WMJ 05 2011

COUNTRY
• WMA Presidential Report, 2010–2011
• On the Epistemological Nature of Clinical Ethics
vol. 57
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 5, October 2011
wmj 5 2011.indd I 9/26/11 4:24 PM
Cover picture from Mozambique
ii
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Dr. Wonchat SUBHACHATURAS
WMA President
Thai Health Professional Alliance
Against Tobacco (THPAAT)
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Dr. Dana HANSON
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WMA Chairperson of the Associate
Members
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Dr. José Luiz
GOMES DO AMARAL
WMA President-Elect
Associaçao Médica Brasileira
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Bela Vista, CEP 01333-903
Sao Paulo, SP Brazil
Dr.Torunn JANBU
WMA Chairperson of the Medical
Ethics Committee
Norwegian Medical Association
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0107 Oslo
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Dr.Frank Ulrich MONTGOMERY
WMA Treasurer
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(Wegelystrasse)
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Dr. Mukesh HAIKERWAL
WMA Chairperson of Council
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Williamstown, VIC 3016
Australia
Dr. Otmar KLOIBER
WMA Secretary General
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France 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
www.wma.net
wmj 5 2011.indd Sec1:ii 9/26/11 4:25 PM
161
This editorial is being written just days be-
fore the UN summit on Non-Communica-
ble Diseases (NCDs), which marks only the
second time in history that the UN General
Assembly has set aside significant time to
discuss a health issue. Preparations have
been underway for more than a year and the
expectations are high.
Non-Communicable diseases now represent
the greatest proportion of the global burden
of disease. The World Health Organisa-
tion, in it approach to NCDs, has focused
its attention on four disease groups: heart
disease, lung disease, cancer and diabetes.
Without doubt, these are crucial problems
worldwide, but there is much more to it.
Mental health, muscular-skeletal diseases,
accident and trauma are just a few examples
of non-communicable diseases that are tremendously important but
do not enjoy the same level of visibility within the WHO – includ-
ing in its planning for the NCD summit. Some, such as mental
health, have been pushed into the Summit agenda by governments,
while others are largely being ignored. This piece-meal approach to
NCDs resurrects critical concerns about a flawed approach to global
health that we believed we had begun to move past.
In the post-Alma Ata period, the work of international organisa-
tions, including WHO, was marked by donor-driven vertical pro-
grams tackling specific diseases like HIV/AIDS, tuberculosis, river
blindness and malaria. These programs were all well-meaning hu-
manitarian efforts, driven by immediate, visible needs that health
funders and the public found very compelling. Yet, as physicians
concerned for the full health of our patients, we criticized the imbal-
anced prioritization of these discrete programs over other programs
that would address the overall health needs in the affected regions
and contribute to the build-up of comprehensive health care systems.
We were encouraged by a sobering series of analyses and reports –
most importantly, the World Health Reports on Human Resources
for Health in 2006 and on Primary Care 2008,and a brilliant analy-
sis on the Social Determinants of Health in 2009 – in which the
WHO recognised the failures inherent in
the silo-based paradigm and recommended
an epochal shift to a more systematic, pri-
mary care-based approach to health. This
new paradigm would focus on person-
centred care and people-centred public
health, building and strengthening health
systems around a solid core of primary care.
The WMA welcomed and supported this
new approach. Thus, we are concerned and
disappointed by the current NCD strategy,
which appears be taking us back down the
road of vertical programs and away from
the holistic approach to human health that
we believed that WHO was committed to
pursuing. Certainly, a strong focus on heart
disease, lung disease, cancer and diabetes is
warranted. These are massive health prob-
lems that affect large populations and consume enormous amounts
of health resources. And many of their causes are preventable
through lifestyle changes, such as smoking cessation, reduction of
alcohol consumption, increased physical activity, and better nutri-
tion. However, preventive care can and should be addressed in the
context of quality health systems, alongside the full complement of
primary, secondary, and tertiary care. Building such comprehensive
systems will simply not be achievable if funding is disproportion-
ately funnelled into disease-specific programs. We have learned this
lesson once already.
During the upcoming Summit, the national leaders in New York
have a chance to turn the focus back toward improved investment
in health and in health care across the board – not only where there
are donor-driven programs,but at the national level in each country.
They can choose to apply the available resources toward the goal of
building real health systems that take in account the social determi-
nants of health and provide effective, accessible, quality health care
for all persons. It is our sincere hope that they will recognize and
seize the opportunity to do exactly that.
Dr. Otmar Kloiber,
Secretary General WMA
Window of Hope
Otmar Kloiber
Editorial
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162
WMA news
On 11 October 2010, I took off from Bang-
kok with my colleagues, Prof. Dr. Somsri
Pausawasdi, CEO and Past President of the
Medical Association of Thailand, Assoc.
Prof. Pasert Sarnvivad, Secretary General
of the MAT, and Dr. Urchart Kanjanapitak,
Past President of the MAT,heading for Van-
couver, Canada, to attend the 2010 General
Assembly of the World Medical Association,
held on 13–16 October, as a delegation team
from the MAT, Thailand. The WMA Gen-
eral Assembly of 2010 was not an ordinary
and usual one because the President Elect,
Dr. Ketan Desai, from the Indian Medical
Association, who had been elected President
Elect of the WMA in New Delhi in 2009,
could not attend the Assembly,which result-
ed in failure of the installation of the Presi-
dent of the WMA for the year 2010–2011 at
the Assembly.The WMA Council,therefore,
decided to have the immediate president
election, which had happened a few times in
the history of the WMA.
On 15 October 2010, the applications for
the office of the Immediate President of the
World Medical Association for 2010–2011
were announced by the Secretary General,
Dr. Otmar Kloiber, at the WMA General
Assembly. There were three applicants on
that day.
The ballot was made according to the regu-
lation of the WMA. I was announced to be
the winner. At that very moment, my life
changed, with the trust and honour that the
members of the WMA Assembly had given
to me,it was a great pressure (and pleasure at
the same time) for me to be not just a mem-
ber of the Organization, but I needed to
carry out heavy tasks and bear responsibility
for the Organization and all members of the
WMA.As I came from a small country with
only one vote, it was a great honour for me,
for the Medical Association of Thailand and
for the people of the Kingdom of Thailand.
I could feel the presidential chain and medal
being put around my neck by Dr. Edward
Hill, Chair of the Council, at the installa-
tion. I realized then that my duty to con-
nect all the medical professions around the
world had begun. The problem was how to
bring the 97 state and country members and
at least 9 million physicians on 6 continents
together. It would be impossible to get ac-
quainted with all the member countries in
one year. I, then, came up with the decision
that if I could get acquainted with them all,I
would do my best to see the most as the time
and opportunity allowed.I would do my best
to encourage them that they are not working
alone, but the WMA can be the centre of
communication.The Secretary General’s of-
fice in Voltaire would be the centre for infor-
mation and collaboration they could utilize
for communication among members and
collaborative partners.The three main stems
of the WMA,the President,the Chair of the
Council, and the Secretary General, must be
closely working to connect and serve the
member countries and all physicians. The
problems of the physicians are ours. The
linkage between the President, the Chair
and the Secretary General must be open at
all times through e-mailings and monthly
Executive Committee calls.
During one year of presidency, a lot of events
have taken place on this planet. Natural di-
sasters have hit a number of places in the
world, from Chile, Christchurch, and Yun-
nan to, worst of all, the city of Sendai in Ja-
pan, killing thousands of people and inflict-
ing a great devastating loss to the city with
a subsequent radiation leak from the power
plant. They are not just the natural disasters,
but also the man-made disasters that have
superimposed and worsened the situation.
The political conflicts around the Mediterra-
nean have created and aggravated instability in
the medical profession and healthcare. Many
of the health personnel have been unethi-
cally and unjustly accused.Many of them have
been injured, tortured, punished, and jailed.
During my past 11 months (while I am
writing this report), I have had the honour
of being invited to visit and deliver speeches
in many places of many countries on special
occasions, such as the annual meetings of
Medical Associations and Medical Forums
on five continents, the only continent that I
have not had the opportunity to visit being
Africa.
The list of my presidential visits:
• Jiangyin, China, 26–27 November 2010:
International Biomedicine and Technol-
ogy & Health Care Summit;
• Taipei, Taiwan, 11–14 November 2010:
Annual General Assembly of the TMA
and Doctor’s Day;
• Hong Kong, 29 December 2010–2 Janu-
ary 2011: Annual General Assembly of
the HKMA and the New Year Celebra-
tion;
• Bangkok, Thailand, 25–29 January 2011:
Global Health Workforce Alliance;
• New Delhi, India, 14–17 February 2011:
SEARO Expert Consultation on Doc-
tor-Patient Relationship;
• Tokyo, Japan, 2–4 March 2011: Task
Shifting;
• New Delhi, India, 16–18 March 2011:
Partners for Health in Southeast Asia;
• Sydney, Australia, 3–10 April 2011: 188th
WMA Council Meeting;
WMA Presidential Report,2010–2011
Wonchat Subhachaturas
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163
WMA news
• Geneva, Switzerland, 13–18 May 2011:
WHPA Assembly;
• Oslo, Norway, 24–27 May 2011: Annual
General Assembly of the NMA;
• Kiel,Germany,29 May–3 June 2011: An-
nual General Assembly of the GMA;
• Chicago, USA, 16–21 June 2011: Annual
General Assembly of the AMA;
• Brussels, Belgium, 22–25 June 2011:
EFMA Congress;
• Cardiff, UK, 26–29 June 2011: Annual
General Assembly of the BMA;
• Taipei, Taiwan, 30 June–2 July 2011:
Seminar on Counterfeit Medicines;
• São Paulo, Brazil, 11–16 July 2011: Pla-
cebo Meeting;
• Beijing, China, 7–8 August 2011: Organ
Transplant;
• Nesebar, Bulgaria, 5–12 September 2011:
2nd
SEEMF Congress;
• New York, USA, 17–22 September 2011:
General Assembly High-level Meeting
on NCDs.
• And the last trip for my presidency would
be that to the WMA General Assembly
in Montevideo, Uruguay, on 9–16 Octo-
ber 2011.
• Then, as the Immediate Past President, I
planned to attend as a representative of
the WMA the Social Health Determi-
nants Meeting in Rio de Janeiro, Brazil,
on 19–21 October 2011.
• And also, as a representative of the
WMA, I planned to attend the Global
Alcohol Policy Conference in Bangkok,
Thailand, on 28–30 November 2011.
• I do apologize to those NMAs and Orga-
nizations that sent me invitations which I
failed to use due to time overlap.
Achievement
Firstandmostimportant:Ihadpartlyfulfilled
my wish and policy in connecting people and
meeting our members as the time allowed. I
encouraged them about medical ethics, pro-
fessional collaboration and empowered them
to work heart and soul for the community
of Medical Profession as representatives of
the World Medical Association. During
my visits, I also had an opportunity to learn
a lot from their views and policies of which
some were similar and some were different
depending on the cultural and economic
context, but they could be bonded together.
Secondly: On many occasions, the WMA,
either on its own or jointly with the part-
ners, alliances in protecting Health Profes-
sions including the Medical Profession, had
produced statements against unacceptable,
illegal treatment and unethical or unfair
justice, such as in Iran, Bahrain, etc.
Thirdly: I had the opportunity to encour-
age our member states and countries for the
unity of our profession, which, I think, is
the most important and essential thing in
establishing close relationships and ties for
the international collaboration and shar-
ing of the Medical and Health informa-
tion.This will give us a stronger voice in the
global community.
Challenges
1. There are still barriers and political con-
flicts among states and countries and,
on many occasions, health provision has
been interfered with and Medical and
Health Professions have been affected.
2. The Economic Crisis that has contin-
ued for the period of my term has been
a great barrier to the development of
medical care in many countries.
3. Apart from the natural disasters that
have happened around the world, killing
thousands of people and inflicting a dev-
astating loss to the economy, there have
also been several man-made disasters,
especially around the Mediterranean,
that have also taken away a lot of lives.
What is my concern?
Provision of health care is the ultimate goal
of all health and medical personnel, but it
cannot be achieved if we don’t have:
1. Professional unity;
2. Ethical practice;
3. Equitable provision of health care;
4. Global collaboration within our pro-
fession and with other health alliances
without discrimination by race, nation-
ality, colours, beliefs, religion, gender;
5. Care for our young generation;
6. Independence from politics;
7. Professional and social responsibility.
I must say that all Medical Associations
and organizers of Forums in the cities and
countries I visited encouraged me and gave
me the opportunity to do what I had said I
would do when I was sworn in, i.e. to con-
nect people for the unity of the WMA.I feel
grateful for that. Furthermore, they showed
great hospitality and generosity to me while I
was staying with them.The people who have
been working behind the scenes and made
my travels possible and comfortable are our
Secretary General, Dr. Otmar Kloiber, who
has always been my adviser and consultant,
and the people at the Secretariat Office in
Voltaire, who have done all the jobs for my
communication and travels: Sunny, Clarisse,
Anna, Julia, Lamine, Nigel and many else.
They deserve to have my sincere thanks.
I would like to cordially thank my colleagues
at the Medical Association of Thailand,
the President, Police Lt. Gen. Dr. Jongjate
Aoajnepong, the CEO and Past President
of the MAT, Prof. Dr. Somsri Pausawasdi,
the Secretary General of the MAT, Assoc.
Prof. Dr. Prasert Sarnvivad, and the MAT
Executive Committee Members.
Most of all, I greatly thank my wife, Profes-
sor Dr. Prapaipan Subhachaturas, Deputy
Dean of the Faculty of Medicine, Rangsit
University, Thailand, and my family, who
have always encouraged me to do the job
and have taken on domestic cares while I
am away, which is almost for one half of the
year now.
Wonchat Subhachaturas M.D.
President, WMA
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164
SOUTH AFRICAPublic Health
Nearly two thirds of the South African popula-
tion is affected by poor public health conditions.
Hardly hit are the poor, in particular rural
based communities. Due to infrastructure, un-
derdeveloped roads in rural areas it is not easy
to get to a health facility. These communities
often have fewer workforce including doctors,
dentists and certain specialists and in some in-
stances primary health care services might not
even be available. The objective of this article
was review government health expenditure,
health insurance coverage and distribution of
health facilities and how these impact on the
Eastern Cape rural communities.We focused on
the Eastern Cape Province because the private
health coverage is minimal and provision of
primary health care services often fails to reach
the targeted population. We then recommended
interventions that could be employed to over-
come some of the barriers to care.
Introduction
Concentration of health facilities in urban
areas especially those providing sophisticat-
ed care results in higher opportunity costs
of accessing services [11; 18]. Hardly hit
by these high costs are mostly the poverty
struck rural based communities [14]. The
rural areas are often inaccessible due to the
poor condition of the roads and accessibility
to health facilities influence people’s ability
to seek health care [2;22].
Ensor and Cooper [11] illustrated that
household use of services tends to decline
with distance.Ensor and Cooper further re-
ported that the main reason urban citizens,
use services more than their rural counter-
parts largely because such services are acces-
sible and are within reach. Literature shows
that poverty, combined with poor public
health conditions overcrowded housing,
lack of accessible drinking water and sani-
tation make Africans most vulnerable to ill
health [28; 29; 34].
High poverty levels in impecunious com-
munities are as a result high unemployment
rates and there are often limited resources
in such communities [23]. Resource alloca-
tions and health care delivery in South Af-
rica varies from province to province were
fewer resources for poor people,in particular
rural based provinces like the Eastern Cape
which face bigger health challenges than
more prosperous provinces like Gauteng
and the Western Cape.
The Eastern Cape Province has the high-
est poverty levels in South Africa. The high
incidence of poverty in the province may be
linked to the economic neglect of the former
homelands Transkei and Ciskei [19]. The
province’s health services have deteriorated
over the past decade of democracy with pa-
tients flocking to neighbouring provinces
in the hope of receiving better treatment
[23]. The objective of this article was review
government health expenditure, health in-
surance coverage and distribution of health
facilities and how these impact on the East-
ern Cape rural communities.We made some
recommendations that could be employed
to accommodate the under resourced and
poverty walloped rural areas in South Africa.
Financing healthcare
in South Africa
South Africa’s health system consists of a
large public sector and a smaller private sec-
tor [8]. There are characteristics differences
in terms of resources between the two sec-
tors. The public sector is under-resourced,
over-used and in most instances the quality
of service delivery offered is shoddier com-
pared to private health care facilities; most
well equipped resources are concentrated in
the private health sector.
Figure 1 illustrates that total health funding
exceeded R200 billion to approximately 250
billion in 2009,this represents an increase of
12% between 2005 and 2009 from R4005.4
per capita in 2005 to R4476.0 per capita in
2009, these figures were adjusted for infla-
tion on 2009 constant prices [21]. Out-of
pocket payments have roughly remained
below 20% of total health care spending
over the period 2005–2011.
The data presented showed that in 2008/09
provincial health expenditure exceeded
medical schemes for the first time in a de-
cade. However the private health sector fi-
nancing continues to exceed public health
funding levels,. Comparison figures were
34% public health and 57% in 2005 com-
pared figures for 2009. Public and private
health expenditure in 2009 was 39% and
54%, respectively. Both the medical aid ex-
penditure and the out-of- pocket reduced
slightly for the 2005 and 2009 comparative
years [21].
Medical schemes expenditure per capita
reduced slightly when adjusting for infla-
tion on 2009 constant prices, the decline
Access to Public Health Facilities:Taking Stock
of South Africa`s Rural Eastern Cape Province
Michael Mncedisi Willie
wmj 5 2011.indd 164 9/26/11 4:25 PM
165
SOUTH AFRICA Public Health
was 6% reducing to R9916.00 in 2009 from
R10500.58 in 2005. Provincial health sector
expenditure increased by 22% to R1667.2
in 2009 from R1368.92 in 2005, and these
were also adjusted for inflation on 2009
prices [21].The Eastern Cape Province had
the highest poverty levels in South Africa,
48% compared with SA average of 33%.
Public health spending in the Eastern Cape
was under R1 500 per person per year [10].
This was the lowest healthcare spending
compared to other provinces. Thus, despite
an increase of government spending at pro-
vincial level on health, poor households in
the province have not shared in the benefits
government.
Healthcare spending in South Africa was
relatively low to International comparative
data on to similar middle income countries
(see Figure 2 below) and is slightly lower
than the global health care expenditure per
capita which is was estimated at R5782.10
using 2007 estimates.
Medical scheme
coverage by province
Medical schemes are insurance institutions
that cover medical expenses in South Africa.
These institutions reimburse their members
for actual expenditure on health. People be-
longing to medical schemes are able to use
private sector services. The services in the
private sector accessed by close to 16% of
the population that is covered by medical
schemes as reported in 2009, the proportion
of the population that benefits from rich re-
sources offered in the private sector in 2009
was not significantly different to the 15%
cover in 2000. This means that a decade
later there has not been a significant growth
in coverage by medical schemes and yet the
private sector takes up the bigger chunk of
health care expenditure [13]. Figure 3 de-
picts the trend of medical schemes coverage.
Figure 3 further depicts the 8.1 lives cov-
ered by medical schemes stratified by prov-
40% 38% 37% 37% 36% 36% 37%
17% 17% 18% 17% 17% 16% 16%
34%
35% 36%
37% 37%
38%
39%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
2005 2006 2007 2008 2009 2010 2011
asa%ofofhealthsectorexpenditure
Medical Schemes Out-of-pocket Provincial department of Health
Figure 1. The Sector health financing (2005–2011).
Source: Figures and the graph were estimated by the author from the National
Treasury provincial report and local government database and Estimates of National
Expenditure, Council for Medical Schemes, Road Accident Fund and South African
Reserve Bank.
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Croatia
Hungary
Argentina
Barbados
Bahrain
TrinidadandTobago
BruneiDarussalam
Niue
Lithuania
Montenegro
Estonia
Seychelles
Latvia
Poland
UnitedArabEmirates
Brazil
Mexico
SouthAfrica
Colombia
Thailand
VietNam
Nigeria
Healthexpenditurepercapita(Rand)
Thousands
Health Expenditure Per Capita (Rand terms) Health Expenditure Per Capita (Global)
Figure 2. Country comparison of health care spending per capita (2007 figures).
Source: Graph populated generated by the author from WHO reports
wmj 5 2011.indd 165 9/26/11 4:25 PM
166
SOUTH AFRICAPublic Health
ince.The Gauteng province took up 37% of
8.1 million covered lives , followed by the
Western Cape Province and third was the
Kwa-Zulu Natal which takes up 15%, only
9% of 8.1 covered lives were from the the
Eastern Cape. Similarly to the 2% of the
8.1 million lives who were residents in the
Northern Cape [6].
Within province analysis revealed that 29%
of the population that reside in Gauteng
has private health insurance, only 26% of
the population that reside in Western Cape
province had medical cover, it is of interest
to note that within province like Northern
Cape 16% of the population has medical
cover, this relatively higher than the Kwa-
Zulu Natal where only 12% of the popu-
lation had private medical cover, similarly
to the Mpumalanga province 15% of the
population in the province belonged to a
medical scheme.
The characteristics presented in this sec-
tion highlighted unequal socio-economic
conditions at provincial levels, in particular
the Eastern Cape and the Limpopo prov-
ince where more than nearly 90% of the
residents in those provinces did not have
medical cover [6]. The GHS by Statistics
South Africa in 2009, respondents were
asked to respond to a question as to why
they do not belong to a medical scheme
[32].The survey reported that 90.0% of
households that do not belong to a medi-
cal aid scheme say that they do not have
money to pay for it. Indeed affordability
is a leading indicator to joining a scheme.
The proportion of the population in par-
ticular, poverty struck provinces residents
do not benefits from rich resources offered
in the private sector as they don’t belong to
medical schemes.
