WMJ 04 2012

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• Medical Association of Thailand
• Regulation of Health Professions
• Protesting a System. Turkey
vol. 58
Official Journal of the World Medical Association, INC
Nr. 4, September 2012
Cover picture from Japan
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cover design by
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Cover painting:
Japanese doctor examining patient. Created by
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author, published on Le Tour Du Monde, Ed.
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WMA Chairperson of the Associate
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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
Clinical, Legal and Political Issues in UK Clinical
& General Practice; Personal Observations
Retired does not mean tired again, it means experienced. I am re-
tired from the National Health Service but I do locum GP work
because I cannot do gardening at home. From the time one is born
until the time one dies, everyone has to fill time. I was lucky to
be born as a positive thinker and to remain so. I believe that even
God only helps those who help themselves. In addition to Locum
GP work, I wear many hats including being an Expert Witness in
Cultural, Religious & Ethnic Issues in Litigation and also in GP
Negligence. Before saying anything, I check three things: Do I have
something new to say? (which I always have). Is there anyone will-
ing to listen to me? How much should I say now and say later?
Some people listen to me like a Samaritan but, unlike them, take
no notice; others find it thought provoking. Criticism is a positive
activity to learn in science and politics. I enjoy knowing that I am a
British citizen. Britain is a democracy.
I am aware that in a democracy everyone but everyone has a right
to be heard before being ignored. The chairman decides. He/she
may ask for a vote if the committee agrees, otherwise the item is
taken on board. Only a leader is often elected but their appointees
are selected. For me, to live and let live is the best policy, as everyone
has their own way.
I enjoy whatever I do, including Locum GP work. The perk in GP
work is that nothing can happen without my signatures.I have to be
skilful, careful, tactful, alert and helpful, without taking any risk to
myself. Locum work is a matter of supply and demand.The Princi-
pals would try before they buy. It is a good business and there is no
reason to cry. I respect idealists, follow realists but listen carefully to
both and take balanced steps.
A locum’s job is as good as his/her last performance. You can
often win but not always. One must remember that eventually
we are all answerable about what we do. One of my GP trainers
used to say “As a GP, do right and fear no man; do not write and
fear no woman”. In golden old days, GPs wrote in patient’s notes,
sometime illegible even to themselves as there were no solicitors
or judges to read their notes. Now it is an era of computers, au-
dits and litigation. Everything changes in this world except this
My suggestions to Clinical Consultants and General Practitioners,
in Britain, are:
1. Politics, economics and law have as much to do with “Patient
care” as medicine.
2. Academics and Politicians, very rarely respect each other. GPs
need them both.
3. Never say “never or always” as anything can really happen in
general practice.
4. A GP knows and is expected to know “something about every-
5. A Specialist knows and is expected to know “everything about
6. A GP should deal what is possible and must refer to a Specialist
what is not.
7. Hospital doctors can only see patients referred by GPs. Let
them see, if needed.
8. Patients’ confidentiality laws must be followed in Britain. Write
notes clearly.
9. Remember, these notes may be read by patients, lawyers, wit-
nesses and judges.
10. No one is immune from law. Idealists get trapped in breeches
more than realists.
11. A GP is akin to a bus driver or a pilot, check everything and
drive safely.
Please beware;
A. Do not become totally subjective.There is no such thing as “my
B. You only need one patient to complain against you and your life
would change.
Please remember;
A. Do every thing objectively and professionally. Write notes wise-
ly and medicolegally.
B. Listen to Patients and Academics but remain a Realist. Change
with changing rules.
Dr. Bashir Qureshi FRCGP, FRCPCH,
GP Locum & Expert Witness in Clinical GP Negligence.
Author of Transcultural Medicine.
Expert Witness in Cultural, Religious
& Ethnic Issues in Litigation
Instead of Editorial
THAILANDRegional and NMA news
As the host of the WMA GA 2012 and
& 193rd
Council Sessions in Bang-
kok, Thailand, October 10–13, 2012, the
Medical Association of Thailand would
like to introduce itself for your back-
ground information of the organization.
Inception of the Organization
The Medical Association of Thailand under
the Royal Patronage symbolizes the collab-
oration and cooperation of every physician
to intertwine their contribution into ‘one-
ness’ in order to carry out the constructive
activities that surveillance all physicians to
practice under the ethical code.
The Medical Association of Thailand under
the Royal Patronage has been functioning
to promote and develop issues concerning
medical studies, researches, including pro-
moting moral and medical ethics among
the member physicians.Moreover,this body
has also a close collaboration with public
sectors and medical organizations nation-
ally and internationally. This is to scale up
medical knowledge and practices of the
members to international standard at pres-
ent and in the future.
The Medical Association of Siam was first
initiated on 25 October, 1921 by being reg-
istered as an association. The temporary
office of the organization at that time was
located at the Administration Building of
Chulalongkorn Hospital Bangkok, Thai-
land. There were 10 senior physicians in-
volved in the setting up of the Association.
Their names were as follows:
1. Naval Colonel M. J. Thavornmongkon-
wong Chaiyata: Senior Naval Medical
Officer, who became a Naval General
later on;
2. Colonel Phrayavibul-Ayuravej: Senior
Army Medical Officer; his name before
royal appointment was Sekh Thamsa-
3. Colonel PhraSakda Pholrak: Director
of Chulalongkorn Hospital; his name
before royal appointment was Chuen
Phutiphat, later on, becoming an Army
General,he was Phraya Damrong
Phatta Phattayakhun by royal appoint-
4. Ammart Tho Luang Ayurapatpises:
Director of Siriraj Hospital; his name
before royal appointment was Sai Kho-
5. Ammart Thri Luang Upphantraphath-
pisan: his name before royal appoint-
ment was Kamchon Bhalangkool, later
by royal appointment he was Phra Up-
6. Ammart Thri Luang Vaitayesarangkool:
his name before royal appointment was
Cheuch Israngkool Na Ayuthaya;
7. Dr. M.E. Barns;
8. Ammart Ek Phraya Vechsithpilas:
Dean of the Faculty of Medicine, Chul-
alongkorn University;
9. Colonel M.J. Wallapakorn Worawan;
10. Dr. Leopold Roberte.
The working committee of the Association
had asked Field Marshall Prince Nakorn-
sawan Worapinis, Vice President and Di-
rector of the Siam Red Cross at that time,
for the name of the Association which he
named “Medical Association of Siam”, and
later on it was changed to “Medical As-
sociation of Thailand” (MAT). The change
affected only the spelling of the name to
make it up-to-date.
In 1930 Phrabath Somdej PhraPoramin-
taramahaprachathipok Phrapokklaocha-
oyuhoa, the 7th
King, graciously accepted
this society under his royal patronage. The
words “under Royal Patronage” have ever
since been added to the name of the As-
At the beginning the Association had
its temporary office at Chulalongkorn
Hospital. The first meeting of the As-
sociation was held on 9 January, 1922,
with 64 members attending. Field Mar-
shall Prince Nakornsawan Worapinis,
Vice President and Director of the Siam
Red Cross and Maha Ammarttho Prince
Chainatnarenthorn, Director General of
the Department of Public Health, also
graciously participated at the meeting.
The temporary office of the Association at
Chulalongkorn Hospital was used until 4
August, 1932, when the office was moved
to Bamrung Muang Road, next to the
Kasatseuk Bridge; the land belonged to
the Red Cross.
In 1923 the Association started using
its own emblem, developed by Prince
Narisaranuwattiwong. The emblem bears
a picture of the naga or King of Snake
snake and the trident, encompassed by the
inscription “Medical Association of Siam”
that was changed later on to “Medical
Association of Thailand”. The trident is
a weapon used by God Isuan or Shiva in
Profile of the Medical Association
of Thailand (MAT)
Wonchat Subhachaturas
THAILAND Regional and NMA news
One of the important issues in the work
of the Association was the launch of the
medical journal, which since then is being
used as a network to communicate with the
current members, including dissemination
of knowledge and information as well as
current medical research. At the beginning
of the establishment of the Association,
there was no official journal produced by
the society, however, the Association pur-
chased the Red Cross Bulletins, issued in
the early period of the establishment of the
Association, to distribute to all its members.
On 17August, 1925 there was a transfer
of administration of the journal from the
Red Cross to the Association, and the jour-
nal was renamed “Medical Bulletin of the
Medical Association of Siam”.
During 1926–1927 there were no concrete
activities provided by the Medical Asso-
ciation of Siam to sensitize the members.
The existing journal did not gain much in-
terest from the members. Moreover, only
a few copies of the journal were sent out
to the members (3 editions annually). The
scientific meeting was also rarely held.
All members who lived in different areas
hardly met one another. Two leading per-
sons  – Dr.  Luang Chalermcampeeravej
and Dr. Luang Chetthawaitayakarn – tried
hard to take an initiative in developing the
Medical Union Club at Chulalongkorn
The Club was legitimately registered on 15
March, 1927 with the temporary office at
Siriraj Hospital. The Medical Union Club
was dealing with scientific matters, but
there was no definite building to house the
activities of the members. In the meantime
the Department of Public Health, the Min-
istry of the Interior had built the Bangrak
health center for the purpose of treating the
venereal diseases. It was a 2-storey build-
ing adjacent to Silom Road. Within the
compound of this hospital building there
was a large wooden high-level house where
Dr. Hays had run his clinic and had already
closed his business. The Department of
Public Health allowed the Medical Union
Club to house there for the purpose of the
member meetings.
The objectives were as follows:
1. to foster athletics;
2. to be the place where the new and se-
nior students could mix; and
3. to enrich knowledge and to create con-
tacts between students and schools.
The Medical Union Club organized the first
scientific meeting on 1 April, 1928. There-
after, there was held a regular annual meet-
ing.After each scientific meeting there were
published papers a copy of which was dis-
tributed to the members every two months.
The first scientific paper was issued in No-
vember, 1929, under the title “Report of the
Meeting of the Medical Union Club”.
The other newsletter that was published by
the Medical Union Club was named ‘Physi-
cians’ News” which was issued in 1928 with
the aim to educate general public about dis-
eases and illnesses. It was sold for 25 stang
per copy and it was issued on a monthly ba-
sis. In 1942 this newsletter was closed due
to World War II.
The aim of the Medical Association of Siam
focused on scientific matters, whereas the
purpose of the Medical Union Club con-
centrated on both scientific and social is-
sues.Thus, it seemed that the work of the
Medical Union Club was more interesting
than that of the Medical Association of
Siam. It was because the membership grew
as graduates from medical schools enrolled
as new members in the Medical Union
Club. Only very few of the new graduates
registered as new members of the Medical
Association of Siam. This seemed to make
the latter more inferior. However, the im-
portant point that had never been revealed
was that the current members of the Medi-
cal Association of Siam at that time had
also registered as members of the Medical
Union Club when this club came into ex-
They had to pay membership fees to both
societies, which meant that those who were
members of the two societies had to pay the
membership fees twice compared to those
who were members of either society. More-
over, the economic situation in the country
at that time was weak. There was an idea
of combining the two societies together in
order to make a stronger body, and at the
same time running only one organization
would be more economial. However, this
idea failed. Until in 1933 Dr. Phrayabori-
rakvechchakarn was elected President of
the Medical Association of Siam as well as
President of the Medical Union Club. The
merge of the two societies was approved by
the members of the societies.
The strategic solution to this combination
was that those members who had already
paid their membership fees to the Medi-
cal Association of Siam were exempted
from the fees of the Medical Union Club.
The combined activities included finances,
the library, medical bulletins and the an-
nual meeting. The offices of both societies
were asked to be in the same premises or
in a place nearby, if possible. Both societ-
ies had a joint agenda for the first time on
2 February, 1933, which was announced as
the annual meeting of the Medical Associa-
tion of Siam and Medical Union Club un-
der the name “Medical Association of Siam
and Medical Union Club of Chulalongkorn
University”. At the beginning each society
had a separate working committee.
In 1936 the Medical Union Club moved
to the Bangrak Health Center, the same
place where the office of the Medical As-
sociation of Siam was located, in Bamrung
Muang Road.The two working committees
were united into one.The office in Bamrung
Muang Road was considered a convenient
place in terms of public transport, as well
as being close to some offices of the De-
partment of Public Health located in Yodse
Road. As a consequence, more members
frequented the Association. The Associa-
tion had acquired two billiard tables and
Regional and NMA news
three tennis courts. This had been consid-
ered as ‘very advanced’ facilities provided
to the members. Besides physicians there
were some visiting civil servants who were
not registered as members, but they utilized
the facilities at the society and considered it
to be a convenient meeting and recreation
The Medical Association and the Medi-
cal Club continued working successfully
until Thailand entered World War II on 8
December 1941, when the Japanese troop
occupied several places in Bangkok. Apart
from the effects of the war, in 1982, there
was a big flood, the biggest in the Thai his-
tory which lasted almost for one month.
Most of the roads in Bangkok were under
deep water and resembled canals; in some
parts of Bangkok cars were not accessible.
During the war and after the flood the Club
was on decline due to difficulties to access it,
but soon after the war ended and gasoline
was available the club started functioning
again, but the space was so limited. During
1940–1942, Naval Rear Admiral Sa-nguan
Rujirapa, the then President of the Asso-
ciation, tried to find a new bigger place. He
was a member of the revolution party,there-
fore, found it easier to communicate with
the country governing people, nevertheless
it took a very long time.When Dr. Chalerm
Prommas was elected President of the As-
sociation the project turned out successful
as the Royal Property Estate Office agreed
to let the “Baan Saladaeng” which used to
be the residence of Chao Phaya Yommarat
and was situated opposite to Chulalongkorn
Hospital at the intersection of Rama 4 road
and Rachadamri and Sirom roads or the lo-
cation of the Dusit Thani Hotel at present.
The reason why the negotiations took so
long was because a residence of high rank-
ing officials and the Old European Students
Association were located in the area and,
besides, we tried to get the possibly cheap-
est rent. More than that, when the members
learned that we were moving to Saladaeng,
there were some disagreement and com-
plaints that it was too far, however, it was
not that far when we got acquainted with
the location.
“Baan Saladaeng”
The extensive renovation of the new site
needed a lot of money, more than tens of
thousands of Baht. Those expenses were
shared with the Dentist Association and the
Pharmacist Association.Therefore, after the
renovation was completed the three Asso-
ciations united and worked together at the
same place.The Medical Association moved
to “Baan Saladaeng”on 4 May, 1948 during
the presidency of Dr. Chalerm Prommas.
In 1949, the Nurses Association asked to
join in. Thus, Baan Saladaeng housed four
Associations – the Medical, the Dentist, the
Pharmacist, and the Nurses and the abbre-
viation of the building was M.D.P.N. Of-
“Baan Saladaeng” consisted of a big build-
ing and possessed an area of more than
Regional and NMA news
eight rais. The Association set a wooden
house near the big building as a club and a
section of the Medical Association acquired
two billiard tables, several bridge tables and
three tennis courts in the rear, a glass court
in the front and a residential house. It was
bigger and more comfortable than the pre-
vious one and more members could be ac-
commodated even though it might seem far
away for someone.
The four Associations worked together until
1966 when the Royal Estate Office notified
about the termination of the rental permit
as it wanted the land to be developed as a
modern commercial arcade and was willing
to pay 2.5 million Baht to the Association.
The negotiations ended in the payment of
5 million Baht. Half of the sum was given
to the three Associations and the remaining
2.5 million Baht were spent to purchase a
piece of land (3 rais, 2 ngarns and 92 square
wahs) from the Kheha Pattana Estate
Company at Soi Soonvijai, 300 metres away
from New Petchburi Road, and 45 square
wahs more for the entrance to the Associa-
tion. The construction of the new Associa-
tion building was started in May, 1967 with
the budget of 1.3 million Baht.
New Home at Soi Soonvijai,
New Petchburi Road
Thus, the Medical Association of Thailand
under Royal Patronage acquired a new and
permanent Office. But before the processes
of land purchasing and the construction
finished, it had to be temporarily moved to
the Tuberculosis Eradication Association. It
moved permanently to Soi Soonvijai on 13
January, 1968.
The Medical Association of Thailand un-
der the Royal Patronage and all the medi-
cal professions were greatly honoured when
His Majesty the King and Her Majesty the
Queen graciously presided over the opening
ceremony of the Association building on 1
February, 1968
Today at the Royal Golden Jubilee
(Chalermprabarami Anniversary)
Since the number of the Royal Colleges and
their activities have been increasing together
with the number of college students grow-
ing there have been no permanent offices for
those colleges due to being non-profit orga-
nizations and lacking the government sup-
port.The colleges have been providing train-
ing for specialists under the supervision of
the Medical Council for more than 20 years
on voluntary basis as they are not included
in the government development plan. Most
of the functions, therefore, were absorbed by
the institutes where the Chairs or the Secre-
tary General of the College associated.Then
the plan of having fixed or permanent offices
for each Royal College was initiated.
Professor Dr.  Arun PAUSAWASDI, the
then Secretary General of the Royal Col-
lege of Surgeons, sent out invitations to all
the Presidents and the Secretary Generals of
the Royal Colleges to meet and discuss the
issue of permanent offices. Representatives
from 9 out of 11 Royal Colleges attended
the meeting and decided on finding suitable
places for the permanent offices that might
be at the Ministry of Health or at the Medi-
cal Association or to find their own places.
Several senior members had looked for the
site for these permanent offices at the Srith-
anya hospital, the Department of Medical
Services, or even at the construction site
of the new Ministry of Public Health, but
nothing seemed acceptable. On 23 Decem-
ber, 1993, at the meeting of the Medical
Council at the Ambassador Hotel Pattaya,
Professor Dr.  Arun Pausawasdi, President
of the Royal College of Surgeons, called a
special meeting to revise the project and at
this important meeting Rear Admiral Air
Marshal Dr.  Kitti Yensudchai, the then
President of the Medical Association, pro-
posed that the construction of the special-
ist consortium should be at the site where
the Medical Association was located. The
proposal was approved and a committee of
eight members was appointed to continue
with the project.
The Consortium of the Medical Specialty
Training Institute was afterwards estab-
lished to strengthen and consolidate the ac-
tivities of the colleges and invited his Royal
Highness, the Crown Prince of Thailand,
to be the Chair of the construction proj-
ect to celebrate the Golden Jubilee of the
King’s Accession to the throne in 1996.
The building was planned to accommo-
date the Medical Association of Thailand,
the Royal Colleges and Medical Societies.
At the beginning the Ministry of Public
Health had coordinated with the Govern-
ment Bureau of Lottery and other charity
foundations for the seed money to construct
a 12-storey building with the working space
of 32,000 square metres to accommodate
11 Royal Colleges, 23 Medical Societies
and the Medical Council. The construction
was budgeted at 440 million Baht and built
on the land which belongs to the Medical
Association. The budget was administered
in the form of foundation that was later
named “Vajiravej-vitayalai Chalermprakiert
Foundation under the Royal Patronage of
His Royal Highness Crown Prince Maha
The building itself was graciously named by
the King as the “Golden Jubilee Building”.
On 18 March, 1997, His Royal Highness,
the Crown Prince Maha Vajiralongkorn
was assigned by the King to preside over
the opening of the Golden Jubilee Building
on his behalf.The event was of great honour
and brought much delight to all the medi-
cal professions of the Kingdom of Thailand.
The Medical Association
of Thailand
At Present 2012–2014
The Executive Committee of The Medical
Association of Thailand under his Majesty
Regional and NMA news
the King’s Patronage (according to the con-
stitution and bylaws) composed of 40 mem-
bers, they are
11 Elective members
– President
– President Elect
– Vice President
– Secretary General
– Treasurer
– House Master
– Publication
– Welfare
– Scientific
– Medical Education
– Ethics
29 Appointed members
– Chair of the Medical Council
– Presidents of the Royal Colleges of
52 Advisors
18 Representatives from national geo-
graphical medical regions
The Meetings of the Executive Board and
Advisors convene every Wednesday of the
week of the month.
