WMJ 02 2014

COUNTRY
• The 197th
Council Meeting
• 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
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Dr. Margaret MUNGHERERA
WMA President
Uganda Medical Association
Plot 8, 41-43 circular rd., P.O. Box
29874
Kampala
Uganda
Dr. Leonid EIDELMAN
WMA Chairperson of the Finance
and Planning Committee
Israel Medical Asociation
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P.O.Box 3566, Ramat-Gan 52136
Israel
Dr. Masami ISHII
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Cecil B. WILSON
WMA Immediate Past-President
American Medical Association
515 North State Street
60654 Chicago, Illinois
United States
Sir Michael MARMOT
WMA Chairperson of the Socio-
Medical-Affairs Committee
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
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Belgium
Dr. Xavier DEAU
WMA President-Elect
Conseil National de l’Ordre des
Médecins (CNOM)
180, Blvd. Haussmann
75389 Paris Cedex 08
France
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Treasurer
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Mukesh HAIKERWAL
WMA Chairperson of Council
2/174 Millers Road/PO Box 577
Altona North, VIC 3025
Australia
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
01212 Ferney-Voltaire
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World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
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41
WMA News
Delegates from more than 30 national
medical associations were welcomed by the
Deputy Governor of Tokyo, Tatsumi Ando.
He delivered a brief speech on behalf of the
Governor who was not able to attend, say-
ing that Japan was experiencing an unprec-
edented ageing society. From the year 2020
the population of Japan would start to de-
cline and in 2025 one in every four residents
in Tokyo would be older than 65. With this
ageing population, the demand and the
need for health care services would grow.As
a result Japan had been developing a society
where everyone could have peace of mind
in terms of receiving health care services.
Moving forward they would like to develop
services where everyone would secure qual-
ity care at home.
Dr. Mukesh Haikerwal, Chair of Council,
thanked Mr. Ando and then opened the
formal Council proceedings. Dr. Otmar
Kloiber, Secretary General, gave apolo-
gies and introduced two new members of
Council, Dr. Walter Vorhauer from France
and Dr. Kenji Matsubara from Japan.
Dr. Margaret Mungherera, President of
the WMA, presented an interim report on
her Presidency, giving details of the many
meetings she had attended and thanking
those NMAs that had hosted her visits. She
spoke about progress on her Africa medi-
cal initiative to support the role of African
national medical associations by strength-
ening the health systems in their country.
She reminded delegates that only 21 out of
the 54 African NMAs were members of the
WMA.
Dr. Kloiber presented his detailed written
report of the secretariat’s activities over the
year (see box) and highlighted several issues.
He referred to the comments that
Dr.  Mungherera had made in Uganda at
the time when the Ugandan Government
was introducing legislation stigmatising ho-
mosexuals and proposing punishment. He
said it had taken a lot of courage for her to
speak out on television in Uganda against
this legislation.
He said he had attended a recent conference
of the International Association of Patients
Organisations and had spoken on the issue
of universal access to health care. The con-
cept was still very cloudy and not ambitious
enough.What the WMA was asking for was
more than universal health care by looking at
the social determinations of health and it was
time to take this further step.
WMJ Council Report
The 197th
Council meeting of the World Medical Association was held at the Hotel Nikko,
Tokyo, Japan from April 24 to 26
42
WMA News
He also spoke about continuing medical ed-
ucation and continual professional develop-
ment and the growing dissatisfaction with
the current ways of dealing with these issues
in rigid frameworks of recertification. The
bureaucracy involved was not welcomed
by physicians who wanted something more
tangible that led to better outcomes in pa-
tient treatment if they had to undergo such
a bureaucracy.
He then alerted the meeting to a problem
that was approaching on the international
non-proprietary names of medicine, what
were called the generic names of medicine.
This was a consequence of the new classes
of medicines that were far more compli-
cated than conventional medicines. The
structure of how the names were given,
their classification and how they were be-
ing reimbursed were all issues that were
likely to become an important topic in the
near future.
Dr. Haikerwal gave his interim report as
Chair and spoke about the WMA’s work to
increase the level of awareness of health as
a core component of a successful and fair
society. Health was a wise investment and
brought with it human, political and eco-
nomic dividends. Physicians were actually
part of the solution in health and health
care research and planning implementa-
tion. But too often international organisa-
tions chose not to work with physicians.The
WMA’s aim was to emphasise the role of
physicians as a solution.
Medical Ethics Committee
The Medical Ethics Committee met under
the chairmanship of Dr. Heike Pälve (Fin-
land).
Person Centered Medicine
Dr. André Bernard (Canada), Chair of the
Workgroup on Person Centered Medicine,
reported on progress in developing a new
policy document. He said there was still a
lack of consensus on this subject and the
question was whether the definition of per-
son centered medicine needed to be broad-
ened. He suggested that further discussion
and debate were needed before proceeding.
After a brief debate it was decided to rec-
ommend to Council to authorise the Work-
group to develop a discussion paper as an
explanatory note with the aim of facilitating
consensus among members.
Databases
Dr. Kloiber highlighted the importance of
revising WMA policy on health databases
and biobanks.The part of the revised Decla-
ration of Helsinki that related to the second-
ary use of material information from clinical
research led to the question of how to deal
with data information and material in health
databases or in biobanks. This had the po-
tential to be one of the key WMA policies.
Dr. Jon Snaedal (Iceland), Chair of the
Workgroup on Health Databases and Bio-
banks, reported on progress in drafting a
Declaration on Ethical Considerations
regarding Health Databases. A successful
meeting had been held in Reykjavik and an-
other meeting was planned for August. He
also spoke about the possibility of a wider
discussion.
During a brief debate it was recommended
that the title of the document should be
extended to include biobanks. It was also
suggested that there was a need for urgency
in developing policy because of legislation
passed by the European Commission and
Parliament which included a new concept
of broad consent instead of individual con-
sent.The WMA needed a speedy answer to
this in a new policy document.
The committee recommended to Council
that the proposed Declaration be circulated
to NMAs for comment along with a list of
key questions relating to the topic. It was
also suggested that NMAs might want to
consult outside groups.
Classification of Policies
The committee recommended rescinding
and archiving WMA Statements on Hu-
man Organ Donation and Transplantation
and on Human Tissue for Transplantation
as these were now covered by new State-
ments.
Norihisa Tamura Yoshitake Yokokura Tatsumi Ando Margaret Mungherera
43
WMA News
Human Rights
Clarisse Delorme, the WMA’s Advocacy
Advisor, reported on the work undertaken
to support the Turkish Medical Association
in its opposition to a new law criminalising
medical professionals helping in emergen-
cies and in the legal action taken against
the Association regarding the health ser-
vices provided by it during the Gezi Park
protests.
The WMA had also been involved in advo-
cacy activities in support of the WHO reso-
lution ‘Strengthening of palliative care as a
component of integrated treatment within
the continuum of care’. This has been ad-
opted by the WHO Executive Board in
January this year with a broad consensus
and Ms Delorme said she was confident
that this resolution would be adopted by the
World Health Assembly in May.
Finance and Planning
Committee
In the absence of the Chair, Dr. Leonid Ei-
delman,the committee was presided over by
Dr. Haikerwal.
Membership Dues Payments
A report was given by the Financial Adviser,
Mr. Adi Hällmayr, who said there had been
an increase in membership dues.
Financial Statement
Mr. Hällmayr provided a detailed explana-
tion of the pre-audited Financial Statement
for 2013 and the committee recommended
that it be sent to Council for approval.
New Dues Structure
The Treasurer,Prof.Dr.Frank Montgomery,
gave an oral report on the new dues struc-
ture and said the financial situation of the
WMA was well balanced.
Strategic Plan
Dr. Kloiber reported on progress in im-
plementing the strategic plan and its four
major sections – ethics, advocacy and rep-
resentation; partnership and collaboration;
communication and outreach; and opera-
tional excellence.
Business Development
Prof. Vivienne Nathanson, Chair of the
Business Development Group, sum-
marised progress on the round table ini-
tiative. The first meeting had taken place
last September and the second meeting
was imminent. She said that future meet-
ings should take place in North America
or Europe, possibly parallel to the World
Health Assembly.
Future WMA Meetings
The committee considered planning for fu-
ture Assemblies and recommended that As-
semblies should be held in Taipei, Taiwan
in 2016, in Chicago, USA in 2017 and in
Reykjavik, Iceland in 2018.
Declaration of Helsinki
It was decided that this year’s 50th
anniversary
of the Declaration of Helsinki should be cel-
ebrated with a special ceremony in Helsinki
on November 11 2014.It was agreed that this
should be recommended to the Council. A
celebratory book had been published, mark-
ing the 50th
anniversary,and it was agreed that
this should be used by the WMA as a gift.
Membership
The committee considered an application
for membership from the Ordre National
des Medicins de Guinée and recommended
to Council that it be forwarded to the As-
sembly for approval.
Associates report
Reports were received from the Associate
Members, the Juniors Doctors Network (add)
and the Past Presidents and Chairs of Council.
The total number of Associate Members whose
annual subscriptions have been paid was 818.
Cecil B. Wilson Xavier Deau Mukesh Haikerwal Masami Ishii
44
WMA News
Outreach
Reports were received from the editor of the
World Medical Journal and from the Public
Relations Consultant.
Presidential Elections
Following the decision at the General As-
sembly in Brazil to lift the suspension of the
inauguration as President of Dr. Ketan De-
sai (India), a debate took place on the tim-
ing of his Presidency. The suspension was
imposed in October 2010 when Dr. Desai
was unable to attend for his inauguration
following charges filed against him in India.
Dr. Haikerwal said the Indian Medical As-
sociation had requested that Dr. Desai be
reinstalled as President following the with-
drawal of charges.
After a debate it was decided that the com-
mittee should recommend to Council that:
• nominations for President in 2015 be
called for at the 2014 Assembly;
• there be no election at the 2015 Assembly
for President in 2016;
• Dr. Desai be inaugurated as President in
October 2016 as long as he remains in
good standing pursuant to WMA byelaws.
Socio-Medical Affairs Committee
Sir Michael Marmot (British Medical As-
sociation) took the chair.
Health and the Environment
Dr. Shin (Korean Medical Association) re-
ported on the environment caucus that had
taken place that day, when the outcome
of the 2013 Global Climate and Health
Summit had been discussed as well as the
report of the Intergovernmental Panel on
Climate Change. Dr. Shin said they had
discussed the importance of ministers of
health in every country being involved in
these issues, as well as the WHO’s role. It
was agreed that the WMA should con-
tinue working on the impact of climate
change on health.
Health Care in Danger
Prof. Nathanson, Chair of the Workgroup,
reported on the activities of the group, in-
cluding the development of a toolkit for
health professionals addressing potential
difficulties faced by health professionals
working in situations of conflict.The toolkit
aimed to provide a framework of practical
responses to the ethical conflicts physicians
might come across.
Chemical Weapons
It was reported that the Workgroup had
not yet met, but Prof. Nathanson offered
to draft a document on behalf of the
group to present to the meeting in Dur-
ban.
Violence Against Women
The committee heard that a WMA side
event on this issue would take place during
the World Health Assembly in Geneva on
May 20. Several delegates reported on work
their NMAs were undertaking in this area,
particularly relating to the linked issue of
child abuse.
Recruitment of Physicians
The committee considered a proposed
revision of the 2003 Statement on Ethi-
cal Guidelines for Recruitment of Physi-
cians and a shorter amended version by
the American Medical Association. Some
delegates wanted to see the AMA draft
recirculated among NMAs for comment.
But Dr. Haikerwal said this was an issue
of concern in every country he had visited
and was a matter of some urgency. After
a brief debate it was decided to postpone
further discussion until the meeting of
Council.
Non-Commercialisation of
Human Reproductive Material
The committee considered a revised version
of the Resolution on Non-Commerciali-
sation of Human Reproductive Material
written by the Israel Medical Association.
The draft had received many comments.The
chairman proposed that in the absence of
Guy Dumont Frank Ulrich Montgomery Jon Snaedal Sir Michael Marmot
45
WMA News
any delegates from Israel, the paper should
be reconsidered by the Israel Medical As-
sociation in the light of the comments made
for further debate at the meeting in Dur-
ban.This was agreed.
Reality TV
Dr. Haikerwal reported that the Israel
Medical Association had agreed to with-
draw a draft document it had submitted on
the role of physicians in reality TV.
Trafficking
A proposed Resolution from the Spanish
Medical Association on the Role of Phy-
sicians in Preventing the Trafficking with
Minors and Illegal Adoptions was consid-
ered.
The meeting heard a report about the ac-
tivities being undertaken at the University
of Granada in Spain on this problem, help-
ing countries to develop DNA databases
about missing children and their relatives.
This had led to more than 800 children be-
ing identified and returned to their fami-
lies.
During the debate that followed, delegates
agreed that this was an important matter,
although it was tied up with the wider is-
sue of trafficking. It was decided that the
WMA was not in a position to involve
itself in this sort of work. However it was
agreed to recommend to Council that a
Workgroup be set up to undertake further
consideration of this matter and to submit
a revised text for consideration at the next
meeting in Durban.
Aesthetic Treatment
The Swedish Medical Association updat-
ed the committee on its proposed State-
ment on Aesthetic Treatments which
had arisen from two documents, one on
aesthetic treatment for minors drafted
by the Israel Medical Association and a
broader document from the Sweden. A
combined document had been circulated
to NMAs for comment. Delegates were
reminded that the reasoning behind these
documents was the absence of regulations
governing aesthetic treatment, partly be-
cause of the question about whether it
was really health care.There were circum-
stances in which aesthetic treatment was
more cosmetic than medical. It was in
an effort to protect people that the draft
Statement had been produced. The docu-
ment as written was addressed primar-
ily to physicians although it was hoped
it would encourage other practitioners
performing aesthetic treatment to adopt
these principles.
During the debate that followed there was
discussion about whether the document
should be directed to physicians only and
whether the title should be changed to
Statement on ‘Aesthetic Medical Treat-
ments’. On a vote it was decided not to
change the title. The discussion about
whether the document should refer to
‘practitioners’ or to ‘physicians’ illustrated
sharp differences of opinion. As a result it
was decided to recommend to Council that
the document, as retitled, be recirculated to
NMAs for comment after being revised by
the Swedish Medical Association.
Physicians Wellbeing
The committee considered the proposed
Statement on Physician Wellbeing drawn
up by the Junior Doctors Network. Del-
egates congratulated the JDN on its work,
and several NMAs said this was an area
on which they had also been working. The
general view was that doctors were not
good at looking after their own health,
with some refusing to seek help because
of privacy and confidentiality. It was sug-
gested that more attention should be
paid to the issue of the mental health of
physicians and substance-abusing physi-
cians. After several speakers referred to
the need for the document to be expanded
and strengthened, it was decided to set
up a Workgroup to submit a more com-
prehensive policy for consideration at the
next meeting. It was agreed to recommend
to the Council that membership of the
Workgroup should be representative of
the various regions of the world.
Vivienne Nathanson Dong Chun Shin Adi Hällmayr Heikki Pälve
46
WMA News
Social Determinants
Plans were discussed for holding a confer-
ence on the role of physicians and NMAs in
addressing the social determinants of health
and health equity. The proposal was for a
two-day conference to be held in London in
March 2015, jointly organised by the Brit-
ish and Canadian Medical Associations and
the Institute for Health Equity. The aims
of the meeting would be to look at what
NMAs could do in their own countries with
their governments, to look at clinical-level
practice and to create an international net-
work of physicians and medical associations
working on this issue.
The committee agreed to recommend to
Council that arrangements should go ahead
for the conference in London.
It was also reported that the subject of the
social determinants of health was on the
agenda for an African conference under
WMA auspices also due to be held next
March. It was hoped that the 54 countries
of the African continent would come to-
gether at this conference.
Air Pollution
A proposed Statement on the Prevention of
Air Pollution and Vehicle Emissions was in-
troduced by the Austrian Medical Chamber.
It was argued that the WMA should have
a policy on what was a global problem. The
Statement referred to the negative health
effects of air pollution and called for a re-
duction in vehicle particulate matter emis-
sions through the implementation of Euro
emission standards, and recommended the
installation of soot filters for all new vehicles
and the retrofitting of existing ones. It also
called on NMAs to raise awareness of these
negative health effects, and to advocate via
their national governments for the introduc-
tion of compulsory emission standards as a
measure to promote clean air and a healthier
environment. The draft Statement said that
air pollution reduced life quality for hun-
dreds of millions of people worldwide, caus-
ing a large burden of disease, as well as eco-
nomic loss and costs in the health systems.
This prompted a debate in which the Japan
Medical Association reported on the mea-
sures taken in their country against air pol-
lution. Japan used to have a major pollution
problem, but now had the world’s leading
measures against air pollution. They had
learned a lot in the process. They had ex-
perienced lots of long term litigation which
had been settled and had introduced various
standards from the US and Europe. As a re-
sult the country now had the most stringent
standards for air pollution.
Speakers said that this was a crucial issue
which needed further consideration and
after further debate the committee rec-
ommended to Council that the proposed
Statement be circulated among NMAs for
comment.
Solitary Confinement
A proposed Statement on Solitary Confine-
ment was presented by the Finnish Medical
Association. The paper sets out guidelines
about the physician’s role in solitary con-
finement,which,it says,should only be used
as a last resort, and never as a prolonged
punishment. A brief debate took place on
the inhumane treatment experienced by
prisoners who suffer solitary confinement,
particular those suffering from mental ill-
ness.The problems of how to deal with par-
ticularly violent prisoners or prisoners who
needed protection from themselves were
also raised.
It was agreed to recommend to Council
that the document be circulated to NMAs
for comment.
Protection of Health Care Workers
The German Medical Association proposed
that the WMA should draw up a stronger
policy on the issue of protecting health care
workers, particularly in the light of recent
events in Syria, Turkey and Ukraine, where
medical personnel and facilities had been
deliberately targeted by the police and se-
curity forces. Physicians had been exposed
to intimidation and prevented from car-
rying out their ethical duties. A proposed
Declaration on the Protection of Health-
care Workers in Situations of Violence was
put forward, focusing on the obligations of
Julia Seyer Clarisse Delorme Greg Koski André Bernard
47
WMA News
physicians rather than governments. It was
agreed to recommend that the document be
circulated for comment.
Street Children
The Conseil National de l’Ordre des Mé-
decins introduced a proposed Statement on
Protecting Health Support to Street Chil-
dren. The committee was told that the doc-
ument’s aim was to raise awareness of the
scale of the problem. These children were
the victims of urbanisation and economic
deprivation. They were excluded from soci-
ety, from education, health care and family
care. The first link should be the doctor-
child relationship.