Poverty lines in the
Eastern Cape
Challenges faced by poverty struck residents
in the Eastern Cape, particularly accessing
6.7 6.7 6.8 7.1 7.5 7.9 8.1
39.7 39.9 40.1 40.3 40.4 40.8 41.2
14% 14%
14%
15%
16%
16%
16%
0
5
10
15
20
25
30
35
40
45
13%
14%
14%
15%
15%
16%
16%
17%
17%
2003 2004 2005 2006 2007 2008 2009
Insuredanduninsured(Millions)
%ofinsured
Insured Uninsured % of insured
Figure 3. The Medical scheme coverage.
Source: Graph generated by the author and background data sourced from Statistics
South Africa and CMS report, 2010
29% 26% 12% 9% 15% 12% 12% 6% 16%
37%
16% 15%
9%
7%
5% 5% 4%
2%
0%
5%
10%
15%
20%
25%
30%
35%
0%
5%
10%
15%
20%
25%
30%
35%
40%
G
auteng
W
estern
Cape
K
w
a-Zulu
N
atalEastern
CapeM
pum
alangaN
orth
W
est
FreeState
Lim
popoN
orthen
Cape
%ofinsuredwithinprovince
%ofinsuredperprovince
% of insured within province % of insured per province
Figure 4. Distribution covered1
lives by province.
Source: (CMS, 2009; Statistics South Africa, 2009)
1 Covered refers to people belonging to medical scheme
wmj 5 2011.indd 166 9/26/11 4:25 PM
167
SOUTH AFRICA Public Health
poorly resourced public health care facilities
are alarming and there are many contribut-
ing factors attributed to these. Poverty lines
in the Eastern Cape vary greatly between
ethnic groups, mostly prevalent in African
and Coloured communities. Almost two
thirds of the population (70%) live in rural
areas, this translate to 30% of the popula-
tion that reside in urban areas [23]. This is
a complete reverse to the national compari-
son (37% rural and 63% urban).
More than two thirds of all Africans in the
province live in rural areas which in most
are under-resourced, under- developed and
do not have adequate health care facilities.
Furthermore, poverty rates in the province
vary greatly between population groups
(73.8% of the Africans are poor compared
to the 48.7% of the Coloureds who are also
poor).The poverty rate in the province is es-
timated at 68.4%, clearly poverty is a rural
phenomenon in the province and most of
the rural based residents are unemployed
and do not have descent income [23].
Health facilities in the
Eastern Cape Province
The 2008 data presented by Medpages
(see Figure 5) estimates 11% of residents
in the Eastern Cape belonging to medical
schemes; this was comparable to the pro-
portion of private hospitals in the province.
Nearly 90% of the population depends on
provincial or public hospitals. Two of the
biggest public hospitals in the province
feature in the top five worst hospitals in
the Country, namely the Cecilia Makhi-
wane and the Umtata General Hospitals
[7].The status due of the two public hospi-
tals further impacts negatively of the pub-
lic seeking health care. Notwithstanding
the feature in the top five worst hospitals
in the country, these two hospital`s have
a responsibility of providing sustainable
health service to the people of the East-
ern Cape, in particular those who reside in
rural areas.
Various underlying factors results to the
health care crisis in the Eastern Cape pub-
lic health sector and these include amongst
others dysfunctional management of the
health care facilities. In some areas clinics
are small and unable to service the nearby
communities. Table 1 presents the number
of public sector health facilities by districts
33
17
16
11
4
6
5
2
6
33
14
17
8
6
6
7
7
2
32
16
19
11
4
5
5
5
3
22
11
21
13
6
7
8
8
2
0 5 10 15 20 25 30 35
Gauteng
Western Cape
KwaZulu-Nata
Eastern Cape
Free State
North West
Mpumalanga
Limpopo
Northern Cape
(%)
Population Medical Aid GDP Contribution Private Hospitals
Figure 5. Private Hospitals by province.
Source: Medpages, 2010
Table 1. Number of public health facilities in the Eastern Cape province (2007)
Cacadu Amathole
Chris
Hani
Ukhahlamba
O.R
Tambo
Alfred
Nzo
Nelson
Mandela
Total
Clinic 58 213 136 44 143 46 43 683
Community
Health
centre
2 7 3 1 10 2 7 32
Mobile
Service
27 42 29 14 13 6 9 140
Satellite
Clinic
2 2 2 1 1 8
District
Hospital
10 14 14 8 10 4 1 61
Regional
Hospital
2 1 3 3 9
Specialised
Hospital
5 5 1 2 1 1 4 19
Public
sector beds
1164 4243 1438 575 3280 629 2092 13421
Source: The District Health Barometer Year 2006/2007
wmj 5 2011.indd 167 9/26/11 4:25 PM
168
SOUTH AFRICAPublic Health
in the Eastern Cape Province.These are not
population based in the province as some of
these facilities are not accessible to many,
especially in rural district Alfred Nzo, and
Ukhahlamba and Cacadu [23].
The Rapid Assessment of Service Delivery
and Socio-economic survey in the Eastern
Cape revealed that 45.4% of the households
in the province had access to hospitals. The
highest accessibility to hospitals was the
Nelson Mandela Metro (79.5%). Nelson
Mandela Metro is more urban compared
to the more rural Alfred Nzo (20.8%) and
Cacadu District municipality (6.4%). Caca-
du District municipality had the lowest
response rate to accessing hospitals. Simi-
lar patterns were noted with regards to ac-
cessing clinics, the lowest level of access to
clinics was Alfred Nzo where only 35.3% of
households had access to clinics, which im-
plied nearly 65% of the population respon-
dents did not have access to primary health
care facilities.
Furthermore, the study reported dispari-
ties in terms of provisions of family plan-
ning services; only 43% of the households
in the province had access to such services,
mostly prevalent in urban areas as opposed
to rural, Nelson Mandela Metro (76.4%)
compared to Alfred Nzo (19%). These data
further presented disparities of health care
provision within the province; there were
great characteristics differences between
the urbanised settings and rural based ar-
eas within the province. Most residents in
rural and poverty struck areas still did not
have access to good quality care and even
at primary level [1]. There survey revealed
correlation between urban setting and rural
setting, poverty and provision of health care
services.
Primary care level is the first level of contact
of individuals, the family and community
with the national system where primary or
essential health care is provided. Most of
the health problems can be dealt with and
resolved at this level [5]. The hierarchy lev-
els of the health care sector in the Eastern
Cape Province as well as at national level are
disintegrated as a result the PHC system
in failing [17]. Shortage of trained staff in
PHC is indeed a regularly cited concern of
the Eastern Cape NDoH itself, particularly
in the rural areas of the Province SHISER
and DRA, 2008. Poor and uncoordinated
referral system between primary, second-
ary and tertiary level of care often result in
work-overload for health care professionals
at secondary level of care institutions [10].
Cullinan [7] further reported that regional
hospitals in the province are often the most
overburdened of all levels of hospitals,bear-
ing the brunt of the many inadequacies in
the district hospitals. A number of district
hospitals in the Eastern Cape are unable to
perform basic operations such as Caesarean
sections because of staff shortages. These
get referred to regional hospitals, which are
only supposed to deal with more compli-
cated health problems. The Eastern Cape
currently does not have any level III hospi-
tals and has a population more than 6 mil-
lion people [7]. A Level III trauma centre
does not have the full availability of special-
ists, but does have resources for emergency
resuscitation, surgery, and intensive care of
most trauma patients; this means that there
are no specialised services in the province.
So as a result people needs to travel; to
neighbouring provinces for such services.
This again pointed out to unavailability of
advances health facilities in the province.
Shortage of ambulance
services and distance as a
barrier to access health care
The rural areas are often inaccessible due to
the poor condition of the roads and this in-
fluences people’s ability to seek health care,
the transport of patients to referral points
as well as the distribution o drugs and other
materials [11]. The Eastern Cape Health
5
26
13
5
26
9
16
44.4
71.2
79.5 78.8 81.2 80.2
40.2
72.8
61 61 62.1
91.1
98
2.1
10.9
29.9
19.5
7.4
18.9
6.2 7.1
0
20
40
60
80
100
120
Cacadu Amathole Chris hani Ukhahlamba O.R Tambo Alfred Nzo Nelson
Mandela
(%)
% of population people in poverty (%) % rural % of health care facilities
Figure 6. Poverty rates, health care facilities, and population rates per district1
Source: generated by the author from different sources: (RASDSSEC, 2008; ECDoH
annual reports; [3])
1 The graph should be interpreted with caution as the data was extracted from different sources and is also
evaluated at different time points
wmj 5 2011.indd 168 9/26/11 4:25 PM
169
SOUTH AFRICA Public Health
Conference cited drug shortages, long
queues, and lack of accountability, a broken
referral system, poor treatment of patients
by health workers, a weak primary health
care system and the long distances patients
have to travel as the major problems in the
province. Participants said the lack of am-
bulances, for patient transport and trauma
incidents was a major concern. It was also
noted that access for emergency deliveries is
clearly hampered by long distances.
Poku-Boansi [25] in their paper established
that poor state of transport infrastructure
and service adversely affected the ability of
pregnant women to seek healthcare in the
recognised health institutions as a results
they rely on traditional birth attendants
who lack the necessary skills and equip-
ments to deal with complicated cases.
Fawcus et al. [12] found that up to 50% of
maternal deaths from hemorrhage were at-
tributed to the absence of emergency trans-
port. Distance was cited as reason women
choose to deliver at home rather than at a
health facility (see for Philippines [31] Ugan-
da [17] and Thailand [27]. In other words,
women living farther away are less likely to
choose a health facility for delivery, although
their inferior access makes them the most
vulnerable group in case of an emergency.
Many studies reveal the unsurprising fact
that household use of services tends to de-
cline with distance, a study conducted by
Tanser, Gijsbertsen, and Herbst showed
that people in rural homesteads travel four
times longer to access care than do their
ore affluent urban counterparts, see table
1 below: Furthermore Literature showed
that 70% of the poor in Ghana cited dis-
tance from a health care facility as a major
obstacle [15].This is a key reason urban citi-
zen, who is often also wealthier, use services
more than their rural counterparts. Lower
rural access, reported in many studies, may
well be the impact of an interaction be-
tween longer distances and less knowledge
of treatment [11].
The data reviewed in this section revealed
key obstacles that are barrier to accessing
care which includes health care charges,
long distances to facilities, inadequate and
unaffordable transport systems, poor quality
of care especially in public sector facilities.
The following section proposes initiatives
that could be explored to reduce or elimi-
nate access barriers to health care in par-
ticular the remote areas.
Discussion
Access barriers faced by many South Afri-
cans in particular those residing in rural ar-
eas require governments, policy makers and
health care providers need to better enforce
existing policies and regulations. There is a
need to engage local government and com-
munities in particular with regard to service
delivery and ensuring that infrastructure is
place [9]. It should also go beyond to just
ensuring that the infrastructure is there, but
the maintenance thereof and both the local
government and the communities need to
play a critical role in this regard.
In addressing access to care, it is important
for governments must avail transportation
options in all communities regardless of
location or population size, this includes
making sure that ambulance services are
accessible. This is critical to the implemen-
tation of the National Health Insurance in
South Africa.
There is a number of initiatives that could
potentially be explored in dealing with
distance and transportation as a barrier to
access health facilities. These include pro-
viding subsidies, ferry discounts or travel
vouchers for patients that have to travel for
medical care these includes transportation
vouchers [4].
The expansion of access to high quality
primary care will make an enormous dif-
ference in health care outcomes in the so
called under resourced areas. It is known
that providing more resources to attract and
retain health care professionals to rural ar-
eas is essential to improving access to health
care in rural areas. It is imperative to deal
with challenges facing residents in rural ar-
eas that compromise accessing public health
services, in particular those that are heavily
struck by poverty. It is pivotal that govern-
ment agencies like, Department of Health,
Social development, and the department of
Public works are integrated to work togeth-
er in improving service delivery.
Conclusions
Poor South Africans do not benefit public
health spending by the government and
those in poverty are often marginalised. In
many instances due to bad communications
between government departments. Other
contributors include maladministration
of public funds which undermine service
delivery and result in deteriorating public
health care facilities. Indeed unemploy-
ment and poverty lines are the highest in
the Eastern Cape compared to any other
province in South Africa. As a result most
Table 2. Travel time to clinics and adjusted odds ratio of clinic usage
Setting
Travel time
(minutes)
 
Adjusted odds
ratio
 
Avg Std. dev OR 95% CI
Urban 20 9.7 11
Peri-urban 55.7 31.8 28.2 19.2–41.3
Rural 83.9 29.3 18 12.5–26.0
Source: [33].
wmj 5 2011.indd 169 9/26/11 4:25 PM
170
SOUTH AFRICAPublic Health
of the citizens cannot afford basic health-
care facilities. Also the province like the
Eastern Cape has a higher concentration of
residents who live in remote or rural areas.
Residents who live in rural areas at times
travel greater distances to access different
points of the health care delivery system. In
most instances health care facilities in these
areas are limited or there are just not enough
healthcare work-forces. The Government
should implement a focused programme
to improve operational efficiencies includ-
ing clear devolution of district and hospital
authorities, simplification and better use of
management information, and better fi-
nancial and performance accounting. If the
provision of health and medical services is
isolated and not seen in the context of pov-
erty reduction, then poor will continue to
experiences problems and the current trends
will still be maintained.
References
1. Armstrong, P, Bongisa, L, Krige, S, 2008. Pov-
erty in South Africa: A profile based on recent
household surveys. Stellenbosch Economic
Working Paper: 04/08. Stellenbosch: Depart-
ment of Economics, University of Stellenbosch.
2. Balabanova, D, Parkhurst, J, McKee, M. et al,
2006. Access to health care: taking into account
health system complexity. London: Health Sys-
tems Development Programme.
3. Barron P,Day C,Monticelli F,editors,2007.The
District Health Barometer Year 2006/07. Dur-
ban: Health Systems Trust.
4. BC Ministry of Health. (2008). Summary of
input on the conversation on health. Retrieved
from http://www.bcconversationonhealth.ca/
EN/home/
5. Bokil, PS , 2006. Engaging, Mobilizing and
sustaining community involvement in health
care. Evidence – based strategies of synergizing
interventionists and stakeholders with special
reference to infectious diseases. NAPSIPAG
conference on the 3rd
4th
and 5th
December 2006
Sydney.
6. Council for Medical Schemes, 2010. Annual
Reports of the Registrar of Medical Schemes,
Hatfield, Pretoria.
7. Cullinan, K, 2006. Health services in South Af-
rica. A basic introduction, Health-e News Ser-
vice.
8. Dambisya YM and Modipa SI, 2009. Capital
flows in the health sector in South Africa: Im-
plications for equity and access to health care.
Discussion paper. Harare: EQUINET.
9. Darlan, G. and K. Anani (2007) Delivering
Services to the Poor: An Assessment of the Ca-
pacity to Deliver Education, Health, and Wa-
ter Services to Local Communities in Ghana.
Washington, DC: World Bank Institute.
10. Eastern Cape Health Conference, 2010. Eastern
Cape Provincial Health Consultative workshop:
a community consultation workshop report.
10–12 May 2010
11. Ensor,T and S, Cooper, 2004. Overcoming Bar-
riers to Health Service Access and Influencing
the Demand Side Through Purchasing, World
Bank’s Resource Allocation Project.Washington
DC: World Bank.
12. Fawcus, S, Mbizvo, M, Lindmark, G and
Nystrom, L, 1996. A community-based inves-
tigation of avoidable factors for maternal mor-
tality in Zimbabwe. Studies in family Planning
27(6),319-27.
13. Gantsho, M, Willie, MM, 2011 The regulatory
framework in the healthcare insurance industry:
In the interest of beneficiaries and public.World
Medical Journal. 57(1), 9-17.
14. Goins, R T, Williams, KA, Carter, MW, Spen-
cer, M, and Solovieva,T, 2005. Perceived barriers
to health care access among rural older adults: a
qualitative study. J Rural Health 21(3), 206–213
15. Heyen-Perschen, J, 2005. Report on Current
Situation in the Health Sector of Ghana and
Possible roles of appropriate Transport Technol-
ogy and Transport related communication inter-
ventions. European section of the Institute for
Transportation and Development Policy.USAID.
16. Institute for Socio-Economic Research (FHIS-
ER) & Development Research Africa (DRA)
and Take Note Trading, 12 June 2008. Eastern
Cape Rapid Assessment of Service Delivery and
Socio-Economic Survey.University of Fort Hare
17. Kaguna-Amoti B, Nuwaha F, 2000. Factors in-
fluencing choice of delivery site in Rakai district
of Uganda. Soc Sci Med. 2000;50:203–213.
18. Kennedy, G Nantel, G, Inge D Brouwer, I and
Kok, F, J, 2005. Does living in an urban envi-
ronment confer advantages for childhood nu-
tritional status? Analysis of disparities in nutri-
tional status by wealth and residence in Angola,
Central African Republic and Senegal. Public
Health Nutrition 9(2), 187–193
19. Leibbrandt, M. et al. , 2010. Trends in South
African Income Distribution and Poverty since
the Fall of Apartheid. OECD Social, Employ-
ment and Migration Working Papers, No. 101,
OECD Publishing.
20. Medpages, 2010. 2009/2010 Geo-Demographic
Analysis: Private Healthcare Providersin South
Africa Medpages
21. National Treasury provincial report, 2010,. Na-
tional Treasury,Pretoria
22. Ntho, M. & Tsikoane,T., 2003. Integrating gen-
der into World Bank Financed transport pro-
grams: Case study Lesotho.
23. Pauw, K, 2005. A Profile of the Eastern Cape
Province: Demographics, Poverty, Inequal-
ity and Unemployment. Provide Project back-
ground paper 1(2).
24. Piette JD, Moos RH, 1996. The influence of
distance on ambulatory care use, death, and
readmission following a myocardial infarction.
Health Services Research 31: 573–91.
25. Poku-Boansi, M, Ekekpe, E and Akua Bonney,
A A, 2010.Combating Maternal Mortality In
The Gushegu District Of Ghana:The Role Of
Rural Transportation. Journal of Sustainable
Development in Africa 12(5)
26. Priyadarshini, S, Bokil, 2006. Engaging, Mobi-
lizing and sustaining community involvement
in health care. Evidence based strategies of syn-
ergizing interventionists and stakeholders with
special reference to infectious diseases. NAPSI-
PAG conference on the 3rd
4th
and 5th
December
2006 Sydney.
27. Raghupathy, S, 1996. Education and the use of
maternal health care in Thailand. Social Science
and Medicine 43(4): 459-471.
28. Rispel L, de Sousa C, Molomo, B, 2008. Rapid
appraisal of social inclusion policies in selected
sub-Saharan African countries. Cape Town:
Human Sciences Research Council Press, 2008.
64 p.
29. Rispel, L, Molomo, B, Dumela, S, 2009. South
African case study on social exclusion. Human
Sciences Research Council , Pretoria. p. 56.
30. Roberts H: A way forward for mental health
care in Ghana? Lancet 2001, 357:1859
31. Schwartz, JB, Akin, JS and Popkin, B, M, 1993.
In: Economic determinants of demand for mod-
ern infant-delivery in low-income countries: the
case of the Phillipines. In: Health
32. Statistics South Africa, 2009. General House-
hold Survey, 2009. Statistics South Africa , Pre-
toria
33. Tanser, F, Gijsbertsen, B and Herbst, A; 2006.
Modeling and understanding primary health
care accessibility
34. The Community Agency for Social Enquiry,
1995. A National Household Survey of Health
Inequalities in South Africa.The Henry J. Kaiser
Family Foundation, 1995, p. 10.
35. ECDoH’s Annual Report, 2010, Department of
Health, Bisho
Michael Mncedisi Willie,
Council for Medical Schemes,
Research and Monitoring,
E-mail: m.willie@medicalschemes.com
wmj 5 2011.indd 170 9/26/11 4:25 PM
171
Person – centred Medicine
The Fourth Geneva Conference on Per-
son-centered Medicine was held on April
30-May 4, 2011, the latest in a series of
annual Geneva Conferences on this topic
since May 2008 [1-3]. It continued build-
ing an initiative on Medicine for the Person
[4] through collaboration with major global
medical and health organizations and a
growing group of committed international
experts all engaged into an International
Network for Person-centered Medicine [5].
The conference took place at the Marcel
Jenny Auditorium and auxiliary halls of the
Geneva University Hospital and at the Ex-
ecutive Board Room of the World Health
Organization. It was organized by the In-
ternational Network for Person-centered
Medicine (INPCM), the World Medical
Association (WMA), the World Organi-
zation of Family Doctors (Wonca) and the
World Health Organization (WHO), in
collaboration with the International Alli-
ance of Patients’ Organizations (IAPO), the
International Council of Nurses (ICN), the
International Federation of Social Workers
(IFSW), the International Pharmaceutical
Federation (FIP), the Council for Interna-
tional Organizations of Medical Sciences
(CIOMS), the International College of Sur-
geons (ICS),the World Federation for Men-
tal Health (WFMH), the World Federation
of Neurology (WFN), the International
Federation of Gynecology and Obstetrics
(FIGO), the Medical Women’s Interna-
tional Association (MWIA), the World
Association for Sexual Health (WAS), the
World Association for Dynamic Psychiatry
(WADP), the World Federation for Medi-
cal Education (WFME), the International
Association of Medical Colleges (IAOMC),
the International Federation of Medical
Students’ Associations (IFMSA), the Inter-
national Federation of Ageing (IFA), the
European Association for Communication
in Health Care (EACH),the European Fed-
eration of Associations of Families of People
with Mental Illness (EUFAMI), Ambro-
siana University, Buckingham University
Medical School, and the Paul Tournier As-
sociation,and with the auspices of the Gene-
va University Medical School and Hospitals.
Under the overall theme of Articulating
Person-centered Clinical Medicine and Peo-
ple-centered Public Health, stimulated by the
WHO World Health Assembly Resolution
promoting people-centered care [6], the
Fourth Geneva Conference on Person-cen-
tered Medicine examined through a set of
diverse sessions how the values and clinical
care practices of person-centeredness could
be organized in diverse settings, from the
bed side to the community.