15 subcommittees are appointed to work
on various fields of interest
1. Funding subcommittee
2. Scientific meeting subcommittee
3. Land asset and Welfare Subcommittee
4. Membership Relations subcommittee
5. Medical Journal Editorial Board
6. Subcommittee for Health Professional
Security Support Acts
7. Subcommittee on
8. Subcommittee on fund Raising Golf
9. Subcommittee for WMA General As-
sembly 2012
10. Subcommittee for Social Medias Ac-
11. Subcommittee for
12. Subcommittee to follow the Medical
Compensation Acts
13. Subcommittee to provide help to flood
Victims (health Professionals)
14. Subcommittee for
15. Subcommittee for the “Royal Kathin
What ‘s Done:
1. Promotion and maintaining the stan-
dards of Professional Ethics
2. Promotion of the professional solidarity
3. Promotion of medical education, re-
search and medical services
4. Promotion of member welfare
5. Cooperation and collaboration with
governmental and private organizations
for improving and maintaining medi-
cal services at the level of International
6. Advocating medical and health educa-
tion to public to improve the social de-
terminants of health
7. Collaboration with international orga-
nizations to leverage the global health
What’s Next
1. Expanding the network by appointing
representatives from 18 National Medi-
cal Geographical Regions to the Execu-
tive Board
2. Support the professional Security Acts
3. Training of the risk management in
medicine twice a year
4. Cooperate Social Responsibility (CSR)
Promotion of Medical Profession
and Medical Ethics
1. The Medical Association of Thailand
(MAT) has initiated the laws consul-
tation session within MAT to provide
consultations to members 24 hours a day
2. Promotion of the member relationships
2.1. Publication of the monthly medi-
cal journal
2.2. Publication of the monthly medi-
cal association news letters
3. Professional Risk Management Project.
Promotion and support the Health Pro-
fessional Security Acts.
4. Medical Professions Guidelines Project.
Advisory and guidelines lectures to the
new graduates from 10–14 institutes
every year under the support of Pfizer
Foundation since 2004
5. Member Visit Project. MAT pays visits
to members working in upcountry from
time to time
6. Promotion of Professional Ethics Proj-
ect. MAT gives lectures on medical eth-
ics to both the public and private hospi-
tal staff and institutes
Promotion of Education,
Training and Research
The Journal of the Medical Association
of Thailand has a long history of publica-
tion and it is the only Medical Journal of
the country which is included in the Index
Medicus. Today it has been developed and
improved to meet the needs of the members
at monthly distribution.
The Medical Association of Thailand with
the collaboration of Takeda Science Foun-
dation has granted funds for its members
to continue their education in Japan. The
funds are granted in 3 groups: 3 months for
three, 6 months for two, and 1–2 years for
one grant-holder. Up to now, the funds had
been granted to 155 recipients.
Three more separate funds have been grant-
ed to members of the Medical Association
of Thailand, “Dr. Prasert Prasartthong-oso-
th Fund” Dr. Prasert Prasartthong-osoth is
a member of the association who graciously
donated a sum of 1,000,000 (one million)
Thai Baht to the association every year to
Regional and NMA news
promote the research for the benefit of the
Thai Medicine and to create innovations to
serve the health care of the national and in-
ternational level. Up to now, 37 researchers
working on 40 projects had been beneficia-
The Medical Association of Thailand itself
also provides a grant for the research on de-
velopment of the primary health care and
development of health care provision.
Promotion of the “Best Performance”
to Doctors Who Had Dedicated
Themselves to the Communities
“Somdej Prawanarat” Award goes to the
doctor, selected by the committee, for dis-
tinguished performance.
The Awards from the Medical Association
go to the doctor for the best performance in
the upcountry hospitals.
Scientific Medical Meetings
Two scientific meetings are routinely con-
vened, one in the periphery and one in
Bangkok together with the administrative
International meetings on various subjects
have also been called from time to time both
in the Medical Associations in the ASEAN
countries (MASEAN) and the Confedera-
tion of the Medical Associations in Asia
and Oceania (CMAAO) communities.
Organization Efficiency
Development Plan
Since 2005, under MAT the Thai Health
Professional Alliance against Tobacco Net-
work has been established,composed of 21
professional organizations. The Network’s
activities are supported by the Bureau of
Health Promotion. The efficiency of the
Network has been well accepted both in the
country and internationally.
The Medical Professional Network for To-
bacco Control has also been established
consisting of 32 executive members to en-
hance the research work in controlling to-
bacco consumption. More than 50 projects
had been granted.
International Contacts
The Medical Association of Thailand has
been working in collaboration with the
international medical and health organi-
zations both in the regions and globally.
Representatives from MAT hold several
administrative posts in international medi-
cal organizations:
Dr.  Songkram Supcharoen: President of
CMAAO: 1987–1989,
Dr.  Kachit Choopanya: the President of
MASEAN and CMAAO: 1997–1999
Prof. Somsri Pausawasdi: President of
CMAAO: 2007–2009
Dr.  Wonchat Subhachaturas: Secretary
General of CMAAO: 1997–1999, Chair
of CMAAO Council: 2007–2011, Advisor
to CMAAO: 2011-Present, 61st
of the World Medical Association: 2010–
and many other roles at the conferences and
Service Efficiency Project
Public Relation and Newsletters for mem-
Health Club Programme on television
channel 9 is aired every Monday–Friday at
09.00–09.30 am with a good rating.
Improvement of membership registration
At present the membership has increased
up to 24,381 for the life members and
5,330 for the Junior members Development
of the modern website 20 new systems
have been developed to meet the needs of
the members. The address of the website of
the Medical Association of Thailand had
been changed from www.medassocthai.org
to www.mat.or.th. The content is adjusted
twice daily. This website includes the elec-
tronic form of the Journal of Medical Asso-
ciation of Thailand that can be traced back
and is directly publishable in the PubMed
educational column, activities, announce-
ments and etc. with more than 10,000 visi-
tors each month.
Social Welfare to Members
For 12 years the Medical Association of
Thailand has been organizing annual trips
to observe the Primary Health care abroad,
e.g. in such countries as Laos, Cambodia,
Malaysia, China, Myanmar, Brunei Darus-
salam, Japan, Nepal, Jordan, Kazakhstan,
Finland a.o.
Association Club
MAT offers 6 furnished accommodation
spaces on the 12th
floor of the Association
building for the members to stay.
The progress and success of the Medi-
cal Association of Thailand are based on
the fruitful and sustainable performance
of our predecessors who had dedicated
themselves to development and facilita-
tion to all members during the past 90
years for the dignity of our Medical Pro-
fession and all members, to be accepted
and respected by the local and interna-
tional communities. We will all follow
the teaching of the King’s Father, Prince
Mahidol Adulyadej, the father of the
modern Thai Medicine and the solidarity
of our Association.
Dr. Wonchat Subhachaturas
President of The Medical
Association of Thailand
Regulation of Health Professions
Regulation of health professions serves nu-
merous purposes and is associated with im-
proved quality of care. Globalization of
health care has prompted discussions of har-
monization of systems of regulation within
various health professions. To inform global
discussion of this issue, the authors developed
an online survey on regulatory environ-
The survey consisted of queries about respon-
dents’ location and profession, followed by
specific questions related to regulation. We
synthesized the survey responses to produce
a final data set consisting of one answer per
country and per profession.
The aggregated data includes 197 responses
from 78 countries representing 22 systems
of regulation for dentists, 38 for doctors of
medicine, 45 systems for nurses, 37 for phar-
macists, and 36 for physiotherapists. Varia-
tions include the type of regulatory bodies,
complexity of systems, the entities that set
rules, and scope of regulation. Collaboration
between governmental bodies and profes-
sional organizations becomes more prevalent
as the number of functions ensured through
the system of regulation increases.
There is significant international diversity
in the systems of regulation for health profes-
sionals. Our data describe more differences
than similarities for systems of regulation
across countries, and illustrate the challenges
of a global movement toward harmoniza-
“It has been said that arguing against glo-
balization is like arguing against the laws of
gravity.” Kofi Annan.
Regulation of health professions serves
numerous purposes, including defining the
scope of competence, ensuring high stan-
dards for entry and practice, and promot-
ing and maintaining professionalism and
ethics. Regulation has also been associated
with better quality of care and improved
patient outcomes in a variety of settings
Globalization of health care has prompted
discussions of harmonization of standards
and systems of regulation within profes-
sions.To advance the discussion about these
issues, the World Health Professions Al-
liance (WHPA), which gathers the global
associations of dentists (World Dental Fed-
eration – FDI), doctors of medicine (World
Medical Association – WMA), nurses
(International Council of Nurses – ICN),
pharmacists (International Pharmaceuti-
cal Federation – FIP), and physiotherapists
(World Confederation for Physical Thera-
py – WCPT), organized the Second World
Health Professions Conference on Regula-
tion (WHPCR 2010) in Geneva on Febru-
ary 18–19, 2010.
The aim of WHPCR 2010 was to shape
the future of health professional regulation
within the context of global health sys-
tems’ redesign and evolving roles, keeping
in mind that public protection should be
Luc Jean René Besançon
Regulation of Health Professions: Disparate Worldwide Approaches
are a Challenge to Harmonization
Paul Rockey Marta van Zanten
Regulation of Health Professions
the primary objective of health professional
regulation. Specific objectives of WHPCR
2010 were to:
• Debate future control and direction of
health professionals’ regulation within
the context of changing scopes of prac-
• Examine regulatory and professional is-
sues related to international migration of
health professionals
• Critically evaluate the relationship be-
tween health professional education, reg-
ulation and standards of practice
The WHPCR 2010 organizers envisioned
that an overview on the current regula-
tion of these five professions would be a
good starting point for debating the future
of regulation (as mentioned in Objective
One). However, we noted that there is a
general lack of knowledge about the sys-
tems of regulation in which health profes-
sions must operate. A few regional or global
comparisons of systems of regulation for
specific health professions have been con-
ducted over the past decade in the fields
of medicine [4–6] and nursing [7], but
little published data were found describ-
ing or comparing systems of regulation in
the fields of dentistry, pharmacy or physio-
therapy. In addition, no study was identified
that had simultaneously collected such data
from multiple countries for these five health
professions. Therefore, to provide a global
overview of the regulation of healthcare
professionals, an online survey was devel-
oped in conjunction with the conference to
collect data on the regulatory environment
of health professions throughout the world.
This study was exploratory; we had no prior
hypotheses regarding the outcomes of the
The online survey consisted of queries
about respondents’ location and profes-
sion, followed by specific questions related
to regulation in five health care professions:
dentistry, medicine, nursing, pharmacy and
physiotherapy.When respondents indicated
knowledge of regulation of one or more of
the five professions for a particular country
they were asked a series of detailed ques-
tions pertaining to the affiliation (e.g., gov-
ernmental or professional) of the regulating
body, the level of regulation (e.g., supra-na-
tional, national, sub-national), and the con-
tact information of the regulator.The survey
prompted consideration of at least eight
potential regulatory activities: 1) accredita-
tion of initial education, 2) registration (or
licensure), 3) investigation, 4) discipline
(or sanction), 5) specialization, 6) re-cer-
tification, 7) accreditation of continuing
education, and 8) practice guidelines. The
survey also queried whether a regulatory
activity was predominantly the responsibil-
ity of the profession (self-regulation), the
government, or was shared. If respondents
mentioned more than one body involved
in regulation, descriptive questions were
repeated for each additional organization.
We also asked about the entity that sets the
rules used by the regulator, the scope and
jurisdiction of the regulating body, and any
additional activities of the regulator. Finally,
free text fields were provided to describe
any unique circumstances in a respondent’s
country or profession.
The survey was available on the WHPCR
website from October 15, 2009 to March
1, 2010, and all WHPCR 2010 registrants
were prompted to complete the survey.
In addition, the five WHPA organiza-
tions encouraged their members and other
knowledgeable individuals to complete the
We synthesized responses to form a data
set consisting of one answer per country
and per profession according to the follow-
ing schema: If more than one individual
from a particular country and profession
completed the survey, for each question
we retained only the answer that was pro-
vided by the majority of respondents. If
respondents provided an equal number of
disparate answers, we retained the answer
given by the respondent employed by the
organization with the broadest jurisdic-
tion. Therefore the final aggregated data
set consisted of just one set of answers to
the survey questions per country and per
Role of the Funding Source
No outside funding was used in this study.
Altogether, there were 292 unique survey
respondents from 78 countries providing
sufficient data for analysis. The final data
set consisted of 197 aggregated responses.
When a specific country has at least one
regulator in place for one profession, we
indentified this as a “system of regulation”.
Existing systems of regulation were report-
ed by 178 (91%) of the aggregated respon-
dents,and nine (5%) indicated that a system
of regulation was about to be implemented.
No regulation was reported by seven (3%)
of the aggregated respondents, and three
(1%) did not know.The aggregated data in-
cluded reports on 22 systems of regulation
for dentists, 38 for doctors of medicine, 45
for nurses, 37 for pharmacists, and 36 for
Income Level
Countries or states represented in the
were classified by income level ac-
cording to the World Bank Atlas Method
(as described on World Bank website:
The countries were divided according
to the 2008 GNI per capita as follows:
<$975 (low income); $976 – $3,855 (lower 1 GDP data was not available for Bermuda, Koso- vo and (China-) Taiwan. These countries and states were excluded from income-level analyses. 130 middle income); $3,856 – $11,905 (upper middle income); >$11,906 (high income).
Figure  1 displays the regulation systems
by profession and income level per capita.
The distribution of systems of regulation
by country income level was similar among
all five professions, and the majority of the
systems of regulation included in this study
are located in high and upper-middle in-
come countries. The presence of a system
of regulation (all professions combined)
is similar by income level of the country.
For low income, lower middle income, and
upper middle income countries, the aggre-
gated responses indicating that a system of
regulation exists ranged from 83% to 86%.
All of the aggregated responses represent-
ing high income countries indicated the
existence of a system of regulation.
Characteristics of Systems of
Models for systems of professional regu-
lation vary around the world. Regulatory
schemes can be developed and administered
by governmental bodies, such as Ministries
of Health or other governmental agencies,
professional organizations (whose gover-
nance is mainly ensured by elected members
of the profession), or a combination of enti-
ties. For the five professions combined, 52%
(n= 95) of the systems of regulation are gov-
ernment-based, 25% (n= 45) are conducted
by non-governmental professional bodies,
20% (n= 37) by a combination of govern-
ment and professional bodies, and 2% (n=4)
unclassified. The types of regulatory bodies
present for the five professions are displayed
separately in Table 1.Across the professions,
there is little variation of the type (govern-
ment, professional body, combination) of
the regulatory bodies. Government-related
regulators ranged from 47% of systems for
nurses to 59% for dentists and physiothera-
pists. The frequency of professional bodies
administering the regulation system ranged
from 14% for physiotherapists to 33% for
18% 20%
18% 18% 20%
18% 15%
14% 17%
50% 44%
37% 44%
of medicine
Nurses Pharmacists
No classi cation
High income (OECD and
non OECD)
Upper middle income
Lower middle income
Low income
Figure 1. Aggregated respondents by profession and country income level
Table 1. Government vs. professional self regulation within each system of regulation across the
five professions
Doctors of
A combination
(A) professional
Number of systems 22 39 45 38 37 181
Table 2. Government vs. professional self regulation by WHO-based geographic region
Government- regulators
A combination
(A) professional body(ies)
Number of systems 29 15 68 24 10 30 181
African region (AFRO); Eastern Mediterranean region (EMRO); European region (EURO);
Region of the Americas (PAHO); South-East Asia region (SEAR); Western Pacific region (WPO)
Regulation of Health Professions
Our preliminary analysis of systems of
regulation showed much greater differences
among countries than among the five pro-
fessions within a country. In fact, we ob-
served strong similarities and concordance
of system of regulation for any of the five
professions within an individual country.
Therefore, we made several analyses using
countries as the unit of analysis.
To see if there were major regional dif-
ferences (based on geography and cul-
ture) among the administration of systems
of regulation, we grouped the countries
based on the World Health Organization
(WHO) geographic regions. Table 2 dem-
onstrates that there is significant variation
worldwide in the control of systems of reg-
ulation based on these geographic regions.
Government administration of systems of
regulation ranges from 25% in the Americas
to 80% in the Eastern Mediterranean, and
professional organization-affiliation ranges
from 3% in the Western Pacific to 50% in
the South East Asian region.
In contrast, country income level appears
to have only a moderate relationship with
the affiliation of the regulatory bodies
(Table 3). Governmental regulation ranged
from 37% in upper middle income coun-
tries to 52% in lower middle income coun-
tries. Professional administration of regu-
lation ranged from 15% in lower middle
income countries to 37% in upper middle
income countries.
Complexity of Systems of Regulation
Worldwide, there is wide variability in how
individual countries organize health care
professions regulation systems, and differ-
ences in the overall complexity of particu-
lar systems. In some countries, there is one
centralized system that controls and man-
ages a specific profession (or more than one
profession); in other countries, numerous
regulators have authority within one sys-
tem.To investigate the relationship between
organization of a country’s government and
the complexity of systems of regulation,
we compared the number of regulators,
the number of regulation systems, and the
number of regulators per system for federal
versus non-federal countries. We defined
a federal country as a sovereign country
characterized by a union of partially self-
governing political entities (regions, states,
provinces) united by a central (federal)
government. Countries that are considered
federal are indicated with an (*) in the Ap-
Across all five professions and countries,
there is an average of 3.92 regulators per
regulation system.In federal countries com-
bined, there is an average of 10.83 regula-
tors per regulation system, compared to an
average of 1.13 regulators per system in all
non-federal countries.
In addition to the relationship between the
number of regulators and the type of po-
litical organization of a country, we also
investigated the influence of country in-
come level on the complexity of systems of
regulation. The numbers of regulators were
compared against World Bank country in-
come level (Table 4), demonstrating that
complexity increases appreciably in coun-
tries with higher income levels.
To further investigate the impact of a
country’s governmental structure on regu-
lation of health professionals, the survey
included a question regarding the level of
regulation (e.g., supranational, national,
Table 3. Government vs. professional self regulation across all professions by country income level
High income
(OECD and
non OECD)
related regulators
A combination
(A) professional
Number of
34 26 30 86 5 181
Table 4. Numbers of regulatory bodies across all professions by country income level
Number of
Number of
systems of
Number of regulatory
bodies per system of
Low income 110 34 3.24
Lower middle income 94 26 3.62
Upper middle income 19 30 0.63
High income (OECD
and non OECD)
482 86 5.60
No classification 4 5 0.80
Total 709 181 3.92
Regulation of Health Professions
or sub-national levels). We compared the
levels of the systems of regulation between
federal and non-federal countries (Figure
2). Non-federal countries were more likely
to have systems of regulation conducted
at the national level compared to federal
countries. In contrast, a large segment of
systems of regulation in federal countries
are conducted at the state or provincial
level, or a combination of sub-national and
national levels.
Who Sets the Rules?
The survey also included a question on the
entities that determine the rules that are
subsequently implemented and enforced
by the regulatory bodies. Results of the
survey demonstrate that even in settings
where systems of regulation are ensured by
professional bodies, the entities that set the
rules are frequently governmental, such as
the Ministries of Health, other government
agencies, or the Parliament. In fact, in 41%
of these systems the rules or laws are actu-
ally solely determined by governmental leg-
islation or Ministry decrees. Only 35% of
professional body-affiliated regulators set
their own rules, and 24% use a combination
of self-determined and governmental rules.
Scope of Regulation and Hierarchy
of Regulatory Activities
The final section of the survey included
several questions related to the various
activities conducted by regulatory bodies.
Participants were then given a list of po-
tential functions and requested to indicate
which of these activities were conducted by
the regulatory body. Across all five profes-
sions , 96% of the aggregated respondents
indicated that regulators were involved
with the activity of registration, 81% in-
dicated discipline, 72% investigation, 70%
recertification, 61% practice guidelines,
53% specialization, 45% accreditation of
initial education, and 43% accreditation of
continuing education.