During a brief debate it was suggested that
the WMA should seek to find out why
street children existed and to protest about
their existence. It was argued that there
should be a way of finding homes for all
people and particular children. It was also
suggested that the issue of protecting these
children from unethical research should be
considered. The committee agreed to rec-
ommend that the document should be cir-
culated to NMAs for comment.
Classification of Policies
The committee agreed to recommend that
the WMA Statement on Health Emergen-
cies Communication and Coordination be
rescinded and archived, that the Statement
on Water and Health be reaffirmed with
minor revision and that the Resolution on
World Federation for Medical Education
Global Standards for Quality Improvement
of Medical Education be reaffirmed.
Dr. Kloiber explained that the standards
had recently been updated by the WFME.
They had been well accepted all over the
world. Now there was a revision of the
WFME standards for post graduate medi-
cal education and CPD and he suggested
that a small Workgroup be set up to con-
sider the documents and make recommen-
dations. The committee agreed to recom-
mend this.
Advocacy
The committee received an oral report
from the new Chair of the Advocacy Advi-
sory Group, Dr. André Bernard. He spoke
about plans for the publication of the book
commemorating the 50th
anniversary of
the Declaration of Helsinki and how vari-
ous stakeholders might use it. He referred
to the advocacy training session being
planned for the scientific session at the
General Assembly in Durban in October
around the question ‘Can physicians be ac-
tivists for change with respect to universal
access to health care?’ and it was agreed to
broaden this question to include social de-
terminants of health. Dr. Bernard stressed
the importance of advocacy and communi-
cations being integrated into the WMA’s
work.
Millennium Development Goals
Sir Michael Marmot referred to the enor-
mous activity going on about MDGs post-
2015. He said the problem for the WMA
was finding the right forum to influence
this important debate and how to broaden
the goal of universal health coverage to in-
clude social determinants of health. He said
the way forward should be for the WMA
to make a strong statement at the Assembly
in Durban.
Alliance for Clinical Research
Excellence and Safety
The meeting heard a presentation by Dr.
Greg Koski, President and Co-founder of
the Alliance, with the request for greater
collaboration between the WMA and
ACRES. (see page….?)
African Medical Initiative
The President, Dr. Mungherera, brought
the meeting up to date with her initiative
to involve African NMAs more in the ac-
tivities of the WMA.She said globally there
had been progress in making people health-
ier. But there had been hardly any progress
in Africa.This was the continent with some
of the lowest health indices in the world.
While Africa had 11 per cent of the world’s
population it had a much higher level of
the disease burden. Forty-nine per cent of
the women who died in the world from
childbirth related problems were in Africa
and 50 per cent under five-year-olds who
died were in Africa. Sixty-seven per cent of
HIV/AIDs cases were in Africa. She said
her Presidential initiative was based on the
fact that only about 20 of the 54 national
medical associations in Africa were mem-
bers of the WMA and only about five were
actively participating in WMA discussions.
Africa’s poor health indices were largely be-
cause of weak health systems and poor uni-
versal health coverage and access.She want-
ed to see not only more African NMAs join
the WMA, but also increased participation
by those NMAs that were members. It was
also important that African NMAs influ-
enced their governments’health policies.To
achieve this it was necessary to strengthen
the capacity of African NMAs in medical
education, continuing professional develop-
ment and national health policies.Nigel Duncan
48
WMA News
Council
Under the chairmanship of Dr. Haikerwal,
the Council met to approve reports from
the three committees.
The reports of the Medical Ethics Commit-
tee and the Finance and Planning Commit-
tees were agreed with little debate.
Discussion took place on several items from
the Socio-Medical Affairs Committee.
Ethical Guidelines for the Interna-
tional Recruitment of Physicians
Further debate took place on the document
produced at the committee by the American
Medical Association. This set out a series of
recommendations which should govern the
recruitment of physicians,including a propos-
al that countries wishing to recruit physicians
from another country should only do so in ac-
cordance with the provisions of a Memoran-
dum of Understanding entered into between
the countries. An amendment was agreed
under which countries recruiting physicians
should ensure that recruiters provided full and
accurate information to potential recruits on
the requirements of the position to be filled,
on immigration, administrative and contrac-
tual requirements, and on the legal and regu-
latory conditions for the practice of medicine
in the recruiting country, including language
skills. The Council agreed the Statement as
revised and this will now be considered by the
Assembly in October for adoption.
Physician Wellbeing
It was agreed that a Workgroup should
be set up under the chairmanship of the
American Medical Association.
Alliance for Clinical Research
Excellence and Safety
Following the presentation by Dr. Koski,
President of the Alliance, the Council
agreed that the idea of the WMA becoming
involved in the activities of ACRES should
be explored by the Executive Committee.
Immunization
During what was World Immunization
Week, Dr. Julia Seyer, WMA Medical Ad-
visor, gave a presentation on the WMA
Campaign for Physician Immunization to
Prevent Influenza Outbreaks. She spoke
about the facts of influenza and immuniza-
tion and the role of physicians. Phase one
of the campaign had started last year and
phase two from 2014-2016 had just begun.
The WHO had estimated that the preva-
lence of influenza was five to 10 per cent
of adults and 20 to 30 per cent of children
per year. Influenza was responsible for three
to five million cases of severe illness and
caused 250,000 to 500,000 deaths annually.
US data showed influenza had been associ-
ated with about 230,000 hospitalisations.
The priority risk groups were the elderly,
people with underlying health conditions,
children between six and 24 months old,
pregnant women and healthcare workers.
Fifty per cent of those with chronic disease
failed to get immunised, 30 per cent of the
elderly and ten per cent of health profes-
sionals. Yet influenza was one of the lead-
ing causes of catastrophic disability such as
strokes, chronic heart failure, pneumonia,
ischemic heart disease, cancer and hip frac-
tures. And once people became ill they were
often unable to live at home or on their
own. This was not only a personal burden,
but a burden on society. The European rate
of immunization varied a lot, between 1.7
per cent up to 64 per cent. If the immunisa-
tion rate could be increased to 75 per cent,
3.2 million cases could be avoided.The ben-
efits of immunisation included fewer GP
visits and hospital visits, as well as lives and
costs saved.
The reasons people did not get vaccinated
included the low perception of risk, includ-
ing the risk of infecting others, the fear of
possible side effects, questions about its ef-
fectiveness and the issue of cost, availabil-
ity and convenience. Immunization advice
from healthcare professions was the most
important driver for patients‘ vaccine ac-
ceptance. The aims of the WMA campaign
were to increase physicians‘ awareness of the
importantace of immunization, to encour-
age physicians themselves to get vaccinated
and to enhance physicians‘ communication
skills to promote health and prevent disease.
49
WMA News
Prime Minister
At the conclusion of the Council’s delib-
erations, the meeting was addressed by the
Prime Minister of Japan, Mr. Shinzo Abe.
(see box) WMA Chairperson of Council
Dr. Mukesh Haikerwal then brought the
proceedings to a close, thanking the Japan
Medical Association for their hospitality
during the meeting.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
It gives me great pleasure to see the 2014 WMA Council Session
being held today in Tokyo with the participation of 40 medical
associations from around the world.I also
would like to express my appreciation to
President Yokokura for all his efforts as
a representative of the host country, and
to everyone else in the Japan Medical
Association. All people share a common
desire of building a society in which we
can live long and healthy lives.Regardless
of the era, the trust we place in medicine
to support our health, and in the medical
professionals who bear this responsibil-
ity, remains the same. Over the long, 67
year history since its founding,the WMA
has worked to improve global health
standards and establish medical ethics. I
would like to once again express my re-
spect for all your activities to date.
I have heard that the theme for the
WMA this year is ‘universal access to healthcare.’ Japan is now
the country with the longest lifespans. And it is precisely univer-
sal access to healthcare that is the principle behind Japan’s health-
care policy. Anyone in possession of a health insurance card can
receive medical treatment at any medical institution. Universal
health insurance and the freedom to choose where you receive
medical treatment are precious assets which the public, includ-
ing those involved in healthcare in Japan, have been safeguarding
for over half a century. We must fully hand these assets down to
future generations.In addition,in the midst of the rapid advance-
ment of the declining birth rate and ageing population, an im-
portant issue is the creation of an environment that allows people
to continue to live in the communities they are accustomed to for
the rest of their lives,even if they need medical treatment or nurs-
ing care. To that end, we must enhance home care and nursing
care. The doctors in charge of primary care in each region play a
key role in bringing together medical treatment and nursing care.
The role of medical associations in fostering such doctors is also
important. Japan will present the world with a model for a society
in which anyone can live to their old age with peace of mind.
Personally, I have long struggled with the
incurable disease of ulcerative colitis. The
worsening of my condition forced me to
suddenly resign from my post as Prime
Minister seven years ago. I am now serv-
ing as Prime Minister for a second time,
which is quite unusual for Japan. That
I am now able to carry out my job in good
health is thanks to the blessing of ad-
vanced medical treatment, including new
pharmaceuticals. I believe that no other
Prime Minister recognizes the importance
of medical treatment and pharmaceutical
products as much as I do.Progress in med-
ical technology does not just improve the
quality of life for patients,it is also a driver
of economic growth that generates wealth
and employment. In addition to leading
the world in the promotion of the practical application of advanced
medical treatment such as regenerative medicine, I would like to
share the results of such efforts with the people around the world
struggling with difficult diseases. Furthermore, it is also important
that we use the experience and knowledge that we have cultivated
in Japan over the years and make an international contribution in
the medical field.I would like to not only supply medical technolo-
gy,pharmaceutical products,and medical devices,but also to export
packages built around the establishment of whole systems, includ-
ing the universal healthcare system that Japan is so proud of.In the
past six months, we have already constructed cooperative relation-
ships with the healthcare sectors of 14 countries. We will continue
to promote efforts to make such an international contribution.
Lastly, I would like to conclude my remarks as Prime Minister
by wishing for the further expansion of the activities of every-
one gathered here today and for the further development of the
WMA.Thank you for listening.
Shinzo Abe
The adress of the Prime Minister of Japan Mr. Shinzo Abe
in the WMA Council Session
50
WMA News
1. Ethics
1.1 Declaration of Helsinki
The Declaration of Helsinki is one of the
most important international ethical regula-
tions of biomedical research, and also one of
the core documents of the WMA.It has been
revised several times since its adoption in
Helsinki in 1964. As a “living document”, it
is continuously adapted to new developments
and challenges in biomedical research.The 7th
revision was adopted by the WMA General
Assembly in Fortaleza in October 2013.
In a special agreement with the Journal
of the American Medical Association
(JAMA), the revised Declaration of Hel-
sinki was published online on the same day
it was adopted by the WMA General As-
sembly, and then later in print.
The revised Declaration attracted consid-
erable attention around the world and was
apparently positively received. WMA Offi-
cers and the Secretariat have been invited
to comment on the new version and the
process of revision on several occasions. We
are currently preparing a celebratory event,
hopefully with the President of Finland, to
commemorate the 50th
anniversary of the
Declaration.
1.2 Databases and Biobanks
In March 2014, the Icelandic Medical
Association organized a seminar in Reyk-
javik, Iceland together with the WMA
workgroup on the proposed revision of the
WMA Declaration on Ethical Consider-
ation Regarding Health Databases on the
ethical problems connected with health
databases and biobanks. The meeting fo-
cused on the potentials of such reposi-
tories, but also on the regulation of their
use with special emphasis on the informed
consent necessary for research. The results
of the discussion have been incorporated
by the workgroup in a revised draft, which
will now be brought to the attention of the
Council.
2. Human rights
2.1 Right to health
The WMA secretariat continues to monitor
the activities of the UN Special Rapporteur
on the Right to Health, as well as health re-
lated matters addressed by the UN Human
Rights Council. In October 2013, the Spe-
cial Rapporteur, Anand Grover, presented
to the UN General Assembly a report dedi-
cated to the right to health obligations of
States and non-State actors towards persons
affected by and/or involved in conflict situ-
ations. The report describes a wide range of
abuses occurring against health workers and
highlights the need for better monitoring
and accountability. The special rapporteur’s
report is the first UN human rights analysis
to describe the responsibilities of countries
to provide and protect health workers and
services in conflict. The WMA Secretariat
sent a letter to Mr. Grover welcoming the
report.
In early December, the Special Rapporteur
and the WMA issued a joint press release
warning against criminalizing independent
medical care in the context of the draft
health bill in Turkey.
[See also item 2.2.1 on the situation in Turkey
and 2.2.2 on Healthcare in Danger]
2.2 Protecting patients and doctors
2.2.1 Actions of support (see table 1)
2.2.2 Protection of health professionals
in areas of armed conflict and other
situations of violence
The WHO’s role in humanitarian emer-
gencies
In January 2014, on the occasion of the
WHO Executive Board meeting, the
WMA took the lead in drafting a public
statement on the implementation of the
resolution “WHO’s response, and role as
the health cluster lead, in meeting the
growing demands of health in humani-
tarian emergencies”. The statement rec-
ommends, within the framework of the
resolution’s implementation, that Member
States adopt as a matter of priority solid
measures to ensure that health care per-
sonnel, facilities and transports exclusively
assigned to caring for the sick and injured
are fully respected and protected in all
circumstances, in accordance with ethics
Secretary General Report to the 197th
WMA Council Session
(October 2013 – March 2014)
Otmar Kloiber
51
WMA News
Table 1
Country Case
TURKEY
01/2014-03/2014
Sources:
TMA
Amnesty International
Human Rights Foundation
of Turkey
Last January, the WMA, together with Physicians for Human Rights, the British Medical
Association (BMA), the German Medical Association (GMA) and the Standing Committee
of European Doctors (CPME), sent a joint letter to the Turkish President, Mr. Abdullah Gül,
expressing their grave concerns about the health bill passed by the Turkish parliament on 2nd
January that criminalizes emergency medical care. The signatories called upon the President to
refuse to sign the bill into law.
[See also under 2.1 above the joint press release with the UN Special Rapporteur on Health]
In March, the same organizations wrote a letter to Prime Minister Erdogan regarding the punitive
actions taken by the Ministry of Health against physicians who acted ethically in providing
emergency medical care to demonstrators injured during the Gezi Park protests that began in May
2013.The authors of the letter asked Mr. Erdogan to take immediate action to drop the current
legal actions against members of the Turkish Medical Association.The letter was published in the
British Medical Journal and a press release was issued.
IRAQ
Sources:
Individual call for support
Amnesty International
UN Working Group on Arbitrary
Detention
Our attention was drawn to the situation of Iranian exiles in Camp Liberty in Iraq. According
to various sources, serious restrictions are imposed on the residents’ access to medical services.
Allegations of psychological and physical torture of the residents were made as well.
C. Delorme met with two representatives of Camp Liberty in February 2014.The Secretariat is
currently checking information with its partners before considering how best to take up the matter
with the Iraqi authorities.
RUSSIA
11/2013
Source:
Individual call for support
Amnesty International
Last November, our attention was drawn to the case of Dr. Marat Gunashev from Russia’s North
Caucasus region of Dagestan. He was arrested and charged with complicity to murder the police
chief of the Dagestan capital in 2010.  He has been in prison ever since and – according to sources –
without evidence of the charges against him, has been exposed to ill-treatment and subject to a lack
of respect for the standards of fair trial.
The Secretariat contacted the Russian Medical Association, alerting them to the case and asking
whether any action had already been taken by the medical association in support of Dr. Gunashev.
The Secretariat also suggested writing a letter to the Russian authorities enquiring about the
conditions of detention of Dr. Gunashev and asking for international fair trial standards to be fully
respected.
There has been no response so far.
BAHRAIN
11/2013
Source:
Amnesty International
On 15th
November, the WMA sent a letter to the King of Bahrain expressing serious concerns
about the two remaining health professionals, Dr. ‘Ali ’Issa Mansoor al-’Ekri and Ebrahim ‘Abdullah
Ebrahim al-Dumestani, still in detention (out of the 20 professionals placed in detention during the
March-April 2011 events).
In the letter, the WMA requested their immediate and unconditional release as it is believed that
they have been imprisoned solely for peacefully exercising their rights to freedom of expression
and assembly and are, as such, prisoners of conscience. It also recommended that the Bahraini
authorities investigate the prisoners’ allegations of torture.
EGYPT
09/2013
Sources:
CMA
Amnesty International
A letter was sent to the Egyptian authorities regarding the case of Canadian physician Tarek
Loubani and filmmaker John Greyson who were arrested during violence in Cairo on 16th
August.
The letter expressed the WMA’s concerns that the Canadian detainees have been accused of a broad
array of offences without apparent consideration of their individual criminal responsibility.The letter
therefore urged the Egyptian authorities to release them immediately, unless they had sufficient
admissible evidence to try them before a civilian court in line with international fair trial standards.
They were released early October.
52
WMA News
principles and the rules of humanitarian
law.
The statement was made on behalf of the
WMA,the International Council of Nurses,
the International Pharmaceutical Federa-
tion, the World Confederation for Physical
Therapy and the World Dental Federation,
as well as the International Hospital Fed-
eration, the International Confederation of
Midwives, the International Federation of
Medical Students Associations and the In-
ternational Pharmaceutical Students’ Fed-
eration.
[See also items 2.1 and 2.2 on the situation in
Turkey]
ICRC “Health Care in Danger” (HCiD)
project
The WMA Secretariat has developed a close
working relationship with the International
Committee of the Red Cross (ICRC) head-
quarters over recent months in the context
of the HCiD project.
As part of the Health Care in Danger
project, the ICRC organizes expert con-
sultations with policymakers, academics,
doctors, weapon bearers and civil society
in order to develop practical recommen-
dations to improve safe access to health
care. Two expert consultations took place
during the reporting period with the in-
volvement of WMA. On 3rd
December,
the ICRC, together with the Conflict and
Catastrophes Forum of the Royal Society
of Medicine and the British Red Cross,
hosted an expert conference in London,
“Health Care in Danger: From consulta-
tion to implementation”. WMA President,
Dr. Margaret Mungherera, made an inter-
vention on the importance of health care in
war and violent situations.
At a workshop on “Domestic regulatory
frameworks for safeguarding health care”,
held in Brussels from 29th
–31st
January,
WMA President-Elect, Dr. Xavier Deau,
made an intervention on the principles of
medical ethics and confidentiality. Further-
more, on 6th
–7th
February, the ICRC orga-
nized an expert meeting ‘Healthcare Ethics
in Danger” in Geneva, which was attended
by Prof. Vivienne Nathanson (BMA) and
Dr. Jeff Blackmer (CMA).