The Conference Core Organizing Commit-
tee was composed of J.E.Mezzich (President,
International Network for Person-centered
Medicine), J. Snaedal (World Medical As-
sociation President 2007–2008),C.van Weel
(World Organization of Family Doctors
President 2007–2010), M. Botbol (World
Psychiatric Association Psychoanalysis in
Psychiatry Section Co-Chair), I. Salloum
(World Psychiatric Association Classifica-
tion Section Chair), and W. Van Lerberghe
(WHO Health Systems Governance and
Service Delivery Director). Also collaborat-
ing organizationally were O.Kloiber (WMA
Secretary General), A.M. Delage (WMA
Secretariat), M. Dayrit (WHO), R. Kawar
(WHO), and J. Dyrhauge (WHO).
Financial or in-kind support for the Con-
ference was provided by: 1) the Internation-
al Network for Person-centered Medicine
(core funding), 2) the World Health Orga-
nization (covering invited participants’trav-
el and accommodation expenses, and some
secretarial and logistic services), 3) Univer-
sity of Geneva Medical School (auditorium
services and coffee breaks), 4) Paul Tournier
Association (the conference dinner), 5) the
World Medical Association (local secretari-
at and printing services) and 6) Participants’
registration fees.
Pre-conference workmeetings
The first workmeeting on April 30, 2011
focused on three substantive projects re-
lated to the informational framework of the
INPCM. These included a presentation on
the launching of the International Journal
Articulating Person-centered Medicine and People-centered
Public Health: A Report from the Fourth Geneva Conference
Standing LtoR: E Ramirez, A Miles, M Dayrit, R Montenegro, C Maguina, S Rawaf, I Sal-
loum, RA Kallivayalil, G Brera, W Van Lerberghe, M Botbol, J Snaedal, T Epperly, J Appleyard,
D Matheson, and H Montenegro. Seated LtoR: E Velasquez, C Etienne, R Kaitiritimba, JE
Mezzich and A Fort, at the Closing Session of the Fourth Geneva Conference, WHO Executive
Board Meeting Room
wmj 5 2011.indd 171 9/26/11 4:25 PM
172
Person – centred Medicine
of Person Centered Medicine (IJPCM)
as a joint venture of the INPCM and the
University of Buckingham Press. The first
issue of the Journal has already been pub-
lished and subsequent issues are in prepara-
tion with papers submitted from across the
world.The second presentation provided an
overview on the updated INPCM institu-
tional website and interactions with related
ones,while the third presentation offered an
overview on the bases for the development
of a bibliographical clearing house and in-
stitutional databases.
The second workmeeting was dedicated to
the development of Person-centered Clini-
cal Care Guidelines. This project was un-
dertaken from a range of perspectives such
as pediatrics, family practice, research, pro-
grammatic, and patient vantage points. The
attendees were engaged in stimulating dis-
cussions on the conceptualization and role
of guiding principles within the context of
person-centered medicine.
The first workmeetings on May 1,2011 paid
detailed attention to the topic of Person-
centered Integrative Diagnosis (PID). An
overview of the current status of PID de-
velopment was followed by 11 brief presen-
tations and discussions addressing the ma-
jor aspects and domains of the PID. These
included diagnostic assessment procedures
such as utilizing categories, dimensions, and
narratives,the evaluators and the assessment
process involving interactions among clini-
cians, patients, and carers.The presentations
also reviewed the PID domains: disorders
and comorbidity, disabilities and function-
ing, positive health and well-being, experi-
ence of illness and health, contributors to
illness and health (etiopathogenic and risk
factors as well as strengths and protective
factors). This workmeeting concluded with
discussions on diagnostic summary, treat-
ment planning, case illustrations, and vali-
dation of the PID model and guide.
The second INPCM workmeeting on May
1, 2011 highlighted person-centered special
developments. These included a pediatric
diagnostic model, the revision of the Latin-
American Guide of Psychiatric Diagnosis, a
French diagnostic project,a person-centered
partnership project, a South Asian project, a
World Federation for Mental Health-IN-
PCM collaborative project,person-centered
care for people abusing substances, and a
Mexico-INPCM collaborative project on
person-centered care on chronic diseases,
and a Janus Project for person-centered
young health professionals.
Core conference
The Core Conference was opened on May
2 by Prof. Panteleimon Giannakopoulos,
Vice-Dean of the Geneva University Medi-
cal School and by Dr. Hernan Montenegro
on behalf of Dr. Carissa Etienne, WHO
Assistant Director General for Health Sys-
tems and Services. They were joined in the
presidium by the core members of the Or-
ganizing Committee.
The opening address was delivered by the
INPCM President, who presented a prog-
ress report on institutional achievements
and horizons. He highlighted the network’s
growing number of participating interna-
tional organizations from 10 in our inaugu-
ral 2008 Geneva Conference to 27 in our
Fourth annual event. He emphasized the
presence of the World Medical Association
which inspired and supported the INPCM
from its inception and the World Health
Organization which has agreed since 2010
to co-organize the Geneva Conference giv-
en that people-centered care is one of the
policy directions for the renewal of primary
health care approved by the World Health
Assembly in 2009 (WHA62.12) and has
commissioned INPCM this year to under-
take a study on the systematic conceptual-
ization and measurement of person- and
people-centered care. At the same time, the
INPCM scholarly community is moving
forward with the procedural construction
of person-centered medicine as exemplified
by the recent publication of the Person-
centered Integrative Diagnosis model in
the Canadian Journal of Psychiatry [7]. An
institutional landmark has been the launch-
ing this May of the International Journal of
Person Centered Medicine [8] which shall
enhance immensurably the prospects of our
initiative on medicine for the person.
The first session of the scientific program
was a symposium on the Person-centered
and Contextualized Study of Disease. The
first two speakers reviewed epistemologi-
cal and conceptual perspectives, prioritizing
phenomenological narratives, in order to
broaden the theoretical framework beyond
reductionistic biological and behavioral ap-
proaches. They also examined possibilities
to study disease in a robust and rigorous
manner that respects the subjectivity, con-
text and uniqueness of the patient’s experi-
ence.The other two presentations examined
dementia and public health and revealed
the feasibility and usefulness of multilevel
person-centered approaches. Emerging as
convergent recommendations were the need
to develop single subject studies,integration
of quantitative and qualitative findings, and
assessment measures informed by compre-
hensive theories (such as the one used in
the Person-centered Integrative Diagnostic
model).
The second scientific session addressed the
Components of Care in Person-centered
Medicine, making clear that in addition to
focused illness treatment, good medical care
also involves understanding and support,
education and counseling, as well as preven-
tion and health promotion.
A considerable body of evidence was sum-
marized indicating that crucial elements of
clinician-patient interaction such as empa-
thy, respect, acceptance, non-judgmental at-
titudes, openness, information-sharing and
joint decision-making may lead to greater
patient satisfaction, acceptance of treat-
ment, and better health outcomes. Also
emphasized was building trust and striving
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173
Person – centred Medicine
to attain professional competence, ethics
faithfulness, and effective communication
and collaboration.
Six parallel sessions followed in the pro-
gram, involving interactive workshops, brief
oral presentations, and INPCM project dis-
cussions.
• The interactive workshop on Enhancing
Person-centeredness in Diagnosis and
Treatment Planning showed how these
two crucial aspects of medical practice can
become a powerful tool to enhance person
centeredness. This is certainly the case of
Diagnosis if considered as a process going
beyond a mere nosographical effort. The
Person-centered Integrative Diagnostic
model carries this process out through the
articulation of health status, experience of
health, and factors contributing to health,
the consideration of both positive and ill
aspects of health at each level, and adding
narratives to categorical and dimensional
descriptions. Although sometimes ne-
glected by clinicians as burdensome ad-
ministrative paperwork, a treatment plan
can become a very helpful instrument to
bring about person-centered medicine. It
is based on a shared understanding of the
patient’s health goals and the identifica-
tion of biopsychosocial barriers that may
interfere with positive outcomes.
• The interactive workshop on Research
on Clinical Communication focused on
practical conditions to promote interna-
tional research on communication. It of-
fered vivid examples on the pros and cons
of observational research on clinical con-
sultations, and stimulated participants to
consider conducting such projects.
• The interactive workshop on the Per-
son with the Disease at the Center of
Teaching presented Western European,
Eastern European and North Ameri-
can approaches to introduce person-
centeredness in medical education. In
addition to interesting particularities in
these regional approaches, joint emphasis
was made on the need to train students
on empathy, subjective observation, com-
munication, and relational skills and the
need to achieve them through early and
supervised contacts with patients.
• The interactive workshop on Advanc-
ing Well Being and Health Promotion
reviewed the place and enhancement of
positive health in person-centered medi-
cine at individual and public health levels.
Work on personality development ap-
peared to be helpful in this regard. Ap-
plications to disabled persons and to work
in low resource countries were also dis-
cussed, highlighting WHO concerns and
experience.
• A session presenting brief oral contribu-
tions to the Advancement of Person-cen-
tered Care was generated by participants
at large.The topics discussed included the
importance of context and method in per-
son-centered medicine, experiences from
Cyprus’ medical education, the teaching
of person- and family-centered care in a
New York pediatrics residency program, a
personal account of experienced disabil-
ity in the UK, combating fragmentation
through integration of health services in
the Americas, primary care in the East
Mediterranean Region, a case study from
Bulgaria, fertility care in the Netherlands,
person-centered psychiatry in Russia,
British perinatal psychiatry, an orthogo-
nal personality assessment procedure
from Puerto Rico, and person-centered
young health professionals’ perspectives.
• A session with complementary INPCM
workgroups meetings was also held. It
discussed the advancement of Diagnostic
Projects, Clinical Care Guidelines, the
Partnership Project (linking professionals
with users and carers), and collaboration
with the World Federation for Mental
Health.
The first General Assembly of the Interna-
tional Network of Person-centered Medi-
cine (INPCM) took then place. It was at-
tended by forty-five colleagues among
representatives of major international or-
ganizations and individual scholars. Brief
presentations were made on the Geneva
Conference’s process and the emergence
and advancement of the INPCM, as well as
on the development and launching of the
International Journal of Person Centered
Medicine. The main agenda item was the
presentation and discussion of an Institu-
tional Plan that reviewed the organization’s
identity, mission, activities, structure, gover-
nance and support, established an Interna-
tional College of Person-centered Medicine
as institutional successor of the INPCM,
and asked the Board to take steps to im-
plement it and report to the 2012 General
Assembly. The General Assembly approved
this Developmental Plan by acclamation.
A Conference Dinner at a typical Geneva
restaurant organized by the Paul Tournier
Association followed.
The second day of the core conference was
held at the WHO Executive Board Room
and started with a Session on Making
Progress in People-centered Care: Coun-
try Experiences with the aim of identifying
health system conditions that are conducive
to people-centered care. It opened with an
address by Dr. Carissa Etienne, WHO As-
sistant Director General, who insisted on
the necessity to link person-centered clini-
cal medicine with people-centered public
health and to involve wide professional and
patient organizations to implement and
promote such perspectives. Relevant expe-
riences from four countries (New Zealand,
Spain, Chile, and Uganda) were then pre-
sented,followed by an analysis of these cases
in terms of aspects of people-centeredness
that were addressed and ending with a final
synthesis of main lessons learnt.
The aim of the second Session on System-
atic Conceptualization and Progress Mea-
surement was to identify and get agreement
on metrics for measuring progress towards
people-centered care. In the first presenta-
tion, INPCM presented the results of a
study that was commissioned by WHO. It
involved a substantial literature review and
the engagement of a broad international ar-
ray of health professionals and some patient
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174
Person – centred Medicine
and family representatives through a Delphi
method and other systematic consultation-
al approaches. This yielded a preliminary
person-centered care index, which was sub-
jected to initial content validity and applica-
bility evaluations. The second presentation
from Australia was on the People-centered
Health Care National Indicators Project
which is a WHO initiative for the Western
Pacific and South-East Asia Regions that
resulted in a regional policy framework on
people-centered care and is currently de-
veloping related monitoring indicators. The
final presentation was done by colleagues in
Belgium and the Netherlands on operation-
alizing the concept of people-centered care
and this also involved a proposed indicators
matrix.
The session on Stakeholders’ Roles and
Contributions to Advance Person- and
People-centered Care revealed specificities
on the prospective contributions of major
international health institutions (from pro-
fessionals to patients and carers) as well as
converging perspectives among them. The
strong interest stimulated in all session par-
ticipants led to recommendations to have a
similar session at the next Geneva Confer-
ence during which institutions would try to
present formal policy statements on person-
centered medicine and perhaps a conference
declaration may be possible.
The third and last day of the core conference
offered a plenary symposium on Education
in Person-centered Medicine. It presented
country perspectives from the UK, Italy,
Peru, and India. The presentations high-
lighted the efforts of medical educators to
strike a balance between the ever-expand-
ing scientific content of the curriculum
with the need to preserve the humanistic,
cultural, and spiritual dimensions of edu-
cation – education ennobled the healer in
both mind and heart allowing him/her to
be truly person-centered. The presenta-
tion of the WHO Initiative to scale up
and transform health professional educa-
tion emphasized the challenges and actions
towards producing health professionals in
poor countries where there were shortages
of health workers and where graduates emi-
grated after completing their training. The
presentation focused on current efforts to
develop evidenced-based recommenda-
tions which might guide policymakers and
educators in undertaking interventions to
address the shortages and imbalances of
health professionals in countries in ways
which truly addressed the needs of people
(people-centered care).
Concluding remarks
The Fourth Geneva Conference was not
only a new landmark in the event series
initiated in 2008, but it was special in the
following regards. It was sponsored by a
record number (27) of international health
institutions, it included for the first time
parallel sessions which expanded the type
and number of sessions offered (including
for the first time oral presentations directly
contributed by general participants), it re-
ported on the INPCM research study com-
missioned by WHO on addressing system-
atic conceptualization and measurement of
person- and people-centered care, it wit-
nessed the launching of the International
Journal of Person Centered Medicine, and
it held our first General Assembly which es-
tablished the International College of Per-
son-centered Medicine as a successor of the
International Network. At its Closing Ses-
sion, Dr. Carissa Etienne, WHO Assistant
Director General, invited all participants
to come back next year for an even greater
5th
Geneva Conference on Person-centered
Medicine.
References
1. Mezzich JE, Snaedal J, van Weel C, Heath I.
Person-centered medicine: a conceptual explo-
ration. International Journal of Integrated Care,
Supplement, 2010.
2. Mezzich JE. The Second Geneva Conference
on Person-centered Medicine. World Medical
Journal 55: 100-101, 2009.
3. Mezzich JE, Miles A. The Third Geneva Con-
ference on Person-centered Medicine: collabo-
ration across specialties, disciplines and pro-
grams. International Journal of Person Centered
Medicine 1: 6-9, 2011.
4. Mezzich J begin_of_the_skype_highlightin-
gend_of_the_skype_highlighting, Snaedal J,
van Weel C, Heath I. Toward person-centered
medicine: from disease to patient to person.
Mount Sinai Journal of Medicine 77: 304-306,
2010.
5. Mezzich JE, Snaedal J, van Weel C, Heath I.
The International Network for Person-centered
Medicine: background and first steps. World
Medical Journal 55: 104-107, 2009.
6. World Health Organization: Resolution
WHA62.12. Primary health care, including
health system strengthening. In: Sixty-Second
World Health Assembly, Geneva, 18–22 May
2009. Resolutions and decisions. Geneva, 2009
(WHA62/2009/REC/1), Page 16.
7. Mezzich JE, Salloum IM, Cloninger CR, Sal-
vador-Carulla L, Kirmayer LJ, Banzato CEM,
Wallcraft J, Botbol M. Person-centered Integra-
tive Diagnosis: conceptual bases and structural
model. Canadian Journal of Psychiatry 55:701-
708, 2010.
8. Miles A, Mezzich JE. Advancing the global
communication of scholarship and research
for personalized health care: the International
Journal of Person Centered Medicine. Interna-
tional Journal of Person Centered Medicine 1:
1-5, 20.
Prof. Juan E. Mezzich, President,
International College of
Personcentered Medicine;
Prof. Jon Snaedal, President
2007-2008, World Medical Association;
Prof. Chris van Weel, President 2007-2010,
World Organization of Family Doctors;
Prof. Michel Botbol, Co-Chair, Section
on Psychoanalysis in Psychiatry,
World Psychiatric Association;
Prof. Ihsan Salloum, Chair, Section on
Classification, World Psychiatric Association;
Dr. Wim Van Lerberghe, Director,
Department for Health System
Governance and Service Delivery,
World Health Organization
E-mail: icpcmSecretariat@aol.com
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175
VATICAN STATE Clinical Ethics
The appearance of contemporary medicine
of the new “ethical dilemmas”, created by
the increase in technical-scientific possibili-
ties but also from social-economic and cul-
tural evolving, has changed the focus from
the formulation of general behavioral norms
in medical ethics – as was proper to ethics
as it was taught in university classrooms – to
problems with the method employed, at the
patient’s bedside, to come up with the best
clinical decision.
The particular “focus” on the decision in the
clinical area has had several positive effects.
It has placed emphasis on the need for a
rigorous ethical reasoning and, consequent-
ly, for the development of tools for ethical
analysis supporting the diagnostic and ther-
apeutic choices. Indeed, since clinical ethics
began to define itself as an autonomous dis-
cipline, between the end of the 1970’s and
the beginning of the 1980’s, it has become
essentially characterized by the application
of an analytical methodology – for a long
time Principialism developed by T. L. Beau-
champ and J. F. Childress and Neocasuistry
by A. Jonsen and M. Siegler – to the decid-
ing process in individual clinical cases.
I consider it undeniable that this practice
has produced good results. However, it is
also undeniable that, over time, limits have
increasingly emerged: the displacement of
the “focus” on the procedures tends toward
a marginalizing of the ethical judgment. It
seems to me that the juridical cases have
produced a noticeable influence – often re-
sulting in a failure of the ethical reasoning
in clinical practice –, to the point that today
it would be possible to outline a kind of his-
tory of medical ethics according to certain
sentences from judges which caught the
attention of public opinion: Quinlan, Cru-
zan, Schiavo, etc. This has often favored a
legalistic interpretation of ethical analysis
in medicine, which is continually more pre-
occupied with observing certain rules, like
good clinical practices, respecting privacy,
informed consensus, etc. (naturally, all the
rules have to be rigorously followed), at the
expense of the reflection on what is the just
and reasonable interest of the patient.
When the center of the attention is taken up
by the decisional process, the ethical analy-
sis can be reduced almost automatically to
the evaluation of possible consequences; for
example, the choice between surgery or a
chemotherapy and/or radiotherapy in the
care regarding laryngeal carcinoma will de-
pend exclussively on the percentile of suc-
cess even though it is well known that, for
the patient, the physical image or the ability
to speak might weigh more heavily.
Moreover, an informed consent concentrat-
ed only on the bare deciding factors which
are available in the clinical arena, would
render it difficult for the patient to express
a true free consent, in that the patient could
be compelled to accept something that in
reality they would not want. Consent is not
so much about the transition from the deci-
sion to its being put into action as it is about
the transition from the ethical value to the
clinical decision.The doctor should help the
patient to consider not only the facts, but
most of all the reasons which are at the basis
of an eventual decision, otherwise it is easy
to subtly fall into the old paternalism which
we thought was buried once and for all.
Thirty years after its initial shaping as an
autonomous discipline, we can say that
the nucleus of clinical ethics still consists
in the methodology of analyzing the ethi-
cal problems of clinical practice (moreover,
well accepted by medical doctors, who re-
ally need a mediation between the general
moral principle and the individual case)
and recourse to ethical consultation (for
example, within the ad hoc committee) as
expertise in the most complex situations.
Nevertheless,it is important to confirm that
the efforts to elaborate an ethical approach
centered on the person should always re-
main a priority. It is necessary to think and
to apply a clinical ethic which does not lean
exclusively on a decisional procedure or on
a methodology of analysis of the situation,
but which understands the attention to the
person – as it regards the patient and as it
regards the doctor – in its entirety.What re-
ally exists, as a matter of fact, is the person
in its individuality and its singularity, while
all the rest, including the ethical analysis of
the clinical decision, constitutes a descrip-
tive perspective unfortunately partial and
sometimes even relative.
The same problematic often in the clinical
decision is only one side of a much greater
ethical issue, which effects the relationship
between the doctor and the patient in its
totality and, probably, the very essence of
the medical profession.Therefore, today it is
becoming increasingly more evident that a
clinical ethic which limits itself to offering a
solution only in terms of the decisional pro-
cedure would not be capable of grasping the
complexity of clinical medicine, much less
On the Epistemological Nature of Clinical
Ethics: Decision Making or Thinking?
Ignacio Carrasco De Paula
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DENMARKNational and Regional news
to give an adequate response to the ethical
dilemmas resulting not from an illness but
from the very same patient even if often
occurring unawares. In any case, we cannot
forget that sickness, just as with any coin,
has two inseparable faces: the pathology
and the way in which the individual patient
reacts in a situation of vulnerability, pain
and dependence.
Certainly, a methodology of analyzing clin-
ical cases offers the advantage of a greater
certainty in the attempt to bring order to
the multiplicity of relevant elements within
an ethically complex situation and to render
objective the assessment of the concrete de-
cision that arises. At any rate, it is good to
remember that the “certainty”offered by the
methodology of an ethical analysis of the
clinical case remains a “morale” certainty,
a certainty which provides and takes into
consideration the real possibility of making
a mistake.