Figure 3 displays the specific functions car-
ried out by systems or regulation according
to the number of functions engaged by each
system. This figure shows a hierarchy of
functions, indicating that across systems of
regulation for all professions, there is a clear
pattern of the specific functions engaged in
by regulators based on the number of func-
tions in their scope. For example, almost
all regulatory bodies, even those that only
engage in one or two functions, handle reg-
istration. As systems of regulation broaden
their scope and undertake additional func-
tions, these responsibilities are generally
increased in a hierarchical manner (e.g.,
discipline is the next most common func-
Both at
nal level
I don’t
Non Federal countries
Both at
nal level
I don’t
Federal countries
Figure 2. Level of systems of regulation by Non-Federal versus Federal countries
1–2 7–85–63–4
Figure 3. Specific function by number of functions engaged by regulatory bodies
Regulation of Health Professions
tion, followed by investigation and recerti-
fication). Only those regulatory bodies that
engage in seven or eight functions are likely
to do accreditation of continuing education
and regulation of practice guidelines.
Figure 4 demonstrates that as systems of
regulation engage in an increasing number
of functions, the system is more likely to
involve professional organizations. Specifi-
cally, if the system of regulation is perform-
ing only one or two functions, professional
organizations are involved in the process in
only 4% of countries and share responsibil-
ity in another 17%. However, if a system in-
cludes seven or eight functions, professional
bodies are primarily responsible for 36% of
the systems of regulation and share respon-
sibility in another 22%.
Based on the survey results, the specific
functions carried out by systems of regula-
tion vary depending on the type of regula-
tors. For example, certain functions, such
as discipline, investigation, recertification,
practice guidelines, and specialization, ap-
pear to be more frequently conducted if
the regulatory body includes a professional
organization. Table 5 displays the functions
carried out by various systems of regulation
stratified by the type of regulator.
Globalization is increasing in all areas of
human endeavor, including health care.
With international migration, advances
in technology, instantaneous communica-
tion and improved transportation these
trends will accelerate. Within the context
of movements towards harmonization of
health professions regulation, our survey
results support several conclusions regard-
ing regulation worldwide. Systems of regu-
lation are highly variable across countries
while being generally similar among the
five professions within a given country, and
the number and type of regulators in sys-
tems of regulation are a reflection of type
of government, wealth of nation, and region
of the world. Systems of regulation appear
to have a hierarchy of functions, with ba-
sic systems almost always including regis-
tration (licensure) and discipline, and only
more complex systems including roles such
as accreditation of initial or continuing pro-
fessional education and regulation of prac-
tice guidelines. Also, as systems of regula-
tion become more complex (e.g., administer
seven, eight or more functions) the level of
collaboration between governmental and
professional regulators increases. Also, even
in systems described as self-regulated by the
profession, governmental organizations fre-
quently determine the rules that are in turn
implemented by the professional body.
Several challenges to potential harmoniza-
tion efforts are evident based on our results.
For example, although elements of regula-
tion may be transportable from one nation
to another (e.g., tests used for initial licen-
sure or examinations used to certify knowl-
edge within a professional specialty), regu-
lators should consider how such elements
43% 41%
4% 4%
1–2 Functions 3–4 Functions 5–6 Functions 7–8 Functions
Professional body
Ministry of Health
Figure 4. The regulators involved in a system of regulation by the number of regulatory functions
Table 5. The regulators involved in a system of regulation by the number of regulatory functions
Government based Combination Professional body
Functions % % %
Registration 96% 97% 97%
Discipline 80% 78% 95%
Investigation 66% 81% 84%
Recertification 68% 72% 84%
Practice Guidelines 49% 69% 86%
Specialization 46% 61% 68%
Accreditation Initial
41% 56% 49%
Accreditation Continuing
41% 36% 54%
Regulation of Health Professions
will be introduced and integrated with the
existing system of regulation. Standardized
“recognition of qualifications” may make it
easier to achieve harmonization for basic
functions such as licensure/registration.
Differences among countries between
scopes of practice may also complicate com-
petence measures within professions. Varia-
tions in levels of access to technology and
expensive therapies will affect measures of
professional competence, the creation and
implementation of clinical guidelines and
the content of specialty examinations. For
example, treatment of chronic diseases such
as those related to obesity (diabetes, hyper-
tension, hyperlipidemia) prevail in affluent
countries whereas developing countries face
more often widespread infectious and para-
sitic diseases.
Harmonization of regulation has often fo-
cused on the cross-border recognition of
professional qualification (diplomas, spe-
cialties, etc.,) both in Europe and North-
ern America, with some systems imple-
mented to ensure such recognition [7, 8].
However, to date little attention has been
given to studying the competent authori-
ties (regulators) and their diversity (e.g., in
numbers, in tasks, in governance) and the
increased importance of investigating the
practical feasibility of expanding systems
of recognition in regions with different
models of regulation. For instance, in the
27 member states of the European Union
and for medical doctors, pharmacists, nurs-
es, midwives and dentists, it is estimated
that there are at least 900 regulators, while
at the same time, there is no common Eu-
ropean definition of a regulator nor an of-
ficial register of these regulators [9]. Such
diversity, complexity, and potential redun-
dancy in tasks will likely lead to difficulties
when authorities need to work together to
ensure validation of the data provided by
healthcare professionals.
In addition, variability in the implementa-
tion of disciplinary sanctions can complicate
Country Number
for Den-
Answers for
Doctors of
for Phar-
Answers for
Low income 40 4 8 14 7 8
Afghanistan 2 × ×
Bangladesh 3 × × ×
Burundi 1 ×
Ethiopia* 5 × × × × ×
Ghana 5 × × × × ×
Malawi 5 × × × × ×
Mali 1 ×
Nepal 3 × × ×
Nigeria* 5 × × × × ×
Pakistan* 1 ×
Rwanda 4 × × × ×
Senegal 1 ×
Tanzania 2 × ×
Viet Nam 2 × ×
Zimbabwe 1 ×
Lower middle income 29 4 6 7 7 5
Albania 1 ×
China 1 ×
El Salvador 1 ×
Georgia 1 ×
India* 5 × × × × ×
Iraq* 1 ×
Jordan 1 ×
Macedonia 2 × ×
Marshall Islands 1 ×
Mongolia 1 ×
Philippines 5 × × × × ×
Samoa 5 × × × × ×
Sudan* 1 ×
Swaziland 1 ×
Syria 2 × ×
Upper middle income 35 3 7 10 8 7
Argentina* 2 × ×
Belarus 1 ×
Botswana 2 × ×
Brazil* 2 × ×
Costa Rica 1 ×
Croatia 5 × × × × ×
Fiji 3 × × ×
Jamaica 1 ×
Libyan Arab Jamahiriya 1 ×
Mexico* 2 × ×
Russian Federation* 1 ×
Serbia 5 × × × × ×
Regulation of Health Professions
efforts towards harmonization, as the capa-
bility of a regulator to transmit information
to a foreign authority is limited by regula-
tor protocols and the national law on pri-
vacy. While some countries would expect
to receive the complete disciplinary file
of a migrating healthcare professional, in
many countries only current sanctions can
be transmitted. The inclusion as part of the
health professionals’official record past sanc-
tions that have been completed varies across
regulators. Similarly, regulators are limited in
their capability to share cases under current
investigation and/or appeal.
While we strived to collect valid informa-
tion on the regulation of health care profes-
sions from a worldwide representative sam-
ple across five professions, there are several
limitations to these survey data. We did not
verify the accuracy of the answers provided
by survey respondents. This was mitigated
somewhat by our method of data synthesis
(e.g., retaining only the answers provided
by the majority of multiple respondents),
but we did not independently validate the
data or adjudicate discrepancies. The survey
instructions did not provide definitions of
various terms, and therefore the same term
could have different meanings across coun-
tries. For example, in Northern Europe and
the United States, “registration” of pharma-
cists documents fulfillment of educational
and competence requirements and a phar-
macist’s capability to practice pharmacy
legally. In contrast, in Southern Europe,
pharmacists can only “register” if, in addi-
tion to the educational and competence re-
quirements, they actually practice pharmacy
in an authorized pharmaceutical outlet; if
they stop practice they are removed from
the registry and cannot be re-registered un-
til they resume a professional activity.
We received survey responses from 78
countries and do not know if these results
are representative of all countries. It is pos-
sible that countries with more effective sys-
tems of regulation are over-represented.The
survey was provided only in English, per-
Country Number
for Den-
Answers for
Doctors of
for Phar-
Answers for
South Africa 2 × ×
Turkey 5 × × × × ×
Uruguay 2 × ×
High income: non
23 3 5 6 3 6
Bahamas 3 × × ×
Bahrain 4 × × × ×
Cyprus 1 ×
Israel 4 × × × ×
Kuwait 1 ×
Malta 1 ×
Qatar 1 ×
Saudi Arabia 1 ×
Singapore 4 × × × ×
Slovenia 1 ×
Trinidad and Tobago 2 × ×
High income: OECD 65 8 13 13 14 15
Australia* 5 × × × × ×
Belgium* 1 ×
Canada* 5 × × × × ×
Denmark 4 × × × ×
Finland 5 × × × × ×
France 2 × ×
Germany* 1 ×
Ireland 2 × ×
Italy 3 × × ×
Japan 1 ×
Netherlands 4 × × × ×
New Zealand 4 × × × ×
Norway 3 × × ×
Portugal 4 × × × ×
Spain 1 ×
Sweden 5 × × × × ×
Switzerland* 3 × × ×
UK* 5 × × × × ×
USA*† 5 × × × × ×
No Classification from
World Bank
5 0 2 1 0 3
Bermuda 1 ×
(China-)Taiwan 2 × ×
Kosovo 3 × × ×
Grand Total 197 22 41 51 39 44
* Federal country
† The term ‘Doctors of Medicine’ for the United States applies to both allopathic and os-
teopathic physicians, who have equal practice rights.
Regulation of Health Professions
haps deterring responses from non-English
speaking countries. In addition, based on
several instances of incongruity within the
survey results, it appears that respondents
in several countries and professions do not
always have a clear understanding of the
composition, affiliations, and roles of the
regulatory bodies governing their profes-
Our point of analysis was at the country
level, but systems of regulation can vary
substantially within countries and across
various states/provinces. Collapsing data at
the country level may have obscured some
differences. Finally, we only reported on the
existence of systems of regulation and vari-
ous functions thought to be implemented
by the regulators. The scope of the survey
did not include gathering information on
the actual execution, efficiency, or success
of the various activities associated with the
regulatory bodies.
Over time, each of these five health profes-
sions has delegated multiple tasks to assis-
tants with lesser training. Such allied health
workers are developing systems of regula-
tion as well. This study provides no infor-
mation about the regulation of such allied
health workers or their systems of regula-
tion, a needed area of further research.
Our data describes the significant differenc-
es among countries in the systems of regula-
tion for health professionals. Although glo-
balization is rapidly advancing in all spheres
of human endeavor, the regulatory systems
controlling the health professions are very
disparate and may not be amenable to rapid
harmonization. These efforts should take
into account the diversity of current system
of regulations to evaluate the feasibility of
harmonization, as similar concepts may
be understood differently throughout the
world and regulation systems vary in orga-
nization and roles.
Competing Interests
The authors declare that they have no com-
peting interests.
Author Contributions
LB led in the development of the question-
naire, ensured the collection of data (via an
online tool),collaborated in the analysis and
interpretation of data, and assisted in draft-
ing and reviewing the manuscript. PR col-
laborated in the design of the initial survey,
analysis and synthesis of the data,and draft-
ing and reviewing the manuscript. MvZ as-
sisted in data synthesis and drafting and
reviewing the manuscript.
1. Holmboe ES, Wang Y, Meehan TP, Tate JP,
Ho SY, Starkey KS et al.: Association between
maintenance of certification examination scores
and quality of care for medicare beneficiaries.
Arch Intern Med 2008; 168(13):1396-1403.
2. Pringle M.: Regulation and revalidation of doc-
tors. BMJ 2006; 333(7560):161-162.
3. Flook DM.: The professional nurse and regula-
tion. J Perianesth Nurs 2003; 18(3):160-167.
4. Rowe A, Garcia-Barbero M.: Regulation and
Licensing of Physicians in the WHO European
Region. 2005. Copenhagen, Denmark, World
Health Organization.
5. de Vries H, Sanderson P, Janta B, Rabinovich
L, Archontakis F, Ismail S et al.: International
comparison of ten medical regulatory systems.
Rand Corporation, editor. 2009. Cambridge,
UK, Rand Europe.
6. Shaw K, Cassel CK, Black C, Levinson W:
Shared medical regulation in a time of increasing
calls for accountability and transparency: com-
parison of recertification in the United States,
Canada, and the United Kingdom. JAMA 2009;
7. International Council of Nurses. The Role and
Identity of the Regulator: An International
Comparative Study. Benton DC, Morrison A,
editors. 2009. Geneva, Switzerland, Internation-
al Council of Nurses.
8. Young A, Chaudhry HJ, Rhyne J, Dugan M: 
A Census of Actively Licensed Physicians in the
United States, 2010. Journal of Medical Regula-
tion 2011;96(4):10-20.
9. Hawkins RE, Weiss KB. Commentary: Build-
ing the evidence base in support of the Ameri-
can Board of Medical Specialties maintenance
of certification program. Academic Medicine
10. HPROCard. Workpackage 1: Identification
of the competent authorities and the author-
ized organisations in charge of issuing con-
tinuing education and training for healthcare
professionals in the European Union Member
States  – Deliverable 1: List of competent au-
thorities for healthcare professionals in each Eu-
ropean Union Member State. Report published
in 2009. Available at: http://www.hprocard.eu/
[latest access on 2011 Oct 11].
Luc Jean René Besançon,
International Pharmaceutical
Federation (FIP)
Andries Bickerweg 52517 JP
The Hague The Netherlands
E-mail: luc@fip.org
Paul Rockey,
American Medical Association (AMA)
515 N. State Street Chicago, IL 60654
United States of America
E-mail: Paul.Rockey@ama-assn.org
Marta van Zanten (Corresponding author)
Foundation for Advancement of International
Medical Education and Research (FAIMER)
3624 Market Street
Philadelphia, PA 19104
United States of America
E-mail: mvanzanten@faimer.org
Regulation of Health Professions
SOUTH AFRICA Healthcare Reform
Over three decades ago, signatories to the Al-
ma-Ata Declaration noted that Health for All
would contribute not only to a better quality of
life but also to global peace and security. They
gave recognition to the fact that promoting and
protecting health is essential not only for hu-
man welfare but also for sustained economic
and social development [1]. In 1996 the Con-
stitution of the Republic of South Africa, in its
preamble, established its constitutional impera-
tive to improve the quality of life for all citizens
and to free the potential of each person. Section
27 of the Bill of Rights of the Constitution af-
firms that everyone has the right to have access
to health care services, including reproductive
health care. Section 27 places an obligation
on the state to take reasonable legislative and
other measures within its available resources
to achieve the progressive realisation of this
right [2]. In 2004, the National Health Act
[3] was promulgated to provide a framework
for a structured and uniform health system that
took into account the obligations imposed by
the Constitution. The Act identifies in its pre-
amble inter alia the socio-economic injustices,
imbalances and inequities of health services of
the past, the need to establish a society based on
social justice and fundamental human rights,
and the need to improve the quality of life for
all in the country as the background context for
its enactment. Section 3 of the Act places the re-
sponsibility for the provision of health care onto
the shoulders of the Minister of Health. One of
the objectives of the Act is the provision of the
best possible health services that available re-
sources can afford in an equitable manner for
the population of South Africa.
In its 2000 Report, the World Health Or-
ganization (WHO) stated that the govern-
ment carried the ultimate responsibility for
the overall performance of a country’s health
system and that all sectors in society should
be involved in working towards positive out-
comes under the government’s stewardship.
Managing the well-being of the population
carefully and responsibly is the very essence
of good government. The best and fairest
health systems possible with the available re-
sources need to be established.‘The health of
the people is always a national priority: gov-
ernment responsibility for it is continuous
and permanent. Ministries of health must
therefore take on a large part of the steward-
ship of health systems [4].’
In August 2011, the Green Paper on the
National Health Insurance (NHI) [1] was
released for debate and comment by all in
the country.The proposed NHI is a step to-
wards health care reform as espoused in the
Constitution and the National Health Act
and a move towards the Alma-Ata’s Health
for All. The seven principles of the NHI,
i.e. the right to access, social solidarity, ef-
fectiveness, appropriateness, equity, afford-
ability and efficiency, could be interpreted
as the value assumptions of the proposed
reforms.The objectives of the NHI are:
1. To improve access to quality health ser-
vices for all
2. To pool risks and funds in order to
achieve equity and social solidarity
3. To procure services on behalf of the en-
tire population and to efficiently mobilise
and control key financial resources, and
4. To strengthen the public health sector
so as to improve health systems perfor-
Major reform in health financing is required
if these objectives are to be realised.In 2005,
member States of the WHO committed to
develop their health financing systems so
that the goals of universal coverage would
be achieved m [1]. The WHO identified
three fundamental, inter-related problems
that restrict countries from moving closer
to universal coverage. The first was the
availability of resources. Even the richest
of countries have not been able to ensure
that everyone has immediate access to every
technology and intervention that may im-
prove their health. Over-reliance on direct
payments at the time that people need care
was another barrier to universal coverage.
Even where some form of health insur-
ance is available, patients may still need to
contribute, e.g. in the form of co-payments
or deductibles. Many are prevented from
receiving health care because of the need
for direct payments. Others are driven into
poverty and financial ruin because of this.
Inefficient and inequitable use of resources
was the third obstacle impeding the passage
towards universal coverage. A conservative
estimate placed the wastage of health care
resources at 20–40% [1]. Corruption could
be added to this list as a fourth hurdle, as is
the case in South Africa. Corruption erodes
10% of all health expenditure in South Af-
rica, and within the private sector this is es-
timated to be between R5 and R15 billion
yearly [6]. At the recent National Health
Insurance Conference: Lessons for South
Africa (National Consultative Health Fo-
rum), [7] views expressed by members
of the World Bank, the WHO and lead-
ing health economists in the country were
that the financing of universal coverage is
not beyond the reach of South Africa, as
Healthcare Reform in South Africa:
a Step in the Direction of Social Justice
Ames Dhai
SOUTH AFRICAHealthcare Reform
currently funds are available within the sys-
tem. However, what is urgently required is
the efficient management and use of the
funds coupled with the elimination of cor-
ruption. In addition, employment taxation
together with other innovative methods of
revenue collection will be necessary.
Reforming the healthcare financing system
in South Africa dates back as early as 1928
when a Commission on Old Age Pension
and National Insurance recommended the
establishment of a health insurance scheme
to cover medical, maternity and funeral
benefits for all low-income formal sector
employees in urban areas. In 1935, similar
proposals were recommended by the Com-
mittee of Enquiry into National Health
Insurance. Between 1942 and 1944, the
National Health Service Commission (also
known as the Gluckman Commission) was
set up.It recommended the implementation
of a National Health Tax that would allow
for the provision of free health services at
the point of delivery for all South Africans.
Health centres providing primary care ser-
vices were to be core to the health system.
Some of the recommendations were imple-
mented, but gains from these were reversed
after the National Party government was
elected in 1948. The Health Care Finance
Committee of 1994 recommended that all
formally employed individuals and their
immediate dependants initially form the
core membership of social health insurance
arrangements, which would be expanded to
cover other groups over time.More work on
this was done by the Committee of Enquiry
on National Health Insurance (1995), the
Social Health Insurance Working Group
(1997), the Committee of Enquiry into a
Comprehensive Social Security for South
Africa (2002) and the Ministerial Task
Team on Social Health Insurance (2002).
In 2009, the Ministerial Advisory Com-
mittee on National Health Insurance was
established with the objective of providing
recommendations on relevant health sys-
tems reforms and matters relating to the
design and roll-out of a National Health
Insurance as per Resolution 53 passed at
the ANC’s conference in Polokwane in De-
cember 2007.5 While several committees,
commissions and working groups have been
established since 1994 to work towards a
way forward for universal coverage, display-
ing positive political will in this direction,
it has only been under the stewardship of
the current Minister of Health that posi-
tive political commitment towards Health
for All has materialised.The two areas to be
worked on as a priority, as articulated by the
Minister, are improving the quality of care
in the public sector and decreasing the cost
of private health care [7].
