuring a brief debate it was recommended
\nthat the title of the document should be
\nextended to include biobanks. It was also
\nsuggested that there was a need for urgency
\nin developing policy because of legislation
\npassed by the European Commission and
\nParliament which included a new concept
\nof broad consent instead of individual con-
\nsent.The WMA needed a speedy answer to
\nthis in a new policy document.
\nThe committee recommended to Council
\nthat the proposed Declaration be circulated
\nto NMAs for comment along with a list of
\nkey questions relating to the topic. It was
\nalso suggested that NMAs might want to
\nconsult outside groups.
\nClassification of Policies
\nThe committee recommended rescinding
\nand archiving WMA Statements on Hu-
\nman Organ Donation and Transplantation
\nand on Human Tissue for Transplantation
\nas these were now covered by new State-
\nments.
\nNorihisa Tamura Yoshitake Yokokura Tatsumi Ando Margaret Mungherera
\n43
\nWMA News
\nHuman Rights
\nClarisse Delorme, the WMA\u2019s Advocacy
\nAdvisor, reported on the work undertaken
\nto support the Turkish Medical Association
\nin its opposition to a new law criminalising
\nmedical professionals helping in emergen-
\ncies and in the legal action taken against
\nthe Association regarding the health ser-
\nvices provided by it during the Gezi Park
\nprotests.
\nThe WMA had also been involved in advo-
\ncacy activities in support of the WHO reso-
\nlution \u2018Strengthening of palliative care as a
\ncomponent of integrated treatment within
\nthe continuum of care\u2019. This has been ad-
\nopted by the WHO Executive Board in
\nJanuary this year with a broad consensus
\nand Ms Delorme said she was confident
\nthat this resolution would be adopted by the
\nWorld Health Assembly in May.
\nFinance and Planning
\nCommittee
\nIn the absence of the Chair, Dr. Leonid Ei-
\ndelman,the committee was presided over by
\nDr. Haikerwal.
\nMembership Dues Payments
\nA report was given by the Financial Adviser,
\nMr. Adi H\u00e4llmayr, who said there had been
\nan increase in membership dues.
\nFinancial Statement
\nMr. H\u00e4llmayr provided a detailed explana-
\ntion of the pre-audited Financial Statement
\nfor 2013 and the committee recommended
\nthat it be sent to Council for approval.
\nNew Dues Structure
\nThe Treasurer,Prof.Dr.Frank Montgomery,
\ngave an oral report on the new dues struc-
\nture and said the financial situation of the
\nWMA was well balanced.
\nStrategic Plan
\nDr. Kloiber reported on progress in im-
\nplementing the strategic plan and its four
\nmajor sections\u00a0\u2013 ethics, advocacy and rep-
\nresentation; partnership and collaboration;
\ncommunication and outreach; and opera-
\ntional excellence.
\nBusiness Development
\nProf. Vivienne Nathanson, Chair of the
\nBusiness Development Group, sum-
\nmarised progress on the round table ini-
\ntiative. The first meeting had taken place
\nlast September and the second meeting
\nwas imminent. She said that future meet-
\nings should take place in North America
\nor Europe, possibly parallel to the World
\nHealth Assembly.
\nFuture WMA Meetings
\nThe committee considered planning for fu-
\nture Assemblies and recommended that As-
\nsemblies should be held in Taipei, Taiwan
\nin 2016, in Chicago, USA in 2017 and in
\nReykjavik, Iceland in 2018.
\nDeclaration of Helsinki
\nIt was decided that this year\u2019s 50th
\nanniversary
\nof the Declaration of Helsinki should be cel-
\nebrated with a special ceremony in Helsinki
\non November 11 2014.It was agreed that this
\nshould be recommended to the Council. A
\ncelebratory book had been published, mark-
\ning the 50th
\nanniversary,and it was agreed that
\nthis should be used by the WMA as a gift.
\nMembership
\nThe committee considered an application
\nfor membership from the Ordre National
\ndes Medicins de Guin\u00e9e and recommended
\nto Council that it be forwarded to the As-
\nsembly for approval.
\nAssociates report
\nReports were received from the Associate
\nMembers, the Juniors Doctors Network (add)
\nand the Past Presidents and Chairs of Council.
\nThe total number of Associate Members whose
\nannual subscriptions have been paid was 818.
\nCecil B. Wilson Xavier Deau Mukesh Haikerwal Masami Ishii
\n44
\nWMA News
\nOutreach
\nReports were received from the editor of the
\nWorld Medical Journal and from the Public
\nRelations Consultant.
\nPresidential Elections
\nFollowing the decision at the General As-
\nsembly in Brazil to lift the suspension of the
\ninauguration as President of Dr. Ketan De-
\nsai (India), a debate took place on the tim-
\ning of his Presidency. The suspension was
\nimposed in October 2010 when Dr. Desai
\nwas unable to attend for his inauguration
\nfollowing charges filed against him in India.
\nDr. Haikerwal said the Indian Medical As-
\nsociation had requested that Dr. Desai be
\nreinstalled as President following the with-
\ndrawal of charges.
\nAfter a debate it was decided that the com-
\nmittee should recommend to Council that:
\n\u2022 nominations for President in 2015 be
\ncalled for at the 2014 Assembly;
\n\u2022 there be no election at the 2015 Assembly
\nfor President in 2016;
\n\u2022 Dr. Desai be inaugurated as President in
\nOctober 2016 as long as he remains in
\ngood standing pursuant to WMA byelaws.
\nSocio-Medical Affairs Committee
\nSir Michael Marmot (British Medical As-
\nsociation) took the chair.
\nHealth and the Environment
\nDr. Shin (Korean Medical Association) re-
\nported on the environment caucus that had
\ntaken place that day, when the outcome
\nof the 2013 Global Climate and Health
\nSummit had been discussed as well as the
\nreport of the Intergovernmental Panel on
\nClimate Change. Dr. Shin said they had
\ndiscussed the importance of ministers of
\nhealth in every country being involved in
\nthese issues, as well as the WHO\u2019s role. It
\nwas agreed that the WMA should con-
\ntinue working on the impact of climate
\nchange on health.
\nHealth Care in Danger
\nProf. Nathanson, Chair of the Workgroup,
\nreported on the activities of the group, in-
\ncluding the development of a toolkit for
\nhealth professionals addressing potential
\ndifficulties faced by health professionals
\nworking in situations of conflict.The toolkit
\naimed to provide a framework of practical
\nresponses to the ethical conflicts physicians
\nmight come across.
\nChemical Weapons
\nIt was reported that the Workgroup had
\nnot yet met, but Prof. Nathanson offered
\nto draft a document on behalf of the
\ngroup to present to the meeting in Dur-
\nban.
\nViolence Against Women
\nThe committee heard that a WMA side
\nevent on this issue would take place during
\nthe World Health Assembly in Geneva on
\nMay 20. Several delegates reported on work
\ntheir NMAs were undertaking in this area,
\nparticularly relating to the linked issue of
\nchild abuse.
\nRecruitment of Physicians
\nThe committee considered a proposed
\nrevision of the 2003 Statement on Ethi-
\ncal Guidelines for Recruitment of Physi-
\ncians and a shorter amended version by
\nthe American Medical Association. Some
\ndelegates wanted to see the AMA draft
\nrecirculated among NMAs for comment.
\nBut Dr.\u00a0Haikerwal said this was an issue
\nof concern in every country he had visited
\nand was a matter of some urgency. After
\na brief debate it was decided to postpone
\nfurther discussion until the meeting of
\nCouncil.
\nNon-Commercialisation of
\nHuman Reproductive Material
\nThe committee considered a revised version
\nof the Resolution on Non-Commerciali-
\nsation of Human Reproductive Material
\nwritten by the Israel Medical Association.
\nThe draft had received many comments.The
\nchairman proposed that in the absence of
\nGuy Dumont Frank Ulrich Montgomery Jon Snaedal Sir Michael Marmot
\n45
\nWMA News
\nany delegates from Israel, the paper should
\nbe reconsidered by the Israel Medical As-
\nsociation in the light of the comments made
\nfor further debate at the meeting in Dur-
\nban.This was agreed.
\nReality TV
\nDr. Haikerwal reported that the Israel
\nMedical Association had agreed to with-
\ndraw a draft document it had submitted on
\nthe role of physicians in reality TV.
\nTrafficking
\nA proposed Resolution from the Spanish
\nMedical Association on the Role of Phy-
\nsicians in Preventing the Trafficking with
\nMinors and Illegal Adoptions was consid-
\nered.
\nThe meeting heard a report about the ac-
\ntivities being undertaken at the University
\nof Granada in Spain on this problem, help-
\ning countries to develop DNA databases
\nabout missing children and their relatives.
\nThis had led to more than 800 children be-
\ning identified and returned to their fami-
\nlies.
\nDuring the debate that followed, delegates
\nagreed that this was an important matter,
\nalthough it was tied up with the wider is-
\nsue of trafficking. It was decided that the
\nWMA was not in a position to involve
\nitself in this sort of work. However it was
\nagreed to recommend to Council that a
\nWorkgroup be set up to undertake further
\nconsideration of this matter and to submit
\na revised text for consideration at the next
\nmeeting in Durban.
\nAesthetic Treatment
\nThe Swedish Medical Association updat-
\ned the committee on its proposed State-
\nment on Aesthetic Treatments which
\nhad arisen from two documents, one on
\naesthetic treatment for minors drafted
\nby the Israel Medical Association and a
\nbroader document from the Sweden. A
\ncombined document had been circulated
\nto NMAs for comment. Delegates were
\nreminded that the reasoning behind these
\ndocuments was the absence of regulations
\ngoverning aesthetic treatment, partly be-
\ncause of the question about whether it
\nwas really health care.There were circum-
\nstances in which aesthetic treatment was
\nmore cosmetic than medical. It was in
\nan effort to protect people that the draft
\nStatement had been produced. The docu-
\nment as written was addressed primar-
\nily to physicians although it was hoped
\nit would encourage other practitioners
\nperforming aesthetic treatment to adopt
\nthese principles.
\nDuring the debate that followed there was
\ndiscussion about whether the document
\nshould be directed to physicians only and
\nwhether the title should be changed to
\nStatement on \u2018Aesthetic Medical Treat-
\nments\u2019. On a vote it was decided not to
\nchange the title. The discussion about
\nwhether the document should refer to
\n\u2018practitioners\u2019 or to \u2018physicians\u2019 illustrated
\nsharp differences of opinion. As a result it
\nwas decided to recommend to Council that
\nthe document, as retitled, be recirculated to
\nNMAs for comment after being revised by
\nthe Swedish Medical Association.
\nPhysicians Wellbeing
\nThe committee considered the proposed
\nStatement on Physician Wellbeing drawn
\nup by the Junior Doctors Network. Del-
\negates congratulated the JDN on its work,
\nand several NMAs said this was an area
\non which they had also been working. The
\ngeneral view was that doctors were not
\ngood at looking after their own health,
\nwith some refusing to seek help because
\nof privacy and confidentiality. It was sug-
\ngested that more attention should be
\npaid to the issue of the mental health of
\nphysicians and substance-abusing physi-
\ncians. After several speakers referred to
\nthe need for the document to be expanded
\nand strengthened, it was decided to set
\nup a Workgroup to submit a more com-
\nprehensive policy for consideration at the
\nnext meeting. It was agreed to recommend
\nto the Council that membership of the
\nWorkgroup should be representative of
\nthe various regions of the world.
\nVivienne Nathanson Dong Chun Shin Adi H\u00e4llmayr Heikki P\u00e4lve
\n46
\nWMA News
\nSocial Determinants
\nPlans were discussed for holding a confer-
\nence on the role of physicians and NMAs in
\naddressing the social determinants of health
\nand health equity. The proposal was for a
\ntwo-day conference to be held in London in
\nMarch 2015, jointly organised by the Brit-
\nish and Canadian Medical Associations and
\nthe Institute for Health Equity. The aims
\nof the meeting would be to look at what
\nNMAs could do in their own countries with
\ntheir governments, to look at clinical-level
\npractice and to create an international net-
\nwork of physicians and medical associations
\nworking on this issue.
\nThe committee agreed to recommend to
\nCouncil that arrangements should go ahead
\nfor the conference in London.
\nIt was also reported that the subject of the
\nsocial determinants of health was on the
\nagenda for an African conference under
\nWMA auspices also due to be held next
\nMarch. It was hoped that the 54 countries
\nof the African continent would come to-
\ngether at this conference.
\nAir Pollution
\nA proposed Statement on the Prevention of
\nAir Pollution and Vehicle Emissions was in-
\ntroduced by the Austrian Medical Chamber.
\nIt was argued that the WMA should have
\na policy on what was a global problem. The
\nStatement referred to the negative health
\neffects of air pollution and called for a re-
\nduction in vehicle particulate matter emis-
\nsions through the implementation of Euro
\nemission standards, and recommended the
\ninstallation of soot filters for all new vehicles
\nand the retrofitting of existing ones. It also
\ncalled on NMAs to raise awareness of these
\nnegative health effects, and to advocate via
\ntheir national governments for the introduc-
\ntion of compulsory emission standards as a
\nmeasure to promote clean air and a healthier
\nenvironment. The draft Statement said that
\nair pollution reduced life quality for hun-
\ndreds of millions of people worldwide, caus-
\ning a large burden of disease, as well as eco-
\nnomic loss and costs in the health systems.
\nThis prompted a debate in which the Japan
\nMedical Association reported on the mea-
\nsures taken in their country against air pol-
\nlution. Japan used to have a major pollution
\nproblem, but now had the world\u2019s leading
\nmeasures against air pollution. They had
\nlearned a lot in the process. They had ex-
\nperienced lots of long term litigation which
\nhad been settled and had introduced various
\nstandards from the US and Europe. As a re-
\nsult the country now had the most stringent
\nstandards for air pollution.
\nSpeakers said that this was a crucial issue
\nwhich needed further consideration and
\nafter further debate the committee rec-
\nommended to Council that the proposed
\nStatement be circulated among NMAs for
\ncomment.
\nSolitary Confinement
\nA proposed Statement on Solitary Confine-
\nment was presented by the Finnish Medical
\nAssociation. The paper sets out guidelines
\nabout the physician\u2019s role in solitary con-
\nfinement,which,it says,should only be used
\nas a last resort, and never as a prolonged
\npunishment. A brief debate took place on
\nthe inhumane treatment experienced by
\nprisoners who suffer solitary confinement,
\nparticular those suffering from mental ill-
\nness.The problems of how to deal with par-
\nticularly violent prisoners or prisoners who
\nneeded protection from themselves were
\nalso raised.
\nIt was agreed to recommend to Council
\nthat the document be circulated to NMAs
\nfor comment.
\nProtection of Health Care Workers
\nThe German Medical Association proposed
\nthat the WMA should draw up a stronger
\npolicy on the issue of protecting health care
\nworkers, particularly in the light of recent
\nevents in Syria, Turkey and Ukraine, where
\nmedical personnel and facilities had been
\ndeliberately targeted by the police and se-
\ncurity forces. Physicians had been exposed
\nto intimidation and prevented from car-
\nrying out their ethical duties. A proposed
\nDeclaration on the Protection of Health-
\ncare Workers in Situations of Violence was
\nput forward, focusing on the obligations of
\nJulia Seyer Clarisse Delorme Greg Koski Andr\u00e9 Bernard
\n47
\nWMA News
\nphysicians rather than governments. It was
\nagreed to recommend that the document be
\ncirculated for comment.
\nStreet Children
\nThe Conseil National de l\u2019Ordre des M\u00e9-
\ndecins introduced a proposed Statement on
\nProtecting Health Support to Street Chil-
\ndren. The committee was told that the doc-
\nument\u2019s aim was to raise awareness of the
\nscale of the problem. These children were
\nthe victims of urbanisation and economic
\ndeprivation. They were excluded from soci-
\nety, from education, health care and family
\ncare. The first link should be the doctor-
\nchild relationship.
\nDuring a brief debate it was suggested that
\nthe WMA should seek to find out why
\nstreet children existed and to protest about
\ntheir existence. It was argued that there
\nshould be a way of finding homes for all
\npeople and particular children. It was also
\nsuggested that the issue of protecting these
\nchildren from unethical research should be
\nconsidered. The committee agreed to rec-
\nommend that the document should be cir-
\nculated to NMAs for comment.
\nClassification of Policies
\nThe committee agreed to recommend that
\nthe WMA Statement on Health Emergen-
\ncies Communication and Coordination be
\nrescinded and archived, that the Statement
\non Water and Health be reaffirmed with
\nminor revision and that the Resolution on
\nWorld Federation for Medical Education
\nGlobal Standards for Quality Improvement
\nof Medical Education be reaffirmed.
\nDr. Kloiber explained that the standards
\nhad recently been updated by the WFME.
\nThey had been well accepted all over the
\nworld. Now there was a revision of the
\nWFME standards for post graduate medi-
\ncal education and CPD and he suggested
\nthat a small Workgroup be set up to con-
\nsider the documents and make recommen-
\ndations. The committee agreed to recom-
\nmend this.
\nAdvocacy
\nThe committee received an oral report
\nfrom the new Chair of the Advocacy Advi-
\nsory Group, Dr. Andr\u00e9 Bernard. He spoke
\nabout plans for the publication of the book
\ncommemorating the 50th
\nanniversary of
\nthe Declaration of Helsinki and how vari-
\nous stakeholders might use it. He referred
\nto the advocacy training session being
\nplanned for the scientific session at the
\nGeneral Assembly in Durban in October
\naround the question \u2018Can physicians be ac-
\ntivists for change with respect to universal
\naccess to health care?\u2019 and it was agreed to
\nbroaden this question to include social de-
\nterminants of health. Dr. Bernard stressed
\nthe importance of advocacy and communi-
\ncations being integrated into the WMA\u2019s
\nwork.
\nMillennium Development Goals
\nSir Michael Marmot referred to the enor-
\nmous activity going on about MDGs post-
\n2015. He said the problem for the WMA
\nwas finding the right forum to influence
\nthis important debate and how to broaden
\nthe goal of universal health coverage to in-
\nclude social determinants of health. He said
\nthe way forward should be for the WMA
\nto make a strong statement at the Assembly
\nin Durban.
\nAlliance for Clinical Research
\nExcellence and Safety
\nThe meeting heard a presentation by Dr.
\nGreg Koski, President and Co-founder of
\nthe Alliance, with the request for greater
\ncollaboration between the WMA and
\nACRES. (see page\u2026.?)
\nAfrican Medical Initiative
\nThe President, Dr. Mungherera, brought
\nthe meeting up to date with her initiative
\nto involve African NMAs more in the ac-
\ntivities of the WMA.She said globally there
\nhad been progress in making people health-
\nier. But there had been hardly any progress
\nin Africa.This was the continent with some
\nof the lowest health indices in the world.
\nWhile Africa had 11 per cent of the world\u2019s
\npopulation it had a much higher level of
\nthe disease burden. Forty-nine per cent of
\nthe women who died in the world from
\nchildbirth related problems were in Africa
\nand 50 per cent under five-year-olds who
\ndied were in Africa. Sixty-seven per cent of
\nHIV\/AIDs cases were in Africa. She said
\nher Presidential initiative was based on the
\nfact that only about 20 of the 54 national
\nmedical associations in Africa were mem-
\nbers of the WMA and only about five were
\nactively participating in WMA discussions.
\nAfrica\u2019s poor health indices were largely be-
\ncause of weak health systems and poor uni-
\nversal health coverage and access.She want-
\ned to see not only more African NMAs join
\nthe WMA, but also increased participation
\nby those NMAs that were members. It was
\nalso important that African NMAs influ-
\nenced their governments\u2019health policies.To
\nachieve this it was necessary to strengthen
\nthe capacity of African NMAs in medical
\neducation, continuing professional develop-
\nment and national health policies.Nigel Duncan
\n48
\nWMA News
\nCouncil
\nUnder the chairmanship of Dr. Haikerwal,
\nthe Council met to approve reports from
\nthe three committees.
\nThe reports of the Medical Ethics Commit-
\ntee and the Finance and Planning Commit-
\ntees were agreed with little debate.
\nDiscussion took place on several items from
\nthe Socio-Medical Affairs Committee.
\nEthical Guidelines for the Interna-
\ntional Recruitment of Physicians
\nFurther debate took place on the document
\nproduced at the committee by the American
\nMedical Association. This set out a series of
\nrecommendations which should govern the
\nrecruitment of physicians,including a propos-
\nal that countries wishing to recruit physicians
\nfrom another country should only do so in ac-
\ncordance with the provisions of a Memoran-
\ndum of Understanding entered into between
\nthe countries. An amendment was agreed
\nunder which countries recruiting physicians
\nshould ensure that recruiters provided full and
\naccurate information to potential recruits on
\nthe requirements of the position to be filled,
\non immigration, administrative and contrac-
\ntual requirements, and on the legal and regu-
\nlatory conditions for the practice of medicine
\nin the recruiting country, including language
\nskills. The Council agreed the Statement as
\nrevised and this will now be considered by the
\nAssembly in October for adoption.
\nPhysician Wellbeing
\nIt was agreed that a Workgroup should
\nbe set up under the chairmanship of the
\nAmerican Medical Association.
\nAlliance for Clinical Research
\nExcellence and Safety
\nFollowing the presentation by Dr. Koski,
\nPresident of the Alliance, the Council
\nagreed that the idea of the WMA becoming
\ninvolved in the activities of ACRES should
\nbe explored by the Executive Committee.
\nImmunization
\nDuring what was World Immunization
\nWeek, Dr. Julia Seyer, WMA Medical Ad-
\nvisor, gave a presentation on the WMA
\nCampaign for Physician Immunization to
\nPrevent Influenza Outbreaks. She spoke
\nabout the facts of influenza and immuniza-
\ntion and the role of physicians. Phase one
\nof the campaign had started last year and
\nphase two from 2014-2016 had just begun.