An exclusive trust in methodology causes a
rigidity in the subsequent action according
to a pre-established pattern which isn’t able
to take into consideration the total human
capacity to act. Reality doesn’t always ad-
equate itself to the model, simply because
no model elaborated by the human mind
can exhaust reality, especially when we base
this reality on the human being in all its
simplicity and complexity. On the other
hand, the same clinical medicine teaches
us how the models and the mechanisms
learned in the university classrooms rarely
work as a direct rule for the cure of illness
in real patients.
One possible solution to the limits of a
clinical ethic, intended only as a decisional
procedure, is to remember that the “ethical”
understanding which the doctor has to ac-
quire in order to arrive at a clinical behavior
which is truly virtuous isn’t only that offered
by the content and the methods of ethical
reasoning, but also that which comes from
an understanding of the individual patient
acquired thanks to clinical experience. The
conceptual information which we possess
regarding a given pathology and its evolu-
tion (medical data, rules and ethical refer-
ences etc.), as it has been said, constitute a
necessary understanding, but this is not suf-
ficient.They are,again,only theoretical ways
of understanding which don’t yet grasp the
variety and dynamic, full of nuances and
sometimes unpredictable, of the existential
dimension of real life. For a doctor, there-
fore, knowing the clinical situation neces-
sarily demands an experience involving that
individual sick person, so that if a clinical
decision is taken, for example, considering
only the laboratory parameters, diagnos-
tic reports and ethical advice, without ever
“meeting” the patient, in no way could this
be called an appropriate ethical behavior.
From this perspective, we know well that,
for the doctor, it is important to develop
a relationship with the way, perhaps even
emotional, in which the patient perceives
their condition. The doctor who is moved
by a true interest and by a real compassion
as it regards his patient, is able to penetrate
his suffering and to recognize the specific
traits of the patient’s living this illness, to
discern the human and existential needs
which the patient doesn’t always manifest.
In the opposite case,if the doctor disregards
or ignores the value and the individual dig-
nity of his patient, it will be hard for him
to listen (the doctor becomes deaf) and to
assume the necessary empathic attitude in
order to obtain that kind of understanding.
Showing interest and friendship constitute
an indispensable attitude in the clinical en-
counter.
We could conclude, then, affirming that
within the clinical ethics of the XXI centu-
ry, if we avoid confusing model and reality,
along with making a decisional procedure
absolute, a methodology of ethical analysis
in clinical cases could constitute a useful,
even though necessary help in the face of
more complex clinical cases. Nevertheless,
today, non-negligible contributions to clini-
cal ethics come from narrative medicine,
from the ethics of healing and, in general,
from the ethics of virtue, perspectives which
are mostly open to an ethics of relationship
and which can effectively integrate the in-
dispensible ethical analysis of the clinical
decision.
Prof. Ignacio Carrasco De Paula M.D. Ph.D.
Emeritus Professor of Bioethics
and Clinical Ethics,
Gemelli Medical School, Rome
For many years, the Danish Medical As-
sociation has been preoccupied with the
question of creating clear guidelines for
the collaboration between doctors and
the pharmaceutical industry. This has
been done per agreement with the indus-
try which in turn also profited from a re-
sponsible way of conducting business in
terms of improving their image. The goal
has been to minimise the interdependency
between doctors and the pharmaceutical
industry.
With regard to the collaboration with
pharmaceutical industry there is Danish
legislation compelling doctors to inform
Dependency on Sponsorships and Relations
to the Pharmaceutical Industry:
Experiences from Denmark
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DENMARK National and Regional news
the Danish Medical Board about their
involvement be it as a consultant or in
the capacity of expert in workshops and
educational activities sponsored by the in-
dustry or shareholder in a specific Phar-
maceutical Company.This practice enables
the Danish Medical Board to evaluate the
dependency of a physician concerning the
relationship with the industry and to re-
view his research findings and actions as a
doctor in this light. Shareholders are more
likely to view the research findings of a
company in a more positive light than in-
dependent physicians. The National Board
of Health has the authority to limit the
right of the physician to prescribe medi-
cine if it fears that the physician is under
undue influence of the pharmaceutical in-
dustry referring to the prescriptions made
by the physician.
In 2006, the Danish Government entered
into agreement with other political parties
on a plan of action in view of a big increase
in the public expenditure on pharmaceuti-
cals. Among the issues for discussion were
provisions on the collaboration between
health care personnel and the pharmaceuti-
cal industry. On the basis of this, the Min-
ister of the Interior and Health passed a set
of rules on advertising.
In 2007 the Danish Medical Association
made an agreement with the pharmaceuti-
cal industry. It was agreed that any initia-
tive or arrangement to which doctors were
invited by the pharmaceutical industry  –
be it post graduate education and courses
abroad – should be declared and reviewed
by a board. This board was instituted based
on an agreement between pharmacists,
medical doctors and the pharmaceutical in-
dustry.
The board could impose sanctions on both
the involved doctors if they did not declare
an application to the industry before the
board and on the industry if the initiative
to invite doctors for postgraduate education
was not cleared with the board beforehand.
The sanctions were pecuniary and the size
of the “fine” was related to the seriousness
of the offence.
The pharmaceutical industry in Denmark
has now terminated the agreement with
the Danish Medical Association and the
pharmacists referring to internal rules of
the multinational companies. Most phar-
maceutical companies are present in many
countries and nowhere else in the world
have the rules for collaboration with doc-
tors been as strict as in Denmark. The mul-
tinational companies have therefore not
been able to fit the Danish Model into their
yearly reports and since it is very common
to do advertising and promotion by present-
ing gifts to doctors or to organisations, the
boards of multinational companies are not
willing to abolish this practise which has a
positive effect on the prescription of their
drugs and the purchases of pharmaceuticals
in the hospitals in general.
It is in this light that we have to view the
willingness of the industry to sponsor what
would appear to be activities irrelevant for
their business and with no immediate fi-
nancial gain. The calculation of these mul-
tinational companies is of course that in the
long run there is indeed a financial gain and
that good relations pay – unfortunately, it
also has an effect on the public expenditure
concerning the purchase of pharmaceuti-
cals.
In the future, the regulation of the col-
laboration between doctors and industry in
Denmark will be subject only to Danish na-
tional laws since the development that the
DMA started has been rolled backwards by
the industry itself.
However, the DMA has introduced a set of
guidelines to its members stating that the
reception of gifts  – even pens and note-
pads – is not appropriate.
The way forward.What should be promoted
in order to increase the credibility of doctors
and attacking accusations of dependency is
securing that there are no ways of influenc-
ing one another in terms of conducting
business. It should not be possible for the
industry to get good will from doctors by
sponsoring dinners and courses. It is impor-
tant to gain the patients’trust that he or she
will receive the best and cheapest medica-
tion and for society it is of great importance
that doctors are not biased when they pre-
scribe drugs at the expense of society. It will
take a lot of dedication to change the ways
of the pharmaceutical industry since they
conduct business and do it well with the
present promotional strategies.
M.D. Poul Jaszczak,
Danish Medical Association
Poul Jaszczak
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NETHERLANDSNational and Regional news
Introduction:The Silvia
Millecam case
In August 2001, Sylvia Millecam died of
breast cancer at the age of 45. Millecam
was a famous Dutch comedienne and had
been voted the most popular woman in the
Netherlands many times. Her death came
all the more as a shock when it was revealed
that her chances of recovery were good in
the early stages of her illness. At the start of
her illness in 1999, more than 30(!) differ-
ent physicians – the majority of whom were
alternative practitioners – were involved in
treating her. Many of the practitioners, in-
cluding a Dutch faith healer known by her
stage name ‘Jomanda’, repudiated the di-
agnosis of breast cancer. They referred to a
‘bacterial infection’, ‘fibrositis’ or a ‘reaction
to silicone breast implants’. These ‘thera-
pists’ then provided her treatments such
as salt therapy, electro-acupuncture and
magnetic field therapies. These all failed to
produce results, resulting in a medical event
and death which an oncologist described as
‘mediaeval’.
What made the case more complicated
was that Millecam rejected conventional
treatment comprising surgery and chemo-
therapy from the start of her illness.She had
observed the side effects of chemotherapy
among her circle of friends and she herself
wanted to avoid this. A second salient detail
is that a number of the alternative practitio-
ners were also doctors. Their title of Doctor
of Medicine instilled in Millecam trust in
the alternative treatment. ‘He is a doctor, so
it should be fine,’ was the way she looked
at it.
The Netherlands Healthcare Inspectorate,
an organisation associated with the Minis-
try of Health which supervises the quality
of health care, conducted an extensive in-
vestigation into the course of events sur-
rounding her treatment and published an
exceptionally detailed report (IGZ 2004),
which incidentally raises a number of in-
teresting privacy concerns. Three doctors
were called to account by the Disciplin-
ary Committee for the Healthcare Sector,
which assesses the professional competence
of physicians. Following an appeal, two of
the physicians permanently lost their title
‘Doctor of Medicine’. A third physician was
suspended for one year.
Apart from the Disciplinary Commit-
tee, the case was also handled by the Pub-
lic Prosecution Service, which found that
criminal errors had also been made as well
as medical and professional errors by the
practitioners treating Millecam. Following
countless legal proceedings, in December
2010 two doctors were sentenced to three
and six-week suspended prison sentences.
The court found sentencing advisable ‘in
view of the seriousness of the facts and the
consequences thereof, and in view of the
importance of marking standards, not only
by means of adjudication but also through
punishment’. Faith healer Jomanda, howev-
er, was acquitted because the court deemed
that it had not been proven that she had
dissuaded Millecam from undergoing con-
ventional care, nor had she left Millecam in
a helpless state.
Freedom of choice
Sylvia Millecam’s tragic death created a great
deal of social unrest in the Netherlands and
spurred social debate that continues to this
day. Her death provoked a turning point
in the debate about alternative and con-
ventional medicine. Since that time, it has
in fact become clear that the often-heard
words ‘it doesn’t hurt to try’no longer holds
true. Alternative methods of treatments can
actually inflict harm, simply because of the
fact that they may cause patients to miss out
on meaningful conventional treatments, or
they could delay the start of such treatment.
Numerous people have therefore become
more critical of alternative practitioners.
Following the disciplinary and criminal
court judgements, an important standards
and legal framework was developed for the
acts of alternative practitioners. Yet these
judgements have not curtailed a patient’s
right of self-determination in choosing his
or her own healthcare provider: after all,
patients will always retain leeway to ap-
proach an alternative practitioner. But the
leeway for alternative practitioners, both
physicians and non-physicians, has been
more clearly defined: they must inform
patients correctly about the effectiveness
of their treatment and distinguish clearly
between conventional and alternative treat-
ments. Practitioners are also not permitted
to blindly concur/agree if the patient refuses
to face the facts. If the patient clings to an
illusion, practitioners must endeavour to re-
fute the illusion and point out to the patient
the importance and necessity of undergo-
ing conventional treatment. If need be, the
practitioner should sever the treatment rela-
tionship. The refusal of patients to undergo
Physicians and Alternative Methods of
Treatment:Do They Go Together?
Gert van Dijk
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NETHERLANDS National and Regional news
conventional treatment does not grant al-
ternative practitioners a licence to practise.
The reason primarily being the vulnerability
of patients suffering from a life-threatening
disease.The position of such patients makes
them grasp at straws all too easily.The court
stated in its judgement that ‘freedom of
choice no longer applies in such a vulner-
able situation’.
The Millecam case raises a number of im-
portant questions, i.e. how much leeway
do physicians still have in diverging from
the professional standard, and what should
physicians do with patients who reject con-
ventional medicine? Partly prompted by the
Millecam case, the Royal Dutch Medical
Association published guidelines in 2008
which were preceded by substantial debate
in the medical profession.
What are alternative and
complementary treatments?
The terms ‘alternative treatments’ and ‘com-
plementary treatments’ are catch phrases,
covering over three hundred different meth-
ods of treatments. A number of these meth-
ods of treatment claim to employ a ‘holistic
concept of mankind’,which revolves around
the patient as a whole rather than the spe-
cific illness. Other methods of treatment,
such as chiropraxy, place less emphasis on
this aspect. Some forms of treatment, such
as bioresonance therapy, acupuncture and
homeopathy, conflict with empiricism, the
biological principles or the laws of physics.
Homeopathy,for instance,assumes that wa-
ter has a ‘memory’which is capable of spur-
ring the body to self-heal. Many alternative
treatments are based on various, conflicting
effectiveness principles. Homeopathy, for
example, assumes extreme dilution, while
orthomolecular medicine in fact uses high
dosages of vitamins and dietary supple-
ments. Some forms of treatment are harm-
less from a medical point of view, such as
homeopathy, which is chemically identical
to the solvent, generally water or alcohol.
Other forms of treatment, such as chelation
therapy or herbal therapy, may cause life-
threatening complications, or interfere with
regular treatments, such as anti-conception
or chemotherapy. Many alternative forms
of treatment lay claim to an aura of ‘natu-
ralness’, even though a description of what
this means is rarely given.All things consid-
ered, alternative or complementary forms of
treatment do not have much in common –
except that there is no scientific proof of
their effectiveness, and for that reason they
are not accepted by conventional medicine.
The main difference between conventional
and alternative forms of treatment is that
conventional medicine seeks to work in line
with the requirements of evidence-based
medicine (EBM). This implies that physi-
cians are guided by the state of the art in
medical science, combined with their clini-
cal expertise, including taking account of
the patient’s expectations, wishes and ex-
periences. Many alternative practitioners
claim that their forms of treatment cannot
be scientifically substantiated because they
work in accordance with a ‘different para-
digm’ or because each patient is different,
and for that reason randomised trials can-
not be conducted. In recent years this line
of reasoning seems to be waning, and alter-
native practitioners are similarly claiming to
employ evidence-based working methods,
and referring to ‘evidence-based comple-
mentary and alternative medicine’ (EBM-
CAM). Despite the purported scientific
proof thereof, alternative practitioners gen-
erally attribute the fact that these forms of
treatment do not belong to conventional
medicine, to ‘conservatism’ or ‘pharmaceuti-
cal industry interests’.
Conventional medicine has always heavily
criticised the term ‘alternative medicine’.
After all, there is no such thing as ‘alterna-
tive physics’ or the ‘alternative legal profes-
sion’. Who in their right mind would board
an aircraft if the pilot were to use alterna-
tive methods to steer the aircraft? And, if
the non-conventional practitioners were to
actually offer alternatives, why are they not
conventional? Moreover, numerous conven-
tional practitioners hold the view that it is
dangerous to suggest that alternative forms
of treatment exist for serious illnesses. To
avert these issues, nowadays alternative
practitioners prefer to talk about ‘comple-
mentary treatments’ to suggest that these
forms of treatment should be viewed as be-
ing supplementary to conventional medicine,
and not as an alternative for the latter.
The term ‘complementary’ too, however, is
subject to criticism. Astrology is also not
‘complementary’ to astronomy, is it? And, if
such medicine can only be complementary,
does the term ‘medicine’still apply? For that
reason the Royal Dutch Medical Associa-
tion KNMG would prefer to refer to ‘non-
conventional forms of treatment’, versus
‘conventional forms of treatment’ (KNMG
2008). Since it is uncertain whether these
treatments also actually cure an illness, the
term ‘form of treatment’ is more neutral
than ‘treatment’. According to the defi-
nition applied by KNMG, conventional
forms of treatment are ‘the forms of treat-
ment based on the knowledge, proficiency
and experience required for the purpose of
obtaining and retaining the title of Doctor
of Medicine, which is generally accepted by
the medical profession and forms part of
the professional standard’ (KNMG 2008).
In other words: conventional medicine is
what physicians who practice conventional
medicine do. This also includes experimen-
tal forms of treatment, the effectiveness of
which still is subject to medical and sci-
entific research, to the extent these have
been tested within the statutory assessment
framework. ‘Non-conventional forms of
treatment’are those forms of treatment that
fall outside the scope of the above defini-
tion. The nature of the definition is purely
procedural, and says nothing about any
methods or concepts of mankind embraced
by the various forms of treatment. The ad-
vantage of the above definition is that it
is neutral, and does not lay down for once
and for all what definition should be ap-
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NETHERLANDSNational and Regional news
plied to conventional medicine. This leaves
open the possibility for incorporating in the
professional standard certain treatments,
which initially were non-conventional, if
it emerges that there is sufficient scientific
proof thereof. Another advantage of such a
neutral definition, which avoids words such
as ‘alternative’ or ‘complementary’, is that it
does not make a statement on the value or
position of alternative forms of treatment.
Legal situation
The Individual Healthcare Professions Act
(Wet op de beroepen in de individuele gezond-
heidszorg, BIG) dating from 1999 regulates
the competence of a wide range of health-
care providers in the Netherlands. In addi-
tion to safeguarding a patient’s freedom of
choice, the key objective of the Act is to en-
sure and monitor the quality of healthcare
provision. A third objective is to protect the
patient against incompetent and improper
conduct by a healthcare provider.According
to the BIG Act anyone is allowed to prac-
tice medicine. The performance of certain
medical acts (such as obstetric and surgical
treatments, punctures, injections and anaes-
thesia) is the preserve of specific profession-
al practitioners. In the Netherlands, making
a medical diagnosis is not an act reserved
for a specific group of practitioners, and it
therefore may be performed by anyone. Be-
cause alternative treatments are not the pre-
serve of a specific professional practitioner,
alternative treatments may be administered
by physicians as well as non-physicians.
Medical disciplinary rules only apply to
professions protected by the BIG Act, such
as doctors and nurses. Alternative practitio-
ners who do not hold a protected title, such
as that of a Doctor of Medicine, fall out-
side the scope of the medical disciplinary
rules. They also do not need an official reg-
istration. Since the BIG Act is also geared
towards the patient’s freedom of choice, a
situation has arisen in which extremely
stringent requirements are imposed on phy-
sicians but where non-physicians virtually
have free rein. They also do not carry a title
protected by law,and consequently also can-
not be discharged from their duties – un-
like physicians. The Healthcare Inspector-
ate does not have any tools for intervening
in the practices of alternative practitioners.
Consequently, in day-to-day practice it has
proven to be extraordinarily difficult to take
legal action against alternative practitioners,
partly because patients often find it diffi-
cult to file a complaint. Moreover, it often
is difficult to prove that the treatment has
inflicted harm on patients.
The legal situation in which everyone is per-
mitted to practice medicine, barring medi-
cal acts reserved for specific practitioners, is
not unique to the Netherlands but occurs in
other Northern European countries as well.
In many Southern European countries,only
physicians are permitted to practice medi-
cine.
Seven percent of the Dutch population
is estimated to visit a non-conventional
practitioner who is not a physician (Statis-
tics Netherlands StatLine database 2007).
Countless people do so for ‘harmless’ ail-
ments, such as the common cold or for
chronic complaints, such as rheumatism or
arthrosis for instance. For more serious ail-
ments, the conventional physician appears
on the scene.There are few people who sole-
ly undergo alternative treatment. A declin-
ing number of Dutch physicians (currently
estimated to be less than one thousand) ap-
ply non-conventional forms of treatment
themselves, usually combined with a con-
ventional practice.
The professional standard
Physicians are required to comply with
the ‘medical professional standard’, which
means: ‘to act with due care in accordance
with the knowledge of medical science and
experience as a reasonably competent phy-
sician in the same medical category, in the
same circumstances with medicines that are
reasonably proportionate to the concrete
treatment objective’ (Netherlands Health
Law Handbook 2000, 41-2, Handboek ge-
zondheidsrecht). The definition that applies
to the above has become increasingly clear
from case law in recent years, as well as how
much leeway physicians still have in apply-
ing alternative treatments.
The first key requirement imposed on
physicians is that each medical treatment
should be based on a conventional diagno-
sis, which must be conducted in the ‘proper
manner’. Physicians are therefore not per-
mitted to begin a treatment ‘out of the blue’,
nor are they permitted to use non-accepted
diagnostic methods. ‘Bioresonance tests’
or ‘vega testing’ are therefore off limits for
physicians.
Once a conventional diagnosis has been
performed, physicians are only permitted to
apply treatments for which a medical indi-
cation exists. There must also be a concrete
treatment objective. For instance, a physi-
cian is therefore not permitted to prescribe
chemotherapy if there is no indication for
doing so, or if this does not, or no longer
serves a purpose. The concrete treatment
objective may obviously also be palliative
care, or removing or relieving the existential
pain suffered by the patient.
According to the rules of evidence-based
medicine (EBM),the treatment indicated at
a certain point in time, is determined by the
state of the art in medical science, the clini-
cal experiences of the medical profession
and the patient’s wishes and expectations.
The professional standard may incorporate
several treatments for a specific diagnosis.
As a rule, the physician will focus on the
treatment that will yield the best results,
having the least burden on the patient. If a
medical indication exists for several treat-
ments, the choice is determined in a meet-
ing between the physician and the patient.
As stated, evidence-based medicine is
founded on three underlying pillars: proof,
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NETHERLANDS National and Regional news
experience and the wishes and expectations
of the patient. The patient’s wish can thus
never form an adequate reason for adminis-
tering a treatment.The fact that a patient has
asked for a particular treatment or the fact
that a patient has consented to a particular
treatment, does not discharge the physician
from his duty to assess the indication and
determine whether a particular treatment
would be meaningful from a medical point
of view. A physician who is confronted with
a patient asking for chemotherapy while
there is no medical indication for doing so,
or in cases where concrete treatment results
cannot be expected based on the state of the
art in medical science, is not permitted to
comply with the patient’s wish. Even if a
patient requests a futile medical treatment,
such as injecting soda into tumours, the
physician is not permitted to comply with
the request.
The aspects incorporated in the professional
standard at a certain point in time have not
been set in stone, and there are always grey
areas too where physicians do not agree with
the prescribed treatment. The professional
standard consequently is not a mandatory
rule or ‘cookery book medicine’. Each pa-
tient is different, and each situation requires
another solution. Physicians therefore defi-
nitely have the necessary leeway to diverge
from the professional standard. If they do
so,they must be able to justify to their peers,
the patient and society as to why they chose
to diverge from the standard.Proper records
and informed patient consent are vital in
this context.