While we embark on the journey towards
universal coverage, it is important to re-
member that there are also other barriers
to accessing health services. Proper financ-
ing will help poor people obtain care, but
will not guarantee it. Lack of transport and
transport costs would also pose an impedi-
ment to access. In addition, other social de-
terminants are a prerequisite for ensuring
the attainment of health,e.g.food and clean
water. Because health is so dependent on
its social determinants, it cannot be viewed
as a silo. It will be imperative for the other
ministries to come on board, and perhaps
the comprehensive package to be offered
by NHI should include some of the social
determinants. In addition, while we have so
many highly skilled and dedicated people
working at all levels to improve the health
of our people, we also have the harsh reali-
ties of severe shortages of human resources
and health care workers with poor attitudes,
in part because of the conditions that they
find themselves in.
The Green Paper, which outlines broad
policy proposals for the implementation of
NHI,is currently undergoing a consultation
process where public comment and engage-
ment with the broad principles are encour-
aged. This will be followed by the policy
document or the White Paper. Thereafter
draft legislation will be developed and pub-
lished for public engagement before being
finalised and submitted to Parliament for
consideration as a Bill. Health reform as
proposed by NHI is history in the making,
and it is vital that we as citizens of South
Africa engage with and interrogate the
document and all the subsequent processes
that follow. There are a number of positive
aspects to the Green Paper. There are also a
number of concerns and insufficient clarity
on some extremely important issues.
The indicator of success of NHI will be the
achievement of universal coverage. Under
discussion at the moment is not whether
NHI should be implemented, but how this
should be done and what method of financ-
ing would be the most fair. Trade-offs will
be inevitable.This is the experience in coun-
tries that have achieved universal coverage
and financial security for their people. The
trajectory is going to be long and challeng-
ing, but worth it for the future of our coun-
try and its people.
1. The World Health Report 2010. Health Sys-
tems Financing. The path to universal cover-
age. http://www.who.int/whosis/whostat/EN_
WHS10_Full.pdf (accessed 1 December 2011).
2. The Constitution of the Republic of South Africa.
3. The National Health Act No 61 of 2003.
4. The World Health Report 2000. Health Sys-
tems: Improving Performance. https://apps.
who.int/whr/2000/en/report.htm (accessed 1
December 2011).
5. Green Paper: National Health Insurance in
South Africa. http://www.hst.org.za/publica-
south-africa (accessed 1 December 2011).
6. Haywood M. Civil Society Perspectives on NHI
and Innovative Funding. Paper delivered at the
National Health Insurance Conference: Lessons
for South Africa. National Consultative Health
Forum (NCHF). Gallagher Conference Centre,
7–8 December 2011.
7. The National Health Insurance Conference:
Lessons for South Africa. National Consultative
Health Forum (NCHF). Gallagher Conference
Centre: 7–8 December 2011.
Ames Dhai
Editor of SAJBL
December 2011, Vol. 4, No. 2.
Regional and NMA newsTURKEY
Background Information
Physicians are having a hard time all
over the world. They lose their job secu-
rity while their salaries are decreasing, and
the social status of the profession is being
eroded gradually. Violence against health-
care workers is so common that it is now
considered normal to hear about a new
incident nearly every day. On the other
hand, the conditions are not any better on
patients’ side. While their rights have been
promoted and enforced by legal regulations
significantly in the last decades, paradoxi-
cally their access to the services they need
is decreasing. What is happening? What is
being changed in this period, what are the
dynamics behind this widespread turmoil?
The short answer to the big question is the
commercialization of healthcare services,
and Turkey is no exception.
The last 30 years passed witnessing the
structural crisis of capitalism, and neo-
liberal policies recommended by the In-
ternational Monetary Fund (IMF,) the
World Bank (WB) and the World Trade
Organization (WTO) were introduced as a
global solution. Neo-liberal theory is based
on the idea of maximizing the size and the
frequency of market mobility and as such it
tries to include all human activities in the
efficiency area of the market [8]. Through
the Washington Consensus between IMF
and WB, the structural adaptation pro-
grams of IMF, and WTO agreements such
as GATS and TRIPS, public services were
reorganized according to market economy,
while nation-states withdraw from their
public responsibilities. Mass privatization
of public properties and services is the main
characteristic of this period.
Like other services such as education,
communication, energy, and transporta-
tion, healthcare services were affected tre-
mendously by commercialization policies.
A “reform”project of the World Bank was
implemented in Turkey under the name
of “Transformation in Health”. The proj-
ect aims to transform the organization, fi-
nancing and provision of healthcare from
a public to a private model. The coverage
of accessible health care provided by the
social insurance system became narrower
and health is no more considered as a right
of citizens. Centers for primary health-
care were transformed into family physi-
cians’ private clinics, and public hospitals
have become autonomous institutions that
are administrated by professional execu-
tive boards. The private sector is financially
supported by public funds, and public ser-
vices are increasingly provided according
to demand and the ability to pay rather
than the need. Competition, performance,
productivity, and cost effectiveness have
become the leading factors that determine
the amount and quality of services provided.
Reimbursement policies are also based on
cost effectiveness rather than quality. Man-
agers of public healthcare institutions must
now learn to buy, sell and compete with
the private sector and to prioritize cost ef-
fectiveness over their patients’ best interests
On the other hand, working conditions of
healthcare workers have changed funda-
mentally. In a very broad spectrum from
production relations to modes of employ-
ment, they have lost many of their rights.
Health workforce was treated as an ordi-
nary commodity in the market; and through
flexible working, job insecurity and subcon-
tracting exploitation of the workforce be-
came more evident. The effectiveness, effi-
ciency, profit making criteria are used as a
tool of control, and if these criteria are not
met the contracts of health workers would
not be renewed. Physicians are compelled
Protesting a System which “Evaluates the Price
of Everything, but cannot Appreciate the Value
of Them”
Feride Aksu Tanık Murat Civaner
Regional and NMA news TURKEY
to work on the basis of performance-based
incentives, which shorten the examining
time per patient and increase the number
of working hours in a day. Health workers
have accepted longer working hours and
heavier workload for lower salaries under
the threat of losing their job and becoming
unemployed.This proves that, in fact, health
workers are compelled to act like that. [12].
In the end, the working life in health sector
has been transformed from independency
to dependency, from qualified and highly
prestigious roles to lesser prestigious roles,
and from economic prosperity to poverty
Another effect of the commercialization
process on physician’s working condi-
tions is that their professional autonomy
was severely compromised. As the cost-
effectiveness became the central measure,
reimbursement policies solely based on
costs were implemented through treatment
protocols, diagnosis related groups, restric-
tions on prescriptions, global budgeting for
healthcare, and narrowing the coverage of
insurance packages. This was clearly an as-
sault to the clinical autonomy of physicians,
simultaneously violating the right of access
to healthcare. The art of medicine which
brings together the knowledge and expe-
rience of the physician, the possibilities
of medicine and the needs of the patient,
started to disappear, and the profession has
been transformed from a kind of craft into
a business entrepreneurship [1].A few phy-
sicians have become capitalists, but many
of them are under the control of capital
and became proletarian [12]. This internal
polarization process differentiated physi-
cians, dissolved them and they fell apart
from solidarity. Physicians are squeezed be-
tween their personal benefits, social rights
and professional values. The team solidar-
ity broken by the performance based pay-
ment made physicians rival one another,
made them strangers, even enemies to
other health workers. It destroyed human
relationships in health team. Healthcare
workers have been alienated from each
other, from their work, and from patients.
In a way, they have been atomized and iso-
lated [1].
TMA and “Many Voices –
One Heart Campaign”
The Turkish Medical Association (TMA) is
the country-wide professional organization
of physicians in Turkey. It was set up by a
law dated 1953, which gives it the author-
ity of regulating the profession. At present
90,000 of 120,000 physicians are mem-
bers, although compulsory membership
was lifted except for physicians who work
in the private sector, after the military coup
in 1980.TMA is interested in all health re-
lated problems and carries out its activities
with its members working on voluntary ba-
sis [2]. The mission of the Association is to
ensure that the profession is practiced so as
to promote the benefit of public in general
as well as each individual, and to protect the
rights of physicians.
Particularly after 2003, TMA paid more
attention to defending professional rights,
as the system which “evaluates the price of
everything, but cannot appreciate the value of
them” was increasingly becoming a major
threat to the profession as well as public
health. Its struggle against the dominant
policies that devalue the labour of physi-
cians was well-accepted by physicians, and
marked in the official statements of the
Ministry of Health as “TMA’s intensive and
noisy opposition”. In addition to presenting
draft laws and opinion on personal rights
and benefits of health workforce,TMA also
organizes demonstrations and other actions
including stopping working temporarily.
In spite of this struggle, the government
continued its policy of commercializing
healthcare. The government decreased the
access to health care by minimum health
packages and increasing co-payments, com-
mercialized the public hospitals through
financial interventions, manipulated the
modes of working,destroyed peace in work-
ing relations by performance based payment
and flexible working, seized the university
hospitals through financial constraints, in-
creased the numbers of students of the
medical schools at the expense of decreasing
the quality of medical education.
After all these policies and regulations
passed through the National Assembly and
became the new legal enforcements for all,
TMA decided to carry out a massive cam-
paign called “Many Voices, One Heart”.
The campaign was basically demanding
ceasing privatization policies in order to be
able to practice our profession respectfully
according to professional values (or “good
doctoring”), and to be able to provide good
quality healthcare services by respecting the
right to healthcare.These demands were not
new; TMA has been carrying out its strug-
gle on the basis of defending the right to
health and professional rights for decades.
So the main themes of the campaign were
defined as democratization, peace, the right
to health and professional rights [1].
A holistic analysis of actual conditions has
been made together with a vision for the
future. Today, physicians are fragmented,
isolated and turned into strangers to one
another. For this reason, the campaign is
based on different components and stages
in order to understand the subjective needs
of physicians and to put them on the agen-
da. In meetings organized in 44 cities, phy-
sicians came together and discussed their
The campaign started on the day when
the National Assembly was discussing the
health budget. “Budget for health, not for
the capital”was TMA’s main statement.The
campaign brought to the foreground the
following: the economic constraint on med-
ical faculties, commercialization of primary
care, the problems of specialization training
and problems of contractual working in the
private sector, violence against health work-
ers, and the policies diminishing access to
Regional and NMA newsTURKEY
the services needed. The conceptual frame-
work of the campaign was based on five de-
mands. These were job security, income as-
surance, safety of life in terms of protection
from violence against health workers, pro-
fessional autonomy and the right to health.
The first four demands were the basic con-
cepts that physicians otherwise fragmented
would agree on. The demand “the right to
health” was the key word to bring health-
care workers and the people together.TMA
made a call to 65 Chambers of Medicine
and 97 Specialty Associations with a view
to involve them in this struggle. While this
struggle was building up in TMA, several
meetings have been carried out with other
health workers’ unions and associations in
order to enhance unity and solidarity. In-
stead of limiting the demands to physicians’
needs, the campaign invited all healthcare
workers, including the cleaning workers,
nurses, dentists, pharmacists, laboratory
technicians, social workers, to struggle to-
gether with the physicians [1].
Organization of the
Mass Meeting
After arranging several local meetings in
44 cities, it was decided to organize a mass
demonstration in front of the Ministry of
Health building in Ankara. The date was
chosen March 13,as March 14 has been cel-
ebrated as Medicine Day all over the coun-
try for a hundred years and this is the day
that media show interest in the problems of
physicians.Seventeen trade unions and pro-
fessional associations urged their members
to participate. Also, different instruments of
the media were used to spread the call. In
addition to classical methods such as print-
ed materials, e-mail and web announce-
ments, invitation to the mass meeting was
made through a collective singing process.
A professional agency prepared a project of
collective singing, in which a famous song
“I can’t take my words back” was chosen as
the symbol of the invitation and message to
the people. First, individual physicians or
groups of healthcare workers sang the song
and recorded it. Then, all over the country
thousands of healthcare workers, medical
students, and physicians sent their record-
ings to TMA, and those records were ed-
ited to build up a video clip. This video clip
has been clicked on tremendously and had
a very positive effect on people in the sense
that they felt themselves a part of the move-
ment. Collective singing and recording was
a way to bring people together (the clip is
accessible through: tinyurl.com/canttake-
The demonstration on March 13, 2011 was
a great success, with the participation of
more than 30,000 healthcare workers. Or-
ganised by the Turkish Medical Associa-
tion, the demonstration was the biggest in
the Republic’s history on the part of health
workers, and the most enthusiastic and par-
ticipative meeting ever (for a short video:
tinyurl.com/13march). Healthcare workers
protested in the streets of Ankara against
the privatisation policies of the Ministry
of Health which transform physicians into
small entrepreneurs, patients into custom-
ers, and healthcare services into a commod-
ity [6].
Over 30, 000 healthcare workers declared
their demands, and if their demands were
not to be met by the authorities, they de-
clared that they would use their power de-
rived from production.
But, unfortunately, the media coverage was
lower than expected, creating intense disap-
pointment among physicians. Mainstream
media did not cover the protesting at all,
or showed it on screen for a few seconds.
Also, there was nearly no reaction from
the government except the comments of
the Minister of Health, stating that only
a few participated in the demonstration
and they were nothing but “old-fashioned
hardliners”. These developments made the
campaign pass to another phase. TMA to-
gether with ten unions and associations of
healthcare workers announced that they
had aggreed on a two-day general strike in
the country on April 19–20.
During the preparation of the strike, we
witnessed the rising movement of research
assistants.Their urgent demands focused on
the time allocated for training,and the right
to have a day-off after their night duties.
Their slogan was “research assistants are not
slaves”.They were also refusing performance
based payment. This rising movement re-
sulted in many local warning strikes before
the April strike in several provinces. Some
of their demands were met,including a day-
off after night duties.
Preparation of the Strike
While preparing the 19–20 April strike,
TMA made a declaration to the press in or-
der to explain the conditions and problems
lying at the basis of the strike.The rationale
of the strike was explained as:
“The worsening working conditions, enforce-
ment of insecure modes of working, disrespect-
ful manner and discourse of the politicians, the
new laws and the regulations which propose
imperceptible future in the field of health, com-
modification and commercialization of health
The demands have been defined as follows:
“We have common demands with other people
which are to live a decent life. We don’t want to
be the “actor” of a commercialized health care;
we don’t want to become the “employee” of the
low-waged, unsecured, flexible working. As
the honorable members of a profession which
is dedicated to society, we want to do our job
without concerns for the future.
By accepting the right to health, we demand
health for all and secure future. We demand
job security, income assurance, and safety of life
which means protection from violence against
health workers, professional autonomy, and the
right to health.”
Regional and NMA news TURKEY
Thus, the urgent demands were formulated
as fifteen items given below:
• Performance based payment which cre-
ates rivalry instead of solidarity and
transform our patients into bonus score
should be terminated.
• All co-payments, out-of-pocket pay-
ments which commodificates health care
should be eliminated.
• Minimum health package which narrows
the coverage of social insurance and in-
terferes with the professional autonomy
of physicians must be abandoned.
• Medical faculties should maintain their
• Day-off after night duties should be given
to all physicians and the weekly working
time should not exceed 56 hours.
• All healthcare workers should be em-
ployed in secure employment modes.
• TMA should be a party in the contracts
of private physicians working on contrac-
tual basis.
• TMA should have authority in assign-
ment and wage determination of occupa-
tional health physicians.
• Income inequality should be ended
among primary care physicians and they
should be employed securely.
• Necessary arrangements should be made
in healthcare institutions in order to es-
tablish life security, diminish violence
against health care staff and legal regula-
tions should be made urgently.
• The humiliating discourses and attitudes
towards healthcare staff before the media
should be ceased.
• The salaries of physicians should be re-
considered and they should be sufficient
to ensure them decent living and provide
assurance regarding the future.
• Physicians should have the right to self-
• There must be a workplace health unit in
health care institutions.
Health and social workers, radiologic tech-
nologists, subcontracted workers in health
care, laboratory technicians, dentists, nurses,
pharmacists and their professional organiza-
tions joined in this call along with TMA. A
call was made to the public by saying – please,
support this justified struggle by not admit-
ting patients to hospitals on April 19–20. At
the same time the public was informed about
the action that emergencies will be taken
care of as usual; health services will be pro-
vided as it has been done during the holidays.
The Law Office of TMA prepared an evalu-
ation on the legal issues of the strike. They
declared that blaming the participants of a
strike is against the legal arrangements of
the country as well as the European Con-
vention on Human Rights. TMA as a con-
stitutional organization has the resposibility
to share the problems physicians are facing
and make society aware of the health care
problems. They informed the physicians on
possible disciplinary proceedings, second-
ment, temporary assignments and litiga-
tions. The Law Office of TMA declared
that they will be defending the rights of
the physicians who would face problems
because of the strike actions. In addition to
the Law Office’s statement, TMA declared
that “any single investigation about a physi-
cian will be the basis of stronger solidarity.”
Ethical Dimension
The Minister of Health announced that be-
ing on strike endangers patients’ health and
lives, and therefore it would be “immoral”,
let alone its illegality. In fact, there is no in-
ternational consensus whether physicians’
strike is compatible with their professional
duties. There are different points of view
that either support or decline strikes in the
health sector due to different reasons (At
this point, we would like to state that there is a
real need of WMA Declaration on this issue, as
physicians all over the world need guidance ur-
gently in this process of commercialization and
violation of rights). However, TMA takes
the position that strikes would be morally
justifiable under certain circumstances, as it
was stated in its Declaration on Physicians’
Strikes, adopted in 2008 (see Box). Two
rationales, namely, defending the right to
health and protecting professional rights,
may allow physicians to go on strike. On
these grounds, physicians should first try
other ways to make a change, and a strike
should be the last option. Moreover, the
public should be informed in advance about
the reasons of this action and the availability
of services. And providing services should
not be interrupted to certain groups of pa-
tients, i.e. pregnant women, those in need
of urgent care, dialysis patients, persons
with cancer, intensive care patients and in-
patients. When all these preconditions are
met, then TMA confirms the strike to be
in conformity with professional ethics. And
beyond that, under these circumstances de-
fending the right to health and protecting
professional rights that are directly linked
to the right to health, constitute a profes-
sional duty based on social responsibility.
That is why TMA is naming the word strike
as “g(ö)rev” (duty), instead of “grev” (strike).
The April 19–20 strike was very-well justi-
fied in this context. The decision on strike
was shared with the public by announc-
ing that “services will be provided just like on
holidays”. Emergency patients, in-patients
a.o. were taken care of without any disrup-
tion in services,and society mostly supported
the action. The only real problem was some
out-patients for whom the date of the visit
to the clinic had been fixed weeks in advance
and not being informed about the strike,they
came from a long distance to be examined,
but couldn’t get the service. This is an issue
to be carefully handled in similar situations
so as to protect patients as much as possible.
Evaluation of the Strike
The slogan of the mass meeting of 13
March was “I can’t take my words back”. In
accordance with this slogan and in spite of
pressures made by the Ministry of Health
physicians and health workers kept their
promise and this very promising participa-
tion encouraged all of us.
Regional and NMA newsTURKEY
The two-day strike took place in most prov-
inces, totally embracing 87.5 % of the phy-
sicians (yellow colored provinces). In some
provinces where 7.2% of the physicians work,
supportive press declarations were made (red
colored provinces), and in the remaining
provinces (white colored) with 5.3% of the
physicians no strike action occured.
Tents were set up in the hospital gardens.
Informative leaflets were distributed to
the people. Meetings and demonstrations
were arranged. University hospitals and
state hospitals lively participated. In many
provinces there were difficulties in partici-
pation of employees of private hospitals
because of intimidating with dismissals.
In each province press declarations were
made. Some conflicts occurred between
the health personnel and the security staff
of the hospitals. The media provided in-
formation about the strike by stating that
“on 19–20 of April the hospitals will not
provide health care except for emergen-
cies”. In the cities which participated
in the strike, people supported it by not
asking admission to hospitals. Although
the Minister of Health made provocative
speeches against the strike, not any single
confrontation between the patients and
the health care staff occurred. TMA ap-
preciates the common sense and tolerance
of our people.