\nThe WHO had estimated that the preva-
\nlence of influenza was five to 10 per cent
\nof adults and 20 to 30 per cent of children
\nper year. Influenza was responsible for three
\nto five million cases of severe illness and
\ncaused 250,000 to 500,000 deaths annually.
\nUS data showed influenza had been associ-
\nated with about 230,000 hospitalisations.
\nThe priority risk groups were the elderly,
\npeople with underlying health conditions,
\nchildren between six and 24 months old,
\npregnant women and healthcare workers.
\nFifty per cent of those with chronic disease
\nfailed to get immunised, 30 per cent of the
\nelderly and ten per cent of health profes-
\nsionals. Yet influenza was one of the lead-
\ning causes of catastrophic disability such as
\nstrokes, chronic heart failure, pneumonia,
\nischemic heart disease, cancer and hip frac-
\ntures. And once people became ill they were
\noften unable to live at home or on their
\nown. This was not only a personal burden,
\nbut a burden on society. The European rate
\nof immunization varied a lot, between 1.7
\nper cent up to 64 per cent. If the immunisa-
\ntion rate could be increased to 75 per cent,
\n3.2 million cases could be avoided.The ben-
\nefits of immunisation included fewer GP
\nvisits and hospital visits, as well as lives and
\ncosts saved.
\nThe reasons people did not get vaccinated
\nincluded the low perception of risk, includ-
\ning the risk of infecting others, the fear of
\npossible side effects, questions about its ef-
\nfectiveness and the issue of cost, availabil-
\nity and convenience. Immunization advice
\nfrom healthcare professions was the most
\nimportant driver for patients\u2018 vaccine ac-
\nceptance. The aims of the WMA campaign
\nwere to increase physicians\u2018 awareness of the
\nimportantace of immunization, to encour-
\nage physicians themselves to get vaccinated
\nand to enhance physicians\u2018 communication
\nskills to promote health and prevent disease.
\n49
\nWMA News
\nPrime Minister
\nAt the conclusion of the Council\u2019s delib-
\nerations, the meeting was addressed by the
\nPrime Minister of Japan, Mr. Shinzo Abe.
\n(see box) WMA Chairperson of Council
\nDr. Mukesh Haikerwal then brought the
\nproceedings to a close, thanking the Japan
\nMedical Association for their hospitality
\nduring the meeting.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nIt gives me great pleasure to see the 2014 WMA Council Session
\nbeing held today in Tokyo with the participation of 40 medical
\nassociations from around the world.I also
\nwould like to express my appreciation to
\nPresident Yokokura for all his efforts as
\na representative of the host country, and
\nto everyone else in the Japan Medical
\nAssociation. All people share a common
\ndesire of building a society in which we
\ncan live long and healthy lives.Regardless
\nof the era, the trust we place in medicine
\nto support our health, and in the medical
\nprofessionals who bear this responsibil-
\nity, remains the same. Over the long, 67
\nyear history since its founding,the WMA
\nhas worked to improve global health
\nstandards and establish medical ethics. I
\nwould like to once again express my re-
\nspect for all your activities to date.
\nI have heard that the theme for the
\nWMA this year is \u2018universal access to healthcare.\u2019 Japan is now
\nthe country with the longest lifespans. And it is precisely univer-
\nsal access to healthcare that is the principle behind Japan\u2019s health-
\ncare policy. Anyone in possession of a health insurance card can
\nreceive medical treatment at any medical institution. Universal
\nhealth insurance and the freedom to choose where you receive
\nmedical treatment are precious assets which the public, includ-
\ning those involved in healthcare in Japan, have been safeguarding
\nfor over half a century. We must fully hand these assets down to
\nfuture generations.In addition,in the midst of the rapid advance-
\nment of the declining birth rate and ageing population, an im-
\nportant issue is the creation of an environment that allows people
\nto continue to live in the communities they are accustomed to for
\nthe rest of their lives,even if they need medical treatment or nurs-
\ning care. To that end, we must enhance home care and nursing
\ncare. The doctors in charge of primary care in each region play a
\nkey role in bringing together medical treatment and nursing care.
\nThe role of medical associations in fostering such doctors is also
\nimportant. Japan will present the world with a model for a society
\nin which anyone can live to their old age with peace of mind.
\nPersonally, I have long struggled with the
\nincurable disease of ulcerative colitis. The
\nworsening of my condition forced me to
\nsuddenly resign from my post as Prime
\nMinister seven years ago. I\u00a0am now serv-
\ning as Prime Minister for a second time,
\nwhich is quite unusual for Japan. That
\nI\u00a0am now able to carry out my job in good
\nhealth is thanks to the blessing of ad-
\nvanced medical treatment, including new
\npharmaceuticals. I believe that no other
\nPrime Minister recognizes the importance
\nof medical treatment and pharmaceutical
\nproducts as much as I do.Progress in med-
\nical technology does not just improve the
\nquality of life for patients,it is also a driver
\nof economic growth that generates wealth
\nand employment. In addition to leading
\nthe world in the promotion of the practical application of advanced
\nmedical treatment such as regenerative medicine, I would like to
\nshare the results of such efforts with the people around the world
\nstruggling with difficult diseases. Furthermore, it is also important
\nthat we use the experience and knowledge that we have cultivated
\nin Japan over the years and make an international contribution in
\nthe medical field.I would like to not only supply medical technolo-
\ngy,pharmaceutical products,and medical devices,but also to export
\npackages built around the establishment of whole systems, includ-
\ning the universal healthcare system that Japan is so proud of.In the
\npast six months, we have already constructed cooperative relation-
\nships with the healthcare sectors of 14 countries. We will continue
\nto promote efforts to make such an international contribution.
\nLastly, I would like to conclude my remarks as Prime Minister
\nby wishing for the further expansion of the activities of every-
\none gathered here today and for the further development of the
\nWMA.Thank you for listening.
\nShinzo Abe
\nThe adress of the Prime Minister of Japan Mr. Shinzo Abe
\nin the WMA Council Session
\n50
\nWMA News
\n1. Ethics
\n1.1 Declaration of Helsinki
\nThe Declaration of Helsinki is one of the
\nmost important international ethical regula-
\ntions of biomedical research, and also one of
\nthe core documents of the WMA.It has been
\nrevised several times since its adoption in
\nHelsinki in 1964. As a \u201cliving document\u201d, it
\nis continuously adapted to new developments
\nand challenges in biomedical research.The 7th
\nrevision was adopted by the WMA General
\nAssembly in Fortaleza in October 2013.
\nIn a special agreement with the Journal
\nof the American Medical Association
\n(JAMA), the revised Declaration of Hel-
\nsinki was published online on the same day
\nit was adopted by the WMA General As-
\nsembly, and then later in print.
\nThe revised Declaration attracted consid-
\nerable attention around the world and was
\napparently positively received. WMA Offi-
\ncers and the Secretariat have been invited
\nto comment on the new version and the
\nprocess of revision on several occasions. We
\nare currently preparing a celebratory event,
\nhopefully with the President of Finland, to
\ncommemorate the 50th
\nanniversary of the
\nDeclaration.
\n1.2 Databases and Biobanks
\nIn March 2014, the Icelandic Medical
\nAssociation organized a seminar in Reyk-
\njavik, Iceland together with the WMA
\nworkgroup on the proposed revision of the
\nWMA Declaration on Ethical Consider-
\nation Regarding Health Databases on the
\nethical problems connected with health
\ndatabases and biobanks. The meeting fo-
\ncused on the potentials of such reposi-
\ntories, but also on the regulation of their
\nuse with special emphasis on the informed
\nconsent necessary for research. The results
\nof the discussion have been incorporated
\nby the workgroup in a revised draft, which
\nwill now be brought to the attention of the
\nCouncil.
\n2. Human rights
\n2.1 Right to health
\nThe WMA secretariat continues to monitor
\nthe activities of the UN Special Rapporteur
\non the Right to Health, as well as health re-
\nlated matters addressed by the UN Human
\nRights Council. In October 2013, the Spe-
\ncial Rapporteur, Anand Grover, presented
\nto the UN General Assembly a report dedi-
\ncated to the\u00a0right to health obligations of
\nStates and non-State actors towards persons
\naffected by and\/or involved in conflict situ-
\nations. The report describes a wide range of
\nabuses occurring against health workers and
\nhighlights the need for better monitoring
\nand accountability. The special rapporteur\u2019s
\nreport is the first UN human rights analysis
\nto describe the responsibilities of countries
\nto provide and protect health workers and
\nservices in conflict. The WMA Secretariat
\nsent a letter to Mr. Grover welcoming the
\nreport.
\nIn early December, the Special Rapporteur
\nand the WMA issued a joint press release
\nwarning against criminalizing independent
\nmedical care in the context of the draft
\nhealth bill in Turkey.
\n[See also item 2.2.1 on the situation in Turkey
\nand 2.2.2 on Healthcare in Danger]
\n2.2 Protecting patients and doctors
\n2.2.1 Actions of support (see table 1)
\n2.2.2 Protection of health professionals
\nin areas of armed conflict and other
\nsituations of violence
\nThe WHO\u2019s role in humanitarian emer-
\ngencies
\nIn January 2014, on the occasion of the
\nWHO Executive Board meeting, the
\nWMA took the lead in drafting a public
\nstatement on the implementation of the
\nresolution \u201cWHO\u2019s response, and role as
\nthe health cluster lead, in meeting the
\ngrowing demands of health in humani-
\ntarian emergencies\u201d. The statement rec-
\nommends, within the framework of the
\nresolution\u2019s implementation, that Member
\nStates adopt as a matter of priority solid
\nmeasures to ensure that health care per-
\nsonnel, facilities and transports exclusively
\nassigned to caring for the sick and injured
\nare fully respected and protected in all
\ncircumstances, in accordance with ethics
\nSecretary General Report to the 197th
\nWMA Council Session
\n(October 2013\u00a0\u2013 March 2014)
\nOtmar Kloiber
\n51
\nWMA News
\nTable 1
\nCountry Case
\nTURKEY
\n01\/2014-03\/2014
\nSources:
\nTMA
\nAmnesty International
\nHuman Rights Foundation
\nof\u00a0Turkey
\nLast January, the WMA, together with Physicians for Human Rights, the British Medical
\nAssociation (BMA), the German Medical Association (GMA) and the Standing Committee
\nof European Doctors (CPME), sent a joint letter to the Turkish President, Mr. Abdullah G\u00fcl,
\nexpressing their grave concerns about the health bill passed by the Turkish parliament on 2nd
\nJanuary that criminalizes emergency medical care. The signatories called upon the President to
\nrefuse to sign the bill into law.
\n[See also under 2.1 above the joint press release with the UN Special Rapporteur on Health]
\nIn March, the same organizations wrote a letter to Prime Minister Erdogan regarding the punitive
\nactions taken by the Ministry of Health against physicians who acted ethically in providing
\nemergency medical care to demonstrators injured during the Gezi Park protests that began in May
\n2013.The authors of the letter asked Mr. Erdogan to take immediate action to drop the current
\nlegal actions against members of the Turkish Medical Association.The letter was published in the
\nBritish Medical Journal and a press release was issued.
\nIRAQ
\nSources:
\nIndividual call for support
\nAmnesty International
\nUN Working Group on Arbitrary
\nDetention
\nOur attention was drawn to the situation of Iranian exiles in Camp Liberty in Iraq. According
\nto various sources, serious restrictions are imposed on the residents\u2019 access to medical services.
\nAllegations of psychological and physical torture of the residents were made as well.
\nC. Delorme met with two representatives of Camp Liberty in February 2014.The Secretariat is
\ncurrently checking information with its partners before considering how best to take up the matter
\nwith the Iraqi authorities.
\nRUSSIA
\n11\/2013
\nSource:
\nIndividual call for support
\nAmnesty International
\nLast November, our attention was drawn to the case of Dr. Marat Gunashev\u00a0from Russia\u2019s North
\nCaucasus region of Dagestan. He was arrested and charged with complicity to murder the police
\nchief of the Dagestan capital in 2010. \u00a0He has been in prison ever since and \u2013 according to sources \u2013
\nwithout evidence of the charges against him, has been exposed to ill-treatment and subject to a lack
\nof respect for the standards of fair trial.
\nThe Secretariat contacted the Russian Medical Association, alerting them to the case and asking
\nwhether any action had already been taken by the medical association in support of Dr.\u00a0Gunashev.
\nThe Secretariat also suggested writing a letter to the Russian authorities enquiring about the
\nconditions of detention of Dr. Gunashev and asking for international fair trial standards to be fully
\nrespected.
\nThere has been no response so far.
\nBAHRAIN
\n11\/2013
\nSource:
\nAmnesty International
\nOn 15th
\nNovember, the WMA sent a letter to the King of Bahrain expressing serious concerns
\nabout the two remaining health professionals, Dr. \u2018Ali \u2019Issa Mansoor al-\u2019Ekri and Ebrahim \u2018Abdullah
\nEbrahim al-Dumestani, still in detention (out of the 20 professionals placed in detention during the
\nMarch-April 2011 events).
\nIn the letter, the WMA requested their immediate and unconditional release as it is believed that
\nthey have been imprisoned solely for peacefully exercising their rights to freedom of expression
\nand assembly and are, as such, prisoners of conscience. It also recommended that the Bahraini
\nauthorities investigate the prisoners\u2019 allegations of torture.
\nEGYPT
\n09\/2013
\nSources:
\nCMA
\nAmnesty International
\nA letter was sent to the Egyptian authorities regarding the case of Canadian physician Tarek
\nLoubani and filmmaker John Greyson who were arrested during violence in Cairo on 16th
\nAugust.
\nThe letter expressed the WMA\u2019s concerns that the Canadian detainees have been accused of a broad
\narray of offences without apparent consideration of their individual criminal responsibility.The letter
\ntherefore urged the Egyptian authorities to release them immediately, unless they had sufficient
\nadmissible evidence to try them before a civilian court in line with international fair trial standards.
\nThey were released early October.
\n52
\nWMA News
\nprinciples and the rules of humanitarian
\nlaw.
\nThe statement was made on behalf of the
\nWMA,the International Council of Nurses,
\nthe International Pharmaceutical Federa-
\ntion, the World Confederation for Physical
\nTherapy and the World Dental Federation,
\nas well as the International Hospital Fed-
\neration, the International Confederation of
\nMidwives, the International Federation of
\nMedical Students Associations and the In-
\nternational Pharmaceutical Students\u2019 Fed-
\neration.
\n[See also items 2.1 and 2.2 on the situation in
\nTurkey]
\nICRC \u201cHealth Care in Danger\u201d (HCiD)
\nproject
\nThe WMA Secretariat has developed a close
\nworking relationship with the International
\nCommittee of the Red Cross (ICRC) head-
\nquarters over recent months in the context
\nof the HCiD project.
\nAs part of the Health Care in Danger
\nproject, the ICRC organizes expert con-
\nsultations with policymakers, academics,
\ndoctors, weapon bearers and civil society
\nin order to develop practical recommen-
\ndations to improve safe access to health
\ncare. Two expert consultations took place
\nduring the reporting period with the in-
\nvolvement of WMA. On 3rd
\nDecember,
\nthe ICRC, together with the Conflict and
\nCatastrophes Forum of the Royal Society
\nof Medicine and the British Red Cross,
\nhosted an expert conference in London,
\n\u201cHealth Care in Danger: From consulta-
\ntion to implementation\u201d. WMA President,
\nDr. Margaret Mungherera, made an inter-
\nvention on the importance of health care in
\nwar and violent situations.
\nAt a workshop on \u201cDomestic regulatory
\nframeworks for safeguarding health care\u201d,
\nheld in Brussels from 29th
\n\u201331st
\nJanuary,
\nWMA President-Elect, Dr. Xavier Deau,
\nmade an intervention on the principles of
\nmedical ethics and confidentiality. Further-
\nmore, on 6th
\n\u20137th
\nFebruary, the ICRC orga-
\nnized an expert meeting \u2018Healthcare Ethics
\nin Danger\u201d in Geneva, which was attended
\nby Prof. Vivienne Nathanson (BMA) and
\nDr. Jeff Blackmer (CMA).
\nIn the context of this project, the ICRC
\nalso organizes regular meetings with
\nhealth professionals\u2019 organizations, i.e.
\nthe WMA, the International Council of
\nNurses (ICN) and the International Hos-
\npitals Federation (IHF). The purpose of
\nthese meetings is to provide an update on
\nthe project advancement, exchange infor-
\nmation on recent policy developments in
\nrelation to the issue, and explore ways of
\nworking together. The last meeting was in
\nDecember.
\nThe WMA Secretariat aims to facilitate
\ndirect contacts between the ICRC and
\nmedical associations at the national\/re-
\ngional level, and to encourage initiatives
\nby national medical associations, where ap-
\nplicable, to promote the goals of the HCiD
\nproject. In this respect, Dr. Bruce Eshaya-
\nChauvin, coordinator of the project, at-
\ntended the WMA General Assembly in
\nFortaleza last October, where he had the
\nopportunity to meet with various medi-
\ncal associations. In view of the upcoming
\nworkshop in Pretoria in April 2014, he also
\nmet with the South African Medical Asso-
\nciation and connected with the ICRC del-
\negation in South Africa. WMA President
\nDr.\u00a0Mungherera will speak at the workshop.
\nDr. Eshaya-Chauvin attended the French-
\nspeaking Conference of Medical Orders
\n(Conf\u00e9rence Francophone des Ordres M\u00e9di-
\ncaux) in Douala, Cameroon last Novem-
\nber.
\nIn December, the ICRC delegation in
\nKathmandu, in collaboration with the Ne-
\npal Medical Association (NMA) and the
\nNepal Red Cross Society (NRCS), orga-
\nnized a half-day Health Care in Danger
\n(HCiD) workshop in Kathmandu. The
\nobjective of the workshop was to sensitize
\nmedical personnel to the issue, share efforts
\nmade by the ICRC to deal with the HCiD
\nissue at the global level, and to reflect at the
\nsituation of Nepal and receive participants\u2019
\nfeedback.
\nOther related activities
\nLast November, 19 experts from the fields
\nof humanitarian practice, human rights,
\nhuman\u00a0 security, academic research, gov-
\nernment, and philanthropy, along with UN
\nrepresentatives and leaders from health
\nprofessional associations, including the
\nWMA, represented by Dr. Mungher-
\nera, issued a\u00a0Call to Action\u00a0to address the
\nproblem of attacks on\u00a0health care. Read the
\nCall to Action from the Bellagio Confer-
\nence on the Protection of Health Workers,
\nPatients and Facilities in Times of Vio-
\nlence (Nov. 2013).
\n2.3 Doctors working in places where
\npeople are deprived of liberty
\nThe Special Rapporteur on torture and oth-
\ner cruel,inhuman or degrading treatment or
\npunishment, Mr. Juan E. M\u00e9ndez, and the
\nCenter for Human Rights & Humanitar-
\nian Law of the American University Wash-
\nington College of Law invited the WMA
\nto participate in an expert meeting on the
\nrevision of the United Nations Standard
\nMinimum Rules for the Treatment of
\nPrisoners (SMR) on 10th
\nJuly 2013 at the
\nUniversity of Oxford, United Kingdom.
\nProf. Vivienne Nathanson represented the
\nWMA at the meeting.
\nIn late September, the latest thematic re-
\nport of the Special Rapporteur focusing
\non this topic was published. One section
\nof the report is dedicated to medical and
\nhealth services and includes recommenda-
\ntions related to the role of health profes-
\nsionals in documenting ill-treatment and
\nacts of torture.
\n53
\nWMA News
\n2.4 Prevention of torture
\nand ill-treatment
\n2.4.1 Cooperation with the
\nInternational Rehabilitation
\nCouncil for Torture
\nVictims (IRCT)
\nIn Budapest in November 2012, C. De-
\nlorme was re-elected as an independent
\nexpert to the IRCT Council and the Ex-
\necutive Committee with a new mandate
\nof three years. Three Executive Committee
\nmeetings took place during the reporting
\nperiod and a Council meeting was held in
\nMarch 2014.
\nC.Delorme is a member of the IRCT work-
\ning group on detention and torture, putting
\nforward the WMA\u2019s perspective during dis-
\ncussions. Physicians\u2019 views are also included
\nin the two other working groups on migra-
\ntion and rehabilitation.
\n2.4.2 Psychiatric treatment
\nThe annual report of Mr. M\u00e9ndez, the UN
\nSpecial Rapporteur on torture, which was
\nsubmitted to the Human Rights Coun-
\ncil last March, was dedicated to abuses
\nin health care settings. In the report, Mr.
\nM\u00e9ndez explores an emerging recogni-
\ntion of different forms of abuses against
\npatients and individuals under medical
\nsupervision.
\nIn May 2013, the WMA Secretariat sent a
\nletter to the Special Rapporteur welcoming
\nthe selection of this topic, but expressing
\nserious concerns about some of the report\u2019s
\nrecommendations in relation to \u2018persons
\nwith psycho-social disabilities\u2019. In particu-
\nlar, it is feared that the report may generate
\nprejudice against psychiatric services, hold-
\ning health professionals responsible for all
\nabuses and ill-treatment of mental health
\npatients.
\nThe Secretariat drew the attention of the
\nWorld Psychiatric Association, as well as
\nthe International Council of Nurses, to
\nthe report. In June, C. Delorme met with
\nthe WHO\u2019s relevant department, as well as
\nChristian Pross, a member of the UN Sub-
\nCommittee on the Prevention of Torture, to
\ndiscuss this matter within the framework
\nof the Mental Health Monitoring Guide,
\non which the Sub-Committee is currently
\nworking.
\nFurthermore, national medical associations
\nwere informed and invited to take action.