In the context of this project, the ICRC
also organizes regular meetings with
health professionals’ organizations, i.e.
the WMA, the International Council of
Nurses (ICN) and the International Hos-
pitals Federation (IHF). The purpose of
these meetings is to provide an update on
the project advancement, exchange infor-
mation on recent policy developments in
relation to the issue, and explore ways of
working together. The last meeting was in
December.
The WMA Secretariat aims to facilitate
direct contacts between the ICRC and
medical associations at the national/re-
gional level, and to encourage initiatives
by national medical associations, where ap-
plicable, to promote the goals of the HCiD
project. In this respect, Dr. Bruce Eshaya-
Chauvin, coordinator of the project, at-
tended the WMA General Assembly in
Fortaleza last October, where he had the
opportunity to meet with various medi-
cal associations. In view of the upcoming
workshop in Pretoria in April 2014, he also
met with the South African Medical Asso-
ciation and connected with the ICRC del-
egation in South Africa. WMA President
Dr. Mungherera will speak at the workshop.
Dr. Eshaya-Chauvin attended the French-
speaking Conference of Medical Orders
(Conférence Francophone des Ordres Médi-
caux) in Douala, Cameroon last Novem-
ber.
In December, the ICRC delegation in
Kathmandu, in collaboration with the Ne-
pal Medical Association (NMA) and the
Nepal Red Cross Society (NRCS), orga-
nized a half-day Health Care in Danger
(HCiD) workshop in Kathmandu. The
objective of the workshop was to sensitize
medical personnel to the issue, share efforts
made by the ICRC to deal with the HCiD
issue at the global level, and to reflect at the
situation of Nepal and receive participants’
feedback.
Other related activities
Last November, 19 experts from the fields
of humanitarian practice, human rights,
human  security, academic research, gov-
ernment, and philanthropy, along with UN
representatives and leaders from health
professional associations, including the
WMA, represented by Dr. Mungher-
era, issued a Call to Action to address the
problem of attacks on health care. Read the
Call to Action from the Bellagio Confer-
ence on the Protection of Health Workers,
Patients and Facilities in Times of Vio-
lence (Nov. 2013).
2.3 Doctors working in places where
people are deprived of liberty
The Special Rapporteur on torture and oth-
er cruel,inhuman or degrading treatment or
punishment, Mr. Juan E. Méndez, and the
Center for Human Rights & Humanitar-
ian Law of the American University Wash-
ington College of Law invited the WMA
to participate in an expert meeting on the
revision of the United Nations Standard
Minimum Rules for the Treatment of
Prisoners (SMR) on 10th
July 2013 at the
University of Oxford, United Kingdom.
Prof. Vivienne Nathanson represented the
WMA at the meeting.
In late September, the latest thematic re-
port of the Special Rapporteur focusing
on this topic was published. One section
of the report is dedicated to medical and
health services and includes recommenda-
tions related to the role of health profes-
sionals in documenting ill-treatment and
acts of torture.
53
WMA News
2.4 Prevention of torture
and ill-treatment
2.4.1 Cooperation with the
International Rehabilitation
Council for Torture
Victims (IRCT)
In Budapest in November 2012, C. De-
lorme was re-elected as an independent
expert to the IRCT Council and the Ex-
ecutive Committee with a new mandate
of three years. Three Executive Committee
meetings took place during the reporting
period and a Council meeting was held in
March 2014.
C.Delorme is a member of the IRCT work-
ing group on detention and torture, putting
forward the WMA’s perspective during dis-
cussions. Physicians’ views are also included
in the two other working groups on migra-
tion and rehabilitation.
2.4.2 Psychiatric treatment
The annual report of Mr. Méndez, the UN
Special Rapporteur on torture, which was
submitted to the Human Rights Coun-
cil last March, was dedicated to abuses
in health care settings. In the report, Mr.
Méndez explores an emerging recogni-
tion of different forms of abuses against
patients and individuals under medical
supervision.
In May 2013, the WMA Secretariat sent a
letter to the Special Rapporteur welcoming
the selection of this topic, but expressing
serious concerns about some of the report’s
recommendations in relation to ‘persons
with psycho-social disabilities’. In particu-
lar, it is feared that the report may generate
prejudice against psychiatric services, hold-
ing health professionals responsible for all
abuses and ill-treatment of mental health
patients.
The Secretariat drew the attention of the
World Psychiatric Association, as well as
the International Council of Nurses, to
the report. In June, C. Delorme met with
the WHO’s relevant department, as well as
Christian Pross, a member of the UN Sub-
Committee on the Prevention of Torture, to
discuss this matter within the framework
of the Mental Health Monitoring Guide,
on which the Sub-Committee is currently
working.
Furthermore, national medical associations
were informed and invited to take action.
The Norwegian Medical Association alert-
ed the Norwegian Psychiatric Association,
which wrote an open letter to the Special
Rapporteur last November.
In December, the WMA was consulted
about the WHO’s project MINDbank, an
online platform bringing together coun-
try and international resources covering
mental health, substance abuse, disability,
general health, human rights and develop-
ment. The platform is now online: http://
www.who.int/mental_health/mindbank/
en/
2.5 Homosexuality
In early March, the WMA wrote to the
President of Uganda expressing its deep
concern about the new law in the coun-
try concerning homosexuality, and urging
him to reverse the measure. On the day
that President Museveni signed the bill
into force, WMA President Dr. Margaret
Mungherera and WMA Chair of Council
Dr. Mukesh Haikerwal appeared on Ugan-
dan television to make the WMA position
clear by speaking out against this law. Previ-
ous international protests had at least led to
the abolishment of a mandatory reporting
clause, which was part of the original law
proposal. The WMA will continue its ef-
forts to get this legal act reversed.
2.6 Violence against women
During the 195th
session of the WMA So-
cio-Medical Affairs Committee (Fortaleza),
members discussed concrete actions con-
cerning the implementation of the WMA
Resolution on Violence Against Women
(Vancouver 2010).
The initiatives proposed included the orga-
nization of a side-event during the upcom-
ing World Health Assembly (May 2014).
The WMA Secretariat is currently working
on this and, in particular, is looking for a
Member State which will agree to sponsor
the event in accordance with the WHO’s
rules. The event, co-organized with the In-
ternational Federation of Medical Students
Association (IFMSA),would aim to discuss
concrete ways for the health sector to en-
gage in stopping violence against women
and, as an outcome, draw recommendations
from the debate.
2.7 Children’s health
Since 2012,the mission of the EveryWom-
an Every Child initiative, spearheaded
by  UN Secretary-General Ban Ki-moon,
has been to mobilize and intensify global
action to improve the health of women and
children around the world.The WMA is an
observer in the advocacy group of this ini-
tiative. http://www.everywomaneverychild.
org
At the Council Session in Sydney, the ques-
tion was raised, but not answered, as to the
impact of smoking in the vicinity of chil-
dren. It was discussed whether smoking in
the vicinity of children should expressively
be generally prohibited, including in private
spaces, instead of calling only for general
protection.
Following this discussion, the Secretary-
General asked the WMA Cooperating
Center at George Mason University for
advice. The Center for the Study of In-
ternational Medical Policies and Practices
performed a literature review to analyze
the evidence on the effect of second hand
smoke on children. The conclusion of the
54
WMA News
study*
clearly points to a recommenda-
tion to call for a stronger policy, includ-
ing legal instruments, to ban smoking in
the vicinity of children. (Individual copies
can be obtained from the Secretariat upon
request.)
2.8 Pain treatment
Last January, the WHO’s Executive Board
adopted a strongly worded resolution en-
titled “Strengthening of palliative care as a
component of integrated treatment within
the continuum of care”. The resolution rec-
ommends integrating routine training on
palliative care into the curricula of health-
care professionals. The resolution was re-
ferred to the World Health Assembly next
May with the recommendation that it be
adopted.
Over recent years, the WMA has been in-
volved in advocacy activities led by Human
Rights Watch together with global/regional
palliative care organizations in support of
this resolution. The Secretariat will keep
monitoring future developments.
2.9 Death penalty & organ
transplantation
In late September, Amnesty International
drew our attention to the practice of the
death penalty in Taiwan. They informed
us, in particular, of a recent letter from the
Taiwan Minister of Justice for their atten-
tion, demonstrating medical involvement in
executions  (giving sedatives and declaring
the prisoner dead). Another issue of con-
cern was the practice of organ procurement
for transplantation from executed prisoners.
The Secretariat had an exchange of corre-
spondence with the Taiwan Medical Asso-
* Himathongkam, T. et al., Updates of Second-
hand Smoke Exposure on Infants’ and Children’s
Health, World Medical & Health Policy, Vol. 5,
No. 2, 2013
ciation, which reiterates its commitment to
WMA policies on these issues and provided
information on the action taken towards the
Taiwanese authorities in this regard.
In November, C. Delorme made contact
with the International Commission against
the Death Penalty in order to exchange in-
formation and explore potential joint activi-
ties.
In March, Dr. O. Kloiber and C. Delorme
met with TAICOT (Taiwan Association for
International Care of Organ Transplants)
and DAFOH (Doctors Against Forced
Organ Harvesting) to share information
on ways to approach an end to forced organ
harvesting.
3. Public health
3.1 Non-communicable diseases (NCDs)
3.1.1 General
Member States and the WHO have made
progress in fulfilling their commitments ac-
cording to the 2011 UN Political Declara-
tion on Prevention and Control of NCDs.
In the last two years, Member States have
adopted a Global Monitoring Framework
with a set of global NCD targets, a Global
NCD Action Plan 2013–2020, and a for-
malized UN Interagency Task Force on
NCDs,which will coordinate a UN system-
wide response to NCDs.
The NCD Global Monitoring Frame-
work comprises nine global targets and 25
indicators. Nine additional voluntary glob-
al targets are aimed at combatting global
mortality from the four main NCDs, ac-
celerating action against the leading risk
factors for NCDs and strengthening na-
tional health system responses. The main
target is to reduce premature mortality
from non-communicable diseases by 25%
by 2025. The WMA was strongly engaged
in the development process and tried to
shift the focus to overarching targets re-
lated to health care systems rather than
single diseases.
At the UN High-level Meeting on NCDs
in 2011,Member States committed to hold-
ing a comprehensive UN NCD Review
and Assessment in 2014 on the progress
achieved on NCDs. The 2014 NCD Re-
view will provide a significant opportunity
for stocktaking on progress in implement-
ing the Political Declaration. The next step
is now to develop the modalities resolution
for this UN NCD Review. This resolution
will determine the date, level, scope, par-
ticipation, and outcome of the NCD Re-
view. The co-facilitators of the Review are
Jamaica and Belgium. At a WHO meeting
in November, Member States did not reach
agreement on the WHO’s engagement
with non-state actors, in particular the pri-
vate sector, and the organizational structure
of the mechanism. The WMA is following
this process and trying to advocate for an
overarching NCD review approach.
Health professionals play an important
role in reducing the global NCD burden
through appropriate health promotional
action, disease prevention, treatment and
rehabilitation, and advocating for research
and finance. Therefore the WMA, together
with the members of the World Health
Professions Alliance (WHPA), has devel-
oped a campaign to help prevent NCDs
by targeting common risk factors and social
determinants of health. More information
on this campaign is included in Section 5.6
of this report.
3.1.2 Multidrug-Resistant
Tuberculosis Project
The WMA has collaborated with the New
Jersey Medical School Global Tuberculosis
Institute and the World Health Organiza-
tion, with financial support from the Eli
Lilly MDR-TB partnership, to create a new
application for tablet computers that will
allow physicians to access a training course
on the treatment of Multidrug-Resistant
TB (MDR-TB).
55
WMA News
The new application contains the eight
training modules which comprise the
WMA’s course on MDR-TB. It is intend-
ed as an introduction to MDR-TB man-
agement, and is consistent with the prin-
ciples of the WHO Stop TB Strategy.The
application, which will be accessible from
the Google and iPhone app webpages, will
be available on 10-inch screen tablets as
well as smaller displays, including smart-
phones.
The New Jersey Medical School Global
TB Institute, together with the University
Research Company in the USA and the
WMA, will update the TB refresher course
for physicians, which was originally devel-
oped in 2008. A revision of the course now
is both appropriate and necessary given
changes in the WHO Guidelines and the
upcoming release of the 3rd
edition of the
International Standards of Tuberculosis
Care.
The goal of the project is to improve physi-
cian understanding and knowledge of TB
management in order to improve patient
outcomes, ensure adequate treatment and
decrease community transmission of TB.
The PDF version of the course will be
updated first. After finalizing its content,
it will be used as a basis for the revision
of the interactive online course, which
will subsequently undergo pilot testing
with interested users. Both courses will
be made widely available, so the WMA
can disseminate the course materials to
its member organizations and promote
the courses at international meetings and
conferences.
3.1.3 Tobacco
The WMA is involved in the implemen-
tation process of the WHO Framework
Convention on Tobacco Control (FCTC)
http://www.who.int/tobacco/framework/
en/. The FCTC is an international treaty
that condemns tobacco as an addictive sub-
stance, imposes bans on advertising and
promotion of tobacco, and reaffirms the
right of all people to the highest standard
of health.
3.1.4 Alcohol
In May 2010, the World Health Assembly
endorsed the Global Strategy to Reduce
the Harmful Use of Alcohol. The Strategy
provides a portfolio of policy options and
interventions for implementation at nation-
al level with the goal of reducing the harm-
ful use of alcohol worldwide. The success-
ful implementation of the strategy requires
concerted action by countries, effective
global governance, and appropriate engage-
ment of all relevant stakeholders, including
health actors. In line with the WMA State-
ment on Reducing the Global Impact of
Alcohol on Health and Society, the WMA
Secretariat monitors progress in this area to
ensure that medical associations at the na-
tional and global levels are engaged in the
process. The Secretariat maintains regular
contact with the WHO staff in charge of
this topic, as well as with the Global Alco-
hol Policy Alliance (GAPA)
3.2 Social determinants of health
The Rio Political Declaration on Social De-
terminants of Health, adopted at the World
Conference on Social Determinants of
Health in Rio de Janeiro, Brazil in October
2011, identifies five action areas for health
professionals to engage in to address the so-
cial determinants of health.One of these ac-
tion areas emphasizes the role of the health
sector in reducing health inequities.
Within this framework, the WMA moni-
tors the WHO’s activities and keeps nation-
al medical associations informed of relevant
developments.
On the initiative of the Canadian Medical
Association, the WMA is considering or-
ganizing a meeting of interested NMAs to
develop plans to address the social determi-
nants of health and health equity through
the collection/dissemination of successful
clinical practice interventions and through
advocacy, as well as policy development ini-
tiatives for NMAs.
3.3 Millennium Development Goals
The United Nations development agenda
is prioritizing the move forward from the
Millennium Development Goals (MDGs)
era. The health-related MDGs have raised
the profile of global health, mobilized polit-
ical support and contributed to the achieve-
ment of significant improvements in health
outcomes, particularly in low- and middle-
income countries. To sustain the health-re-
lated gains and make the linkages between
health and sustainable development even
clearer, the UN saw a need to build on the
momentum achieved by the MDGs and
develop a more overarching development
framework post-2015. The UN has linked
all their other health and development re-
lated key activities to the post MDG dis-
cussion. For example, the Rio+ discussions
and the climate change negotiations will
feed the development process of the new
post-2015 MDGs.The aim is not just to fo-
cus on poverty eradication, but also on the
health of the planet.
The United Nations Secretary-General
(UNSG) Ban Ki-moon appointed a High-
level Panel of eminent persons chaired by
the UK Prime Minister and the Presidents
of Liberia and Indonesia to advise on the
global development agenda beyond 2015.
The Panel delivered a report entitled “A
New Global Partnership: Eradicate Poverty
and Transform Economies through Sus-
tainable Development” to the UN General
Assembly in September 2013.
A compilation of the global conversation
on the post-2015 development agenda can
be found at the ‘World We Want 2015’
website, which is jointly owned by United
Nations agencies and civil society orga-
nizations. This site gives an overview of
the different stakeholders involved in the
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WMA News
post-MDG discussions and the various
thematic focus areas.
Within the health track of the post-MDG
discussions, the WHO and the World
Bank have developed a draft framework
for the monitoring of Universal Health
Coverage at country and global levels and
opened it up for consultation. The World
Medical Association has commented on
the proposed framework. The main criti-
cism was that governments would need to
offer universal health coverage to only 40%
of the poorest people in the country and
only 80% of them would need to receive
health care, which leads to a coverage of
only one third of the population. This can
hardly be called “universal health coverage”.
Besides this, the framework again focusses
only on single diseases.With this approach,
the WMA fears that governments would
concentrate only on improvements in these
specific disease areas, detracting from the
significant needs caused by other major
health, social and environmental threats. In
order to achieve universal access we need
to strengthen health systems at the point
of service, with a special emphasis on in-
creasing the number and appropriate dis-
tribution of health professionals per head
of population
The Geneva-based Global Social Obser-
vatory hosted a series of events devoted to
the MDGs with the participation of Uni-
lever, whose CEO Paul Paulman served on
the High-level Panel. Representatives of a
variety of international NGOs, diplomatic
missions and UN institutions were invited
to participate in an inter-active dialogue
and identify opportunities for innovation
and partnerships to tackle future global
health and development challenges. The
WMA was an active participant in these
events and will continue to contribute to
thematic consultations and seminars orga-
nized by the WHO and other international
institutions to make sure that health-related
development goals remain high on the po-
litical agenda.
3.4 Immunization campaign
At the beginning of 2013, the WMA
identified low vaccination rates among
physicians as a significant public health
threat that was receiving little attention,
particularly from the medical profession.
After conducting background research of
the literature, the WMA national associa-
tion members were invited to participate
in a survey to document the magnitude of
the problem and its root causes.The survey
results helped the WMA plan a campaign
that reflected the needs of our members.
The International Federation of Phar-
maceutical Manufacturers and Associa-
tions (IFPMA) provided funding for the
campaign, which was officially launched
during the 66th
WHO World Health As-
sembly week for which the WMA hosted a
luncheon seminar entitled: “Influenza: We
Can Do Better.”
The campaign went smoothly and received
positive feedback. It was featured on the
WHO, CDC and Vaccine Europe websites.
Several national associations approached
the WMA with a request to use the WMA
campaign materials for their national cam-
paigns.
Over the course of the campaign, a vari-
ety of promotional and advocacy materials
were developed that were widely circulated
and posted on the WMA website. For ex-
ample, a brief promotional video featuring
real healthcare workers in a clinic caring
for their patients and getting vaccinated
by a colleague was launched at the WMA
luncheon in May 2013. The luncheon itself
was videotaped, which included interviews
with experts encouraging physicians to get
immunized against seasonal influenza.Both
videos, the promotional video and the event
video, are available on the WMA influenza
campaign website: http://bit.ly/15wcput.