Turkish Medical Association
Declaration on Physicians’ Strikes
Adopted in“Ethics Declarations Workshop” held in Ankara on 4–5 April
2008, with the participation of representatives from 33 medical specialty
societies, Society of Turkish Nurses, Istanbul and Ankara Bars, and acade-
micians from Departments of Medical Ethics in universities.
In the “Professional Ethics Rules of Physicians” adopted by the
Turkish Medical Association, a holistic approach to health is
considered as the responsibility of individual physicians and it is
further stated that self-development by human beings is possible
only in healthy living conditions:
“Physicians are aware that the profession of medicine cannot be ab-
stracted from social and cultural circumstances surrounding the profes-
sion and that the most fundamental precondition for developing and
realizing human potential is the state of physical and mental health.”
Another fundamental responsibility is stated as protecting human
life and health:
“The primary task of the physician is to protect human life and health
by preventing diseases and curing patients through fulfilling scientific
requirements. It is also among the paramount duties of the physician to
respect human dignity while performing his profession.”
These responsibilities make it necessary to take into account also
social circumstances under which service delivery takes place.Sci-
entific evidence shows that the health status of individuals and
societies are determined not only by services provided but also
by many other factors including social class, level of education,
genetics, nutrition, sheltering, working and environmental condi-
The Turkish Medical Association declares that, in the context
of responsibilities mentioned above, the action of strike is con-
sistent with professional ethics on the basis of following two
• Policies currently pursued may limit or hinder individuals’access
to healthcare services they need. Furthermore, there may also be
problems related to the other determinants of health status in-
cluding social inequalities,human rights violations,environmen-
tal health problems, unhealthy sheltering, unfavourable working
environments and unemployment. Since all these factors and
conditions affect the health status of individuals and society and
are in contrast with the requirements of the right to health, it is
also among the social responsibilities of physicians to warn pol-
icy makers and the executive and to build awareness in public at
large. In this context, physicians may talk issues with authorities
through their professional organization, make press statements,
organize marches,engage in training and extension activities and,
when necessary,make strike.An action of strike in this sense is in
conformity with professional ethics given that service delivery to
pregnant women, those in need of urgent care, dialysis patients,
persons with cancer, under intensive care and in-patients is not
interrupted and the right to health is properly defended.
• Another fact which justifies the action of strike is the losses that
physicians suffer in their professional rights. It runs parallel to
the realization of the right to health. It is because health work-
ers themselves can be healthy in conditions of decent life and
can provide their services better in case they get a fair return to
their efforts and work in safe and secure conditions. Yet, poli-
cies geared to establishing rivalry instead of solidarity among
health workers, to introducing cheap and insecure employment
through privatizations and on-contract recruitment will inevi-
tably undermine the health of health workers and society and
further deepen existing inequalities.
When strike decision is taken, the public should have been in-
formed in advance and the reasons for this action should be clear-
ly stated and shared with the public.
Regional and NMA news TURKEY
The Ministry of Health has conducted dis-
ciplinary proceedings, secondment, tempo-
rary assignments and litigations.Some pres-
idents of medical chambers, some members
of the Board of Directors,even one member
of the Central Council of TMA have faced
disciplinary proceedings and litigations.The
Law Office of TMA has provided a sample
of petition to physicians who have been ex-
posed to any kind of pressure.The lawyers of
TMA have provided legal assistance. In the
end all arbitrary actions of the Ministry of
Health were legally halted.
However,on June 6,2012,47 students from
medical, dental and health sciences schools
were detained, and after the prosecution
and court inquiries 13 of them were arrest-
ed. 11 of these students are from schools
of medicine and they are also members of
the Student Branch of the Turkish Medi-
cal Association. Without being accused
of anything, these students were asked by
the Prosecutor and the Court about their
participation in legal activities organized
by the Turkish Medical Association. Due
to their prolonged detention the students
could not attend to their internship duties,
could not take their regular tests; there are
even some among them who would have
graduated if not detained. Meanwhile, all
these events also “criminalize” the Turkish
Medical Association as a constitutional
body. The idea is to “criminalize” involve-
ment of medical students in public health
issues and health policies in order to deter
other students from such activities. This is
nothing less than restricting the freedom of
expression and association in a state under
the rule of law.The process that the Turkish
Medical Association has experienced upon
the Decree Law No. 663 is clearly articu-
lated in the Editorial by the WMA Sec-
retary General Dr. Otman Kloiber in the
first issue of WMJ in 2102; the article by
Dr. Eriş Bilaloğlu who was then the Presi-
dent of TMA and the council decision ad-
opted by WMA in April 2012 in relation
to TMA. It is considered that the arrest of
our students is a part and extension of the
same process.
Lessons Learned and
a Call From TMA
It was very risky to organize a strike of this
scale,as there were serious doubts about phy-
sicians’ participation. Most of the physicians
were unhappy and hopeless during the meet-
ings organized all over the country before
the strike. But in terms of participation, the
strike was successful. Physicians massively
took part in the action. On the other hand,
in terms of the results or positive gain, it is
not possible to claim that it was a success in
the short run; the Ministry of Health and
policy makers didn’t care about the rightful
demands of healthcare workers, instead they
focused on decrying the action in the public
eye.Nevertheless,it would be unfair to recog-
nize an action of this scale as a failure.On the
contrary, TMA and the other organizations
have made a very clear signal to the Ministry
of Health and to society by this strike. Also
healthcare workers have learnt and gathered
experience that they have enough power to
be heard and to negotiate when they are
united under a common platform and act-
ing together.This point is so critical that the
World Bank’s expert recommends another
approach in the book titled “Getting Health
Reform Right”[11]:
“On the negative side, it is important to consid-
er how to divide or undermine coalitions that
are opposing you. Suppose that the medical as-
sociation has decided to oppose a new insurance
scheme because it will limit reimbursement for
high cost procedures, which would negatively
affect the income of some physicians. It may be
possible to persuade doctors who provide pri-
mary care to switch sides and support the plan,
and thereby divide the medical association, if
primary-care doctors can be persuaded to see
their interests in a different light.”
This book was translated into Turkish under
the editorialship of the Minister of Health
himself, and this is one of their main guides
in policy-making, besides the World Bank
project “Transformation of Health” (for a
detailed information, please, visit the related
project site of WB: tinyurl.com/WB-Trans-
formationinHealth. It is possible to follow the
past, current and future policies of the Ministry
of Health in a timeline until July 31, 2013). It
is crystal clear that national medical asso-
ciations are direct targets of these commer-
cialization policies, and standing together is
It is also clear that the rights of patients
and society in general are not to be sepa-
Provinces going on strike
Provinces making supportive press declaration
Provinces not participating
rated from healthcare workers; they will
be either exercised or violated all together.
That is why, we, physicians, always need
to claim our rights together with those of
patients and society. We always need to
defend the right to health, emphasize that
health care should be financed from gen-
eral taxes and should be provided by the
public sector according to needs. Health
care should be equal, accessible, of good
quality and free for every one. Otherwise,
struggles focused only on professional
rights are doomed to fail, as it is not pos-
sible to protect professional rights and in-
terests without opposing commercializa-
tion policies.
We would like to finish with a call from
TMA to all NMAs: It is important to share
the experience, as we need to know our
shortcomings and gaps, and improve our
methods wisely. In this context we would
like to propose that WMA would establish
a database for physicians struggle all around
the world. What were their motives? What
were the actions and consequences? What
can be improved and how? What was soci-
ety’s reaction? What would they change for
the next time? Every NMA might send in-
formation about such actions during the last
decade. We believe it to be a very precious
resource for all of us.
1. Aksu Tanık, Feride. (2011) “Many Voices-One
Heart” Struggle Campaign for Good Medicine,
Good Quality of Health Care and Health Right
Crisis of Capitalism and Health XVI. Confer-
ence of International Association of Health
Policy in Europe, http://www.ttb.org.tr/kutu-
phane/kapitalizm.pdf ISBN 978-605-5867-50-
8, p.162-165
2. Bilaloğlu, E. (2012) Turkish Medical As-
sociation (TTB). World Medical Journal,
3. Boratav, K. (2011) Hak Mücadeleleri ve
Ekonomill Kuramsal ve Tarihsel Boyutlarıyla
Hak Mücadeleleri cilt I, s.153-164, Nota Bene
Yayınları. (Struggle for Rights and Economy:
Struggle for Rights with Theoretical and His-
torical Dimensions)
4. Braverman, (2008) Emek ve Tekelci Sermaye,
İstanbul: Kalkedon. (Labour and Monopoly
5. Civaner M. Sale strategies of pharmaceuti-
cal companies in a “pharmerging” country: the
problems will not improve if the gaps remain.
Health Policy, 2012; 106(3):225-32.
6. Civaner M. “Transforming” our health by
privatisation. British Medical Journal, 2011;
7. Çıdamlı,Ç.(2011) – Kamusal Alanın Dönüşümü
Sorunu Devrimci Bir Sorundur Kuramsal ve
Tarihsel Boyutlarıyla Hak Mücadeleleri cilt I,
s.241-252, Ankara: NotaBene Yayınları. (The
Problem of the Transformation of Public Sphere
is a Revolutionary One: Struggle for Rights with
Theoretical and Historical Dimensions)
8. Harvey, D. (2007) A Brief History of Neo-liber-
alism. Oxford: Oxford University Press.
9. Karahanoğulları,O.(2004),Kamu Hizmeti,An-
kara: Turhan. (Public Services)
10. Özuğurlu, M. (2003) – Sosyal Politikanın
Dönüşümü ya da Sıfatın Suretten Kopuşu, Mül-
kiye Dergisi, C.27, S.239, s.59-75. (Transforma-
tion of Social Policy or Rupture of Atrribute
from Appearance)
11. Roberts M. et al. Getting Health Reform Right:
A Guide to Improving Performance and Equity.
Oxford University Press, USA; 2004. p.80
12. Ünlütürk Ulutaş, Ç. (2011) Türkiye‘de Sağlık
Emek Sürecinin Dönüşümü, Ankara: NotaBene
Yayınları (Transfromation of Health Labour
Process in Turkey)
Feride Aksu Tanık,
Former Secretary General, Turkish
Medical Association,
Professor of Public health
Ankara University School of Medicine,
E-mail: ferideaksu59@gmail.com
Murat Civaner,
Former Secretary of Turkish Medical
Association Ethics Committee,
Assoc.Professor, Department
of Medical Ethics,
Uludag University School of Medicine,
E-mail: mcivaner@gmail.com
Today, our country and many others around
the world are faced with the epidemics of ar-
thritis, hypertension, obesity, diabetes, heart
disease, stroke, and cancer. Obviously, our
health prevention strategy of more than half
a century has failed in our race and battle
against these diseases. While the world has
succeeded significantly in the area of infec-
tious diseases, eliminating the killer small
pox, and to a great extent, polio, we are still
lagging far behind in the race against those
seven common illnesses enumerated above.
During the past six decades,medical science
and technology have made mind-boggling
diagnostic and therapeutic advances. Both
pharmaceutical and surgical treatments
of diseases have progressed significantly.
More effective antibiotics and medications
for various illnesses have been developed.
Open heart surgery, angioplasty, brain and
joint surgeries,conventional and endoscopic
(minimally invasive techniques) have come
to the forefront, saving and making lives
more comfortable. This cutting-edge thera-
pies include new and more effective chemo-
therapies with lesser side-effects, albeit still
far from ideal.
In essence, the world’s state-of-the-art
knowledge and ability to diagnose diseases
and manage many of those illnesses are
great strides we have gained during the post
World War II period to the present.
But the stark reality today glaringly points
to our massive failure as a global society in
the vital area of disease prevention. Testa-
ment to this are the escalating statistics –
the worsening incidence of those major
Our Failed Health Strategy
diseases, their morbidity, complications, and
death tolls. We have barely put a dent on
them. Evidently, our conventional preven-
tive strategy has not worked and diseases
are way ahead of us in the race.
Is medical science to blame? Don’t we have
enough scientific data in this exploding in-
formational age to help guide us to the right
path to health and longevity?
Lifestyle diseases (self-induced or self-in-
flicted illnesses) are the major killer diseases
today. In general, except in impoverished
nations who deserve our compassion and
help, we abuse ourselves with our abun-
dance and blessings.We eat the wrong food,
we overeat and simply loosen our belt, we
neglect physical and exercises, we indulge in
unhealthy behaviour and vices, like smok-
ing, undisciplined alcohol intake, and even
unsafe sex.
Worse than what majority of us are doing to
ourselves are the bad examples we are setting
for our children, as pointed out in the 800-
page coffee-table health guide, entitled Let’s
Stop “Killing” Our Children, which is avail-
able at PhilipSchua.com, xlibris.com, ama-
zon.com, and barnesandnobel.com. Anyone
not positively contributing to the health and
well-being of children under our care, for
whatever reason, including love, is literally
cutting short the life span of these young-
sters and shortchanging them unfairly.
Unfortunately, the negative impact of our
bad examples as parents is so subtle and
shows up late – when our children are al-
ready in their middle-age, where all these
infirmities start bothering them, like ar-
thritis, high blood pressure, diabetes, heart
disease, stroke, and cancer – that the deadly
effects of our unhealthy behaviour on our
children before they are born and as they are
growing up are not immediately apparent.
Many of us shrug this off and rationalize
“When they grow up,they will develop their
own habits, behaviour, and preferences.”
But we do not realize, as science has clearly
shown, that the first five years in the life of
children are the formative years, where “the
dye is almost cast,” where their mindset,
as influenced by what they learn from us,
their parents and guardians, has taken roots,
and has become a permanent part of their
thinking, behaviour, and choices in life. So,
if we waited for them to grow up, it would
be a bit too late to iron out the kinks they
learned from us, adults.
The proper timing for gifting our children
healthy lifestyle starts before they are con-
ceived, when they are in the womb, when
they get in the crib, and at least during their
first five years and teen years. Doing this
will ensure that we maximize the protection
of their DNA and immune system, start-
ing healthy lifestyle from the cellular level,
or from what I call “Ground Zero” in my
new book, to effectively reduce their risk for
acquiring arthritis, hypertension, diabetes,
heart diseases, stroke and even cancer when
they reach their middle age and beyond.
Unfortunately, many seemed to have dis-
counted convincing scientific evidences
showing we can chart the course of our
own health destiny to a significant extent.
As a consequence, they have surrendered to
their “fate”(que sera,sera),which they feel is
beyond their control. In essence, they have
unwittingly programmed their mindset to
a casual, careless, self-destruct, slow-suicide
mode.They simply accept whatever happens
and seek treatment of the diseases when
they occur, instead of preventing them in
the first place.
The incidence, complications, and death
rates from obesity, diabetes, cardiovascular
diseases, cancer and other illnesses are es-
calating to epidemic proportion. And this
is unfortunate, because, to a great extent,
these diseases are, believe it or not, mostly
Trite and corny, perhaps, but the adage
by Ben Franklin, “an ounce of prevention
is worth a pound of cure,” rings truer and
louder when it comes to health, and well-
being, and illnesses, especially those that
kill. Indeed, no medical treatment is more
effective than prevention of diseases.
However,I would like to underscore the fact
that the timing of prevention is of utmost
importance, which I propose to be at the
cellular, DNA level, during infancy in order
to be truly effective, and not later.
Our past and current strategy has failed
miserably as present day medical statistics
show. Common sense tells us we, as a soci-
ety and as individuals, are doing something
wrong in our race against diseases. We are
Johnny-come-lately in this battle. We have
been joining the race a bit late, when the
integrity of our DNAs have already been
damaged after years of self-abuse. The race
begins at the starting line and not in the
There is a serious need for world society
as a whole to re-evaluate our failed strat-
egy and put emphasis on early prevention
by being pro-active and pre-emptive in the
way we deal with health and longevity, oth-
erwise the future generations are doomed
as we are.
While it is never too late for any of us, at
any age, to start disease prevention or ame-
lioration through healthier lifestyle, we can
save our young children and grandchildren,
and theirs, from the ravages of preventable
illnesses we ourselves have acquired through
negligence and carelessness, by implement-
ing the timely intervention before con-
ception of the child, when in the crib, all
through its teenage years, and beyond.
I strongly propose we start at “Ground
Philip S. Chua, MD, FACS, FPCS
Cardiac Surgeon, Northwest Indiana
Author, Let’s Stop “Killing” Our Children
E-mail: scalpelpen@gmail.com
Regional and NMA news
‘Spend not more, but smarter!’ – this idea is
the driving force behind the “International
Research on Financing Quality in Health-
care (InterQuality)”. Co-financed by the
European Commission’s Framework Pro-
gramme 7,InterQuality is led by the Medical
University of Warsaw.Its consortium is com-
posed of the Universities of Hannover (DE),
Syddansk (DK), Catania (IT), York (UK), as
well as the think tank “The Urban Institute”
(US), a Polish research and education-ori-
ented SME specialised in the pharmaceuti-
cal sector, Sopharm Sp z.o.o. (PL) and the
European Patients’ Forum (EPF) as well as
the Standing Committee of European Doc-
tors (CPME). The CPME President Dr.
Konstanty Radziwill sees the project’s objec-
tive as an attempt to resolve a fundamental
challenge: “The problem of how to pay for medi-
cal services probably already arose thousands
of years ago. It is said that ancient Sumerian
kings paid their doctors until they regained their
health. Today the idea of paying for healthcare
outcomes rather than for procedures is still viv-
id.” While Europe’s healthcare systems vary
significantly in structure, economic pressure
on budgets is a unifying reason to review
financing systems. “The problem still exists –
how much to pay for efforts and how much for
results, how much for procedures performed and
how much for availability, presence and care”,
states the CPME President.
Launched in 2010, InterQuality strives to
address these questions by concentrating
on four models of care and their respec-
tive financing systems, i.e. hospital care,
outpatient care, pharmaceutical care, and
integrated care. In these focal areas, Inter-
Quality works towards establishing a com-
mon understanding of the terminology and
concepts used to describe different financ-
ing system and identify payment systems’
incentives, as well as indicators suitable
to assessing quality of care. On this basis,
the focal areas will be examined in-depth,
with a view to assessing good practices and
processing these findings in guidelines for
policy-makers. “There are many solutions in
the world; most of them of mixed nature. The
question is how to pay in a just and effective
way. These questions are addressed by the In-
terQuality project which is designed to at least
get us closer to answering the dilemma: how to
fulfil growing patient demand in  shrinking
economic possibilities?”
Dr. Radziwill explains that “while this is
definitely a task for the economists, the medi-
cal profession is also necessary in this research.
This is why CPME decided to take part in In-
terQuality.” CPME will be contributing to
several project deliverables to share the doc-
tor’s perspective on the impact of financing
systems on quality of care. As one of the
primary stakeholders in the implementation
of healthcare financing reforms, CPME
shall also be looking at communication
strategies which support reform cycles to
establish how governments can best ensure
that stakeholders’ views are considered and
processed. CPME shall be carrying out this
work in close collaboration with the Euro-
pean Patients’ Forum (EPF), who is leading
the project’s communication activities.
The project is currently entering into its
empirical phase in which the four selected
models of care will be studied. Results are
expected for mid-2013. In the meantime,
the consortium will be presenting interim
findings at conferences and other events, an
up-to-date list of which can be found on the
project’s website www.interqualityproject.eu.
The questions InterQuality seeks to answer
will increase in relevance as public budgets
deal with the mid- and long-term impact of
the economic crisis. However, the consor-
tium hopes to show that quality need not
be compromised. As the project leader, Prof.
Dr. Hab. Tomasz Hermanowski, concludes,
“the good news is that we can realign payment
incentives to drive quality improvement and
foster better use of our health care resources. To
get to better quality, we don’t need to pay more:
we need to pay smarter.”
Dr. Konstanty Radziwill,
CPME President;
Ms Sarada Das,
CPME EU Policy Advisor’
Financing Quality in Healthcare – the
InterQuality Project Takes on the Challenge
Konstanty Radziwill Sarada Das
GERMANYAlternative Medicine
Problems of Defining Alternative
Medicine and Possible Solutions
What is alternative medicine? Unfortunate-
ly,there is no clear definition.In general it is
grouped with complementary medicine or
integrative medicine. In the literature there
are basically two definitions:
Alternative medicine is considered to sum-
marize treatments which are outside of con-
ventional medicine
1. which are used instead of conventional
medicine to treat a disease or
2. which are used to directly treat a disease.