\nThe Norwegian Medical Association alert-
\ned the Norwegian Psychiatric Association,
\nwhich wrote an open letter to the Special
\nRapporteur last November.
\nIn December, the WMA was consulted
\nabout the WHO\u2019s project MINDbank,\u00a0an
\nonline platform bringing together coun-
\ntry and international resources covering
\nmental health, substance abuse, disability,
\ngeneral health, human rights and develop-
\nment. The platform is now online: http:\/\/
\nwww.who.int\/mental_health\/mindbank\/
\nen\/
\n2.5 Homosexuality
\nIn early March, the WMA wrote to the
\nPresident of Uganda expressing its deep
\nconcern about the new law in the coun-
\ntry concerning homosexuality, and urging
\nhim to reverse the measure. On the day
\nthat President Museveni signed the bill
\ninto force, WMA President Dr. Margaret
\nMungherera and WMA Chair of Council
\nDr. Mukesh Haikerwal appeared on Ugan-
\ndan television to make the WMA position
\nclear by speaking out against this law. Previ-
\nous international protests had at least led to
\nthe abolishment of a mandatory reporting
\nclause, which was part of the original law
\nproposal. The WMA will continue its ef-
\nforts to get this legal act reversed.
\n2.6 Violence against women
\nDuring the 195th
\nsession of the WMA So-
\ncio-Medical Affairs Committee (Fortaleza),
\nmembers discussed concrete actions con-
\ncerning the implementation of the WMA
\nResolution on Violence Against Women
\n(Vancouver 2010).
\nThe initiatives proposed included the orga-
\nnization of a side-event during the upcom-
\ning World Health Assembly (May 2014).
\nThe WMA Secretariat is currently working
\non this and, in particular, is looking for a
\nMember State which will agree to sponsor
\nthe event in accordance with the WHO\u2019s
\nrules. The event, co-organized with the In-
\nternational Federation of Medical Students
\nAssociation (IFMSA),would aim to discuss
\nconcrete ways for the health sector to en-
\ngage in stopping violence against women
\nand, as an outcome, draw recommendations
\nfrom the debate.
\n2.7 Children\u2019s health
\nSince 2012,the mission of the EveryWom-
\nan Every Child initiative, spearheaded
\nby\u00a0 UN Secretary-General Ban Ki-moon,
\nhas been to mobilize and intensify global
\naction to improve the health of women and
\nchildren around the world.The WMA is an
\nobserver in the advocacy group of this ini-
\ntiative. http:\/\/www.everywomaneverychild.
\norg
\nAt the Council Session in Sydney, the ques-
\ntion was raised, but not answered, as to the
\nimpact of smoking in the vicinity of chil-
\ndren. It was discussed whether smoking in
\nthe vicinity of children should expressively
\nbe generally prohibited, including in private
\nspaces, instead of calling only for general
\nprotection.
\nFollowing this discussion, the Secretary-
\nGeneral asked the WMA Cooperating
\nCenter at George Mason University for
\nadvice. The Center for the Study of In-
\nternational Medical Policies and Practices
\nperformed a literature review to analyze
\nthe evidence on the effect of second hand
\nsmoke on children. The conclusion of the
\n54
\nWMA News
\nstudy*
\nclearly points to a recommenda-
\ntion to call for a stronger policy, includ-
\ning legal instruments, to ban smoking in
\nthe vicinity of children. (Individual copies
\ncan be obtained from the Secretariat upon
\nrequest.)
\n2.8 Pain treatment
\nLast January, the WHO\u2019s Executive Board
\nadopted a strongly worded resolution en-
\ntitled \u201cStrengthening of palliative care as a
\ncomponent of integrated treatment within
\nthe continuum of care\u201d. The resolution rec-
\nommends integrating routine training on
\npalliative care into the curricula of health-
\ncare professionals. The resolution was re-
\nferred to the World Health Assembly next
\nMay with the recommendation that it be
\nadopted.
\nOver recent years, the WMA has been in-
\nvolved in advocacy activities led by Human
\nRights Watch together with global\/regional
\npalliative care organizations in support of
\nthis resolution. The Secretariat will keep
\nmonitoring future developments.
\n2.9 Death penalty & organ
\ntransplantation
\nIn late September, Amnesty International
\ndrew our attention to the practice of the
\ndeath penalty in Taiwan. They informed
\nus, in particular, of a recent letter from the
\nTaiwan Minister of Justice for their atten-
\ntion, demonstrating medical involvement in
\nexecutions\u00a0 (giving sedatives and declaring
\nthe prisoner dead). Another issue of con-
\ncern was the practice of organ procurement
\nfor transplantation from executed prisoners.
\nThe Secretariat had an exchange of corre-
\nspondence with the Taiwan Medical Asso-
\n* Himathongkam, T. et al., Updates of Second-
\nhand Smoke Exposure on Infants\u2019 and Children\u2019s
\nHealth, World Medical & Health Policy, Vol. 5,
\nNo. 2, 2013
\nciation, which reiterates its commitment to
\nWMA policies on these issues and provided
\ninformation on the action taken towards the
\nTaiwanese authorities in this regard.
\nIn November, C. Delorme made contact
\nwith the International Commission against
\nthe Death Penalty in order to exchange in-
\nformation and explore potential joint activi-
\nties.
\nIn March, Dr. O. Kloiber and C. Delorme
\nmet with TAICOT (Taiwan Association for
\nInternational Care of Organ Transplants)
\nand DAFOH (Doctors Against Forced
\nOrgan Harvesting) to share information
\non ways to approach an end to forced organ
\nharvesting.
\n3. Public health
\n3.1 Non-communicable diseases (NCDs)
\n3.1.1 General
\nMember States and the WHO have made
\nprogress in fulfilling their commitments ac-
\ncording to the 2011 UN Political Declara-
\ntion on Prevention and Control of NCDs.
\nIn the last two years, Member States have
\nadopted a Global Monitoring Framework
\nwith a set of global NCD targets, a Global
\nNCD Action Plan 2013\u20132020, and a for-
\nmalized UN Interagency Task Force on
\nNCDs,which will coordinate a UN system-
\nwide response to NCDs.
\nThe NCD Global Monitoring Frame-
\nwork comprises nine global targets and 25
\nindicators. Nine additional voluntary glob-
\nal targets are aimed at combatting global
\nmortality from the four main NCDs, ac-
\ncelerating action against the leading risk
\nfactors for NCDs and strengthening na-
\ntional health system responses. The main
\ntarget is to reduce premature mortality
\nfrom non-communicable diseases by 25%
\nby 2025. The WMA was strongly engaged
\nin the development process and tried to
\nshift the focus to overarching targets re-
\nlated to health care systems rather than
\nsingle diseases.
\nAt the UN High-level Meeting on NCDs
\nin 2011,Member States committed to hold-
\ning a comprehensive UN NCD Review
\nand Assessment in 2014 on the progress
\nachieved on NCDs. The 2014 NCD Re-
\nview will provide a significant opportunity
\nfor stocktaking on progress in implement-
\ning the Political Declaration. The next step
\nis now to develop the modalities resolution
\nfor this UN NCD Review. This resolution
\nwill determine the date, level, scope, par-
\nticipation, and outcome of the NCD Re-
\nview. The co-facilitators of the Review are
\nJamaica and Belgium. At a WHO meeting
\nin November, Member States did not reach
\nagreement on the WHO\u2019s engagement
\nwith non-state actors, in particular the pri-
\nvate sector, and the organizational structure
\nof the mechanism. The WMA is following
\nthis process and trying to advocate for an
\noverarching NCD review approach.
\nHealth professionals play an important
\nrole in reducing the global NCD burden
\nthrough appropriate health promotional
\naction, disease prevention, treatment and
\nrehabilitation, and advocating for research
\nand finance. Therefore the WMA, together
\nwith the members of the World Health
\nProfessions Alliance (WHPA), has devel-
\noped a campaign to help prevent NCDs
\nby targeting common risk factors and social
\ndeterminants of health. More information
\non this campaign is included in Section 5.6
\nof this report.
\n3.1.2 Multidrug-Resistant
\nTuberculosis Project
\nThe WMA has collaborated with the New
\nJersey Medical School Global Tuberculosis
\nInstitute and the World Health Organiza-
\ntion, with financial support from the Eli
\nLilly MDR-TB partnership, to create a new
\napplication for tablet computers that will
\nallow physicians to access a training course
\non the treatment of Multidrug-Resistant
\nTB (MDR-TB).
\n55
\nWMA News
\nThe new application contains the eight
\ntraining modules which comprise the
\nWMA\u2019s course on MDR-TB. It is intend-
\ned as an introduction to MDR-TB man-
\nagement, and is consistent with the prin-
\nciples of the WHO Stop TB Strategy.The
\napplication, which will be accessible from
\nthe Google and iPhone app webpages, will
\nbe available on 10-inch screen tablets as
\nwell as smaller displays, including smart-
\nphones.
\nThe New Jersey Medical School Global
\nTB Institute, together with the University
\nResearch Company in the USA and the
\nWMA, will update the TB refresher course
\nfor physicians, which was originally devel-
\noped in 2008. A revision of the course now
\nis both appropriate and necessary given
\nchanges in the WHO Guidelines and the
\nupcoming release of the 3rd
\nedition of the
\nInternational Standards of Tuberculosis
\nCare.
\nThe goal of the project is to improve physi-
\ncian understanding and knowledge of TB
\nmanagement in order to improve patient
\noutcomes, ensure adequate treatment and
\ndecrease community transmission of TB.
\nThe PDF version of the course will be
\nupdated first. After finalizing its content,
\nit will be used as a basis for the revision
\nof the interactive online course, which
\nwill subsequently undergo pilot testing
\nwith interested users. Both courses will
\nbe made widely available, so the WMA
\ncan disseminate the course materials to
\nits member organizations and promote
\nthe courses at international meetings and
\nconferences.
\n3.1.3 Tobacco
\nThe WMA is involved in the implemen-
\ntation process of the WHO Framework
\nConvention on Tobacco Control (FCTC)
\nhttp:\/\/www.who.int\/tobacco\/framework\/
\nen\/. The FCTC is an international treaty
\nthat condemns tobacco as an addictive sub-
\nstance, imposes bans on advertising and
\npromotion of tobacco, and reaffirms the
\nright of all people to the highest standard
\nof health.
\n3.1.4 Alcohol
\nIn May 2010, the World Health Assembly
\nendorsed the Global Strategy to Reduce
\nthe Harmful Use of Alcohol. The Strategy
\nprovides a portfolio of policy options and
\ninterventions for implementation at nation-
\nal level with the goal of reducing the harm-
\nful use of alcohol worldwide. The success-
\nful implementation of the strategy requires
\nconcerted action by countries, effective
\nglobal governance, and appropriate engage-
\nment of all relevant stakeholders, including
\nhealth actors. In line with the WMA State-
\nment on Reducing the Global Impact of
\nAlcohol on Health and Society, the WMA
\nSecretariat monitors progress in this area to
\nensure that medical associations at the na-
\ntional and global levels are engaged in the
\nprocess. The Secretariat maintains regular
\ncontact with the WHO staff in charge of
\nthis topic, as well as with the Global Alco-
\nhol Policy Alliance (GAPA)
\n3.2 Social determinants of health
\nThe Rio Political Declaration on Social De-
\nterminants of Health, adopted at the World
\nConference on Social Determinants of
\nHealth in Rio de Janeiro, Brazil in October
\n2011, identifies five action areas for health
\nprofessionals to engage in to address the so-
\ncial determinants of health.One of these ac-
\ntion areas emphasizes the role of the health
\nsector in reducing health inequities.
\nWithin this framework, the WMA moni-
\ntors the WHO\u2019s activities and keeps nation-
\nal medical associations informed of relevant
\ndevelopments.
\nOn the initiative of the Canadian Medical
\nAssociation, the WMA is considering or-
\nganizing a meeting of interested NMAs to
\ndevelop plans to address the social determi-
\nnants of health and health equity through
\nthe collection\/dissemination of successful
\nclinical practice interventions and through
\nadvocacy, as well as policy development ini-
\ntiatives for NMAs.
\n3.3 Millennium Development Goals
\nThe United Nations development agenda
\nis prioritizing the move forward from the
\nMillennium Development Goals (MDGs)
\nera. The health-related MDGs have raised
\nthe profile of global health, mobilized polit-
\nical support and contributed to the achieve-
\nment of significant improvements in health
\noutcomes, particularly in low- and middle-
\nincome countries. To sustain the health-re-
\nlated gains and make the linkages between
\nhealth and sustainable development even
\nclearer, the UN saw a need to build on the
\nmomentum achieved by the MDGs and
\ndevelop a more overarching development
\nframework post-2015. The UN has linked
\nall their other health and development re-
\nlated key activities to the post MDG dis-
\ncussion. For example, the Rio+ discussions
\nand the climate change negotiations will
\nfeed the development process of the new
\npost-2015 MDGs.The aim is not just to fo-
\ncus on poverty eradication, but also on the
\nhealth of the planet.
\nThe United Nations Secretary-General
\n(UNSG) Ban Ki-moon appointed a High-
\nlevel Panel of eminent persons chaired by
\nthe UK Prime Minister and the Presidents
\nof Liberia and Indonesia to advise on the
\nglobal development agenda beyond 2015.
\nThe Panel delivered a report entitled \u201cA
\nNew Global Partnership: Eradicate Poverty
\nand Transform Economies through Sus-
\ntainable Development\u201d to the UN General
\nAssembly in September 2013.
\nA compilation of the global conversation
\non the post-2015 development agenda can
\nbe found at the \u2018World We Want 2015\u2019
\nwebsite, which is jointly owned by United
\nNations agencies and civil society orga-
\nnizations. This site gives an overview of
\nthe different stakeholders involved in the
\n56
\nWMA News
\npost-MDG discussions and the various
\nthematic focus areas.
\nWithin the health track of the post-MDG
\ndiscussions, the WHO and the World
\nBank have developed a draft framework
\nfor the monitoring of Universal Health
\nCoverage at country and global levels and
\nopened it up for consultation. The World
\nMedical Association has commented on
\nthe proposed framework. The main criti-
\ncism was that governments would need to
\noffer universal health coverage to only 40%
\nof the poorest people in the country and
\nonly 80% of them would need to receive
\nhealth care, which leads to a coverage of
\nonly one third of the population. This can
\nhardly be called \u201cuniversal health coverage\u201d.
\nBesides this, the framework again focusses
\nonly on single diseases.With this approach,
\nthe WMA fears that governments would
\nconcentrate only on improvements in these
\nspecific disease areas, detracting from the
\nsignificant needs caused by other major
\nhealth, social and environmental threats. In
\norder to achieve universal access we need
\nto strengthen health systems at the point
\nof service, with a special emphasis on in-
\ncreasing the number and appropriate dis-
\ntribution of health professionals per head
\nof population
\nThe Geneva-based Global Social Obser-
\nvatory hosted a series of events devoted to
\nthe MDGs with the participation of Uni-
\nlever, whose CEO Paul Paulman served on
\nthe High-level Panel. Representatives of a
\nvariety of international NGOs, diplomatic
\nmissions and UN institutions were invited
\nto participate in an inter-active dialogue
\nand identify opportunities for innovation
\nand partnerships to tackle future global
\nhealth and development challenges. The
\nWMA was an active participant in these
\nevents and will continue to contribute to
\nthematic consultations and seminars orga-
\nnized by the WHO and other international
\ninstitutions to make sure that health-related
\ndevelopment goals remain high on the po-
\nlitical agenda.
\n3.4 Immunization campaign
\nAt the beginning of 2013, the WMA
\nidentified low vaccination rates among
\nphysicians as a significant public health
\nthreat that was receiving little attention,
\nparticularly from the medical profession.
\nAfter conducting background research of
\nthe literature, the WMA national associa-
\ntion members were invited to participate
\nin a survey to document the magnitude of
\nthe problem and its root causes.The survey
\nresults helped the WMA plan a campaign
\nthat reflected the needs of our members.
\nThe International Federation of Phar-
\nmaceutical Manufacturers and Associa-
\ntions (IFPMA) provided funding for the
\ncampaign, which was officially launched
\nduring the 66th
\nWHO World Health As-
\nsembly week for which the WMA hosted a
\nluncheon seminar entitled: \u201cInfluenza: We
\nCan Do Better.\u201d
\nThe campaign went smoothly and received
\npositive feedback. It was featured on the
\nWHO, CDC and Vaccine Europe websites.
\nSeveral national associations approached
\nthe WMA with a request to use the WMA
\ncampaign materials for their national cam-
\npaigns.
\nOver the course of the campaign, a vari-
\nety of promotional and advocacy materials
\nwere developed that were widely circulated
\nand posted on the WMA website. For ex-
\nample, a brief promotional video featuring
\nreal healthcare workers in a clinic caring
\nfor their patients and getting vaccinated
\nby a colleague was launched at the WMA
\nluncheon in May 2013. The luncheon itself
\nwas videotaped, which included interviews
\nwith experts encouraging physicians to get
\nimmunized against seasonal influenza.Both
\nvideos, the promotional video and the event
\nvideo, are available on the WMA influenza
\ncampaign website: http:\/\/bit.ly\/15wcput.
\nIn addition to the videos, some printed ma-
\nterials were produced, including a calendar
\nfor 2014 with campaign messages, an info-
\ngraphic postcard, and letters for member
\nassociations to send to their governments
\nin support of physician immunization
\nagainst influenza. Other promotional ac-
\ntivities included Dr. Julia Seyer hosting a
\ncampaign booth and giving a presentation
\nat the Global Health Workforce Alliance\/
\nWHO Global Forum on Human Resources
\nfor Health from 10th
\n\u201313th
\nNovember 2013
\nin Brazil. Dr. T\u00e9a Collins gave an inter-
\nview to Vaccine Today, which is available
\nat: http:\/\/www.vaccinestoday.eu\/vaccines\/
\ndoctors-tell-doctors-get-your-flu-shot\/ and
\npublished an article in Person-Centered
\nMedicine on the campaign: \u2018The Role of
\nPhysician Immunization in Preventing In-
\nfluenza Outbreaks: Practicing Person-Cen-
\ntered Medicine\u2019.
\nBy the end of November 2013, Phase I of
\nthe campaign was successfully complet-
\ned. In order to maintain the momentum
\nachieved during Phase I and expand the
\ncampaign\u2019s reach and impact in 2014, the
\nWorld Medical Association requested ad-
\nditional funding from IFPMA to continue
\nthe project.
\nPhase II will build on the success of Phase
\nI with the goal of expanding the campaign\u2019s
\nscope and will include vulnerable popula-
\ntions (people with chronic diseases, the el-
\nderly, children and pregnant women) and
\nidentify flu champions and peer vaccinators
\nwho will serve as role models to physicians
\nand stimulate their interest in getting im-
\nmunized. The campaign will also make a
\ngreater effort to ensure national member
\nassociations\u2019 active involvement in the cam-
\npaign and to streamline global and national
\nadvocacy efforts.
\nHence, the overarching objective for this
\nphase will be to expand the influenza im-
\nmunization educational campaign among
\nphysicians with a greater focus on:
\n\u2022 Enhancing physicians\u2019 advocacy skills to
\naddress the barriers to seasonal flu vacci-
\nnations on multiple levels (personal,orga-
\nnizational, national)
\n57
\nWMA News
\n\u2022 Enhancing physicians\u2019 communication
\nskills to promote seasonal influenza im-
\nmunizations among vulnerable popula-
\ntions (the chronically ill, the elderly, preg-
\nnant women and children)
\n\u2022 Increasing WMA member national
\nassociations\u2019 involvement in the cam-
\npaign
\n\u2022 Identifying influenza immunization
\n\u201cchampions\u201d to serve as role models for
\nphysicians to increase their vaccination
\ncoverage against seasonal flu
\nThe WMA Proposal for Phase II was well
\nreceived and the IPFMA proposed that, in
\norder for the campaign to gain greater vis-
\nibility and longer-term engagement with its
\ntarget audiences,the proposal be revised and
\nthe activities spread over a three year period
\ninstead of one.Continuing IFPMA support
\nfor the campaign will ensure the visibility of
\nthe campaign all year round, which is criti-
\ncal given the seasonality of influenza. The
\nproposal is currently being revised and will
\nbe submitted to the IFPMA for their final
\napproval.
\n3.5 Counterfeit medical products
\nCounterfeit medicines are manufactured
\nbelow established standards of safety,
\nquality and efficacy. They are deliberately
\nand fraudulently mislabeled with respect
\nto identity and\/or source. Counterfeiting
\ncan apply to both brand name and generic
\nproducts, and counterfeit medicines may
\ninclude products with the correct ingre-
\ndients but fake packaging, products with
\nthe wrong ingredients, products without
\nactive ingredients, or products with in-
\nsufficient active ingredients. Counterfeit
\nmedicinal products threaten patient safe-
\nty, endanger public health e.g. by increas-
\ning the risk of antimicrobial resistance,
\nand undermine patients\u2019 trust in health
\nprofessionals and health systems. The in-
\nvolvement of health professionals is cru-
\ncial to combating counterfeit medicinal
\nproducts.
\nThe WMA and the members of the World
\nHealth Professions Alliance (WHPA)
\nhave stepped up their activities on counter-
\nfeit medical issues and developed an anti-
\ncounterfeit campaign with an educational
\ngrant from Pfizer Inc. and Eli Lilly.The ba-
\nsis of the campaign is the \u2018Be Aware\u2019 tool-
\nkit for health professionals and patients,
\nwhich is intended to increase awareness of
\nthis topic and provide practical advice for
\nactions to take in case of a suspected coun-
\nterfeit medical product. The WHPA orga-
\nnized several regional WHPA Counterfeit
\nMedical Products workshops to imple-
\nment this toolkit. This year\u2019s focus of the
\ncampaign is on active women aged 30\u201345
\nin urban areas.