Physicians and alternative
treatments
There are patients like Sylvia Millecam,
who reject conventional treatment and wish
to undergo alternative treatment – even if
they are suffering from a serious disorder.
What should physicians do in such cases?
Physicians should be the first to earnestly
point out the consequences to the patient
if they wish to be treated by an alternative
therapist. They are required to continuously
highlight the need for conventional treat-
ment. In the Millecam case the alternative
healers stated that Millecam herself had re-
fused conventional treatment and they felt
that this served as a licence for them to ad-
minister their treatments. In the Millecam
case, the Disciplinary Committee, however,
stated the following in respect of the above:
‘A physician can no longer provide a person
alternative treatment with impunity if the
patient proves to need help which clearly
can only be provided in conventional medi-
cal circles.’ If conventional treatment exists,
physicians are not permitted to simply ig-
nore it. And if the patient refuses conven-
tional treatment, this should not serve as
a licence permitting physicians to offer all
kinds of non-conventional treatments. Af-
ter all, by doing so they wrongfully raise
the patient’s hope and expectations. The
Amsterdam Court of Justice formulates the
above as follows:
“The law gives precedence to the well-in-
formed patient’s right of self-determination.
This does not mean to say, however, that the
physician or the party providing individual
healthcare does not carry any further re-
sponsibility. If he is asked to provide insight
into the motives underlying his choice for
applying a certain method of diagnostics or
therapy, it will not suffice for the physician
or healthcare provider to refer solely to the
wish expressed by the patient.’
Another aspect that has emerged from the
Millecam case is that patients have faith
in the title of Doctor of Medicine. ‘He is a
doctor, so that should be fine,’ Sylvia Mil-
lecam’s doctors were insufficiently aware
of that fact. Physicians must at all times
understand that their title of Doctor of
Medicine carries a certain authority with it.
This imposes heavy demands on what they
advise and offer the patient. As the Disci-
plinary Committee stated in the Millecam
case: ‘A physician, who also practices in the
domain of alternative medicine, is thus not
discharged from acting in the capacity of a
physician.’ The KNMG formulates this as
follows: ‘Physicians are constantly aware
that the diagnostics, methods of treatments
and advice they offer revolve around the
authority of the medical doctor/medical
specialist education programme and the
title of Doctor of Medicine or Medical
Specialist.’
Are physicians allowed
to offer alternative
methods of treatment?
Coming to the key question: are physicians
still permitted to apply alternative treat-
ments, such as homeopathy or acupunc-
ture? Clearly, such treatments may only be
administered under very strict conditions.
Doctors should always first ask themselves
whether conventional treatment exists for
the relevant diagnosis, and advise the pa-
tient thereof. After all, according to the
KNMG rules of conduct ‘the doctor is not
permitted to apply treatments and disregard
generally accepted diagnostic and treatment
methods in the medical world’. The doctor
must provide clear information to patients
about the nature of their illness. The doc-
tor must also make clear to the patient what
the consequences are of not undergoing
conventional treatment. But even if there
is no conventional treatment, or this no
longer exists, or if the patient rejects such
treatment, the doctor cannot simply offer
all kinds of treatments, the benefit of which
has not been proven. Patients who are dying
or whose treatments have finished are still
required to be treated in accordance with
the professional standard. After all, atten-
tion, comfort, pain control and palliative
care fall within the scope of conventional
medicine.
Furthermore, doctors must at all times
avoid inflicting harm on the patient when
providing non-conventional treatment.
Harm is more than simply immediate
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ISRAELNational and Regional news
medical damage caused by the treatment
itself. When providing conventional treat-
ment, the benefit of the treatment always
counters harm. That benefit has not been
proven in non-conventional treatments,
which makes it more difficult to justify
any harmful effects. Harm is also inflicted
if the doctor offers false hope of improve-
ment, or recovering from the complaints.
And if, as a result of the non-conventional
treatment, the patient does not start un-
dergoing a meaningful conventional treat-
ment or does so too late (doctor’s delay),
this is also viewed as inflicting harm. The
doctor is likewise not permitted to provide
misleading information about the effec-
tiveness of the non-conventional treatment
or substitute a conventional diagnosis for
a non-conventional diagnosis. Doctors are
also not permitted to attribute a thera-
peutic effect to a particular treatment if
this has not been scientifically proven.
The proof must be stronger than the evi-
dence of a certain method. Stating that it
has been proven that homeopathy works,
therefore will not suffice. So, this rules out
‘there is scientific evidence that homeopa-
thy works’. A statement of this nature is as
meaningless as the statement saying that
‘there is scientific evidence that conven-
tional medicine works’. Doctors will have
to specify what scientific evidence exists
for a particular treatment and a particular
dosage for a particular indication.
All in all, the leeway doctors have in apply-
ing non-conventional treatments therefore is
not that large. And that leeway will probably
become even smaller with the continued pro-
tocols and professionalisation of the profes-
sion of medical doctor,and the continued ad-
vancement of EBM. EBM will undoubtedly
prove that parts of conventional medicine
will likewise not prove to be meaningful, and
they will be deleted from the professional
standard as a result. That is what progress
is all about. The scientific underpinning of
other parts of conventional medicine will see
further improvement,and that will only serve
to enlarge the gap between non-convention-
al and conventional methods of treatment.
Continued scientific research may possibly
also show that certain non-conventional
treatments are effective, and they will be in-
corporated in the professional standard as a
result. But many non-conventional methods
of treatment will end up in the circular files
of history – joining the countless others that
havebeenlaidtoresthere.Thattooisprogress.
References
1. Biesaart M, Hubben JH. Strafbepalingen en
tuchtrecht: Wet BIG beschermt burger onvoldoende.
Med Contact 200;58 (26/27).
2. Dijk, G. van, Legemaate, J. Alternatieve be-
handelwijzen na Millecam, Med Contact,
No. 20-20 May 2010, pp. 900-903.
3. Facts and figures on alternative methods of
treatment. In: Raad voor de Volksgezondheid
& Zorg. Medische diagnose: achtergrondstudies.
Zoetermeer: RVZ; 2005.
4. KNMG rules of conduct: de arts en niet-reguliere
behandelwijzen (April 2008) (www.knmg.nl).
5. Amsterdam Court of Justice Decision dated
9  April 2008 on the complaint with applica-
tion numbers K06/1685 and K06/1886. Can be
found on .
6. Amsterdam Court of Justice, LJN: BI7445, Dis-
trict Court of Amsterdam, 13/412172-08,
7. 12 June 2009. LJN: BI7422, District Court of
Amsterdam, 13/412169-08,
8. 12 June 2009.
9. Amsterdam Court of Justice, LJN: BO7708, 23-
003451-09, 16 December 2010.
10. IGZ. De zorgverlening aan S.M. Een voorbeeld-
casus. The Hague: Healthcare Inspectorate; Feb-
ruary 2004.
11. Leenen HJJ. Handboek gezondheidsrecht, Deel
I Rechten van de mensen in de gezondheidszorg.
Houten/Diegem; 2000.
12. Regional Disciplinary Committee for the
Healthcare Sector in Amsterdam, appeal dated
7 April 2006 against three doctors in the Mil-
lecam case.
13. Renckens C. Kwakzalvers op kaliloog. Amster-
dam: RVZ; Prometheus; 2000.
14. RVZ. Kiezen voor deskundigheid. Zoetermeer:
Raad voor de Volksgezondheid & Zorg; 2005.
15. Renckens CN, van Dam FS, Koene RA. Severe
disciplinary measures in the Millecam case: impor-
tant precedent for revising the rules of conduct by
scientific associations and the KNMG. Ned Tijd-
schr Geneeskd. 2006 Aug 19;150(33):1847-51.
(Article in Dutch).
Gert van Dijk,
Royal Dutch Medical Association, Utrecht;
Erasmus Medical Centre, Rotterdam
E-mail: e.van.rijs@fed.knmg.nl
After a long and complex struggle,a ground-
breaking agreement was reached, one that
will greatly benefit public medicine.
Deterioration of the
Israeli Health System
In November 2010, the Israeli Medical
Association (IMA) officially began nego-
tiations with the Israeli Treasury to discuss
ways to improve the deteriorating health
system. The IMA negotiated on behalf of
17,000 doctors employed in public hospitals
and clinics. Unfortunately, after months of
negotiations, little progress was made.
In early 2011, the Israeli Medical As-
sociation (IMA) publically announced
the launch of “a mission to save public
medicine,” demanding additional man-
power, more beds in hospitals, an increase
in physician salaries in the periphery and
incentive pay for doctors working in spe-
cialties suffering from physician shortages.
A Mission to Save Public Medicine
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ISRAEL National and Regional news
Dr.  Leonid Eidelman, IMA President,
reported that a doctor’s basic gross wage
(without overtime and duty work) is only
NIS 42 per hour (approx $12) and should
be raised by 50%.
Warning Strike
On the 3rd
April, the IMA announced a
2-day warning strike, emphasizing that al-
though we did not want a strike that could
harm patients, to remain silent at this time
would be akin to abandoning future pa-
tients.
Dr. Eidelman stated: “For the past ten years
we have worked with the government agen-
cies to warn them about the biggest problems
in public health. For ten years, we spoke with
anyone who would listen, but have seen noth-
ing done. Last year, when we realized that the
situation was escalating, and soon we will not
be able to provide the appropriate treatment
for our patients- we decided to act more deci-
sively against the Treasury. After months of
negotiations, I regret to say that the Treasury is
not interested in improving the health system,
whether by adding hospitals beds, by adding
positions for physicians, or by providing in-
depth treatment to existing problems.”
The warning strike operated in all the pub-
lic health system facilities in the country.
Hospitals operated with a skeleton staff, as
they do on the Sabbath. Negotiations and
sanctions continued throughout the months
of March and April, but no agreement was
reached.
Physician demonstrations
and sanctions
After reaching a stalemate in discussions
with the Treasury, on the 27th
April physi-
cians staged a large demonstration: approxi-
mately 2,500 physicians, medical students
and supporters assembled in Jerusalem op-
posite the Israeli Parliament to protest the
government’s failure
to effectively address
Israel’s collapsing
public health system.
Medical students
from all four medical
schools in the coun-
try also took on the
cause, with around
a thousand students
transported from
their various univer-
sities to the capital in
order to protest. The
students declared
a strike and classes
were cancelled for the day.
Further protests in support of the phy-
sicians struggle were staged during the
months of April and May, at the Tel Aviv
annual marathon, on Israeli Indepen-
dence Day and on the Jewish festival Lag
B’Omer. This day is typically celebrated by
lighting bonfires, and the IMA held a mass
rally under the slogan “Doctors are unwill-
ing to continue putting out fires.”Approxi-
mately 1,500 doctors, interns and medical
students attended the rally, threatening to
heighten the protest and announcing that
on the 1st
July they will start to ‘work by
the book’.
The IMA gave employers and the Trea-
sury 6 weeks’ notice, stating that if an
agreement were not reached, doctors in
the public health care system would start
to work in literal agreement with cur-
rent contracts and collective bargaining
agreements, regarding issues such as work
hours and on duty shifts. These issues
are rarely literally implemented or en-
forced due to a lack of medical manpower.
Despite an ongoing series of sanctions and
protests launched by the Israeli Medical As-
sociation,negotiations with the government
on public health reform and increased wag-
es for physicians remained unsuccessful. Al-
though inconvenienced, public support for
the physicians ran high as people recognized
that the system was in vital need of repair.
Other than several days of general strikes,
sanctions during this period were inter-
spersed between hospitals and ambulatory
clinics, and the North and South of the
country, so as not to cause undue hardship
to any patient. In addition, throughout the
strike, the IMA’s “exception committees”
worked to ensure that all urgent medical
needs were addressed. The committees ap-
proved more than half of the requests for
treatment presented by patients and their
doctors. Physicians continued to treat all
patients in life-threatening situations, even
on days of full sanctions.
Appeal for Injunction
At the end of May,the Ministries of Health
and Finance appealed to the Tel Aviv Dis-
trict Labour Court, requesting that it issue
an injunction banning the Israeli Medical
Association and doctors working in public
hospitals from further work stoppages. On
the 2nd
June, the court rejected the State’s
petition. The court accepted a compromise
proposed by the IMA, by which the doc-
tors would limit their labor sanctions. The
court also ordered the parties to conduct
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ISRAELNational and Regional news
intensive negotiations for two weeks, after
which they would notify the court of their
progress. Judge Michael Spitzer told the
Ministry of Finance that there was no case
for an injunction, since the doctors had not
completely shut down the health system,
and the strike was considered proportion-
ate.
For three weeks in June the IMA held in-
tensive negotiations with theTreasury under
the auspices of the National Labour Court
President. At the request of the Court Pres-
ident, the process took place behind closed
doors. Partial agreements were reached on
several issues; however, there were still ma-
jor points of contention between the parties.
Work by the Book
On the 1st
of July, doctors began to “work
by the book”, according to which residents
worked only 6 night and weekend shifts per
month, instead of the 10-12 which some
were working. They worked shorter shifts
and left the hospital after completing the
handover of their patients. Specialists who
were not listed for shift work left the hospi-
tals by 16:00 (except during a medical emer-
gency) and did not take on additional work
without remuneration. Out of responsibility
to patients the IMA continued to run the
exceptions committees to deal with appeals
from patients who required urgent care.
Despite the fact that doctors had provided
advance warning, the Ministry of Finance
and Employers made no effort to prepare in
advance or to negotiate matters that would
end the crisis. Dr. Eidelman, reported
“We are conducting a fierce struggle to save the
public health care system.We were disappointed
with the conduct of the Treasury, who refuses
to reach an agreement that will bring about
health care reform. Now everyone will see the
outcome if we work according to contracts and
regulations. Unfortunately, if we do not take
this step today and show decision makers what
happens when there are not enough doctors and
positions for doctors, we will find ourselves in
this reality in the future.”
The National Labour Court threatened to
issue restraining orders against the physi-
cians, as requested by the state, unless an
agreement was reached. On the 24th
July,
after 15 hours of deliberations, the La-
bour Court announced that they accepted
the position of the IMA, and rejected the
employers’ requests for injunctions and the
imposition of arbitration on the parties.The
court declared that the sanctions which the
IMA imposed have been reasonable and
proportionate and therefore do not justify
an order for an injunction.
The IMA was happy with this decision,
which meant we could continue to fight to
save the public health system.
Hunger Strike and
March to Jerusalem
The following day, on the 25th
July, the IMA
held a press conference at which Dr. Eidel-
man called upon the Israeli Prime Minister
and Health Minister, Benjamin Netanyahu,
to intervene in the dispute. Dr.  Eidelman
took leave from his hospital and began a
hunger strike, which he declared he would
not stop until the end of the conflict. He
requested that his colleagues not join him
in the hunger strike, so that they could con-
tinue to responsibly care for their patients.
Concurrently, Dr. Eidelman began a 4-day
walk from the IMA offices in Ramat Gan
to the Prime Minister’s office in Jerusalem.
Following police instructions, he walked
with a small group of about 20 doctors each
day,so as not interfere with traffic.Through-
out the week, protest marches were held at
local hospitals and among community phy-
sicians across the country. Dr Eidelman ar-
rived in Jerusalem on Friday 29th
July where
he set up a tent outside the Prime Minister’s
office.
134 days after the physicians declared a
labor dispute and following months of ne-
gotiations, there was still no agreement. On
the 31st
July, Dr. Eidelman met with Presi-
dent Shimon Peres. President Peres prom-
ised that he would speak with the political
leadership in order to try and reach a solu-
tion to the deadlock in negotiations. Dr Ei-
delman restated his call for Netanyahu to
personally intervene.”
“We were deeply honored to be hosted at the res-
idence of the country’s number one citizen. But
it is not honor that we are looking for; we are
looking for a solution to the problems plaguing
the public health system. We need more doctors
to treat our citizens,” Dr.  Eidelman stated.
Later that day, approximately 3,000 doctors
and residents again protested opposite the
Israeli Parliament, demanding a solution to
the crisis in the health care system. Despite
pleas from government officials and fellow
doctors to end his hunger strike, Dr. Eidel-
man stated that he would continue until an
agreement was reached.
Following the demonstration, the protesters
marched to the Prime Minister’s residence,
where Dr.  Eidelman presented a petition
with more than 30,000 signatures calling
for a solution to save the public health sys-
tem in Israel.
A most moving display of support afforded
Dr. Eidelman by many in the government
occurred on the 2nd
of August, when he was
greeted by a rousing standing ovation at a
meeting of the health lobby in the Parlia-
ment.
Breakthrough in Negotiations
On the 3rd
of August, a breakthrough was
achieved in the discussions between the
IMA and the Ministry of Finance. The
state agreed to add 1,000 staff positions for
doctors in hospitals, effective immediately.
The 1,000 job slots would be fixed in the
wmj 5 2011.indd 184 9/26/11 4:25 PM
185
National and Regional news
agreement and would be in addition to al-
locations to expand the number of hospital
beds within the next few years. The state
also agreed to grants of up to 300,000NIS
(approximately $83,000) for doctors who
move to the periphery or transfer to spe-
cialties where there is a manpower short-
age. In addition, the number of night and
weekend shifts of 26 consecutive hours
would be reduced to six per month. Follow-
ing this breakthrough, Dr. Eidelman, ended
his hunger strike, which had begun 10 days
earlier.
With hope to end the dispute, and follow-
ing a hearing in the High Court of Justice,
the Treasury and the IMA entered into ac-
celerated and intensive negotiations in or-
der to deal with the remaining issues. The
IMA also agreed to cancel the work sanc-
tions scheduled for the beginning of the
next week. Dr. Eidelman reiterated that the
struggle was not over and that many issues
still remained on the agenda.
Week-long Mediation
At a High Court hearing on the 15th
Au-
gust, after another week of intensive but
ultimately unsuccessful negotiations, the
parties agreed to adopt the recommenda-
tion of the Court and enter into mediation.
The IMA accepted this on the condition
that the mediation would be limited to one
week only, over the course of which public
health care institutions would continue to
strike.
The parties agreed that the mediation would
include only a few issues, about which an
agreement had not yet been reached:
1. Cost of the agreement
2. Distribution of the agreement
3. Duration of the agreement
4. The requirement that doctors clock in
and out for shifts.
An Agreement is Reached!
After more than five months of a difficult
and complex struggle, marked by intensive
negotiations, on Thursday the 25th
Au-
gust 2011 a breakthrough agreement was
signed.
The Israeli Medical Association and rep-
resentatives of the Treasury signed a new
collective bargaining agreement, which will
change the face of the public health system.
Under the agreement, there will be signifi-
cant additions to the health care system,
including:
• The addition of more than 2.5 billion NIS
in funding
• 1000 new doctor positions in public hos-
pitals
• A limit to the number of resident on-call
shifts: 6 a month
• Salary increases between 32%–80%
• 49% increase in average hourly wage
• Very significant salary increases for doc-
tors working in the periphery, and a one-
time grant of 300,000 NIS for doctors
who move to the periphery
• Salary supplements and special grants for
doctors who choose to work in specialties
with a severe shortage, of up to 300,000
NIS
• 20% of the increases will go into effect
immediately, and 70% will be phased in
over the next 3 years.
Dr. Leonid Eidelman, President of the
IMA stated: “We set out to bring about change
in public medicine in Israel and I’m proud to
say that we achieved the goal.
The road was not easy. But throughout the
journey we believed in ourselves and the im-
portance of the goal we set.
In fact, the change we made to the concept, that
those who work more will get more, and those
who invest more in public medicine will earn
significantly more, will assure that the people of
Israel will receive a better quality of medicine
in a more equal health system.
It is important for me to thank the multitudes
of doctors who persevered with the demonstra-
tions and took an active part in the long fight.
I also send my thanks and deep appreciation to
the Israeli public and patients, who stood be-
hind the doctors and showed us their support
and tolerance. You have given us the power to
bring about a real change.”
Dr. Leonid Eidelman,
President of the
Israel Medical Association
There are many definitions and attempts to
describe united Europe. No doubt the most
important features of this unique consolida-
tion are sense and wisdom. Created in 1990
by doctors from the 12 member states, the
European Medical Association (EMA) was
established as an “international association
pursuing a scientific aim” according to the
Belgian law dating 25/10/1919. Now we
have members in all European countries
and many doctors from non-European
countries are interested in our initiatives.
Twenty years later, the concept of Europe
has evolved, and the free movement of
people and services is a reality. We have all
become more aware of the need for the op-
timisation of our resources, including in the
field of health care.
European Medical Association
Future Dimensions of Medicine and Wellbeing
wmj 5 2011.indd 185 9/26/11 4:25 PM
186
European Medical Association
The role of associations such as EMA, that
facilitate the creation of networks and profes-
sional collaborations are growing at fast pace.
The European Union, with its 5th
, 6th
, and
7th
Framework Program has given more and
more space to research, patient’s safety and
economic evaluation of healthcare.
Many projects, ranging from undergraduate
to postgraduate education, from training of
medical translators to paediatricians, from
predictive medicine to medicine and mete-
orology have been carried out and others are
still underway. A complete list of projects is
available on the EMA website.
EMA is a non-profit association free of any
political, linguistic, ethical, philosophical or
financial interests; it is aimed at all doctors
in the EU confronted with a new concept
of European healthcare and offers the op-
portunity to be part of a European network
of doctors.
EMA’s mission is to be a service association;
to create an interactive network; to support
doctors who decide to practise in another
Member State; to encourage and promote
European projects; to collect and distribute
information on:
• The medical structure of universities,hos-
pitals, etc.
• Doctor’s associations
• Specialist medical centres in Europe
• Healthcare legal aspects
• Medical ethics in the Member States
• Therapeutic protocols
• European medical jour-
nals
• Training centres in Eu-
rope
• Congresses and scien-
tific meetings
Essentially EMA is a fo-
rum that brings together
colleagues working in the
European medical com-
munity which aims at im-
proving information, services, transparency
and above all, encouraging collaboration
and mobility. It’s a privileged meeting place
between East and West.