Accordingly, complementary medicine is
considered to cover treatments
1. which are used parallel to conventional
treatments in order to improve their ef-
ficacy or to decrease side effects or
2. which are used to treat the symptoms of
a disease.
From the view point of conventional medi-
cine there may be no need to distinguish
between alternative and complementary
medicine. Clearly, both are not generally ac-
cepted by conventional medicine, which led
to them being grouped together. However,
it seems that the distinction is important.In
contrast to the protagonists of complemen-
tary medicine who accept the conventional
medicine’s underlying concepts of disease
etiology, pathogeneses and treatment, the
protagonists of alternative medicine often
have developed their own disease concepts,
which often are of esoteric nature and con-
flicting with the concepts of conventional
medicine. Thus, protagonists of comple-
mentary medicine disclaim the concepts of
alternative medicine and do not feel com-
fortable when grouped with followers of
alternative medicine.
In order to write about alternative medicine
it seems important to have a clear defini-
tion. A possible solution to the problem
could be an approach comparable to the use
of crosstabulation with the question of ac-
ceptance of conventional medicine’s disease
concepts on one side and the question of a
direct treatment approach versus a focus on
the treatment effects on the other. Figure
depicts the result of such a combined defi-
nition and gives some examples on where
various treatments could be grouped to.
However, such a solution allows defining 3
subsets of alternative medicine:
A – Approaches directly against the disease
which are not consistent with scientific con-
B – Approaches directly against the disease
and consistent with scientific concepts but
without scientific proof of efficacy;
C – Supportive approaches directly which
are not consistent with scientific concepts.
In the following part, the evidence of vari-
ous methods will be summarized based on
the referred grouping.
Scientific Evidence of
Approaches Directly against the
Disease,which are not Consistent
with Scientific Concepts (Group
A – alternative medicine)
Hamer‘s German New Medicine
In brief, Hamer‘s German New Medicine
considers every cancer or cancer-like disease
to originate with a Dirk Hamer Syndrome
(‘DHS’) which is a very difficult,highly acute,
dramatic and isolating shock, which affects
the psyche,the brain and the organ.Basically,
the resolution of the underlying problem is
believed to induce the cure of the disease.
According to the followers of Dr.Hamer,the
method is supposed to work well. Unfortu-
nately, the so-called successes have not been
reviewed by independent scientists; howev-
er, there are several reports on the internet
which show that 149, perhaps another 500
deaths of cancer patients are due to the fact
that cancer patients are not allowed to accept
any part of conventional medicine, not even
pain medication (http://www.deathsect.com/;
htm; accessed on August 26th
, 2012).
Alternative Medicine in Oncology
Karsten Münstedt Thomas Karl Riepen
Faith Healing
Faith healing is healing through spiritual
means. It is believed that healing of a per-
son can be brought about by religious faith
through prayer and/or rituals, which again
would stimulate a divine presence and power
toward correcting the disease and disability.
A recent analysis shows that it is widely used
in pediatrics [1].Detailed analyses on efficacy
are lacking; however, some reports show that
cancer cure is out of the scope of faith heal-
ing [2]. A meta-summary has confirmed the
fundamental importance of spirituality at
the end of life and highlighted the shifts in
spiritual health that are possible when a ter-
minally ill person is able to do the necessary
spiritual work; however, in cancer survivors
praying for one’s own health was inversely as-
sociated with good or better health status [3].
Homeopathy is based on the idea that the
dilution of a substance that causes the symp-
toms of a disease in healthy people will cure
that disease in sick people. This dilution is
called “potentization”. Some protagonists of
homeopathy,like Dr.Wurster from Germany,
claim that cancer may be cured by homeo-
pathic means. In his book, Wurster describes
several cases which he believed to have been
cured by this method [4].There has not been
any independent proof for these claims.
Dr. Hulda Clark‘s Therapy
Dr. Hulda Regehr Clark (1928–2009)
claimed that all human diseases were related
to parasitic infections, which she claimed to
be able to cure by destroying the parasites by
“zapping”them with electrical devices which
she marketed.So far there are no studies that
could provide evidence for these claims.
Anthroposophical Medicine
Anthroposophical medicine mainly seeks to
extend, not replace, conventional medicine.
Especially, the use of mistletoe extracts in
the treatment of cancer has become quite
popular after it was first proposed by Rudolf
Steiner and anthroposophical researchers.
However, the anthroposophical concepts
are not founded on the phytotherapeutic
effects of mistletoe extracts, but the merely
believed similarity between the mistletoe,
which is a hemi-parasitic plant in a tree and
a cancer in an organism. There have been
several trials which were designed to sup-
port the use of mistletoe in oncology. So far,
the evidence to support the view that the
application of mistletoe extracts has impact
on survival is weak [5]. Even protagonists
of mistletoe therapy acknowledge that the
survival benefit that has been shown is
not beyond critique [6]. Positive evidence
comes from non-randomized, prospective,
controlled cohort studies in matched pair
design, or retrolective studies. Prospective,
randomized controlled trials failed to show
positive effects [7,8].
Approaches Directly against the
Disease and Consistent with
Scientific Concepts, but without
Scientific Proof of Efficacy
(Group B – alternative medicine)
Galvanotherapy, also called electrotherapy,
uses direct electric current especially to
treat superficial tumors. Recently, modern
imaging techniques allowed positioning of
galvanotherapy wires into tumors in deeper
parts of the body (e.g. magnetic resonance
imaging-guided galvanotherapy). So far,
there has been only one trial on galvano-
therapy, which is more or less a feasibility
study. It shows that there are some partial
remissions, some stable diseases and few
progressive diseases in patients with pros-
tate cancer. However, the lack of a control
arm and long-term results does not allow
any conclusions on whether this method
Alternative MedicineGERMANY
Acceptance of conventional medicine‘s disease concepts
Di Bella Multitherapy
High-dose vitamins;
Dr. Rath‘s Vitamines
Insulin Potentiated erapy
Enzyme erapy
Dr. Coy‘s Diet
Hamer‘s German New Medicine
Faith healing
Dr. Hulda Clark‘s erapy
Anthroposophical Medicine
Anthroposophical Medicine
could be recommended to patients with
prostate cancer or other cancer diseases [9].
Di Bella Multitherapy
Di Bella Multitherapy is based on the the-
ory that growth hormones and prolactin are
involved in neoplastic growth.The treatment
comprised a multidrug, custom-made medi-
cal treatment developed by Luigi Di Bella,
an Italian physician, who claimed effective-
ness in blocking, if not curing altogether,
most cancers. Because of his claims the Ital-
ian government initiated trials which clearly
failed to show that the treatment was effec-
tive [10,11].In spite of these results,relatives
of Luigi Di Bella are again promoting this
method and claiming higher survival rates
for patients with metastatic breast cancer
compared to the literature [12].
Dr. Rath‘s Vitamins, High-
dose Vitamins
According to Dr.Rath,all diseases are caused
by a lack of lysine and vitamin C (http://
www.quackwatch.org/11Ind/rath.html; ac-
cessed August 26th
, 2012). In the past, Dr.
Rath claimed to have cured patients from
cancer.However,in his publications he pres-
ents only evidence from preclinical studies.
So far, there have been only few trials which
have addressed the effects of high-dose vi-
tamins. Probably the most important study
concluded that high-dose vitamin C therapy
is not effective against advanced malignant
disease regardless of whether the patient has
had any prior chemotherapy [13].
Insulin Potentiated Therapy
This is a cancer treatment where insulin is
used in order to bring chemotherapeutic
drugs selectively into cancer cells. It was
developed by Donato Perez Garcia in the
1930s. Due to the combination of insulin
and chemotherapy it is believed that only
10-15 % of a standard dose is required [14].
Just recently, a study on this study was re-
ported. However, it does not allow any con-
clusion on the possible importance of Insu-
lin Potentiated Therapy because all patients
with prostate cancer received conventional
hormone therapy in conjunction with low-
dose chemotherapy and Insulin Potentiated
Therapy [15].
This is a Russian drug with an immunomod-
ulatory potential. In 1999 and 2000 it was
recommended as an anticancer drug. About
170 cancer patients mainly with advanced
diseases were treated with galavit. However,
almost all patients died from cancer dis-
ease, although they were told that cure rates
were expected to range around 70% (http://
Laetrile (vitamin B 17)
Laetrile has been promoted as a cancer cure
since the early 1950s. In spite of the name,
it is not a vitamin in any sense.A recent sys-
tematic review found no evidence for ben-
eficial effects for cancer, but a considerable
risk of serious adverse effects from cyanide
poisoning [16].
Enzyme Therapy
Generally, enzyme therapy is mainly used
as a complementary treatment in combina-
tion with conventional treatment. However,
in the early years it has also been promoted
as an anticancer treatment by the Scottish
physician John Beard and later by Freund
and Kaminer in Vienna. Recently, the re-
sults of a randomized, phase III, controlled
trial of proteolytic enzyme therapy versus
chemotherapy in pancreatic cancer was
published, which showed that conventional
treatment was clearly superior to enzyme
therapy [17].
Ukrain is a combination product of ex-
tracts of the plant Chelidonium and thio-
tepa. A recent systematic review concluded
Ukrain to have potential as an anticancer
drug, but this positive conclusion cannot
clearly been drawn because of the need for
independent rigorous studies [18].
Supportive Treatments
Inconsistent with Scientific
Concepts (Group C –
alternative medicine)
Homeopathy has been investigated in the
supportive setting as well.Two independent
systematic reviews have shown that there is
no convincing evidence for the efficacy of
homeopathic medicines for other adverse
effects of cancer treatments [19,20]. There
is some evidence favoring topical calendula
for prophylaxis of acute dermatitis during
radiotherapy and Traumeel S mouthwash
in the treatment of chemotherapy-induced
stomatitis; however, these trials need repli-
Anthroposophical Medicine
Anthroposophical medicine may possibly
improve patients’ wellbeing. A recent meta-
analysis concludes that the methodological
quality of most studies was poor, but that
the analyzed studies give some evidence
that anthroposophical mistletoe treatment
might have beneficial short-time effects on
quality-of-life-associated dimensions [21].
Dealing with Alternative
As demonstrated above there is lacking
or insufficient evidence for all type A ap-
GERMANYAlternative Medicine
proaches. Furthermore, there is no proof for
any concept of alternative medicine which is
not consistent with scientific concepts.Since
analyses have shown that prognosis of pa-
tients who give themselves over to alterna-
tive medicine of this type is clearly inferior
to patients undergoing conventional thera-
pies, these methods cannot be recommend-
ed to patients, with no exceptions [22,23].
For type B alternative treatments there
is some evidence for some of the named
methods. Clearly, they cannot be recom-
mended in general, but there may be certain
situations in which some may be considered
after conventional treatments have failed.
In this group of treatments, some deserve
further investigation and may eventually
become part of conventional treatment one
When alternative medicine is used in a sup-
portive context, it may be used if patients
have the desire to try this approach. This
conclusion is mainly due to the fact that the
methods named here do not interfere with
the use of conventional medicine. Since
evidence regarding these methods is low, it
seems important that new studies are con-
In general, it is important to know how
to deal with alternative medicine. In 1983,
Klimm endeavored to address these issues
by devising 10 “golden” rules which should
govern CAM use in relation to convention-
al medicine [24]. Although these rules are
almost 30 years old, they still seem appro-
priate today.These rules state:
1. Conventional medicine is the founda-
tion of a physician’s work.
2. Practitioners of conventional medicine
must recognize that CAM beliefs and
methods exist and are being widely
practiced. Ignoring CAM’s existence is
3. Misjudgment of CAM represents igno-
rance and arrogance – gathering infor-
mation about CAM represents increas-
ing knowledge.
4. The necessity of educating patients
about medical facts is self-evident; edu-
cating them about CAM is essential,
5. Practitioners of conventional medicine
must keep themselves informed about
6. CAM methods should be clearly reject-
ed where conventional treatments have
proven benefits.
7. CAM methods can be allowed where
reasonable conventional treatment is
not compromised.
8. Harmless CAM methods may be al-
lowed when conventional methods are
unlikely to be successful.
9. CAM practitioners and their methods
must be critically observed.
10. Physicians who only practice CAM
should be censured unless they are able
to prove the efficacy of their methods.
If these rules are followed, physicians
should be able to cope with dubious practi-
tioners and their offerings. Physicians must
be aware that dubious practitioners of al-
ternative medicine are very good at setting
up the concept of an enemy, namely con-
ventional medicine. In contrast they pres-
ent themselves as true advocates of patients’
rights and well-being, overemphasizing the
side effects of conventional medicine and
supporting their conclusions with selective
citations.Rhetorically,they are well-educat-
ed and very good at alienating patients by
various means.For example,they often omit
facts which contradict their claims, cite only
those which support their ideas and cre-
ate pseudoscientific technical terms, which
suggest competence. One major problem is
the fact that critics of alternative medicine
are often the subject of personal attacks and
What Should Be Done?
Patients must be protected against dubi-
ous practitioners of alternative medicine.
Since many of them are well organized, it
seems virtually impossible to achieve this
goal without support from governmental
authorities. It is suggested that it should be
ruled that all alternative methods should
only be used within clinical studies or under
clearly defined circumstances. An institu-
tion comparable to the European Medi-
cines Agency (EMEA) could be useful in
order to define such situations and decide
about the mechanisms that could lead to ac-
ceptance of the methods. In contrast, meth-
ods with clearly proven inefficacy should
be forbidden. On the other hand concepts
for the scientific investigation of reasonable
methods should be developed.
1. Baverstock A, Finlay F. Faith healing in paedi-
atrics: what do we know about its relevance to
clinical practice? Child Care Health Dev. 2012
2. Blazer DG,Cohen HJ,George LK,Koenig HG,
Verhey A. Why John wasn’t healed by prayer:
perspectives across disciplines. Int J Psychiatry
Med. 2011;42(4):377-91.
3. Ross LE, Hall IJ, Fairley TL, Taylor YJ, How-
ard DL. Prayer and self-reported health among
cancer survivors in the United States, National
Health Interview Survey, 2002. J Altern Com-
plement Med. 2008 Oct;14(8):931-8.
4. Wurster J. Die homöopathische Behandlung
und Heilung von Krebs und metastasierter Kar-
zinome. Buchendorf (Irl) 2012.
5. Horneber MA, Bueschel G, Huber R, Linde
K, Rostock M. Mistletoe therapy in oncol-
ogy. Cochrane Database Syst Rev. 2008 Apr
6. Kienle GS, Kiene H. Complementary cancer
therapy: a systematic review of prospective clini-
cal trials on anthroposophic mistletoe extracts.
Eur J Med Res. 2007 Mar 26;12(3):103-19.
7. Kleeberg UR, Suciu S, Bröcker EB, Ruiter DJ,
Chartier C, Liénard D, Marsden J, Schadendorf
D, Eggermont AM; EORTC Melanoma Group
in cooperation with the German Cancer Soci-
ety (DKG). Final results of the EORTC 18871/
DKG 80-1 randomised phase III trial. rIFN-
alpha2b versus rIFN-gamma versus ISCADOR
M versus observation after surgery in melanoma
patients with either high-risk primary (thickness
>3 mm) or regional lymph node metastasis. Eur
J Cancer. 2004 Feb;40(3):390-402.
8. Steuer-Vogt MK, Bonkowsky V, Ambrosch P,
Scholz M, Neiss A, Strutz J, Hennig M, Lenarz
T, Arnold W.The effect of an adjuvant mistletoe
Alternative MedicineGERMANY
WMA news
The Fifth Geneva Conference on Person-
centered Medicine was held on April 28th
May 2nd
, 2012, the latest in the series of
annual Geneva Conferences on this per-
spective since May 2008 [1-4].The gradual
building of this conceptual and method-
ological perspective [5-8] has proceeded
through collaboration with major global
medical and health organizations, aca-
demic institutions, and an expanding com-
munity of committed international experts
all engaged in an International Network
[9], now International College of Person-
centered Medicine [10].
As for all previous Geneva Conferences, the
main venue of the Fifth one was the Mar-
cel Jenny Auditorium and auxiliary halls of
the Geneva University Hospital. Within
the framework of growing institutional col-
laboration (from 27 entities in the previ-
ous to 33 in the latest), the Fifth Geneva
Conference on Person-centered Medicine
was organized by the International College
of Person-centered Medicine (ICPCM) in
collaboration with the World Medical As-
sociation (WMA), the World Health Or-
ganization (WHO), 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 World Organization
of Family Doctors (WONCA), the World
Federation for Mental Health (WFMH),
the World Federation of Neurology
(WFN),the Council for International Or-
ganizations of Medical Sciences (CIOMS),
the International College of Surgeons
(ICS), the International Federation of
Gynecology and Obstetrics (FIGO), the
Medical Women’s International Associa-
tion (MWIA), the International Federation
of Ageing (IFA), the World Association
for Sexual Health (WAS), the European
Federation of Associations of Families of
People with Mental Illness (EUFAMI), the
World Federation for Medical Education
treatment programme in resected head and neck
cancer patients: a randomised controlled clinical
trial. Eur J Cancer. 2001 Jan;37(1):23-31.
9. Vogl TJ, Mayer HP, Zangos S, Selby JB Jr, Ack-
ermann H, Mayer FB. Prostate cancer: MR
imaging-guided galvanotherapy–technical de-
velopment and first clinical results. Radiology.
2007 Dec;245(3):895-902.
10. Italian Study Group for the Di Bella Multith-
erapy Trials. Evaluation of an unconventional
cancer treatment (the Di Bella multitherapy):
results of phase II trials in Italy. BMJ. 1999 Jan
11. 11. Buiatti E, Arniani S, Verdecchia A, Tomatis
L.Results from a historical survey of the survival
of cancer patients given Di Bella multitherapy.
Cancer. 1999 Nov 15;86(10):2143-9.
12. Di Bella G. The Di Bella Method (DBM) im-
proved survival, objective response and perfor-
mance status in a retrospective observational
clinical study on 122 cases of breast cancer. Neu-
ro Endocrinol Lett. 2011;32(6):751-62.
13. Moertel CG, Fleming TR, Creagan ET, Ru-
bin J, O’Connell MJ, Ames MM. High-dose
vitamin C versus placebo in the treatment of
patients with advanced cancer who have had
no prior chemotherapy. A randomized double-
blind comparison. N Engl J Med. 1985 Jan
14. Ayre SG, Perez Garcia y Bellon D, Perez Garcia
D Jr.Insulin potentiation therapy: a new concept
in the management of chronic degenerative dis-
ease. Med Hypotheses. 1986 Jun;20(2):199-210.
15. Damyanov C, Gerasimova D, Maslev I,
Gavrilov V. Low-dose chemotherapy with in-
sulin (insulin potentiation therapy) in combi-
nation with hormone therapy for treatment of
castration-resistant prostate cancer. ISRN Urol.
16. Milazzo S, Ernst E, Lejeune S, Boehm K,
Horneber M. Laetrile treatment for can-
cer. Cochrane Database Syst Rev. 2011 Nov
17. Chabot JA,Tsai WY, Fine RL, Chen C, Kumah
CK, Antman KA, Grann VR. Pancreatic pro-
teolytic enzyme therapy compared with gem-
citabine-based chemotherapy for the treatment
of pancreatic cancer. J Clin Oncol. 2010 Apr
18. Ernst E, Schmidt K. Ukrain – a new cancer
cure? A systematic review of randomised clinical
trials. BMC Cancer. 2005 Jul 1;5:69.
19. Kassab S, Cummings M, Berkovitz S, van Hase-
len R, Fisher P. Homeopathic medicines for
adverse effects of cancer treatments. Cochrane
Database Syst Rev. 2009 Apr 15;(2):CD004845.
20. Milazzo S, Russell N, Ernst E. Efficacy of ho-
meopathic therapy in cancer treatment. Eur J
Cancer. 2006 Feb;42(3):282-9.