\nThe WMA joined the Fight the Fakes cam-
\npaign that aims to raise awareness about the
\ndangers of fake medicines. Coordination
\namong all actors involved in the manufac-
\nturing and distribution of medicines is vital
\nto tackle this public health threat.
\nAs part of this effort, Fight the Fakes is
\ncollecting and sharing the stories of those
\nwho are impacted by fake medicines and
\nare speaking out. The website also serves as
\na resource for organizations and individu-
\nals who are looking to support this effort
\nby outlining opportunities for action and
\nsharing what others are doing to fight fake
\nmedicines.
\n3.6 Health and the environment
\nIn April 2012, an Environment Caucus
\nwas set up on the initiative of the Korean
\nand British medical associations together
\nwith Dr. Peter Orris, associate member and
\nexpert on environmental issues. The Cau-
\ncus provides a forum for open discussion
\nbetween medical associations interested
\nin environmental issues and willing to ex-
\nchange experiences. Since then, the Caucus
\nhas been meeting during WMA statutory
\nmeetings and is open to any medical asso-
\nciations interested in attending.
\n3.6.1 Climate change
\nThe WMA continues to be involved in the
\nUN climate change negotiations. Due to its
\nUN observer status to the Convention, the
\nWMA Secretariat can facilitate the partici-
\npation of medical associations interested in
\nthe various official meetings taking place
\nwithin this framework.
\nAt the conclusion of the first Climate
\nand Health Summit*, where the WMA
\nwas represented by Dr. Dong-Chun Shin
\n(KMA, Korea), the health NGO organiz-
\ners adopted the Durban Declaration on
\nClimate and Health and the Health Sector
\nCall to Action.The same partners organized
\na second Climate and Health Summit par-
\nallel to the 19th
\nCOP negotiations in War-
\nsaw on 16th
\nNovember with the support of
\nthe WHO. It provided an opportunity for
\ngroups to collaborate and share progress in
\nthe development and implementation of
\nstrategies and projects to build resilience
\nto the impacts of climate change on health.
\nProf. Vivienne Nathanson (British Medical
\nAssociation), co-chair of the WMA Envi-
\nronment Caucus, attended the event and
\nchaired the opening plenary session.
\nThis second Summit was also an opportunity
\nto formalize the Global Climate & Health
\nAlliance, composed of the health organiza-
\ntions\u2019 partners, working together to ensure
\nthat health impacts are integrated into glob-
\nal, national and local responses to climate
\nchange and to encourage the health sector
\nto mitigate and adapt for climate change.
\nThe WMA is not part of the Alliance, but
\nis committed to work with its members to-
\nwards the same goals, when appropriate.
\n* The Summit was co-organized by Health Care
\nWithout Harm, Climate and Health Council,
\nWorld Public Health Associations, and the Nel-
\nson Mandela School of Medicine, with the sup-
\nport of the WMA, WHO, Public Health Asso-
\nciation of South Africa, International Council of
\nNurses, the International Federation of Medical
\nStudents\u2019 Associations, groundWork, Health and
\nEnvironment Alliance, Europe, and the Climate
\nand Health Alliance, Australia.
\n58
\nWMA News
\n3.6.2 Mercury
\nThe WMA has been a member of the
\nUNEP Global Mercury Partnership (Mer-
\ncury product) since December 2008 in or-
\nder to contribute towards the partnership\u2019s
\ngoal of protecting human health and the
\nglobal environment from the release of mer-
\ncury and its compounds.This engagement is
\nbased on the WMA Statement on Reduc-
\ning the Global Burden of Mercury (Seoul,
\n2008).
\nRepresenting the WMA, Dr. Peter Or-
\nris has been following the negotiating
\nprocess of the UNEP (UN Environment
\nProgramme) for a legally binding instru-
\nment on mercury. The Mercury Treaty was
\nadopted in January 2013 in Geneva. The
\nTreaty sets a phase-out date of 2020 for
\nmost mercury containing products and calls
\nfor the phase-down of dental amalgam.This
\naspect of the treaty is a major victory for all
\nwho have worked for mercury-free health
\ncare.The WMA is following the ratification
\nprocess of the Treaty.
\n3.6.3 Chemicals
\nIn December 2009, the WMA joined
\nthe Strategic Approach to International
\nChemicals Management (SAICM) of the
\nChemicals Branch of the United Nations
\nEnvironment Programme (UNEP), which
\naims to develop a strategy for strength-
\nening the engagement of the health sec-
\ntor in the implementation of the Stra-
\ntegic Approach. In consultation with the
\nWHO, Prof. Shin (Korean Medical Asso-
\nciation) has represented the WMA at sev-
\neral SAICM meetings, bringing forward
\nthe WMA Statement on Environmental
\nDegradation and Sound Management of
\nChemicals (October 2010, Vancouver).
\n3.6.4 WMA Green Page
\nAt the request of the WMA Green Group,
\nwhich was set up in 2011, the Secretariat
\ncreated a Green Page in the environment
\nsection of its website.The green page focus-
\nes on the role of doctors in making health-
\ncare practice environmentally responsible.
\n4. Health systems
\n4.1 Person-centered medicine
\nThe WMA co-sponsored and participated
\nin the Sixth Geneva Conference on Person-
\nCentered Medicine, which took place in
\nGeneva from 28th
\nApril to 1st
\nMay 2013.
\nThe conference was organized by the In-
\nternational College of Person-Centered
\nMedicine in collaboration with Geneva
\nUniversity Hospital and the World Health
\nOrganization.The conference included the-
\nmatic symposia on Person-Centered Health
\nResearch, interactive workshops and oral
\npresentations by experts. Dr. Otmar Kloiber
\ndelivered a presentation on the revisions of
\nthe WMA Declaration of Helsinki and Dr.
\nT\u00e9a Collins spoke about the importance of
\nphysicians\u2019 immunization to prevent influ-
\nenza outbreaks.
\n4.2 Health workforce
\n4.2.1 Third Global Forum
\non Human Resources
\nfor Health (GHWA)
\nThe GHWA Third Global Forum on Hu-
\nman Resources for Health, entitled Hu-
\nman Resources for Health\u00a0\u2013 Foundation
\nfor Universal Health Coverage and the
\nPost-2015 Development Agenda, was
\nheld in Recife, Brazil from 10th
\n\u201313th
\nNo-
\nvember 2013. With 1800 participants
\nand attendance by 93 Member States,
\nincluding more than 40 ministers and\/
\nor deputy ministers, the Third Global Fo-
\nrum on Human Resources for Health was
\nthe largest ever HRH event. The Forum
\nhad two major goals. The technical goal
\nwas to provide the best evidence available
\nand share the lessons learned among the
\nHRH experts. The political goal was to
\ninspire and facilitate support and action
\nby policy-makers.
\nHigh-level plenaries, technical sessions
\nand satellite meetings with exhibition ar-
\neas, poster presentations, photo galleries
\nand awards for excellence provided oppor-
\ntunities for professional development and
\nnetworking. The Conference program was
\norganized around the following thematic
\nareas:
\n1. Health workers and health goals: Prog-
\nress in HRH actions over the past de-
\ncade
\n2. Matching health workforce production
\nto population needs and expectations
\n3. Social needs and the regulatory role of
\nthe State
\n4. Deployment, retention and manage-
\nment
\n5. Empowerment and incentives
\nThe WMA served on the technical advi-
\nsory board of the Conference and contrib-
\nuted to the content of the program. The
\nWMA also organized a session on build-
\ning collaborations and synergies among
\nhealthcare professions for the World
\nHealth Professions Alliance.The objectives
\nof the session were to demonstrate the
\nrole of professional associations in policy-
\nmaking, to advocate for inter-professional
\neducation and collaborative practice at the
\nnational and global levels using the ex-
\nample of the WHPA, and to highlight the
\nimportance of inter-professional education
\nfor inter-professional teamwork and col-
\nlaborative practice. The WHPA presidents
\nand CEOs participated in the session,
\nwhich was well attended and received in
\nBrazil.
\nIn addition, the WMA organized a parallel
\nsession on the role of the health workforce
\nin meeting citizens\u2019 needs and expectations
\nin collaboration with colleagues from the
\nAfrican Medical and Research Founda-
\ntion and the Capacity Plus Project in the
\nUSA. WMA\u2019s Dr. Julia Seyer served on the
\npanel and gave a presentation on healthcare
\nworkers responsiveness as one of the goals
\nof health systems and a main component
\nof quality person-centered care. Dr. Seyer
\nalso hosted a WMA booth to showcase the
\nWMA influenza immunization campaign
\nmaterials.
\n59
\nWMA News
\n4.2.2 The Prince Mahidol Award
\nConference (PMAC)
\nThe Prince Mahidol Award Conference
\nwas hosted by the Prince Mahidol Award
\nFoundation and the Royal Thai Govern-
\nment, in cooperation with the World
\nHealth Organization (WHO), the World
\nBank, the U.S. Agency for International
\nDevelopment (USAID), Japan Interna-
\ntional Cooperation Agency (JICA), the
\nRockefeller Foundation and the China
\nMedical Board. The Conference, entitled
\n\u201cTransformative Learning For Health Eq-
\nuity\u201d, took place in Thailand from 27th
\n\u201331st
\nJanuary 2014.
\nThe PMAC had four main objectives:
\n1. To identify, share and learn about the
\nstrengths and weaknesses of current
\nhealth professional education, teaching
\nand learning systems in different coun-
\ntry contexts.
\n2. To identify how health professional ed-
\nucation, teaching and learning systems
\ncan be transformed by advancing the
\nhealth equity agenda and be responsive
\nto the health of people in a dynamic
\nsocio-economic environment.
\n3. To support the development of strate-
\ngies and interventions for transforming
\nhealth professional education systems at
\nthe national level.
\n4. To strengthen the regional networks
\ncontributing to evidence for health pro-
\nfessional education transformation.
\nThrough a number of plenary and interac-
\ntive parallel sessions, as well as a number of
\nside events, the conference aimed to fos-
\nter collaboration and partnerships among
\nhealth professional education and train-
\ning institutions, along with health service
\ndelivery organizations, with the goal of
\ntransforming health professional educa-
\ntion systems and advancing the health eq-
\nuity agenda.
\nThe PMAC was a closed, invitation only
\nevent. The WMA President, Dr. Margaret
\nMungherera,Chair of Council,Dr.\u00a0Mukesh
\nHaikerwal, and Secretary General,
\nDr.\u00a0Otmar Kloiber, were invited as speakers
\nand served on the panels of the plenary and
\nparallel sessions of the conference.
\n4.2.3 Education & research
\nIn fall 2013,Prof.David Gordon (U.K.) was
\nelected as President of the World Federa-
\ntion for Medical Education (WFME). Dr.
\nGordon has advised the WMA on educa-
\ntional and workforce issues several times in
\nthe past. The WMA welcomed his presi-
\ndency and is fully prepared to continue its
\nintensive collaboration with the WFME.
\nThe Federation has now started to revise
\nits standards for Medical Education. The
\nWMA Secretariat will share the new draft
\nstandards with its members as soon as they
\nare available.
\nThe World Health Organization\u2019s Depart-
\nment for Human Resources for Health has
\nformed a Technical Working Group on
\nHealth Workforce Education Assessment
\nTools and invited the WMA to become
\na member. In view of the historical prob-
\nlem of, not only a global health workforce
\nshortage, but an urgent need to ensure that
\nsuch a workforce has a broader training
\nwhich more accurately reflects their every-
\nday working practices, a WHO Resolution
\nwas passed in 2013 to develop a standard
\nprotocol and health workforce education
\nassessment tool.
\nThe aim of the workgroup is to produce
\ndifferent quality measurements for trainees
\nor practitioners since no single assessment
\ntool can evaluate all competencies and, in
\naddition, the same competency may be
\nmeasured by more than one tool. Another
\nimportant point is that the use of multiple
\nassessment tools reduces the risk of bias to-
\nwards any one tool.
\n4.3 Violence in the health sector
\nDuring the reporting period,the Secretariat
\nhas been working on the preparation of the
\nfourth International Conference \u201cTowards
\nsafety, security and wellbeing for all\u201d, which
\nwill take place in Miami (FL), USA from
\n22nd
\n\u201324th
\nOctober 2014. The WMA is rep-
\nresented in the Steering Group in charge of
\nthe organization of the event and C. Delo-
\nrme is part of the Scientific Committee.
\nThe Steering Group met in early April for
\nthe final review and selection of the ab-
\nstracts in order to establish the preliminary
\nprogram.It is already planned that Dr.Mar-
\ngaret Mungherera will represent the WMA
\nin Miami.
\n4.4 Caring Physicians of the World
\nInitiative Leadership Course
\nThe CPW Project began with the Caring
\nPhysicians of the World book, published
\nin English in October 2005 and in Span-
\nish in March 2007, which is now available
\nin html and pdf. Some hard copies (Eng-
\nlish and Spanish) are still available from the
\nWMA Secretariat upon request. Please visit
\nthe WMA website (https:\/\/www.wma.net\/
\nen\/30publications\/60cpwbook\/index.html)
\nto access the electronic versions and to or-
\nder any hard copies. Regional conferences
\nwere held in Latin America,the Asia-Pacif-
\nic region, Europe and Africa between 2005
\nand 2007. The CPW Project was extended
\nto include a leadership course organized by
\nthe INSEAD Business School in Fontaine-
\nbleau, France in December 2007 in which
\n32 medical leaders from a wide range of
\ncountries participated. The curriculum in-
\ncluded training in decision-making, policy
\nwork, negotiating and coalition building,
\nintercultural relations and media relations.
\nThe fifth course was held at the INSEAD
\ncampus in Singapore from 13th
\n\u201318th
\nJanu-
\nary 2013. The courses were made possible
\nby educational grants provided by Bayer
\nHealthCare and Pfizer, Inc. This work, in-
\ncluding the preparation and evaluation of
\nthe course, is supported by the WMA co-
\noperating center, the Center for Global
\n60
\nWMA News
\nIn Poland, physicians were made liable
\nfor managing the reimbursement entitle-
\nments of the insured. Everyone in Poland
\nis insured under a state health insurance
\nscheme, which sets out various entitle-
\nments for reimbursement. These differ-
\nent entitlements were, at least in part, not
\ntransparent to physicians, who should not
\nbe held liable for wrongly assigning reim-
\nbursement statuses for drugs on prescrip-
\ntion. Together with the Polish Chamber
\nof Physicians and Dentists, the WMA
\nprotested against this measure, which was
\nlater revoked.
\nAt the end of 2011, the Turkish Govern-
\nment withdrew key functions, such as the
\nsupervision of physicians and the regula-
\ntion of post-graduate education, from the
\nTurkish Medical Association and other
\nself-governing institutions. Interestingly,
\nthese institutional rights were assigned by
\nlaw and the government is trying to lift
\nthem using a government order. Together
\nwith the Turkish Medical Association, the
\nWMA staged public events in Ankara and
\nIstanbul on 16th
\nand 17th
\nApril 2012 to fight
\nfor the retention of these critical rights of
\nphysician self-governance.
\nCHAPTER II
\nPartnership & Collaboration
\nDuring the reporting period, the WMA
\nSecretariat held bilateral meetings with
\nthe WHO and staff of other UN agencies
\non the following areas: Prevention of alco-
\nhol abuse, mental health, violence against
\nwomen, the environment, the migration of
\nhealth professionals and the prevention of
\ntorture. In addition, the Secretariat voiced
\nthe WMA\u2019s concerns in various public set-
\ntings as follows*
\n:
\n1. World Health Organization (WHO)
\n(see table 2)
\n2. UNESCO Conference on Bioethics,
\nMedical Ethics and Health Law
\nIn recent years, the WMA has already sup-
\nported the \u201cUNESCO Chair in Bioethics
\nWorld Conference on Bioethics, Medi-
\ncal Ethics and Health Law\u201d organized
\nby the UNESCO Bioethics Chair, Prof.
\nDr.\u00a0 Amnon Carmi. In November 2014,
\n* More information on activities mentioned is set
\nout under the relevant section of the report.
\nHealth and Medical Diplomacy at the Uni-
\nversity of North Florida. A sixth course is
\nplanned, again at the INSEAD campus in
\nSingapore, from 29th
\nApril to 3rd
\nMay 2014.
\n5. Health policy & education
\n5.1 Medical and health policy
\ndevelopment & education
\nIn recent years, the Center for the Study of
\nInternational Medical Policies and Practices
\nat George Mason University,which is one of
\nthe WMA\u2019s cooperating centers,has studied
\nthe need for educational support in the field
\nof policy creation. The surveys, performed
\nin cooperation with the WMA, found a
\ndemand for education and exchange. The
\nCenter invited the WMA to participate
\nin the creation of a scientific platform for
\ninternational exchange on medical and
\nhealth policy development. In the fall of
\n2009, the first issue of a scientific journal,
\nWorld Medical & Health Policy, was
\npublished by Berkeley Electronic Press as an
\nonline journal. It has recently been moved
\nto the Wiley Press. The World Medical &
\nHealth Policy Journal can be accessed at:
\nhttp:\/\/onlinelibrary.wiley.com\/journal\/
\n10.1002\/(ISSN)1948-4682
\n5.2 Support for national
\nconstituent members
\nAt the beginning of 2012, the WMA inter-
\nvened three times on matters of health poli-
\ntics at the request of member associations:
\nIn Slovakia,the government declared a state
\nof emergency in hospitals in order to stop
\nprotests and industrial action by physicians
\nfighting for better working conditions and
\nagainst the privatization of public hospitals.
\nIn consultation with the Slovak Medical
\nAssociation, the WMA wrote to the Prime
\nMinister and the President of the Republic
\nto call for proper working conditions and
\nfair payment.
\nTable 2.
\nGovernance WHO public events
\n34th
\nsession of the Executive Board (January
\n2014):
\n\u2022 Written statement (on behalf of the WHPA) on
\nthe WHO\u2019s role in humanitarian emergencies;
\n\u2022 Written statement (on behalf of the WMA, IF-
\nMSA1
\nand WONCA2
\n) on the global challenge
\nof violence, in particular against women and girls;
\n\u2022 Written statement on antimicrobial resistance
\n(influenza)
\nGlobalHealthWorkforceAlliance
\n2013:
\nThe WHO invited the WMA to
\nco-organize a session at the Third
\nGlobal Forum on Human Resources
\nfor Health in November 2013 in
\nBrazil.The WMA is working with
\nthe African Medical and Research
\nFoundation and IntraHealth Inter-
\nnational to organize the session
\n67th
\nWorld Health Assembly (May 2014):
\nThe Secretariat monitors issues of interest that
\nwill be addressed at the next World Health As-
\nsembly, such as non-communicable and commu-
\nnicable diseases, palliative care, violence against
\nwomen, the global vaccine action plan, and
\nantimicrobial resistance (influenza).
\nPrince Mahidol Award Conference
\n2014:
\nThe WHO invited the WMA to
\nengage in the WHO side session
\non the social determinants of health
\n(SDH), as well as in the WHO
\nproposed e-book on SDH.
\n61
\nWMA News
\nTable 3.
\nAgency Activities
\nHuman Rights Coun-
\ncil
\nUN Special Rapporteur
\n(SR) on the right of
\neveryone to the enjoy-
\nment of the highest
\nattainable standard of
\nphysical and mental
\nhealth (A.\u00a0Grover)\u00a0\u2013
\nSee item 2.1 for details
\nSpecial Rapporteur on
\ntorture and other cruel,
\ninhuman or degrading
\ntreatment or punish-
\nment (J.\u00a0E.\u00a0Mendez)
\nSub-Committee on the
\nPrevention of Torture
\n(SPT)
\n\u2022 Circulation of the SR\u2019s report to the
\nUN General Assembly on the\u00a0right
\nto health obligations of States and
\nnon-State actors towards persons af-
\nfected by and\/or involved in conflict
\nsituations along with a WMA letter
\nwelcoming the report (October
\n2013)
\n\u2022 Joint press release regarding the
\nTurkish health bill (December 2014)
\n\u2022 Monitoring the follow-up to the
\nannual report on torture and ill-
\ntreatment in healthcare settings
\n\u2022 Meeting with Suzanne Jabour, Vice-
\nPresident\/Continuing exchange of
\ninformation.
\nUnited Environment
\nProgramme (UNEP),
\nChemical Branch
\nDiscussion of the Minamata Conven-
\ntion on Mercury and the ratification
\nprocess.
\nTable 4.
\nWMA Cooperating Center Areas of cooperation
\nCenter for the Study of
\nInternational Medical Poli-
\ncies and Practices, George-
\nMason-University, Fairfax,
\nVirginia, USA
\nPolicy development, microbial
\nresistance, public health issues
\n(tobacco), publishing the World
\nMedical and Health Policy
\nJournal.
\nCenter for Global Health and
\nMedical Diplomacy, Univer-
\nsity of North Florida, USA
\nLeadership development, medical
\ndiplomacy
\nInstitute of Ethics and His-
\ntory of Medicine, University
\nof T\u00fcbingen, Germany
\nRevising the Declaration of Hel-
\nsinki, medical ethics
\nInstitut de droit de la sant\u00e9,
\nUniversit\u00e9 de Neuch\u00e2tel,
\nSwitzerland
\nInternational health law, medical
\nethics, deontology
\nSteve Biko Centre for Bio-
\nethics, University of Wit-
\nwatersrand, Johannesburg,
\nSouth Africa
\nRevising the Declaration of Hel-
\nsinki, medical ethics, bioethics
\nTable 5.
\nOrganization Activity
\nAmnesty Internation-
\nal\u00a0\u2013 Health Unit
\nOngoing contacts (exchange of informa-
\ntion and support) during the reporting
\nperiod on the situations in Turkey, Iraq,
\nBahrain, Egypt and Russia.