In addition to the videos, some printed ma-
terials were produced, including a calendar
for 2014 with campaign messages, an info-
graphic postcard, and letters for member
associations to send to their governments
in support of physician immunization
against influenza. Other promotional ac-
tivities included Dr. Julia Seyer hosting a
campaign booth and giving a presentation
at the Global Health Workforce Alliance/
WHO Global Forum on Human Resources
for Health from 10th
–13th
November 2013
in Brazil. Dr. Téa Collins gave an inter-
view to Vaccine Today, which is available
at: http://www.vaccinestoday.eu/vaccines/
doctors-tell-doctors-get-your-flu-shot/ and
published an article in Person-Centered
Medicine on the campaign: ‘The Role of
Physician Immunization in Preventing In-
fluenza Outbreaks: Practicing Person-Cen-
tered Medicine’.
By the end of November 2013, Phase I of
the campaign was successfully complet-
ed. In order to maintain the momentum
achieved during Phase I and expand the
campaign’s reach and impact in 2014, the
World Medical Association requested ad-
ditional funding from IFPMA to continue
the project.
Phase II will build on the success of Phase
I with the goal of expanding the campaign’s
scope and will include vulnerable popula-
tions (people with chronic diseases, the el-
derly, children and pregnant women) and
identify flu champions and peer vaccinators
who will serve as role models to physicians
and stimulate their interest in getting im-
munized. The campaign will also make a
greater effort to ensure national member
associations’ active involvement in the cam-
paign and to streamline global and national
advocacy efforts.
Hence, the overarching objective for this
phase will be to expand the influenza im-
munization educational campaign among
physicians with a greater focus on:
• Enhancing physicians’ advocacy skills to
address the barriers to seasonal flu vacci-
nations on multiple levels (personal,orga-
nizational, national)
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WMA News
• Enhancing physicians’ communication
skills to promote seasonal influenza im-
munizations among vulnerable popula-
tions (the chronically ill, the elderly, preg-
nant women and children)
• Increasing WMA member national
associations’ involvement in the cam-
paign
• Identifying influenza immunization
“champions” to serve as role models for
physicians to increase their vaccination
coverage against seasonal flu
The WMA Proposal for Phase II was well
received and the IPFMA proposed that, in
order for the campaign to gain greater vis-
ibility and longer-term engagement with its
target audiences,the proposal be revised and
the activities spread over a three year period
instead of one.Continuing IFPMA support
for the campaign will ensure the visibility of
the campaign all year round, which is criti-
cal given the seasonality of influenza. The
proposal is currently being revised and will
be submitted to the IFPMA for their final
approval.
3.5 Counterfeit medical products
Counterfeit medicines are manufactured
below established standards of safety,
quality and efficacy. They are deliberately
and fraudulently mislabeled with respect
to identity and/or source. Counterfeiting
can apply to both brand name and generic
products, and counterfeit medicines may
include products with the correct ingre-
dients but fake packaging, products with
the wrong ingredients, products without
active ingredients, or products with in-
sufficient active ingredients. Counterfeit
medicinal products threaten patient safe-
ty, endanger public health e.g. by increas-
ing the risk of antimicrobial resistance,
and undermine patients’ trust in health
professionals and health systems. The in-
volvement of health professionals is cru-
cial to combating counterfeit medicinal
products.
The WMA and the members of the World
Health Professions Alliance (WHPA)
have stepped up their activities on counter-
feit medical issues and developed an anti-
counterfeit campaign with an educational
grant from Pfizer Inc. and Eli Lilly.The ba-
sis of the campaign is the ‘Be Aware’ tool-
kit for health professionals and patients,
which is intended to increase awareness of
this topic and provide practical advice for
actions to take in case of a suspected coun-
terfeit medical product. The WHPA orga-
nized several regional WHPA Counterfeit
Medical Products workshops to imple-
ment this toolkit. This year’s focus of the
campaign is on active women aged 30–45
in urban areas.
The WMA joined the Fight the Fakes cam-
paign that aims to raise awareness about the
dangers of fake medicines. Coordination
among all actors involved in the manufac-
turing and distribution of medicines is vital
to tackle this public health threat.
As part of this effort, Fight the Fakes is
collecting and sharing the stories of those
who are impacted by fake medicines and
are speaking out. The website also serves as
a resource for organizations and individu-
als who are looking to support this effort
by outlining opportunities for action and
sharing what others are doing to fight fake
medicines.
3.6 Health and the environment
In April 2012, an Environment Caucus
was set up on the initiative of the Korean
and British medical associations together
with Dr. Peter Orris, associate member and
expert on environmental issues. The Cau-
cus provides a forum for open discussion
between medical associations interested
in environmental issues and willing to ex-
change experiences. Since then, the Caucus
has been meeting during WMA statutory
meetings and is open to any medical asso-
ciations interested in attending.
3.6.1 Climate change
The WMA continues to be involved in the
UN climate change negotiations. Due to its
UN observer status to the Convention, the
WMA Secretariat can facilitate the partici-
pation of medical associations interested in
the various official meetings taking place
within this framework.
At the conclusion of the first Climate
and Health Summit*, where the WMA
was represented by Dr. Dong-Chun Shin
(KMA, Korea), the health NGO organiz-
ers adopted the Durban Declaration on
Climate and Health and the Health Sector
Call to Action.The same partners organized
a second Climate and Health Summit par-
allel to the 19th
COP negotiations in War-
saw on 16th
November with the support of
the WHO. It provided an opportunity for
groups to collaborate and share progress in
the development and implementation of
strategies and projects to build resilience
to the impacts of climate change on health.
Prof. Vivienne Nathanson (British Medical
Association), co-chair of the WMA Envi-
ronment Caucus, attended the event and
chaired the opening plenary session.
This second Summit was also an opportunity
to formalize the Global Climate & Health
Alliance, composed of the health organiza-
tions’ partners, working together to ensure
that health impacts are integrated into glob-
al, national and local responses to climate
change and to encourage the health sector
to mitigate and adapt for climate change.
The WMA is not part of the Alliance, but
is committed to work with its members to-
wards the same goals, when appropriate.
* The Summit was co-organized by Health Care
Without Harm, Climate and Health Council,
World Public Health Associations, and the Nel-
son Mandela School of Medicine, with the sup-
port of the WMA, WHO, Public Health Asso-
ciation of South Africa, International Council of
Nurses, the International Federation of Medical
Students’ Associations, groundWork, Health and
Environment Alliance, Europe, and the Climate
and Health Alliance, Australia.
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WMA News
3.6.2 Mercury
The WMA has been a member of the
UNEP Global Mercury Partnership (Mer-
cury product) since December 2008 in or-
der to contribute towards the partnership’s
goal of protecting human health and the
global environment from the release of mer-
cury and its compounds.This engagement is
based on the WMA Statement on Reduc-
ing the Global Burden of Mercury (Seoul,
2008).
Representing the WMA, Dr. Peter Or-
ris has been following the negotiating
process of the UNEP (UN Environment
Programme) for a legally binding instru-
ment on mercury. The Mercury Treaty was
adopted in January 2013 in Geneva. The
Treaty sets a phase-out date of 2020 for
most mercury containing products and calls
for the phase-down of dental amalgam.This
aspect of the treaty is a major victory for all
who have worked for mercury-free health
care.The WMA is following the ratification
process of the Treaty.
3.6.3 Chemicals
In December 2009, the WMA joined
the Strategic Approach to International
Chemicals Management (SAICM) of the
Chemicals Branch of the United Nations
Environment Programme (UNEP), which
aims to develop a strategy for strength-
ening the engagement of the health sec-
tor in the implementation of the Stra-
tegic Approach. In consultation with the
WHO, Prof. Shin (Korean Medical Asso-
ciation) has represented the WMA at sev-
eral SAICM meetings, bringing forward
the WMA Statement on Environmental
Degradation and Sound Management of
Chemicals (October 2010, Vancouver).
3.6.4 WMA Green Page
At the request of the WMA Green Group,
which was set up in 2011, the Secretariat
created a Green Page in the environment
section of its website.The green page focus-
es on the role of doctors in making health-
care practice environmentally responsible.
4. Health systems
4.1 Person-centered medicine
The WMA co-sponsored and participated
in the Sixth Geneva Conference on Person-
Centered Medicine, which took place in
Geneva from 28th
April to 1st
May 2013.
The conference was organized by the In-
ternational College of Person-Centered
Medicine in collaboration with Geneva
University Hospital and the World Health
Organization.The conference included the-
matic symposia on Person-Centered Health
Research, interactive workshops and oral
presentations by experts. Dr. Otmar Kloiber
delivered a presentation on the revisions of
the WMA Declaration of Helsinki and Dr.
Téa Collins spoke about the importance of
physicians’ immunization to prevent influ-
enza outbreaks.
4.2 Health workforce
4.2.1 Third Global Forum
on Human Resources
for Health (GHWA)
The GHWA Third Global Forum on Hu-
man Resources for Health, entitled Hu-
man Resources for Health – Foundation
for Universal Health Coverage and the
Post-2015 Development Agenda, was
held in Recife, Brazil from 10th
–13th
No-
vember 2013. With 1800 participants
and attendance by 93 Member States,
including more than 40 ministers and/
or deputy ministers, the Third Global Fo-
rum on Human Resources for Health was
the largest ever HRH event. The Forum
had two major goals. The technical goal
was to provide the best evidence available
and share the lessons learned among the
HRH experts. The political goal was to
inspire and facilitate support and action
by policy-makers.
High-level plenaries, technical sessions
and satellite meetings with exhibition ar-
eas, poster presentations, photo galleries
and awards for excellence provided oppor-
tunities for professional development and
networking. The Conference program was
organized around the following thematic
areas:
1. Health workers and health goals: Prog-
ress in HRH actions over the past de-
cade
2. Matching health workforce production
to population needs and expectations
3. Social needs and the regulatory role of
the State
4. Deployment, retention and manage-
ment
5. Empowerment and incentives
The WMA served on the technical advi-
sory board of the Conference and contrib-
uted to the content of the program. The
WMA also organized a session on build-
ing collaborations and synergies among
healthcare professions for the World
Health Professions Alliance.The objectives
of the session were to demonstrate the
role of professional associations in policy-
making, to advocate for inter-professional
education and collaborative practice at the
national and global levels using the ex-
ample of the WHPA, and to highlight the
importance of inter-professional education
for inter-professional teamwork and col-
laborative practice. The WHPA presidents
and CEOs participated in the session,
which was well attended and received in
Brazil.
In addition, the WMA organized a parallel
session on the role of the health workforce
in meeting citizens’ needs and expectations
in collaboration with colleagues from the
African Medical and Research Founda-
tion and the Capacity Plus Project in the
USA. WMA’s Dr. Julia Seyer served on the
panel and gave a presentation on healthcare
workers responsiveness as one of the goals
of health systems and a main component
of quality person-centered care. Dr. Seyer
also hosted a WMA booth to showcase the
WMA influenza immunization campaign
materials.
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WMA News
4.2.2 The Prince Mahidol Award
Conference (PMAC)
The Prince Mahidol Award Conference
was hosted by the Prince Mahidol Award
Foundation and the Royal Thai Govern-
ment, in cooperation with the World
Health Organization (WHO), the World
Bank, the U.S. Agency for International
Development (USAID), Japan Interna-
tional Cooperation Agency (JICA), the
Rockefeller Foundation and the China
Medical Board. The Conference, entitled
“Transformative Learning For Health Eq-
uity”, took place in Thailand from 27th
–31st
January 2014.
The PMAC had four main objectives:
1. To identify, share and learn about the
strengths and weaknesses of current
health professional education, teaching
and learning systems in different coun-
try contexts.
2. To identify how health professional ed-
ucation, teaching and learning systems
can be transformed by advancing the
health equity agenda and be responsive
to the health of people in a dynamic
socio-economic environment.
3. To support the development of strate-
gies and interventions for transforming
health professional education systems at
the national level.
4. To strengthen the regional networks
contributing to evidence for health pro-
fessional education transformation.
Through a number of plenary and interac-
tive parallel sessions, as well as a number of
side events, the conference aimed to fos-
ter collaboration and partnerships among
health professional education and train-
ing institutions, along with health service
delivery organizations, with the goal of
transforming health professional educa-
tion systems and advancing the health eq-
uity agenda.
The PMAC was a closed, invitation only
event. The WMA President, Dr. Margaret
Mungherera,Chair of Council,Dr. Mukesh
Haikerwal, and Secretary General,
Dr. Otmar Kloiber, were invited as speakers
and served on the panels of the plenary and
parallel sessions of the conference.
4.2.3 Education & research
In fall 2013,Prof.David Gordon (U.K.) was
elected as President of the World Federa-
tion for Medical Education (WFME). Dr.
Gordon has advised the WMA on educa-
tional and workforce issues several times in
the past. The WMA welcomed his presi-
dency and is fully prepared to continue its
intensive collaboration with the WFME.
The Federation has now started to revise
its standards for Medical Education. The
WMA Secretariat will share the new draft
standards with its members as soon as they
are available.
The World Health Organization’s Depart-
ment for Human Resources for Health has
formed a Technical Working Group on
Health Workforce Education Assessment
Tools and invited the WMA to become
a member. In view of the historical prob-
lem of, not only a global health workforce
shortage, but an urgent need to ensure that
such a workforce has a broader training
which more accurately reflects their every-
day working practices, a WHO Resolution
was passed in 2013 to develop a standard
protocol and health workforce education
assessment tool.
The aim of the workgroup is to produce
different quality measurements for trainees
or practitioners since no single assessment
tool can evaluate all competencies and, in
addition, the same competency may be
measured by more than one tool. Another
important point is that the use of multiple
assessment tools reduces the risk of bias to-
wards any one tool.
4.3 Violence in the health sector
During the reporting period,the Secretariat
has been working on the preparation of the
fourth International Conference “Towards
safety, security and wellbeing for all”, which
will take place in Miami (FL), USA from
22nd
–24th
October 2014. The WMA is rep-
resented in the Steering Group in charge of
the organization of the event and C. Delo-
rme is part of the Scientific Committee.
The Steering Group met in early April for
the final review and selection of the ab-
stracts in order to establish the preliminary
program.It is already planned that Dr.Mar-
garet Mungherera will represent the WMA
in Miami.
4.4 Caring Physicians of the World
Initiative Leadership Course
The CPW Project began with the Caring
Physicians of the World book, published
in English in October 2005 and in Span-
ish in March 2007, which is now available
in html and pdf. Some hard copies (Eng-
lish and Spanish) are still available from the
WMA Secretariat upon request. Please visit
the WMA website (https://www.wma.net/
en/30publications/60cpwbook/index.html)
to access the electronic versions and to or-
der any hard copies. Regional conferences
were held in Latin America,the Asia-Pacif-
ic region, Europe and Africa between 2005
and 2007. The CPW Project was extended
to include a leadership course organized by
the INSEAD Business School in Fontaine-
bleau, France in December 2007 in which
32 medical leaders from a wide range of
countries participated. The curriculum in-
cluded training in decision-making, policy
work, negotiating and coalition building,
intercultural relations and media relations.
The fifth course was held at the INSEAD
campus in Singapore from 13th
–18th
Janu-
ary 2013. The courses were made possible
by educational grants provided by Bayer
HealthCare and Pfizer, Inc. This work, in-
cluding the preparation and evaluation of
the course, is supported by the WMA co-
operating center, the Center for Global
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WMA News
In Poland, physicians were made liable
for managing the reimbursement entitle-
ments of the insured. Everyone in Poland
is insured under a state health insurance
scheme, which sets out various entitle-
ments for reimbursement. These differ-
ent entitlements were, at least in part, not
transparent to physicians, who should not
be held liable for wrongly assigning reim-
bursement statuses for drugs on prescrip-
tion. Together with the Polish Chamber
of Physicians and Dentists, the WMA
protested against this measure, which was
later revoked.
At the end of 2011, the Turkish Govern-
ment withdrew key functions, such as the
supervision of physicians and the regula-
tion of post-graduate education, from the
Turkish Medical Association and other
self-governing institutions. Interestingly,
these institutional rights were assigned by
law and the government is trying to lift
them using a government order. Together
with the Turkish Medical Association, the
WMA staged public events in Ankara and
Istanbul on 16th
and 17th
April 2012 to fight
for the retention of these critical rights of
physician self-governance.
CHAPTER II
Partnership & Collaboration
During the reporting period, the WMA
Secretariat held bilateral meetings with
the WHO and staff of other UN agencies
on the following areas: Prevention of alco-
hol abuse, mental health, violence against
women, the environment, the migration of
health professionals and the prevention of
torture. In addition, the Secretariat voiced
the WMA’s concerns in various public set-
tings as follows*
:
1. World Health Organization (WHO)
(see table 2)
2. UNESCO Conference on Bioethics,
Medical Ethics and Health Law
In recent years, the WMA has already sup-
ported the “UNESCO Chair in Bioethics
World Conference on Bioethics, Medi-
cal Ethics and Health Law” organized
by the UNESCO Bioethics Chair, Prof.
Dr.  Amnon Carmi. In November 2014,
* More information on activities mentioned is set
out under the relevant section of the report.
Health and Medical Diplomacy at the Uni-
versity of North Florida. A sixth course is
planned, again at the INSEAD campus in
Singapore, from 29th
April to 3rd
May 2014.
5. Health policy & education
5.1 Medical and health policy
development & education
In recent years, the Center for the Study of
International Medical Policies and Practices
at George Mason University,which is one of
the WMA’s cooperating centers,has studied
the need for educational support in the field
of policy creation. The surveys, performed
in cooperation with the WMA, found a
demand for education and exchange. The
Center invited the WMA to participate
in the creation of a scientific platform for
international exchange on medical and
health policy development. In the fall of
2009, the first issue of a scientific journal,
World Medical & Health Policy, was
published by Berkeley Electronic Press as an
online journal. It has recently been moved
to the Wiley Press. The World Medical &
Health Policy Journal can be accessed at:
http://onlinelibrary.wiley.com/journal/
10.1002/(ISSN)1948-4682
5.2 Support for national
constituent members
At the beginning of 2012, the WMA inter-
vened three times on matters of health poli-
tics at the request of member associations:
In Slovakia,the government declared a state
of emergency in hospitals in order to stop
protests and industrial action by physicians
fighting for better working conditions and
against the privatization of public hospitals.
In consultation with the Slovak Medical
Association, the WMA wrote to the Prime
Minister and the President of the Republic
to call for proper working conditions and
fair payment.
Table 2.