The purpose of the European Medical As-
sociation is to optimise European scientific
and socio-cultural resources.
EMA’s main objectives are ambitious but
realistic.These are:
1. To boost knowledge and skills to im-
prove medical practice in Europe
2. To influence health policies in line with
practising doctor’s priorities.
EMA is not a union and does not interfere
with actions of existing medical associations
or other professional bodies.
Our philosophy is “Better-informed doctors
make better-treated patients”
EMA’s website (http://www.emanet.org/)
contains information on its activities, his-
tory, legal status, mission, main projects and
its governing body (i.e.: EMA Board of Di-
rectors and National Representatives).
EMA is a forum constantly adapting that
seeks to interpret and respond to the needs
of European doctors and that aims at help-
ing the creation of a European Health
Service which is the real challenge for the
future.
Prof. Lyubima Despotova-Toleva,
Bulgarian representative,
E-mail: desptol@abv.bg;
Dr. Vincenzo Costigliola,
EMA President,
E-mail: vincenzo@EMAnet.org;
contact@EMAnet.org
World Distribution of Physicians (WHO, 2007)
Total Number – 7’500’000
150.708
383.426
844.994
1.624.583
1.869.216
2.810.063
0 1.000.000 2.000.000 3.000.000
AFR
MED
SE ASIA
AMR
WPAC
EUR
Vincenzo Costigliola Lyubima Despotova-Toleva
wmj 5 2011.indd 186 9/26/11 4:25 PM
187
National and Regional news
What is EMASH?
The European Medical Association on
Smoking or Health was founded in 1988
in the premises of the French Medical
Association in Paris under the leadership
of Prof. Paul Fréour. It is registered at the
Prefecture of Gironde, in Bordeaux. It is
quoted in the Yearbook of International
Organizations 2011 (www.uia.org, item
10009). Cost-free membership is open
to physicians, biomedical scientists, phar-
macists, nurses and other health profes-
sionals mainly from European countries,
although health professionals from non-
European countries are welcome as as-
sociate members. It publishes a quarterly
newsletter which is emailed to all its mem-
bers. The newsletter can also be found in
www.hon.ch/emash/.
The aims of EMASH
include:
• no-smoking among health professionals;
• no-smoking policies in health associa-
tions, hospitals and health centres;
• involvement of health professionals in
counselling smokers wishing to quit the
addiction;
• pre- and post-graduate education of
medical students and physicians in smok-
ing control and cessation.
EMASH and WHO
• As a special chapter of the International
Hospital Federation, an NGO in offi-
cial relations with WHO, EMASH is
also in working relations with WHO.
It fully supports the WHO Frame-
work Convention on Tobacco Control
(FCTC).
International contacts and the
EMASH Collaborating Centres
Besides WHO,EMASH maintains contacts
with individual experts as well as with inter-
national and national health bodies which
are active in smoking cessation, prevention
and control, including the World Health
Organization (WHO), the International
Union Against Tuberculosis and Lung Dis-
ease (IUATLD), the International Union
Against Cancer (UICC), the International
Non-governmental Coalition Against To-
bacco (INGCAT), the Society for Research
on Nicotine and Tobacco (SRNT), the Eu-
ropean Network for Smoking Prevention
(ENSP), the International Hospital Federa-
tion (IHF) and the International Network
Towards Smoke-free Hospitals.
Of specific value are the two EMASH
Scientific Collaborating Centres: the
EMASH/Portugal section at the Medical
School, Coimbra, Portugal, and the Insti-
tute of Social Medicine, University of Vi-
enna and its subsidiary,the Vienna Nicotine
Institute. Besides being present in numer-
ous congresses,EMASH has held so far six-
teen international seminars, namely:
1. Health Professionals and Smokers,
Royaumont Abbey (Paris), 21-23 No-
vember 1990;
2. Smoking and Health, Zandvoort (Am-
sterdam), 22-24 November 1991;
3. Economic Issues of Smoking and
Smoking Cessation, Bari (Italy), 22-24
October 1992;
4. The Role of Health Professional Organ-
isations in Anti-smoking Activities,Sit-
ges (Barcelona), 18-20 November 1993;
5. Guidelines on smoking cessation for
general practitioners and other health
professionals, Helsingborg (Sweden),
29 Aug.-1 Sept. 1996;
6. Social and economic aspects of reduc-
tion of tobacco smoking by use of alter-
native nicotine delivery system (in col-
laboration with the UN and the ICAA),
United Nations, Geneva, 22-24 Sep-
tember 1997;
7. Consensus seminar on the role of physi-
cians in smoking cessation, risk reduc-
tion, and nicotine replacement therapy:
the WHY,the WHAT,the HOW.Ath-
ens, 5-7 March 1998;
8. Smokingandsmokingcessation –IUATLD
Congress, Budapest, 12 April 2000.
9. Since 2001, the yearly EMASH/Por-
tugal seminar on Smoking or Health,
which is held in October at the medical
school in Coimbra, Portugal.
EMASH has also received grants from
the EU to carry out international projects:
1) the production of Guidelines on Smok-
ing Cessation for Health Professionals and,
2) Health Professions in Public Education
against Smoking.
Need of the future: treatment
of tobacco dependence
and smoking cessation
WHO’s International Classification of Dis-
eases, in its 10th
edition, classifies the use of
tobacco (F17.2 and 17.3) among the mental
and behavioural disorders due to psychoac-
tive substance use (F10-F19) together with
alcohol, cocaine, opioids and similar drugs.
Although the preventive approaches are
essential and must proceed, consideration
should be given to medical treatment of
smoking which includes therapy and assis-
tance to smokers in giving up the addiction.
EMASH on the WEB
The Health On the Net Foundation, an
NGO from the Geneva Cantonal Hospital
is hosting the present EMASH website, at:
http://www.hon.ch/emash/.
European Medical Association on Smoking
or Health (EMASH)
wmj 5 2011.indd 187 9/26/11 4:25 PM
188
National and Regional news
The Southeast European Medical Forum
(SEEMF) was founded in 2005 by medical
organizations of Albania, Bulgaria, Greece,
and Macedonia as a society of organiza-
tions of physicians from Southeast Euro-
pean countries – neighboring countries with
similar problems. It was later joined by the
medical associations of Slovenia, Bosnia and
Herzegovina, and Ukraine, and the Serbian
Medical Chamber. SEEMF is a legal non-
for-profit entity. It has adopted its Statutes
and is registered under Bulgarian legislation.
This year,four new applications for member-
ship were received and at a Board Meeting
held in September the Forum welcomed its
new members: the Georgian Medical Asso-
ciation, the Medical Association of Kazakh-
stan,the Belarusian Medical Association and
the European Medical Students Association.
Its main purpose is to promote the part-
nership of the medical profession in the
SEEMF region, to discuss common prob-
lems and to find solutions; to enable ex-
change of experience, strengthen the rela-
tions and elaborate common approaches
in all fields of activity of the medical orga-
nizations; to develop continuous medical
education through medical congresses and
other forms of mutual activity; to assist its
members for improvement of their medi-
cal and management-related qualification;
to establish contacts and partnership with
other international organizations.
The SEEMF has so far held 8 Board meet-
ings and as of 2010 it held the first interna-
tional Multidisciplinary Medical congress
which is intended to provide CME and to
update the participants on the latest achieve-
ments of the medical science and practice
in fields related to high morbidity medical
conditions.The first such congress was con-
vened in Bulgaria in September 2010. It fo-
cused on different specialized topics as well
as on Patient Safety and Health Issues and
Health Policies under Conditions of Eco-
nomic Crisis. The Congress received Euro-
pean accreditation. More than 500 partici-
pants from 14 countries attended the event
and presentations were made by outstand-
ing physicians from the region, including
from Turkey and Germany.
The 2nd
International Medical Congress
of SEEMF was held in September, 7–11,
2011, Nessebar (Bulgaria) with participa-
tion of more than 600 participants from 12
countries and prominent representatives of
WMA/WHO.
It was accredited by the European Ac-
creditation Council for Continuing Medi-
cal Education (EACCME) and the Euro-
pean Board for Accreditation in Cardiology
(EBAC) for 18 hours of External CME
credits.
The main Congress topics were four:
• Diabetes and Complications
• Cardiovascular Diseases
• Infectious Diseases
• Oncologic Diseases
The need of such training results from the
fact that cardiovascular diseases, diabetes,
oncologic diseases, chronic diseases are
widespread all over the world and they rep-
resent major health issues for the region of
Southeast Europe from which region were
substantial part of the participants. Car-
diovascular diseases cause 2/3 of the over-
all mortality in the region, another 14% is
due to oncologic diseases. About 10% of
the population suffers from diabetes and its
complications. Another major issue is the
treatment of chronic noninfectious diseases
which consumes considerable resources. It
is necessary that all physicians are aware of
the latest concepts of prevention, treatment
and early detection methods which could
help improve such indicators.The event was
intended for a wide range of participants –
from general practitioners to senior hospital
physicians and managers.
The exceptionally high interest in the
Round Table held during the First Con-
gress and the spontaneous vivid discussion
it evoked obliged the organizers to allocate
some time to similar topics this year as well.
The topic of this year’s Round Table,namely
Health Reforms and Funding, opened a
broad field for discussion and exchange of
experience between the organizations from
the region. The list of speakers grew very
Southeast European Medical Forum
Andrey Kehayov Jovan Tofoski
wmj 5 2011.indd 188 9/26/11 4:25 PM
189
long – everybody wanted to share his or her
views and/or experience. The participants
adopted a declaration which is enclosed.
Two other events that took place during the
Congress are worth mentioning.On the last
day, before the Round Table discussion a
book was presented providing information
about all Bulgarian physicians who have
dedicated their lives both to the medical
profession and to different public functions.
This year SEEMF for the first time award-
ed eminent physicians. Two persons ob-
tained the award of Outstanding Physician
of Southeastern Europe. These were the
well-known Bulgarian cardiosurgeon, Prof.
Gencho Nachev, and the SEEMF Vice
President, Prof. Jovan Tofoski. Dr. Oleg
Musii, president of the Ukrainian Medical
Association, was awarded for his contribu-
tion in the field of healthcare management
and policy, Dr. Stylianos Antypas of the
Panhellenic Medical Association received
award for his efforts directed to health-
care improvement in Southeastern Europe,
Dr. Vladimir Lazarevik received award for
his contribution to the development of
SEEMF. A special award was presented to
the WMA President, Dr. Wonchat Subha-
chaturas, in recognition of his distinguished
contribution to the development of interna-
tional medical collaboration.
A general conclusion was that the Congress
was much more than just professional event,
SEEMF became also a cultural phenome-
non trough which was discovered that we
have to take now every advantage to live and
communicate in a world without political
boundaries. The SEEMF Board is making
all efforts in a spirit of peace, friendship and
collaboration continuously to strengthen
the Forum and moreover to maintain it as
reputable partner to other European and
international associations.
Dr. Andrey Kehayov
Prof. Dr. Jovan Tofoski
E-mail: bulgmed@gmail.com
National and Regional news
189
We, the participants in the Second International Medical con-
gress of the Southeast European Medical Forum, namely phy-
sicians from Albania, Belarus, Bulgaria, Greece, Kazakhstan,
Latvia, Macedonia, Romania, Republic of Srpska – Bosnia and
Herzegovina, Serbia, Ukraine, in the presence of representatives
of the World Health Organization (WHO) and the President
of the World Medical Association (WMA), abiding by the basic
principles and responsibilities of the WHO and WMA, as well
as by the priorities and goals of the unique European Strategy
2020:
1. Shall initiate joint collaboration for promotion of health and
welfare of the citizens from the whole region;
2. Shall work for providing conditions for better quality of life and
higher life expectancy for the people in the region;
3. Shall work for improvement of the healthcare management by
providing expertise, analyses and particular problem solutions
with the ambition for real involvement in the health policy of
the respective countries;
4. Shall contribute to making health a priority for the whole so-
ciety, the authorities, non-governmental sector, citizens, private
companies, academic community and all other stakeholders.
Governments together with healthcare professionals have to recon-
sider correlations between economics and healthcare policies.
Medical organizations should safeguard the interests of all physi-
cians, should be self-governing bodies and quality guarantor, and
should represent and work for the benefit of the profession.
The issue of healthcare funding in the region is very grave,as was indi-
cated by the participants in the Congress, but each country should try
to find solutions according to the specific local situation.What is nec-
essary is adequate and equitably distributed healthcare budget, strong
decisions on the reforms to be carried out, prioritising on investments
in human capital, improvement of its productivity and better use.
It is high time that the Health Ministries and all other ministries
place health issues among the priorities of the politicians and soci-
ety. A basic principle of a democratic and socially responsible state
should be the responsibility for health and the access to healthcare
for all citizens, irrespectively of their ability to pay for medical care.
Nesebar, September 2011
Declaration of the Second International Medical Congress of the
Southeast European Medical Forum
Nesebar, 7–10 September 2011
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190
National and Regional news
Life and governance
of the Federation
HOPE, the European Hospital and Health-
care Federation, is a European non-profit
organisation, created in 1966. HOPE rep-
resents national public and private hospi-
tal associations and hospital owners, either
federations of local and regional authorities
or national health services. Today, HOPE is
made up of 32 organisations coming from 26
Member States of the European Union (EU),
plus Switzerland,covering around 80% of the
hospital landscape. HOPE’s mission is to
promote improvements in the health of citi-
zens throughout Europe, and high standards
of hospital care, and to foster efficiency with
humanity in the organization and operation
of hospital and healthcare services.
HOPE is organised around a Board of Gov-
ernors, a President’s Committee, Liaison
Officers, a network of national coordinators
of the HOPE exchange programme, and a
Central office based in Brussels. The Board
of Governors consists of the President and
of Governors, one from each EU member
state. It is the forum for all major policy
decisions. George Baum, chief executive of
the German Hospital Federation was re-
cently elected President, while Sara Pupato,
head of the National Inter-regional Agency,
was selected Vice President.The President’s
Committee consists of the President, the
Vice-President and three Governors; it
oversees implementation and execution of
the Board of Governors’ decisions, co-or-
dinates the working parties’ work, acts for
HOPE, and authorizes legal representation.
Two specific networks are worth mention-
ing. The network of Liaison Officers was
created to improve and professionalize ac-
tivities. Each Liaison Officer represents his/
her organization and is the permanent link
between each HOPE member and the cen-
tral office as well as with other members.
Liaison Officers facilitate provide infor-
mation or facilitate access to information
in two main areas: information concerning
hospitals and healthcare services in his/her
country; and information concerning the
position of the represented organization on
EU-related issues.This information sharing
requires a strong network of contacts and
expertise on a wide range of topics.
The network of National coordinators of
the HOPE Exchange programme is key
to its efficient development. In 1981, pur-
suant to its objectives, HOPE decided to
set up an Exchange Programme for hos-
pital professionals. One of the basic ob-
jectives of HOPE is to promote exchange
of knowledge and expertise within the
European Union and to provide training
and experience for hospital and healthcare
professionals in this European context.
Originally intended for hospital profes-
sionals the Exchange Programme is now
open to other healthcare professionals and
some countries are already hosting partici-
pants in non-hospital healthcare facilities.
This Exchange Programme aims to lead to
better understanding of the functioning of
healthcare and hospital systems within the
EU and neighbour countries by facilitating
co-operation and exchange of best prac-
tices. The HOPE Exchange Programme
proposes a 4-week training period intended
for managers and other professionals with
managerial responsibilities.
Comparative analysis and
exchange of best practices
Fostering and facilitating the exchange of
information has always been one of the
prominent HOPE objectives. In its 45 years
of existence, Hope has achieved success in
this area in various topics covered though
reports, conferences, and seminars. Most
recently, HOPE has focused on three main
topics: hospital organisation and financ-
ing; quality and patient safety; and care
in border regions. Members are asked for
contributions to activities on some of those
issues. For others HOPE joins forces with
partners, in particular in consortia of EU
financed projects.
On hospital organisation and financing, the
most recent element is certainly the grow-
ing impact of the financial and economic
crisis on healthcare systems in the European
Member States. HOPE published a report
in April 2011 describing national situations.
HOPE also follows several other items.
Pharmaceuticals are high on the agenda. In
2009 HOPE joined as a partner the Phar-
maceutical Health Information System net-
work. Funded by the European Commis-
sion, it aims at increasing knowledge and
exchange of information on pharmaceutical
policies, in particular on pricing and reim-
bursement. It puts also a clear focus on the
hospital sector, seeking to learn more about
pharmaceuticals in hospitals. Another pri-
ority topic is personalized medicine and its
influence on organization and functioning
of hospitals.
HOPE, the European Hospital and
Healthcare Federation
Pascal Garel
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191
BANGLADESH National and Regional news
In the last few years (before 2009), there
were unjustified acts prevailing throughout
the country, which stopped routine promo-
tion of public physicians in the respective
position. Addressing this issue (including
also other ones), the current BMA body
received a landslide victory and started to
implement their promised acts one by one
and part of this; the current body (led by
Prof. Dr. Md. Sharfuddin Ahmed, Secretary
General,BMA) initiated a series of commu-
nication with different relevant stakeholders
including the Government of Bangladesh to
reestablish the withheld promotion for all
posts in health through the Departmental
Promotion Committee (DPC).
The idea was to promote most (around 80%)
of professors, associate professors, assistant
professors and specialized doctors through a
quick inbuilt alternative promotion system,
the DPC,and the rest (nearly 20%) through
a routine bureaucratic, lengthy process, the
Public Service Commission (PSC), which
will certainly provide a lot of encourage-
ment to public physicians. This policy was
finally approved by the country’s powerful
inter-ministerial body. The process activi-
ties were observed in terms of providing a
selection grade and senior scale to track out
doctors. Though the process of promotion
HOPE has various activities patient safety. A
major development took place in the frame-
work of the EUNetPaS project that con-
cluded in 2010.The main goal of this project,
started in 2008 and financed by the European
Public Health Programme, was to establish
an umbrella network to improve cooperation
among Member States in the field of Patient
Safety. The results of the project, including
the analyses and the recommendations on the
implementation of goods practices in medica-
tion safety, were presented by HOPE during
the EUNetPaS final conference in Brussels
on 1 July. As a follow up on this, HOPE was
invited by the European Commission to take
part in a Joint Action on Patient Safety and
Quality of Care. On the basis of its the in-
volvement in the MarQuiS research project,
HOPE started in 2010 its activities on qual-
ity strategies with the project consortium
DUQuE (Deepening our understanding of
quality improvement in Europe), co-funded
by the 7th
Research Framework Programme.
Care in border regions as well as public
health activities are traditional activities
in which HOPE devotes time and energy
through projects and networks. HOPE is
now in the final stage of its EU financed
project EUREGIO II, working on coop-
eration in border regions in the challenging
time of the transposition of the Directive on
the cross-border care.
Representation and influence
HOPE’s representation and advocacy ef-
forts have been of high importance in the
recent years in the context of the political
changes that occurred at European Union
level. The election of a new European Par-
liament in 2009 and the selection of a new
European Commission for President Bar-
roso’s second term has indeed had a strong
impact on the life of those institutions, in
particular within the framework of the 2009
Lisbon treaty. HOPE monitors the Euro-
pean health agenda on a daily basis, build-
ing its relationship with institutions and
other stakeholders, providing technical ad-
vice, and influencing on topics that matter.
There are important developments for
healthcare on the European agenda. Several
significant decisions have been adopted on
cross-border care late payments. HOPE is
also involved in other issues such as the Di-
rectives of the Pharmaceutical Package and
the new initiative “Pilot European Inno-
vation Partnership on Active and Healthy
Ageing”. HOPE also takes an active part
in European debates on patient safety and
quality, medical devices, clinical trials, rare
diseases, eHealth and healthcare workforce.
Those are some of the key issues for which
HOPE has had to be vigilant and quick to
respond and intervene.
As part of its strategy to increase its visibil-
ity,HOPE co-organised and participated in
several meetings, seminars and conferences
significant at EU level. In line with HOPE
activities on patient safety and quality, for
example, HOPE participated in the Coun-
cil of Europe workshop on patient safety
organized in Ukraine, going outside of its
membership remit. This returned HOPE
to the technical assistance realm that was a
core of its activities in the 1990s.
Another important HOPE activity is the
development of links with the other Eu-
ropean associations active in the healthcare
field, through exchange of information,
joint projects, and joint conferences and
seminars. HOPE has regular meetings or-
ganized with AIM (payers), AEMH (hos-
pital doctors), BEUC (consumers), CPME
(doctors), EFN (nurses), EPF (patients),
EUMS (specialist doctors), FEMS (sala-
ried doctors), EAHM (managers), EHMA
(managers and academics), EAHP (hos-
pital pharmacists), PGEU (community
pharmacists) and UEMO (GPs), as well as
with representatives of the industry (EU-
COMED, COCIR, CONTINUA). To
know more about HOPE: www.hope.be
Pascal Garel,
Chief Executive,
E-mail: sg@hope.be
Promotion of Public Physicians: a Recent
Step Made by the Bangladesh Medical
Association (BMA)
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192
MOZAMBIQUENational and Regional news
The Mozambican Medical Association was
created on the 28th
of March 1992 and has
the following objectives:
• Defend the legitimate interests of their
associates;
• Defend and promote the health care of
the population by having an active posi-
tion in all aspects that affect or are beyond
affecting the health of the population;
• Promote and defend the medical profes-
sion concerning the medical education,the
working conditions, professional progress,
social security and working relationship;
• Promote and defend Professional Ethics
and Deontology;
• Promote the continuous medical training
to all their members.