\nHuman Rights Watch Regular contacts on palliative care
\n(WHO resolution) and on matters
\nrelating to mercury and human rights
\nGlobal Alliance on Al-
\ncohol Policy (GAPA)
\nRegular exchange of information.
\nInternational Commit-
\ntee of the Red Cross
\n(ICRC)
\nPartners in the Health Care in Danger
\nproject since September 2011. Coopera-
\ntion with the health and legal units
\nInternational Fed-
\neration of Health and
\nHuman Rights Organ-
\nisations (IFHHRO)
\nRegular exchange of information on hu-
\nman rights and health matters,in particular
\nduring the reporting period: the health bill
\nin Turkey,homosexuality,mental health.
\nInternational Federation
\nof Medical Students
\nAssociations (IFMSA)
\nInternship program since 2013 (3 stu-
\ndents in 2013 and 4 students in 2014)
\nUniversity of Penn-
\nsylvania International
\nInternship Program
\nInternship program on health policy,
\npublic health, human rights, project
\nmanagement (2\u00a0students in 2014)
\nPlanning of a joint side-event on vio-
\nlence against women at the next World
\nHealth Assembly (May 2014).
\nInternational Rehabili-
\ntation Council for Tor-
\nture Victims (IRCT)
\nMember of the Council and Executive
\nCommittee (seat as an independent expert)
\nMember of IRCT working group on
\ndetention.
\nRegular input on policy development in
\nadvance of the next Council meeting in
\nMarch 2014.
\nGlobal Climate &
\nHealth Alliance
\nParticipation in the joint Global Summit
\non Health and Climate Change (COP
\n19th
\nNovember 2013, Warsaw)
\nExchange of information in the follow-up.
\nNew Jersey Medical
\nSchool Global TB
\nInstitute
\nThe WMA is working with the New Jer-
\nsey Medical School Global TB Institute
\nand the University Research Company
\n(URC) to update its online TB refresher
\ncourse for physicians with the support of
\nthe US Agency for International Devel-
\nopment (USAID)
\nSafeguarding Health in
\nConflict Coalition
\nObserver status in the coalition.
\nRegular exchange of information.
\n62
\nWMA News
\nthe WMA for the first time took an active
\nrole, structuring its own sessions at the
\nconference in Naples, Italy. WMA Past-
\nPresident, Dr.\u00a0Yoram Blachar, WMA Eth-
\nics Advisor, Dr. Jeff Blackmer, and WMA
\nLegal Counsel, Ms. Annabel Seebohm,
\norganized sessions on the Declaration of
\nHelsinki and the ethical and legal aspects
\nof hunger strikes. Among the speakers were
\nWMA advisors Prof. Vivienne Nathanson,
\nDr.\u00a0Hernan Reyes and Ms. Malke Borrow.
\n3. Other UN agencies (see table 3)
\n4. World Health Professions Alliance
\n(WHPA)
\nThe WMA submitted a proposal for a side
\nsession at the Global Health Workforce
\nAlliance (GHWA) Global Forum in No-
\nvember 2013: \u2018From Interprofessional Edu-
\ncation to Interprofessional Collaborative
\nPractice: The Role of Professional Asso-
\nciations\u2019. The proposal was accepted by the
\nGlobal Health Workforce Alliance.
\nThe WMA made interventions on behalf of
\nthe WHPA at the 134th
\nExecutive Board
\nof WHO on antimicrobial drug resistance,
\nthe WHO\u2019s role as the health cluster lead in
\nmeeting the growing demands of health in
\nhumanitarian emergencies, multi-sectorial
\naction for a life course approach to healthy
\nageing and the engagement of the WHO
\nwith the non-state sector.
\nThe WHPA will hold the third World
\nHealth Professions Regulation Confer-
\nence in Geneva from 17th
\n\u201318th
\nMay 2014.
\nThe conference will take place immediately
\nprior to the WHO World Health Assem-
\nbly and discuss the challenges and provide
\ninsights into the issues surrounding health
\nprofessions\u2019 regulation.
\nAs a continuation of the NCD health im-
\nprovement card in paper form and the in-
\nteractive version on the internet,the WHPA
\nis now developing an application for mobile
\nphones. It should better encourage and sup-
\nport people to develop a healthier lifestyle
\nin their everyday lives. Finally, the health
\nimprovement card will be available free of
\ncharge in three different formats.
\n5. WMA Cooperating Centers
\nThe WMA is now proud to enjoy the sup-
\nport of four academic cooperating centers.
\nThe WMA Cooperating Centers bring spe-
\ncific scientific expertise to our projects and\/
\nor policy work, improving our professional
\nprofile and outreach.
\nThe latest addition to our cooperating cen-
\nters is the Institute of Health Law at the
\nUniversity of Neuchatel, Switzerland (In-
\nstitut de droit de la sant\u00e9, Universit\u00e9 de
\nNeuch\u00e2tel). (see table 4)
\n6. Other partnerships or collaborations
\n(see table 5)
\nCHAPTER III
\nCommunication & Outreach
\n1. WMA newsletter
\nIn April 2012, the WMA Secretariat start-
\ned a bi-monthly e-newsletter for its mem-
\nbers. The Secretariat appreciates any com-
\nments and suggestions for developing this
\nservice and making it as useful for members
\nas possible.
\n2. WMA social media (Twitter and Face-
\nbook)
\nIn 2013, the WMA launched its official
\nFacebook and Twitter accounts (@med-
\nwma). The Secretariat encourages members
\nto spread the word within their associations
\nthat they can follow the WMA\u2019s activities
\non twitter and via Facebook.
\n3. The World Medical Journal
\nThe World Medical Journal is issued every
\n3 months and includes articles on WMA
\nactivities and feature articles from mem-
\nbers and partners. It enjoys a wide circula-
\ntion.
\n4. Roundtable Meeting
\nDuring recent years, the Business Develop-
\nment Group of the World Medical Associa-
\ntion has developed the Roundtable concept
\nunder the leadership of the Secretary of the
\nBritish Medical Association, Tony Bourne.
\nThe idea of the Roundtable is to provide a
\nforum for international business leaders and
\nthe leaders of the WMA to meet up and
\ndiscuss issues of common interest relating
\nto medicine and health care, etc.
\nThe first roundtable took place at BMA
\nHouse in London on 26th
\nSeptember 2013.
\nThe second meeting is scheduled to take
\nplace in Tokyo on 24th
\nApril 2014.
\n5. WMA African Initiative
\nWMA President Dr. Margaret Mungher-
\nera has started an initiative to bring African
\nmedical associations closer to the WMA. A
\nstronger inclusion of organized medicine in
\ninternational cooperation should not only
\nhelp to get the African voice better heard,
\nbut would also leverage their national vis-
\nibility and standing.
\nDr. Mungherera has been bringing together
\nmedical associations from various parts of
\nAfrica in small regional meetings to dis-
\ncuss issues around their current work, what
\nobstacles they are facing and where they
\nhave had success. Invitations are open to
\nall African medical associations, regardless
\nof whether they are members of the WMA
\nalready or not.
\nThree meetings have been held up to the re-
\nporting date,with the West African medical
\nassociations in Nairobi, Kenia in November
\n2013, with the Southern African medical
\nassociations in Johannesburg, South Africa
\nin February 2014, and in March 2014 with
\nthe North African medical associations in
\n63
\nWMA News
\nHammamet, Tunisia. Further meetings are
\nplanned in Nigeria and in Mozambique.
\nThis initiative has been supported by the
\nmedical associations of South Africa and
\nTunisia, our President-Elect, Dr. Xavier
\nDeau, Chair of Council, Dr. Mukesh Hai-
\nkerwal, as well as the Chairman of the
\nPast-Presidents and Chairs Committee, Dr.
\nDana Hanson.
\nCHAPTER IV
\nOperational Excellence
\n1. Advocacy
\nThe WMA set up a permanent Advisory
\nAdvocacy Committee in 2007 with the
\nmission:
\n\u2022 To maintain effective liaison with rel-
\nevant UN organizations, branches and
\ninstitutions, health care organizations,
\ncoalitions and NGOs;
\n\u2022 To ensure that WMA policies and posi-
\ntions are promoted among appropriate
\norganizations, associations and institu-
\ntions;
\n\u2022 To simultaneously provide advocacy tools
\nand content with the ultimate goal of be-
\ning visible and having a positive impact.
\nThe Advisory Group is chaired by Dr.\u00a0An-
\ndr\u00e9 Bernard (Canadian Medical Asso-
\nciation) and includes representatives of the
\nmedical associations of the following coun-
\ntries: Germany, Israel, UK, Uruguay and
\nUS. The Chair of Council, Dr. M. Haiker-
\nwal, takes part in the meetings, as well as
\nWMA Public Relations Consultant, Nigel
\nDuncan. Participants from WMA Secre-
\ntariat include the Secretary General, Dr. O.
\nKloiber, and the Advocacy Advisor, Ms. C.
\nDelorme.
\nIn April 2013, the Committee agreed to
\ndevelop an advocacy strategy for the pub-
\nlic release of the revised Declaration of
\nHelsinki, further to its expected approval
\nby the General Assembly in Fortaleza in
\nOctober 2013.
\nIn 2012, the Committee conducted an ad-
\nvocacy survey of the WMA membership in
\norder to identify the needs of the constitu-
\nent members regarding advocacy, as well
\npotential synergies that could be developed
\nin a more global context.One clear outcome
\nof the survey was a request from members
\nthat the WMA provide advocacy training.
\nIn this context, the Committee is consider-
\ning the organization of an advocacy train-
\ning session in Durban, South Africa during
\nthe 2014 WMA General Assembly in col-
\nlaboration with the South African Medical
\nAssociation.
\n2. Business Development Group
\nPleaseseeChapterIV\u201cRoundtablemeeting\u201d
\n3. Secondment program
\nThe WMA has continued a secondment
\nprogram with its members. Constituent
\nmembers may send staff members or vol-
\nunteers to the WMA office for a limited
\nperiod of time.
\n4. Paperless meetings
\nAt the 188th
\nCouncil meeting, the WMA
\nCouncil expressed its desire to reduce its
\nenvironmental impact by going paperless.
\nSince the 189th
\nCouncil meeting, docu-
\nments posted on the website before the
\nmeeting have no longer been provided at
\nthe venue in print. Council members and
\nofficials are responsible for downloading
\ndocuments from the members\u2019 area of the
\nWMA website and bringing them to the
\nmeeting via electronic media or on pa-
\nper, if desired. Documents developed on
\nsite during the meeting will be available
\nonline through a Wi-Fi connection or in
\nprint.
\n5. gTLD (generic Top Level Domains in
\nthe Internet)
\nThe WMA Executive Committee explored
\nthe suggestion by the British Medical As-
\nsociation to consider building a consortium
\nto tender for a generic top-level domain
\nof the Internet. Currently there is a sug-
\ngestion to install a gTLD \u201c.med\u201d, which
\nmay be of interest to physicians, medi-
\ncal facilities and medical associations, but
\nalso to pharmaceutical companies, medical
\ntechnology companies, insurers and many
\nothers. An exploratory group could not de-
\ntermine the chances of success of such a
\nbusiness venture and found that the finan-
\ncial and legal risks outweigh the potential
\nbenefits.
\nMeanwhile, the WHO expressed concern
\nthat the applications that had been made
\nfor a potential gTLD \u201c.health\u201d were too
\ncommercially orientated. The WHO re-
\nquested our support in asking the Internet
\nsteering body ICANN for a moratorium
\nand not to issue this gTLD for the time
\nbeing. On behalf of the WMA, and in sup-
\nport of the WHO request, the Secretary
\nGeneral raised concerns with ICANN via
\nthe request for comments from the organi-
\nzation, as well as to their government rela-
\ntions body.
\nCHAPTER V
\nAcknowledgement
\nThe Secretariat wishes to record its appre-
\nciation to member associations and inter-
\nnational organizations for their interest in,
\nand cooperation with, the World Medical
\nAssociation and its Council during the
\npast year. We thank all those who have
\nrepresented the WMA at various meet-
\nings and gratefully acknowledge the col-
\nlaboration and guidance received from the
\nofficers, as well as the association\u2019s editors,
\nits legal, public relations and financial ad-
\nvisors, staff of constituent members, coun-
\ncil advisors, associate members, friends of
\nthe association, cooperating centers and its
\nofficials.
\n64
\nUGANDASpeaking Book
\nBackground: Informed consent is premised
\non the participants\u2019 understanding the scope
\nof the research and the associated risks and
\nbenefits. The objective was to evaluate the
\nimprovement in knowledge in a population
\nunfamiliar with clinical trial concepts about
\n\u201cwhat it means to be part of a clinical trial\u201d
\nusing an innovative educational tool called
\nthe \u2018Speaking Book\u2019.
\nMethods: This was a randomized con-
\ntrolled trial conducted at a research site
\nin Uganda. 201 participants were ran-
\ndomized to: (1) clinical trials information
\nsession control arm, or (2) clinical trials
\ninformation session followed by instruc-
\ntion in the use of the Speaking Book with
\na take-home copy (intervention arm). Af-
\nter the session, participants of both groups
\ncompleted a 22-item multiple-choice test
\non the rights and responsibilities of par-
\nticipants. Participants returned after one
\nweek to complete the same test to assess
\nknowledge retention. The mean pre- and
\npost-test score difference was assessed
\naccording to trial arm using an unpaired
\nt-test of proportions.Results: Ninety-one
\n(90%) participants completed both the
\ninitial and follow-up tests in the control
\narm and 100 (100%) in the intervention
\narm.The average age of participants was 38
\nyears, 53% were female and 67% were em-
\nployed; 20% had previously been invited to
\nparticipate in a clinical trial; of these, 19%
\nhad participated. The mean difference in
\nproportion of correct responses from test
\n1 to test 2 was 2.7% (95%CI 0.3\u20135.0%)
\nfor the control arm and 11.6% (95%CI
\n9.3\u201313.7%) for the intervention arm (t-
\nscore=-5.3, p-value<0.0001).Conclusion:\nParticipants who had instruction in the\nuse of the Speaking Book had a larger in-\ncrease in knowledge than those who had\nno access to this tool. To better engage\npatients unfamiliar with clinical trial con-\ncepts, innovative educational techniques\ncan assist to increase knowledge to make\nan informed decision about participation\nin a clinical trial.\nIn the twentieth century, a participant\u2019s\ninformed consent became the backbone\nof ensuring ethical participation in a clini-\ncal trial. The key elements of the informed\nconsent are: the provision of information\nabout the research, the understanding of\nthe information that is passed on, and the\nfree agreement by the patients to partici-\npate in the study [1]. Research participants\nshould be informed about the purpose of\nthe research, the study procedures, the\nrisks and the benefits of such procedures;\nthe participant should also be informed\nregarding alternative options and the ex-\ntent to which confidentiality will be main-\ntained. Many of the precautions and con-\nsiderations involved in ethical conduct rest\non the basic foundation of informed con-\nsent.However,with conventional informed\nconsent procedures, it has been observed\nthat patients often misunderstand or for-\nget basic practical information regarding\nthe trials in which they participate [2, 3].\nIt is important to note too, that the con-\nsent procedure alone does not necessarily\nensure that research participants have ob-\ntained sufficient knowledge to make an\ninformed choice about participation [4],\nand that limitations specific to populations\nwith low literacy levels have been identi-\nfied [5].\nA number of studies have found low levels\nof understanding in terms of what consti-\ntutes a clinical trial and details on partici-\npation. For example, one study found that\nonly 28% of participants knew the study\u2019s\naim [4] while in another, 88% of women\nreported that they felt that trial participa-\ntion was mandatory [6]. There appears to\nbe a need for better ways of presenting\ninformation about clinical trials to enable\nresearch participants to make an informed\ndecision. Various methods of improving\npatient knowledge and understanding of\nclinical trials used during the informed\nMulti-media Educational Tool Increases Knowledge of Clinical\nTrials in Uganda\nBarbara Castelnuovo Kevin Newell Yukari C Manabe Gavin Robertson\n65\nUGANDA Speaking Book\nconsent process have been evaluated, such\nas discussion groups, booklets and video-\ntapes, \u201cteach back\u201d methods, educational\nmodules to discuss research terminology,\nand audio\/visual presentations [7\u201312]. The\nsuccess of these approaches often depends\non literacy level.\nIn a meta-analysis by Flory and Emanuel\nof 12 trials of multimedia interventions, all\nbut one intervention failed to improve the\nparticipant\u2019s understanding of the clinical\ntrial [13]. The one trial which showed ef-\nficacy had a small sample size and used a\ncomputerized presentation of information\nfor participants who were primarily men-\ntally ill [14]. The authors concluded that\nmultimedia and enhanced consent forms\nhad a limited impact on participant un-\nderstanding and targeted individualized\neducation was preferable. Another recent\nstudy of a video intervention corroborated\nthis finding [15]. Two recent publications\non a targeted educational session and a\nvideo intervention to increase participant\u2019s\nunderstanding of informed consent with-\nout the details of a particular clinical trial\ndid show improved post-training scores in\naddition to retention of this information\n[16,17].\nResearch initiatives driven by both external\nand local investigators are rapidly increas-\ning in countries within Sub-Saharan Africa\nwhere the familiarity with clinical trial con-\ncepts is generally low. Potential risks in con-\nducting research in these environments are\nincreased vulnerability to research exploita-\ntion and abuse but also low compliance to\nthe study procedures, which can include\nlow adherence to medication schedules.\nEducating people who are unfamiliar with\nclinical trial concepts often requires more\ncreative methods to ensure a sufficient level\nof comprehension.\nOne such creative method to support these\npopulations in understanding their rights\nand responsibilities when participating in\na clinical trial is a multi-media educational\ntool, a \u201cSpeaking Book\u201d entitled \u2018What it\nmeans to be part of a Clinical Trial\u2019. Clini-\ncal trials are the gold standard method for\ncollecting safety and efficacy data for health\ninterventions.The Speaking Book (SB) is a\nrichly illustrated book designed to enhance\nknowledge and understanding of what\nclinical trials are, how they are conducted,\nand the rights and responsibilities of par-\nticipants in a clinical trial. The SB consists\nof sixteen pages and sixteen corresponding\nbuttons. The text on each page describes\none topic around the participation in clini-\ncal trials and can be read aloud in English\nby a sound device within the book, which\ncan be activated by pushing the corre-\nsponding button. Each monologue lasts\nless than a minute. The content of this\nparticular book was reviewed by the World\nMedical Association to ensure alignment\nwith the principles of the Declaration of\nHelsinki [1]; by the South African Medi-\ncal Association to ensure the clinical rel-\nevance; and by the Steve Biko Centre of\nBioethics to ensure that the rights of hu-\nman research subjects were addressed. The\nbook can be used by researchers to provide\ngeneral education to potential clinical trial\nparticipants. In a pilot study of 52 partici-\npants working in a mass catering company\nconducted in South Africa [18], the SB\nwas evaluated for efficacy in knowledge\nuptake and ease of use. The results of this\npilot study indicate that incorporating the\nSB into the consent process increases the\nlevel of knowledge of clinical trials among\nstudy participants. The study also showed\nthat the participants perceived the educa-\ntional tool as easy to use.\nIn order to obtain information about the\nefficacy of the SB in a research setting in\nUganda, a clinical trial was conducted in a\nbusy public clinic located within the Na-\ntional Hospital where patients are recruited\nfor clinical trials. The research team sought\nto provide information about the effec-\ntiveness of the SB in the type of environ-\nment for which it was designed. The team\nalso assessed the acceptability of the SB by\nresearch participants and health profession-\nals working on clinical trials.\nThe study was reviewed and approved by\nthe Joint Clinical Research Centre (JCRC)\nEthics Committee and by the Uganda\nNational Council for Science and Tech-\nnologym (UNCST). Written consent was\nobtained from each participant and the eth-\nics committee approved this procedure. The\nclinical trial is registered with the Pan Af-\nrican Clinical Trials Registry, trial number\nPACTR201307000574378.\nThis study was a randomized, controlled\nclinical trial design comprising 2 groups,\neach of approximately 100 adult (older than\n18 years) participants, in a research site in\nKampala, Uganda. Patients attending a\nhealth clinic in Kampala were invited to\nparticipate in the study by a site research as-\nsistant. Those consenting to participate and\nwho could understand and read English (as\nassessed by a literacy test) were random-\nized sequentially according to pre-allocated\ngroup assignments in blocks of 4 to either\nthe control group or the SB group. Both\ngroups took part in a standard clinical trial\ninformation session and participants were\nassessed immediately afterward using a\nwritten 22-item knowledge assessment that\nwas developed by the study team based on\nthe information covered during the session.\nThe total score was calculated as the per-\ncentage of correct answers. The assessment\naddressed the nature of clinical trials, and\nthe rights and responsibilities of partici-\npants in clinical trials. After the initial in-\nformation session and assessment of knowl-\nedge, the participants in the SB group were\nprovided instructions on the use of the SB,\nreceived a copy of the SB to take home and\nwere encouraged to listen to it as may time\nthey wished to as well to invite other people\nlisten to it. After one week, participants\nin both groups were re-assessed using the\nsame tool to determine retention of knowl-\nedge. Participants in the SB group were also\nasked a set of additional qualitative ques-\ntions about their experiences with the SB.\n66\nParticipants in both groups were given ap-\nproximately $3 to cover transport costs on\neach of the 2 days.\nIn a separate qualitative evaluation, ten\nhealth professionals employed in the same\nresearch clinic, but not part of the study,\nwere given the book to listen to and were\nasked to respond to a brief survey about\ntheir perceptions of informed consent, and\nthe efficacy and acceptability of using the\nSB as part of the consent process.