Governance WHO public events
34th
session of the Executive Board (January
2014):
• Written statement (on behalf of the WHPA) on
the WHO’s role in humanitarian emergencies;
• Written statement (on behalf of the WMA, IF-
MSA1
and WONCA2
) on the global challenge
of violence, in particular against women and girls;
• Written statement on antimicrobial resistance
(influenza)
GlobalHealthWorkforceAlliance
2013:
The WHO invited the WMA to
co-organize a session at the Third
Global Forum on Human Resources
for Health in November 2013 in
Brazil.The WMA is working with
the African Medical and Research
Foundation and IntraHealth Inter-
national to organize the session
67th
World Health Assembly (May 2014):
The Secretariat monitors issues of interest that
will be addressed at the next World Health As-
sembly, such as non-communicable and commu-
nicable diseases, palliative care, violence against
women, the global vaccine action plan, and
antimicrobial resistance (influenza).
Prince Mahidol Award Conference
2014:
The WHO invited the WMA to
engage in the WHO side session
on the social determinants of health
(SDH), as well as in the WHO
proposed e-book on SDH.
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WMA News
Table 3.
Agency Activities
Human Rights Coun-
cil
UN Special Rapporteur
(SR) on the right of
everyone to the enjoy-
ment of the highest
attainable standard of
physical and mental
health (A. Grover) –
See item 2.1 for details
Special Rapporteur on
torture and other cruel,
inhuman or degrading
treatment or punish-
ment (J. E. Mendez)
Sub-Committee on the
Prevention of Torture
(SPT)
• Circulation of the SR’s report to the
UN General Assembly on the right
to health obligations of States and
non-State actors towards persons af-
fected by and/or involved in conflict
situations along with a WMA letter
welcoming the report (October
2013)
• Joint press release regarding the
Turkish health bill (December 2014)
• Monitoring the follow-up to the
annual report on torture and ill-
treatment in healthcare settings
• Meeting with Suzanne Jabour, Vice-
President/Continuing exchange of
information.
United Environment
Programme (UNEP),
Chemical Branch
Discussion of the Minamata Conven-
tion on Mercury and the ratification
process.
Table 4.
WMA Cooperating Center Areas of cooperation
Center for the Study of
International Medical Poli-
cies and Practices, George-
Mason-University, Fairfax,
Virginia, USA
Policy development, microbial
resistance, public health issues
(tobacco), publishing the World
Medical and Health Policy
Journal.
Center for Global Health and
Medical Diplomacy, Univer-
sity of North Florida, USA
Leadership development, medical
diplomacy
Institute of Ethics and His-
tory of Medicine, University
of Tübingen, Germany
Revising the Declaration of Hel-
sinki, medical ethics
Institut de droit de la santé,
Université de Neuchâtel,
Switzerland
International health law, medical
ethics, deontology
Steve Biko Centre for Bio-
ethics, University of Wit-
watersrand, Johannesburg,
South Africa
Revising the Declaration of Hel-
sinki, medical ethics, bioethics
Table 5.
Organization Activity
Amnesty Internation-
al – Health Unit
Ongoing contacts (exchange of informa-
tion and support) during the reporting
period on the situations in Turkey, Iraq,
Bahrain, Egypt and Russia.
Human Rights Watch Regular contacts on palliative care
(WHO resolution) and on matters
relating to mercury and human rights
Global Alliance on Al-
cohol Policy (GAPA)
Regular exchange of information.
International Commit-
tee of the Red Cross
(ICRC)
Partners in the Health Care in Danger
project since September 2011. Coopera-
tion with the health and legal units
International Fed-
eration of Health and
Human Rights Organ-
isations (IFHHRO)
Regular exchange of information on hu-
man rights and health matters,in particular
during the reporting period: the health bill
in Turkey,homosexuality,mental health.
International Federation
of Medical Students
Associations (IFMSA)
Internship program since 2013 (3 stu-
dents in 2013 and 4 students in 2014)
University of Penn-
sylvania International
Internship Program
Internship program on health policy,
public health, human rights, project
management (2 students in 2014)
Planning of a joint side-event on vio-
lence against women at the next World
Health Assembly (May 2014).
International Rehabili-
tation Council for Tor-
ture Victims (IRCT)
Member of the Council and Executive
Committee (seat as an independent expert)
Member of IRCT working group on
detention.
Regular input on policy development in
advance of the next Council meeting in
March 2014.
Global Climate &
Health Alliance
Participation in the joint Global Summit
on Health and Climate Change (COP
19th
November 2013, Warsaw)
Exchange of information in the follow-up.
New Jersey Medical
School Global TB
Institute
The WMA is working with the New Jer-
sey Medical School Global TB Institute
and the University Research Company
(URC) to update its online TB refresher
course for physicians with the support of
the US Agency for International Devel-
opment (USAID)
Safeguarding Health in
Conflict Coalition
Observer status in the coalition.
Regular exchange of information.
62
WMA News
the WMA for the first time took an active
role, structuring its own sessions at the
conference in Naples, Italy. WMA Past-
President, Dr. Yoram Blachar, WMA Eth-
ics Advisor, Dr. Jeff Blackmer, and WMA
Legal Counsel, Ms. Annabel Seebohm,
organized sessions on the Declaration of
Helsinki and the ethical and legal aspects
of hunger strikes. Among the speakers were
WMA advisors Prof. Vivienne Nathanson,
Dr. Hernan Reyes and Ms. Malke Borrow.
3. Other UN agencies (see table 3)
4. World Health Professions Alliance
(WHPA)
The WMA submitted a proposal for a side
session at the Global Health Workforce
Alliance (GHWA) Global Forum in No-
vember 2013: ‘From Interprofessional Edu-
cation to Interprofessional Collaborative
Practice: The Role of Professional Asso-
ciations’. The proposal was accepted by the
Global Health Workforce Alliance.
The WMA made interventions on behalf of
the WHPA at the 134th
Executive Board
of WHO on antimicrobial drug resistance,
the WHO’s role as the health cluster lead in
meeting the growing demands of health in
humanitarian emergencies, multi-sectorial
action for a life course approach to healthy
ageing and the engagement of the WHO
with the non-state sector.
The WHPA will hold the third World
Health Professions Regulation Confer-
ence in Geneva from 17th
–18th
May 2014.
The conference will take place immediately
prior to the WHO World Health Assem-
bly and discuss the challenges and provide
insights into the issues surrounding health
professions’ regulation.
As a continuation of the NCD health im-
provement card in paper form and the in-
teractive version on the internet,the WHPA
is now developing an application for mobile
phones. It should better encourage and sup-
port people to develop a healthier lifestyle
in their everyday lives. Finally, the health
improvement card will be available free of
charge in three different formats.
5. WMA Cooperating Centers
The WMA is now proud to enjoy the sup-
port of four academic cooperating centers.
The WMA Cooperating Centers bring spe-
cific scientific expertise to our projects and/
or policy work, improving our professional
profile and outreach.
The latest addition to our cooperating cen-
ters is the Institute of Health Law at the
University of Neuchatel, Switzerland (In-
stitut de droit de la santé, Université de
Neuchâtel). (see table 4)
6. Other partnerships or collaborations
(see table 5)
CHAPTER III
Communication & Outreach
1. WMA newsletter
In April 2012, the WMA Secretariat start-
ed a bi-monthly e-newsletter for its mem-
bers. The Secretariat appreciates any com-
ments and suggestions for developing this
service and making it as useful for members
as possible.
2. WMA social media (Twitter and Face-
book)
In 2013, the WMA launched its official
Facebook and Twitter accounts (@med-
wma). The Secretariat encourages members
to spread the word within their associations
that they can follow the WMA’s activities
on twitter and via Facebook.
3. The World Medical Journal
The World Medical Journal is issued every
3 months and includes articles on WMA
activities and feature articles from mem-
bers and partners. It enjoys a wide circula-
tion.
4. Roundtable Meeting
During recent years, the Business Develop-
ment Group of the World Medical Associa-
tion has developed the Roundtable concept
under the leadership of the Secretary of the
British Medical Association, Tony Bourne.
The idea of the Roundtable is to provide a
forum for international business leaders and
the leaders of the WMA to meet up and
discuss issues of common interest relating
to medicine and health care, etc.
The first roundtable took place at BMA
House in London on 26th
September 2013.
The second meeting is scheduled to take
place in Tokyo on 24th
April 2014.
5. WMA African Initiative
WMA President Dr. Margaret Mungher-
era has started an initiative to bring African
medical associations closer to the WMA. A
stronger inclusion of organized medicine in
international cooperation should not only
help to get the African voice better heard,
but would also leverage their national vis-
ibility and standing.
Dr. Mungherera has been bringing together
medical associations from various parts of
Africa in small regional meetings to dis-
cuss issues around their current work, what
obstacles they are facing and where they
have had success. Invitations are open to
all African medical associations, regardless
of whether they are members of the WMA
already or not.
Three meetings have been held up to the re-
porting date,with the West African medical
associations in Nairobi, Kenia in November
2013, with the Southern African medical
associations in Johannesburg, South Africa
in February 2014, and in March 2014 with
the North African medical associations in
63
WMA News
Hammamet, Tunisia. Further meetings are
planned in Nigeria and in Mozambique.
This initiative has been supported by the
medical associations of South Africa and
Tunisia, our President-Elect, Dr. Xavier
Deau, Chair of Council, Dr. Mukesh Hai-
kerwal, as well as the Chairman of the
Past-Presidents and Chairs Committee, Dr.
Dana Hanson.
CHAPTER IV
Operational Excellence
1. Advocacy
The WMA set up a permanent Advisory
Advocacy Committee in 2007 with the
mission:
• To maintain effective liaison with rel-
evant UN organizations, branches and
institutions, health care organizations,
coalitions and NGOs;
• To ensure that WMA policies and posi-
tions are promoted among appropriate
organizations, associations and institu-
tions;
• To simultaneously provide advocacy tools
and content with the ultimate goal of be-
ing visible and having a positive impact.
The Advisory Group is chaired by Dr. An-
dré Bernard (Canadian Medical Asso-
ciation) and includes representatives of the
medical associations of the following coun-
tries: Germany, Israel, UK, Uruguay and
US. The Chair of Council, Dr. M. Haiker-
wal, takes part in the meetings, as well as
WMA Public Relations Consultant, Nigel
Duncan. Participants from WMA Secre-
tariat include the Secretary General, Dr. O.
Kloiber, and the Advocacy Advisor, Ms. C.
Delorme.
In April 2013, the Committee agreed to
develop an advocacy strategy for the pub-
lic release of the revised Declaration of
Helsinki, further to its expected approval
by the General Assembly in Fortaleza in
October 2013.
In 2012, the Committee conducted an ad-
vocacy survey of the WMA membership in
order to identify the needs of the constitu-
ent members regarding advocacy, as well
potential synergies that could be developed
in a more global context.One clear outcome
of the survey was a request from members
that the WMA provide advocacy training.
In this context, the Committee is consider-
ing the organization of an advocacy train-
ing session in Durban, South Africa during
the 2014 WMA General Assembly in col-
laboration with the South African Medical
Association.
2. Business Development Group
PleaseseeChapterIV“Roundtablemeeting”
3. Secondment program
The WMA has continued a secondment
program with its members. Constituent
members may send staff members or vol-
unteers to the WMA office for a limited
period of time.
4. Paperless meetings
At the 188th
Council meeting, the WMA
Council expressed its desire to reduce its
environmental impact by going paperless.
Since the 189th
Council meeting, docu-
ments posted on the website before the
meeting have no longer been provided at
the venue in print. Council members and
officials are responsible for downloading
documents from the members’ area of the
WMA website and bringing them to the
meeting via electronic media or on pa-
per, if desired. Documents developed on
site during the meeting will be available
online through a Wi-Fi connection or in
print.
5. gTLD (generic Top Level Domains in
the Internet)
The WMA Executive Committee explored
the suggestion by the British Medical As-
sociation to consider building a consortium
to tender for a generic top-level domain
of the Internet. Currently there is a sug-
gestion to install a gTLD “.med”, which
may be of interest to physicians, medi-
cal facilities and medical associations, but
also to pharmaceutical companies, medical
technology companies, insurers and many
others. An exploratory group could not de-
termine the chances of success of such a
business venture and found that the finan-
cial and legal risks outweigh the potential
benefits.
Meanwhile, the WHO expressed concern
that the applications that had been made
for a potential gTLD “.health” were too
commercially orientated. The WHO re-
quested our support in asking the Internet
steering body ICANN for a moratorium
and not to issue this gTLD for the time
being. On behalf of the WMA, and in sup-
port of the WHO request, the Secretary
General raised concerns with ICANN via
the request for comments from the organi-
zation, as well as to their government rela-
tions body.
CHAPTER V
Acknowledgement
The Secretariat wishes to record its appre-
ciation to member associations and inter-
national organizations for their interest in,
and cooperation with, the World Medical
Association and its Council during the
past year. We thank all those who have
represented the WMA at various meet-
ings and gratefully acknowledge the col-
laboration and guidance received from the
officers, as well as the association’s editors,
its legal, public relations and financial ad-
visors, staff of constituent members, coun-
cil advisors, associate members, friends of
the association, cooperating centers and its
officials.
64
UGANDASpeaking Book
Background: Informed consent is premised
on the participants’ understanding the scope
of the research and the associated risks and
benefits. The objective was to evaluate the
improvement in knowledge in a population
unfamiliar with clinical trial concepts about
“what it means to be part of a clinical trial”
using an innovative educational tool called
the ‘Speaking Book’.