21. Büssing A, Raak C, Ostermann T. Quality of
life and related dimensions in cancer patients
treated with mistletoe extract (iscador): a meta-
analysis. Evid Based Complement Altern Med.
22. Bagenal FS, Easton DF, Harris E, Chilvers CE,
McElwain TJ. Survival of patients with breast
cancer attending Bristol Cancer Help Centre.
Lancet. 1990 Sep 8;336(8715):606-10.
23. Han E, Johnson N, DelaMelena T, Glissmeyer
M, Steinbock K. Alternative therapy used as
primary treatment for breast cancer negatively
impacts outcomes. Ann Surg Oncol. 2011
24. Klimm HD. Der Krebskranke und sein Arzt
im Spannungsfeld medizinischer und paramed-
izinischer Behandlungsmethoden. Kassenarzt
1983; 9: 40–4.
Karsten Münstedt,
Thomas Karl Riepen
Department of Obstetrics
and Gynecology,
Corresponding author:
Prof. Dr. med. Karsten Münstedt
Klinikstraße 33
D-35392 Giessen, Deutschland
Tel.: +49 641 985-45120
Fax.: +49 641 1313443
E-mail: karsten.muenstedt@
The Fifth Geneva Conference on
Person-centered Medicine
WMA news
(WFME), the International Association
of Medical Colleges (IAOMC), the Paul
Tournier Association, the World Associa-
tion for Dynamic Psychiatry (WADP), the
European Association for Communication
in Health Care (EACH), the WHO Col-
laborating Center for Public Health Edu-
cation and Training at Imperial College
London, the International Federation of
Medical Students’ Associations (IFMSA),
the Zagreb University Medical School,
the University of Gothenburg Centre for
Person-Centred Care, the George Wash-
ington University Institute on Spirituality
and Health, the Peruvian University Cay-
etano Heredia, the Universita degli studi di
Milano, the Medical University of Plovdiv,
and the Buckingham University Press, and
with the auspices of the Geneva University
Medical School and Hospitals.
With the overall theme of Chronic Diseases:
Person- and People-centered Perspectives, the
Fifth Geneva Conference on Person-cen-
tered Medicine encompassed a number of
sessions larger than ever before and com-
prised plenary symposia, workshops, brief
oral presentations, and posters, all having
an international framework. Additionally,
institutional work meetings were held fo-
cusing on the guiding principles for person-
centered clinical care,person-centered diag-
nosis, an organizational informational base,
and special institutional projects.
The Conference Core Organizing Com-
mittee was composed of Juan E. Mezzich
(President,International College of Person-
Centered Medicine), Jon Snaedal (World
Medical Association,President 2007-2008),
Chris van Weel (World Organization of
Family Doctors,President 2007-2010),Mi-
chel Botbol (World Psychiatric Association
Psychoanalysis in Psychiatry Section),Ihsan
Salloum (World Psychiatric Association
Classification Section), Tesfamicael Ghe-
brehiwet (International Council of Nurses),
Shanthi Mendis (WHO Chronic Diseases
Department), and Ruben Torres (PAHO/
WHO Health Systems Area).
Financial or in-kind support for the Con-
ference was provided by 1) the International
College of Person-centered Medicine (core
funding),2) the University of Geneva Med-
ical School (auditorium services and coffee
breaks), 3) the Paul Tournier Association
(conference dinner), and 4) Participants’
registration fees.
Pre-conference Work Meetings
– The first Work Meeting on April 28,
2012 focused on activities and projects
related to the organizational and infor-
mational framework of ICPCM.
– The International Journal of Person
Centered Medicine was launched at the
Fourth Geneva Conference on Person
Centered Medicine in 2011. As the
official journal of the International
College of Person Centered Medicine
(ICPCM) and created in partnership
with the Buckingham University Press,
the Journal is advancing the global
communication of scholarship and
research for personalized healthcare
[11]. As it was reported and discussed,
the full first volume of quarterly issues
has been completed. The first issue of
the second volume was presented at
the Conference. In this short time,
the journal has achieved considerable
strength and prestige and is attracting
a continuous stream of quality manu-
scripts from all regions of the world.
A productive meeting of the Journal’s
Editorial Board took place at the end
of the first day.
– Upgrading of College and Journal web-
sites. The main institutional website for
the initiative on person-centered medi-
cine was established early in the course
of the Geneva Conferences process
and has been upgraded regularly [11].
Advanced videos and interactive capa-
bilities are being planned. The website
of the International Journal of Person
Centered Medicine was launched along
with the Journal itself and is serving as
an increasingly effective instrument to
access the Journal as well as acquiring
and managing subscriptions.
– Use of Social Media in the Promotion of
Person-centered Medicine. Within the
framework of the Internet and the
World Wide Web (WWW), there
is a popular trend to engage in Social
Networking Sites. The potential use of
these resources to promote person-cen-
tered medicine activities was discussed
along with concerns and limitations.
– International Conference and Publica-
tion Series. Dealing primarily with per-
Logos of the institutions collaborating on the organization of the Fifth Geneva Conference on
Person-centered Medicine.
WMA news
son-centered care for specific clinical
conditions, this project is due to start
in the second half of 2012. Its general
plan was outlined during the initial
work meetings and it was the subject of
a panel discussion during the course of
the core conference.
– Person Centered Medicine Book Projects.
Monographs have a distinct place in the
development of the field,and in person-
centered medicine there are early prec-
edents such as Paul Tournier’s Medicine
de la Personne in Switzerland [13], as
well as recent contributions appearing
in Croatia [14] and France [15]. Future
projects were outlined for major text-
books with systematic presentations of
the status quo in the field, as well as on
broad specialty and discipline areas.
The second ICPCM Work Meeting focused
on Person-centered Integrative Diagnosis
(PID) and Related Diagnostic Projects.The
work is predicated on the understanding
that one of the key aspects of clinical care
is comprehensive diagnosis as fundamental
basis for treatment planning and care. This
renders person-centered diagnosis as crucial
for the implementation of person-centered
medicine.The first session focused on mov-
ing forward the PID development process
from a theoretical model to practical guide,
started in psychiatry and mental health.The
conceptual base and structure of the model
were published in the Canadian Journal of
Psychiatry [16] and more recently a concep-
tual appraisal was conducted and published
[17].The presentations in this initial session
dealt with general development strategies,
the heuristic value of ontological analysis,
the instrumentation of the various domains
and levels of the PID, the utilization of
descriptive categories, dimensions and nar-
ratives, and the establishment of common
ground among clinicians, patients and fam-
ilies towards the formulation of a compre-
hensive diagnosis and a plan of care.
An ensuing session on Related Diagnostic
Projects discussed first the ongoing revision
of the Latin American Guide for Psychiatric
Diagnosis (Guía Latinoamericana de Diag-
nóstico Psiquiátrico) (GLADP) [18-19],
an official Priority Program of the Latin
American Psychiatric Association, and its
next steps leading to the publication of the
revised version towards the end of 2012.
Other presentations presented updates on
the French Diagnostic Project, the World
Federation for Mental Health Assessment
Project, a pediatric diagnostic plan, and the
grounds towards an internal and family
medicine diagnostic effort.
The third ICPCM Work Meeting was
dedicated to the ongoing development of
Person-centered Clinical Care Guiding
Principles. Earlier work on this project was
summarized and placed in perspective as
an orientation to the next steps. It was fol-
lowed by several brief presentations made
by members of the respective workgroup,
particularly those representing geriatric, pe-
diatric, family medicine and mental health
An extended 3-hour working luncheon
took place on the second pre-core-con-
ference day to further discussions in vari-
ous ICPCM workgroups, each meeting
separately. The group participants included
those who had made earlier initial presenta-
tions as summarized above, and those deal-
ing with person-centered partnership and
person-centered young health professionals
(the Janus Group).This extended session fa-
cilitated the formulation of conclusions and
the delineation of next steps. The conclu-
sions were briefly presented in the plenary
Complementing the scientific program,
two major ICPCM institutional meetings
took place during the Fifth Geneva Con-
ference. One was a face-to-face meeting
of the Board, which regularly manages the
organization through monthly teleconfer-
ences. The other was the General Assembly
which heard a report from the Board, re-
viewed prospective activities (the Sixth Ge-
neva Conference and other events, ongoing
advancement of the International Journal
and other publications, continued work of
research groups and projects, and further
development of the ICPCM institutional
structure and governance), and discussed a
draft of the Geneva Declaration on Person-
centered Care for Chronic Diseases, an ef-
fort for the first time to extend on public
policy an impact of the main Conference
Core Conference
The Core Conference was opened on April
30 by Prof. Panteleimon Giannakopoulos,
Vice-Dean of the Geneva University Medi-
cal School, and Dr. Manuel Dayrit, Direc-
tor, World Health Organization. They were
joined in the presidium by the members of
the Board of the International College of
Person Centered Medicine.
The opening address was delivered by the
ICPCM president, who presented the
progress report, ranking as the most im-
portant the consolidation of the Interna-
tional College of Person-centered Medicine
which emerged from the International Net-
work and the Geneva Conferences [9, 10].
Among the vital activities is the engage-
ment of a growing number (33 at present)
of international medical and health bodies
(including WHO for the third time) as
co-sponsors of the Fifth Geneva Confer-
ence, the strengthening of the International
Journal of Person Centered Medicine as a joint
venture with the University of Bucking-
ham Press [11], activities of the workgroups
particularly those on Person-centered Care
Guiding Principles and Person-centered
Integrative Diagnosis (the latter reflected
in several journal publications and books)
[16-19], WHO supported path-opening
research activities initiated towards the sys-
tematic conceptualization and measurement
of person-centered care, and collaboration
in the anticipated launching of an Interna-
tional Conference and Publication Series
WMA news
addressing specific clinical conditions. The
preparation for the first time of a Geneva
Declaration focused on the Conference’s
main theme (chronic diseases) promises to
extend substantially the impact of our flag-
ship event [20].
The first scientific session of the Core
Conference was the Symposium on the
Effectiveness of Person-centered Care for
Chronic Diseases. It started with apprais-
ing the contextualized approach to endur-
ing clinical complexity. After affirming the
crucial role of relationships and trust in per-
son-centered care, it unfolded the principal
aspects of context in terms of family, social
network, physical (including left and right
brain integration), financial, occupational,
spiritual and health literacy concerns. Next,
when focusing on well-being and work on
personality development it was recognized
as highly important, particularly for dealing
with people’s chronic diseases. Finally, there
was addressed the issue of the critical role
that the patient can and should play in the
cases of chronic diseases, identifying specif-
ic approaches for ensuring that the patient’s
voice is heard in clinical and public health
The Workshop on Person-centered Care for
Oncological Diseases started with a review
of informational procedures to support the
patient’s decision making in cancer care.
This was followed by a discussion on cancer
pain which is currently acquiring a strong
person-centered framework. This involves
the need for a comprehensive evaluation of
the situation and of the patient’s attitudes
and preferences, paying considerable at-
tention to good clinical communication,
the patient engagement, and participation
in decision making. Next, the interface be-
tween cancer and sexual health was focused
on. Substantial numbers of cancer patients
experience long-term sexual dysfunctions,
and these need to be addressed emphasizing
exchange of information and fluent com-
munication between clinicians and patients.
Concluding the session, person-centered
care at the end of life was discussed. This
encompassed ensuring empathy, family en-
gagement,advance planning,symptom con-
trol, fluid management, place of death, and
spiritual support.
The Workshop on Person-centered Care for
Chronic Psychiatric & Neurological Dis-
eases, addressed the first two of the most
common psychiatric disorders, depression
and substance abuse, that tend to be chronic
and rank among the top human disease
burdens. The benefits of employing a holis-
tic theoretical framework, attending to the
patient’s experience, the range of contribut-
ing factors, and the integration of care were
emphasized. The personal integrity to be
considered when treating the patient with
dementia was discussed next. This would
include a comprehensive examination of
the patient’s clinical condition as well as full
consideration of his/her needs and prefer-
ences. Concerning child and adolescent
chronic psychiatric condition, emphasis was
placed on attending to the specific objec-
tive and subjective dimensions of the child’s
illness and health. Finally, a comparative
analysis was presented of recovery-oriented
and person-centered models of care, not-
ing that the former developed and remains
principally in the mental health field, while
the latter has broader origins and presence
in general medicine and comprehensive
health. Both largely coincide in theoreti-
cal perspectives, ethical commitment, and
clinical procedures.
The Poster Session was held during lunch
time on the first day of the Core Conference.
The presentations reviewed the relations
of person-centered care and, respectively,
Eastern Orthodox psychotherapy, reduction
of self-report uncertainty in chronic heart
failure, care experiences among hospitalized
Swedish patients, experiences of “broken
heart” syndrome patients, culture-specific
patient education in Bulgaria, adherence
and self-management in hypertension, and
contextualization of functional symptoms
in primary health care.
The Workshop on Person-centered Care
for Chronic Circulatory and Respiratory
Conditions started with a presentation on
experiences of patients with acute coro-
nary syndromes. These challenging situa-
tions emphasize the importance of indi-
vidual treatment plans and person-centered
Part of the collaborating organizations’ leaders, speakers and participants at the Fifth Geneva Conference 2012
WMA news
care in order to help patients return to the
activities of regular life. Next, the outcome
studies on person-centered cardiovascu-
lar care were reviewed. Recommendations
were offered to design such studies from the
patients’ perspectives and samples of such
designs were presented. It was followed by
a presentation on person-centeredness in
intensive care medicine. It was noted that
physiological circumstances often lead to
limit the patients’ choices in intensive care
units. Therefore clinicians have a high de-
gree of responsibility to ensure that care is
individualized and the patients’ individual-
ity is respected.
The Workshop on Self-Care and Integra-
tive Approaches to Non-communicable
Diseases began with a WHO review on the
evidence of self care for non-communicable
diseases, and ended with a review of educa-
tional efforts needed in this field. It noted
that today’s chronic and non-communi-
cable diseases (NCDs) are the main cause
of morbidity and mortality in almost all
countries around the world. It addressed
approaches needed within our health and
educational systems to increase awareness,
knowledge and skills to prevent and man-
age cardiovascular disease, cancer, diabetes
and chronic lung disease. It also pointed out
that most NCDs are preventable and that
most risks factors (smoking, obesity, lack of
physical activity,hypertension,and excessive
use of alcohol) can be managed if identified
early. It emphasized that all approaches to
control NCDs must be person-centered and
that continuity of care is crucial for achiev-
ing better health outcomes at individual and
population levels.
The Symposium on Person-centered Care
and Modern Clinical Practice started with
a presentation on ethics and social deter-
minants of health. Next it addressed case-
based models of practice, arguing that these
are more relevant than evidence-based ones
for clinical decision-making in person-
centered medicine. The casuistic approach
seeks warrants from clinical research,
pathophysiologic rationales, personal expe-
rience, patient’s goals and preferences, and
system features, which all must be weighed
and negotiated by the clinician and the pa-
tient to arrive at reasonable decisions. The
following presentation discussed Bayes-
ian statistical procedures for systematically
taking into consideration local factors and
the results of large multi-center trials lead-
ing to more accurate estimations of inter-
vention effects than in case each factor is
considered separately, and potentially con-
tributing to the coalescence of evidence-
based and person-centered models. Finally,
remarks were offered stimulated by the
above presentations and an ongoing review
of the literature towards an integrated clin-
ical care model.
The Symposium on Transformative Edu-
cation for Person- and People- centered
Care started with a presentation of the
WHO Transformative Education Initia-
tive. It pointed out that the World Health
Report of 2006 documented the severe
shortages of health professionals around
the globe and their poor preparation for
the needs of health service delivery. There-
fore, an adequate transformation of health
professional education should put popu-
lation health needs and expectations at
the centre and should be directed by the
reality of health service delivery. Next an
outline was given on the Health Improve-
ment Card being developed by the World
Health Professional Alliance to help pre-
vent chronic diseases.The Card would seek
to assess lifestyle and biometric risk factors
to enable individuals and their health pro-
fessionals to take preventive actions. Then
professional training to optimize team
work for person-centered care was dis-
cussed. It noted that in addition to short-
age of health professionals there are severe
limitations in opportunities for health pro-
fessional students of different disciplines
to learn together and interact adequately
during their training. It caused innovative
and strategic responses to this challenge.
Finally, recommendations from academic
medical centers were formulated for devel-
oping person-centered medical education
and training. These include group learn-
ing with patients and families, shadowing,
video-recording, and role plays.
The Symposium on Spirituality and
Health started with a presentation on
clinical applications towards integrating
spirituality into healthcare. It proposed
the recognition of spirituality as a com-
ponent of health and as an important el-
ement of compassionate person-centered
care, as well as outlined a procedure for a
bio-psycho-social-spiritual assessment and
plan. Another presentation discussed that
healing of the body and the spirit is an
integral part of many faith traditions and
the lessons learned by chaplains caring for
people living with AIDS. It was followed
by a presentation examining religious and
secular counseling with regard to faith, the
need for science, and the variety of avail-
able values. Remarks on personal spiritual
experiences while facing health challenges
and a scholarly summary of the presenta-
tions completed the symposium.
The Workshop on Conceptualization and
Measurement of Person- and People- cen-
tered Care encompassed first the presenta-
tion of a literature review on conceptual-
izing person- and people-centeredness in
primary health care. It explored the no-
tions of person and people within primary
care as defined in the 1978 Alma Ata Dec-
laration and the 2008 World Health Re-
port, as well as their relevance to the dis-
cussion of equity and social justice, causes
of ill health, and the integration of primary
care and public health. This was followed
by a set of short papers on the conceptual
refinement and further development of a
prototype Person-centered Care Index
(PCI) conducted by the International Col-
lege of Person-centered Medicine.The ini-
tial work engaged broad international pan-
els composed of clinicians, public health
experts, patients and family representa-
tives, who through Delphi-type consulta-
WMA news
tions discussed the results of a review of
the literature and identified key elements
of person-centered care, which led to the
design of a prototype PCI. This was sub-
jected to an initial evaluation of its content
validity and general applicability to health
systems. More recently, the prototype PCI
was revised to improve the wording of its
items and rating arrangement and was
subjected to pilot studies of its internal
structure, of its content validity among
mental health users in London, and of its
inter-rater reliability across various types
of health programs in Santa Cruz, Califor-
nia and Lucknow, India.
The Workshop on Swedish Clinical Re-
search on Person-Centered Care encom-
passed six papers from a specialized and
multidisciplinary research center at Go-
thenburg University, Sweden. It opened
with a review of fundamentals in person-
centered care. Two ensuing papers dealt
with the effects of person-centered care
concerning hip fractures and heart failure.
Another paper discussed patient reported
outcomes. The implementation of person-
centered care was the subject of the fifth
paper. The last one discussed organization
of person-centered care
The Workshop on Person-centered Pain
Management started with an examination
of the complexity and challenges imposed
by pain in chronic conditions such as can-
cer. Maximizing quality of life must be a
guiding principle and a multidisciplinary
team approach is usually required. Progress
may be achieved by evaluating systemati-
cally treatment options towards enhanc-
ing health outcomes. When considering
invasive procedures for the management
of cancer pain, attending to the patient’s
wishes is crucial. Maximizing quality of
life and social integration are important
outcomes here. Another presentation pos-
ited that pain management largely depends
on bio-psycho-social understanding of
the situation, as well as on analyzing pain
mechanisms, patients’ attitudes, and the
role of culture. A presentation on person-
centered pain management in the realm of
palliative medicine completed this work-
The Workshop on Shared Care Plan and
Personalized Diagnosis focused on the
structure of a treatment plan with particu-
lar attention to the development of whole-
health objectives. It proposed the integra-
tion of general medical, psychological and
social interventions to promote wellness
The Oral Presentations Session on Con-
ceptual Studies on Person-centered Care
began with a presentation of neuroscience
perspectives towards person-centered care.
It was followed by a presentation on the
prospects of personalizing education and
mental health through neuroscience and
neuroesthetics. Next the Islamic heritage
and traditions concerning person-centered
medicine were discussed. Person-centered
gynecology and obstetrics was the subject
of the following paper. Then a review of
personality concepts and their impact on
the development of Russian psychology
and psychiatry was presented. Providing
child-centered hospital care to Serbian chil-
dren was reported in the presentation on a
rights-based approach. Another paper dealt
with building a person-centered culture in
prevention and recovery care service. A role
of traditional birth attendants in promoting
person-centered care in Asia was reviewed.