\nThe mean pre- and post-test score dif-\nference was assessed by trial arm using an\nunpaired t-test of proportions. Qualitative\ndata was summarized using tabulations.\nData was analyzed using SAS version 9.2.\nA total of 201 participants were random-\nized on this trial, including 100 partici-\npants in the SB group and 101 in the con-\ntrol group. Ninety- one (90%) participants\nin the control group and 100 (100%) in\nthe Speaking Book group completed both\nthe initial and follow-up tests.The average\nage of participants was 38 years, 53% were\nfemale and 67% were employed. Forty\n(20%) participants reported they had been\ninvited to participate in a clinical trial, in-\ncluding thirty-nine (19%) who reported\nthey had participated previously in a clini-\ncal trial. The demographic characteristics\nof study participants in the two arms were\nsimilar (Table 1), though there was a trend\ntoward higher education level in the con-\ntrol group.\nThe mean score for the first assessment\nwas 76.5% in the control group and 71.7%\nin the SB group, which was similar (Table\n2). The change in proportion of correct\nresponses from test 1 to test 2 was 2.7%\n(95%CI 0.3\u20135.0) for the control group\nand 11.6% (95%CI 9.3\u201313.7) for the SB\ngroup, which was statistically significant\n(p<0.0001). The allocation group was the\nonly variable associated with significance\nfor knowledge increase, measured by pro-\nportional score difference; there was no as-\nsociation between knowledge change and\nother variables such as demographic char-\nacteristics, educational level, or previous\nexposure to clinical trials.\nWe reviewed item-level responses to the\nknowledge assessment to determine if\nthere were any trends in knowledge up-\ntake or retention by trial arm. In the in-\ntervention arm, there were improvements\nof greater than 10% from pre-intervention\nto post intervention in the proportion re-\nsponding correctly for 11 of 22 (50%) the\nassessment items, whereas in the control\narm, there were improvements of this same\nmagnitude in only 2 (9%) questionnaire\nitems. Among intervention participants,\nthere were no items with a decrease in pro-\nportion responding correctly between the\nassessments; however, in the control group\nthere was a decrease in proportion of cor-\nrect responses for 7 of 22 (32%) assessment\nitems.\nAll participants in the intervention group\nwere asked questions about their experi-\nence with the SB. Almost all participants\n(99%) liked the illustrations and found the\nbook easy to use (98%). Most participants\n(96%) heard the spoken voice clearly and\nTable 1. Demographic characteristics of study participants by study arm\nVariable\nSB n=100\nControl\nn=101 p-value\nN (%) N (%)\nGender\nFemale 55(55) 51(50.5) 0.52\nEducational Level 0.10\nPrimary 1(1) 6(5.9)\nS1-S4 48(48) 36(35.6)\nS5-S7 25(25) 25(24.7)\nTertiary 26(26) 34(33.7)\nEmployment 0.49\nEmployed 69(69) 65(64.4)\nEver asked to participate in a Clinical\nTrial?\n0.50\nNo 82(82) 79(78.2)\nEver participated in a Clinical Trial? 0.53\nNo 82(82) 80(79.2)\nAge (yrs)\nMean (SD) 37.8(8.6) 37.8(11.5) 0.97\nSB: Speaking book; S: secondary; SD: standard deviation.\nTable 2. Knowledge test scores (proportion of correct responses) by group\nGroup\nTest 1\nMean\nTest 2\nMean\nMean\nof Score\nDifference\nt-score p-value\nControl 76.5% 79.2% 2.7%\nSpeaking Book 71.7% 83.3% 11.6% \u20135.3 <0.0001\nUGANDASpeaking Book\n67\n98% reported understanding the content.\nAlmost all participants (99%) indicated\nthat members of their community would\nunderstand the content if given the speak-\ning book to use. Seventy-two percent of\nparticipants reported showing the book to\nothers. On average, participants showed\nthe book to 8 other people in their homes,\nworkplace, church, mosque, clinic or hospi-\ntal. Most participants (93%) reported that\nafter listening to the speaking book, they\nwould, in principle, be willing to participate\nin a clinical trial. Table 3 summarizes the\nresponses given by participants in the SB\ngroup.\nInterviews were conducted with ten health\nprofessionals to assess their perceptions of\nthe potential efficacy, acceptability and use\nof the SB. The average age of the health\nprofessionals interviewed was 31.6 years\nand they had been working in their cur-\nrent position for an average of 3.8 years.\nOf the ten health professionals surveyed,\nseven (70%) thought that their current\nconsent process at their clinic provided\nparticipants with sufficient understanding\nto sign an informed consent before enter-\ning a clinical trial. Most (90%) thought\nthat participants in clinical trials are aware\nof their role and responsibilities prior to\nsigning the informed consent form. Four\n(40%) thought the person who explains\nthe information sheet and consent form to\nthe patient does not have enough time to\nmake sure that the patient completely un-\nderstands all the information. Nine (90%)\nthought that the consent process would be\neasier if patients were asked to read the SB\nfirst on their own. Seven (70%) thought\nthat participants take study drug as pre-\nscribed and inform the study staff about\nany additional drugs used. Of the health\nprofessionals who thought participants do\nnot take study drug as prescribed (30%),\nall thought that the SB would help in ex-\nplaining the importance of this to them.\nFive (50%) of the health professional re-\nspondents reported that they had been\nasked about the term \u201cplacebo\u201d during\nthe consent process. Most (80%) of these\nthought they understood the term placebo\nwell enough to explain it. Six (60%) of all\nhealth professionals interviewed thought\nthe SB explained the concept sufficiently.\nAll ten (100%) interviewed reported that\nthey usually told patients that they can\nquit participation in the trial at any time,\nand nine (90%) thought the SB addressed\nthis issue adequately. Three (30%) thought\nthat the SB contained all the necessary in-\nformation while seven (70%) thought the\nSB contained most but not all of the infor-\nmation necessary to make a decision about\nparticipating. Almost all (90%) thought\nthat each participant should be given a SB\nto take home before agreeing to partici-\npate in a clinical trial, and all ten (100%)\nthought the SB would assist participants\nbetter than a brochure when screening\nor informing them about a clinical trial\n(Table 4).\nIn settings with patients unfamiliar with\nclinical trial concepts, innovative tech-\nniques can improve knowledge acqui-\nsition and retention in order for indi-\nviduals to make a more informed choice\nabout participation in clinical trials. Par-\nticipants who had instruction in the use\nof the SB and used it for one week had\na larger improvement in knowledge as-\nsessment score compared to those who\nhad no access to this tool. Our data is in\ncontrast to a meta-analysis by Flory and\nEmanuel [13].\nTable 3. Summary of participant responses to questions about the Speaking Book\nQuestion\nYes\nTotal (mean)\nNo\nTotal (mean)\nIf yes, how\nmany?\nTotal (mean)\nDid you like the pictures and drawings? 99(99) 1(1)\nDid you find the book easy to use? 98(98) 2(2)\nCould you hear the person talking to you\nclearly?\n96(96) 4(4)\nDid you understand all the information\nthat she told you in the book?\n98(98) 2(2)\nDo you think members of your church,\ncommunity, and township will understand\nwhat a clinical trial is, if they were given\nthis book to listen to?\n99(99) 1(1)\nDid you show the book to anyone else in\nyour community?\n72(72) 28(28)\nDid you show the book to anyone else at\nChurch\/Mosque?\n54(54) 46(46) 190(1.9)\nDid you show the book to anyone at work? 41(41) 59(59) 144(1.4)\nDid you show the book to anyone in your\nfamily?\n66(66) 34(34) 291(2.9)\nDid you show the book to anyone at the\nclinic or hospital?\n47(47) 53(53) 161(1.6)\nDid you show the book to someone any-\nwhere else?\n9(9) 91(91) 18(0.2)\nAfter listening to the information and the\nstory in the book would you ever be willing\nto be in a clinical trial?\n93(93) 7(7)\nUGANDA Speaking Book\n68\nThe SB seems to be a valuable tool in im-\nproving patients\u2019 understanding of clinical\ntrials and their rights and responsibilities\nassociated with participation in a trial.The\nqualitative assessment of the interven-\ntion group showed that participants who\nwere instructed in the use of the SB and\nbrought it home for a week found it use-\nful and shared it extensively with friends,\nfamily, work colleagues and other associ-\nates, thereby increasing the value of the\nbook as an educational tool. This allowed\npatients to discuss the ethical aspects of\nclinical trials with others whose opinions\nthey valued.\nA structured questionnaire was used with\na limited pool of health professionals who\nviewed the SB as a useful tool for increas-\ning the capacity of patients to make an in-\nformed decision regarding participation in\na clinical trial.\nOne limitation of our study was that the\nparticipants included only those who\nspoke and understood English since the\nSB was not translated into local languages.\nTherefore, participants likely had a higher\neducational status than the average for\nthe clinic. In the meta- analysis [13], re-\nsearch participants with higher education\nstatus were more likely to have better un-\nderstanding. Nonetheless, having a group\nof participants capable of taking the test\nrepresented an appropriate first group in\nwhom to test the intervention.The investi-\ngators also noted that despite the random-\nization the control arm had slightly higher\neducation level, though of marginal sig-\nTable 4. Summary of Health Professionals responses to questions about the Speaking Book\nQuestion\nYes\nn(%)\nNo\nn(%)\nNo response\nn(%)\nDo you think that the consent process at your clinic now is enough for the participants to understand\nthe consent forms provided and the details of the trial? 7(70) 3(30)\nIn general, do you think that participants in clinical trials are aware of their medical responsibilities\nprior to signing the consent form? 9(90) 1(10)\nDo your patients understand that they should inform the doctor or nurses about any other medication\nthat they take before or during the trial, even from a pharmacy or a traditional healer? 7(70) 2(20) 1(10)\nDo you think the participants in a clinical trial take their medication exactly as they are told to do? 7(70) 3(30)\nIf NO, do you think the book can help you explain the importance of this to them? 3(30)\nDo patients ever ask you what a placebo is during the consent process? 5(50) 4(40) 1(10)\nIf YES, do you think that you know about a placebo well enough to explain it properly? 4(40) 1(10)\nDo you think the speaking book explains the concept of a placebo enough? 6(60) 4(40)\nDo you usually tell the patient that they can stop the clinical trial at any time? 10(100) 0(0)\nDoes the book tell the patient clearly enough that they can stop the clinical trial at any time? 9(90) 1(10)\nDo you think that the person who explains the information sheet and consent form to the patient has\nenough time to make sure that the patient completely understands all the information? 6(60) 4(40)\nDo you think that the consent process would be easier if the patient was asked to read the book first\non their own?\n9(90) 1(10)\nDo you think that the information in the book gives all the information needed to make a decision\nabout participating?\n3(30) 0(0)\nDo you think the book should include any other information we have forgotten? 3(30) 7(70)\nAt what time do you think that the books should be given to the new person applying for the trial?\nAt time of first visit to the research clinic\nAt time of first talk about clinical trial\n4(40)\n6(60)\nDo you think that each participant should be given a speaking book to take home before agreeing to\nparticipate in a clinical trial? 9(90) 1(10)\nIf you were going through screening or informing a patient about a clinical trial, in addition to normal\npractices which do you think would help a participant more?\nSpeaking Book\nBrochure\n10\n(100)\n0(0)\nUGANDASpeaking Book\n69\nnificance (p=0.10), and therefore the use of\nthe SB could have had an even higher im-\npact on the absolute score change if groups\nhad a more similar level of education.\nThe fact that a differential improvement\nin knowledge was identified between the\nstudy groups suggests that the SB might\ndemonstrate an even greater improvement\nin knowledge among a less literate popula-\ntion. Further studies with use of the tool\nin the local language such that participants\nwith lower educational status could be in-\ncluded would be warranted.\nA disadvantage of using the SB to pass\ninformation on clinical trials is that it re-\nquires a two-visit procedure with increase\nin study costs and potential for loss to fol-\nlow up in between the visits. However in\nour study all participants in the SB arm\n(as compared to 90% in the control arm),\nreturned for the follow up visit after the\nweek, possibly as the result of learning the\nimportance of participating clinical tri-\nals; in addition most of the participants\nshowed the book to an average of 8 other\npeople in their homes, contributing to the\nsensitization of the general population on\nclinical trials.\nIn summary, the use of a SB multi-media\ntool for one week after a standard explana-\ntion of clinical trials was able to increase\ncomprehension scores significantly com-\npared to participants who received only one\neducational session. The SB is an introduc-\ntory tool that can be used to inform patients\non topics common to all clinical trials and\nmay be a valuable adjunctive instrument for\nuse among potential research participants\nto improve understanding of clinical trials\nand make an informed decision during the\nconsent process.\nReferences\n1. World medical Association (1964) Declaration\nof Helsinki - Ethical Principles for Medical Re-\nsearch Involving Human Subjects.\n2. Byrne DJ, Napier A, Cuschieri A (1988) How\ninformed is signed consent? Br Med J (Clin Res\nEd) 296: 839-840.\n3. Lavelle-Jones C, Byrne DJ, Rice P, Cuschieri\nA (1993) Factors affecting quality of informed\nconsent. BMJ 306: 885-890.\n4. Joubert G, Steinberg H, van der Ryst E,\nChikobvu P (2003) Consent for participation\nin the Bloemfontein vitamin A trial: how in-\nformed and voluntary? Am J Public Health 93:\n582-584.\n5. Molyneux CS, Peshu N, Marsh K (2004) Un-\nderstanding of informed consent in a low-in-\ncome setting: three case studies from the Kenyan\nCoast. Soc Sci Med 59: 2547-2559.\n6. Abdool Karim Q, Abdool Karim SS, Coovadia\nHM, Susser M (1998) Informed consent for\nHIV testing in a South African hospital: is it\ntruly informed and truly voluntary? Am J Public\nHealth 88: 637-640.\n7. Agre P, Kurtz RC, Krauss BJ (1994) A rand-\nomized trial using videotape to present consent\ninformation for colonoscopy. Gastrointest En-\ndosc 40: 271-276.\n8. Ives NJ,Troop M, Waters A, Davies S, Higgs C,\net al. (2001) Does an HIV clinical trial infor-\nmation booklet improve patient knowledge and\nunderstanding of HIV clinical trials? HIV Med\n2: 241-249.\n9. Llewellyn-Thomas HA, Thiel EC, Sem FW,\nWoermke DE (1995) Presenting clinical trial\ninformation: a comparison of methods. Patient\nEduc Couns 25:97-107.\n10. Bygrave H, Kranzer K, Hilderbrand K, Jouquet\nG, Goemaere E, et al. (2011) Renal safety of a\ntenofovir-containing first line regimen: experi-\nence from an antiretroviral cohort in rural Leso-\ntho. PLoS One 6: e17609.\n11.Ryan RE, Prictor MJ, McLaughlin KJ, Hill SJ\n(2008) Audio-visual presentation of informa-\ntion for informed consent for participation in\nclinical trials. Cochrane Database Syst Rev:\nCD003717.\n12.Tamariz L, Palacio A, Robert M, Marcus EN\n(2013) Improving the informed consent pro-\ncess for research subjects with low literacy: a\nsystematic review. J Gen Intern Med 28: 121-\n126.\n13. Flory J, Emanuel E (2004) Interventions to im-\nprove research participants\u2019understanding in in-\nformed consent for research: a systematic review.\nJAMA 292: 1593-1601.\n14. Dunn LB, Lindamer LA, Palmer BW, Golshan\nS, Schneiderman LJ, et al. (2002) Improving un-\nderstanding of research consent in middle-aged\nand elderly patients with psychotic disorders.\nAm J Geriatr Psychiatry 10: 142-150.\n15. Hoffner B, Bauer-Wu S, Hitchcock-Bryan S,\nPowell M, Wolanski A, et al. (2012) \u201cEntering\na Clinical Trial: Is it Right for You?\u201d: a rand-\nomized study of The Clinical Trials Video and\nits impact on the informed consent process.\nCancer 118: 1877-1883.\n16. Sengupta S, Lo B, Strauss RP, Eron J, Gifford\nAL (2011) Pilot study demonstrating effective-\nness of targeted education to improve informed\nconsent understanding in AIDS clinical trials.\nAIDS Care 23: 1382-1391.\n17. Joseph P, Schackman BR, Horwitz R, Nerette\nS, Verdier RI, et al. (2006) The use of an educa-\ntional video during informed consent in an HIV\nclinical trial in Haiti. J Acquir Immune Defic\nSyndr 42: 588-591.\n18. Dhai A, Etheredge H, Cleaton-Jones P (2010)\nA pilot study evaluating an intervention de-\nsigned to raise awareness of clinical trials among\npotential participants in the developing world. J\nMed Ethics 36: 238-242.\nBarbara Castelnuovo,\nInfectious Diseases Institute,\nMakerere College of Health\nSciences, Kampala, Uganda\nKevin Newell,\nClinical Research Directorate\/Clinical\nMonitoring Research Program, Leidos\nBiomedical Research, Inc. (formerly\nSAIC-Frederick Inc.), Frederick National\nLaboratory for Cancer Research, USA\nYukari C Manabe,\nInfectious Diseases Institute,\nMakerere College of Health\nSciences, Kampala, Uganda,\nDivision of Infectious Diseases,\nDepartment of Medicine, Johns\nHopkins University School of\nMedicine, Baltimore, USA\nGavin Robertson,\nInfectious Diseases Institute,\nMakerere College of Health\nSciences, Kampala, Uganda\nAeras (Current affiliation),\nCape Town, South Africa\nE-mail: grobertson@aeras.org\nUGANDA Speaking Book\n70\nThe South African health care system\nconsists of both the public and private\nhealth systems and these are very simi-\nlar to the types found in similar middle\nincome countries as well as other devel-\noped markets. The private health system\nin South African is currently serving close\nto nine (9) million people and these are\npeople who currently have medical aid\nand those who can afford and are able to\npay for health care from their own pocket.\nIt is also a well known phenomenon and\nhas been covered extensively in literature\nthat private health system in South Africa\nis costly and mostly used by the middle\nto high income individuals and families.\nComparisons have also been made assess-\ning levels of inequalities between the pri-\nvate and the public health system, where\nis stated that more than forty (40) mil-\nlion people solely use the public health\nsystems. There have been policy develop-\nments towards the introduction of the\nnational health insurance. This is a major\nhealth sector reform which is currently in\nthe pilot phases, and is likely to increase\npublic\u00a0\u2013 private partnership between the\ntwo health sectors.\nNotwithstanding; the inequality challenges\nbetween the private and public health sec-\ntor\u00a0\u2013 the health financing and health deliv-\nery components of health systems\u00a0\u2013 there\nare other challenges facing the health care\nsystem in South Africa. These are also ob-\nserved in other global markets and include\nincreasing cost of health care. The private\nhealth care expenditure data reported by\nthe CMS (Council for Medical Schemes)\nrevealed that private hospitals, medical spe-\ncialists and medicines accounted for more\nnearly eighty (80) percent of risk benefits\npaid by medical schemes in 2012.\nAnother factor of significance is; the impact\nof market structure on the conduct and per-\nformance of market participants.The struc-\nture of private voluntary health financing\nmarkets has impact on:\n\u2022 The nature of health plan concentra-\ntion (the market penetration of health\nplans);\n\u2022 The level of health plan rivalry (market\nparticipation) [11,18]; and\n\u2022 The conduct of all market participants is\nthus informed by patterns in market or-\nganization.\nMarket structure has an impact on con-\nsumer welfare policy objectives, these are\nobservable in (but not exclusive to) the fol-\nlowing factors:\n\u2022 Benefit design (the role of product de-\nsign) [9];\n\u2022 Differences in demographic profiles\nacross risk pools ( [15];\n\u2022 Unequal distribution of disease burden\nacross health plans [11].\nThus; cost pressures in health sector, are\npartially, a function of the impact market\nstructure on market segments covering\nvulnerable risk groups [19]. The absence of\nprice regulation in health insurance mar-\nkets\u00a0\u2013 i.e. price regulation on health service\nprocedures\u00a0\u2013 may fuel market failure out-\ncomes [12; 6].\nEconomic theory suggests that absence\nof regulation may result in low-quality\nservices at high-quality prices for unac-\nquainted consumers [12; 19; 6]. This anal-\nysis seeks to provide similar evidence for\nthe South African private health financing\nsystem.\nPurpose\nHealthcare providers and consumables\nhave been stated in the aforementioned\nsection to contribute significantly to the\nescalating costs of health care in the pri-\nvate health sector. Commentators such as\nHalse et al [7] studied the role of competi-\ntion policy in healthcare markets and the\nimpact thereof on price increases. Studies\nby Gaynor, [4], Morrisey [11], Wholey\n[18] also identified ways in which competi-\ntion policy can be used to ensure the effec-\ntive functioning of healthcare markets. Van\nden Heever [16] advocates for regulatory\nMarket Structure in the South African\nHealth Care System\nMichael Mncedisi Willie Phakamile Nkomo\nSOUTH AFRICAHealth Care System\n71\nframework which; enhances solidarity in\nhealth plan risk pools [17].\nThe objective of the current research note is\nto conduct a high level review of the con-\nsolidation in the medical schemes industry,\nstructural features of the healthcare sec-\ntor and policy themes. The covered policy\nthemes are directly related to the interpre-\ntation of restricted and prohibited conduct,\nin terms of the Competition Act of 1998.\nMost of these prescriptive standards re-\ngarding market conduct were enacted on\nthe promulgation of the Competition Act\n89 of 1998.The timing of this enabling Act\nwas simultaneous with that of the Medi-\ncal Schemes Act 131 of 1998. At the time\nof instituting both these Acts; the policy\nagendas within the regulatory environ-\nments are discussed in the sub headings\nwhich follow.