Methods: This was a randomized con-
trolled trial conducted at a research site
in Uganda. 201 participants were ran-
domized to: (1) clinical trials information
session control arm, or (2) clinical trials
information session followed by instruc-
tion in the use of the Speaking Book with
a take-home copy (intervention arm). Af-
ter the session, participants of both groups
completed a 22-item multiple-choice test
on the rights and responsibilities of par-
ticipants. Participants returned after one
week to complete the same test to assess
knowledge retention. The mean pre- and
post-test score difference was assessed
according to trial arm using an unpaired
t-test of proportions.Results: Ninety-one
(90%) participants completed both the
initial and follow-up tests in the control
arm and 100 (100%) in the intervention
arm.The average age of participants was 38
years, 53% were female and 67% were em-
ployed; 20% had previously been invited to
participate in a clinical trial; of these, 19%
had participated. The mean difference in
proportion of correct responses from test
1 to test 2 was 2.7% (95%CI 0.3–5.0%)
for the control arm and 11.6% (95%CI
9.3–13.7%) for the intervention arm (t-
score=-5.3, p-value<0.0001).Conclusion: Participants who had instruction in the use of the Speaking Book had a larger in- crease in knowledge than those who had no access to this tool. To better engage patients unfamiliar with clinical trial con- cepts, innovative educational techniques can assist to increase knowledge to make an informed decision about participation in a clinical trial. In the twentieth century, a participant’s informed consent became the backbone of ensuring ethical participation in a clini- cal trial. The key elements of the informed consent are: the provision of information about the research, the understanding of the information that is passed on, and the free agreement by the patients to partici- pate in the study [1]. Research participants should be informed about the purpose of the research, the study procedures, the risks and the benefits of such procedures; the participant should also be informed regarding alternative options and the ex- tent to which confidentiality will be main- tained. Many of the precautions and con- siderations involved in ethical conduct rest on the basic foundation of informed con- sent.However,with conventional informed consent procedures, it has been observed that patients often misunderstand or for- get basic practical information regarding the trials in which they participate [2, 3]. It is important to note too, that the con- sent procedure alone does not necessarily ensure that research participants have ob- tained sufficient knowledge to make an informed choice about participation [4], and that limitations specific to populations with low literacy levels have been identi- fied [5]. A number of studies have found low levels of understanding in terms of what consti- tutes a clinical trial and details on partici- pation. For example, one study found that only 28% of participants knew the study’s aim [4] while in another, 88% of women reported that they felt that trial participa- tion was mandatory [6]. There appears to be a need for better ways of presenting information about clinical trials to enable research participants to make an informed decision. Various methods of improving patient knowledge and understanding of clinical trials used during the informed Multi-media Educational Tool Increases Knowledge of Clinical Trials in Uganda Barbara Castelnuovo Kevin Newell Yukari C Manabe Gavin Robertson 65 UGANDA Speaking Book consent process have been evaluated, such as discussion groups, booklets and video- tapes, “teach back” methods, educational modules to discuss research terminology, and audio/visual presentations [7–12]. The success of these approaches often depends on literacy level. In a meta-analysis by Flory and Emanuel of 12 trials of multimedia interventions, all but one intervention failed to improve the participant’s understanding of the clinical trial [13]. The one trial which showed ef- ficacy had a small sample size and used a computerized presentation of information for participants who were primarily men- tally ill [14]. The authors concluded that multimedia and enhanced consent forms had a limited impact on participant un- derstanding and targeted individualized education was preferable. Another recent study of a video intervention corroborated this finding [15]. Two recent publications on a targeted educational session and a video intervention to increase participant’s understanding of informed consent with- out the details of a particular clinical trial did show improved post-training scores in addition to retention of this information [16,17]. Research initiatives driven by both external and local investigators are rapidly increas- ing in countries within Sub-Saharan Africa where the familiarity with clinical trial con- cepts is generally low. Potential risks in con- ducting research in these environments are increased vulnerability to research exploita- tion and abuse but also low compliance to the study procedures, which can include low adherence to medication schedules. Educating people who are unfamiliar with clinical trial concepts often requires more creative methods to ensure a sufficient level of comprehension. One such creative method to support these populations in understanding their rights and responsibilities when participating in a clinical trial is a multi-media educational tool, a “Speaking Book” entitled ‘What it means to be part of a Clinical Trial’. Clini- cal trials are the gold standard method for collecting safety and efficacy data for health interventions.The Speaking Book (SB) is a richly illustrated book designed to enhance knowledge and understanding of what clinical trials are, how they are conducted, and the rights and responsibilities of par- ticipants in a clinical trial. The SB consists of sixteen pages and sixteen corresponding buttons. The text on each page describes one topic around the participation in clini- cal trials and can be read aloud in English by a sound device within the book, which can be activated by pushing the corre- sponding button. Each monologue lasts less than a minute. The content of this particular book was reviewed by the World Medical Association to ensure alignment with the principles of the Declaration of Helsinki [1]; by the South African Medi- cal Association to ensure the clinical rel- evance; and by the Steve Biko Centre of Bioethics to ensure that the rights of hu- man research subjects were addressed. The book can be used by researchers to provide general education to potential clinical trial participants. In a pilot study of 52 partici- pants working in a mass catering company conducted in South Africa [18], the SB was evaluated for efficacy in knowledge uptake and ease of use. The results of this pilot study indicate that incorporating the SB into the consent process increases the level of knowledge of clinical trials among study participants. The study also showed that the participants perceived the educa- tional tool as easy to use. In order to obtain information about the efficacy of the SB in a research setting in Uganda, a clinical trial was conducted in a busy public clinic located within the Na- tional Hospital where patients are recruited for clinical trials. The research team sought to provide information about the effec- tiveness of the SB in the type of environ- ment for which it was designed. The team also assessed the acceptability of the SB by research participants and health profession- als working on clinical trials. The study was reviewed and approved by the Joint Clinical Research Centre (JCRC) Ethics Committee and by the Uganda National Council for Science and Tech- nologym (UNCST). Written consent was obtained from each participant and the eth- ics committee approved this procedure. The clinical trial is registered with the Pan Af- rican Clinical Trials Registry, trial number PACTR201307000574378. This study was a randomized, controlled clinical trial design comprising 2 groups, each of approximately 100 adult (older than 18 years) participants, in a research site in Kampala, Uganda. Patients attending a health clinic in Kampala were invited to participate in the study by a site research as- sistant. Those consenting to participate and who could understand and read English (as assessed by a literacy test) were random- ized sequentially according to pre-allocated group assignments in blocks of 4 to either the control group or the SB group. Both groups took part in a standard clinical trial information session and participants were assessed immediately afterward using a written 22-item knowledge assessment that was developed by the study team based on the information covered during the session. The total score was calculated as the per- centage of correct answers. The assessment addressed the nature of clinical trials, and the rights and responsibilities of partici- pants in clinical trials. After the initial in- formation session and assessment of knowl- edge, the participants in the SB group were provided instructions on the use of the SB, received a copy of the SB to take home and were encouraged to listen to it as may time they wished to as well to invite other people listen to it. After one week, participants in both groups were re-assessed using the same tool to determine retention of knowl- edge. Participants in the SB group were also asked a set of additional qualitative ques- tions about their experiences with the SB. 66 Participants in both groups were given ap- proximately $3 to cover transport costs on each of the 2 days. In a separate qualitative evaluation, ten health professionals employed in the same research clinic, but not part of the study, were given the book to listen to and were asked to respond to a brief survey about their perceptions of informed consent, and the efficacy and acceptability of using the SB as part of the consent process. The mean pre- and post-test score dif- ference was assessed by trial arm using an unpaired t-test of proportions. Qualitative data was summarized using tabulations. Data was analyzed using SAS version 9.2. A total of 201 participants were random- ized on this trial, including 100 partici- pants in the SB group and 101 in the con- trol group. Ninety- one (90%) participants in the control group and 100 (100%) in the Speaking Book group completed both the initial and follow-up tests.The average age of participants was 38 years, 53% were female and 67% were employed. Forty (20%) participants reported they had been invited to participate in a clinical trial, in- cluding thirty-nine (19%) who reported they had participated previously in a clini- cal trial. The demographic characteristics of study participants in the two arms were similar (Table 1), though there was a trend toward higher education level in the con- trol group. The mean score for the first assessment was 76.5% in the control group and 71.7% in the SB group, which was similar (Table 2). The change in proportion of correct responses from test 1 to test 2 was 2.7% (95%CI 0.3–5.0) for the control group and 11.6% (95%CI 9.3–13.7) for the SB group, which was statistically significant (p<0.0001). The allocation group was the only variable associated with significance for knowledge increase, measured by pro- portional score difference; there was no as- sociation between knowledge change and other variables such as demographic char- acteristics, educational level, or previous exposure to clinical trials. We reviewed item-level responses to the knowledge assessment to determine if there were any trends in knowledge up- take or retention by trial arm. In the in- tervention arm, there were improvements of greater than 10% from pre-intervention to post intervention in the proportion re- sponding correctly for 11 of 22 (50%) the assessment items, whereas in the control arm, there were improvements of this same magnitude in only 2 (9%) questionnaire items. Among intervention participants, there were no items with a decrease in pro- portion responding correctly between the assessments; however, in the control group there was a decrease in proportion of cor- rect responses for 7 of 22 (32%) assessment items. All participants in the intervention group were asked questions about their experi- ence with the SB. Almost all participants (99%) liked the illustrations and found the book easy to use (98%). Most participants (96%) heard the spoken voice clearly and Table 1. Demographic characteristics of study participants by study arm Variable SB n=100 Control n=101 p-value N (%) N (%) Gender Female 55(55) 51(50.5) 0.52 Educational Level 0.10 Primary 1(1) 6(5.9) S1-S4 48(48) 36(35.6) S5-S7 25(25) 25(24.7) Tertiary 26(26) 34(33.7) Employment 0.49 Employed 69(69) 65(64.4) Ever asked to participate in a Clinical Trial? 0.50 No 82(82) 79(78.2) Ever participated in a Clinical Trial? 0.53 No 82(82) 80(79.2) Age (yrs) Mean (SD) 37.8(8.6) 37.8(11.5) 0.97 SB: Speaking book; S: secondary; SD: standard deviation. Table 2. Knowledge test scores (proportion of correct responses) by group Group Test 1 Mean Test 2 Mean Mean of Score Difference t-score p-value Control 76.5% 79.2% 2.7% Speaking Book 71.7% 83.3% 11.6% –5.3 <0.0001 UGANDASpeaking Book 67 98% reported understanding the content. Almost all participants (99%) indicated that members of their community would understand the content if given the speak- ing book to use. Seventy-two percent of participants reported showing the book to others. On average, participants showed the book to 8 other people in their homes, workplace, church, mosque, clinic or hospi- tal. Most participants (93%) reported that after listening to the speaking book, they would, in principle, be willing to participate in a clinical trial. Table 3 summarizes the responses given by participants in the SB group. Interviews were conducted with ten health professionals to assess their perceptions of the potential efficacy, acceptability and use of the SB. The average age of the health professionals interviewed was 31.6 years and they had been working in their cur- rent position for an average of 3.8 years. Of the ten health professionals surveyed, seven (70%) thought that their current consent process at their clinic provided participants with sufficient understanding to sign an informed consent before enter- ing a clinical trial. Most (90%) thought that participants in clinical trials are aware of their role and responsibilities prior to signing the informed consent form. Four (40%) thought the person who explains the information sheet and consent form to the patient does not have enough time to make sure that the patient completely un- derstands all the information. Nine (90%) thought that the consent process would be easier if patients were asked to read the SB first on their own. Seven (70%) thought that participants take study drug as pre- scribed and inform the study staff about any additional drugs used. Of the health professionals who thought participants do not take study drug as prescribed (30%), all thought that the SB would help in ex- plaining the importance of this to them. Five (50%) of the health professional re- spondents reported that they had been asked about the term “placebo” during the consent process. Most (80%) of these thought they understood the term placebo well enough to explain it. Six (60%) of all health professionals interviewed thought the SB explained the concept sufficiently. All ten (100%) interviewed reported that they usually told patients that they can quit participation in the trial at any time, and nine (90%) thought the SB addressed this issue adequately. Three (30%) thought that the SB contained all the necessary in- formation while seven (70%) thought the SB contained most but not all of the infor- mation necessary to make a decision about participating. Almost all (90%) thought that each participant should be given a SB to take home before agreeing to partici- pate in a clinical trial, and all ten (100%) thought the SB would assist participants better than a brochure when screening or informing them about a clinical trial (Table 4). In settings with patients unfamiliar with clinical trial concepts, innovative tech- niques can improve knowledge acqui- sition and retention in order for indi- viduals to make a more informed choice about participation in clinical trials. Par- ticipants who had instruction in the use of the SB and used it for one week had a larger improvement in knowledge as- sessment score compared to those who had no access to this tool. Our data is in contrast to a meta-analysis by Flory and Emanuel [13]. Table 3. Summary of participant responses to questions about the Speaking Book Question Yes Total (mean) No Total (mean) If yes, how many? Total (mean) Did you like the pictures and drawings? 99(99) 1(1) Did you find the book easy to use? 98(98) 2(2) Could you hear the person talking to you clearly? 96(96) 4(4) Did you understand all the information that she told you in the book? 98(98) 2(2) Do you think members of your church, community, and township will understand what a clinical trial is, if they were given this book to listen to? 99(99) 1(1) Did you show the book to anyone else in your community? 72(72) 28(28) Did you show the book to anyone else at Church/Mosque? 54(54) 46(46) 190(1.9) Did you show the book to anyone at work? 41(41) 59(59) 144(1.4) Did you show the book to anyone in your family? 66(66) 34(34) 291(2.9) Did you show the book to anyone at the clinic or hospital? 47(47) 53(53) 161(1.6) Did you show the book to someone any- where else? 9(9) 91(91) 18(0.2) After listening to the information and the story in the book would you ever be willing to be in a clinical trial? 93(93) 7(7) UGANDA Speaking Book 68 The SB seems to be a valuable tool in im- proving patients’ understanding of clinical trials and their rights and responsibilities associated with participation in a trial.The qualitative assessment of the interven- tion group showed that participants who were instructed in the use of the SB and brought it home for a week found it use- ful and shared it extensively with friends, family, work colleagues and other associ- ates, thereby increasing the value of the book as an educational tool. This allowed patients to discuss the ethical aspects of clinical trials with others whose opinions they valued. A structured questionnaire was used with a limited pool of health professionals who viewed the SB as a useful tool for increas- ing the capacity of patients to make an in- formed decision regarding participation in a clinical trial. One limitation of our study was that the participants included only those who spoke and understood English since the SB was not translated into local languages. Therefore, participants likely had a higher educational status than the average for the clinic. In the meta- analysis [13], re- search participants with higher education status were more likely to have better un- derstanding. Nonetheless, having a group of participants capable of taking the test represented an appropriate first group in whom to test the intervention.The investi- gators also noted that despite the random- ization the control arm had slightly higher education level, though of marginal sig- Table 4. Summary of Health Professionals responses to questions about the Speaking Book Question Yes n(%) No n(%) No response n(%) Do you think that the consent process at your clinic now is enough for the participants to understand the consent forms provided and the details of the trial? 7(70) 3(30) In general, do you think that participants in clinical trials are aware of their medical responsibilities prior to signing the consent form? 9(90) 1(10) Do your patients understand that they should inform the doctor or nurses about any other medication that they take before or during the trial, even from a pharmacy or a traditional healer? 7(70) 2(20) 1(10) Do you think the participants in a clinical trial take their medication exactly as they are told to do? 7(70) 3(30) If NO, do you think the book can help you explain the importance of this to them? 3(30) Do patients ever ask you what a placebo is during the consent process? 5(50) 4(40) 1(10) If YES, do you think that you know about a placebo well enough to explain it properly? 4(40) 1(10) Do you think the speaking book explains the concept of a placebo enough? 6(60) 4(40) Do you usually tell the patient that they can stop the clinical trial at any time? 10(100) 0(0) Does the book tell the patient clearly enough that they can stop the clinical trial at any time? 9(90) 1(10) Do you think that the person who explains the information sheet and consent form to the patient has enough time to make sure that the patient completely understands all the information? 6(60) 4(40) Do you think that the consent process would be easier if the patient was asked to read the book first on their own? 9(90) 1(10) Do you think that the information in the book gives all the information needed to make a decision about participating? 3(30) 0(0) Do you think the book should include any other information we have forgotten? 3(30) 7(70) At what time do you think that the books should be given to the new person applying for the trial? At time of first visit to the research clinic At time of first talk about clinical trial 4(40) 6(60) Do you think that each participant should be given a speaking book to take home before agreeing to participate in a clinical trial? 9(90) 1(10) If you were going through screening or informing a patient about a clinical trial, in addition to normal practices which do you think would help a participant more? Speaking Book Brochure 10 (100) 0(0) UGANDASpeaking Book 69 nificance (p=0.10), and therefore the use of the SB could have had an even higher im- pact on the absolute score change if groups had a more similar level of education. The fact that a differential improvement in knowledge was identified between the study groups suggests that the SB might demonstrate an even greater improvement in knowledge among a less literate popula- tion. Further studies with use of the tool in the local language such that participants with lower educational status could be in- cluded would be warranted. A disadvantage of using the SB to pass information on clinical trials is that it re- quires a two-visit procedure with increase in study costs and potential for loss to fol- low up in between the visits. However in our study all participants in the SB arm (as compared to 90% in the control arm), returned for the follow up visit after the week, possibly as the result of learning the importance of participating clinical tri- als; in addition most of the participants showed the book to an average of 8 other people in their homes, contributing to the sensitization of the general population on clinical trials. In summary, the use of a SB multi-media tool for one week after a standard explana- tion of clinical trials was able to increase comprehension scores significantly com- pared to participants who received only one educational session. The SB is an introduc- tory tool that can be used to inform patients on topics common to all clinical trials and may be a valuable adjunctive instrument for use among potential research participants to improve understanding of clinical trials and make an informed decision during the consent process. References 1. World medical Association (1964) Declaration of Helsinki - Ethical Principles for Medical Re- search Involving Human Subjects. 2. Byrne DJ, Napier A, Cuschieri A (1988) How informed is signed consent? Br Med J (Clin Res Ed) 296: 839-840. 3. Lavelle-Jones C, Byrne DJ, Rice P, Cuschieri A (1993) Factors affecting quality of informed consent. BMJ 306: 885-890. 4. Joubert G, Steinberg H, van der Ryst E, Chikobvu P (2003) Consent for participation in the Bloemfontein vitamin A trial: how in- formed and voluntary? Am J Public Health 93: 582-584. 5. Molyneux CS, Peshu N, Marsh K (2004) Un- derstanding of informed consent in a low-in- come setting: three case studies from the Kenyan Coast. Soc Sci Med 59: 2547-2559. 6. Abdool Karim Q, Abdool Karim SS, Coovadia HM, Susser M (1998) Informed consent for HIV testing in a South African hospital: is it truly informed and truly voluntary? Am J Public Health 88: 637-640. 7. Agre P, Kurtz RC, Krauss BJ (1994) A rand- omized trial using videotape to present consent information for colonoscopy. Gastrointest En- dosc 40: 271-276. 8. Ives NJ,Troop M, Waters A, Davies S, Higgs C, et al. (2001) Does an HIV clinical trial infor- mation booklet improve patient knowledge and understanding of HIV clinical trials? HIV Med 2: 241-249. 9. Llewellyn-Thomas HA, Thiel EC, Sem FW, Woermke DE (1995) Presenting clinical trial information: a comparison of methods. Patient Educ Couns 25:97-107. 