The first constituent members were 94 and
the actual number is nearly 800 between
members and associates. In a country with a
population of more or less than 22,416,881
inhabitants (INE, 2010) and covered by
1042 physicians (MISAU; DNPC; DRH-
SIP,2010) between national and expat (spe-
cialists that are working in special assign-
ments with the government), it is a defy for
the health professionals, especially for the
physicians that have a reasoning of 1 doc-
tor per 21,500 inhabitants to assist all the
population in this young country (Mozam-
bican independence was gained on the 25th
of June 1975).
The age pyramid is one with a large base,
with a gross mortality rate of 13.5/1000
(INE, 2007), infant mortality rate of
93.6/1000 (INE, 2007) and life expectancy
of 50 years.
The main causes of mortality are still the
infectious diseases, such as malaria, diar-
rhea and pulmonary infections.The HIV/
AIDS infection only came to aggravate the
described situation and, although it has re-
duced (it was 16% in adults between 15 and
49 years), it prevails at a rate of 11.5% in
adults from 15 to 49 years (INSIDA, 2009).
In a brief way, I’ve tried to present the coun-
try’s health situation where,in some districts,
there is only one physician, usually a general
practitioner that has to assist the population
24 hours a day, every week and all year.
has been started, a few obstacles have been
observed like cadre and non-cadre demar-
cation, very few departmental posts, the
country’s administrative bureaucracy, etc.
But these have also been resolved through
combined effort from the current BMA
body discussion along with the respective
ministries and professional societies. The
highest commitment to activate the physi-
cian’s quick promotion system came from
the country’s Honorable Prime Minister
Sheikh Hasina with her address to the re-
cent (19th
) Bangladesh Medical Conference
held in Dhaka, Bangladesh. Her Excellen-
cy’s commitment also makes the situation
easy to achieve other goals, many of which
are in the process of completion, like:
1. Quick ad hoc recruitment of 3,551 doctors
and arrangement of study leaves for them.
2. Under a special consideration, eight
DPCs and the Superior Selection Board
(SSB) have been organized, which have
promoted and posted one director gen-
eral of health, five directors, 119 deputy
directors, 189 assistant directors/civil
surgeons, 100 senior consultants in dif-
ferent disciplines and also awarded a se-
lection grade to 961 doctors.
3. 1,000 assistant professor posts have
been created and assignment has also
been completed.
4. The Bangladesh Medical and Dental
Council Act has been passed by the Na-
tional Assembly of Bangladesh.
5. Intern doctors’stipend has been increased
from 6,500 BDT to 10,000 BDT.
The Bangladesh Medical Association is
committed to extend its continuous support
to all unfinished or pending decisions about
the physician promotion, education and
skill development program and to bring the
rural and poor population under national
health coverage throughout the country.
Professor Dr. MD. Sharfuddin Ahmed,
Secretary General,
Bangladesh Medical Association
Sharfuddin Ahmed
Mozambican Medical Association
Rosel Salomão
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193
ICELAND National and Regional news
With this, the AMM is trying to put into
practice the continuous medical education in
the local working place,allowing the practitio-
ners that are far from the main Health Unit
in his/her province but with internet access
to review and be aware of the new practices.
As, on the one hand, the Mozambican
Medical Association was created to defend
the interests of their associates and, on the
other hand, is directed at defending the
population’s health and care, it chose the
theme “Medical Ethics and Deontology” as
slogan for the year 2011, to create an open
debate where it is expected that the Medi-
cal Ethics and Deontology Code approved
this year, is known by all physicians and the
civil society.
References
1. Escritura Pública da Associação Médica de
Moçambique.
2. Instituto Nacional de Estatística, www.ine.gov.
mz/populacao/indicadores
3. INSIDA (Inquérito Nacional de Prevalência,
Riscos Comportamentais e
4. Informação sobre o HIV e SIDA em Moçam-
bique), INS, MISAU, 2009.
5. Registos da Associação Médica de Moçam-
bique.
Dr. Rosel Salomão,
President,
Mozambican Medical Association
The population of Iceland is a little above
300,000 and the total number of physicians
is around 1000. The vast majority of them
work directly for the national health care
system receiving salary by collective bargain-
ing agreement between the Icelandic Medi-
cal Association (IcMA) and the Icelandic
Ministry of Finance.The global recession hit
Iceland very badly in 2008 and the govern-
ment had to put up a huge amount of money
to guarantee personal individual bank credits
in the Icelandic bank system that mostly col-
lapsed and would otherwise have gone bank-
rupt.This has profoundly affected the health
care system in Iceland because the govern-
ment had to borrow the money abroad and
the Icelandic currency krona became worth
½ of its former value. Doctors’ salaries have
been cut, for very many of them their per-
sonal debt,i.e.house mortgage loans,etc.,has
grossly risen. This situation has led to worse
recruitment of young doctors from special-
ist training that they traditionally do abroad.
We used to have 30% of Icelandic doctors
working and doing training abroad, but now
the percentage has risen to almost 40%. The
IcMA has great concerns about this serious
situation, and regardless of how we try to
wake up the responsible politicians no plans
are made and the current round of negotia-
tions is moving very slowly.
The IcMA is both a trade union and a pro-
fessional society of all doctors in Iceland.
We have, as subgroups of different regional
societies,different age groups,and especially
a very active society of elderly doctors, who
regularly meet in our local in Hlidasmari
over the winter and organize several travels
both in Iceland and overseas every year. Be-
ing only a little over 1000, we all more or
less know or know of each other.
Iceland has for long been known as the land
of ice and fire. Being a not so small volcanic
island in the North Atlantic Ocean, it rose to
previously unknown infamous fame when the
volcano Eyjafjallajökull burst out last year and
created an enormous ash cloud that interfered
with flight traffic for many weeks in a large
part of Europe. This volcanic outburst has as
a spin-off given us more tourists than we have
ever had and currently is helping the economy.
Economic recovery is the most important fac-
tor we have to rely on, or our health care sys-
tem will be seriously damaged.The IcMA has
monitored the medical work force since 2008
and doctors are now almost 15% fewer than
were estimated by a long term statistic prog-
nosis worked out in collaboration with our
Nordic sister organizations. Icelandic medical
doctors have good compliance and most of
them who move out of the country get jobs as
doctors. Those staying at home load on more
work, long hours and postpone retirement.
That decision came easily for many since the
pension funds greatly suffered in the recession.
How this will affect the long term health of
Icelanders is yet to be seen – hopefully the re-
covery will be fast,but the IcMA has taken the
standpoint that it is still a wonderful profes-
sion we have and one of the major advantages
is you can have a choice of many countries to
work in when properly trained as a doctor.
The volcano in southern Ilacier sends ash
into the air just prior to sunset ON Friday,
April 16, 2010. Thick drifts of volcanic ash
blanketed parts of rural Iceland on Friday
as a vast, invisible plume of grit drifted over
Europe, emptying the skies of planes and
sending hundreds of thousands in search of
hotel rooms, train tickets or rental cars.
Dr. Jonsdottir Birna,
President, Icelandic Medical Association
Icelandic Medical Association
Jonsdottir Birna
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National and Regional news
Introduction
At its board meeting in April 2011, the
CPME (Standing Committee of Europe-
an Doctors) adopted a number of policies
which demonstrate the variety of health
policy of interest to the European Medical
Profession.
Furthermore, the current revision of the
Professional Qualifications Directive, the
Commission’s work on a European Profes-
sional Card and last but not least,the review
of the European Working Time Directive
are high on the European doctors’ agenda
and the CPME is busy consulting its mem-
bers for the best way forward at European
level.
Outcome of the CPME board
meeting in April 2011
European Innovation Partnership
on Active and Healthy Ageing
At the EU Council meeting on 4 February
2011, Commissioner Máire Geoghegan-
Quinn stated:
“I am particularly pleased that EU leaders
gave the green light for the launch of the first
European Innovation Partnership. This will
be on the theme of active and healthy ageing,
and will aim to give the average European
two more years of good health. As well as hav-
ing enormous benefits for older people and their
families, this would contribute to relieving the
strain on public finances”.
In a very short time, the European Com-
mission kick-started the European Inno-
vation Partnership on Active and Healthy
Ageing which involves three different Di-
rectorates-General: DG Health and Con-
sumer, DG Information Society and DG
Research. This multi-disciplinary approach
is very much appreciated by the CPME
which in the past has stressed the need for a
holistic approach to health policies.
The Commission, Member States and a
number of selected stakeholders (among
which there is the CPME) have formed a
Steering Group which sets out the strategy
to achieve the overall goal, namely to give
the average European two more years of good
health.
The CPME participates very actively
in the work as member of the Steering
Group through its president, Dr Konstanty
Radziwill, but already at its board meeting
the CPME adopted a Statement CPME
2011/066 FINAL. In its statement, the
CPME defines the main principles to be
considered in order to make this partner-
ship successful: while the CPME stresses
the important role of eHealth in contrib-
uting innovative solutions to long-term
chronic care, other more basic issues need
to be addressed for the initiative to make a
measurable impact.These issues include the
changes needed for the healthcare work-
force and roles, better integration of social
and medical care, improved flows of infor-
mation across boundaries between primary,
secondary and social care, reducing multiple
prescribing (polypharmacy) and improv-
ing patient involvement through enhanced
communication and information, just to
mention a few.
The CPME will remain an active partner
in this worthy undertaking and looks for-
ward to achieving the goal together with the
other stakeholders.
Health inequalities
As mentioned above, the CPME recognises
the need for a holistic approach to health
policy and its latest policy on health in-
equalities. CPME 2011/019 FINAL analy-
ses three major reasons for caring about
health inequalities. The first is that avoid-
able health inequalities are simply and many
would say immorally unfair. The second is
that avoidable health inequalities often in-
fringe an internationally acknowledged hu-
man right to health.The third is that health
inequalities are economically costly – soci-
eties with smaller health disparities do bet-
ter in economic terms than societies with
wider health inequalities.
The statement proposes concrete actions
which the CPME and its members can
undertake to contribute to the fight against
health inequalities.
The CPME also referred to the six policy
recommendations for reducing health in-
equalities recently made in Sir Michael
Marmot’s UK report on health inequali-
ties1
.
These are:
1. “Give every child the best start in life: in-
crease the proportion of overall expenditure
allocated to the early years and ensure it is
focused progressively across the [health in-
equalities] gradient;
2. Enable all children, young people, and
adults to maximise their capabilities and
have control over their lives: reduce the
social gradient in skills and qualifications;
3. Create fair employment and good work for
all: improve quality of jobs across the social
gradient;
4. Ensure a healthy standard of living for all:
reduce the social gradient through progres-
sive taxation and other fiscal policies;
1 Marmot M. Strategic review of health inequali-
ties in England post 2010. Marmot review final
report. University College London.
www.ucl.ac.uk/gheg/marmotreview/Documents
News from the Standing Committee of
European Doctors (CPME)
wmj 5 2011.indd 194 9/26/11 4:25 PM
195
National and Regional news
5. Create and develop healthy and sustain-
able places and communities;
6. Strengthen the role and effect of the pre-
vention of ill health: prioritise investment
across government to reduce the social gra-
dient.”
An interesting report on health equalities in
the different Member States of the CPME
membership will be soon published on the
CPME web-site (www.cpme.eu).
Task shifting
In its position paper on task shifting
CPME 2010/128 FINAL, the CPME
makes reference to the WMA resolution
of October 2008 and raises its particular
concern about the fact that task shifting is
often initiated by health authorities, with-
out consulting with physicians and their
professional representative associations.
The CPME emphasises that patient safety,
quality and continuity of care should be the
underlying objective of organisation and re-
forms of healthcare.Therefore, task shifting,
if decided by health authorities, should only
be through consultation and in accordance
with the medical profession and not solely
as a cost saving measure.
Revision of the Clinical
Trials Directive
The CPME contributed to the Commis-
sion’s consultation on the revision of the
Clinical Trials Directive 2001/20/EC
(please see CPME 2011/037 REV2 FINAL)
and stressed the need to preserve ethical
principles in particular with regard to vul-
nerable persons.
Climate Change
Through its immediate past president, Dr
Michael Wilks, the CPME is involved
in the United Nations Climate Change
Conference and sought together with the
WMA and WHO to make a change at the
last conference in Cancun. However, what
was almost universally apparent was that
little is understood about the beneficial
effects on health brought about by green-
house gas reduction.In addition to the work
on the global agenda, the CPME has joined
the EU’s recently established Green Infra-
structure working party. This initiative has
been created out of concern for the effect
climate change will have on biodiversity.
The uncertain effects on infectious disease
transmission and prevalence is just one ex-
ample of a damaging biodiversity impact,
but CPME’s membership has been addi-
tionally welcomed because of its interest
in co-benefits, and therefore expertise in
emphasising within new Commission work
a “health in all”approach to all the EU’s cli-
mate change work.
For more information on the CPME pol-
icy on climate change and environmental
health, please see CPME 2011/059 FI-
NAL.
Current items high on
the political agenda for
European Doctors
Currently ongoing work of the CPME very
much focuses on two potential revisions of
directives of high relevance for the medical
profession in Europe: the European Work-
ing Time Directive (2003/88/EC) and
the Professional Qualifications Directive
(2005/36/EC).
The future potential revision of the Euro-
pean Working Time Directive is an issue
followed with high interest by the CPME
and its members.The CPME together with
AEMH, FEMS and EANA responded
to 2nd
phase social dialogue consultation
(CPME 2011/014 FINAL EMO). The re-
sponse recalled the objective of the Work-
ing Time Directive which is protecting the
health and safety of workers. If the WTD –
as suggested by the Commission  – is re-
viewed solely in the areas of on-call time
and compensatory rest, the level of protec-
tion (both doctors and their patients) will
decrease.Therefore, it is urged that the opt-
out clause is to be removed, on-call time is
working time as stipulated by the European
Court of Justice and compensatory rest has
to be granted immediately following longer
working periods as also stipulated by the
European jurisprudence. The CPME will
closely follow the political developments in
order to defend the interest of the European
medical profession.
The CPME is currently finalising its re-
sponse to the Green Paper of the European
Commission on the revision of the Profes-
sional Qualifications Directive. As in its
earlier response to the Commission’s con-
sultation (http://cpme.dyndns.org:591/data-
base/2011/cpme.2011-015.CPME.response.
PQD.consultation.Final.pdf), the CPME
pointed out that Directive 2005/36/EC has
made the migration of physicians in Europe
substantially easier. Access to professional
employment in other Member States of
the European Union has been made con-
siderably simpler by the minimum training
requirements set out in Article 24 of the
Directive. The medical profession provides
a prime example of the advantages of auto-
matic recognition with regard to (specialty)
designations and the minimum period of
specialty training. This needs to be main-
tained and enforced provided that specialty
designations and the duration, content and
quality of specialty training are guaranteed.
In the context of the revision of the Profes-
sional Qualifications Directive, the Europe-
an Commission also develops case studies
and pilot projects for the professions under
the directive. The CPME is rapporteur in
the Commission’s steering sub-group for
doctors and firmly maintains that any at-
tempts to speed-up and simplify the rec-
ognition procedure through a professional
card and electronic communication tools
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NORWAYSocial Disparities
must ensure patient safety and not compro-
mise the existing recognition and registra-
tion procedures and the necessary public
safeguards.
Giving the high relevance of the Profes-
sional Qualifications Directive, the CPME
will hold a pre-conference on the subject
in Warsaw ahead of its board meeting and
General Assembly on 26 November 2011.
The conference will take place on 25 No-
vember and will gather the European
Medical profession, representatives from
the European Commission, the European
Parliament and the Polish EU Presidency.
More information is to be found on the
CPME web-site: www.cpme.eu ; also,please
do not hesitate to contact Birgit Beger
(birgit.beger@cpme.eu).
Dr. Konstanty Radziwill, CPME President
Birgit Beger,CPME Secretary General
In this article, the authors address the eth-
ics of providing individual healthcare fairly
in populations with a social gradient in the
distribution of health. They expose a ten-
sion within the ethical recommendations of
the World Medical Association (WMA):
The Physician’s Oath in the Declaration of
Geneva states that socioeconomic factors
should never come between the patient and
the physician, while the WMA Statement
on Inequality in Health emphasizes that
the physician should contribute to a reduc-
tion in the unacceptable social inequality in
health – an inequality that clearly correlates
with social and economic factors. Empirical
research indicates that this tension is not of
theoretical interest only; it may have practi-
cal implications as well, in terms of a risk
of reproducing and/or enhancing health
inequalities in clinical practice. Empirical
studies confirm that healthcare to some
extent favors the advantaged. This gives no
reason to assume the recommendation in
the Oath is violated as such. However, the
Oath’s recommendation of not taking non-
medical factors into account can explain an
inaccurate understanding and awareness of
the fair role of social and cultural factors in
patient treatment. By clarifying the positive
role of socioeconomic and cultural factors in
healthcare and stating this explicitly in phy-
sicians’ ethical guidelines, these factors may
warrant attention both through medical ed-
ucation and in clinical practice.The authors
conclude by suggesting a reformulation of
the Physician’s Oath that may guide more
effective and fair care of the disadvantaged
and help reduce health inequities produced
at the point of care.
Introduction
The World Medical Association (WMA)
International Code of Medical Ethics states
that “(A) physician shall not allow his/her
judgments to be influenced by personal
profit or unfair discrimination”. At the same
Social Disparities in Health and the Physician’s Role: A Call for
Clarifying the Professional Ethical Code
Berit Bringedal Kristine Bærøe Eli Feiring
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NORWAY Social Disparities
time a social gradient in the distribution
of health and disease is well documented;
there are dramatic differences in health be-
tween the socially advantaged and disad-
vantaged between and within any country
[1]. Should physicians take this fact into
account in their clinical practice and act af-
firmatively to correct socioeconomic biases?
Would this be possible whilst preserving
the ethos of avoiding unfair discrimination
in their professional work?
WMA ethical
recommendations: A tension
Avoidance of unfair discrimination is stated
in the Physician’s Oath in the WMA Dec-
laration of Geneva as: “I will not permit
considerations of religion, nationality, race,
party politics or social standing to intervene
between my duty and my patient”. Adopted
just three months before the UN Declara-
tion of Human Rights, the Oath acknowl-
edges the equal worth of every human being;
every individual is morally entitled to equal
concern.The Oath does not,however,estab-
lish any broader concern for social justice.
At the same time, the WMA recognizes
the challenges that social disparities in
health poses to the health care system. In
2009, the association adopted a Statement
on Inequalities in Health (quoted in Box
1). Although the major causes of health in-
equalities lie outside health care, the WMA
insisted that within the health care system
physicians play a major role in health pro-
motion and disease prevention, and states
their responsibility “(t)o identify, treat and
reduce existing health inequality”. The
recommended list of physicians’ responsi-
bilities includes identification of social and
financial factors that impact on inequality,
advocating for equal access to health care,
and promotion of research and education
on social inequality.
The Physician’s Oath and the Statement on
Inequalities in Health can be seen to pull in
opposite directions. On the one hand, the
physician should not let social and econom-
ic factors influence clinical judgments. On
the other hand, the physician should con-
tribute to a reduction in the unacceptable
social inequality in health  – an inequality
that clearly correlates with social and eco-
nomic factors.
Empirical support for clarifying
the ethical regulation of
professional practice
Whether the different regulations are in-
consistent depends on their practical inter-
pretations and implications.Some empirical
evidence indicates a need for clarification of
how ‘unfair discrimination’ actually should
be interpreted in practice. A recent survey
of a representative sample of Norwegian
physicians found that 55% agreed that phy-
sicians should contribute to reducing social
health inequalities in the population by
supplying extra help to patients of low so-
cioeconomic status [2]. On the other hand,
most of the responding physicians reported
‘never’ or ‘rarely’ to take social factors into
account in their clinical practice.
The need for clarification is also supported
by other empirical findings. Several studies
find that physicians, as everyone else, are
subject to unacknowledged influence from
social and cultural factors. Such influence
can e.g. be observed when physician and
patient are similar in socio-cultural aspects,
which makes it easier for the physician to
judge the patient’s situation and needs [3].
Other studies show that patients with high-
er socioeconomic status have better access
to specialized care [4].
To explicitly ignore information about the
patient’s socioeconomic status in clinical
decision making as expressed in the Oath,
may lead to an unjustified unawareness
of the interplay between socioeconomic
factors and access to healthcare. Conse-
quently, physicians may end up enhanc-
ing health disparities rather than reducing
them because of a lack of attention to the
ways socioeconomic factors work in favor
of the socioeconomically advantaged on
one side and against the disadvantaged on
the other.
A reasonable way to take non-
medical factors into account
Hence, the open question is how the rel-
evant non-medical factors should be taken
into account at the point of individual care.
The need to underscore the importance of
avoiding irrelevant and/or unfair factors in
healthcare decisions is clear. The risk of an
unacceptable influence on healthcare deci-
sion making from strong economic and/
or social interests is always present; as is
the risk that prejudice or political belief
leads to discrimination – unconsciously or
not. Therefore, ordinary medical fairness is
commonly interpreted as to allow no other
concerns than medical need to influence the
decision [5].
That medical need should be the only cri-
terion for priority to care is, however, not
as straightforward as it may look at first
sight. The reason for this is the close in-
terplay between socioeconomic status and
medical need. Any physician will know that
patients differ in their ability to utilize the
same medical regimen; some patients need
more information than others, some need
more follow up in order to comply, some
need financial support, etc. The differences
in ability to benefit from treatment are not
only due to medical factors, but are also
closely connected to factors in the social
and cultural settings of the individual. A
reasonable interpretation of what it means
to treat patients as moral equals by giving
them equal concern is that every patient
should have the same opportunity to bene-
fit from treatment. Consequently, a medical
need for healthcare must be understood ac-
cording to the patient’s individual biologi-
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198
NORWAYSocial Disparities
cal potential in combination with identifica-
tion of what it takes to overcome the patient’s
potential socioeconomic and cultural barriers to
benefit.