\nStakeholders\u00a0&\u00a0Policy\nLandscape\nMedical schemes industry\npolicy landscape\nThe Medical Schemes Act 131 of 1998\ncame about at a time when market failure\nwas present in the private medical schemes\nindustry. Vulnerable risk groups, such as\nthe sick and healthy, were not able to secure\naffordable access to health insurance. That\nsituation was as a direct result of a series of\nderegulation occurring in the 1990\u2019s. These\nderegulations resulted in a gap in the prod-\nuct, as a market for covering vulnerable risk\ngroups was not provided in the private sec-\ntor.\nThe anti-trust policy landscape\nThe regulatory philosophy behind the com-\npetition Act was to increase the transpar-\nency of market behaviour. The intention\nwas to promote the efficiency of industries,\nand prohibit conduct deemed to be anti-\ncompetitive. This has resulted in efficiency\nfocused interpretations of provisions of the\nCompetition Act.Thus, the socio-economic\ngoals of industrial policy were mostly not\nconsidered in assessing the competitive\nnature of transactions and market conduct.\nResulting policy gap\nThe enabling clauses of the two statutes\nresulted in a polarities; i.e. public interest\nrelative to pure market efficiency objectives.\nThe current inquiry into the private health\nsector by the Competition Commission\n(Comp.Com); seeks to establish whether\ntheir interventions in the private health\nsector have negatively impacted access to\nhealth care.\nAll activities related to collecting informa-\ntion, and sharing information pursuant to\nsetting a guideline on prices,after the Com-\npetition Act, were now violations of section\n4.Although the practice of setting the \u201cscale\nof benefits\u201d (SOB) was previously, an activ-\nity conducted among professional and stat-\nutory organizations\u00a0\u2013 that said; it was now\nprohibited practice.\nThe purpose of SOB was conducted for the\npurposes of:\n\u2022 Upholding the social solidarity principles\nof medical schemes; and\n\u2022 Coordinating the activities between pro-\nviders and funders for the purpose of pro-\nducing accessible health financing.\nAlthough section 4(1)(b)(i) expressly makes\nexception for instances when prohibitive\nconduct can shown to be the result of nor-\nmal commercial activities prevailing in the\nmarket; this did not apply in considering\nall three of these cases. Notwithstanding\nthat HASA (Hospital Association of South\nAfrica) had previously able to gain exemp-\ntion from section 4, that exemption was not\nconsidered in the hearing. The interpreta-\ntion of the Competition commission was\nbased on new evidence submitted in other\ncourt cases.\nMost importantly, we have learned that\nthe socio-economic policy objectives of the\nCompetition Act come second to efficiency\npractices. In fact, collusive practices allowed\nin the provider environment (arrangements\nbetween specialists and providers) are al-\nlowed as normal commercial practice for\nefficiency purposes [8; 13].\nIn fact, the reason behind all three judge-\nments by the Competition Tribunal, were as\na result of [13]:\n\u2022 Submissions made in other cases regard-\ning the conduct of HASA, BHF (Board\nof Healthcare Funders of South Africa)\nand SAMA (South African Medical As-\nsociation)\u00a0\u2013 as it relates to setting price\nbenchmarks;\n\u2022 On the basis of these submissions, an in-\nvestigation\/inquiry into the private health\nsector was conducted by the Competition\nCommission; and\n\u2022 The investigation focused on the price\nbenchmarking activities of the SAMA,\nBHF and the HASA.\nAs a result of the inquiry into the private\nhealth sector, emerging policy issues had\nsignificant impact on the health financing\nregulatory framework and market outcomes.\nSignificant observations\n\u2022 Anti-trust policy made in the interests\nof efficiency markets were not balanced\nwith socio-economic policy objectives;\ntherefore\n\u2022 The public interest intentions behind\nthe Competition Commission inquiry\ninto the health sector are an important a\nwindow of opportunity, the CMS policy\nagenda; and\n\u2022 Table 1 reports the significant policy is-\nsues and regulatory impact of the Com-\npetition Commission\u2019s intervention into\nissues related to RPL (Reference Price\nList).\nSOUTH AFRICA Health Care System\n72\nDefining Market Structure\nFrom Different Perspectives\nWillig [22] explains the analytic process re-\nquired to be undertaken, in order to, under-\nstand the different perspectives related to\npotential merger outcomes. Danzig states\nthe steps to this process:\n\u2022 An understanding the how product and\ngeographic markets delineated; i.e. prod-\nuct and geographic definition of market\nstructure;\n\u2022 Once discrete market demarcations are\nestablished, all the firms belonging to\neach market segment are to be identi-\nfied;\n\u2022 The market participants within each mar-\nket need to be taken into consideration\nwhen calculating and making interpreta-\ntions regarding market share and concen-\ntration;\n\u2022 On the quantification of market concen-\ntration and market shares, an assessment\nof how existing market conditions impact\nmarket rivalry and ease of access (concen-\ntration\/potential for abuse of power) need\nto be taken into consideration; Assessing\nease of entry;\n\u2022 Consideration of other factors may be\nmade; i.e. the outcome of an amalga-\nmation (merger) on market efficiency\nand public interest issues\/consumer\nwelfare.\nThis section proceeds to paint a picture of\nthe market structure from numerous di-\nmensions.The intentions is to provide a sit-\nuational analysis on how product and con-\nsumer demarcations of the market, could\npotentially impact solidarity. On the basis\nthat solidarity is affected positively or nega-\ntively, judgements can be made. To the ex-\ntent that market organization compromises\nor improves solidarity; a judgement could\nbe made on the implied effect of a prospec-\ntive amalgamation may have on community\nrating.\nSolidarity: Scheme VS.\nBenefit option level\nFigure 1 and 2 illustrates industry solidarity\nfrom two different perspectives. A picture\nof risk pool solidarity is provided at scheme\nlevel and at option level.\nSolidarity in medical\nschemes\u00a0\u2013 industry level\n\u2022 Overall the industry lost more than a\nthird of schemes over the review period;\nthe declining trend is likely to continue\nin the next few years, thus giving a posi-\ntive perspective of how consolidation has\nincreased the solidarity of both the open\nand restricted scheme markets.\n\u2022 The open* scheme sector saw a reduc-\ntion of nearly half 2012 from a level of 49\nschemes (2002) to 25 (2012);\n\u2022 The restricted** schemes sector saw a re-\nduction of nearly thirty (30) percent by\n2012 from a level of 94 schemes (2002)\nto 67 (2012);\nSolidarity in benefit options\u00a0\u2013\nindustry level\nSolidarity within risk pools does not share\nthe same patterns viewed from the perspec-\ntive benefit options (Figure 2). Benefit op-\ntions for restricted scheme show a constant\n* Health plans that accept all applicants regardless\nof health status\n** Health plans that are Employer based\nTable 1. Emerging policy issues & regulatory impact\n1. Consequences of Intervention by the Competition Commission (Comp.Com):\n\u2022 As a result providers and schemes could only negotiate prices on a bilateral agree-\nment between a single seller and single payer\n\u2022 Implication\u00a0\u2013 price divergence between tariffs and re-imbursement rates across\nproviders and payers\n\u2022 As a result, copayments increased and balanced billing was the result.\n\u2022 Subsequent attempts at instituting and independent reference list of prices by\nNDoH & CMS from 2004\/5 were unsuccessful\n\u2022 As a result; medical schemes offer cost sharing benefit options, these have been\neffected through:\n- Discriminatory structuring of supplementary benefits to the essential benefit\npackage\n- These have been effected through efficiency based options with out-of-net-\nwork penalties & financial limits on formularies\n2. Although RPL was supposed to be non-binding effective guideline on tariff levels; it\neffectively determined re-imbursement rates\n3. Providers are not able to recoup costs based on low RPL tariff rates\n4. At the risk of leaving the market\u00a0\u2013 doctors would have to generate revenue on high\nvolumes and not quality care\n5. RPL rates set as low rates\u00a0\u2013 means members are under-covered for true costs of\nhealth care\n6. There could not be any certainty in setting prices for scheme members, and uncer-\ntainty in benefit entitlements\n7. Low tariff rates would force providers to embark in double billing practices\n8. Financial viability of options would be prejudiced without proper cost productions by\nproviders included in RPL\nSOUTH AFRICAHealth Care System\n73\ntrend.That said; risk pool solidarity for open\nschemes show an increasing but moderate\ntrend.\nThe average number of benefit options per\nscheme in:\n\u2022 Open scheme benefit options increased\nfrom a base of 5 (2002) to 6 (2012) op-\ntions per scheme; and\n\u2022 Restricted scheme benefit options re-\nmained around two (2) benefit options\nper scheme on average.\nWhat may lie behind the different observed\npatterns at scheme and benefit option may\nbe related to the following factors:\n\u2022 Product diversification or proliferation\nmore benefit designs in open schemes,\nrelative to, restricted schemes;\n\u2022 The need to diversify against the chang-\ning demographic profile experienced in\nthe open scheme market. This occurred\nafter the establishment of the GEMS\n(Government Employees Medical\nScheme).\nSignificant observations\n\u2022 Changes in market structure from the\noverview at industry level shows strong\nconsolidation; that said\n\u2022 This scenario is not sustainable at the\nbenefit option level of market structure,\ni.e.:\n- Market structure from a product per-\nspective shows that scheme communi-\nties are potentially split as a result of\noption\/product diversification\n- This type of market rivalry is much\nstronger in the open scheme environ-\nment\n- This may have unintended consequenc-\nes for community rating\n- This observation may also be of interest\nto the Competition Commission\u2019s In-\nquiry into the Private Health Sector, as\nmarket structure is affected by product\ndiversification (benefit option prolif-\neration within schemes)\n2002 201120102009200820072006200520042003 2012\n0\n140\n120\n100\n80\n60\n40\n20\n160\nNumberofschemes\nOpen schemes\nRestrictes schemes\nConsolidated\nFigure 1. Schemes Solidarity\u00a0\u2013 Sector and industry level (2002\u20132012)\n2002 201120102009200820072006200520042003 2012\n0\n140\n120\n100\n80\n60\n40\n20\nNumberofbenefitoptions\nOpen schemes\nRestrictes schemes\nConsolidated\nSource: CMS annual reports 2002\u20132012\nFigure 2. Benefit option Solidarity\u00a0\u2013 Sector and industry level (2002\u20132012), figures in the\ngraph are rounded off.\nSOUTH AFRICA Health Care System\n74\nMarket Entrants\nDescribing the trends\nFigure 3 reports the number of new market\nentrants (new scheme registrations) from\n2002 to 2012.The development of new reg-\nistrations was as follows:\n\u2022 There were twelve new registered sche-\nmes;\n\u2022 Five of the twelve, were within the open\nscheme environment; and\n\u2022 The other seven, were within the restrict-\ned scheme environment\nOn the viability of new market\nentrants (2002\u20132012)\n\u2022 Six of the twelve new schemes were going\nconcerns (still in operations)\n\u2022 Five of the six going concerns were\nschemes from the restricted scheme en-\nvironment\n\u2022 One (1) of the six going concern schemes\nare within the open scheme environment\nSignificant observations\n\u2022 The consolidation that has occurred at\nthe industry level has been driven though\namalgamations and liquidations\n\u2022 There have been far less market entrants,\nand their survival rate has been 50%.That\nsaid,new scheme registration like GEMS,\nhave had a far reaching impact on the\nconditions of market rivalry and consoli-\ndation in the medical schemes industry\nOutcomes of Market Rivalry:\nAmalgamations & Liquidations\nAmalgamations (Mergers) &\nLiquidations (2002\u20132012)\n\u2022 There were a total of 63 schemes amal-\ngamations and liquidation between 2002\nand 2012:\n- 44% occurred in the open scheme envi-\nronment; and\n- 56% occurred in the restricted scheme\nenvironment.\n2002 201120102009200820072006200520042003 2012\n0\n7\n6\n5\n4\n3\n2\n1\nNumberofschemes\nSource: CMS annual reports 2002\u20132012,\nNWR: no new registration (excludes schemes registered and deregistered within 12 months)\n1 11\n1 1 1\n1 1\n2 2\n3 3\nNWR NWR\nLiquidations Amalgamations Total\nFigure 3. New scheme registrations (2002\u20132012)\n2\n3\n5\n1\n2\n3\n1\n5\n6\n3\n1\n4\n6\n5\n11\n2\n3\n5\n4\n3\n7\n1\n2\n3\n3\n1\n4\n4\n6\n10\n1\n4\n5\n2002 201120102009200820072006200520042003 2012\n0\n25\n20\n15\n10\n5\nNumberofmedicalschemes\nSource: CMS annual reports 2002-2012\nLiquidations Amalgamations Total Median\nFigure 4. Liquidations & amalgamations\u00a0\u2013 all schemes (2002\u20132012)\nSOUTH AFRICAHealth Care System\n75\n\u2022 The highest peaks of activity occurred in\n2003 and 2008 (10 and 11 liquidations\nand amalgamations, respectively). The\ntwin peaks are characterized by double\nthe market exit activity for the relevant\nperiod; i.e. the median of both amalga-\nmations and liquidations was five (5) for\nthe period (Figure 4).\nLiquidations (2002\u20132012)\n\u2022 There were a total of 28 liquidations;\n\u2022 These were 32% for open schemes and\n68% in the restricted scheme environ-\nment; and\n\u2022 Liquidations accounted 44% of market\nexits in the period over review.\nAmalgamations (2002\u20132012)\n\u2022 There were a total of 35 amalgamations;\n\u2022 Amalgamations accounted 56% of the\nmarket exits;\n\u2022 There were significantly more amalgama-\ntion in restricted schemes, 61% (n=23)\nthan open schemes,39% (n=15)\nPolicy Trajectory\nFigure 5 illustrates a projection of expected\nnumber of medical schemes. The projected\nis based on an exponential trend model de-\nrived from actual trends from 2001 to 2012.\nTherefore,the expected medical schemes are\nbased on a three year forecast. Based on the\nforecasted projection there will 64 medical\nschemes in 2016. This provides an estimate\nof the projected rate of consolidation in the\nindustry, and an estimated quantification of\nthe policy trajectory; assuming that trends\ncontinue as they did since 2012.\nMarket Concentration\n& Rivalry\nThe concept of market concentration was\nassessed using the Herfindahl-Hirschman\nIndex (HHI). HHI is a measure of market\nconcentration that incorporates the market\nshare of the largest firms within an industry\nor sector.This measure is defined as the sum\nof the squares of the market shares of the\nfifty largest firms within an industry, where\nthe market share is expressed as a propor-\ntion of the total market share.\nThe method applied in analysing\u00a0\u2013 the rela-\ntive extent of market participation (level\nof competition), and market concentration\n(level of market penetration)\u00a0\u2013 is based on\na similar used by Wholey and Morrisey\n[18;\u00a0 11]. In this analysis, the health in-\nsurance industry is divided into 8 market\nsegments. Market share calculations are\nbased health plan turnover in 2011. Arm-\nstrong and Kotler [1] describe how market\n2002 201120102009200820072006200520042003 2015\n0\n140\n120\n100\n80\n60\n40\n20\nNumberofMedicalSchemes\nActual\nForecast\nForecasting Model: Holt Exponential Smoothing Method for non-stationary trend data\n201420132012 2016\n160\n143\n85\n64\n71\n77\nFigure 5: Actual Trend vs. Forecast of the Number of Medical Schemes (2002\u20132016)\nTable 2. Market participation and penetration\nMarket segments\nMarket Participation:\n(%) of competing medical scheme\nMarket Penetration:\n(%) share of enrolees\nS 1 5 0.3\nS 2 5 0.2\nS 3 15 1.2\nS 4 24 3.4\nS 5 24 7.4\nS 6 15 16.3\nS 7 5 11.3\nS 8 4 59.9\nSource: developed by the authors\nSOUTH AFRICA Health Care System\n76\npositioning in targeted market segments\nimpacts of certain sale and thus gaining\ncompetitive advantage.\nTable 2 shows the relative degree of mar-\nket rivalry (health plan participation) and\nmarket concentration (market penetration).\nMarket participation quantifies the distri-\nbution of medical schemes across market\nsegments. Market participation quantifies\nthe distribution of beneficiaries covered by\nmedical scheme across all market segments.\nThe table below depicts that there is a dis-\nproportionate share of medical scheme en-\nrolees across the industry.\nProduct Diversification\nMost medical schemes offer multiple ben-\nefit options where contributions\/ premiums\nand access to benefits differ. Willie [20]\nand colleague [21], find that open schemes\n(individual plans) offer more benefit offer-\nings than restricted schemes (group plans).\nThe CMS annual report denotes that 55%\nof open scheme benefit options are mak-\ning losses and this different to the 45% in\nrestricted schemes. This is a worrying phe-\nnomenon in the industry in particular with\nregards to the principle of risk-pooling at\nbenefit option level, the medical schemes\nact clearly stipulates that benefit options\nneed to be self-sustainable.\nFigure 6 reports the average number of ben-\nefit offerings offered by open and restricted\nschemes, there are significantly more ben-\nefit options in open schemes compared to\nrestricted schemes (nearly as twice). The\naverage number of benefit options in the\nopen schemes market segments is generally\nhigher than the industry average of three\n(3).Overall,more than half (55%) of benefit\noptions in opens schemes on market seg-\nment 8 (2 market players who account for\n65% of open schemes) are in loss making\noptions. There is a high degree of product\ndifferentiation in the market segments and\nsuggesting variation in the risk characteris-\ntics of the individuals in those benefits op-\ntions making them less sustainable.\nFigure 7 extends on the analysis conducted\nby Morrisey [11] and Wholey [18].\nThe figure illustrates the market positioning\nof medical schemes across the industry.Two\nscenarios are presented, they are described\nbelow.\nScenario 1\n\u2022 Market structure and concentration ef-\nfects when all eight market segments\n(S1\u00a0to S8) are included in the analysis;\n\u2022 The trend shows the results of market\npositioning and market power across the\nindustry market segments;\n\u2022 There is a negative trend in terms of the\nproportion of scheme competing across\nmarket segments, and the proportion of\nenrolees covered by the medical schemes;\n\u2022 The share of market power is unequal and\nthus, resulting in less competition as one\nmoves across the market segments.\nScenario 2\n\u2022 Market structure and concentration ef-\nfects when all eight market segments\n(S1\u00a0to S4) are included in the analysis\n\u2022 The trend shows the results of market\npositioning and market power across the\nindustry market segments\n\u2022 There is a positive trend in terms of the\nproportion of scheme competing across\nmarket segments, and the proportion\nof enrolees covered by the medical\nschemes\n\u2022 The share of market power is more equal\nand thus, resulting in a more competitive\nmarket environment as one moves across\nthe market segments.\nTable 3 reports two different standard\nguidelines for triggering concerns about\nmarket abuse power. These are: An interna-\ntional standard used as an anti-trust guide-\nline\n5\n8.8\n3.9\n7.1\n2.4\n4.8\n1.6\n3.5\n1.21.4\n3.5\n10\n1 8765432\n0\n10\n8\n6\n4\n2\nAveregenumberofbenefitoptions\nSource: developed by the authors from the CMS annual reports, 2011\n12\nOpen schemes Restricted schemes Open schemes\nConsolidatedRestricted schemes\n1.66.2\n1.63.3\n1.62.2 3.0\nMarket segment\nFigure 6. Average number of benefit options by market sector and segment\nSOUTH AFRICAHealth Care System\n77\n\u2022 Trigger point for a moderate level of con-\ncern:\n- HHI of 1,000 points for an individual firm;\n- Percentage transformation 32% market\nshare for an individual firm.\n\u2022 Trigger point for a High level of concern:\n- HHI of 1,800 points;\n- Percentage transformation 42% market\nshare.\n\u2022 The South Competition Act guideline\n\u2022 Trigger point for a Moderate level of con-\ncern:\n- HHI of 1,225 points for an individual firm;\n- Percentage transformation 35% market\nshare for an individual firm.\n\u2022 Trigger point for a High level of concern:\n- HHI of 2,025 points for an individual\nfirm;\n- Percentage transformation 45% market\nshare for an individual firm.\nThe significance of what is reported in the\ntable (table 3) is; the trigger points in in-\nternational jurisdictions are, somewhat\nlower than what is prescribed by the South\nAfrican Competition Act. Table 4 reports\nthe relative market influence from different\n0 50302010\n0\n25\n10\n5\nMarketParticipation:\n%ofschemespermarketsegment\n20\n15\n30\n40 60\nMarket Penetration:\n% share of covered enrolees per market segment\nMarket Segment 1\u20138\n0 321\n0\n25\n10\n5\nMarketParticipation:\n%ofschemespermarketsegment\n20\n15\n30\n4\nMarket Penetration:\n% share of covered enrolees per market segment\nMarket Segment 1\u20134\nS8\nS6S3\nS7\nS4 S5 S4\nS3\nS1 & S2\nS1 & S2\nFigure 7. Market positioning of medical schemes\u00a0\u2013 8 vs. 4 market segments (2011)\nTable 3. Trigger point for concern of abuse of market\npower\nDescription\nTrigger Points\u00a0\u2013 Abuse of market\npower\nModerate level\nof concern\nHigh level of\nconcern\nindex (%) index (%)\nInternational\nstandard1 1,000 323\n1,800 423\nPrescription of\nSouth African\nCompetition Act2\n1,2253\n35 2,0253\n45\n1\n(Robinson, [14])\n2\nsection 7 of the South African Competition Act\n3\nGenerated using (Gaynor, [4]) method\nTable 4. Relative market influence of different industry market participants\n(2011)\nSector\/Industry\nMarket Concentration Indicators\nIndicator HHI2\nSquare\nroot of\nHHI3\nCategory index %\nHospitals Market (upstream) Hospital beds1\n2,273 48\nAdministrators Market (down-\nstream)\nBeneficiaries 2,498 50\nMedical Schemes Industry (non-\nprofit)\nRisk contribu-\ntion income\n1,157 34\nOpen Medical Schemes Market\n(non-profit)\nRisk contribu-\ntion income\n778 28\nRestricted Medical Schemes Mar-\nket (non-profit)\nRisk contribu-\ntion income\n379 19\n1\nData on hospital beds (van den Heever, [16])\n2\nMethod for calculating HHI\u00a0\u2013 (Baker, [2])\n3\nMethod for HHI transformation to percentage\u00a0\u2013 (Gaynor, [4])\nSOUTH AFRICA Health Care System\n78\nsides of the private health financing and\nprovider sector. The figure provides a con-\nsolidated index for HHI, and then splits the\nindex for restricted and open schemes. The\nreasons for the split are:\n\u2022 It would methodologically incorrect to\nreflect a combined HHI score for prod-\nuct markets which not direct substitutes;\n\u2022 Reflecting HHI score restricted schemes\nonly and open schemes only, as in other\nreports on the same axis with provid-\ners. Suggests, administrators and hospi-\ntals only exclusively accept either open\nscheme contract or restricted scheme\ncontract; that said\n\u2022 The HHI for restricted and open schemes\nis much lower than that of both adminis-\ntrators and providers.