Finally, a paradigm in pediatrics to deliver
family- and child-centered care was dis-
The other Oral Presentations Session en-
compassed Experimental Studies on Per-
son-centered Care. The Project PARIS:
Parents and Residents in Session is study-
ing the teaching of person- and family-cen-
tered care in a pediatrics residency program
in New York. An innovative medical school
in Madrid reported on the effects of an ear-
ly clinical experience program in a medical
school aimed at raising awareness of the re-
lational and communicative needs of clini-
cal practice and of the structure and perfor-
mance of health systems. The UK Program
on Type 2 Diabetes presented risk assess-
ment results and their implications for prac-
titioners and patients,as well as a systematic
review of barriers and facilitators in the life
style modifications for prevention purposes.
There was a Swedish presentation on their
results when analysing the relationship be-
tween organizational culture and the imple-
mentation of person-centered care. A study
from Cyprus assessed the implementation
of person-centered medicine in treating
patients with dementia. Victoria, Australia,
presented a review on the importance of in-
terdisciplinary support to manage medica-
tions in an optimal way when dealing with
patients with multiple chronic conditions.
A report from Milan focused on reliability
and validity evaluation of a person-centered
clinical method.
The Workshop on Person-centered Health
Systems started with a presentation from
WHO on integrated health systems, in-
cluding conceptual and empirical elements.
The other presentation from WHO argued
that a person-centered approach is of ut-
most need to attain the state of reproductive
health. It concluded that the adoption of a
person-centered approach will often pre-
clude the need for complicated checklists
and contribute greatly to improving qual-
ity of care and patient satisfaction. A third
presentation represented a contribution
to the early assessment and prevention of
burn-out in the form of a person-centered
approach to human resources management
in health care. The final presentation dealt
with educational factors in health systems.
It pointed out that human interactions are
the most important aspect of health sys-
tems, that learning opportunities are em-
bedded in health system facilities, and that
an operational linkage between education
and health systems needs a clear definition
at the different stages of training and prac-
tice paying attention to local, national and
global contexts.
WMA news
The Workshop on Internet and Person-
centered Medicine was based on the pre-
senter’s experience and perspectives on the
use of the internet for health professional
purposes. He suggested that the future of
scientific professional communication is on
the web, promoting useful and dynamic in-
teractions among institutional members, for
which videos may be quite helpful, and with
webmasters continuously evaluating the of-
fered contents.
A Scientific Panel was organized to launch
an International Conference and Publica-
tion Series on Person-centered Healthcare.
It embraced brief presentations on the aims
and scope of the series and on their impli-
cations as perceived by officers of public
health, clinical, educational and patient or-
The Session on Region and Country Ex-
periences on Person- and People- centered
Care started with a presentation from Thai-
land on the measurement of responsiveness
as part of person-centered healthcare. It
used a set of questionnaires and vignettes
to assess the experience at the intersection
between person and health system. A pre-
sentation from Europe focused on the uti-
lization of health ontologies (terminology,
nomenclature,taxonomy) to discuss person-
centeredness (as illustrated by the Person-
centered Integrative Diagnosis model) and
personal factors (as defined in WHO’s In-
ternational Classification of Functioning
and Health). It posited that limitations in
conceptualization and terminology are key
barriers to scientific progress and the con-
solidation of a new scientific field. Another
presentation described a collaborative proj-
ect to promote person-centered care for
diabetes and depression in South Africa,
Lesotho, Botswana, Swaziland and Uganda.
It demonstrated that a holistic person-cen-
tered approach may help the recognition,
management and outcomes of diabetes and
depression. The final presentation discussed
African contributions to decision-making
in person-centered health practice. It drew
on indigenous knowledge, such as the isi-
Zulu term “indaba” that refers to a meeting
(such as that between a health professional
and a service user) that is so substantive that
it is an end in itself, and therefore person-
The Workshop on Dance Therapy in Per-
son-centered Medicine reflected interest in
the field of experiential creative and artistic
opportunities aimed at ameliorating illness
and enhancing well-being. Initial intro-
ductions referred to the numerous studies
documenting the value of dance for health.
It may contribute to self-awareness, expres-
sion of feelings, improved communication,
and personal development. One presenta-
tion focused on expressive psychoanalytic
dance therapy; the other on integrative
dance/movement psychotherapy addressed
to facilitating the fulfillment of a personal
life project. Each included an experiential
The Special Session on Stakeholders’ Poli-
cies and Contributions for Person- and
People-centered Care took place with
the participation of major global medical
and health institutions co-sponsoring the
Fifth Geneva Conference. It started with
introductory statements from officers of
the World Health Organization and the
International College of Person-centered
Medicine. They were followed by contribu-
tions from the World Medical Association,
WONCA, International Alliance for Pa-
tients’ Organizations, International Coun-
cil of Nurses, International Federation of
Social Workers, International Pharmaceu-
tical Federation, Council for International
Organizations of Medical Sciences, World
Federation for Mental Health, Internation-
al Federation of Gynecology & Obstetrics,
International Federation of Medical Stu-
dents’ Associations, and European Federa-
tion of Associations of Families of People
with Mental Illness.
Concluding Remarks
As discussed at the Conference’s Closing
Session, the Fifth Geneva Conference rep-
resented a strong step forward in the process
of building person-centered medicine.It was
co-sponsored by a record 33 global medi-
cal and health organizations, introduced
new presentation formats, documented the
advancement of our International Journal
and scientific workgroups, and launched
new initiatives. Furthermore, the inaugural
Geneva Declaration on Person-centered Care
for Chronic Diseases was wrapped-up at this
session and was then issued in final form
by the ICPCM Board on May 19. Also at
the Closing Session, and earlier than ever
before, an announcement was made for the
Sixth Geneva Conference to take place on
April 27-May 1, 2013 with the main theme
Person-centered Health Research.
LtoR: Manuel Dayrit, Juan E. Mezzich, Carissa Etienne, and Wim Van Lerberghe, at WHO
Headquarters following the Fifth Geneva Conference.
WMA news
As a colophon to the Fifth Geneva Confer-
ence, the ICPCM president was invited the
next day to a meeting at the World Health
Organization headquarters with Assistant
Director General Dr. Carissa Etienne and
Directors Drs. Wim van Lerberghe and
Manuel Dayrit. They expressed congratula-
tions for the Conference that had just ended
and strong interest for the Sixth Geneva
Conference and the prospective develop-
ment of a WHO Guide on Person-centered
1. Mezzich JE, Snaedal J, Van Weel C, Heath I.
Person-centered Medicine: A Conceptual Ex-
ploration. International Journal of Integrated
Care, Supplement, 2010.
2. Mezzich JE, Snaedal J, van Weel C, Botbol M,
Salloum IM: Introduction to Person-centered
Medicine: From Concepts to Practice. Journal of
Evaluation in Clinical Practice 17: 330-332,2011.
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 JE, Miles A, Snaedal J, van Weel C,
Botbol M, Salloum IM, Van Lerberghe W: The
Fourth Geneva Conference on Person-centered
Medicine: Articulating Person-centered Medi-
cine and People-centered Public Health. Inter-
national Journal of Person Centered Medicine
2: 1-5, 2012.
5. Heath, I: Promotion of disease and corrosion of
medicine. Canadian Family Physician; 51:1320-
22, 2005
6. Mezzich J, Snaedal J, van Weel C, Heath I. To-
ward Person-Centered Medicine: From Disease
to Patient to Person. Mount Sinai Journal of
Medicine 77: 304-306, 2010.
7. Snaedal J: Presidential Address. World Medical
Journal 53: 101-102, 2007.
8. 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), p.16.
9. 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.
10. Mezzich JE: The construction of person-cen-
tered medicine and the launching of an Interna-
tional College. International Journal of Person
Centered Medicine 2: 6-10, 2012.
11. Miles A, Mezzich JE. Advancing the global
communication of scholarship and research for
personalized health care: the International Jour-
nal of Person Centered Medicine. International
Journal of Person Centered Medicine 1: 1-5,
12. Montenegro RM. Upgrading the ICPCM in-
stitutional website and interactions with related
ones. International Journal of Person Centered
Medicine 2: 323-325, 2012.
13. Tournier P. Medicine de la Personne. Neuchatel,
Switzerland: Delachaux et Niestle, 1940.
14. Dordevic V, Bras M, Milicic D (eds): Person-
oriented Medicine and Healthcare. Medicinska
Naklada, Zagreb, 2012.
15. Kipman S-D (ed): Manifest pour une Medicine
de la Personne. Doin, Paris, 2012.
16. 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.
17. Salloum IM, Mezzich JE: Conceptual appraisal
of the Person-centered Integrative Diagnosis
Model. International Journal of Person Cen-
tered Medicine 1: 39-42, 2011.
18. Otero A, Saavedra JE, Mezzich JE, Salloum
IM. La Guía Latinoamericana de Diagnóstico
Psiquiátrico y su proceso de revisión. Revista
Latinoamericana de Psiquiatria 11:18-25. 2011.
19. Saavedra JE, Mezzich JE, Otero A, Salloum IM:
The revision of the Latin American Guide for
Psychiatric Diagnosis (GLADP) and an initial
survey on its utility and prospects. International
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221, 2012.
20. International College of Person Centered Medi-
cine. Geneva Declaration on Person-centered
Care for Chronic Diseases.International Journal
of Person Centered Medicine 2: 153-154, 2012.
Juan E. Mezzich
(International College of Person-
centered Medicine President),
Jon Snaedal (World Medical
Association President 2007–2008),
Chris van Weel
(Wonca President 2007–2010),
Michel Botbol (WPA Psychoanalysis
in Psychiatry Section),
Ihsan Salloum (WPA Classification Section),
Tesfa Ghebrehiwet (International
Council of Nurses).
All members of the ICPCM Board and of the
Fifth Geneva Conference Organizing Com-
We are writing to you in order to propose to
join forces in co-signing the attached Open
Letter on “Standards for medical practice”.
We already had the occasion to raise and
share our concerns with you all regarding
the process that the European Standardisa-
tion Committee (CEN – Centre européen
de normalization) has initiated in Aes-
thetic Medicine. We have had a report on
their meeting that was recently organised in
Delft and this confirmed our worries.
This invitation to you also provides us with
an opportunity to (re)state our position
firmly, i.e. that the UEMS was not at the
origin of this initiative, was not actively in-
volved and is strongly opposed to it.
We would be grateful to you for joining
this Open Letter as well as circulating it as
widely as possible within your networks, the
aim being to get as many co-signatories as
UEMS calls to the Presidents of the European Medical
Organisations, National Medical Associations
WMA news
WMA General Assembly, Bangkok 2012
This year’s General Assembly will be held
from 10–13 October at the Centara Grand
Hotel, Bangkok, Thailand. The scientific
session “Megacity – Megahealth?” will be
on Thursday, 11 October.
WMA Expert Conference: Revision of
the Declaration of Helsinki
The first in a series of expert conferences on
this topic will be hosted by the South Afri-
can Medical Association from 5–7 Decem-
ber, 2012 at the Westin Cape Town, South
Africa. Registration, open to the public on
WMA website, closes 5 November 2012
WMA Council Session, Bali April
This meeting will be held from 4–6 April
2013 at The Laguna, Nusa Dua, Bali, Indo-
WMA General Assembly, Fortaleza Oc-
tober 2013
The General Assembly 2013 will be held
from 16–19 October in Fortaleza, Brazil.
WMA TB courses rewarded by CDC
The newly launched MDR-TB online
course was rewarded by US Centers of
Disease Control (CDC) as the educational
highlight of the month. Both TB courses
developed by WMA have received this
CDC recognition.
TB Courses at The Union World Con-
WMA has been accepted to present the
development of the TB refresher course
and MDR-TB course at the 43rd
World Conference on Lung Health in
Kuala Lumpur, Malaysia, 12–17 Novem-
ber, 2012.
Forthcoming Events
Standards for of Medical Practice
Open Letter
Brussels, 14th
September 2012
The undersigned European Medical Organisations and National
Medical Associations are committed to the achievement of high
standards in healthcare because they recognise the importance of
these for the safety and quality of care for patients.
These Medical Organisations strongly support the considerable
work that has been, and continues to be performed by medical
experts in healthcare in developing standards and guidelines for
practice based on their clinical experience and research findings.
These Medical Organisations recognise that standards and guide-
lines are best implemented when the doctors who will be imple-
menting them are engaged in their development and in their ap-
plication in local healthcare services.
Accordingly, these Medical Organisations have profound con-
cerns about the attempts by the European Committee on Stan-
dardisation (CEN – Centre Européen de Normalisation) to in-
troduce standards based on quality management systems that do
not have a solid evidence-base within the clinical environment of
healthcare systems.
These Medical Organisations further question the rationale for
CEN to extend its remit into this area as this would appear to be
in breach of core elements of European legislation as applied to
healthcare which is subject to the principle of subsidiarity.
These Medical Organisations consider that the CEN initiative
to develop standards derived from the ISO 9000 series and apply
them top down in healthcare systems conflicts with:
• The Treaty of Lisbon, Article 168 (update of Treaty of Amster-
dam, Article 152)
• The European Directive on the mutual recognition of profes-
sional qualifications (2005/36/EC) and in particular the recog-
nition of the right of individual Member States to determine
their own training structure while ensuring compliance with
criteria set out in the Directive.
• National laws and regulations on healthcare systems and pro-
fessional practice that are specific to the different healthcare
systems in Europe.
These Medical Organisations have attempted to engage in a con-
structive dialogue with CEN but finds that there is a lack of re-
ciprocation for a meaningful dialogue.
These Medical Organisations have concluded that CEN does not
wish to engage in partnership working with representatives of the
medical profession.
These Medical Organisations therefore call on the European Com-
mission and Parliament,the EU Member States and other relevant
institutions or bodies to challenge the approach being taken by
CEN and to question the rationale of its initiative in healthcare.
The South African Mail and Guardian has
identified 15 ideas they believe can help
transform Africa. The Speaking Book is
honoured to be recognised as one of the 15
innovative ideas.
A range of easy-to-use audio books de-
signed to get potentially life-saving health
messages out to millions of isolated people
struggling with depression and mental
health problems.
In 2003, Zane Wilson, the founder of the
South African Depression & Anxiety Group
(Sadag), the country’s largest mental health
initiative, was horrified at how suicide rates
among young South Africans were spiking.
Mental health carries a huge social stigma
across Africa and information booklets
designed to help people with depression
or mental health problems simply weren’t
working, especially in remote communi-
ties with high illiteracy rates. People weren’t
getting the help they needed – a 2009 study
showed that only a quarter of the 16.5% of
South Africans suffering from mental health
problems had received any kind of treatment.
Speaking Books created a range of free
books with simple audio buttons talking the
user through each page. The first Speaking
Book, voiced by South African actress and
celebrity Lillian Dube, was called Suicide
Shouldn’t Be a Secret and focused on how
depression is a real and treatable illness,
encouraging people to get help when they
need it.
Speaking Books have now produced 48 ti-
tles in 24 different languages and are now
used in 20 African countries across the con-
tinent. The books now tackle a number of
critical healthcare issues outside of suicide
prevention such as HIV and Aids, malaria,
maternal health and clinical trials. Speaking
Books has also expanded to China, India
and South America. “The situation we face
in rural South Africa is the same in any other
African country – low literacy compounded
by lack of access to services and affordable
healthcare,” says Wilson. “This means that
patients are often not able to get help for
many health problems. We believe that this
interactive, durable, high-quality, hardcover
book engages the user or patient, and allows
them to build self-confidence and skills with
a simple action plan”. AK


Speaking Books Recognised as One of 15
Most Innovative African Ideas!
WMA news
Violence in the Health Sector conference:
“Linking local initiatives with global learning”
24–26 October, 2012 Vancouver, Cana-
da. Dr.  Mukesh Haikerwal, Chair of the
WMA Council, will open the conference.
WMA President-Elect Dr.  Cecil Wilson
as well as Dr. Dana Hanson, past President,
will also participate.
Call for papers: violence and disability
In 2013, the Journal of Interpersonal Vio-
lence will publish a special issue on the topic
of violence against people with disabilities.
Deadline for submissions: 2 Nov, 2012.
WFME World Conference 2012, Malmö,
Sweden, 14–16 November 2012
The World Federation for Medical Edu-
cation – bringing together the faculties
of medical schools worldwide, the global
representation of medical students and the
World Medical Association – invites par-
ticipants to its global conference on qual-
ity development in medical education. The
conference will discuss the future role of the
doctor in health care, standards for medical
education and the accreditation of medical
Fifth session of the Conference of Parties
to the WHO Framework Convention on
Tobacco Control will take place in Seoul,
Korea from 17–20 Nov. 2012.
Governments around the world have been encouraged by the World
Medical Association to follow the example of the Australian Gov-
ernment in legislating on plain cigarette packaging following this
week’s High Court victory.
The WMA welcomed the High Court decision in Australia to dis-
miss the challenge brought against the legislation by tobacco com-
panies. Dr. Mukesh Haikerwal, Chair of the WMA and a family
physician in Melbourne, hailed the court’s decision as a major step
forward in the fight against tobacco.
‘The WMA condemned the legal action brought by the tobacco in-
dustry and the court’s decision shows that governments can with-
stand and defeat the bullying tactics of the big tobacco companies.
‘Governments around the world must now rise to the challenge and
follow the example of the Australian Government in banning logos
on cigarette packets. We firmly believe that when this legislation is
implemented,it will save lives by reducing the terrible health related
deaths, long-term illnesses and disability caused by smoking.
‘Governments have a duty to do what they can to help smokers give
up and choose a healthier way of life.
‘When the WMA General Assembly meets in Thailand in Octo-
ber, it will discuss further steps to strengthen its anti-tobacco policy
against the aggressive promotion by the tobacco industry to make
their products more appealing to young people.’
WMA Hails Australian Government Victory on Tobacco
World Health Summit aims at a common goal: to shape Health-
care for the 21st
century. From October 21st
to 24th
, 1.400 partici-
pants from over 90 countries and all health related fields will gather
to discuss the challenges of global health.
Selection of Topics: Diseases of Modern Environments, Translat-
ing Research into Policy, Health and Economics, Educating Health
Professionals, Information Technology for Health
Selection of Speakers: Peter Agre (Nobel prize in Chemistry 2003),
Josef Ackermann (Zurich Financial Services), Daniel Bahr (Min-
ister of Health, Germany), Gerd Binnig (Nobel prize in Physics
1986), Zsuzsanna Jakab (Regional Director, WHO Regional Office
for Europe), Gan Kim Yong (Minister of Health, Singapore)
The World Health Summit 2012 offers an excellent forum for in-
formal discussions and new connections, besides a wealth of infor-
mation, debates and presentations of the newest developments from
all fields of research and global health.
Instead of Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Profile of the Medical Association of Thailand (MAT) . . . 122
Regulation of Health Professions: Disparate Worldwide
Approaches are a Challenge to Harmonization . . . . . . . . . 128
Healthcare Reform in South Africa:
a Step in the Direction of Social Justice . . . . . . . . . . . . . . . 137
Protesting a System which “Evaluates the Price of
Everything, but cannot Appreciate the Value of Them” . . . 139
Our Failed Health Strategy . . . . . . . . . . . . . . . . . . . . . . . . 145
Financing Quality in Healthcare – the InterQuality
Project Takes on the Challenge . . . . . . . . . . . . . . . . . . . . . 147
Alternative Medicine in Oncology . . . . . . . . . . . . . . . . . . . 148
The Fifth Geneva Conference on Person-centered Medicine . . .152
UEMS calls to the Presidents of the European Medical
Organisations, National Medical Associations . . . . . . . . . . 159
Forthcoming Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Speaking Books Recognised as One of 15 Most
Innovative African Ideas! . . . . . . . . . . . . . . . . . . . . . . . . . . II
The 4th
World Health Summit 2012 Research for Health and
Sustainable Development