Reducing social disparities
by fair discrimination
Although it can be argued that factors that
influence a patient’s ability to benefit from
treatment is part of what normally consti-
tutes the concept ‘medical need’, there is
indeed empirically supported reason to be
more explicit and clear on this point.Socio-
economic and cultural factors are legitimate
concerns to consider in individual care in
the following sense: When social, cultural,
or economic factors are a hindrance to ben-
eficial treatment for the individual, action
should be taken to circumvent the obstacles
they represent. In this sense, socioeconomic
and cultural factors have a role to play in
fair discrimination among patients who
experience such barriers and those who do
not [6].
That the physician should consider socio-
economic and cultural factors as irrelevant
in his/her judgment, or, should not let the
judgment be influenced by such factors (as
suggested by the Oath), may lead to unjus-
tified ignorance of socioeconomic and cul-
tural factors and increased social disparities
in health. Instead, guiding ethical education
and physicians’ practice by a clarification of
how fairness actually may require attention
to socioeconomic and cultural factors can
help to warrant attention to how socioeco-
nomic factors affect the patient’s ability to
benefit from treatment.This can, in the next
turn, lead to a reduction of unfair dispari-
ties.
Conclusion: A call for
a reformulation in the
Physician’s Oath
Based on the reasoning above, we suggest
that the Geneva Declaration’s negative
formulation of the physician’s duty to dis-
regard non-medical factors is reformulated
to the following positive statement: All
my patients are entitled to equal concern, ir-
respective of religion, nationality, race, party
politics or social standing. I will do my best to
distribute my time and resources so that my pa-
tients have equal opportunities to benefit from
treatment despite socioeconomic and cultural
barriers. This proposal will dissolve the ten-
sion between the recommendations of the
Oath and the Statement on Inequalities in
Health and, most importantly, it may help
to reduce health inequality by improving
the effectiveness of healthcare, also for the
disadvantaged.
References
1. CSDH. Closing the gap in a generation: health
equity through action on the social determinants
of health. Final Report of the Commission on
Social Determinants of Health. Genève: World
Health Organisation, 2008.
2. Bringedal B, Bærøe K. Should medical doc-
tors contribute to reducing social inequality in
health? Tidsskr Nor Legefor 2010;130:1024-1027
doi: 10.4045/tidsskr.09.0648 (in Norwegian).
3. van Ryn M, Burke J, Hart JT. The effect of pa-
tient race and socio-economic status on physi-
cians’ perceptions of patients. Social Science &
Medicine 2000;50(6):813-828.
4. Scott A, Shiell A, King M. Is general practi-
tioner decision making associated with patient
socio-economic status? Social Science & Medicine
1996;42(1):35-46.
5. Hurst S. Just care: should doctors give priority
to patients of low socioeconomic status? J Med
Ethics 2009;35:7-11.
6. Bærøe K, Bringedal B. Just health: on the con-
ditions for acceptable and unacceptable priority
settings with respect to patients’ socioeconomic
status. J Med Ethics 2011; jme.2010.042085,
doi:10.1136/jme.2010.042085.
Berit Bringedal, Senior Researcher,
Research Insitiute of NMA;
Kristine Bærøe, Post Doctor,
University of Oslo;
Eli Feiring, Associate Professor,
University of Oslo
E-mail: berit.bringedal@legeforeningen.no
Inequalities in health: WMA recommendations
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
The members of the medical profession … have a major responsibility and call on their
national medical associations to:
• Recognize the importance of health inequality and the need to influence national
policy and action for its prevention and reduction.
• Identify the social and cultural risk factors to which patients and families are ex-
posed and to plan clinical activities (diagnostic and treatment) to counter their con-
sequences.
• Advocate for the abolishment of financial barriers to obtaining needed medical care.
• Advocate for equal access for all to health care services irrespective of geographic,
social, gender, religious, ethnic and economic differences or sexual orientation.
• Require the inclusion of health inequality studies (including the scope, severity,
causes, health, economic and social implications) as well as the provision of cultural
competence tools, at all levels of academic medical training, including further train-
ing for those already in clinical practice.
wmj 5 2011.indd 198 9/26/11 4:25 PM
199
POLAND Patient rights
Non-adherence – a bird’s eye view
Inadequate adherence to medication is a
frequent phenomenon in both chronic and
acute conditions.Frequently cited WHO re-
port concludes that adherence to long-term
therapy for chronic illnesses averages 50%
[1]. Indeed, even under conditions of strict
healthcare professionals’ inspection, which
takes place within randomised controlled
trials, almost half of the patients who were
prescribed an antihypertensive medication
have stopped taking the treatment by the
end of one year [2]. Surprisingly, the rates of
non-adherence with short-term, symptom-
atic treatments are very similar: when pre-
scribed an antibiotic to cure the infection,up
to 40% of patients reveal sub-optimal adher-
ence [3].Thus,non-adherence to medication
seems to be a rule, not the exception.
Medical and economical consequences of
non-adherence are profound.Poor execution
of medication plan creates a risk to treat-
ment effectiveness. In fact, the poorer the
adherence,the poorer the outcome [4].Thus,
poor adherence leads to higher morbidity
and mortality [5]. Considering high rates
of non-adherence, this phenomenon stands
for one of the major barriers for realising the
benefits of evidence-based therapies.
Further consequences of non-adherence in-
clude also increased health services utilisa-
tion, with hospitalizations at the first place
[6]. Finally, this phenomenon is associated
with enormous costs. Direct and indirect
healthcare costs due to non-adherence were
estimated in the USA at the level of $177
billion in 2000 in total [7].
Recent changes to both economies, and
demography brought the problem of poor
medication plan execution to the new places
in the word. Countries such as China and
India struggle now with a tide of chronic
conditions, in which effective remedies re-
lay on the daily intake of medication. Solv-
ing the problem of poor adherence might
be even more urgent need to the healthcare
systems of these countries, compared to
better prepared, and more wealthy health-
care systems of Western countries.
Concluding this bird’s eye view assessment,
patient adherence to medication become the
global problem of the utmost importance,
and the major challenge for the public health.
Patients’ right to adhere, or not
No question that the patients are free to
choose non-adherence. A portion of this
behaviour is unintentional, mostly due to
the forgetfulness. However, in the most of
cases, non-adherent patients are fully aware
of not following the treatment plan. And
they have their right to do so.
Changing approach to healthcare profes-
sional – patient relationship with regards to
adherence is reflected with changing termi-
nology. The term which was predominating
scientific publication for approximately four
decades was ‘compliance’. Unfortunately,
over the years it started to evoke negative
associations. The concept of ‘compliance’
was based on one-direction communication,
from healthcare professional to patient. In
the other words, under this paradigm, pa-
tient was only supposed to strictly execute
the treatment plan, designed by his or her
doctor. There was no place for mutual dis-
cussion, and negotiations of the medication
scheme. Any deviation from this treatment
plan was assumed to be a patient’s fault, and
was called ‘patient non-compliance’.
Over recent years, ‘compliance’ has been
gradually replaced in the medical literature
by ‘adherence’ [8]. This reflects a substantial
change from paternalistic perspective of
‘compliance’ to acceptance of the active role
of the patient – in not only the execution,
but also a design of medication plan. Just
to give a simple example, accepting patient’s
preferences upfront increases the chances of
adherence to the treatment.
Recent findings of the ABC project [9] –
European research project developed under
7th
Framework Programme – point at even
more complex nature of medication-related
behaviour. A number of previous studies
tried to identify patient profiles associated
with either adherence, or non-adherence.
Contrary to these attempts, we have found
that the same patients might be either ad-
herent, or non-adherent, depending on cir-
cumstances.Namely,those strictly following
their anti-hypertensive medication are not
taking their antibiotics as prescribed in the
case of acute infections, and vice versa [10].
Therefore, it seems that ALL the patients
need some level of support to be adherent,
and to obtain the full benefits of prescribed
treatments.
This assumption might be perceived as very
similar to ‘informed choice’ concept.Taking
right, beneficial decision by the consumer,
who is the patient it this case, might only
Patient Non-Adherence and the Patient Rights
Przemyslaw Kardas
wmj 5 2011.indd 199 9/26/11 4:25 PM
200
The World Heart Federation leads the glob-
al fight against heart disease and stroke via a
united community of 200 member organi-
zations that brings together the strength of
cardiac societies and heart foundations from
more than 100 countries. Through our col-
lective efforts, we help people all over the
world to lead longer, better, heart-healthy
lives.
Every year, 17.1 million lives are claimed by
the global burden of cardiovascular disease
(CVD), which includes heart disease and
stroke, with 82 per cent of deaths occurring
in low- and middle-income countries. It is
the world’s number one killer but a majority
of these deaths could be prevented by eating
a healthy diet, carrying out regular physical
activity and avoiding tobacco.
Global leaders have recognized the urgency
to prioritize the prevention and control of
CVD with other non-communicable dis-
eases (NCDs), including cancers, chronic
respiratory disease and diabetes by holding
the first ever United Nations High-Level
Summit on NCDs, 10 days before World
Heart Day. This year’s campaign theme re-
flects the importance of elevating NCDs
up the global health agenda and each indi-
vidual’s responsibility to incorporate heart-
healthy behaviours in their home.
With the UN High-Level Meeting on
Non-Communicable Diseases (NCDs)
taking place in September, World Heart
Day presents a great opportunity to com-
municate messages about the meeting
outcomes, and the importance of elevating
NCDs up the global health agenda. After
two years of focusing on heart health in the
workplace, this year we call on individuals
to reduce their own and their family’s risk
of heart disease and stroke. We ask people
to take charge of their home’s heart health
by taking steps such as choosing healthy
food options, increasing physical activity,
and saying no to tobacco. As always, our
emphasis will be on improving heart health
across all nations.
World Heart Day was created by the
World Heart Federation in 2000 to in-
form people around the globe that heart
disease and stroke are the world’s leading
cause of death, claiming 17.1 million lives
each year. Together with its members, the
World Heart Federation spreads the news
that at least 80% of premature deaths from
heart disease and stroke could be avoided
if the main risk factors, tobacco, unhealthy
diet and physical inactivity, are controlled.
This year, World Heart Day is taking place
on 29 September 2011. National activities
organized by members and partners of the
World Heart Federation may include public
talks and screenings, walks and runs, con-
certs, sporting events and much more.
Find out more about the World
Heart Federation
http://www.worldheart.org/
POLANDPatient rights
be expected after providing him or her with
well-balanced, objective information, and
relevant encouragement. One has to have in
mind that nowadays, more and more pow-
erful treatments (eg. anti-cancer, HIV) are
being made available in self-administered
form. This make the patients responsible
for execution of expensive treatments under
ambulatory conditions, without continuous
help from healthcare professionals. Not to
forget that these treatments are often lead-
ing to the adverse effects.
Therefore, it is a need to let all the patients
have their right to adhere, as well. How-
ever, certain actions are necessary to take
to make this happen. Within ABC project,
we are aiming to designed evidence-based
recommendations for European policymak-
ers to increase adherence [8]. We hope that
on their grounds, relevant actions would be
taken, to turn the patients right to adhere
into reality.
References:
1. Sabate E. Adherence to long-term therapies:
evidence for action. Geneva, World Health Or-
ganization, 2003.
2. Vrijens B, Vincze G, Kristanto P, Urquhart J,
Burnier M. Adherence to prescribed antihyper-
tensive drug treatments: longitudinal study of
electronically compiled dosing histories. BMJ.
2008;336(7653):1114-7.
3. Kardas P, Devine S, Golembesky A, Roberts C.
A systematic review and meta-analysis of misuse
of antibiotic therapies in the community. Int J
Antimicrob Agents. 2005 Aug;26(2):106-13.
4. Hughes DA, Bagust A, Haycox A, Walley T.
The impact of non-compliance on the cost-ef-
fectiveness of pharmaceuticals: a review of the
literature. Health Econ. 2001 Oct;10(7):601-15.
5. Simpson SH, Eurich DT, Majumdar SR, Pad-
wal RS, Tsuyuki RT, Varney J, Johnson JA. A
meta-analysis of the association between ad-
herence to drug therapy and mortality. BMJ
2006;333(7557):15.
6. Sokol MC, McGuigan KA, Verbrugge RR, Ep-
stein RS. Impact of medication adherence on
hospitalization risk and healthcare cost. Med
Care 2005;43(6):521-30.
7. Ernst FR, Grizzle AJ. Drug-related morbidity
and mortality: updating the cost-of-illness mod-
el.J Am Pharm Assoc (Wash).2001;41(2):192-9.
8. Kardas P, for ABC Project Team. ABC Project –
European initiative to improve patient adher-
ence to medication. WONCA Europe 2011
book of abstracts, 8-11 September Warsaw, Po-
land, 57.
9. www.ABCproject.eu
10. Kardas P, for ABC Project Team. Medication
adherence as the precondition for continuity of
care: in-depth insight into patients perspective
on the grounds of European survey. WONCA
Europe 2011 book of abstracts, 8-11 September
Warsaw, Poland, 86-7.
Prof. Przemyslaw Kardas MD, PhD
Medical University of Lodz
E-mail: przemyslaw.kardas@umed.lodz.pl
OneWorld,one Home,one Heart
wmj 5 2011.indd 200 9/26/11 4:25 PM
iii
URUGUAY National and Regional news
The Uruguayan Medical Association was
founded in 1920. Since its beginnings, the
founders decided that the new entity was to
be a civil association of free and voluntary
entry, a nonprofit organization. Its objec-
tives were the moral and material backup of
its members. Improvement of esteem and
consideration for the medical profession is
also amongst its objectives.
Through the National Medical Conven-
tions, eight of which have been held since
1939, the Uruguayan Medical Associa-
tion has made important contributions to
the continuous study and improvement of
health structures in the country.The core of
the actual national health system, which the
Uruguayan Medical Association supports
fiercely, had its origins in the Medical Con-
ventions. The Uruguayan Medical Associa-
tion not only cares for its members but also
is conscious of the role it has within the so-
ciety and shares with the national health au-
thorities its preoccupation with the health
care for all Uruguayan population.
At present, Uruguay has approximately
14,700 active medical doctors. 8,500 of
these professionals are members of the Uru-
guayan Medical Association, and member-
ship is completed with 1,750 medical stu-
dents, who have representations in all the
Association activities.
The organization of the Uruguayan Medical
Association is as follows: Assemblies, which
convene all members; the Executive Com-
mittee formed by 10 members elected by
medical doctors and 3 members elected by
students; a Referee Council, a Fiscal Com-
mittee.There are also 31 advisory committees.
The Uruguayan Medical Association is also
member of the CONFEMEL (Medical
Confederation of Latin America and the
Caribbean) and also member of the World
Medical Association.
Uruguay will host
medical doctors from
all over the world
The most important meeting of worldwide
leading medical doctors will be held at the
Radisson Hotel in Montevideo from 12th
to 15th
October 2011, co-organized by the
Uruguayan Medical Association and the
World Medical Association.
It is the first time that the Uruguayan Med-
ical Association will host the World Medi-
cal Association Assembly, where delegates
representing professional organizations
from 94 countries will be attending. There
have been only two WMA Council meet-
ings (1969 and 1998) held in Uruguay.Only
three countries in South America have
hosted the WMA Assembly: Brazil, Chile
and Venezuela.
The host country
Uruguay (República Oriental del Uruguay
as its official name) – is a South American
country bordering Brazil in the northeast,
Argentina in the west, with coast over
the Atlantic Ocean on the southeast and
over the River Plate (Rio de la Plata) on
the south. With little more than 176,000
sq.kms of land, it has approximately
3,400,000 inhabitants. The capital city,
Montevideo, is located in the south of the
country, with a natural port on the River
Plate, with 1,400,000 inhabitants. Uruguay
is member of the United Nations, of the
MERCOSUR (Southern Cone Common
Market), the OAS and G77, amongst other
international organizations.
Spanish is the native Uruguayan language.
This shows the uniform population, its
cultural and ethnic profile, characteristics
which have helped towards the develop-
ment of a tolerant and democratic coun-
try. More than 95% of the population is
literate. The vast majority of young people
study a second language, preferably Eng-
lish.
The Uruguayan stability, its profound dem-
ocratic and cultural tradition, and a high
level of safety within its population, makes
it a key country in the region.
Traditionally, the Uruguayan economy had
depended upon farming produce mostly.
At present, the production is being inten-
sified and every day there is an increase in
forestry, dairy industry, fishing and agricul-
ture.
Uruguay also plays a fundamental role in
the field of services, with great develop-
ment in the financial and tourism sectors.
With outstanding economic indicators for
Latin America, the unemployment index
is around 5.4%. The national currency is
the Uruguayan Peso ($). Its relation with
the US dollar is 20 to a dollar. There is free
exchange system in all transactions and fi-
nancial activities. Buying and selling opera-
tions are performed by banks and exchange
offices. Many purchases and transactions
are also carried out in American Dollars or
Euros. The flourishing telecommunications
system ensures instant connectivity with
anywhere in the world through digital sys-
tem, internet data transmission and mobile
connection systems.
The World Assembly will be held in spring
when temperature ranges around 17.5°C.
www.smu.org.uy
E-mail: secretaria@smu.org.uy
Uruguayan Medical Association
(Sindicato Médico del Uruguay)
wmj 5 2011.indd iii 9/26/11 4:25 PM
iv
Contents
Window of Hope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
WMA Presidential Report, 2010–2011 . . . . . . . . . . . . . . 162
Access to Public Health Facilities . . . . . . . . . . . . . . . . . . . 164
Articulating Person-centered Medicine
and Peoplecentered Public Health . . . . . . . . . . . . . . . . . . 171
On the Epistemological Nature of Clinical Ethics:
Decision Making or Thinking? . . . . . . . . . . . . . . . . . . . . . 175
Dependency on Sponsorships and Relations to the
Pharmaceutical Industry . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Physicians and Alternative Methods of
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
A Mission to Save Public Medicine . . . . . . . . . . . . . . . . . 182
European Medical Association . . . . . . . . . . . . . . . . . . . . . 185
European Medical Association on Smoking
or Health (EMASH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Southeast European Medical Forum . . . . . . . . . . . . . . . . 188
Declaration of the Second International Medical
Congress of the Southeast European Medical Forum . . . 189
HOPE, the European Hospital and Healthcare
Federation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Promotion of Public Physicians . . . . . . . . . . . . . . . . . . . . 191
Mozambican Medical Association . . . . . . . . . . . . . . . . . . 192
Icelandic Medical Association . . . . . . . . . . . . . . . . . . . . . 193
News from the Standing Committee of European
Doctors (CPME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Social Disparities in Health and the Physician’s Role . . . 196
Patient Non-Adherence and the Patient Rights . . . . . . . . 199
One World, one Home, one Heart . . . . . . . . . . . . . . . . . . 200
Uruguayan Medical Association . . . . . . . . . . . . . . . . . . . . iii
The life expectancy at birth in Hungary between 1970 and 2009 has
increased from 69,3 years to 74,45 years, the vast majority of which
has been achieved in the past 15 years.This seems to be a great suc-
cess until we compare these figures to the EU-15 (member counties
before 2004) which reveals that our lag has increased during this
time span from 2,53 years to 6,37 years (WHO HFA database).The
main contributors to this are the cardiovascular diseases. In the last
decade the underlying lifestyle risk factors were targeted by major,
nation-wide public health programs to the tool set of which recently
a new element has been added, the so-called “chips-tax”.
The law No. CIII. of year 2011 on the public health product taxation
entered into force on 1. Sept. 2011. It has three main targets: the
sugar, salt and caffeine content with the aim of improving dietary
habits and combat obesity. The legislators found important not to
burden the disadvantaged groups financially so only convenience
foods were included except certain salty spice mixes. Though this is
a highly considerable social aspect, on the other hand it might be a
weakness of the law: the consumption originated from normal diet
itself exceeds the recommended amount of sugar and salt (sodium).
It is also controversial that only pre-packaged foods are taxed. The
chips-tax skips the problem of energy density or “empty calories”
other than refined sugar. Fat content, including the type and special
dangers of certain fats (trans fatty acids), though originally was a
main element of the law in the planning phase,has been also left out
from the scope of this law during its evolution.
The soft drinks are important contributors to the childhood obesity
epidemic, so the taxation of the fizzy beverages containing less than
25% fruit and more than 8 grams sugar per decilitre would seem an
ideal target; though applying a tax of 5 HUF (1,8 euro cent) per litre
the price of which is between 250-400 HUF doesn’t seem too strict.
It is questionable whether the temptation and perceived “coolness”
of this convenience food group would be stronger or the price sen-
sitivity. In case of energy drinks, the tax is 250 HUF per litre if the
caffeine content exceeds 10mg per 100ml.
Sweet snacks are taxed by 100 HUF per kilogram if their sugar
content is higher than 25%; in case of chocolates max. 40% of sugar
content goes untaxed.
Taxing the savoury snacks is an important addition to the national
Stop-salt strategy.The tax on wheat and potato chips and oily seeds
will be 200 HUF per kilogram if the salt content is higher than 1%,
with the exception of bread and pastry products. The same tax ap-
plies to food flavourers if their salt content is higher than 5%.
It is an open question, in lack of available impact surveys, whether
the price elevation of savoury snacks would result in a significant
decrease in total dietary salt intake resulting a detectable advantage
in terms of public health benefits; taking into account that the law
doesn’t affect the salt intake originated from ordinary, “normal” diet
while salt content exceeding the threshold defined by the law occurs
in 53, 93 and 97 % of the diary, processed meat and bakery products
according to a recent survey of the National Institute for Food and
Nutrition Science. Similarly, a diet survey in Hungarian kindergar-
tens proved a salt intake of 3,5-13,1 grams/day.
Based upon the abovementioned, we regard the „chips-tax” a useful
first step but it is important to stress that the end of the road is still
far away.
Prof. Dr Denes Molnar,
Dr. Eva Kovacs
“Chips-tax” in Hungary: fiscal measures for public health benefits
wmj 5 2011.indd iv 9/26/11 4:25 PM