\nThe table (table 4) shows the level of market\nconcentration for, hospitals (upstream mar-\nket participants) and medical scheme ad-\nministrators (upstream market participants),\nare higher than that of medical schemes.\nThis is significant since, the downstream\nand upstream market participants are for-\nprofit entities. Since medical schemes are\nnot for-profit trust funds, incentives are not\naligned. Further to this, high market con-\ncentration levels yield greater profit margins\nfor profit making entities.\nDiscussion & Policy\nImplications\nLately, there have been numerous policy\nrecommendations emerging from research\nfindings. Most of the recommendations\nadvocate; greater market concentration in\nmedical schemes creates more bargaining\npower. Greater bargaining power for medi-\ncal schemes means better contracting ar-\nrangements with health care providers and\nthus; lower premiums for medical scheme\nbeneficiaries [10].\nWhat this analysis has shown is; mar-\nket structure needs to be scrutinized and\ndefined from many perspectives. This is\nnecessary, particularly in instances when\nvulnerable risk groups are covered by in-\ndividual contracts (open schemes), as\nopposed to, group contracts (restricted\nschemes). Gaynor has shown that, medi-\ncal schemes with vulnerable risk groups are\nnot able to contract low prices with man-\naged care providers [5]. As a result, the\nmarket contestability and sustainability\nof such health plans have waned. Wholey\nand colleagues found that there are scope\ndiseconomies in providing access to health\ncare services [19]. This outcome is to the\ndetriments of achieving affordable health\ninsurance policy objectives.\nReferences\n1. Armstrong, G. & Kotler, P., 2007. Marketing: An\nintroduction. 9th\ned.Upper Saddle River: Prentice\nHall.\n2. Baker, L., 2001. Measuring competition in\nhealth care markets. Health Services Research,\n36(1), pp. 223-251.\n3. Bateman, C., 2013. Whistle blast on the private\nhealthcare\u2019s \u2018zero sum game\u2019. South African Med-\nical Journal, 103(5), pp. 278-279.\n4. Gaynor, M., 2011. Health Care Industry Consoli-\ndation: Statement before The Committee on Ways\nand Means Health Sub-committee, Washington,\nD.C.: US House of Representatives.\n5. Gaynor, M. & Haas-Wilson, D., 1999. Change,\nconsolidation and competition in health care\nmarkets. Journal of Economic Perspectives, 13(1),\npp. 141-164.\n6. Hsiao, W., 1995. Abnormal economic in the\nhealth sector. Health Policy, Volume 32, pp. 125-\n139.\n7. Halse P, Moeketsi N, Mtombeni S, Robb G,\nVilakazi T, Weni Y,2012. Competition Com-\nmission of South Africa. The role of competition\npolicy in healthcare markets\u00a0\u2013 2011\/2012\u00a0 Com-\npetition Commission\u00a0Annual Report. Pretoria:\nSouth African Competition Commission.\n8. In the large merger between: Business ventures In-\nvestments 790 (Pty) Ltd (primary acquiring firm)\nand Afrox Healthcare Limited (primary acquiring\nfirm) (Case no. 105\/LM\/Dec 2004).\n9. Marquis, S., Beeuwkes Buntin, B., Escarce, J.\n& Kapur, K., 2007. The role of health product\ndesign in consumers\u2019 choices in the individual\ninsurance market. HSR: Health Services Research,\n42(6), pp. 2194-2223.\n10. Melnick, G., Shen, Y. & Wu, V., 2011. The in-\ncreased concentration of health plan markets can\nbenefit consumers through lower hospital prices.\nHealth Affairs, 30(1), pp. 1728-1733.\n11. Morrisey, M., 2001. Competition in hospital\nand healthcare insurance markets: a review and\nresearch agenda. HSR: Health Service Research ,\n36(1), pp. 191-221.\n12. Newhouse, P., 2002. Why is there a quality\nchasm?. Health Affairs, 21(4), pp. 13-25.\n13. Njisane,Y., van Buuren, A. & Blignaut, L., 2012.\nIn sickness and in health: Competition law in the\nhealthcare sector, Johannesburg: Edward Nathan\nSonnenbergs.\n14. Robinson, J. C., 2004. Consolidation and the\ntransformation of competition in health insur-\nance. Health Affairs, 23(6), pp. 11-24.\n15. Town, R. & Liu, S., 2003. The welfare impact\nof Medicare HMO\u2019s. Rand Journal of Economics,\n34(4), pp. 719-736.\n16. van den Heever, A., 2012. Review of Competi-\ntion in the South African Health System, Pretoria:\nSouth African Competition Commission.\n17.van den Ven, W., 2012. Risk adjustment and\nrisk equalization: what needs to be done?.\nHealth economics, Policy & Law, Volume 6, pp.\n147-156.\n18. Wholey,D.,Christianson,J.& Engberg,J.,1997.\nHMO Market Structure and Performance:\n1985-1995. Health Affairs, 16(6), pp. 75-84.\n19. Wholey, D., Feldman, R. & Christianson, J. &.\nE. J., 1996. Scale and scope economies among\nhealth maintenance organizations. Journal of\nHealth Economics, Volume 15, pp. 657-684.\n20. Willie, M., 2012. Caesarean section rates in\nlarge medical schemes in South Africa: An ex-\nplorative descriptive study. Journal of Medical\nResearch, 1(6), pp. 84-90.\n21. Willie, M. & Nkomo, P., 2010. Intra-class cor-\nrelation and multilevel analysis of contributions\ndata. First Global Symposium on Health Systems\nResearch. Montreux, s.n.\n22. Willig, R., 1991. Merger analysis, industrial or-\nganization theory and merger guidelines. Brook-\nings Papers on Economic Activity - Microeconomics,\nVolume 1991, pp. 281-332.\nMr. Michael Mncedisi Willie, Senior\nResearcher (until 30 April 2014),\nCouncil for Medical Schemes\u00a0\nMr. Phakamile Nkomo, Senior Policy\nAnalyst, Council for Medical Schemes\nSOUTH AFRICAHealth Care System\n79\nThe Indian Medical Association (IMA) was\nestablished in 1928 with 222 members as an\noffshoot of the Indian freedom struggle.The\nIMA was a founder member of the WMA\nin 1946. Any doctor of modern medicine\nirrespective of the field and discipline may\nbecome an IMA member voluntarily. The\nIMA has a three tier structure. The IMA\nheadquarters are in New Delhi. It has 29\nstate and 7 territorial branches. The current\nIMA membership is 230,000 embracing\nmembers of 1700 branches spread all over\nIndia.The IMA has a sub-district level rep-\nresentation in almost all 640 districts of the\ncountry. The IMA has a democratic struc-\nture.The office bearers are elected every year\nat all the three levels. Bicameral legislative\nbodies assist in decision making at all the\nlevels.\nThe IMA objectives focus on the advance-\nment of medical sciences, improvement of\npublic health and medical education, and\nupholding the honour and dignity of the\nmedical profession. The aim is to provide\naffordable, accessible and quality health\ncare for all. The IMA members have a\nstrong presence in the Medical Council\nof India and various state medical coun-\ncils which are statutory bodies to regulate\nmedical education and practice. The IMA\nis also represented in various committees\nof the central and state Governments. The\nIMA takes its role as a nation builder seri-\nously and voices the opinion of the peo-\nple. All legislation pertaining to health\nare carefully scrutinized and commented\nupon by the IMA. The Hhealth policy of\nthe country has substantial inputs from\nthe IMA which is the parent organiza-\ntion of numerous service and professional\norganizations. The IMA forms a bridge\nbetween the public and private sectors\nand also between various specialists and\nfamily physicians and acts as a coordina-\ntor for a national cause as well. The IMA\nis a member not only of the WMA, but\nalso of the Commonwealth Medical Asso-\nciation (CMA) and the Confederation of\nMedical Associations of Asia & Oceania\n(CMAAO). The IMA also works closely\nwith the World Health Organization\n(WHO) at national, regional and interna-\ntional levels.\nThe IMA prime responsibility is to update\nthe medical knowledge of its members\nthrough its continuing medical educa-\ntion programmes. The Association also\nconducts regular workshops and fellow-\nship examinations through its academic\naffiliations: the IMA College of Gen-\neral Practitioners, the IMA Academy of\nMedical Specialists and the IMA AKN\nSinha Institute. The IMA provides legal\nadvice to its members through profes-\nsional protection scheme. The Social Se-\ncurity Schemes, the Health Scheme and\nthe Pension Scheme are run by its various\nstate branches as welfare activities for the\nmembers.\nThe IMA is a major player in the public\nprivate mix for the National TB Con-\ntrol Programme. The IMA has sensitized\n87292 and trained 15099 private doctors\nin tuberculosis care. 4359 DOT centres\nand 93 microscopy centres have been ini-\ntiated by the IMA.The IMA played a ma-\njor role in India\u2019s successful polio eradica-\ntion programme. The Association directly\nmanages the entire biomedical waste of\nthe southern state of Kerala and assists in\nother states. Across the country the IMA\nruns several blood banks and in some\nstates handles as much as 20% of the blood\ndemand. Pain and palliative care centres\nare run by many local branches. Through\nthe initiative \u2018Aao Gaon Chalen\u2019 (Let us\ngo to the villages) the IMA is involved in\nholistic health care in 1040 villages. The\nIMA is a strong participant in the \u2019Save\nthe Girl Child\u2019 project in India\u2019s struggle\nagainst female feticide. The IMA has its\nown \u2018Care of the Elderly\u2019 programme and\nhas the capacity to execute PAN INDIA\nhealth surveys.The IMA has recently add-\ned a hospitals division\u00a0\u2013 the IMA Hospital\nBoard of India. The IMA serves as a fam-\nily circle in towns and villages of India for\nits members. The IMA participates in all\nthe National Health Programmes start-\ning from HIV-AIDS control to blindness\nprevention. The IMA remains a dynamic\ninterface between the people and the\nIndian Medical Association\nNarendra SainiJitendra B. Patel\nINDIA NMA News\n80\nBOSNIA AND HERZEGOVINANMA News\nBosnia and Herzegovina renewed its 1000-\nyear statehood in the process of the creation\nof new states as a result of the dissolution\nof Yugoslavia. A price of its independence\nwas bloodshed. The Dayton Peace Agree-\nment ensured peace but it did not make\nBosnia and Herzegovina a functional coun-\ntry. It consists of three parts: the Federa-\ntion of Bosnia and Herzegovina (BiH), the\nRepublika Srpska and the Br\u010dko District.\nBosnia and Herzegovina is a unique model\nof the state organisation that does not exist\nanywhere in the world.The state health care\nsystem is divided accordingly.\nThere is an additional division within the\nFederation of BiH. The Federation consists\nof 10 cantons. It is important to mention\nthat there is no single legal framework for\nhealth care at the level of Bosnia and Her-\nzegovina, and it is also divided into enti-\nties\u00a0 \u2013 the Federation and the Republika\nSrpska, while the health care in the Fed-\neration is organised at the level of cantons.\nThus, in Bosnia and Herzegovina there\nis one Ministry of Health in the Repub-\nlika Srpska, one Ministry of Health in the\nFederation, 10 Ministries at the level of 10\ncantons in the Federation and one Ministry\nof Health in the Br\u010dko District. There is a\ntotal of 13 Ministries of Health at the level\nof Bosnia and Herzegovina with slightly\nless than 4,000,000 inhabitants and slightly\nmore than 9,000 doctors of medicine. (This\ninformation is for the Guinness Book of\nRecords, but it is a result of the Dayton\nPeace Agreement). If health care were or-\nganised at the level of the State of Bosnia\nand Herzegovina, there would be the 14th\nMinistry of Health in this poor country ex-\nhausted by the war.\nThe budget amounts for health care differ\nsignificantly from one canton to another\nwith 5,600 doctors working in the Fed-\neration. Political divisions to entities and\ncantons were not beneficial for the health\ncare system that has been trying to be ef-\nfective and functional, and in the mutual\ninterest of doctors and patients. Such dif-\nferences discriminate not only patients\nin terms of providing health care services\nbetween the \u201crich\u201d and the \u201cpoor\u201d cantons,\nbut also discriminate doctors who work in\nthe 10 different health care systems in the\nFederation. The number of doctors ranges\nfrom 2,300 in the Sarajevo Canton (SC),\n1,400 in the Tuzla Canton (TC), 700 in\nMostar (HNK), 680 in the Zenica Canton\n(ZDC), 334 in the Biha\u0107 Canton (USC),\n343 in the Travnik Canton (CBC), 96 in\nthe Livno Canton (HBC), 72 in the \u0160iroki\nBrijeg Canton (WHC), 48 in the Ora\u0161je\nCatnon (PC) and 24 in the Gore\u017ede Can-\nton (BPC). Proportionally, the health care\nbudgets vary from one canton to another,\nbut such dynamics worsens the quality of\nhealth care and working conditions for\ndoctors in those cantons. It is compensated\nnot only with cooperation in the provision\nof health services between the \u201crich\u201d and\nthe \u201cpoor\u201d cantons, but also with the health\ncare systems of the neighbouring coun-\ntries (Croatia and Serbia for the Republika\nSrpska).\nThe main task of the Ministry of Health of\nthe Federation of BiH is to decide on the\ndevelopment of the health care system in\nthe Federation harmonising the 10 legal\nSome Specific Features of the Health Care System and Working\nConditions of Doctors in the Federation of Bosnia and Herzegovina\nHarun Drljevi\u0107\nGovernment of India playing a proactive\nrole in health issues.\nMany IMA state branches have ethics com-\nmittees receiving complaints from patients\nand sometimes from fellow doctors. The\nIMA exerts peer pressure to correct its errant\nmembers. One of the major ethical issues is\nfees splitting between the referring doctors\nand hospitals, scan centers and laboratories.\nNow patients can avail of the IMA fixed\nrates for scans. The High Court upheld the\nright of the IMA to regulate its members.\nFemale feticide remains an important ethi-\ncal issue where the IMA has played a signif-\nicant role to regulate its members.The IMA\nis legitimately concerned about the conflict\nof interest between the medical profession\nand the hospital industry. The IMA holds\nthe view that any health care institution\ninvolved in patient care should uphold the\nethics and etiquette of the medical profes-\nsion.\nDr. Jitendra B. Patel\nDr. Narendra Saini\nNational President, IMA\nHonorary Secretary General\nNMA NewsBOSNIA AND HERZEGOVINA\ncantonal health care strategies in the 10\ncantons of the Federation. The further is-\nsue is harmonising the development of the\nhealth care system in the Federation be-\ntween the \u201cpoorer\u201dand the \u201cricher\u201dcantons.\nHow could it be done if the establishment\nof good health care system depends upon\nthe political stability in the state which is\ncurrently non-existent.\nThe same issues are equally important for\nthe Medical Chamber of the Federation,\nthough in a different way: how to ensure\nequal working conditions for doctors, for\ntheir professional development and ad-\nvancement, for CME in the Federation,\nunhindered flow of doctors from one can-\nton to another, i.e. how to eliminate dis-\ncrimination among colleagues that arises\nmerely from the fact that doctors work in\ndifferent cantons. While the WMA is deal-\ning with equalizing standards for doctors in\nentire Europe and in the world,the Medical\nChamber of the Federation is trying to do it\nin the Federation of BiH and entire Bosnia\nand Herzegovina.\nIf we want to provide good level health care\nservices, then the medical space in Bosnia\nand Herzegovina must be free and open for\nall patients and doctors. There must be no\nrigid administrative or political boundaries\nin that unique health space.There should be\na principle of solidarity among the health\ncare institutions of the same or different\nlevel.\nAnswers to these questions should be\nsought not only in a new, better organisa-\ntion of the health care system of the Federa-\ntion but also in the use of all available health\ncare benefits and medical capacities in the\nFederation of BiH including entire Bosnia\nand Herzegovina.\nPrim.dr. Harun Drljevi\u0107\nPresident of the Medical Chamber\nof the Federation\nof Bosnia and Herzegovina\n35th\nWorld Medical and\nHealth Games\nMEDIGAMES will take place in Wels (Upper-Austria), from\nJune 21 to 28 2014.\nMany participants from more than 30 countries already con-\nfirmed their registration, so join them shortly! Massages and\nmedical care on the afternoons, visit of the city of Wels, climb-\ning initiation, gokart race... we prepare you lots of nice surprises!\nDo not forget that you have the possibility to take part to vari-\nous competitions! This is a nice opportunity to test yourself on a\ndiscipline that you usually don\u2019t practice in competition.\nIf you wish to take part to our Congress, please send us your ab-\nstract by email to fanny@medigames.com\nFor any further information, contact us by email to\ninfo@medigames.com or by phone to 0033 1 77 70 65 15.\nThe Organising Committee\nIV\nContents\nPhysicians should routinely ask their women patients about domes-\ntic abuse where they have reason to suspect violence.\nProfessor Sir Michael Marmot, speaking in Geneva, said that phy-\nsicians should ask about domestic abuse more often so that it nor-\nmalises the question. He said domestic violence was a global pub-\nlic health concern with one in three women throughout the world\nexperiencing physical and\/or sexual violence by a partner or sexual\nviolence by a non partner.\nSir Michael, Director of University College London Institute of\nHealth Equity, and chair of the World Medical Association\u2019s Socio-\nMedical Affairs Committee, was speaking at a luncheon seminar\nduring the World Health Assembly, organised by the WMA and\nthe International Federation of Medical Students\u2019 Associations.\nHe outlined the extent of domestic violence around the world and\nsaid that in many countries married women believed a husband was\njustified in beating a wife if she refused to have sex.Education,how-\never, is key, he said. The more educated women are the less likely\nthey are to think that violence from a husband is justified.\nSir Michael said that although domestic violence was evident across\nall classes, economic and ethnic groups, the statistics showed that\nthis pattern of behaviour was more prevalent among the less well\neducated. A study among nine countries showed that those women\nmost likely to report having experienced violence were married at a\nyoung age, had multiple children and a family history of domestic\nviolence between their parents.\nAs well as resulting in murder and injury, domestic violence also\nled to suicide, induced abortions, depressive disorders and alcohol\nproblems. And women with mental health disorders were also more\nlikely to have experienced domestic violence.\nSir Michael said that physicians and health professionals had to be\nmore active in this field. Staff training in equality and diversity is-\nsues should be improved so that physicians and others could detect\nmore easily cases of abuse among their patients and could ask rel-\nevant questions.\n\u2018For instance, much domestic abuse starts during a woman\u2019s preg-\nnancy and physicians should be aware that asking questions during\nthis time is particularly effective.Previously silent women may come\nforward because of fear of harm to their baby\u2019. In addition, he said,\nwomen and girls should be empowered through education and so-\ncial support.\nDr. Margaret Mungherera, WMA President, who also spoke, said:\n\u2018Domestic \u201cGender Based Violence\u201d is only one of the many forms\nof violence that women experience worldwide.In conflict situations,\nsexual violence is common and is often associated with physical vio-\nlence and abductions. Unwanted pregnancies, HIV\/AIDS, mental\ndisorders and traumatic fistula are common complications. \u2018In ad-\ndition, low use of family planning services has also been associated\nwith GBV and hence the need to integrate such services into the\nreproductive health services. It is also important that GBV is in-\ncluded in the pre-service training and continuing education cur-\nricula of physicians and other health workers. GBV services should\nbe integrated into mental health and primary care services and these\nshould be made available universally.\n\u2018The recent kidnapping of young Nigerian girls illustrates in the most\nhorrific way this devastating scourge. It is not enough to deplore the\nmagnitude of the phenomenon.Urgent,strong and concrete policies\nmust be taken now with the participation of all sections of society,\nincluding the health sector, to meet this major global public health,\ngender equality and human rights challenge.\u2019\nPhysicians Urge Action on Violence against Women and Girls\nThe 197th\nCouncil meeting of the World Medical\nAssociation was held at the Hotel Nikko,Tokyo,\nJapan from April 24 to 26. WMJ Council Report . . . . . . . 41\nThe adress of the Prime Minister of Japan\nMr. Shinzo Abe in the WMA Council Session . . . . . . . . . 49\nSecretary General Report to the 197th\nWMA Council\nSession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50\nMulti-media Educational Tool Increases Knowledge\nof Clinical Trials in Uganda . . . . . . . . . . . . . . . . . . . . . . . . 64\nMarket Structure in the South African Health Care\nSystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70\nIndian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . 79\nSome Specific Features of the Health Care System and\nWorking Conditions of Doctors in the Federation\nof Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . . . . . . . 80\n35th\nWorld Medical and Health Games . . . . . . . . . . . . . . . III\n\n<\/p>\n"},"caption":{"rendered":"

wmj201402 COUNTRY \u2022 The 197th Council Meeting \u2022 Market Structure in the South African Health Care System vol. 60 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 2, May 2014 Cover picture from LATVIA Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 […]<\/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\/wmj201402.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3665"}],"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=3665"}]}}