10. Bygrave H, Kranzer K, Hilderbrand K, Jouquet G, Goemaere E, et al. (2011) Renal safety of a tenofovir-containing first line regimen: experi- ence from an antiretroviral cohort in rural Leso- tho. PLoS One 6: e17609. 11.Ryan RE, Prictor MJ, McLaughlin KJ, Hill SJ (2008) Audio-visual presentation of informa- tion for informed consent for participation in clinical trials. Cochrane Database Syst Rev: CD003717. 12.Tamariz L, Palacio A, Robert M, Marcus EN (2013) Improving the informed consent pro- cess for research subjects with low literacy: a systematic review. J Gen Intern Med 28: 121- 126. 13. Flory J, Emanuel E (2004) Interventions to im- prove research participants’understanding in in- formed consent for research: a systematic review. JAMA 292: 1593-1601. 14. Dunn LB, Lindamer LA, Palmer BW, Golshan S, Schneiderman LJ, et al. (2002) Improving un- derstanding of research consent in middle-aged and elderly patients with psychotic disorders. Am J Geriatr Psychiatry 10: 142-150. 15. Hoffner B, Bauer-Wu S, Hitchcock-Bryan S, Powell M, Wolanski A, et al. (2012) “Entering a Clinical Trial: Is it Right for You?”: a rand- omized study of The Clinical Trials Video and its impact on the informed consent process. Cancer 118: 1877-1883. 16. Sengupta S, Lo B, Strauss RP, Eron J, Gifford AL (2011) Pilot study demonstrating effective- ness of targeted education to improve informed consent understanding in AIDS clinical trials. AIDS Care 23: 1382-1391. 17. Joseph P, Schackman BR, Horwitz R, Nerette S, Verdier RI, et al. (2006) The use of an educa- tional video during informed consent in an HIV clinical trial in Haiti. J Acquir Immune Defic Syndr 42: 588-591. 18. Dhai A, Etheredge H, Cleaton-Jones P (2010) A pilot study evaluating an intervention de- signed to raise awareness of clinical trials among potential participants in the developing world. J Med Ethics 36: 238-242. Barbara Castelnuovo, Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda Kevin Newell, Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc. (formerly SAIC-Frederick Inc.), Frederick National Laboratory for Cancer Research, USA Yukari C Manabe, Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA Gavin Robertson, Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda Aeras (Current affiliation), Cape Town, South Africa E-mail: grobertson@aeras.org UGANDA Speaking Book 70 The South African health care system consists of both the public and private health systems and these are very simi- lar to the types found in similar middle income countries as well as other devel- oped markets. The private health system in South African is currently serving close to nine (9) million people and these are people who currently have medical aid and those who can afford and are able to pay for health care from their own pocket. It is also a well known phenomenon and has been covered extensively in literature that private health system in South Africa is costly and mostly used by the middle to high income individuals and families. Comparisons have also been made assess- ing levels of inequalities between the pri- vate and the public health system, where is stated that more than forty (40) mil- lion people solely use the public health systems. There have been policy develop- ments towards the introduction of the national health insurance. This is a major health sector reform which is currently in the pilot phases, and is likely to increase public – private partnership between the two health sectors. Notwithstanding; the inequality challenges between the private and public health sec- tor – the health financing and health deliv- ery components of health systems – there are other challenges facing the health care system in South Africa. These are also ob- served in other global markets and include increasing cost of health care. The private health care expenditure data reported by the CMS (Council for Medical Schemes) revealed that private hospitals, medical spe- cialists and medicines accounted for more nearly eighty (80) percent of risk benefits paid by medical schemes in 2012. Another factor of significance is; the impact of market structure on the conduct and per- formance of market participants.The struc- ture of private voluntary health financing markets has impact on: • The nature of health plan concentra- tion (the market penetration of health plans); • The level of health plan rivalry (market participation) [11,18]; and • The conduct of all market participants is thus informed by patterns in market or- ganization. Market structure has an impact on con- sumer welfare policy objectives, these are observable in (but not exclusive to) the fol- lowing factors: • Benefit design (the role of product de- sign) [9]; • Differences in demographic profiles across risk pools ( [15]; • Unequal distribution of disease burden across health plans [11]. Thus; cost pressures in health sector, are partially, a function of the impact market structure on market segments covering vulnerable risk groups [19]. The absence of price regulation in health insurance mar- kets – i.e. price regulation on health service procedures – may fuel market failure out- comes [12; 6]. Economic theory suggests that absence of regulation may result in low-quality services at high-quality prices for unac- quainted consumers [12; 19; 6]. This anal- ysis seeks to provide similar evidence for the South African private health financing system. Purpose Healthcare providers and consumables have been stated in the aforementioned section to contribute significantly to the escalating costs of health care in the pri- vate health sector. Commentators such as Halse et al [7] studied the role of competi- tion policy in healthcare markets and the impact thereof on price increases. Studies by Gaynor, [4], Morrisey [11], Wholey [18] also identified ways in which competi- tion policy can be used to ensure the effec- tive functioning of healthcare markets. Van den Heever [16] advocates for regulatory Market Structure in the South African Health Care System Michael Mncedisi Willie Phakamile Nkomo SOUTH AFRICAHealth Care System 71 framework which; enhances solidarity in health plan risk pools [17]. The objective of the current research note is to conduct a high level review of the con- solidation in the medical schemes industry, structural features of the healthcare sec- tor and policy themes. The covered policy themes are directly related to the interpre- tation of restricted and prohibited conduct, in terms of the Competition Act of 1998. Most of these prescriptive standards re- garding market conduct were enacted on the promulgation of the Competition Act 89 of 1998.The timing of this enabling Act was simultaneous with that of the Medi- cal Schemes Act 131 of 1998. At the time of instituting both these Acts; the policy agendas within the regulatory environ- ments are discussed in the sub headings which follow. Stakeholders & Policy Landscape Medical schemes industry policy landscape The Medical Schemes Act 131 of 1998 came about at a time when market failure was present in the private medical schemes industry. Vulnerable risk groups, such as the sick and healthy, were not able to secure affordable access to health insurance. That situation was as a direct result of a series of deregulation occurring in the 1990’s. These deregulations resulted in a gap in the prod- uct, as a market for covering vulnerable risk groups was not provided in the private sec- tor. The anti-trust policy landscape The regulatory philosophy behind the com- petition Act was to increase the transpar- ency of market behaviour. The intention was to promote the efficiency of industries, and prohibit conduct deemed to be anti- competitive. This has resulted in efficiency focused interpretations of provisions of the Competition Act.Thus, the socio-economic goals of industrial policy were mostly not considered in assessing the competitive nature of transactions and market conduct. Resulting policy gap The enabling clauses of the two statutes resulted in a polarities; i.e. public interest relative to pure market efficiency objectives. The current inquiry into the private health sector by the Competition Commission (Comp.Com); seeks to establish whether their interventions in the private health sector have negatively impacted access to health care. All activities related to collecting informa- tion, and sharing information pursuant to setting a guideline on prices,after the Com- petition Act, were now violations of section 4.Although the practice of setting the “scale of benefits” (SOB) was previously, an activ- ity conducted among professional and stat- utory organizations – that said; it was now prohibited practice. The purpose of SOB was conducted for the purposes of: • Upholding the social solidarity principles of medical schemes; and • Coordinating the activities between pro- viders and funders for the purpose of pro- ducing accessible health financing. Although section 4(1)(b)(i) expressly makes exception for instances when prohibitive conduct can shown to be the result of nor- mal commercial activities prevailing in the market; this did not apply in considering all three of these cases. Notwithstanding that HASA (Hospital Association of South Africa) had previously able to gain exemp- tion from section 4, that exemption was not considered in the hearing. The interpreta- tion of the Competition commission was based on new evidence submitted in other court cases. Most importantly, we have learned that the socio-economic policy objectives of the Competition Act come second to efficiency practices. In fact, collusive practices allowed in the provider environment (arrangements between specialists and providers) are al- lowed as normal commercial practice for efficiency purposes [8; 13]. In fact, the reason behind all three judge- ments by the Competition Tribunal, were as a result of [13]: • Submissions made in other cases regard- ing the conduct of HASA, BHF (Board of Healthcare Funders of South Africa) and SAMA (South African Medical As- sociation) – as it relates to setting price benchmarks; • On the basis of these submissions, an in- vestigation/inquiry into the private health sector was conducted by the Competition Commission; and • The investigation focused on the price benchmarking activities of the SAMA, BHF and the HASA. As a result of the inquiry into the private health sector, emerging policy issues had significant impact on the health financing regulatory framework and market outcomes. Significant observations • Anti-trust policy made in the interests of efficiency markets were not balanced with socio-economic policy objectives; therefore • The public interest intentions behind the Competition Commission inquiry into the health sector are an important a window of opportunity, the CMS policy agenda; and • Table 1 reports the significant policy is- sues and regulatory impact of the Com- petition Commission’s intervention into issues related to RPL (Reference Price List). SOUTH AFRICA Health Care System 72 Defining Market Structure From Different Perspectives Willig [22] explains the analytic process re- quired to be undertaken, in order to, under- stand the different perspectives related to potential merger outcomes. Danzig states the steps to this process: • An understanding the how product and geographic markets delineated; i.e. prod- uct and geographic definition of market structure; • Once discrete market demarcations are established, all the firms belonging to each market segment are to be identi- fied; • The market participants within each mar- ket need to be taken into consideration when calculating and making interpreta- tions regarding market share and concen- tration; • On the quantification of market concen- tration and market shares, an assessment of how existing market conditions impact market rivalry and ease of access (concen- tration/potential for abuse of power) need to be taken into consideration; Assessing ease of entry; • Consideration of other factors may be made; i.e. the outcome of an amalga- mation (merger) on market efficiency and public interest issues/consumer welfare. This section proceeds to paint a picture of the market structure from numerous di- mensions.The intentions is to provide a sit- uational analysis on how product and con- sumer demarcations of the market, could potentially impact solidarity. On the basis that solidarity is affected positively or nega- tively, judgements can be made. To the ex- tent that market organization compromises or improves solidarity; a judgement could be made on the implied effect of a prospec- tive amalgamation may have on community rating. Solidarity: Scheme VS. Benefit option level Figure 1 and 2 illustrates industry solidarity from two different perspectives. A picture of risk pool solidarity is provided at scheme level and at option level. Solidarity in medical schemes – industry level • Overall the industry lost more than a third of schemes over the review period; the declining trend is likely to continue in the next few years, thus giving a posi- tive perspective of how consolidation has increased the solidarity of both the open and restricted scheme markets. • The open* scheme sector saw a reduc- tion of nearly half 2012 from a level of 49 schemes (2002) to 25 (2012); • The restricted** schemes sector saw a re- duction of nearly thirty (30) percent by 2012 from a level of 94 schemes (2002) to 67 (2012); Solidarity in benefit options – industry level Solidarity within risk pools does not share the same patterns viewed from the perspec- tive benefit options (Figure 2). Benefit op- tions for restricted scheme show a constant * Health plans that accept all applicants regardless of health status ** Health plans that are Employer based Table 1. Emerging policy issues & regulatory impact 1. Consequences of Intervention by the Competition Commission (Comp.Com): • As a result providers and schemes could only negotiate prices on a bilateral agree- ment between a single seller and single payer • Implication – price divergence between tariffs and re-imbursement rates across providers and payers • As a result, copayments increased and balanced billing was the result. • Subsequent attempts at instituting and independent reference list of prices by NDoH & CMS from 2004/5 were unsuccessful • As a result; medical schemes offer cost sharing benefit options, these have been effected through: - Discriminatory structuring of supplementary benefits to the essential benefit package - These have been effected through efficiency based options with out-of-net- work penalties & financial limits on formularies 2. Although RPL was supposed to be non-binding effective guideline on tariff levels; it effectively determined re-imbursement rates 3. Providers are not able to recoup costs based on low RPL tariff rates 4. At the risk of leaving the market – doctors would have to generate revenue on high volumes and not quality care 5. RPL rates set as low rates – means members are under-covered for true costs of health care 6. There could not be any certainty in setting prices for scheme members, and uncer- tainty in benefit entitlements 7. Low tariff rates would force providers to embark in double billing practices 8. Financial viability of options would be prejudiced without proper cost productions by providers included in RPL SOUTH AFRICAHealth Care System 73 trend.That said; risk pool solidarity for open schemes show an increasing but moderate trend. The average number of benefit options per scheme in: • Open scheme benefit options increased from a base of 5 (2002) to 6 (2012) op- tions per scheme; and • Restricted scheme benefit options re- mained around two (2) benefit options per scheme on average. What may lie behind the different observed patterns at scheme and benefit option may be related to the following factors: • Product diversification or proliferation more benefit designs in open schemes, relative to, restricted schemes; • The need to diversify against the chang- ing demographic profile experienced in the open scheme market. This occurred after the establishment of the GEMS (Government Employees Medical Scheme). Significant observations • Changes in market structure from the overview at industry level shows strong consolidation; that said • This scenario is not sustainable at the benefit option level of market structure, i.e.: - Market structure from a product per- spective shows that scheme communi- ties are potentially split as a result of option/product diversification - This type of market rivalry is much stronger in the open scheme environ- ment - This may have unintended consequenc- es for community rating - This observation may also be of interest to the Competition Commission’s In- quiry into the Private Health Sector, as market structure is affected by product diversification (benefit option prolif- eration within schemes) 2002 201120102009200820072006200520042003 2012 0 140 120 100 80 60 40 20 160 Numberofschemes Open schemes Restrictes schemes Consolidated Figure 1. Schemes Solidarity – Sector and industry level (2002–2012) 2002 201120102009200820072006200520042003 2012 0 140 120 100 80 60 40 20 Numberofbenefitoptions Open schemes Restrictes schemes Consolidated Source: CMS annual reports 2002–2012 Figure 2. Benefit option Solidarity – Sector and industry level (2002–2012), figures in the graph are rounded off. SOUTH AFRICA Health Care System 74 Market Entrants Describing the trends Figure 3 reports the number of new market entrants (new scheme registrations) from 2002 to 2012.The development of new reg- istrations was as follows: • There were twelve new registered sche- mes; • Five of the twelve, were within the open scheme environment; and • The other seven, were within the restrict- ed scheme environment On the viability of new market entrants (2002–2012) • Six of the twelve new schemes were going concerns (still in operations) • Five of the six going concerns were schemes from the restricted scheme en- vironment • One (1) of the six going concern schemes are within the open scheme environment Significant observations • The consolidation that has occurred at the industry level has been driven though amalgamations and liquidations • There have been far less market entrants, and their survival rate has been 50%.That said,new scheme registration like GEMS, have had a far reaching impact on the conditions of market rivalry and consoli- dation in the medical schemes industry Outcomes of Market Rivalry: Amalgamations & Liquidations Amalgamations (Mergers) & Liquidations (2002–2012) • There were a total of 63 schemes amal- gamations and liquidation between 2002 and 2012: - 44% occurred in the open scheme envi- ronment; and - 56% occurred in the restricted scheme environment. 2002 201120102009200820072006200520042003 2012 0 7 6 5 4 3 2 1 Numberofschemes Source: CMS annual reports 2002–2012, NWR: no new registration (excludes schemes registered and deregistered within 12 months) 1 11 1 1 1 1 1 2 2 3 3 NWR NWR Liquidations Amalgamations Total Figure 3. New scheme registrations (2002–2012) 2 3 5 1 2 3 1 5 6 3 1 4 6 5 11 2 3 5 4 3 7 1 2 3 3 1 4 4 6 10 1 4 5 2002 201120102009200820072006200520042003 2012 0 25 20 15 10 5 Numberofmedicalschemes Source: CMS annual reports 2002-2012 Liquidations Amalgamations Total Median Figure 4. Liquidations & amalgamations – all schemes (2002–2012) SOUTH AFRICAHealth Care System 75 • The highest peaks of activity occurred in 2003 and 2008 (10 and 11 liquidations and amalgamations, respectively). The twin peaks are characterized by double the market exit activity for the relevant period; i.e. the median of both amalga- mations and liquidations was five (5) for the period (Figure 4). Liquidations (2002–2012) • There were a total of 28 liquidations; • These were 32% for open schemes and 68% in the restricted scheme environ- ment; and • Liquidations accounted 44% of market exits in the period over review. Amalgamations (2002–2012) • There were a total of 35 amalgamations; • Amalgamations accounted 56% of the market exits; • There were significantly more amalgama- tion in restricted schemes, 61% (n=23) than open schemes,39% (n=15) Policy Trajectory Figure 5 illustrates a projection of expected number of medical schemes. The projected is based on an exponential trend model de- rived from actual trends from 2001 to 2012. Therefore,the expected medical schemes are based on a three year forecast. Based on the forecasted projection there will 64 medical schemes in 2016. This provides an estimate of the projected rate of consolidation in the industry, and an estimated quantification of the policy trajectory; assuming that trends continue as they did since 2012. Market Concentration & Rivalry The concept of market concentration was assessed using the Herfindahl-Hirschman Index (HHI). HHI is a measure of market concentration that incorporates the market share of the largest firms within an industry or sector.This measure is defined as the sum of the squares of the market shares of the fifty largest firms within an industry, where the market share is expressed as a propor- tion of the total market share. The method applied in analysing – the rela- tive extent of market participation (level of competition), and market concentration (level of market penetration) – is based on a similar used by Wholey and Morrisey [18;  11]. In this analysis, the health in- surance industry is divided into 8 market segments. Market share calculations are based health plan turnover in 2011. Arm- strong and Kotler [1] describe how market 2002 201120102009200820072006200520042003 2015 0 140 120 100 80 60 40 20 NumberofMedicalSchemes Actual Forecast Forecasting Model: Holt Exponential Smoothing Method for non-stationary trend data 201420132012 2016 160 143 85 64 71 77 Figure 5: Actual Trend vs. Forecast of the Number of Medical Schemes (2002–2016) Table 2. Market participation and penetration Market segments Market Participation: (%) of competing medical scheme Market Penetration: (%) share of enrolees S 1 5 0.3 S 2 5 0.2 S 3 15 1.2 S 4 24 3.4 S 5 24 7.4 S 6 15 16.3 S 7 5 11.3 S 8 4 59.9 Source: developed by the authors SOUTH AFRICA Health Care System 76 positioning in targeted market segments impacts of certain sale and thus gaining competitive advantage. Table 2 shows the relative degree of mar- ket rivalry (health plan participation) and market concentration (market penetration). Market participation quantifies the distri- bution of medical schemes across market segments. Market participation quantifies the distribution of beneficiaries covered by medical scheme across all market segments. The table below depicts that there is a dis- proportionate share of medical scheme en- rolees across the industry. Product Diversification Most medical schemes offer multiple ben- efit options where contributions/ premiums and access to benefits differ. Willie [20] and colleague [21], find that open schemes (individual plans) offer more benefit offer- ings than restricted schemes (group plans). The CMS annual report denotes that 55% of open scheme benefit options are mak- ing losses and this different to the 45% in restricted schemes. This is a worrying phe- nomenon in the industry in particular with regards to the principle of risk-pooling at benefit option level, the medical schemes act clearly stipulates that benefit options need to be self-sustainable. Figure 6 reports the average number of ben- efit offerings offered by open and restricted schemes, there are significantly more ben- efit options in open schemes compared to restricted schemes (nearly as twice). The average number of benefit options in the open schemes market segments is generally higher than the industry average of three (3).Overall,more than half (55%) of benefit options in opens schemes on market seg- ment 8 (2 market players who account for 65% of open schemes) are in loss making options. There is a high degree of product differentiation in the market segments and suggesting variation in the risk characteris- tics of the individuals in those benefits op- tions making them less sustainable. Figure 7 extends on the analysis conducted by Morrisey [11] and Wholey [18]. The figure illustrates the market positioning of medical schemes across the industry.Two scenarios are presented, they are described below. Scenario 1 • Market structure and concentration ef- fects when all eight market segments (S1 to S8) are included in the analysis; • The trend shows the results of market positioning and market power across the industry market segments; • There is a negative trend in terms of the proportion of scheme competing across market segments, and the proportion of enrolees covered by the medical schemes; • The share of market power is unequal and thus, resulting in less competition as one moves across the market segments. Scenario 2 • Market structure and concentration ef- fects when all eight market segments (S1 to S4) are included in the analysis • The trend shows the results of market positioning and market power across the industry market segments • There is a positive trend in terms of the proportion of scheme competing across market segments, and the proportion of enrolees covered by the medical schemes • The share of market power is more equal and thus, resulting in a more competitive market environment as one moves across the market segments. Table 3 reports two different standard guidelines for triggering concerns about market abuse power. These are: An interna- tional standard used as an anti-trust guide- line 5 8.8 3.9 7.1 2.4 4.8 1.6 3.5 1.21.4 3.5 10 1 8765432 0 10 8 6 4 2 Averegenumberofbenefitoptions Source: developed by the authors from the CMS annual reports, 2011 12 Open schemes Restricted schemes Open schemes ConsolidatedRestricted schemes 1.66.2 1.63.3 1.62.2 3.0 Market segment Figure 6. Average number of benefit options by market sector and segment SOUTH AFRICAHealth Care System 77 • Trigger point for a moderate level of con- cern: - HHI of 1,000 points for an individual firm; - Percentage transformation 32% market share for an individual firm. • Trigger point for a High level of concern: - HHI of 1,800 points; - Percentage transformation 42% market share. • The South Competition Act guideline • Trigger point for a Moderate level of con- cern: - HHI of 1,225 points for an individual firm; - Percentage transformation 35% market share for an individual firm. • Trigger point for a High level of concern: - HHI of 2,025 points for an individual firm; - Percentage transformation 45% market share for an individual firm. The significance of what is reported in the table (table 3) is; the trigger points in in- ternational jurisdictions are, somewhat lower than what is prescribed by the South African Competition Act. Table 4 reports the relative market influence from different 0 50302010 0 25 10 5 MarketParticipation: %ofschemespermarketsegment 20 15 30 40 60 Market Penetration: % share of covered enrolees per market segment Market Segment 1–8 0 321 0 25 10 5 MarketParticipation: %ofschemespermarketsegment 20 15 30 4 Market Penetration: % share of covered enrolees per market segment Market Segment 1–4 S8 S6S3 S7 S4 S5 S4 S3 S1 & S2 S1 & S2 Figure 7. Market positioning of medical schemes – 8 vs. 4 market segments (2011) Table 3. Trigger point for concern of abuse of market power Description Trigger Points – Abuse of market power Moderate level of concern High level of concern index (%) index (%) International standard1 1,000 323 1,800 423 Prescription of South African Competition Act2 1,2253 35 2,0253 45 1 (Robinson, [14]) 2 section 7 of the South African Competition Act 3 Generated using (Gaynor, [4]) method Table 4. Relative market influence of different industry market participants (2011) Sector/Industry Market Concentration Indicators Indicator HHI2 Square root of HHI3 Category index % Hospitals Market (upstream) Hospital beds1 2,273 48 Administrators Market (down- stream) Beneficiaries 2,498 50 Medical Schemes Industry (non- profit) Risk contribu- tion income 1,157 34 Open Medical Schemes Market (non-profit) Risk contribu- tion income 778 28 Restricted Medical Schemes Mar- ket (non-profit) Risk contribu- tion income 379 19 1 Data on hospital beds (van den Heever, [16]) 2 Method for calculating HHI – (Baker, [2]) 3 Method for HHI transformation to percentage – (Gaynor, [4]) SOUTH AFRICA Health Care System 78 sides of the private health financing and provider sector. The figure provides a con- solidated index for HHI, and then splits the index for restricted and open schemes. The reasons for the split are: • It would methodologically incorrect to reflect a combined HHI score for prod- uct markets which not direct substitutes; • Reflecting HHI score restricted schemes only and open schemes only, as in other reports on the same axis with provid- ers. Suggests, administrators and hospi- tals only exclusively accept either open scheme contract or restricted scheme contract; that said • The HHI for restricted and open schemes is much lower than that of both adminis- trators and providers. The table (table 4) shows the level of market concentration for, hospitals (upstream mar- ket participants) and medical scheme ad- ministrators (upstream market participants), are higher than that of medical schemes. This is significant since, the downstream and upstream market participants are for- profit entities. Since medical schemes are not for-profit trust funds, incentives are not aligned. Further to this, high market con- centration levels yield greater profit margins for profit making entities. Discussion & Policy Implications Lately, there have been numerous policy recommendations emerging from research findings. Most of the recommendations advocate; greater market concentration in medical schemes creates more bargaining power. Greater bargaining power for medi- cal schemes means better contracting ar- rangements with health care providers and thus; lower premiums for medical scheme beneficiaries [10]. What this analysis has shown is; mar- ket structure needs to be scrutinized and defined from many perspectives. This is necessary, particularly in instances when vulnerable risk groups are covered by in- dividual contracts (open schemes), as opposed to, group contracts (restricted schemes). Gaynor has shown that, medi- cal schemes with vulnerable risk groups are not able to contract low prices with man- aged care providers [5]. As a result, the market contestability and sustainability of such health plans have waned. Wholey and colleagues found that there are scope diseconomies in providing access to health care services [19]. This outcome is to the detriments of achieving affordable health insurance policy objectives. References 1. Armstrong, G. & Kotler, P., 2007. Marketing: An introduction. 9th ed.Upper Saddle River: Prentice Hall. 2. Baker, L., 2001. Measuring competition in health care markets. Health Services Research, 36(1), pp. 223-251. 3. Bateman, C., 2013. Whistle blast on the private healthcare’s ‘zero sum game’. South African Med- ical Journal, 103(5), pp. 278-279. 4. Gaynor, M., 2011. Health Care Industry Consoli- dation: Statement before The Committee on Ways and Means Health Sub-committee, Washington, D.C.: US House of Representatives. 5. Gaynor, M. & Haas-Wilson, D., 1999. Change, consolidation and competition in health care markets. Journal of Economic Perspectives, 13(1), pp. 141-164. 6. Hsiao, W., 1995. Abnormal economic in the health sector. Health Policy, Volume 32, pp. 125- 139. 7. Halse P, Moeketsi N, Mtombeni S, Robb G, Vilakazi T, Weni Y,2012. Competition Com- mission of South Africa. The role of competition policy in healthcare markets – 2011/2012  Com- petition Commission Annual Report. Pretoria: South African Competition Commission. 8. In the large merger between: Business ventures In- vestments 790 (Pty) Ltd (primary acquiring firm) and Afrox Healthcare Limited (primary acquiring firm) (Case no. 105/LM/Dec 2004). 9. Marquis, S., Beeuwkes Buntin, B., Escarce, J. & Kapur, K., 2007. The role of health product design in consumers’ choices in the individual insurance market. HSR: Health Services Research, 42(6), pp. 2194-2223. 10. Melnick, G., Shen, Y. & Wu, V., 2011. The in- creased concentration of health plan markets can benefit consumers through lower hospital prices. Health Affairs, 30(1), pp. 1728-1733. 11. Morrisey, M., 2001. Competition in hospital and healthcare insurance markets: a review and research agenda. HSR: Health Service Research , 36(1), pp. 191-221. 12. Newhouse, P., 2002. Why is there a quality chasm?. Health Affairs, 21(4), pp. 13-25. 13. Njisane,Y., van Buuren, A. & Blignaut, L., 2012. In sickness and in health: Competition law in the healthcare sector, Johannesburg: Edward Nathan Sonnenbergs. 14. Robinson, J. C., 2004. Consolidation and the transformation of competition in health insur- ance. Health Affairs, 23(6), pp. 11-24. 15. Town, R. & Liu, S., 2003. The welfare impact of Medicare HMO’s. Rand Journal of Economics, 34(4), pp. 719-736. 16. van den Heever, A., 2012. Review of Competi- tion in the South African Health System, Pretoria: South African Competition Commission. 17.van den Ven, W., 2012. Risk adjustment and risk equalization: what needs to be done?. Health economics, Policy & Law, Volume 6, pp. 147-156. 18. Wholey,D.,Christianson,J.& Engberg,J.,1997. HMO Market Structure and Performance: 1985-1995. Health Affairs, 16(6), pp. 75-84. 19. Wholey, D., Feldman, R. & Christianson, J. &. E. J., 1996. Scale and scope economies among health maintenance organizations. Journal of Health Economics, Volume 15, pp. 657-684. 20. Willie, M., 2012. Caesarean section rates in large medical schemes in South Africa: An ex- plorative descriptive study. Journal of Medical Research, 1(6), pp. 84-90. 21. Willie, M. & Nkomo, P., 2010. Intra-class cor- relation and multilevel analysis of contributions data. First Global Symposium on Health Systems Research. Montreux, s.n. 22. Willig, R., 1991. Merger analysis, industrial or- ganization theory and merger guidelines. Brook- ings Papers on Economic Activity - Microeconomics, Volume 1991, pp. 281-332. Mr. Michael Mncedisi Willie, Senior Researcher (until 30 April 2014), Council for Medical Schemes  Mr. Phakamile Nkomo, Senior Policy Analyst, Council for Medical Schemes SOUTH AFRICAHealth Care System 79 The Indian Medical Association (IMA) was established in 1928 with 222 members as an offshoot of the Indian freedom struggle.The IMA was a founder member of the WMA in 1946. Any doctor of modern medicine irrespective of the field and discipline may become an IMA member voluntarily. The IMA has a three tier structure. The IMA headquarters are in New Delhi. It has 29 state and 7 territorial branches. The current IMA membership is 230,000 embracing members of 1700 branches spread all over India.The IMA has a sub-district level rep- resentation in almost all 640 districts of the country. The IMA has a democratic struc- ture.The office bearers are elected every year at all the three levels. Bicameral legislative bodies assist in decision making at all the levels. The IMA objectives focus on the advance- ment of medical sciences, improvement of public health and medical education, and upholding the honour and dignity of the medical profession. The aim is to provide affordable, accessible and quality health care for all. The IMA members have a strong presence in the Medical Council of India and various state medical coun- cils which are statutory bodies to regulate medical education and practice. The IMA is also represented in various committees of the central and state Governments. The IMA takes its role as a nation builder seri- ously and voices the opinion of the peo- ple. All legislation pertaining to health are carefully scrutinized and commented upon by the IMA. The Hhealth policy of the country has substantial inputs from the IMA which is the parent organiza- tion of numerous service and professional organizations. The IMA forms a bridge between the public and private sectors and also between various specialists and family physicians and acts as a coordina- tor for a national cause as well. The IMA is a member not only of the WMA, but also of the Commonwealth Medical Asso- ciation (CMA) and the Confederation of Medical Associations of Asia & Oceania (CMAAO). The IMA also works closely with the World Health Organization (WHO) at national, regional and interna- tional levels. The IMA prime responsibility is to update the medical knowledge of its members through its continuing medical educa- tion programmes. The Association also conducts regular workshops and fellow- ship examinations through its academic affiliations: the IMA College of Gen- eral Practitioners, the IMA Academy of Medical Specialists and the IMA AKN Sinha Institute. The IMA provides legal advice to its members through profes- sional protection scheme. The Social Se- curity Schemes, the Health Scheme and the Pension Scheme are run by its various state branches as welfare activities for the members. The IMA is a major player in the public private mix for the National TB Con- trol Programme. The IMA has sensitized 87292 and trained 15099 private doctors in tuberculosis care. 4359 DOT centres and 93 microscopy centres have been ini- tiated by the IMA.The IMA played a ma- jor role in India’s successful polio eradica- tion programme. The Association directly manages the entire biomedical waste of the southern state of Kerala and assists in other states. Across the country the IMA runs several blood banks and in some states handles as much as 20% of the blood demand. Pain and palliative care centres are run by many local branches. Through the initiative ‘Aao Gaon Chalen’ (Let us go to the villages) the IMA is involved in holistic health care in 1040 villages. The IMA is a strong participant in the ’Save the Girl Child’ project in India’s struggle against female feticide. The IMA has its own ‘Care of the Elderly’ programme and has the capacity to execute PAN INDIA health surveys.The IMA has recently add- ed a hospitals division – the IMA Hospital Board of India. The IMA serves as a fam- ily circle in towns and villages of India for its members. The IMA participates in all the National Health Programmes start- ing from HIV-AIDS control to blindness prevention. The IMA remains a dynamic interface between the people and the Indian Medical Association Narendra SainiJitendra B. Patel INDIA NMA News 80 BOSNIA AND HERZEGOVINANMA News Bosnia and Herzegovina renewed its 1000- year statehood in the process of the creation of new states as a result of the dissolution of Yugoslavia. A price of its independence was bloodshed. The Dayton Peace Agree- ment ensured peace but it did not make Bosnia and Herzegovina a functional coun- try. It consists of three parts: the Federa- tion of Bosnia and Herzegovina (BiH), the Republika Srpska and the Brčko District. Bosnia and Herzegovina is a unique model of the state organisation that does not exist anywhere in the world.The state health care system is divided accordingly. There is an additional division within the Federation of BiH. The Federation consists of 10 cantons. It is important to mention that there is no single legal framework for health care at the level of Bosnia and Her- zegovina, and it is also divided into enti- ties  – the Federation and the Republika Srpska, while the health care in the Fed- eration is organised at the level of cantons. Thus, in Bosnia and Herzegovina there is one Ministry of Health in the Repub- lika Srpska, one Ministry of Health in the Federation, 10 Ministries at the level of 10 cantons in the Federation and one Ministry of Health in the Brčko District. There is a total of 13 Ministries of Health at the level of Bosnia and Herzegovina with slightly less than 4,000,000 inhabitants and slightly more than 9,000 doctors of medicine. (This information is for the Guinness Book of Records, but it is a result of the Dayton Peace Agreement). If health care were or- ganised at the level of the State of Bosnia and Herzegovina, there would be the 14th Ministry of Health in this poor country ex- hausted by the war. The budget amounts for health care differ significantly from one canton to another with 5,600 doctors working in the Fed- eration. Political divisions to entities and cantons were not beneficial for the health care system that has been trying to be ef- fective and functional, and in the mutual interest of doctors and patients. Such dif- ferences discriminate not only patients in terms of providing health care services between the “rich” and the “poor” cantons, but also discriminate doctors who work in the 10 different health care systems in the Federation. The number of doctors ranges from 2,300 in the Sarajevo Canton (SC), 1,400 in the Tuzla Canton (TC), 700 in Mostar (HNK), 680 in the Zenica Canton (ZDC), 334 in the Bihać Canton (USC), 343 in the Travnik Canton (CBC), 96 in the Livno Canton (HBC), 72 in the Široki Brijeg Canton (WHC), 48 in the Orašje Catnon (PC) and 24 in the Gorežde Can- ton (BPC). Proportionally, the health care budgets vary from one canton to another, but such dynamics worsens the quality of health care and working conditions for doctors in those cantons. It is compensated not only with cooperation in the provision of health services between the “rich” and the “poor” cantons, but also with the health care systems of the neighbouring coun- tries (Croatia and Serbia for the Republika Srpska). The main task of the Ministry of Health of the Federation of BiH is to decide on the development of the health care system in the Federation harmonising the 10 legal Some Specific Features of the Health Care System and Working Conditions of Doctors in the Federation of Bosnia and Herzegovina Harun Drljević Government of India playing a proactive role in health issues. Many IMA state branches have ethics com- mittees receiving complaints from patients and sometimes from fellow doctors. The IMA exerts peer pressure to correct its errant members. One of the major ethical issues is fees splitting between the referring doctors and hospitals, scan centers and laboratories. Now patients can avail of the IMA fixed rates for scans. The High Court upheld the right of the IMA to regulate its members. Female feticide remains an important ethi- cal issue where the IMA has played a signif- icant role to regulate its members.The IMA is legitimately concerned about the conflict of interest between the medical profession and the hospital industry. The IMA holds the view that any health care institution involved in patient care should uphold the ethics and etiquette of the medical profes- sion. Dr. Jitendra B. Patel Dr. Narendra Saini National President, IMA Honorary Secretary General NMA NewsBOSNIA AND HERZEGOVINA cantonal health care strategies in the 10 cantons of the Federation. The further is- sue is harmonising the development of the health care system in the Federation be- tween the “poorer”and the “richer”cantons. How could it be done if the establishment of good health care system depends upon the political stability in the state which is currently non-existent. The same issues are equally important for the Medical Chamber of the Federation, though in a different way: how to ensure equal working conditions for doctors, for their professional development and ad- vancement, for CME in the Federation, unhindered flow of doctors from one can- ton to another, i.e. how to eliminate dis- crimination among colleagues that arises merely from the fact that doctors work in different cantons. While the WMA is deal- ing with equalizing standards for doctors in entire Europe and in the world,the Medical Chamber of the Federation is trying to do it in the Federation of BiH and entire Bosnia and Herzegovina. If we want to provide good level health care services, then the medical space in Bosnia and Herzegovina must be free and open for all patients and doctors. There must be no rigid administrative or political boundaries in that unique health space.There should be a principle of solidarity among the health care institutions of the same or different level. Answers to these questions should be sought not only in a new, better organisa- tion of the health care system of the Federa- tion but also in the use of all available health care benefits and medical capacities in the Federation of BiH including entire Bosnia and Herzegovina. Prim.dr. Harun Drljević President of the Medical Chamber of the Federation of Bosnia and Herzegovina 35th World Medical and Health Games MEDIGAMES will take place in Wels (Upper-Austria), from June 21 to 28 2014. Many participants from more than 30 countries already con- firmed their registration, so join them shortly! Massages and medical care on the afternoons, visit of the city of Wels, climb- ing initiation, gokart race... we prepare you lots of nice surprises! Do not forget that you have the possibility to take part to vari- ous competitions! This is a nice opportunity to test yourself on a discipline that you usually don’t practice in competition. If you wish to take part to our Congress, please send us your ab- stract by email to fanny@medigames.com For any further information, contact us by email to info@medigames.com or by phone to 0033 1 77 70 65 15. The Organising Committee IV Contents Physicians should routinely ask their women patients about domes- tic abuse where they have reason to suspect violence. Professor Sir Michael Marmot, speaking in Geneva, said that phy- sicians should ask about domestic abuse more often so that it nor- malises the question. He said domestic violence was a global pub- lic health concern with one in three women throughout the world experiencing physical and/or sexual violence by a partner or sexual violence by a non partner. Sir Michael, Director of University College London Institute of Health Equity, and chair of the World Medical Association’s Socio- Medical Affairs Committee, was speaking at a luncheon seminar during the World Health Assembly, organised by the WMA and the International Federation of Medical Students’ Associations. He outlined the extent of domestic violence around the world and said that in many countries married women believed a husband was justified in beating a wife if she refused to have sex.Education,how- ever, is key, he said. The more educated women are the less likely they are to think that violence from a husband is justified. Sir Michael said that although domestic violence was evident across all classes, economic and ethnic groups, the statistics showed that this pattern of behaviour was more prevalent among the less well educated. A study among nine countries showed that those women most likely to report having experienced violence were married at a young age, had multiple children and a family history of domestic violence between their parents. As well as resulting in murder and injury, domestic violence also led to suicide, induced abortions, depressive disorders and alcohol problems. And women with mental health disorders were also more likely to have experienced domestic violence. Sir Michael said that physicians and health professionals had to be more active in this field. Staff training in equality and diversity is- sues should be improved so that physicians and others could detect more easily cases of abuse among their patients and could ask rel- evant questions. ‘For instance, much domestic abuse starts during a woman’s preg- nancy and physicians should be aware that asking questions during this time is particularly effective.Previously silent women may come forward because of fear of harm to their baby’. In addition, he said, women and girls should be empowered through education and so- cial support. Dr. Margaret Mungherera, WMA President, who also spoke, said: ‘Domestic “Gender Based Violence” is only one of the many forms of violence that women experience worldwide.In conflict situations, sexual violence is common and is often associated with physical vio- lence and abductions. Unwanted pregnancies, HIV/AIDS, mental disorders and traumatic fistula are common complications. ‘In ad- dition, low use of family planning services has also been associated with GBV and hence the need to integrate such services into the reproductive health services. It is also important that GBV is in- cluded in the pre-service training and continuing education cur- ricula of physicians and other health workers. GBV services should be integrated into mental health and primary care services and these should be made available universally. ‘The recent kidnapping of young Nigerian girls illustrates in the most horrific way this devastating scourge. It is not enough to deplore the magnitude of the phenomenon.Urgent,strong and concrete policies must be taken now with the participation of all sections of society, including the health sector, to meet this major global public health, gender equality and human rights challenge.’ Physicians Urge Action on Violence against Women and Girls The 197th Council meeting of the World Medical Association was held at the Hotel Nikko,Tokyo, Japan from April 24 to 26. WMJ Council Report . . . . . . . 41 The adress of the Prime Minister of Japan Mr. Shinzo Abe in the WMA Council Session . . . . . . . . . 49 Secretary General Report to the 197th WMA Council Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Multi-media Educational Tool Increases Knowledge of Clinical Trials in Uganda . . . . . . . . . . . . . . . . . . . . . . . . 64 Market Structure in the South African Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Indian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . 79 Some Specific Features of the Health Care System and Working Conditions of Doctors in the Federation of Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . . . . . . . 80 35th World Medical and Health Games . . . . . . . . . . . . . . . III